OUTSIDE FRONT COVER - FEP Blue...OUTSIDE FRONT COVER 2019 ABBREVIATED FORMULARY As of January 1, 2019 ... INSIDE FRONT COVER. 2 We’re excited to offer federal employees, retirees

OUTSIDE FRONT COVER

2019 ABBREVIATED FORMULARY

As of January 1, 2019

fepblue.org

3

REVIEW THIS ABBREVIATED FORMULARY TO LEARN HOW TO GET THE MOST FROM YOUR PHARMACY BENEFIT SUCH AS:

n Understanding the Formulary

n How to use the Abbreviated Formulary

n Abbreviated Formulary

n “Managed Not Covered” Drugsn Excluded Drug List

YOUR PHARMACY BENEFIT

The Blue Cross and Blue Shield Service Benefit Plan works with Pharmacy Benefit Managers (PBMs) to administer your pharmacy benefit.

n Retail Pharmacy Program - CVS Caremark

n Mail Service Pharmacy Program - CVS Caremark

n Specialty Pharmacy Program - AllianceRx Walgreens Prime

NEW FOR 2019

n Added new coverage option FEP Blue Focus. See p. 2

n Changed select cost shares. See pp. 8–11 n Expanded Standard Option excluded drug list. See p. 44

n Expanded Basic Option “Managed Not Covered” drug list. See p. 46 n Reduced cost share for Metformin, Tier 2 diabetic drugs, test strips

and supplies. See p. 52

n Eliminated cost share for certain opioid reversal agents. See p. 52

n Certain auto-immune infusions are required to be obtained through the medical benefit. See p. 53

INSIDE FRONT COVER

1

TABLE OF CONTENTS

NEW FOR 2019 : FEP BLUE FOCUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

UNDERSTANDING THE FORMULARY . . . . . . . . . . . . . . . . . . . . . . . . . . .4n Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4n “Non-Covered” Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4n Quantity Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4n Prior Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5n How Tiers Relate to Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6n How Prescription Drugs are Assigned to Tiers . . . . . . . . . . . . . . .7

COST SHARE TIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8n Standard Option Cost Share Tiers . . . . . . . . . . . . . . . . . . . . . . . . .8n Basic Option Cost Share Tiers . . . . . . . . . . . . . . . . . . . . . . . . . . .10n FEP Blue Focus Cost Share Tiers . . . . . . . . . . . . . . . . . . . . . . . . .13

HOW TO USE THE ABBREVIATED FORMULARY . . . . . . . . . . . . . . . . . .14n Program Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 n Legend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION) . . . . . . . . .16

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) . . . . . .28

EXCLUDED DRUG LIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

“MANAGED NOT COVERED” DRUG LIST . . . . . . . . . . . . . . . . . . . . . . .46

CHANGES FOR 2019 PHARMACY BENEFIT HIGHLIGHTS . . . . . . . . . . .52

HOW TO CONTACT US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

THIS PAGE FACESINSIDE FRONT COVER

2

We’re excited to offer federal employees, retirees and their families a new coverage option called FEP Blue Focus! We’ve designed this product to give you quality coverage at an affordable cost.

FEP Blue Focus covers certain Preferred drugs—mainly generics, and some Preferred brand name and Preferred specialty drugs. This is what’s known as a “closed formulary.”

Under this plan, there are two covered drug tiers. The amount you pay for your drug depends on the tier it’s in.

If you’re currently taking a prescription, you should check whether your drug is covered under this plan since the plan only covers Preferred drugs. You can see some of the drugs covered on pages 16 –43. You can also view the full FEP Blue Focus formulary at fepblue.org/formulary. If your drug is not on the approved drug list, you’ll pay the full cost of the drug.

Once you know that we cover your drug, getting your prescription filled is easy. For most drugs, all you’ll need to do is go to a Preferred retail pharmacy and show your member ID card.

If your drug is a Preferred generic specialty drug or Preferred brand name specialty drug, you’ll need to use the Specialty Pharmacy Program.

What You’ll Pay for a 30-Day Supply

Tier 1 - Preferred generics Up to $5 copayment

Tier 2 - Preferred brand name drugs and Preferred specialty drugs

40% of our allowance up to $350

FEP BLUE FOCUS

To learn more about the 2019 benefits prior to January 1, 2019, please visit www.fepblue.org/whatsnew or call our Pharmacy Benefit Managers listed on page 56.

3

4

We continually review drugs in support of safe and appropriate therapies. This helps ensure that drugs in your benefit plan work well and are cost-effective.

UNDERSTANDING THE FORMULARY

FORMULARY

The formulary is a complete list of your covered prescription drugs. It includes generic, brand name, and specialty drugs, as well as Preferred drugs that will lower your out-of-pocket costs. The Standard Option and Basic Option formularies have 5 tiers of drugs. The FEP Blue Focus formulary has 2 tiers of drugs. See p. 6

NON-COVERED DRUGS

There are certain drugs approved by the U.S. Food and Drug Administration (FDA) that we don’t cover. We call these drugs “excluded,” “Managed Not Covered” or “not formulary.” These drugs all have Preferred alternatives that you can use.

Standard Option has a comprehensive formulary. This means we cover almost all FDA approved drugs. There is a small list of excluded drugs that are not covered.

Basic Option has a managed formulary. This means that we cover most FDA approved drugs. There is a list of “Managed Not Covered” drugs that provides the Preferred alternatives that you may use.

FEP Blue Focus has a limited (or closed) formulary. This means that we only cover some FDA approved drugs. Any drug not on the FEP Blue Focus formulary is not covered.

If you buy a drug that is not covered, you will pay full price.

QUANTITY LIMITS (QL)

Certain drugs on the formulary have quantity limits (for example, number of pills). This means your pharmacy benefit will only cover up to a specific amount per prescription or a limited amount per year. Quantity limits help ensure drugs are used safely and appropriately. Drug quantities are approved based on accepted standards of healthcare practice in the United States.

See pp. 44–45

See pp. 46–51

5

PRIOR APPROVAL (PA)

Some prescription drugs and supplies need approval in advance, or “prior approval” before we provide coverage for them. We need to confirm:

n Your use of the drug is related to a service or condition covered under the Service Benefit Plan.

n Your doctor prescribes it in a way that matches generally accepted medical practices.

FACTS TO KNOW ABOUT PRIOR APPROVAL n You will need to renew your

prior approval periodically.

n Drugs and supplies on the Prior Approval list may change throughout the year.

n Mail Service and Specialty Programs will not fill prescriptions that need prior approval until you receive prior approval.

n Preferred retail pharmacies will fill your prescriptions, but you will pay the full cost of the drug until you get prior approval. If prior approval is received, you may file a claim for reimbursement of out-of-pocket costs paid while awaiting approval.

HELP WITH PRIOR APPROVAL

Visit fepblue.org/pharmacy. Or call toll-free any time at 1-800-624-5060. You will be able to:

n See a list of drugs that need prior approvaln Get a prior approval request form

Your doctor can submit requests for prior approval by:

n Submitting an ePA (electronic prior approval) n Calling toll-free 1-877-727-3784 n Filling out the Prior Approval Form found at

fepblue.org/priorapproval

6

HOW TIERS RELATE TO COSTS

The costs of drugs vary. How much you pay is your cost share. Look for your drug in the formulary for your plan option. The tier level where your drug type is listed determines your cost.


Standard and Basic Options

TIER DRUG TYPE

Tier 1 Generic Drugs: typically the most affordable, and are equal to their brand name counterparts in quality, performance characteristics and intended use.

Tier 2 Preferred Brand Name Drugs: proven to be safe, effective, and favorably priced compared to Non-preferred brands.

Tier 3 Non-preferred Brand Name Drugs: typically higher cost share since there is a generic or Preferred brand.

Tier 4 Preferred Specialty Drugs: proven to be safe, effective, and favorably priced compared to Non-preferred specialty drugs.

Tier 5 Non-preferred Specialty Drugs: typically higher cost share since there is a Preferred specialty drug.

FEP Blue Focus

TIER DRUG TYPE

Tier 1 Preferred Generic Drugs: typically the most affordable, and are equal to their brand name counterparts in quality, performance characteristics and intended use.

Tier 2 Preferred Brand Name Drugs and Preferred Specialty Drugs: proven to be safe, effective, and favorably priced compared to non-covered drug options.

7

HOW PRESCRIPTION DRUGS ARE ASSIGNED TO TIERS

The Pharmacy and Medical Policy Committee (PMPC) is an independent group of doctors and pharmacists. This group recommends drugs for each tier based on their:

n Effectiveness

n Safety

n How they compare to other drugs in the same class

The PMPC meets every quarter to review new drugs and other changes to the formulary. Based on that review, drugs may change tiers, be added or removed from the formulary. Check your formulary often to be aware of any changes.

To see your cost share for a prescription drug: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: 1-800-624-5060

- call AllianceRx Walgreens Prime for Specialty drugs: 1-888-346-3731

8


STANDARD OPTION COST SHARE TIERS

Standard Option members save by using the Mail Service Pharmacy and Preferred retail pharmacies for filling prescription drugs. Members can also save by asking for generic and/or Preferred brand name drugs when possible. Use the charts below to find your cost share.

Standard Option - GENERIC AND BRAND NAME DRUGS Cost Share Based on Where You Fill Your Prescription

TIER MAIL SERVICE PHARMACY

PREFERRED RETAIL PHARMACY

NON-PREFERRED RETAIL PHARMACY

Tier 1: Generic Drugs

- $15* for up to a 90-day supply

- $7.50* for up to a 30-day supply

- $22.50* for a 31 to 90-day supply

- 45% of the average wholesale price plus any difference between our allowance and the billed amount

- If you use a Non-preferred retail pharmacy, you need to file a paper claim for reimbursement

Tier 2: Preferred Brand Name Drugs

- $90 for up to a 90-day supply

- 30% of our allowance

Tier 3: Non-preferred Brand Name Drugs



* Lower cost shares are available to Standard Option members with Medicare Part B.

SO

9

Standard Option - SPECIALTY DRUGS Cost Share Based on Where You Fill Your Prescription

TIER SPECIALTY PHARMACY

PREFERRED RETAIL PHARMACY

NON-PREFERRED RETAIL PHARMACY

Tier 4: Preferred Specialty Drugs


- $140 for a 31 to a 90-day supply

- You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get up to a 90-day supply after the third fill


- When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy

- 45% of the average wholesale price plus any difference between our allowance and the billed amount

- When you buy specialty drugs at a Non-preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy

Tier 5: Non-preferred Specialty Drugs




To see Standard Option with Medicare Part B cost shares: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: 1-800-624-5060


10


BASIC OPTION COST SHARE TIERS

Basic Option members must use a Preferred retail pharmacy and will save by choosing generic drugs and Preferred brand name drugs when possible. Use the charts below to find your cost share.

* Basic Option members with Medicare Part B coverage have Mail Service Pharmacy benefits and some lower cost shares.

Basic Option - GENERIC AND BRAND NAME DRUGS Cost Share Based on Where You Fill Your Prescription*

TIER PREFERRED RETAIL PHARMACY NON-PREFERRED RETAIL PHARMACY & MAIL SERVICE PHARMACY

Tier 1: Generic Drugs


- $30 for a 31 to 90-day supply

Not covered*

Tier 2: Preferred Brand Name Drugs



Tier 3: Non-preferred Brand Name Drugs

- 60% of our allowance with a $75 minimum for up to a 30-day supply and $210 minimum for a 31 to 90-day supply

BO

11


Basic Option - SPECIALTY DRUGS Cost Share Based on Where You Fill Your Prescription*

TIER SPECIALTY PHARMACY PREFERRED RETAIL PHARMACY

Tier 4: Preferred Specialty Drugs




- $65 for up to a 30-day supply only


Tier 5: Non-preferred Specialty Drugs




- $90 for up to a 30-day supply only


* Basic Option members with Medicare Part B coverage have some lower cost shares.

To see Basic Option with Medicare Part B cost shares: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: 1-800-624-5060


12


13


FEP BLUE FOCUS COST SHARE TIERS

Members who use generic medications will benefit the most from FEP Blue Focus. This plan has a limited (or closed) formulary of covered drugs.

FEP Blue Focus Cost Share Based on Where You Fill Your Prescription

TIER PREFERRED RETAIL PHARMACY AND SPECIALTY PHARMACY

Tier 1: Preferred Generic Drugs



Tier 2: Preferred Brand Name Drugs and Preferred Specialty Drugs

- 40% of our allowance up to $350 for up to a 30-day supply

- 40% of our allowance up to $1,050 for a 31 to 90-day supply

- You are limited to a 30-day supply for each specialty drug prescription.

To learn more about FEP Blue Focus: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: 1-800-624-5060


BF

14

Use the abbreviated formulary to find the most cost-effective drugs for your condition.

1. Find the tier related to your drug. The charts are organized by: n Drug category for non-

specialty drugs

n Alphabetic for all drugs

2. See if there are any limitations for your drug.

3. Review the cost share charts to find your copay or coinsurance.

4. If your drug is in Tiers 2, 3 or 5, ask your doctor if there is a generic drug to treat your condition. If there is no generic drug, ask your doctor to prescribe a Preferred brand name drug.

PROGRAM OPTIONS

The benefit for Standard Option (SO), Basic Option (BO) and FEP Blue Focus (BF) varies. The charts list the SO, BO and BF tiers for each drug. In many cases the tier is the same, but not in every case.

See pp. 16–26

See pp. 28–43

See pp. 8–13

To see the current full formulary: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: 1-800-624-5060


HOW TO USE THE ABBREVIATED FORMULARY

15

PROGRAM LEGEND

Some drugs are noted with letters in the columns next to them. The letters describe any limitations.

‡ Quantity Limit: benefit will only cover up to a specified, limited amount of the drug each time you fill a prescription or a limited amount per year.

◊ Prior Approval: needs approval in advance before a drug is covered.

* For certain drugs, this list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.

** Generic oral contraceptives and select brand contraceptives are available to female members at no copay.

NC Not Covered

SO Standard Option

BO Basic Option

BF FEP Blue Focus

BOLD Bold type means there is a generic for this drug.

ITALIC Italic type means this is a specialty drug.

This abbreviated formulary lists the most commonly used drugs. Please note this list may change.

SO

BO

BF

16

CONDITION/DRUG SO TIER

BO TIER

BFTIER

ALLERGY/COUGH & COLD

acetaminophen/ codeine ‡

1 1 1

ASTEPRO 3 3 NC

azelastine 1 1 1

BECONASE AQ 3 NC NC

benzonatate 1 1 1

CLARINEX 3 NC NC

CLARINEX-D 3 NC NC

desloratadine 1 NC NC

flunisolide spray 1 1 1

fluticasone spray 1 1 1

levocetirizine 1 NC NC

NASONEX 3 NC NC

promethazine/codeine ‡ 1 1 1

triamcinolone spray 1 1 1

VERAMYST 2 NC NC

XYZAL 3 NC NC

ANTI-INFECTIVES/ANTIBIOTICS/ ANTIFUNGAL/ANTIVIRAL

amoxicillin 1 1 1

amoxicillin/ clavulanate potassium

1 1 1


BO TIER

BFTIER

azithromycin 1 1 1

cephalexin 1 1 1

ciprofloxacin 1 1 1

clotrimazole/betamethasone 1 1 1

doxycycline hyclate 1 1 1

ERTACZO ◊ 3 NC NC

EXELDERM ◊ 3 3 NC

fluconazole 1 1 1

JUBLIA ◊ 3 NC NC

KERYDIN* ◊ 3 NC NC

ketoconazole tabs ◊ 1 1 1

levofloxacin 1 1 1

LOPROX 3 NC NC

LOTRISONE* 3 NC NC

LUZU ◊ 3 NC NC

MENTAX 3 NC NC

metronidazole 1 1 1

naftifine 1 1 1

NAFTIN 2 NC NC

oseltamivir phosphate ‡ 1 1 1

OXISTAT ◊ 3 NC NC

Bold Type means there is a generic version for this drug. Drugs that are listed in CAPITAL LETTERS are brand name drugs, while those in lowercase are generic versions.

ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)

17


BO TIER

BFTIER

sulfamethoxazole/trimethoprim

1 1 1

TAMIFLU CAPS ‡ 3 3 NC

valacyclovir 1 1 1

VALTREX 3 3 NC

VUSION* 3 NC NC

ZOVIRAX 3 3 NC

ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS

anastrozole 1 1 1

ASTAGRAF XL 2 2 2

azathioprine 1 1 1

CELLCEPT 3 3 NC

cyclosporine 1 1 1

letrozole 1 1 1

megestrol acetate 1 1 1

mycophenolate mofetil 1 1 1

MYFORTIC 3 3 NC

NEORAL 3 3 NC

NILANDRON ◊ 3 3 NC

PROGRAF 3 3 NC

RAPAMUNE 3 3 NC

sirolimus 1 1 1

tacrolimus 1 1 1

tamoxifen citrate 1 1 1


BO TIER

BFTIER

ANTIVIRAL/HIV

abacavir 1 1 1

abacavir/ lamivudine/zidovudine 1 1 1

APTIVUS 2 2 2

ATRIPLA 2 2 2

COMBIVIR 3 3 NC

didanosine delayed release

1 1 1

EDURANT 2 2 2

EMTRIVA 2 2 2

EPIVIR 3 3 NC

EPZICOM 3 3 NC

GENVOYA 2 2 2

INTELENCE 2 2 2

ISENTRESS 2 2 2

lamivudine 1 1 1

lamivudine/zidovudine 1 1 1

nevirapine ext-rel 1 1 1

PREZISTA 2 2 2

RETROVIR 3 3 NC

REYATAZ 3 3 NC

stavudine 1 1 1

STRIBILD 2 2 2

SUSTIVA 3 3 NC

18


BO TIER

BFTIER

TRIZIVIR 3 3 NC

TRUVADA 2 2 2

VIDEX EC 3 3 NC

VIRACEPT 2 2 2

VIRAMUNE/XR 3 3 NC

VIREAD 2 2 2

ZERIT 3 3 NC

ZIAGEN 3 3 NC

zidovudine 1 1 1

ASTHMA/COPD

ALVESCO 3 NC NC

ACCOLATE 3 3 NC

ADVAIR DISKUS 2 2 2

ADVAIR HFA 2 2 2

albuterol sulfate tablet/solution 1 1 1

ATROVENT HFA 2 2 2

COMBIVENT RESPIMAT 2 2 2

DULERA 2 2 2

FLOVENT HFA 2 2 2

FORADIL 3 3 NC

INCRUSE ELLIPTA 3 NC NC

montelukast sodium 1 1 1

PERFOROMIST 3 3 NC

PROAIR HFA 2 2 2


BO TIER

BFTIER

PROVENTIL HFA 2 NC NC

QVAR 2 2 2

SINGULAIR 3 3 NC

SPIRIVA 2 2 2

STRIVERDI RESPIMAT 3 3 NC

SYMBICORT 2 2 2

TUDORZA PRESSAIR 3 NC NC

VENTOLIN HFA 2 NC NC

XOPENEX HFA 3 NC NC

XOPENEX/CONCENTRATE 3 3 NC

zafirlukast 1 1 1

CARDIOVASCULAR DRUGS HIGH BLOOD PRESSURE

amlodipine besylate/benazepril hydrochloride

1 1 1

ATACAND/HCT 3 NC NC

atenolol 1 1 1

AVALIDE 3 NC NC

AVAPRO 3 NC NC

AZOR 3 3 NC

BENICAR/HCTZ 3 3 NC

BREVIBLOC 3 3 NC

BYSTOLIC 2 2 2

candesartan/hctz 1 1 1

carvedilol 1 1 1


19


BO TIER

BFTIER

clonidine 1 1 1

COZAAR 3 NC NC

diltiazem cd 1 1 1

DIOVAN/HCT 3 NC NC

doxazosin mesylate 1 1 1

EDARBI 3 NC NC

EDARBYCLOR 3 NC NC

enalapril maleate 1 1 1

EXFORGE/HCTZ 3 3 NC

furosemide 1 1 1

hydralazine 1 1 1

hydrochlorothiazide 1 1 1

HYZAAR 3 NC NC

irbesartan/hctz 1 1 1

LEVATOL 3 3 NC

lisinopril/hctz 1 1 1

losartan/hctz 1 1 1

metoprolol succinate 1 1 1

metoprolol tartrate 1 1 1

MICARDIS/HCT 3 NC NC

propranolol 1 1 1

ramipril 1 1 1

spironolactone 1 1 1

telmisartan/hctz 1 1 1

triamterene/hctz 1 1 1

valsartan/hctz 1 1 1

verapamil/er 1 1 1


BO TIER

BFTIER

CARDIOVASCULAR DRUGS HIGH CHOLESTEROL

amlodipine/atorvastatin 1 1 1

atorvastatin calcium 1 1 1

CADUET 3 NC NC

CRESTOR 3 NC NC

ezetimibe 1 1 1

fenofibrate 1 1 1

fenofibric acid 1 1 1

gemfibrozil 1 1 1

LESCOL/XL 3 NC NC

LIPITOR 3 NC NC

LIVALO 3 NC NC

lovastatin 1 1 1

LOVAZA 3 3 NC

niacin er 1 1 1

omega-3 acid ethyl esters 1 1 1

PRAVACHOL 3 NC NC

pravastatin sodium 1 1 1

rosuvastatin 1 1 1

simvastatin 1 1 1

TRIGLIDE 3 3 NC

VYTORIN 3 NC NC

WELCHOL 3 3 NC

ZETIA 3 3 NC

ZOCOR 3 NC NC

20


BO TIER

BFTIER

CARDIOVASCULAR DRUGS OTHER

AGGRASTAT 3 3 NC

AGGRENOX 3 3 NC

clopidogrel 1 1 1

COUMADIN 2 3 NC

digoxin 1 1 1

EFFIENT 3 3 NC

ELIQUIS 2 2 2

enoxaparin sodium 1 1 1

ENTRESTO ◊ 3 3 2

isosorbide mononitrate er 1 1 1

NITROSTAT 3 3 NC

PLAVIX 3 3 NC

potassium chloride 1 1 1

PRADAXA 3 NC NC

warfarin 1 1 1

XARELTO 2 2 2

CENTRAL NERVOUS SYSTEM ANXIETY AND DEPRESSION

alprazolam 1 1 1

amitriptyline 1 1 1

bupropion/xl 1 1 1

citalopram 1 1 1

CYMBALTA 3 3 NC

diazepam 1 1 1

duloxetine ER 1 1 1

EFFEXOR XR 3 3 NC


BO TIER

BFTIER

escitalopram oxalate 1 1 1

fluoxetine 1 1 1

LEXAPRO 3 3 NC

lorazepam 1 1 1

paroxetine 1 1 1

PRISTIQ ER 3 3 NC

sertraline 1 1 1

trazodone 1 1 1

venlafaxine/er 1 1 1

WELLBUTRIN XL 3 3 NC

CENTRAL NERVOUS SYSTEM ATTENTION DEFICIT DISORDER

amphetamine salt combo ◊ 1 1 1

DAYTRANA ◊ 3 3 NC

dextro-amphetamine/amphetamine salts ◊

1 1 1

FOCALIN XR ◊ 3 3 NC

INTUNIV 3 3 NC

METHYLIN ◊ 3 3 NC

methylphenidate/er ◊ 1 1 1

STRATTERA 3 3 NC

VYVANSE ◊ 2 2 2

CENTRAL NERVOUS SYSTEM MIGRAINE

RELPAX ‡ 3 3 NC

rizatriptan ‡ 1 1 1

sumatriptan succinate ‡

1 1 1


21


BO TIER

BFTIER

zolmitriptan ‡ 1 1 1

ZOMIG/ZMT ‡ 3 3 NC

CENTRAL NERVOUS SYSTEM OTHER

ABILIFY 3 3 NC

AMRIX 3 NC NC

AZILECT 3 3 NC

baclofen 1 1 1

carbidopa/ levodopa & er 1 1 1

cyclobenzaprine 1 1 1

donepezil 1 1 1

EQUETRO 3 3 NC

EXELON 3 3 NC

NAMENDA TABS 3 3 NC

NEUPRO 2 2 2

pramipexole dihydrochloride 1 1 1

quetiapine fumarate 1 1 1

risperidone 1 1 1

ropinirole 1 1 1

SAVELLA ‡ 3 3 NC

SEROQUEL XR 3 3 NC

CENTRAL NERVOUS SYSTEM PAIN

butalbital/APAP ‡ 1 1 1

BUTRANS ‡ 3 3 NC

EMBEDA ‡ 3 3 NC

fentanyl patch ‡ 1 1 1

hydrocodone/ acetaminophen ‡

1 1 1


BO TIER

BFTIER

hydromorphone ‡ 1 1 1

MORPHABOND ‡ 3 3 NC

oxycodone/ acetaminophen ‡

1 1 1

OXYCONTIN ‡ 3 3 NC

SUBOXONE FILM ‡ 2 2 2

tramadol/er ‡ 1 1 1

ZUBSOLV ‡ 2 2 2

CENTRAL NERVOUS SYSTEM SEIZURE DISORDERS

clonazepam 1 1 1

gabapentin ‡ 1 1 1

lamotrigine 1 1 1

levetiracetam 1 1 1

LYRICA ‡ 2 2 2

topiramate 1 1 1

CENTRAL NERVOUS SYSTEM SLEEP AGENTS

AMBIEN/CR ‡ 3 NC NC

EDLUAR ‡ 3 NC NC

eszopiclone ‡ 1 1 1

INTERMEZZO ‡ 3 NC NC

LUNESTA ‡ 3 NC NC

ROZEREM ‡ 3 NC NC

SONATA ‡ 3 NC NC

temazepam ‡ 1 1 1

zaleplon ‡ 1 1 1

zolpidem/ER ‡ 1 1 1

22


BO TIER

BFTIER

CONTRACEPTIVES OTHER**

NATAZIA 3 3 NC

NUVARING 2 2 2

PARAGARD T 380A 2 2 2

DERMATOLOGY

BENZACLIN 3 3 NC

betamethasone 1 1 1

CARAC 3 NC NC

ciclopirox 1 1 1

clindamycin phosphate 1 1 1

clobetasol propionate 1 1 1

CLOBEX 3 3 NC

CORDRAN 3 3 NC

doxepin crm ‡ 1 1 1

EPIDUO ◊ 3 3 NC

ERYGEL 3 3 NC

fluocinonide 1 1 1

fluorouracil cream 0.5% 1 NC NC

lidocaine topical ‡ 1 1 1

methylprednisolone 1 1 1

mupirocin 1 1 1

NORITATE 3 NC NC

ORACEA 3 3 NC


BO TIER

BFTIER

TAZORAC ◊ 3 3 NC

tretinoin ◊ 1 1 1

triamcinolone acetonide 1 1 1

DIABETES BLOOD GLUCOSE MONITORING

ACCU CHEK TEST STRIPS ‡ 2 2 2

ONETOUCH TEST STRIPS ‡ 2 2 2

DIABETES DRUGS

AFREZZA ◊ 3 3 NC

BYDUREON 3 3 NC

BYETTA 3 3 NC

FORTAMET ◊ 3 NC NC

glimepiride 1 1 1

glipizide 1 1 1

glipizide er 1 1 1

glipizide xl 1 1 1

GLUCOPHAGE/XR 3 3 NC

glyburide 1 1 1

GLYSET 3 3 NC

INVOKANA ◊ 3 NC NC

JANUMET 2 2 2

JANUMET XR 2 2 2

JANUVIA 2 2 2

JENTADUETO 3 2 2

KAZANO 3 NC NC


23


BO TIER

BFTIER

KOMBIGLYZE XR 2 NC NC

metformin ER § 1 1 1

NESINA 3 NC NC

ONGLYZA 2 NC NC

OSENI 3 NC NC

pioglitazone 1 1 1

TRADJENTA 3 2 2

TRULICITY 2 2 2

VICTOZA 2 PAK & 3 PAK 2 2 2

DIABETES INSULIN

APIDRA/SOLOSTAR 2 NC NC

BASAGLAR 2 2 2

HUMALOG/ MIX/KWIKPEN 2 NC NC

HUMULIN U-500 CONCENTRATE 2 2 2

HUMULIN/KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE)

2 NC NC

LANTUS 2 3 NC

NOVOLIN 2 2 2

NOVOLOG MIX 70/30 2 2 2

TOUJEO 2 3 NC

TRESIBA 2 3 NC

EYE/EAR

ALPHAGAN P (0.15%) 3 3 NC

AZOPT 2 2 2


BO TIER

BFTIER

brimonidine tartrate 1 1 1

CIPRODEX 2 2 2

COMBIGAN 2 2 2

dorzolamide/timolol maleate 1 1 1

DUREZOL 2 2 2

erythromycin 1 1 1

latanoprost 1 1 1

LOTEMAX 2 2 2

LUMIGAN 2 NC NC

PATADAY 3 3 NC

PATANOL 3 3 NC

prednisolone acetate 1 1 1

RESCULA 3 3 NC

RESTASIS ◊ 2 2 2

timolol maleate 1 1 1

TRAVATAN Z 2 2 2

VIGAMOX 3 3 NC

ZIOPTAN 3 3 NC

GASTROINTESTINAL DRUGS

ACIPHEX ‡ 3 NC NC

ALOXI ◊ 3 3 NC

AMITIZA ◊ 3 3 NC

ASACOL HD 2 NC NC

DELZICOL 3 NC NC

DEXILANT ‡ 3 NC NC

§ Generic versions of GLUMETZA and FORTAMET (metformin ext-rel tabs) require Prior Approval.

24


BO TIER

BFTIER

dicyclomine 1 1 1

EMEND ‡ 3 3 NC

esomeprazole ‡ 1 1 1

lansoprazole ‡ 1 1 1

LIALDA 3 3 NC

LINZESS ◊ 2 2 2

MOVIPREP 2 2 2

NEXIUM ‡ 3 NC NC

omeprazole 1 1 1

omeprazole/sodium bicarbonate ‡

1 1 1

ondansetron/odt ‡ 1 1 1

pantoprazole sodium ‡ 1 1 1

polyethylene glycol 3350

1 1 1

PRILOSEC 3 NC NC

PROTONIX ‡ 3 NC NC

rabeprazole ‡ 1 1 1

ranitidine 1 1 1

RELISTOR ◊ 3 3 2

sucralfate 1 1 1

SUPREP BOWEL PREP KIT

2 2 2

VARUBI ‡ 3 3 NC

ZEGERID ‡ 3 NC NC

ZUPLENZ ‡ 3 3 NC


BO TIER

BFTIER

HORMONE REPLACEMENT

ANDRODERM ◊ 2 2 2

ANDROGEL ◊ 2 NC NC

ESTRACE 3 3 NC

estradiol 1 1 1

FORTESTA ◊ 3 3 NC

MINIVELLE 2 2 2

PREFEST 3 3 NC

PREMARIN 2 2 2

PREMPRO 2 2 2

progesterone ◊ 1 1 1

STRIANT ◊ 3 3 NC

TESTIM ◊ 3 NC NC

testosterone cypionate ◊

1 1 1

testosterone gel ◊ 1 1 1

VAGIFEM 3 3 NC

VIVELLE DOT 3 3 NC

VOGELXO ◊ 3 NC NC

INFLAMMATION - CORTICOSTEROIDS

CORTEF 3 NC NC

MEDROL 3 NC NC

MILLIPRED 3 NC NC

ORAPRED ODT 3 NC NC

prednisone 1 1 1

RAYOS ◊ 3 NC NC


25


BO TIER

BFTIER

MISCELLANEOUS

allopurinol 1 1 1

calcitriol 1 1 1

CHANTIX 2 2 2

COLCRYS 3 3 NC

epinephrine injection 1 1 1

EPIPEN 2 PAK 2 2 2

EVISTA 3 3 NC

naloxone 1 1 1

NARCAN 1 1 1

ULORIC 2 2 2

ORAL CONTRACEPTIVES BIPHASIC**

MIRCETTE 3 3 NC

ORAL CONTRACEPTIVES MONOPHASIC**

cryselle 1 1 1

DESOGEN 3 3 NC

gianvi 1 1 1

LOESTRIN/FE 3 3 NC

ORTHO-NOVUM 3 3 NC

zovia 1 1 1

ORAL CONTRACEPTIVES TRIPHASIC**

ORTHO TRI-CYCLEN 3 3 NC

ORTHO TRI-CYCLEN LO

3 3 NC

OSTEOPOROSIS/BONE DISEASES

ACTONEL 3 3 NC

alendronate 1 1 1


BO TIER

BFTIER

ibandronate 1 1 1

risedronate 1 1 1

PSORIASIS

acitretin 1 1 1

calcipotriene- betamethasone

1 1 1

RHEUMATOLOGY

ANAPROX DS 3 NC NC

ARTHROTEC 3 NC NC

CELEBREX ◊ 3 3 NC

celecoxib ◊ 1 1 1

diclofenac tablets 1 1 1

FELDENE 3 NC NC

ibuprofen 1 1 1

meloxicam 1 1 1

methotrexate inj 1 1 1

NAPRELAN 3 NC NC

NAPROSYN 3 NC NC

naproxen 1 1 1

OTREXUP ◊ 3 3 NC

RASUVO ◊ 3 3 NC

VOLTAREN GEL ‡ 3 3 NC

THYROID MEDICATIONS

ARMOUR THYROID 3 3 NC

levothyroxine 1 1 1

SYNTHROID 2 2 2

26


BO TIER

BFTIER

oxybutynin/er 1 1 1

OXYTROL 3 NC NC

phenazopyridine 1 1 1

RAPAFLO 2 2 2

tamsulosin 1 1 1

tolterodine/ER 1 1 1

TOVIAZ 2 NC NC

trospium/er 1 1 1

VESICARE 2 2 2


BO TIER

BFTIER

UROLOGIC DISORDERS

AVODART 3 3 NC

DETROL 3 NC NC

DETROL LA 3 NC NC

ENABLEX 3 NC NC

finasteride 1 1 1

GELNIQUE 3 NC NC

JALYN 3 NC NC

MYRBETRIQ 2 3 NC


To see the 2019 full formularies:

- prior to January 1, 2019, visit fepblue.org/whatsnew

- after January 1, 2019, visit fepblue.org/formulary

- call CVS Caremark for retail or mail order drugs: 1-800-624-5060

- call AllianceRx Walgreens Prime for specialty drugs: 1-888-346-3731

27

28

NAME SO

TIERBO

TIERBF

TIER

abacavir 1 1 1

abacavir/ lamivudine/zidovudine

1 1 1

ABILIFY 3 3 NC

ABRAXANE 4 4 2

ACCOLATE 3 3 NC

ACCU CHEK TEST STRIPS ‡

2 2 2

acetaminophen/codeine ‡ 1 1 1

ACIPHEX ‡ 3 NC NC

acitretin 1 1 1

ACTEMRA ◊ 5 5 2

ACTHAR HP ◊ 5 5 NC

ACTIMMUNE ◊ 4 4 2

ACTONEL 3 3 NC

ADCETRIS ◊ 4 4 2

ADCIRCA ◊ 5 5 NC

ADEFOVIR 4 4 2

ADEMPAS ◊ 5 5 2

ADRIAMYCIN PFS 4 4 2

ADRUCIL 4 4 2

ADVAIR DISKUS 2 2 2

ADVAIR HFA 2 2 2

ADVATE 4 4 2

ADYNOVATE 5 5 2

NAMESO

TIERBO

TIERBF

TIER

AFINITOR ◊ 4 4 2

AFINITOR DISPERZ TAB ◊

4 4 2

AFREZZA ◊ 3 3 NC

AFSTYLA 4 4 2

AGGRASTAT 3 3 NC

AGGRENOX 3 3 NC

albuterol sulfate tablet/solution

1 1 1

ALDURAZYME ◊ 4 4 2

ALECENSA ◊ 5 5 2

alendronate 1 1 1

ALIMTA 4 4 2

ALKERAN INJ 5 5 NC

ALKERAN TAB 5 5 NC

allopurinol 1 1 1

ALOXI ◊ 3 3 NC

ALPHAGAN P (0.15%) 3 3 NC

ALPHANATE 4 4 2

ALPHANINE SD 4 4 2

alprazolam 1 1 1

ALPROLIX 4 4 2

ALVESCO 3 NC NC

AMBIEN/CR ‡ 3 NC NC

AMIFOSTINE 4 4 2

Bold Type means there is a generic version for this drug. Italic Type means this is a specialty drug. Drugs that are listed in CAPITAL LETTERS are brand name drugs, while those in lowercase are generic versions.

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

29

NAMESO

TIERBO

TIERBF

TIER

AMITIZA ◊ 3 3 NC

amitriptyline 1 1 1

amlodipine besylate/benazepril hydrochloride

1 1 1

amlodipine/atorvastatin 1 1 1

amoxicillin 1 1 1

amoxicillin/ clavulanate potassium 1 1 1

amphetamine salt combo ◊

1 1 1

AMPYRA ◊ 5 5 NC

AMRIX 3 NC NC

ANAPROX DS 3 NC NC

anastrozole 1 1 1

ANDRODERM ◊ 2 2 2

ANDROGEL ◊ 2 NC NC

APIDRA/SOLOSTAR 2 NC NC

APOKYN 4 4 2

APTIVUS 2 2 2

ARALAST /NP ◊ 4 4 2

ARANESP ◊ 4 4 2

ARCALYST ◊ 4 4 2

ARMOUR THYROID 3 3 NC

ARRANON 4 4 2

ARTHROTEC 3 NC NC

ARZERRA ◊ 4 4 2

ASACOL HD 2 NC NC

ASTAGRAF XL 2 2 2

NAMESO

TIERBO

TIERBF

TIER

ASTEPRO 3 3 NC

ATACAND/HCT 3 NC NC

atenolol 1 1 1

atorvastatin calcium 1 1 1

ATRIPLA 2 2 2

ATROVENT HFA 2 2 2

AUBAGIO ◊ 4 4 2

AVALIDE 3 NC NC

AVAPRO 3 NC NC

AVASTIN ◊ 4 4 2

AVEED ◊ 4 4 2

AVODART 3 3 NC

AVONEX ◊ 4 4 2

AZACITIDINE 4 4 2

azathioprine 1 1 1

azelastine 1 1 1

AZILECT 3 3 NC

azithromycin 1 1 1

AZOPT 2 2 2

AZOR 3 3 NC

baclofen 1 1 1

BARACLUDE SOLN 4 4 2

BARACLUDE TABS 5 5 NC

BASAGLAR 2 2 2

BEBULIN 4 4 2

BECONASE AQ 3 NC NC

BELEODAQ ◊ 4 4 2

BENDEKA ◊ 4 4 2

30

NAMESO

TIERBO

TIERBF

TIER

BENEFIX 4 4 2

BENICAR/HCTZ 3 3 NC

BENLYSTA ◊ 4 4 2

BENZACLIN 3 3 NC

benzonatate 1 1 1

BERINERT ◊ 4 4 2

betamethasone 1 1 1

BETASERON ◊ 4 4 2

BETHKIS 4 4 2

BEXAROTENE 4 4 2

BICNU 4 4 2

BIVIGAM ◊ 4 4 2

BLEOMYCIN 4 4 2

BLINCYTO ◊ 4 4 2

BOSULIF ◊ 4 4 2

BOTOX ◊ 4 4 2

BRAFTOVI ◊ 5 5 NC

BREVIBLOC 3 3 NC

brimonidine tartrate 1 1 1

BUPHENYL ◊ 5 5 NC

bupropion/xl 1 1 1

butalbital/APAP ‡ 1 1 1

BUTRANS ‡ 3 3 NC

BYDUREON 3 3 NC

BYETTA 3 3 NC

BYSTOLIC 2 2 2

CADUET 3 NC NC

calcipotriene- betamethasone

1 1 1

NAMESO

TIERBO

TIERBF

TIER

calcitriol 1 1 1

CALQUENCE ◊ 4 4 2

CAMPTOSAR 5 5 NC

candesartan/hctz 1 1 1

CARAC 3 NC NC

carbidopa/levodopa & er 1 1 1

CARBOPLATIN 4 4 2

carvedilol 1 1 1

CELEBREX ◊ 3 3 NC

celecoxib ◊ 1 1 1

CELLCEPT 3 3 NC

cephalexin 1 1 1

CEPROTIN ◊ 4 4 2

CERDELGA ◊ 4 4 2

CEREZYME ◊ 4 4 2

CETROTIDE ◊ 4 4 2

CHANTIX 2 2 2

CHORIONIC GONADOTROPIN ◊

4 4 2

ciclopirox 1 1 1

CIMZIA ◊ 5 5 NC

CINRYZE ◊ 4 4 2

CIPRODEX 2 2 2

ciprofloxacin 1 1 1

CISPLATIN 4 4 2

citalopram 1 1 1

CLADRIBINE 4 4 2

CLARINEX 3 NC NC


31

NAMESO

TIERBO

TIERBF

TIER

CLARINEX-D 3 NC NC

clindamycin phosphate 1 1 1

clobetasol propionate 1 1 1

CLOBEX 3 3 NC

CLOLAR 5 5 NC

clonazepam 1 1 1

clonidine 1 1 1

clopidogrel 1 1 1

clotrimazole/betamethasone

1 1 1

COAGADEX 4 4 2

COLCRYS 3 3 NC

COMBIGAN 2 2 2

COMBIVENT RESPIMAT 2 2 2

COMBIVIR 3 3 NC

COPAXONE 20MG ◊ 5 NC NC

COPAXONE 40MG ◊ 5 NC NC

COPEGUS ◊ 5 5 NC

CORDRAN 3 3 NC

CORIFACT 4 4 2

CORTEF 3 NC NC

COSENTYX ◊ 5 5 NC

COSMEGEN 5 5 NC

COUMADIN 2 3 NC

COZAAR 3 NC NC

CRESTOR 3 NC NC

cryselle 1 1 1

CUVITRU ◊ 5 5 2

NAMESO

TIERBO

TIERBF

TIER

cyclobenzaprine 1 1 1

CYCLOPHOSPHAMIDE 4 4 2

cyclosporine 1 1 1

CYCLOSPORINE INJ 4 4 2

CYMBALTA 3 3 NC

CYSTAGON 4 4 2

CYTARABINE 4 4 2

CYTOGAM 4 4 2

CYTOVENE 5 5 NC

DACARBAZINE 4 4 2

DACOGEN 5 5 NC

DACTINOMYCIN 4 4 2

DAKLINZA ◊ 5 NC NC

DARZALEX ◊ 4 4 2

DAUNORUBICIN HCL 4 4 2

DAYTRANA ◊ 3 3 NC

DECITABINE 4 4 2

DEFEROXAMINE 4 4 2

DELZICOL 3 NC NC

DESFERAL 5 5 NC

desloratadine 1 NC NC

DESOGEN 3 3 NC

DETROL 3 NC NC

DETROL LA 3 NC NC

DEXILANT ‡ 3 NC NC

DEXRAZOXANE 4 4 2

dextro-amphetamine/ amphetamine salts ◊

1 1 1

diazepam 1 1 1

32

NAMESO

TIERBO

TIERBF

TIER

diclofenac tablets 1 1 1

dicyclomine 1 1 1

didanosine delayed release

1 1 1

digoxin 1 1 1

diltiazem cd 1 1 1

DIOVAN/HCT 3 NC NC

DOCETAXEL 4 4 2

DOFETILIDE 4 4 2

donepezil 1 1 1

DOPTELET ‡ 5 5 NC

dorzolamide/timolol maleate

1 1 1

doxazosin mesylate 1 1 1

doxepin crm ‡ 1 1 1

DOXIL 5 5 NC

DOXORUBICIN HCL 4 4 2

doxycycline hyclate 1 1 1

DULERA 2 2 2

duloxetine ER 1 1 1

DUREZOL 2 2 2

DYSPORT ◊ 4 4 2

EDARBI 3 NC NC

EDARBYCLOR 3 NC NC

EDLUAR ‡ 3 NC NC

EDURANT 2 2 2

EFFEXOR XR 3 3 NC

EFFIENT 3 3 NC

NAMESO

TIERBO

TIERBF

TIER

EGRIFTA ◊ 4 4 2

ELAPRASE ◊ 4 4 2

ELIGARD ◊ 4 4 2

ELIQUIS 2 2 2

ELITEK 4 4 2

ELLENCE 5 5 NC

ELOCTATE 4 4 2

EMBEDA ‡ 3 3 NC

EMEND ‡ 3 3 NC

EMPLICITI ◊ 4 4 2

EMTRIVA 2 2 2

ENABLEX 3 NC NC

enalapril maleate 1 1 1

ENBREL ◊ 4 4 2

enoxaparin sodium 1 1 1

ENTECAVIR 4 4 2

ENTRESTO ◊ 3 3 2

ENTYVIO ◊ 5 5 NC

EPCLUSA ◊ 4 4 2

EPIDUO ◊ 3 3 NC

epinephrine injection 1 1 1

EPIPEN 2 PAK 2 2 2

EPIRUBICIN 4 4 2

EPIVIR 3 3 NC

EPOGEN ◊ 5 5 NC

EPZICOM 3 3 NC

EQUETRO 3 3 NC

ERBITUX ◊ 4 4 2


33

NAMESO

TIERBO

TIERBF

TIER

ERIVEDGE ◊ 4 4 2

ERLEADA ◊ 5 5 NC

ERTACZO ◊ 3 NC NC

ERYGEL 3 3 NC

erythromycin 1 1 1

ESBRIET ◊ 4 4 2

escitalopram oxalate 1 1 1

esomeprazole ‡ 1 1 1

ESTRACE 3 3 NC

estradiol 1 1 1

eszopiclone ‡ 1 1 1

ETHYOL 5 5 NC

ETOPOPHOS 4 4 2

ETOPOSIDE 4 4 2

EUFLEXXA ◊ 5 5 NC

EVISTA 3 3 NC

EXELDERM ◊ 3 3 NC

EXELON 3 3 NC

EXFORGE/HCTZ 3 3 NC

EXJADE ◊ 4 4 2

EXONDYS 51 ◊ 5 5 2

EXTAVIA ◊ 5 5 NC

EYLEA ◊ 4 4 2

ezetimibe 1 1 1

FABRAZYME ◊ 4 4 2

FARYDAK ◊ 5 5 2

FASLODEX 4 4 2

FEIBA 4 4 2

NAMESO

TIERBO

TIERBF

TIER

FELDENE 3 NC NC

fenofibrate 1 1 1

fenofibric acid 1 1 1

fentanyl patch ‡ 1 1 1

finasteride 1 1 1

FIRAZYR ◊ 4 4 2

FIRMAGON ◊ 4 4 2

FLOVENT HFA 2 2 2

FLOXURIDINE 4 4 2

fluconazole 1 1 1

FLUDARABINE 4 4 2

flunisolide spray 1 1 1

fluocinonide 1 1 1

FLUOROURACIL 4 4 2

fluorouracil cream 0.5% 1 NC NC

fluoxetine 1 1 1

fluticasone spray 1 1 1

FOCALIN XR ◊ 3 3 NC

FOLLISTIM /AQ ◊ 4 4 2

FOLOTYN 4 4 2

FORADIL 3 3 NC

FORTAMET ◊ 3 NC NC

FORTEO ◊ 4 4 2

FORTESTA ◊ 3 3 NC

FULPHILA ◊ 4 4 2

furosemide 1 1 1

FUZEON 4 4 2

gabapentin ‡ 1 1 1

GAMASTAN S/D ◊ 4 4 2

34

NAMESO

TIERBO

TIERBF

TIER

GAMMAGARD ◊ 4 4 2

GAMMAKED ◊ 4 4 2

GAMMAPLEX ◊ 4 4 2

GAMUNEX ◊ 4 4 2

GAMUNEX-C ◊ 4 4 2

GANCICLOVIR 4 4 2

GANIRELIX ACETATE ◊ 4 4 2

GATTEX ◊ 4 4 2

GAZYVA ◊ 4 4 2

GELNIQUE 3 NC NC

GEL-ONE ◊ 4 4 2

GELSYN-3 ◊ 4 4 2

GEMCITABINE 4 4 2

gemfibrozil 1 1 1

GEMZAR 5 5 NC

GENOTROPIN ◊ 5 NC NC

GENVOYA 2 2 2

gianvi 1 1 1

GILENYA ◊ 4 4 2

GLASSIA ◊ 4 4 2

GLEEVEC ◊ 5 5 NC

glimepiride 1 1 1

glipizide 1 1 1

glipizide er 1 1 1

glipizide xl 1 1 1

GLUCOPHAGE/XR 3 3 NC

glyburide 1 1 1

GLYSET 3 3 NC

GONAL-F ◊ 5 5 NC

GONAL-F RFF ◊ 5 5 NC

NAMESO

TIERBO

TIERBF

TIER

GRANIX ◊ 4 4 2

HALAVEN ◊ 4 4 2

HARVONI ◊ 4 4 2

HEMOFIL M 4 4 2

HEPAGAM B 4 4 2

HEPSERA 5 5 NC

HERCEPTIN ◊ 4 4 2

HIZENTRA ◊ 4 4 2

HUMALOG/ MIX/KWIKPEN

2 NC NC

HUMATE-P 4 4 2

HUMATROPE ◊ 5 NC NC

HUMIRA ◊ 4 4 2

HUMULIN U-500 CONCENTRATE

2 2 2

HUMULIN/KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE)

2 NC NC

HYALGAN ◊ 4 4 2

HYCAMTIN CAP 4 4 2

HYCAMTIN INJ 5 5 NC

hydralazine 1 1 1

hydrochlorothiazide 1 1 1

hydrocodone/ acetaminophen ‡

1 1 1

hydromorphone ‡ 1 1 1

HYPERHEP B 4 4 2

HYPERRHO S/D 4 4 2

HYQVIA ◊ 4 4 2

HYZAAR 3 NC NC

ibandronate 1 1 1


35

NAMESO

TIERBO

TIERBF

TIER

IBRANCE ◊ 4 4 2

ibuprofen 1 1 1

ICLUSIG ◊ 4 4 2

IDAMYCIN PFS 5 5 NC

IDARUBICIN HCL 4 4 2

IDELVION 4 4 2

IFEX 5 5 NC

IFOSFAMIDE 4 4 2

ILARIS ◊ 4 4 2

IMATINIB ◊ 4 4 2

IMBRUVICA ◊ 4 4 2

INCRELEX ◊ 4 4 2

INCRUSE ELLIPTA 3 NC NC

INLYTA ◊ 4 4 2

INTELENCE 2 2 2

INTERMEZZO ‡ 3 NC NC

INTRON-A ◊ 4 4 2

INTUNIV 3 3 NC

INVOKANA ◊ 3 NC NC

irbesartan/hctz 1 1 1

IRESSA ◊ 5 5 2

IRINOTECAN 4 4 2

ISENTRESS 2 2 2

isosorbide mononitrate er 1 1 1

ISTODAX ◊ 5 5 NC

IXEMPRA 4 4 2

IXINITY 4 4 2

JADENU ◊ 5 5 NC

JAKAFI ◊ 4 4 2

NAMESO

TIERBO

TIERBF

TIER

JALYN 3 NC NC

JANUMET 2 2 2

JANUMET XR 2 2 2

JANUVIA 2 2 2

JENTADUETO 3 2 2

JEVTANA ◊ 4 4 2

JUBLIA ◊ 3 NC NC

JYNARQUE ◊ 5 5 2

KADCYLA ◊ 4 4 2

KALBITOR ◊ 4 4 2

KALYDECO ◊ 4 4 2

KAZANO 3 NC NC

KEPIVANCE ◊ 4 4 2

KERYDIN* ◊ 3 NC NC

ketoconazole tabs ◊ 1 1 1

KEYTRUDA ◊ 4 4 2

KINERET ◊ 5 5 2

KOATE-DVI 4 4 2

KOGENATE FS 4 4 2

KOMBIGLYZE XR 2 NC NC

KRYSTEXXA ◊ 5 5 NC

KUVAN ◊ 4 4 2

KYPROLIS ◊ 5 5 2

lamivudine 1 1 1

lamivudine/zidovudine 1 1 1

lamotrigine 1 1 1

lansoprazole ‡ 1 1 1

LANTUS 2 3 NC

LARTRUVO ◊ 4 4 2

36

NAMESO

TIERBO

TIERBF

TIER

latanoprost 1 1 1

LEMTRADA ◊ 5 5 2

LESCOL/XL 3 NC NC

LETAIRIS ◊ 4 4 2

letrozole 1 1 1

LEUKINE ◊ 5 5 NC

LEUPROLIDE ◊ 4 4 2

LEVATOL 3 3 NC

levetiracetam 1 1 1

levocetirizine 1 NC NC

levofloxacin 1 1 1

levothyroxine 1 1 1

LEXAPRO 3 3 NC

LIALDA 3 3 NC

lidocaine topical ‡ 1 1 1

LILETTA 5 5 NC

LINZESS ◊ 2 2 2

LIPITOR 3 NC NC

lisinopril/hctz 1 1 1

LIVALO 3 NC NC

LOESTRIN/FE 3 3 NC

LOPROX 3 NC NC

lorazepam 1 1 1

losartan/hctz 1 1 1

LOTEMAX 2 2 2

LOTRISONE* 3 NC NC

lovastatin 1 1 1

LOVAZA 3 3 NC

LUCENTIS ◊ 4 4 2

NAMESO

TIERBO

TIERBF

TIER

LUMIGAN 2 NC NC

LUMIZYME ◊ 4 4 2

LUNESTA ‡ 3 NC NC

LUPANETA PACK 4 4 2

LUPRON DEPOT ◊ 4 4 2

LUZU ◊ 3 NC NC

LYNPARZA ◊ 4 4 2

LYRICA ‡ 2 2 2

MACUGEN ◊ 5 5 NC

MEDROL 3 NC NC

megestrol acetate 1 1 1

MEKINIST ◊ 4 4 2

MEKTOVI ◊ 5 5 NC

meloxicam 1 1 1

MELPHALAN HCL 4 4 2

MENOPUR ◊ 4 4 2

MENTAX 3 NC NC

MESNA 4 4 2

MESNEX INJ 5 5 NC

MESNEX TAB 4 4 2

metformin ER § 1 1 1

methotrexate inj 1 1 1

METHYLIN ◊ 3 3 NC

methylphenidate/er ◊ 1 1 1

methylprednisolone 1 1 1

metoprolol succinate 1 1 1

metoprolol tartrate 1 1 1

metronidazole 1 1 1

MICARDIS/HCT 3 NC NC


§ Generic versions of GLUMETZA and FORTAMET (metformin ext-rel tabs) require Prior Approval.

37

NAMESO

TIERBO

TIERBF

TIER

MICRHOGAM 4 4 2

MIGLUSTAT ◊ 4 4 2

MILLIPRED 3 NC NC

MINIVELLE 2 2 2

MIRCETTE 3 3 NC

MIRENA 4 4 2

MITOMYCIN 4 4 2

MITOXANTRONE 4 4 2

MONONINE 4 4 2

MONOVISC ◊ 5 5 NC

montelukast sodium 1 1 1

MORPHABOND ‡ 3 3 NC

MOVIPREP 2 2 2

MOZOBIL 4 4 2

mupirocin 1 1 1

MUSTARGEN 4 4 2

mycophenolate mofetil 1 1 1

MYFORTIC 3 3 NC

MYOBLOC ◊ 4 4 2

MYRBETRIQ 2 3 NC

NABI-HB 4 4 2

naftifine 1 1 1

NAFTIN 2 NC NC

NAGLAZYME ◊ 4 4 2

naloxone 1 1 1

NAMENDA TABS 3 3 NC

NAPRELAN 3 NC NC

NAPROSYN 3 NC NC

naproxen 1 1 1

NAMESO

TIERBO

TIERBF

TIER

NARCAN 1 1 1

NASONEX 3 NC NC

NATAZIA 3 3 NC

NAVELBINE 5 5 NC

NEORAL 3 3 NC

NESINA 3 NC NC

NEULASTA ◊ 5 5 NC

NEUPOGEN ◊ 5 NC NC

NEUPRO 2 2 2

nevirapine ext-rel 1 1 1

NEXAVAR ◊ 4 4 2

NEXIUM ‡ 3 NC NC

niacin er 1 1 1

NILANDRON ◊ 3 3 NC

NIPENT 4 4 2

NITROSTAT 3 3 NC

NORDITROPIN ◊ 4 4 2

NORITATE 3 NC NC

NORTHERA ◊ 5 5 2

NOVAREL ◊ 4 4 2

NOVOLIN 2 2 2

NOVOLOG MIX 70/30 2 2 2

NOVOSEVEN RT 4 4 2

NPLATE ◊ 4 4 2

NUCALA ◊ 5 5 NC

NULOJIX 4 4 2

NUTROPIN AQ ◊ 5 NC NC

NUVARING 2 2 2

NUWIQ 4 4 2

38

NAMESO

TIERBO

TIERBF

TIER

OCALIVA ◊ 5 5 2

OCTAGAM ◊ 4 4 2

OCTREOTIDE 4 4 2

OFEV ◊ 4 4 2

OLUMIANT ◊ 5 5 NC

OLYSIO ◊ 5 NC NC

omega-3 acid ethyl esters 1 1 1

omeprazole 1 1 1

omeprazole/sodium bicarbonate ‡

1 1 1

OMNITROPE ◊ 5 NC NC

ONCASPAR 4 4 2

ondansetron/odt ‡ 1 1 1

ONETOUCH TEST STRIPS ‡

2 2 2

ONGLYZA 2 NC NC

ONIVYDE ◊ 5 5 NC

OPDIVO ◊ 4 4 2

OPSUMIT ◊ 4 4 2

ORACEA 3 3 NC

ORALAIR ◊ 5 5 2

ORAPRED ODT 3 NC NC

ORENCIA ◊ 5 5 NC

ORENITRAM ◊ 4 4 2

ORKAMBI ◊ 4 4 2

ORTHO TRI-CYCLEN 3 3 NC

ORTHO TRI-CYCLEN LO 3 3 NC

ORTHO-NOVUM 3 3 NC

ORTHOVISC ◊ 5 5 NC

NAMESO

TIERBO

TIERBF

TIER

oseltamivir phosphate ‡ 1 1 1

OSENI 3 NC NC

OTEZLA ◊ 4 4 2

OTREXUP ◊ 3 3 NC

OVIDREL ◊ 4 4 2

OXALIPLATIN 4 4 2

OXISTAT ◊ 3 NC NC

oxybutynin/er 1 1 1

oxycodone/ acetaminophen ‡

1 1 1

OXYCONTIN ‡ 3 3 NC

OXYTROL 3 NC NC

PACLITAXEL 4 4 2

PALYNZIQ ◊ 5 5 NC

PAMIDRONATE 4 4 2

pantoprazole sodium ‡ 1 1 1

PARAGARD T 380A 2 2 2

paroxetine 1 1 1

PATADAY 3 3 NC

PATANOL 3 3 NC

PEGASYS ◊ 4 4 2

PEGINTRON ◊ 4 4 2

PERFOROMIST 3 3 NC

PERJETA ◊ 4 4 2

phenazopyridine 1 1 1

pioglitazone 1 1 1

PLAVIX 3 3 NC

PLEGRIDY /PEN ◊ 4 4 2

polyethylene glycol 3350 1 1 1


39

NAMESO

TIERBO

TIERBF

TIER

POMALYST ◊ 5 5 2

potassium chloride 1 1 1

PRADAXA 3 NC NC

PRALUENT ◊ 5 NC NC

pramipexole dihydrochloride

1 1 1

PRAVACHOL 3 NC NC

pravastatin sodium 1 1 1

prednisolone acetate 1 1 1

prednisone 1 1 1

PREFEST 3 3 NC

PREGNYL ◊ 4 4 2

PREMARIN 2 2 2

PREMPRO 2 2 2

PREVYMIS ◊ 4 4 2

PREZISTA 2 2 2

PRILOSEC 3 NC NC

PRISTIQ ER 3 3 NC

PRIVIGEN ◊ 4 4 2

PROAIR HFA 2 2 2

PROCRIT ◊ 5 5 NC

PROFILNINE SD 4 4 2

progesterone ◊ 1 1 1

PROGRAF 3 3 NC

PROLEUKIN 4 4 2

PROLIA ◊ 4 4 2

PROMACTA ◊ 4 4 2

promethazine/ codeine ‡

1 1 1

NAMESO

TIERBO

TIERBF

TIER

propranolol 1 1 1

PROTONIX ‡ 3 NC NC

PROVENTIL HFA 2 NC NC

PULMOZYME ◊ 4 4 2

quetiapine fumarate 1 1 1

QVAR 2 2 2

rabeprazole ‡ 1 1 1

ramipril 1 1 1

ranitidine 1 1 1

RAPAFLO 2 2 2

RAPAMUNE 3 3 NC

RASUVO ◊ 3 3 NC

RAVICTI ◊ 4 4 2

RAYOS ◊ 3 NC NC

REBETOL ◊ 4 4 2

REBIF ◊ 4 4 2

REBIF REBIDOSE ◊ 4 4 2

REBINYN 4 4 2

RECLAST 5 5 NC

RECOMBINATE 4 4 2

RELISTOR ◊ 3 3 2

RELPAX ‡ 3 3 NC

REMODULIN ◊ 5 5 NC

REPATHA ◊ 4 4 2

RESCULA 3 3 NC

RESTASIS ◊ 2 2 2

RETACRIT ◊ 4 4 2

RETROVIR 3 3 NC

REVATIO ◊ 5 5 NC

40

NAMESO

TIERBO

TIERBF

TIER

REVLIMID ◊ 4 4 2

REYATAZ 3 3 NC

RHOGAM 4 4 2

RHOGAM PLUS 4 4 2

RHOPHYLAC 4 4 2

RIASTAP 4 4 2

RIBASPHERE ◊ 4 4 2

RIBAVIRIN ◊ 4 4 2

risedronate 1 1 1

risperidone 1 1 1

RITUXAN ◊ 5 5 2

RIXUBIS 4 4 2

rizatriptan ‡ 1 1 1

ROMIDEPSIN ◊ 4 4 2

ropinirole 1 1 1

rosuvastatin 1 1 1

ROZEREM ‡ 3 NC NC

SABRIL TABS ◊ 5 5 2

SAIZEN ◊ 5 NC NC

SAMSCA ◊ 4 4 2

SANDOSTATIN LAR ◊ 4 4 2

SAVELLA ‡ 3 3 NC

SENSIPAR ◊ 4 4 2

SEROQUEL XR 3 3 NC

SEROSTIM ◊ 4 4 2

sertraline 1 1 1

SIKLOS ◊ 5 5 NC

SILDENAFIL ◊ 4 4 2

SIMPONI /ARIA ◊ 5 5 NC

NAMESO

TIERBO

TIERBF

TIER

simvastatin 1 1 1

SINGULAIR 3 3 NC

sirolimus 1 1 1

SKYLA 4 4 2

SODIUM PHENYLBUTYRATE ◊

4 4 2

SOLESTA 4 4 2

SOLIRIS ◊ 4 4 2

SOMATULINE DEPOT ◊ 4 4 2

SOMAVERT 4 4 2

SONATA ‡ 3 NC NC

SOVALDI ◊ 4 4 2

SPIRIVA 2 2 2

spironolactone 1 1 1

SPRYCEL ◊ 4 4 2

stavudine 1 1 1

STELARA ◊ 5 5 NC

STIMATE 4 4 2

STIVARGA ◊ 4 4 2

STRATTERA 3 3 NC

STRIANT ◊ 3 3 NC

STRIBILD 2 2 2

STRIVERDI RESPIMAT 3 3 NC

SUBLOCADE ◊ 5 5 2

SUBOXONE FILM ‡ 2 2 2

sucralfate 1 1 1

sulfamethoxazole/trimethoprim

1 1 1

sumatriptan succinate ‡ 1 1 1

SUPARTZ ◊ 4 4 2


41

NAMESO

TIERBO

TIERBF

TIER

SUPPRELIN LA ◊ 4 4 2

SUPREP BOWEL PREP KIT

2 2 2

SUSTIVA 3 3 NC

SUTENT ◊ 4 4 2

SYMBICORT 2 2 2

SYMDEKO ◊ 5 5 2

SYNAGIS ◊ 4 4 2

SYNTHROID 2 2 2

SYNVISC ◊ 5 5 NC

SYNVISC ONE ◊ 5 5 NC

tacrolimus 1 1 1

TAFINLAR ◊ 4 4 2

TAMIFLU CAPS ‡ 3 3 NC

tamoxifen citrate 1 1 1

tamsulosin 1 1 1

TARCEVA ◊ 4 4 2

TARGRETIN CAPS ◊ 5 5 NC

TASIGNA ◊ 5 5 2

TAVALISSE ◊ 5 5 NC

TAXOTERE 5 5 NC

TAZORAC ◊ 3 3 NC

TECFIDERA ◊ 4 4 2

TECHNIVIE ◊ 5 NC NC

telmisartan/hctz 1 1 1

temazepam ‡ 1 1 1

TEMODAR 5 5 NC

TEMOZOLOMIDE 4 4 2

temsirolimus 4 4 2

NAMESO

TIERBO

TIERBF

TIER

TESTIM ◊ 3 NC NC

testosterone cypionate ◊ 1 1 1

testosterone gel ◊ 1 1 1

TETRABENAZINE ◊ 4 4 2

THALOMID 4 4 2

THERACYS 4 4 2

THIOTEPA 4 4 2

THYROGEN 4 4 2

TICE BCG 4 4 2

TIKOSYN 5 5 NC

timolol maleate 1 1 1

TOBI 5 5 NC

TOBI PODHALER 4 4 2

TOBRAMYCIN INH SOLN 4 4 2

tolterodine/ER 1 1 1

topiramate 1 1 1

TOPOTECAN 4 4 2

TOTECT 5 5 NC

TOUJEO 2 3 NC

TOVIAZ 2 NC NC

TRACLEER ◊ 4 4 2

TRADJENTA 3 2 2

tramadol/er ‡ 1 1 1

TRAVATAN Z 2 2 2

trazodone 1 1 1

TREANDA ◊ 5 5 NC

TRELSTAR ◊ 4 4 2

TRESIBA 2 3 NC

42

NAMESO

TIERBO

TIERBF

TIER

tretinoin ◊ 1 1 1

TRETTEN 4 4 2

triamcinolone acetonide 1 1 1

triamcinolone spray 1 1 1

triamterene/hctz 1 1 1

TRIGLIDE 3 3 NC

TRISENOX 4 4 2

TRIZIVIR 3 3 NC

TROGARZO ◊ 5 5 2

trospium/er 1 1 1

TRULICITY 2 2 2

TRUVADA 2 2 2

TUDORZA PRESSAIR 3 NC NC

TYKERB ◊ 4 4 2

TYSABRI ◊ 4 4 2

TYVASO ◊ 5 5 NC

TYZEKA 4 4 2

ULORIC 2 2 2

UVADEX 4 4 2

VAGIFEM 3 3 NC

valacyclovir 1 1 1

valsartan/hctz 1 1 1

VALSTAR 4 4 2

VALTREX 3 3 NC

VANTAS ◊ 4 4 2

VARIZIG ◊ 4 4 2

VARUBI ‡ 3 3 NC

VECTIBIX ◊ 4 4 2

VELCADE ◊ 5 5 NC

NAMESO

TIERBO

TIERBF

TIER

VELETRI ◊ 5 5 NC

VEMLIDY 4 4 2

venlafaxine/er 1 1 1

VENTAVIS ◊ 4 4 2

VENTOLIN HFA 2 NC NC

VERAMYST 2 NC NC

verapamil/er 1 1 1

VERZENIO ◊ 4 4 2

VESICARE 2 2 2

VICTOZA 2 PAK & 3 PAK 2 2 2

VIDAZA 5 5 NC

VIDEX EC 3 3 NC

VIGAMOX 3 3 NC

VIMIZIM ◊ 4 4 2

VINBLASTINE 4 4 2

VINCRISTINE 4 4 2

VINORELBINE 4 4 2

VIRACEPT 2 2 2

VIRAMUNE/XR 3 3 NC

VIREAD 2 2 2

VISUDYNE 4 4 2

VIVELLE DOT 3 3 NC

VIVITROL 4 4 2

VOGELXO ◊ 3 NC NC

VOLTAREN GEL ‡ 3 3 NC

VOTRIENT ◊ 4 4 2

VPRIV ◊ 4 4 2

VUSION* 3 NC NC

VYTORIN 3 NC NC


43

NAMESO

TIERBO

TIERBF

TIER

VYVANSE ◊ 2 2 2

warfarin 1 1 1

WELCHOL 3 3 NC

WELLBUTRIN XL 3 3 NC

WILATE 4 4 2

WINRHO SDF 4 4 2

XALKORI ◊ 4 4 2

XARELTO 2 2 2

XELJANZ / XR ◊ 5 5 NC

XELJANZ ◊ 5 5 NC

XELODA 5 5 NC

XENAZINE ◊ 5 5 NC

XEOMIN ◊ 4 4 2

XGEVA ◊ 4 4 2

XIAFLEX ◊ 4 4 2

XOLAIR ◊ 4 4 2

XOPENEX HFA 3 NC NC

XOPENEX/CONCENTRATE

3 3 NC

XTANDI ◊ 4 4 2

XYNTHA 4 4 2

XYNTHA SOLOFUSE 4 4 2

XYZAL 3 NC NC

YERVOY ◊ 4 4 2

YONSA ◊ 5 5 2

zafirlukast 1 1 1

zaleplon ‡ 1 1 1

ZALTRAP ◊ 4 4 2

ZANOSAR 4 4 2

NAMESO

TIERBO

TIERBF

TIER

ZARXIO ◊ 4 4 2

ZEGERID ‡ 3 NC NC

ZELBORAF ◊ 4 4 2

ZEMAIRA ◊ 4 4 2

ZERIT 3 3 NC

ZETIA 3 3 NC

ZIAGEN 3 3 NC

zidovudine 1 1 1

ZINECARD 5 5 NC

ZIOPTAN 3 3 NC

ZOCOR 3 NC NC

ZOLADEX ◊ 4 4 2

ZOLEDRONIC ACID 4 4 2

ZOLINZA ◊ 4 4 2

zolmitriptan ‡ 1 1 1

zolpidem/ER ‡ 1 1 1

ZOMACTON ◊ 5 NC NC

ZOMETA 5 5 NC

ZOMIG/ZMT ‡ 3 3 NC

ZORBTIVE ◊ 4 4 2

ZORTRESS 4 4 2

zovia 1 1 1

ZOVIRAX 3 3 NC

ZUBSOLV ‡ 2 2 2

ZUPLENZ ‡ 3 3 NC

ZYKADIA ◊ 4 4 2

ZYTIGA ◊ 4 4 2

44

These listed drugs are not covered under Standard Option. If you use any of these Excluded Drugs, you will pay the full cost of the drug(s).

If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options.

CATEGORY* DRUG CLASS*

DRUG NOT COVERED IN 2019 FOR STANDARD OPTION

COVERED OPTIONS**

Anaphylaxis Treatment AUVI-Q epinephrine injection (0.15 mg and 0.30 mg), ADRENACLICK, EPIPEN, EPIPEN JR.

Antidiarrheals opium tincture loperamide, diphenoxylate, diphenoxylate/atropine

Anti-inflammatories Non Steroidal Anti-Inflammatories (NSAIDs)

PENNSAID, VIVLODEX, ZORVOLEX

diclofenac DR/ER, diclofenac gel/soln, etodolac/ER, flurbiprofen, ibuprofen, indomethacin ER, ketoprofen/ER, meloxicam, nabumetone, naproxen/ER, oxaprozin, piroxicam, sulindac, VOLTAREN GEL

Anti-inflammatoriesNon Steroidal Anti-Inflammatories (NSAIDs) Combinations

DUEXIS, VIMOVO diclofenac/misoprostol, esomeprazole, famotidine, ibuprofen, naproxen, ranitidine

Antirheumatics CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate

Antispasmotics LIBRAX clidinium/chlordiazepoxide, dicyclomine, hyoscyamine

Cardiovascular YOSPRALA aspirin*** and esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole

Dermatology Antifungal

ALCORTIN-A , XOLEGEL ciclopirox, clotrimazole, hydrocortisone/iodoquinol, hydrocortisone/iodoquinol/aloe ketoconazole 2% cream, naftifine, nystatin, terbinafine, ECOZA, LAMISIL, NAFTIN

EXCLUDED DRUG LIST STANDARD OPTION

45


DRUG NOT COVERED IN 2019 FOR STANDARD OPTION

COVERED OPTIONS**

Dermatology Corticosteroids

OLUX/OLUX-E clobetasol propionate, fluocinonide, halobetasol propionate

Dermatology Psoriasis

SORIATANE, TACLONEX acitretin, calcipotriene/betamethasone, calcitriol, methoxsalen, DOVONEX, OXSORALEN ULTRA

Diabetes Metformin

GLUMETZA metformin ER

Diabetes Other

CYCLOSET alogliptin, alogliptin/metformin, alogliptin/pioglitazone, bromocriptine mesylate, chlorpropamide, glimepiride, glipizide, glyburide, glyburide/metformin, pioglitazone, repaglinide, repaglinide/metformin, rosiglitazone

High Cholesterol FLOLIPID, ZYPITAMAG amlodipine-atorvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvasta tin, simvastatin

Nausea And Vomiting Therapy (5HT-3 Blocker)

ANZEMET dolasetron, granisetron, ondasetron, palonosetron, promethazine

OpthalmologyMiscellaneous

atropine sulfate eye ointment

atropine ophthalmic solution, cyclopentolate ophthalmic solution, homatropine ophthalmic solution

* This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.

** For more covered options, view the 2019 Standard Option formulary.

*** Low dose aspirin (81 mg) is covered for men age 45 through 79, women age 12 through 79 and for pregnant women at risk of preeclampsia.

46

These listed drugs are not covered under Basic Option. If you use any of these “Managed Not Covered” Drugs, you will need to pay the full cost of the drug(s).

If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options.


DRUG NOT COVERED IN 2019 FOR BASIC OPTION

COVERED OPTIONS**

Allergies Antihistamines

cetirizine solution, desloratadine, levocetirizine, CLARINEX, CLARINEX-D, XYZAL

montelukast, zafirlukast, ACCOLATE, SINGULAIR

Allergies Nasal Steroids

BECONASE AQ, DYMISTA, NASONEX, OMNARIS, QNASL, VERAMYST, ZETONNA

flunisolide spray, fluticasone spray, triamcinolone spray

Anaphylaxis Treatment

AUVI-Q epinephrine injection (0.15 mg and 0.30 mg), ADRENACLICK EPIPEN, EPIPEN JR

Anticoagulants PRADAXA warfarin, ELIQUIS, XARELTO

Antidiarrheals opium tincture loperamide, diphenoxylate, diphenoxylate/atropine

Anti-inflammatories Non Steroidal Anti-inflammatories (NSAIDS)

ANAPROX DS, FELDENE, NAPRELAN, NAPROSYN, PENNSAID, TIVORDEX, VIVLODEX, ZORVOLEX

diclofenac DR/ER, diclofenac gel/soln, etodolac/ER flurbiprofen, ibuprofen, indomethacin ER, ketoprofen/ER, meloxicam, nabumetone, naproxen/ER, oxaprozin, piroxicam, sulindac, VOLTAREN GEL

Anti-inflammatories Non Steroidal Anti-inflammatories (NSAIDS) Combinations

ARTHROTEC, DUEXIS, VIMOVO

diclofenac/misoprostol, esomeprazole, famotidine, ibuprofen, naproxen, ranitidine

Antirheumatics CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate

Antispasmotics LIBRAX clidinium/chlordiazepoxide, dicyclomine, hyoscyamine

“MANAGED NOT COVERED” DRUG LISTBASIC OPTION

47

“MANAGED NOT COVERED” DRUG LISTBASIC OPTION

CONTINUED ON NEXT PAGE



COVERED OPTIONS**

Asthma Beta Agonist (Rescue Inhaler)

PROVENTIL HFA, VENTOLIN HFA, XOPENEX HFA

albuterol solution, levalbuterol inhalation solution, PROAIR HFA

Asthma: Inhaled Corticosteroid

AEROSPAN, ALVESCO budesonide inhalation suspension, ASMANEX, FLOVENT HFA, PULMICORT, QVAR

Benign Prostatic Hyperplasia (BPH)

JALYN alfuzosin, dutasteride, dutasteride/tamsulosin, finasteride, tamsulosin

Bladder Agents DETROL, DETROL LA, ENABLEX, GELNIQUE, OXYTROL, TOVIAZ

oxybutynin, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, VESICARE

Cardiovascular YOSPRALA aspirin*** and esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole

COPD Inhaled Long Acting Muscarinic Receptor Antagonist (LAMA)

INCRUSE ELLIPTA, TUDORZA PRESSAIR

ipratropium, ATROVENT HFA, SPIRIVA

Corticosteroids CORTEF, DELTASONE, DEXPAK, MEDROL, MILLIPRED, ORAPRED ODT, RAYOS, TAPERDEX

cortisone, dexamethasone, fludrocortisone, hydrocortisone, methylprednisolone, prednisone

Dermatology Antifungal

ALCORTIN-A, ERTACZO, JUBLIA, KERYDIN*, LOPROX, LOTRISONE*, LUZU, MENTAX, NAFTIN*, OXISTAT, VUSION*, XOLEGEL*

ciclopirox, clotrimazole, clotrimazole/betamethasone, econazole, hydrocortisone/iodoquinol, hydrocortisone/iodoquinol/aloe, ketoconazole, naftifine, nystatin, terbinafine, ECOZA, EXELDERM, LAMISIL

Dermatology Corticosteroids

NOVACORT, OLUX, OLUX-E

clobetasol propionate, fluocinoide, halobetasol propionate, hydrocortisone/pramoxine, PRAMOSONE

Dermatology Fluorouracil

CARAC, FLUOROURACIL CREAM 0.5%

diclofenac sodium, PICATO, TOLAK

48

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION



COVERED OPTIONS**

Dermatology Psoriasis

SORIATANE, TACLONEX acitretin, calcipotriene-betamethasone, calcitriol, methoxsalen, DOVONEX, OXSORALEN ULTRA

Dermatology Rosacea

NORITATE clindamycin/benzoyl peroxide, doxycycline (except 20 mg), flurandrenolide, metronidazole cream/gel/lotion, FINACEA, METROCREAM, METROGEL, METROLOTION, MIRVASO, ORACEA, SOOLANTRA

Diabetes Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/ Combinations

NESINA, ONGLYZA, KAZANO, KOMBIGLYZE XR, OSENI

alogliptin, alogliptin/metformin, alogliptin/pioglitazone, JANUMET, JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA

Diabetes Insulins

APIDRA/SOLOSTARHUMALOG

NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 NOVOLIN 70/30

HUMULIN N NOVOLIN N

HUMULIN R NOVOLIN R

NOTE: HUMULIN R U-500 concentrate will continue to be covered

Diabetes Metformin

GLUMETZA, FORTAMET, RIOMET

metformin ER

Diabetes Other

CYCLOSET alogliptan, aloglliptan/metformin, alogliptan/pioglitazone, bromocriptine mesylate, chlorpropamide, glimepiride, glipizide, glyburide, glyburide/metformin, pioglitazone, repaglinide, repaglinide/metformin, rosiglitazone

49CONTINUED ON NEXT PAGE



COVERED OPTIONS**

Diabetes SGLT2 Inhibitors

INVOKAMET, INVOKAMET XR, INVOKANA, SEGLUROMET, STEGLATRO, STEGLUJAN

Farxiga, Jardiance, Syjardy, Synjardy XR, Xigduo XR

Glaucoma LUMIGAN latanoprost, RESCULA, TRAVATAN Z, XALATAN, ZIOPTAN

Granulocyte Colony Stimulating Factor

NEUPOGEN GRANIX, ZARXIO

Growth Hormone GENOTROPIN, HUMATROPE, NUTROPIN, NUTROPIN AQ, OMNITROPE, SAIZEN, ZOMACTON

NORDITROPIN

HEPATITIS C DAKLINZA, OLYSIO, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, ZEPATIER

EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI

High Blood Pressure Angiotensin II Receptor Blockers/Combinations (ARBs)

ATACAND, AVAPRO, COZAAR, DIOVAN, EDARBI, MICARDIS, ATACAND HCT, AVALIDE, DIOVAN HCT, EDARBYCLOR, HYZAAR, MICARDIS HCT

candesartan, irbesartan, losartan, telmisartan, BENICAR, candesartan/hctz, irbesartan/hctz, losartan/hctz, telmisartan/hctz, valsartan/hctz, BENICAR/HCT, olmesartan/hctz

High Cholesterol PCSK9 Inhibitors

PRALUENT REPATHA

High Cholesterol Statins

ADVICOR, ALTOPREV, CADUET, CRESTOR, LESCOL/XL, LIPITOR, LIPTRUZET, LIVALO, MEVACOR, PRAVACHOL, VYTORIN, ZOCOR, ZYPITAMAG

amlodipine-atorvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Multiple Sclerosis COPAXONE glatiramer, GLATOPA

50

* This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.

** For more covered options, view the 2019 Basic Option formulary.

*** Low dose aspirin (81 mg) is covered for men age 45 through 79, women age 12 through 79 and for pregnant women at risk of preeclampsia.

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION



COVERED OPTIONS**

Muscle Relaxants AMRIX baclofen, cyclobenzaprine, dantrolene

Nausea And Vomiting Therapy (5HT-3 Blocker)

ANZEMET granisetron, ondasetron, palonosetron, promethazine

OpthalmologyMiscellaneous


atropine ophthalmic solution, cyclopentolate ophthalmic solution, homatropine ophthalmic solution

Pancreatic Enzymes PERTZYE, ZENPEP pancrelipase, CREON, PANCREAZE, VIOKACE

Proton Pump Inhibitors ACIPHEX, DEXILANT, FIRST-LANSOPRAZOLE, FIRST-OMEPRAZOLE, NEXIUM, NEXIUM PACKETS, PREVACID , PRILOSEC, PROTONIX, ZEGERID

esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate, pantoprazole, rabeprazole

Sleep Agents AMBIEN, AMBIEN CR, EDLUAR, INTERMEZZO, LUNESTA, ROZEREM, SONATA

estazolam, eszopiclone, flurazepam, temazepam, triazolam, zaleplon, zolpidem/ER

Testosterone Agents ANDROGEL, NATESTO, TESTIM, VOGELXO

testosterone gel, ANDRODERM, FORTESTA

Ulcerative Colitis ASACOL HD, DELZICOL balsalazide, budesonide caps, mesalamine, sulfasalazine, APRISO, LIALDA, PENTASA

51

ACIPHEX

ADVICOR

AEROSPAN

ALCORTIN-A

ALTOPREV

ALVESCO

AMBIEN

AMBIEN CR

AMRIX

ANAPROX DS

ANDROGEL

ANZEMET

APIDRA

ARTHROTEC

ASACOL HD

ATACAND

ATACAND HCT


AUVI-Q

AVALIDE

AVAPRO

BECONASE AQ

CADUET

CARAC

cetirizine solution

CLARINEX

CLARINEX-D

COPAXONE

CORTEF

COZAAR

CRESTOR

CUPRIMINE

CYCLOSET

DAKLINZA

DELTASONE

DELZICOL

desloratadine

DETROL

DETROL LA

DEXILANT

DEXPAK

DIOVAN

DIOVAN HCT

DUEXIS

DYMISTA

EDARBI

EDARBYCLOR

EDULAR

ENABLEX

ERTACZO

FELDENE

FIRST-LANSOPRAZOLE

FIRST-OMEPRAZOLE

FLUOROURACIL CREAM 0.5%

FORTAMET

GELNIQUE

GENOTROPIN

GLUMETZA

HUMALOG

HUMALOG MIX

HUMATROPE

HUMULIN N

HUMULIN R U-100

HYZAAR

INCRUSE ELLIPTA

INTERMEZZO

INVOKAMET

INVOKAMET XR

INVOKANA

JALYN

JUBLIA

KAZANO

KERYDIN

KOMBIGLYZE XR

LESCOL/XL

levocetirizine

LIBRAX

LIPITOR

LIPTRUZET

LIVALO

LOPROX

LOTRISONE

LUMIGAN

LUNESTA

LUZU

MEDROL

MENTAX

MEVACHOR

MICARDIS

MICARDIS HCT

MILLIPRED

NAFTIN

NAPRELAN

NAPROSYN

NASONEX

NATESTO

NESINA

NEUPOGEN

NEXIUM

NEXIUM PACKETS

NORITATE

NOVACORT

NUTROPIN

NUTROPIN AQ

OLUX

OLUX-E

OLYSIO

OMNARIS

OMNITROPE

ONGLYZA

opium tincture

ORAPRED ODT

OSENI

OXISTAT

OXYTROL

PENNSAID

PERTYE

PRADAXA

PRALUENT

PRAVACHOL

PRESSAIR

PREVACID

PRILOSEC

PROTONIX

PROVENTIL HFA

QNASL

RAYOS

RIOMET

ROZEREM

SAIZEN

SEGLUROMET

SONATA

SORIATANE

STEGLATRO

STEGLUJAN

TACLONEX

TAPERDEX

TECHNIVIE

TESTIM

TIVORDEX

TOVIAZ

TUDORZA

VENTOLIN HFA

VERAMYST

VIEKIRA PAK

VIEKIRA XR

VIMOVO

VIVLODEX

VOGELXO

VUSION

VYTORIN

XOLEGEL

XOPENEX HFA

XYZAL

YOSPRALA

ZEGERID

ZENPEP

ZEPATIER

ZETONNA

ZOCOR

ZOMACTON

ZORVOLEX

ZYPITAMAG

“MANAGED NOT COVERED” DRUG LISTBASIC OPTION (ALPHABETIC)

52

LOWER COST SHARES FOR DIABETIC DRUGS AND SUPPLIES

Your cost share for the Tier 1 Metformin is now $1 for up to a 90-day supply for Standard and Basic Option members. Remember, you must receive it from a Preferred retail pharmacy or the Mail Order Pharmacy Program.

Additionally, there are lower costs for Tier 2 Preferred diabetic medications, Preferred test strips and Preferred supplies:

OPIOID REVERSAL AGENTS

Your cost share for Narcan nasal spray/naloxone generic injectable is now $0 for up to a 90-day supply per calendar year when obtained through a Preferred retail pharmacy or the Mail Service Prescription Drug Program. Refills after a 90-day supply are subject to the Tier 1 cost share.

NEW FOR 2019 PHARMACY BENEFIT HIGHLIGHTS

SO BO

SO BO BF

Preferred Diabetic Medication and Supplies: Cost Share Based on Where You Fill Your Prescription

TIER MAIL SERVICE PHARMACY PREFERRED RETAIL PHARMACY

Standard Option

$40 for up to a 90-day supply 20% of our allowance

Basic Option without Medicare B primary

Not covered - $35 for up to a 30-day supply


Basic Option with Medicare B primary

$50 for up to a 90-day supply - $30 for up to a 30-day supply


53

These are just a few of your pharmacy benefit highlights. Your Service Benefit Plan includes so much more, see:- the Service Benefit Plan brochures (Standard and Basic Option: RI 71-005; FEP Blue Focus: RI 71-017)

- prior to January 1, 2019, visit fepblue.org/whatsnew- after January 1, 2019, visit fepblue.org/pharmacy

AUTO-IMMUNE INFUSIONS

We now provide medical benefits for the infusion drug Remicade and its two biosimilars, Renflexis and Inflectra. For information about coverage contact customer service at the number on the back of your member ID card.

SO BO BF

54

The Blue Cross and Blue Shield Service Benefit Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

THE BLUE CROSS AND BLUE SHIELD SERVICE BENEFIT PLAN:Provides free aids and services to people with disabilities to communicate effectively with us, such as:n Qualified sign language

interpretersn Written information in other

formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:n Qualified interpreters

n Information written in other languages

If you need these services, contact the Civil Rights Coordinator of your local Blue Cross and Blue Shield company

by calling the customer service number on the back of your member ID card.

If you believe that this Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Civil Rights Coordinator of your local BCBS company. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, your local BCBS company’s Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Ave, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

NOTICE OF NONDISCRIMINATION

55

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

LANGUAGE ASSISTANCE

Para obtener asistencia en español, llame al servicio de atención al cliente al número que aparece en su tarjeta de identificación.

請撥打您 ID 卡上的客服號碼以尋求中文協助。

Gọi số dịch vụ khách hàng trên thẻ ID của quý vị để được hỗ trợ bằng Tiếng Việt.

한국어로 도움을 받고 싶으시면 ID 카드에 있는 고객 서비스 전화번호로 문의해 주십시오.

Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card.

Обратитесь по номеру телефона обслуживания клиентов, указанному на Вашей идентификационной карточке, для помощи на русском языке.

دوجوملا ءالمعلا ةمدخ مقرب لصتا ىلع لوصحلل كتيوُه ةقاطب ىلع.ةيبرعلا ةغللاب ةدعاسملا

Rele nimewo sèvis kliyantèl ki nan kat ID ou pou jwenn èd nan Kreyòl Ayisyen.

Pour une assistance en français du Canada, composez le numéro de téléphone du service à la clientèle figurant sur votre carte d’identification.

Ligue para o número de telefone de atendimento ao cliente exibido no seu cartão de identificação para obter ajuda em português.

Aby uzyskać pomoc w języku polskim, należy zadzwonić do działu obsługi klienta pod numer podany na identyfikatorze.日本語でのサポートは、IDカードに記載のカスタマーサービス番号までお電話でお問い合わせください。

Per assistenza in italiano chiamate il numero del servizio clienti riportato nella vostra scheda identificativa.

Rufen Sie den Kundendienst unter der Nummer auf Ihrer ID-Karte an, um Hilfestellung in deutscher Sprache zu erhalten.

نابز هب ییامنهار تفایرد یارب هک یرتشم تامدخ هرامش اب ، یسراف جرد امش ییاسانش تراک یور رب..دیریگب سامت تسا هدش

56

Call these numbers for prescription drug information:

RETAIL PHARMACY PROGRAMCVS Caremark (Standard Option, Basic Option and FEP Blue Focus) Toll-free any time at 1-800-624-5060

MAIL SERVICE PHARMACY PROGRAMCVS Caremark (All Standard Option and Basic Option with Medicare Part B) Toll-free any time at 1-800-262-7890

SPECIALTY PHARMACY PROGRAMAllianceRx Walgreens Prime (Basic, Standard, and FEP Blue Focus) Toll-free at 1-888-346-3731

Monday-Friday: 7 a.m. to 9 p.m. Eastern time

Saturday-Sunday: 8 a.m. to 6:30 p.m. Eastern time

OTHER BENEFIT OR CLAIMS INFORMATIONCall your local Blue Cross and Blue Shield plan. The customer service number is on the back of your member ID card.

GENERAL QUESTIONSn See the Blue Cross and Blue

Shield Service Benefit Plan brochure (RI 71-005)

n Visit fepblue.org

This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan’s Federal brochures (Standard Option and Basic Option: RI 71-005; FEP Blue Focus: RI 71-017). All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochures.

HOW TO CONTACT US

RXABRFRM2019

OUTSIDE BACK COVER

Documents

OUTSIDE FRONT COVER - FEP Blue...OUTSIDE FRONT COVER 2019 ABBREVIATED FORMULARY As of January 1, 2019 ... INSIDE FRONT COVER. 2 We’re excited to offer federal employees, retirees