PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary July 1, 2018 Updates Formulary. Alternatives

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1 oseltamivir sus 6mg/ml (Brand = Tamiflu ) carvedilol cap ER 10mg, 20mg, 40mg, 80mg (Brand = Coreg CR ) timolol maleate sol 0.5% (Brand = Istalol Sol 0.5% OP) tenofovir 300mg (Brand = Viread ) efavirenz cap 50mg, 200mg (Brand = Sustiva ) carbinoxamin 6mg (Brand = Ryvent ) PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select July 1, 2018 Updates G No Change Generic Addition 11/6/17 G No Change Generic Addition 11/13/17 G No Change Generic Addition 12/4/17 G No Change Generic Addition 12/25/17 G No Change Generic Addition 12/2517 G No Change Generic Addition 12/25/17 atazanavir G No Change Generic Addition 1/1/18 150mg, 200mg, 300mg (Brand = Reyataz ) estradiol cre 0.01% G No Change Generic Addition 1/8/18 (Brand = Estrace vag cre 0.01%) Repatha NPD/SP* + PA PB/SP* + PA Brand Downtier 7/1/18 Otezla NPD/SP* + PA PB/SP* + PA Brand Downtier 7/1/18 Tremfya NPD/SP* + PA PB/SP* + PA Brand Downtier 7/1/18 Anoro Ellipta NPD + PA PB Brand Downtier PA Removal 7/1/18 Stiolto Respimat NPD + PA PB Brand Downtier PA Removal 7/1/18 Incruse Ellipta NPD PB Brand Downtier 7/1/18 (continued)

2 Glyxambi NPD PB Brand Downtier 7/1/18 Glucagen Hypokit NPD PB Brand Downtier 7/1/18 Calquence cap 100mg NPD/SP* + PA No Change 11/6/17 Qtern tab 10mg/5mg NPD + PA No Change 11/13/17 Vyzulta Sol 0.024% NPD + PA No Change 11/27/17 Rebinyn Sol NPD/SP*+PA No Change 11/27/ unit, 1000 unit, 2000 unit Hemlibra Inj 30mg/ml, NPD/SP*+PA No Change 11/27/17 60/0.4, 105/0.7 Ozempic Inj 2/1.5ml NPD + PA No Change 12/11/17 Odactra Sub NPD + PA No Change 12/18/17 Admelog NPD + PA No Change 1/1/18 Lyrica CR NPD + PA No Change 1/8/ mg, 165mg, 330mg Steglatro 5mg, 15mg NPD + PA No Change 1/15/18 Adzenys ER Sus 1.25mg NPD + PA + QL No Change 1/22/18 Steglujan tab NPD + PA No Change 1/29/ mg, mg Segluromet tab , NPD + PA No Change 2/5/ , Noctiva Emu 0.83/0.1 NPD NPD + PA PA Addition 7/1/18 Noctiva Spr 1.66/01 NPD NPD + PA PA Addition 7/1/18 D.H.E. 45 Excluded NPD + PA Coverage Added PA Addition 7/1/18 dihydroergotamine mesylate Excluded G + PA Coverage Added PA Addition 7/1/18 Inj 1mg/ml clindamycin/benzoyl peroxide G NPD + PA Generic Uptier PA Addition 7/1/18 1%/5% alendronate sodium G LCG Generic Downtier 7/1/18 amoxicillin G LCG Generic Downtier 7/1/18 (continued)

3 ampicillin G LCG Generic Downtier 7/1/18 carteolol hcl G LCG Generic Downtier 7/1/18 carvedilol G LCG Generic Downtier 7/1/18 chlorhexidine gluconate G LCG Generic Downtier 7/1/18 diazepam G LCG Generic Downtier 7/1/18 isoniazid G LCG Generic Downtier 7/1/18 levofloxacin G LCG Generic Downtier 7/1/18 losartan potassium G LCG Generic Downtier 7/1/18 meclizine hcl G LCG Generic Downtier 7/1/18 medroxyprogesterone G LCG Generic Downtier 7/1/18 acetate meloxicam G LCG Generic Downtier 7/1/18 pediatric multivitamin G LCG Generic Downtier 7/1/18 with fluoride prednisone G LCG Generic Downtier 7/1/18 promethazine/codeine G LCG Generic Downtier 7/1/18 promethazine-dm G LCG Generic Downtier 7/1/18 sertraline hcl G LCG Generic Downtier 7/1/18 tobramycin op soln G LCG Generic Downtier 7/1/18 vitamin D G LCG Generic Downtier 7/1/18 allopurinol LCG G Generic Uptier 7/1/18 amiloride- LCG G Generic Uptier 7/1/18 hydrochlorothiazide amitriptyline hcl LCG G Generic Uptier 7/1/18 atenolol/chlorthalidone LCG G Generic Uptier 7/1/18 bumetanide LCG G Generic Uptier 7/1/18 buspirone hcl LCG G Generic Uptier 7/1/18 captopril LCG G Generic Uptier 7/1/18 (continued)

4 cimetidine LCG G Generic Uptier 7/1/18 clonidine hydrocloride LCG G Generic Uptier 7/1/18 diltiazem hcl LCG G Generic Uptier 7/1/18 diltiazem hcl ER LCG G Generic Uptier 7/1/18 doxepin hcl LCG G Generic Uptier 7/1/18 enalapril maleate LCG G Generic Uptier 7/1/18 erythromycin ethylsuccinate LCG G Generic Uptier 7/1/18 famotidine LCG G Generic Uptier 7/1/18 fluoxetine LCG G Generic Uptier 7/1/18 glimepiride LCG G Generic Uptier 7/1/18 glipizide LCG G Generic Uptier 7/1/18 haloperidol LCG G Generic Uptier 7/1/18 indapamide LCG G Generic Uptier 7/1/18 isosorbide dinitrate LCG G Generic Uptier 7/1/18 jantoven LCG G Generic Uptier 7/1/18 levothyroxine sodium LCG G Generic Uptier 7/1/18 metformin hcl LCG G Generic Uptier 7/1/18 metoclopramide hcl LCG G Generic Uptier 7/1/18 nortriptyline hcl LCG G Generic Uptier 7/1/18 oxybutynin ER LCG G Generic Uptier 7/1/18 propranolol hcl LCG G Generic Uptier 7/1/18 ranitidine hcl LCG G Generic Uptier 7/1/18 simvastatin LCG G Generic Uptier 7/1/18 triamterene-hctz LCG G Generic Uptier 7/1/18 verapamil hcl LCG G Generic Uptier 7/1/18 warfarin sodium LCG G Generic Uptier 7/1/18 Glucagon Emergency Kit PB NPD Brand Uptier 7/1/18 (continued)

5 Istalol Sol 0.5% OP PB NPD Brand Uptier 7/1/18 Viread tab 300mg PB NPD Brand Uptier 7/1/18 Reyataz cap PB NPD Brand Uptier 7/1/18 150mg, 200mg, 300mg Vanos cre 0.1% NPD + PA Exclude Brand Deletion 7/1/18 (Generic: fluocinonide 0.1% cream) fluocinonide 0.1% cream (Brand: Vanos cre 0.1%) G Exclude Generic Deletion 7/1/18 Tudorza Pressair NPD NPD + PA PA Addition 7/1/18 Tirosint NPD NPD + PA PA Addition 7/1/18

6 Abbreviation Key G LCG PB NPD SP NF PA QL Generic Addition Generic Downtier Generic Uptier Brand Downtier Brand Uptier Brand Addition Brand/Generic Deletion Generic Low Cost Generic Preferred Brand Non-Preferred Drug Specialty Drug. Specialty Tier cost-share will apply for those benefits that have a prescription drug specialty tier. Non-. Non- refers to drugs not covered on the formulary. A formulary exception is available upon request. Prior Authorization is required. Quantity limits A generic drug that recently became available in the marketplace This generic drug will be covered at the appropriate preferred drug level of cost-sharing. This generic drug will be covered at the appropriate non-preferred drug level of cost-sharing. These brand drugs were added to the formulary as of the date indicated and are covered at the appropriate preferred brand formulary level of cost-sharing. These brand drugs will be covered at the appropriate non-preferred drug level of cost-sharing. Coverage was added to this drug. Coverage was removed from this drug. alternatives are available. DL Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.

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