2018 Preferred Formulary Changes

1 2018 Preferred Formulary Changes Every year, BlueCross Formularies are reviewed to determine Changes based on a drug s effectiveness, safety, and affordability. While many Changes to BlueCross Formularies occur at the beginning of the year, Formulary Changes may occur at any time because of market Changes such as: Release of new drugs to the market after FDA approval Removal of drugs from the market by the FDA Release of new generic drugs to the market Preferred Formulary Tier Changes effective 1/1/18: Drug 2017 Tier 2018 Tier abacavir-lamivudine 600-300 mg Tier 1 Tier 1 SpRx Alkeran* Tier 2 Tier 3 Azor* Tier 2 Tier 3 Bevespi NF Tier 2 Dexilant NF Tier 3 Effient* Tier 2 Tier 3 Epzicom* Tier 3 Tier 3 SpRx Forteo GrastekPA Tier 2 SpRx Tier 3 Tier 3 SpRx Tier 2 Isentress Tier 3 Tier 3 SpRx Lialda* Tier 2 Tier 3 Nilandron* Tier 3 Tier 3 SpRx Nilutamide Tier 1 Tier 1 SpRx Pataday* Tier 2 Tier 3 Prezista Tier 3 Tier 3 SpRx Pristiq* Tier 2 Tier 3 rabeprazole NF Tier 1 Renvela packets* Tier 2 Tier 3 Renvela tablets* Tier 2 Tier 3 Reyataz Tier 3 Tier 3 SpRx Sabril powder Tier 3 SpRx Tier 3 Sabril tablets Tier 3 SpRx Tier 3 Seroquel XR* Tier 2 Tier 3 Strattera* Tier 2 Tier 3 Tribenzor* Tier 2 Tier 3 Truvada Tier 3 Tier 3 SpRx Vigamox* Tier 2 Tier 3 Vytorin* XyremPA Tier 2 Tier 3 Tier 3 Tier 3 SpRx Zetia* Tier 2 Tier 3 Zortress Tier 3 Tier 3 SpRx NF

2 Non- Formulary PA Prior authorization is required. SpRx Specialty drug. Many plans require you to get this type of drug from a Preferred Specialty Pharmacy. Specialty drugs are limited to a 30-day supply per prescription. * - Indicates a m ulti-source brand drug that now has a generic e quivalent which is a lso covered on the Preferred Formulary . - Non - Formulary Drugs effective 1/1/18: Non Formulary Drug Preferred Alternative(s) Altoprev lovastatin, pravastatin Differin lotion adapalene cream or gel Fortamet generic Glucophage XR (metformin ER 500 mg, metformin ER 750 mg) levocetirizine tablets OTC levocetirizine tablets, Xyzal Allergy 24HR levocetirizine solution OTC levocetirizine solution, Children s Xyzal 24HR solution metformin ER (generic Fortamet) generic Glucophage XR (metformin ER 500 mg, metformin ER 750 mg) Retin-A Micro tretinoin microsphere gel PA OTC Over the counter; may be purchased without a prescription.

3 PA Prior authorization is required. Non -FDA Approved Drug Exclusions effective 1/1/18: NOTE: Unapproved drug products have not been evaluated and approved by the FDA. Unapproved drugs are not generic medications, and neither their safety nor their efficacy can be assured. Talk to your doctor about alternatives. To see if an alternative drug is covered, review the Preferred Formulary at or call BlueCross Member Services at the phone number on your member ID card. ANA-LEX 2- 2% KIT HYOPHEN TABLET SYMAX DUOTAB ANASPAZ MG TABLET ODT HYOSYNE MG/ML DROP SYMAX-SR MG TABLET ATOPICLAIR CREAM HYOSYNE 125 MCG/5 ML ELIXIR TRICITRATES ORAL SOLUTION AVAR PRODUCTS HYPER-SAL , 7% VIAL UMECTA 40% MOUSSE AVO CREAM TOPICAL EMULSION ISOXSUPRINE 10 MG TABLET UR N-C TABLET BELLADONNA-OPIUM SUPPOSITORY KERALYT SCALP COMPLETE KIT URAMIT MB CAPSULE BENSAL HP 3% OINTMENT LATRIX 50% TOPICAL SUSPENSION UREA 39%,40%.

4 45% CREAM BIFERA RX TABLET NEPHROCAPS QT TABLET UREA 50% NAIL STICK BP 10-1 WASH OPIUM TINCTURE 10 MG/ML URELLE TABLET BP CLEANSING WASH OSCIMIN TABLET URIBEL CAPSULE BPO 6% FOAMING CLOTHS PHOSPHASAL TABLET URIN TABLET CYTRA-2 ORAL SOLUTION POTASSIUM CIT-CITRIC ACID SOLN UROGESIC-BLUE TABLET CYTRA-3 SYRUP REA LO 40 LOTION URO-MP CAPSULE CYTRA-K CRYSTALS PACKET REMEVEN 50% CREAM USTELL CAPSULE CYTRA-K ORAL SOLUTION SALACYN 6% CREAM UTIRA-C TABLET DEBACTEROL SWABSTICK SALVAX 6% FOAM UTOPIC 41% CREAM GELCLAIR ORAL GEL PACKET SELRX SHAMPOO VIRASAL ANTIVIRAL WART REMOVER HEMETAB IRON SUPPLEMENT SOD CITRATE-CITRIC ACID SOLN VIRTRATE-K SOLUTION HOMATROPAIRE 5% EYE DROPS SONAFINE TOPICAL EMULSION ZENCIA WASH HOMATROPINE 5% EYE DROPS SULFACLEANSE 8- 4 SUSPENSION ZITHRANOL 1% SHAMPOO Quantity Limit Changes effective 1/1/18: Drug Quantity Limit Alcohol swabs #300 swabs/month Stendra# #8 tablets/month # -Some plans do not cover these medications.

5 Check with BlueCross Member Services to determine coverage at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. ACA $0 Copay Contraceptive List Changes effective 1/1/18: Additions Removals drospirenone-eth-estra Beyaz (brand name only) Fayosim Minastrin 24 FE (brand name only) Mibelas 24Fe Quartette (brand name only) norethin-eth estra-fer 1/20 Rajani Rivelsa Other generic contraceptives as they are released to market ACA Affordable Care Act. The products with the ACA indicator may be available to you at no out-of-pocket cost depending on your plan. Some plans may differ, so check your Evidence of Coverage (EOC) for details. ACA $0 Copay Preventive List Changes : Additions Coverage criteria aspirin 81 mg, 325 mg Adults < 70 years of age (effective 1/1/18) atorvastatin 10 mg, 20 mg Adults 40 75 years of age (effective 12/1/17) fluvastatin 20 mg, 40 mg capsule Adults 40 75 years of age (effective 12/1/17) fluvastatin 80 mg ER tablet Adults 40 75 years of age (effective 12/1/17) lovastatin 10 mg, 20 mg, 40 mg Adults 40 75 years of age (effective 12/1/17) pravastatin 10 mg, 20 mg, 40 mg, 80 mg Adults 40 75 years of age (effective 12/1/17) rosuvastatin 5 mg, 10 mg Adults 40 75 years of age (effective 12/1/17) simvastatin 5 mg, 10 mg, 20 mg, 40 mg Adults 40 75 years of age (effective 12/1/17) ACA Affordable Care Act.

6 The products with the ACA indicator may be available to you at no out-of-pocket cost depending on your plan. Some plans may differ, so check your Evidence of Coverage (EOC) for details. BlueCross Preventive Drug List * Changes effective 1/1/18: Additions Removals Bevespi Ampyra PA Trintellix Avonex Utibron Neohaler Copaxone Vraylar PA Gilenya Korlym PA Rebif Rebif Rebidose Tecfidera *Only applies to plans that utilize the BlueCross Preventive Drug List. Check with BlueCross Member Services to determine coverage at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. PA Prior authorization is required. OTC Savings Program* Changes effective 1/1/18: Additions Removals azelastine eye drops levocetirizine tablets Dexilant PA levocetirizine solution epinastine eye drops olopatadine eye drops olopatadine eye drops Pataday eye drops Patanol eye drops Pazeo eye drops rabeprazole PA *Only applies to plans that include the OTC Savings Program.

7 Check with Bl ueCross Member Services to de termine coverage at the p hone n umber listed on your BlueCross BlueShield of Tennessee m ember ID card. PA Prior authorization is required. Compound Program Changes effective 1/1/18: Beginning January 1, 2018, compounded medications will no longer be covered by BlueCross BlueShield of Tennessee Commercial and Marketplace pharmacy plans. Safety concerns of compounded medications have had nationwide news attention, prompting legislation on both the national and state levels. Compounded medications are not proven to be clinically effective or medically necessary. Due to availability of commercial products, lack of approval by the FDA, questionable drug efficacy, and exceptionally high cost, all compounded medications are being excluded from coverage. Providers may submit an appeal by faxing a request to 1-888-343-4232.

8 The appeal must include member information and supportive clinical rationale. Approval consideration will be given to patients who may not be capable of taking a commercially available capsule or tablet due to age, physical condition or need for an alternative route of dosage. Unusually high or low concentration of a primary drug will also be reviewed and considered for coverage. This list is su bje ct to change throughout the year. Please call Member Service at the phone number listed on your Bl ueCr oss Blue Shield of Tennessee member ID card or visit our websi te at bcbs for the most up-to-date information. Spanish: Para obtener ayuda en espa ol, llame al 1-800-565-9140 Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-565-9140 Chinese: 1- 800-565-9140 Navajo: Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1- 800-565-9140 BlueCross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

9 BlueCross BlueShield of Tennessee 1 Cameron Hill Circle | Chattanooga, TN 37402 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association