UMASTER PREFERRED DRUG LIST (DRUG FORMULARY) Effective July 1, 2015 RA05/15.654

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1 UMASTER PREFERRED DRUG LIST (DRUG FORMULARY) Effective July 1, 2015

2 1PU 2PU 3PU 4PU UPU UPU UPU UPU P P P P P Tier Master List (PDL) (Drug Formulary) Effective July 1, 2015 THE BLUEGRASS FAMILY HEALTH MASTER PREFERRED DRUG LIST (DRUG FORMULARY) HAS BEEN COMPILED TO RESPOND TO THE CONSTANTLY CHANGING NATURE OF MEDICATION THERAPY. ALTHOUGH EVERY EFFORT HAS BEEN MADE TO ENSURE THE ACCURACY OF THIS DOCUMENT, THE LIST IS DYNAMIC AND SUBJECT TO CHANGE. YOU WILL BE NOTIFIED AT LEAST 30 DAYS IN ADVANCE OF ALL CHANGES. GENERAL DEFINITIONS OF TERMS ST MEDICATIONSU Typically generic medications. A generic medication is called by its chemical name; a manufacturer assigns a brand name. The price of the generic medication is usually lower than that of a brand name medication. Both generic and brand name products have the same active ingredients. Overall, the generic medication is just as safe and effective as the brand name medication. ND MEDICATIONSU Typically preferred brand medications. Preferred brand medications may have generic equivalents. rd Once a branded medication is available as a generic product, the branded medication will move to a non-preferred 3P status and st the generic medication will become the preferred 1P Tier medication unless listed otherwise in the PDL. RD MEDICATIONSU Typically non-preferred brand medications. Only those 3P Tier medications that have restrictions are rd listed. All other brand medications not listed within the PDL are 3P Tier medications unless 4-Tier Benefit applies. TH MEDICATIONSU Applies to 4-Tier Benefit plans ONLY and includes ALL Specialty Pharmacy medications. A list of the most commonly utilized Specialty Pharmacy medications is included in this document. All other Specialty Pharmacy medications th not listed within this document are 4P Tier medications. Bluegrass Family Health (BFH) requires special processing for some medications. Types of this special processing are: UPRIOR AUTHORIZATION ()U Due to the nature of some medications, Prior Authorization U() Umay be required for certain medications to be covered at any cost-sharing tier. Medications that require U()U do so because of their potential for misuse and/or abuse and will require that Plan criteria be met before approval is given. Claims exceeding $2, will reject for required. Experimental or investigational use of a medication is not covered, unless such use is consistent with standard medical practice and has been demonstrated as effective in published peer review medical literature. If a medication requires U()U, the ordering physician must contact BFH s Pharmacy Services Department PRIOR to you receiving your medication. U( s)u will NOT be issued after the prescription has been filled. U( s)u for brand name medications also apply to generic alternatives. USTEP EDIT ()U Step edit is an electronic U()U process that takes place at the time the pharmacist files the claim. A step edit may include an age edit, a specialty prescriber edit, or a therapeutic alternative edit. If the step edit criterion is met, the system will approve the claim. If the step edit criterion is not met, the system will not approve the claim and will send a message back to the pharmacy advising that the step edit protocol has not been met. At that time, the pharmacy may contact your physician and request that they contact the plan for U()U. If this does not happen, you will be responsible for contacting the physician to get the drug prior authorized. Step Edits for brand name medications also apply to generic alternatives. UQUANTITY LIMITS ()U Quantity limits have been placed on medications to be consistent with the maximum dosages that the Food and Drug Administration (FDA) has designated to be both safe and effective. Prescriptions for which the quantity to be dispensed exceeds the FDA s maximum daily dose are excluded. Quantity Limits for brand name medications also apply to generic alternatives. UTABLET SPLITTING PROGRAM (½T) U Certain medications are eligible for the BFH Tablet Splitting Program. The Tablet Splitting Program provides an opportunity for you to reduce your prescription medication copayments or coinsurance by using doublestrength tablets and splitting them in half. The program is voluntary. Consult your doctor before splitting any prescription tablets. Only those medications determined to be appropriate for splitting are included in the Tablet Splitting Program. HOW TO ACCESS YOUR PHARMACY BENEFITS You must use a participating pharmacy and present your valid BFH member ID card to access your pharmacy benefits. To be eligible for coverage, medications must be processed online by your pharmacist. Claims not filed online by a participating pharmacy may not be eligible for reimbursement. If you are at the pharmacy and you do not have your ID card, or if the pharmacist is having trouble filing the claim online, you or the pharmacist may contact the BFH Pharmacy Services Department at (877) or (859) URGENT AND EMERGENT SITUATIONSU If you are out of the area and need to have a prescription filled for an urgent or emergent condition, for your convenience you may take the prescription and your BFH ID card to any participating chain pharmacy. If the pharmacist has difficulty processing the claim, he or she may contact the BFH Pharmacy Services Department at (877) rd

3 P and P Tier P Tier P Tier IMPORTANT INFORMATION REGARDING YOUR PHARMACY BENEFITS UBENEFIT EXCLUSIONSU BFH will not cover, at any cost-sharing tier, any medications prescribed for the treatment of diagnoses st nd excluded from coverage. The list of 1P 2P medications does not provide information regarding the specific coverage and limitations an individual member may have. The list applies only to outpatient medications provided to members and does not apply to medications used in inpatient settings. If you have any specific questions regarding their coverage, you should contact BFH. The following general exclusions pertain to all covered individuals unless specified in plan documentation: A. Over the Counter (OTC) medications or their equivalents are not covered, unless otherwise specified in the PDL. B. Medication Products specifically listed as not covered. C. Any medication products used for cosmetic purposes, including hair loss, are not covered. D. Replacement of lost, stolen, misplaced, damaged, or spilled medication is not covered. E. Weight loss medications are not covered. F. Medications for the treatment of sexual dysfunction are not covered. G. Medications for travel prophylaxis are not covered. H. Compounded medications, which are prepared by a pharmacist and are not FDA-approved in their final form, are not covered. I. Medications obtained from out-of-network pharmacies are not covered. J. Medications for which the quantity to be dispensed exceeds BFH Quantity Limit () are not covered. K. Convenience kits are not covered when active ingredient products are available individually. L. Medications or other prescription drugs used by an Outpatient to maintain a treatment plan of an addiction or dependency on drugs, alcohol, or chemicals are not covered. This includes: Medications used by an Outpatient to maintain a treatment plan of a drug addiction, drug dependency, or a drug maintenance program with methadone or buprenorphine-containing products. M. Modified food or supplements for the treatment of lactose intolerance, protein intolerance, food allergy, food sensitivity, or any other condition or disease are not covered except special formulas Medically Necessary for the treatment of certain inborn errors of metabolism or genetic conditions. N. New prescription drugs to the market which contain a new manner of action or new delivery system will not be considered for coverage until six (6) months after the product is widely available. O. Drugs used for diagnostic purposes are not covered. P. Vaccines when recommended and/or required by a third-party entity for the purpose of sports, school (except approved well visits), camp, employment, license requirements, travel, insurance, marriage, or adoption are not covered. UEXCEPTIONS POLICYU Non-preferred brand medications not included in the PDL are covered at your 3P cost-sharing rd amount. Prescription drugs specifically listed as not covered in the PDL will be approved at your 3P cost-sharing amount ONLY when clear medical documentation from the requesting provider includes evidence that the requested medication is appropriate and medically necessary. Clear medical documentation must include adequate trial and failure, contraindications, or an established allergy, of other prescription drugs of the same class or those used to treat your condition, which are included in the PDL. UPRESCRIPTIONS DRUG OVERRIDESU BFH provides prescription drug overrides as required by applicable state law. Prescription drug overrides do not apply to any controlled medication. Only 12 fills per year of a medication are allowed, regardless of override and no more than 3 refills of a covered drug may be obtained within a 90 day period. UREFUNDSU If you pay out-of-pocket for a prescription at a participating pharmacy, you may return to the pharmacy within 60, have the claim processed online and be reimbursed the eligible out-of-pocket expenses. If you are reimbursed by BFH for an eligible out-of-pocket prescription expense, you will be paid based on the BFH s contracted pharmacy rates. These contracted rates are usually less than the pharmacy s retail charges, resulting in a net cost to you greater than your usual co-payment or coinsurance. Requests for out-of-pocket prescription reimbursement received more than 6 months after the prescription was filled will not be eligible for reimbursement. ALL requests for reimbursement must include your BFH ID #, a pharmacy receipt that includes the name of the medication, the name of the pharmacy where the medication was purchased, the quantity dispensed, the day supply, the amount the pharmacy charged, and a BFH Prescription Claim Form. You will be reimbursed based on your benefits and the applicable co-payment or coinsurance will be deducted from your reimbursement. UDISPEN AS WRITTEN (DAW) 1 AND 2 PENALTYU State law requires that when there is a generic medication available for a branded medication that the pharmacist dispense the generic product unless otherwise stated by the prescriber to dispense as written or it is requested by the patient. If a prescriber or a member specifically requests a brand name medication when a generic medication is available, the member will be subject to their applicable co-payment and will be responsible for any difference in price between the generic medication and the brand name medication. USPECIALTY DRUGS/INJECTABLESU Specialty drugs and Injectables may only be obtained through Accredo Specialty Pharmacy Services. You or your physician may contact the BFH Pharmacy Services Department to obtain information on this process. Prior Authorization is required for certain specialty drugs when delivered in the physician office, clinic, or home setting. Please refer to the Medical Prior Authorization List as reference to these medications. A list of the most commonly utilized Specialty Pharmacy medications is included in this document. For additional information, visit us on the web at 30TUwww.bgfh.comU30T. rd

4 Abilify Maintena Abilify Tab ½T Abraxane Absorica Abstral 120 x 30 Accu-Chek Test Strips Acebutolol Acetamin/Butalbital 372 x 30 Acetamin/Codeine 3750mL x 30 Elixir Acetamin/Codeine Tablets 372 x 30 Aciphex* Actemra 162mg SQ 4 syringes x 28 Actemra IV 800mg x 28 Acthar, H.P. Actiq* Actonel/Ca Acyclovir Aczone Adapalene 120 x 30 Required Required Adcetris Adcirca Adderall XR* 30mg/day Adempas 90 x 30 ADHD Stimulants Advair Diskus/HFA Advicor Aerochamber Afinitor 30 x 30 Aggrenox Akynzeo Albuterol Alendronate Alimta Alkeran Tabs Allopurinol Aloxi Injection Alprolix Alphagan P 0.1% only Alprazolam/XR 5mL x 30 Ambien*/CR* 30 x 30 Amerge* 9 x 30 Amitiza 60 x 30 Amitriptyline Amlodipine Besylate ½T Amnesteem Amlodipine/ Benazepril Amoxicillin Amoxicillin, Clavulanate Potassium/ER Amphetamine Salt Combo Amphetamine Salt Combo ER 30mg/day Ampyra 60 x 30 Anastrozole Androderm Androgel Androxy* Angiotensin II Receptor Blockers (ARBs) Antabuse* Antihemophilic Factor Agents Antineoplastic Inj. & Powders Anzemet Tab Aplenzin Apriso Aranesp Arava 10mg* Arava 20mg* Arcalyst 3 per prescription 30 x 30 4 vials/ syr x x x 30 4 vials x 30 Arixtra* 20 x 30 Arranon Arzerra Asacol Atenolol Atenolol/ Chlorthalidone Atorvastatin ½T Atralin Required

5 Atripla Atrovent Inhaler Aubagio 28 x 28 Avapro* Avastin Avinza* 60 x 30 Avita Avodart Required Avonex 4 syringes x 30 Axert 9 x 30 Axiron Azathioprine Azelastine Azelex Required Azithromycin Azopt Azor Baclofen Bayer Contour/ Breeze Test Strips Beleodaq Belsomra Benazepril 30 x 30 Benicar ½T Benicar HCT Benlysta Benzocaine/ Antipyrine Otic Benzonatate Bepreve 5mL x 30 Berinert Betaseron 15 vials x 30 Betoptic S Bisoprolol Bisoprolol/HCTZ Blincyto Bosulif 30 x 30 Botox Breo Ellipta Brilinta Bunavail 60 x 30 ; 9 months per lifetime Buprenex* Buprenorphine/ Naloxone Tablet 90 x 30 ; 9 months per lifetime Bupropion ER 150mg 90 x 30 Bupropion ER 300mg 30 x 30 Bupropion/SR Buspirone HCl Butalbital/AP/ Caffeine 372 x 30 Butalbital/Aspirin/ Caffeine (tabs only) 372 x 30 Butorphanol Tartrate 2 canisters x 30 Butrans Bydureon Byetta Bystolic Carisoprodol Carvedilol Cayston 4 x 30 4 x 28 1 x mL x 56 Cefdinir Cefuroxime Celebrex 60 x 30 Celecoxib 60 x 30 Celexa 10mg* Celexa 20mg* Celexa 40mg* Cephalexin Ceprotin Cerdelga Cerezyme Cesamet Chantix Chloromycetin Opth Chlorthalidone Chlorzoxazone Cholbam Cialis 5mg only Cimetidine 30 x x x tabs per Rx Age 18 years 180 per year 30 x 30

6 Cimzia 2 x 30 Cinryze Ciprofloxacin ER Citalopram 10mg 30 x 30 Citalopram 20mg 90 x 30 Citalopram 40mg 45 x 30 Citrolith Claravis Clarinex/D* Clarithromycin Climara Pro Clindamycin Clobetasol Clonazepam Clonidine/TDS Clopidogrel Codeine Phos/AP # 2,3,4 372 x 30 Codeine/Aspirin 372 x 30 Codeine/CPM/P 372 x 30 Combivent Respimat Cometriq Concerta* ConZip ER 30 x 30 Copaxone 1 x 30 Copegus* 180 x 30 Coreg CR Corifact Cosentyx 2 x 28 Creon Crestor ½T Crinone Crixivan Cuprimine Cyclobenzaprine Cymbalta 20 & 30mg* 60 x 30 Cymbalta 60mg* 30 x 30 Cyramza Dacogen* Dapsone Daraprim Daytrana Patch Delzicol Desvenlafaxine ER (tab only) Dexamethasone Dexedrine/ Spansules* 30 x 30 Dexilant 30 x 30 Dextroamphetamine Diabetic Needles & Lancets Diazepam Tab/Gel Dibenzyline Diclegis Diclofenac Sodium Dicyclomine Differin* Diflucan 150mg* 120 x 30 Required 1 tab per prescription (max of 2 scripts x 30 ) Dilantin (30mg only) Diltiazem/ER Tabs & Caps Diovan* Diphenoxylate/ Atropine Doxycycline Tabs, Caps only Duexis Duloxetine 20 & 30mg 60 x 30 Duloxetine 60mg 30 x 30 Duragesic* 10 x 30 Dysport Edarbi 30 x 30 Edarbyclor 30 x 30 Edluar 30 x 30 Effexor* 90 x 30 Effexor XR* 225mg/day Elelyso Elidel Required over 18 years Eligard 22.5mg Eligard 30mg Eligard 45mg Eligard 7.5mg 1 kit x 90 1 kit x kit x kit x 30

7 Eliquis 60 x 30 Ellence* Elmiron Embeda 60 x 30 Emcyt Emend 40mg, 115mg, 125mg, & 150mg Emend 80mg Emend Therapy Pack Enalapril Enbrel 2 x 30 4 x 30 6 x 30 4 x 30 Endocet* 100 x 30 Endodan* 100 x 30 Endometrin Enjuvia Enoxaparin Entyvio Epiduo Epipen/JR Epivir HBV Epogen 20 syringes x 30 Initial = 4 x 4 months, Maintenance = 7 x Calendar Year Required 1 twin pack per co-payment 12 vials x 30 Erbitux Erythromycin Esbriet Escitalopram ½T Esomeprazole Strontium Estradiol Tabs & Patches Eszopiclone 30 x 30 Euflexxa Evekeo 60mg/day Exalgo ER* 60 x 30 Exelon Patch/Soln Exjade Extavia 15 vials x 30 Eylea EZ-Spacer Factor VIII Concentrates Factor IX Concentrates Famotidine Fanapt 60 x 30 Farxiga 30 x 30 Farydak Fenofibrate 48mg 60 x 30 Fenofibrate 145mg 30 x 30 Fentanyl Lozenge 120 x 30 Fentanyl Patch 10 x 30 Fentora 120 x 30 Ferriprox Fexofenadine Finacea Required Finasteride Firazyr 3 syringes x 30 Flolan* Flonase* 1 x 30 Flovent/HFA/Diskus Floxin Tab* 28 x 30 Fluconazole 150mg 1 tab per prescription (max of 2 scripts x 30 ) Fluoxetine HCl (excluding 60mg) Fluoxetine Weekly 4 x 30 Fluoxymesterone Fluticasone 1 x 30 FML Forte/S Focalin*/XR* Folic Acid Foradil Forfivo 30 x 30 Forteo Fortesta Fortical NS* Fragmin 20 x 30 Freestyle Test Strips Frova 9 x 30 Furosemide

8 Gabapentin Gazyva Gelnique Gel-One Gemfibrozil Genotropin (Miniquick not covered) Geodon* Gilenya 30 cartridges/ syr x x x x 30 Gilotrif Gleevec Glimepiride Glipizide Glucagon Emergency Kit Glyburide Glyxambi Gralise 90 x 30 Granisetron 6 every 3 Granix Grastek Guanfacine Guanfacine ER 30 x 30 Halaven Halcion* 30 x 30 Harvoni 28 x 28 Helidac 1 per year Herceptin Hetlioz 30 x 30 Horizant 60 x 30 Humalog/Mix Humatrope Humira 2 x 30 Humulin Hyalgan 1800mL x 30 Hycet Hydrochlorothiazide Hydrocod/AP 120 x 30 Hydrocod/Chlorphen 180mL x 30 ER Susp Hydrocod/ Homatropine 372 x 30 Hydrocod/IBU 50 x 30 Hydroxychloroquine Hydroxyzine Hysingla ER 30 x 30 Ibrance Ibuprofen Iclusig Ilaris Imbruvica Imitrex Tablets, Nasal Spray, Inj.* Increlex Indomethacin/SR Infergen Injection Inlyta Inspirease Intermezzo Intron A Vials/Pens Intuniv* Invega Sustenna Invega Tab Invirase Invokamet 9 tabs; 6 nasal sprays/vials/ syringes; 2 inj. kits x vials x x x x 30 Invokana 30 x 30 Iprivask 20 x 30 Irbesartan ½T Isosorbide Mono-/Di-nitrate Itraconazole 60 x 30 ; max of 90 IVIG Ixempra Jadenu Janumet/XR Januvia Jardiance 30 x 30 Jentadueto Jetrea 2 injections per lifetime Jevtana Jublia Juvisync Juxtapid 84 x 28 Kadcyla Kadian* 60 x 30 Kalydeco

9 Kapvay* required over 17 years 120 x 30 Kazano 60 x 30 Kerydin Ketoconazole Ketoralac Tromethamine 20 x 30 Keytruda RA doc required Kineret Kombiglyze XR Korlym K-Phos Krystexxa Kuvan 4 syringes x 28 Kynamro Kyprolis Kytril* 6 every 3 Lamisil* 30 x 30 ; max of 90 Lamotrigine ½T Lansoprazole Required over 12 years Lansoprazole ODT 30 x 30 Lantus Lariam* 5 x 30 Latanoprost Required < 60 years Lazanda 30 x 30 Leflunomide 10mg Leflunomide 20mg 30 x x 30 Lemtrada Lenvima Letairis 30 x 30 Leukeran Leukine Levemir Levetiracetam Levocetirizine Levofloxacin Levora Levothyroxine Levoxyl* Lexapro* Lialda Lidocaine Viscous Lindane (except shampoo) Lindane Shampoo 60mL per 30 Linzess 30 x 30 Lisinopril/HCTZ Lithium Carbonate Lorazepam Losartan ½T Losartan/HCTZ Lotemax Opth Susp Lotronex Lovastatin 60 x 30 Lovaza* Lovenox* 20 syringes x 30 Lucentis Lumigan Lunesta* Lupron Depot & 22.5mg Lupron Depot 3.75 & 7.5mg & All Pediatric Formulations Required < 60 years 30 x 30 1 kit x 90 1 kit x 30 Lupron Depot 30mg 1 kit x 120 Lupron Depot 45mg 1 kit x 180 Luzu 60g x 30 Lynparza Lyrica Macugen Makena 5 vials per 365 Malarone* 12 x 30 Matulane Maxalt/MLT* 9 x 30 Meclizine HCl Medroxyprogesterone Mefloquine 5 x 30 Mekinist 2mg/day Meloxicam 30 x 30 Metadate CD* 30 x 30 Metaxalone

10 Metformin Methadone Liquid 500mL x 30 Methadone Tablets 100 x 30 Methadose* 100 x 30 Methocarbamol Methotrexate Methylphenidate/ER/ SR Methylprednisolone Metoclopramide Metoprolol/HCTZ/ ER Metronidazole 15 vials x 30 Miacalcin Injection Migranal* 8 x 30 Minocycline ER Mircera Required Mirvaso Mobic* 30 x 30 Modafinil 30 x 30 Moexipril HCl ½T Monovisc Montelukast Sodium ½T Morphine Sulfate 100 x 30 Morphine Sulfate SR 60 x 30 Mozobil Multaq Mupirocin Myalept 30 x 30 Myleran Myobloc Myorisan Nabumetone Namenda XR Naproxen Naratriptan 9 x 30 Nardil Nasonex Natesto Natpara 2 x 28 Nebupent Nefazodone ½T Neomycin/ Polymyxin/HC Nesina Neulasta Neumega 30 x 30 Neupogen 14 syringes x 30 Neupro Nexavar Nexium Nilandron Nitrofurantoin Nitroglycerin Ointment/ Patches/SL Tab Norditropin Northera Nortriptyline Norvir Novolin Vials only Novolog Nplate 30 x x 30 Nucynta 120 x 30 Nucynta ER 60 x 30 Nutropin Nuvaring 1 x 28 Nuvigil 30 x 30 Nystatin (except oral powder) Obizur Ofev Ofloxacin Tab 28 x 30 Ogestrel Olanzapine/ Fluoxetine Olysio 30 x x 28 Omeprazole Omnitrope Ondansetron 24mg Tabs 3 x 3 Ondansetron 4mg & 8mg Tabs/ODT 9 x 3 Ondansetron Oral Soln 50mL x 30 One Touch Ultra Test Strips Onglyza Onmel 30 x 30 ; max of 90 Onsolis Opana ER (new formulation only) 120 x x 30 Opdivo

11 Opium Tincture 118mL x 30 Opsumit 30 x 30 Optichamber Optihaler Optipranolol Oralair Oramorph SR 100 x 30 Orencia 4 vials/ syr x 30 Orenitram ER Orfadin Ortho Evra* 1 pack of 3 x 28 - No Indiv. Packs Orthovisc Oseni Otezla 30 x 30 1 starter kit x 365, 60 x 30 Otrexup Oxecta 100 x 30 Oxybutynin/ER Oxycodone HCl Tabs 100 x 30 Oxycodone/AP 100 x 30 Oxycodone/Aspirin 100 x 30 Oxycontin* 60 x 30 Oxymorphone ER 60 x 30 Pantoprazole Paroxetine HCl Patanol Pegasys Peg-Intron Penicillin VK Pentasa Percocet* 4 vials/syr x 30 4 vials/ pens x x 30 Percodan* 100 x 30 Perjeta Phenazopyridine Pioglitazone Pioglitazone/ metformin 1 starter pack x 365 ; 2 pens/syringes x 28 Plegridy Polymyxin B Sul- Trimethoprim Pomalyst Potassium Chloride Pradaxa Prandimet Pravastatin Prednisolone Prednisone Premarin Premphase Prempro Prevacid SoluTab Only* 21 x x 30 Required over 12 years 30 x 30 Prevacid* (except SoluTab) Prevpac* 1 per year Prialt Primaquine Pristiq 30 x 30 ProAir HFA Procentra Soln* Procrit Prolia Promacta 12.5mg Promacta 25mg Promacta 50 & 75mg Prometh/ Codeine/PE Promethazine/ Codeine Promethazine/DM Propranolol HCl/ER Protonix* Protopic ointment* Required over 18 years 12 vials x x x x mL x mL x 30 Required over 18 years

12 Provenge Provigil* Prozac Weekly* 1 treatment cycle per lifetime 30 x 30 4 x 30 Pulmicort Flexhaler Qualaquin* 42 x 30 Quillivant XR Quinapril HCl ½T Qvar Ragwitek Ramipril Ranexa 60 x 30 Ranitidine Rasuvo Ravicti Rayos Rebetol 200mg Tabs 180 x 30 Rebetol Soln Rebif 900mL x syringes x 30 Reclast* Regranex Relenza 1 box per year Relpax 9 x 30 Remicade 4 vials x 6 weeks Remodulin Renova Required Reprexain* 50 x 30 Rescriptor Rescula Retin-A Micro* Required < 60 years Required Retrovir Revatio* Ribasphere 1200mg/day Ribatab 1200mg/day Ribavirin 1200mg/day Ridaura Risperdal Consta Ritalin LA*/ SR* Rituxan 300mL x 30 Rizatriptan/ODT 9 x 30 Roferon-A 500mL x 30 Roxicet Soln Roxicodone Tabs* 100 x 30 Rozerem 30 x 30 Ruconest Rybix ODT 240 x 30 Ryzolt* 30 x 30 Saizen Sancuso Sandostatin/LAR Depot 2 patches x 15 Sarafem 14 x 30 Savaysa 30 x 30 Savella Selective Serotonin Reuptake Inhibitors (SSRIs) Sensipar 60 x 30 Serevent Diskus Seroquel XR Serostim Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs) Sertraline ½T Signifor 60 x 30 Signifor LAR 1 kit x 28 Silenor 30 x 30 Simponi Aria (IV) 5 vials per 8 weeks Simponi SQ 1 x 30 Simvastatin ½T Sitavig 2 x 30 Sivextro Smoking Cessation Products (Generic Rx and OTC only) Soliris Solodyn* Age 18 years 180 per year

13 Somavert Sonata* 14 x 30 Soolantra Soriatane Sotret 28 x 28 Sovaldi Spiriva Spironolactone/ HCTZ Sporanox* Sprintec Sprix Sprycel Stadol Nasal Spray* Stelara Stivarga Strattera (all strengths except 80 & 100mg) 60 x 30 ; max of 90 5 x 30 2 canisters x 30 1 vial x 12 weeks 84 x x 30 Strattera 80 & 100mg 30 x 30 Striant Suboxone Tab*/Film 90 x 30 ; 9 months per lifetime Subsys Subutex Sucralfate Tablets Sulfacetmide/Pred SMZ/TMP Sumatriptan Sumavel DosePro 120 x x 30 ; 9 months per lifetime 9 tabs; 6 nasal sprays/vials/ syringes; 2 inj. kits x 30 6 syringes x 30 Supartz Supprelin LA Sustiva Sutent Sylatron 4 vials x 30 Sylvant Symbicort Symbyax* 30 x 30 Symlin Synagis 2 vials x 30 Synarel Synribo Synthroid* Synvisc/ Synvisc-One Tacrolimus ointment Required over 18 years 300mg/day Tafinlar Tamiflu - Liquid 150mL x 1 year Tamiflu - Tablets 10 x 30 ; 20 per year Tamsulosin HCl Tanzeum Tarceva Tasigna Tazorac Tecfidera 120mg Tecfidera 240mg Temazepam Temodar 5, 20, & 100mg* Temodar 140 & 180mg* Temodar 250mg* Terbinafine Testim Testopel 4 x x x x x x x x x 30 ; max of 90 6 pellets every 3 months Testosterone Agents (generics) Tetracycline Teveten* Tev-Tropin Thalomid Thioguanine Thyroid, Desiccated Tilade Inhaler

14 Tizanidine TOBI Inhalation Soln* 280mL x 56 TOBI Podhaler 224 x 56 Tobramycin Drops Tolterodine Tartrate Topiramate Toradol* 20 x 30 Toujeo Toviaz Tracleer 60 x 30 Tradjenta Tramadol 240 x 30 Tramadol ER 30 x 30 Travatan Z Travoprost Trazodone Tretinoin Tretinoin Micro Tretin-X Required < 60 years Required < 60 years Required Required Tretten Treximet 9 x 30 Triamcinolone/ Nystatin Triamterene/HCTZ Triazolam 30 x 30 Tribenzor Tricor 48mg* 60 x 30 Tricor 145mg* 30 x 30 Truetest Test Strips Truetrack Test Strips Trulicity 4 x 28 Tussionex* 180mL x 30 Tykerb Tylenol #3* 372 x 30 Tylenol with Codeine 3750mL x 30 Elixir* Tysabri 1 vial x 30 Tyvaso 30 amp x 30 Ultram* Ultram ER* Valacyclovir HCl 240 x x 30 Valsartan HCTZ Vantas Vascepa 120 x 30 Vectibix Veletri* Veltin Venlafaxine HCl Venlafaxine HCl ER Cap Venlafaxine HCl ER Tab Ventavis ½T Ventolin HFA Required 90 x mg/day 225mg/day 270 x 30 Vexol eye drops Vicodin* 120 x 30 Vicoprofen* 50 x 30 Victoza 3 x 30 Victrelis 2400mg/day Vidaza* Viekira Pak 1 pak x 28 Vigamox Viibryd Vimizim Vimovo Viracept Viramune XR Visudyne Vivelle/Dot Vivitrol Vogelxo Vpriv Vyvanse 30 x 30 Warfarin Sodium Wellbutrin XL 150mg* 90 x 30 Wellbutrin XL 300mg* 30 x 30 Xalatan* Required < 60 years Xalkori Xarelto 10mg Xarelto 15mg 60 x x x 30

15 Xarelto 20mg 30 x 30 Xarelto Starter Pack Xartemis XR 100 x 30 Xeljanz 60 x 30 Xeloda* Xeomin Xgeva Xiaflex Xifaxan Xigduo XR 30 x 30 Xolair Xtandi 120 x 30 Xyrem Xyzal* Yervoy Yodoxin Zaleplon 14 x 30 Zaltrap Zavesca Zegerid Zelboraf 120 x 30 Zortress Zubsolv 90 x 30 ; 9 months per lifetime Zuplenz 9 x 3 Zydelig Zykadia 150 x 30 Zyprexa Relprevv Zytiga Zyvox * Brands with Generic Alternatives Zenatane Ziana Zioptan Required Required < 60 years Ziprasidone HCl 60 x 30 Zofran Oral Soln* 50mL x 30 Zofran 4 & 8mg Tabs/ODT * 9 x 3 Zofran 24mg Tabs* 3 x 3 Zohydro ER 60 x 30 Zoladex 3.6mg 1 kit x 30 Zoladex 10.8mg 1 kit x 90 Zoledronic Acid Zolpidem/ER 30 x 30 Zolpimist 1 container x 30 Zolvit 1800mL x 30 Zometa* Zomig Spray 6 x 30 Zomig/ZMT* 9 x 30 Zontivity Zorbtive

16 Specialty Drug List by Disease State The following Specialty Medications are subject to the fourth (4 th ) tier copayment/coinsurance on all fourth (4 th ) tier plans. Restrictions may apply. ANTICOAGULANT Arixtra Enoxaparin Fondaparinux Fragmin Iprivask Lovenox Refludan BLOOD CELL DEFICIENCY Aranesp Epogen Granix Leukine Mozobil Neulasta Neumega Neupogen Omontys Procrit Promacta CANCER Abraxane Adcetris Adriamycin Adrucil Afinitor/Disperz Alferon N Alimta Alkeran Amifostine Aredia Arranon Arzerra Avastin Azacitadine Beleodaq Bexxar Bicnu Bleomycin Sulfate Bosulif Busulfex Calcium Folinate Camptosar Capecitabine Caprelsa Carboplatin Cerubidine Cisplatin Cladribine Clolar Cometriq Cosmegen Cyclophosphamide Cyramza Cytarabine Dacarbazine Dacogen Dactinomycin Daunarubicin HCL Daunaxome Decitabine Depocyt Docefrez Docetaxel Doxil Doxorubicin Eligard Elitek Ellence Eloxatin Elspar Epirubicin Erbitux Erivedge Erwinaze Ethyol Etopophos Etoposide Faslodex Firmagon Floxuridine Fludara Fludarabine Phosphate Fluorouracil Folotyn FUDR Fusilev Gazyva Gemcitabine HCL Gemzar Gilotrif Gleevec Halaven Herceptin Hycamtin Idamycin PFS Idarubicin HCL Ifex Ifosfamide Ifosfamide-Mesna Inlyta Intron A Irinotecan HCL Istodax Ixempra Jakafi Jevtana Kadcyla Kepivance Kyprolis Leucovorin Calcium Leuprolide Acetate Leustatin Lipodox Lipodox 50 Lupron Lupron Depot Lupron Depot-PED Matulane Mekinist Melphalan HCL Mesna Mesnex Methotrexate Methotrexate Mitomycin Mitoxantrone Mustargen Navelbine Nexavar Nipent Oforta Oncaspar Onxol Oxaliplatin Paclitaxel Pamidronate Disodium Paraplatin Perjeta Photofrin Pomalyst Proleukin Purixan Revlimid Rituxan Sprycel Stivarga Sutent Sylatron Synribo Tafinlar Tarceva Tasigna Taxotere Temodar Temozolomide Thalomid Theracys Thiotepa Thyrogen TICE BCG Toposar Topotecan Torisel Treanda Trelstar Depot Trelstar LA Trisenox Tykerb Valchlor Valstar Vandetanib Vantas Vectibix Velcade Veletri Vidaza Vincasar Vinblastine Vincristine Vinorelbine Votrient Vumon Xalkori Xeloda Xgeva Xofigo Xtandi Yervoy Zaltrap Zanosar Zelboraf Zevalin Zoladex Zolinza Zydelig Zykadia Zytiga ENDOCRINE DISORDERS DDVAP Desmopressin Acetate Korlym Kuvan Octreotide Acetate Sandostatin Sandostatin LAR Signifor Somatuline Depot Somavert Testopel ENZYME DEFICIENCIES Adagen Aldurazyme Carbaglu Cerezyme Elaprase Elelyso Fabrazyme Lumizyme Myozyme Naglazyme Orfadin Sucraid Vpriv Zavesca

17 Specialty Drug List by Disease State The following Specialty Medications are subject to the fourth (4 th ) tier copayment/coinsurance on all fourth (4 th ) tier plans. Restrictions may apply. GROWTH DEFICIENCY Genotropin Humatrope Increlex Norditropin Flexpro Norditropin Nordiflex Nutropin Nutropin AQ Omnitrope Saizen Serostim Tev-Tropin Zorbtive HEMOPHILIA Advate Alphanate Alphanine SD Alprolix Bebulin Benefix Cortifact Eloctate Feiba Helixate FS Hemofil M Humate-P Koate-DVI Kogenate FS Monarc-M Monoclate-P Mononine Novoseven Profilnine SD Recombinate Rixubis Tretten Xyntha HETITIS B Hepagam B HyperHEP B S/D Nabi-HB HETITIS C Copegus Harvoni Infergen Moderiba Olysio Pegasys Peg-Intron Peg-Intron Redipen Rebetol Ribapak Ribasphere Ribatab Ribavirin Sovaldi Victrelis HIV Abacavir-Lamivudine- Zidovudine Aptivus Atripla Combivir Complera Crixivan Didanosine Edurant Emtriva Epivir Epivir HBV Epzicom Fuzeon Intelence Invirase Isentress Kaletra Lexiva Nevirapine Norvir Prezista Rescriptor Retrovir Reyataz Selzentry Stavudine Stribild Sustiva Tivicay Triumeq Trizivir Truvada Tybost Videx Videx EC Viracept Viramune Viramune XR Viread Zerit Ziagen Zidovudine IMMUNE DEFICIENCY Actimmune Bivigam Carimune NF Cytogam Flebogamma Flebogamma DIF GamaSTAN S/D Gammagard Liquid Gammagard S/D Gammaked Gammaplex Gamunex Gamunex C Hizentra HyperHEP B SD HyperRAB S/D HyperRHO S/D Hyqvia Immune Globulin Imogam Rabies-HT MICRhoGAM Octagam Privigen RhoGam RhoGam Plus Rhophylac Varicella-Zoster- Imm Globulin Vivaglobin Winrho SDF IMMUNILOGICALS AND VACCINES Provenge INFERTILITY Bravelle Cetrotide Chorionic Gonadotropin Follistim AQ Ganirelix Acetate Gonal-F Gonal-F RFF Luveris Makena Menopur Novarel Ovidrel Pregnyl Progesterone Repronex INFLAMMATORY CONDITIONS Actemra Amevive Benlysta Cimzia Enbrel Entyvio Humira Kineret Krystexxa Orencia Otezla Remicade Simponi Simponi ARIA Stelara Xeljanz IRON TOXICITY Deferoxamine Desferal Exjade Ferriprox MISCELLANEOUS SPECIALTY CONDITIONS 8-Mop Apokyn Arcalyst Arestin Berinert Botox Botox Cosmetic Ceprotin Chenodal Cinryze Cuvposa Cystagon Dysport Firazyr Gattex Hetlioz Ilaris Implanon Juxtapid Kalbitor Kynamro Mirena MuGard Myalept Myobloc Nexplanon Northera Nplate Onsolis Panretin Paragard T 380a Prialt Procysbi Qutenza Ravicti Rilutek Ruconest Sabril Solesta Soliris Supplrelin LA Sylvant

18 Specialty Drug List by Disease State The following Specialty Medications are subject to the fourth (4 th ) tier copayment/coinsurance on all fourth (4 th ) tier plans. Restrictions may apply. Vimizim Vivitrol Xenazine Xenomin Xiaflex Xyrem MULTIPLE SCLEROSIS Acthar H.P. Ampyra Aubagio Avonex Betaseron Copaxone Extavia Gilenya Plegridy Rebif Rebif Rebidos Tecfidera Tysabri OPTHALMIC CONDITIONS Cystaran Eylea Jetrea Lucentis Macugen Ozurdex Visudyne Remodulin Revatio Sildenafil Tracleer Tyvaso Ventavis RESPIRATORY CONDITIONS Aralast NP Bethkis Cayston Esbriet Glassia Kalydeco Prolastin Pulmozyme Tobi Tobi Podhaler Tobramycin Xolair Zemaira RSV PREVENTION Synagis OSTEOARTHRITIS Euflexxa Gel-One Hyalgan Monovisc Orthovisc Supartz Synvisc OSTEOPOROSIS Boniva Forteo Ibandronate Prolia Reclast Zoledronic Acid Zometa PULMONARY HYPERTENSION Adcirca Adempas Epoprostenol Flolan Letairis Opsumit Orenitram ER

19 Specialty Drug List by Disease State The following Specialty Medications are subject to the fourth (4 th ) tier copayment/coinsurance on all fourth (4 th ) tier plans. Restrictions may apply. TRANSPLANT Astagraf Atgam Azasan Azathioprine Cellcept Cyclosporine Gengraf Hecoria Imuran Mycophenolate Mofetil Mycophenolic Acid Myfortic Neoral Nulojix Orthoclone Okt-3 Prograf Rapamune Sandimmune Simulect Sirolimus Tacrolimus Thymoglobulin Zortress NOTE: This drug list is provided as a guide and is updated periodically based on information from Express Scripts. For precise details related to your specialty-drug benefit, please contact BFH Pharmacy Services Department at (877) or (859)

20 651 Perimeter Drive, Suite 300, Lexington, KY (859) or (800) Internal Use Only: KL, KF, IL, KS (Grandfathered)

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