2016 Formulary Exclusion List for Essential Formulary

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1 2016 Formulary Exclusion List for Essential Formulary The medications shown below are not covered on the 2016 Essential Formulary. An exclusion does not mean you cannot have a particular drug. It simply means that no benefits will be provided, and you will be responsible for the total cost of the drug. Take action to avoid paying full price. If you re currently using one of the excluded medications, please ask your provider to consider writing you a new prescription for one of the following preferred alternatives. Excluded Absorica Aciphex Acticlate acyclovir ointment* Adynovate Adzenys XR-ODT Akynzeo alogliptin alogliptin-metformin alogliptin-pioglitazone amphetamine mix ER* Analpram E Aplenzin Aptensio XR Axiron Belbuca Belsomra Bethkis Brintellix Brisdelle Bulk Powders/Select Bulk Chemicals Cambia Cetraxal Clindacin Pac colchicine (single source) Comfort Pac-Cyclobenzaprine Comfort Pac-Ibuprofen Comfort Pac-Meloxicam Comfort Pac-Tizanidine Conzip Cosentyx Daklinza Claravis, Myorisan, Zenatane doxycycline hyclate Zovirax ointment Advate SPRx granisetron, ondansetron, Anzemet Januvia, Tradjenta Janumet, Jentadueto Januvia or Tradjenta plus pioglitazone hydrocortisone-pramoxine bupropion XL methylphenidate ER**, Concerta buprenorphine/naloxone, Bunavail, Suboxone, Zubsolv eszopiclone, zaleplon, zolpidem, zolpidem ER SPRx QL all tobramycin ampules, Tobi, TobiPodhaler generic SSRI paroxetine hcl diclofenac oral tablet ciprofloxacin otic solution clindamycin topical Colcrys, Uloric cyclobenzaprine oral tablet ibuprofen oral tablet meloxicam oral tablet tizanidine oral tablet tramadol, tramadol ER Enbrel, Humira Harvoni QL all

2 Dapsone (multi source) desvenlafaxine ER (single source) Dexilant, Dexilant SoluTab Diclegis Doryx doxycycline IR-DR Duexis Dyanavel XR Ecoza Edluar Egrifta Eligen B12 Eloctate Embeda Emverm Enstilar Envarsus XR esomeprazole magnesium* esomeprazole strontium Evekeo Evzio Exalgo fenofibrate 50 mg and 150 mg capsule (single source) fenofibrate 40 mg and 120 mg tablet (single source) fentanyl patch 37.5/62.5/87.5 mcg Fetzima Forfivo XL Fortesta Gralise Growth Hormone (including, but not limited to: Genotropin, Humatrope, Nutropin, And Omnitrope) Hemangeol Hetlioz hydromorphone ER Hysingla ER Incruse Ellipta Intermezzo Ixinity Jardiance Jublia Karbinal ER Kazano dapsone (generic) generic SSRI, generic SNRI, Pristiq OTC doxylamine plus OTC pyridoxine doxycycline hyclate, doxycycline monohydrate doxycycline hyclate, doxycycline monohydrate OTC ibuprofen plus OTC famotidine econazole nitrate zolpidem oral tablet cyanocobalamin Advate SPRx morphine sulfate CR/ER/SR, Nucynta ER, Opana ER, Oxycontin Albenza, ivermectin calcipotriene/betamethasone dipropionate ointment tacrolimus oral capsule, Astagraf XL SPRx Nexium naloxone hydromorphone IR QL (generic) fenofibrate 67 mg, 134 mg, 200 mg capsule (generic) fenofibrate 48 mg, 54 mg, 145 mg, and 160 mg tablet QL all fentanyl patch 12/25/50/75/100 mcg generic SSRI, generic SNRI bupropion XL gabapentin Norditropin propranolol oral solution OTC melatonin hydromorphone IR QL hydrocodone-apap QL Spiriva, Tudorza Pressair zaleplon, zolpidem, zolpidem ER BeneFIX SPRx Farxiga, Invokana ciclopirox topical solution carbinoxamine maleate Janumet, Jentadueto QL all

3 Kerydin Khedezla Kitabis Pak Kombiglyze XR Kovaltry Lamisil oral granules Latisse Lazanda Lovaza Luzu Medical Foods/Nutritional Supplements methylphenidate ER* metoclopramide hcl ODT Migralam minocycline ER Mirvaso Mitigare Monodox Morgidox Movantik Moxatag Narcan Nasacort AQ Nascobal Natesto Nesina Novoeight Nymalize Olysio omega-3 acid ethyl esters omeprazole-sodium bicarb Onexton Onglyza Oracea Oseni Otrexup oxycodone hcl ER (single source) Pediaderm HC Pennsaid Prescription Drugs With Over The Counter (OTC) Equivalents Prodrin Provigil Prumyx ciclopirox topical solution generic SSRI, generic SNRI tobramycin ampules, Tobi, TobiPodhaler Janumet XR Helixate SPRx, Recombinate SPRx terbinafine oral tablet SPRx QL all fentanyl lozenge QL OTC fish oil, fenofibrate, gemfibrozil econazole nitrate Concerta metoclopramide oral tablet isometheptene-caffeine-apap minocycline IR Finacea, topical metronidazole Colcrys, Uloric doxycycline monohydrate doxycycline hyclate Amitiza amoxicillin naloxone cyanocobalamin Januvia, Tradjenta Advate SPRx nimodipine Harvoni, Sovaldi OTC fish oil, fenofibrate, gemfibrozil Acanya, benzoyl peroxide/clindamycin Januvia, Tradjenta doxycycline hyclate, doxycycline monohydrate Januvia or Tradjenta plus pioglitazone methotrexate Oxycontin QL OTC hydrocortisone cream diclofenac oral tablet isometheptene-caffeine-apap modafinil PA, Nuvigil PA OTC moisturizers and emollients

4 Qnasl/Qnasl Children QuilliChew ER methylphenidate ER**, Concerta rabeprazole sodium Rasuvo methotrexate Rayos prednisone Rectiv nitroglycerin ointment Regimex PA all # diethylpropion, phendimetrazine, phentermine Rexulti PA all aripiprazole, risperidone, quetiapine Ribasphere Ribapak ribavirin, Ribasphere Rytary carbidopa/levodopa ER Sancuso granisetron oral tablet Savaysa Eliquis, Pradaxa, Xarelto Seebri Neohaler Spiriva, Tudorza Pressair Select Single Source Brand Generics Sernivo betamethasone dipropionate cream/lotion/ointment Silenor doxepin Sitavig acyclovir, famciclovir, valacyclovir Sivextro linezolid QL sodium sulfacetamide 10% cleanser gel sodium sulfacetamide 10% cleanser, sodium sulfacetamide 10% shampoo sodium sulfacetamide-s 9/4.5% kit sodium sulfacetamide-s 9/4.5% cleanser/cream/lotion, sodium sulfacetamide-s 10/5% cleanser/cream/lotion Solodyn minocycline hcl Soolantra Finacea, topical metronidazole Strensiq Subsys fentanyl lozenge QL Sumadan sodium sulfacetamide-s 9/4.5% cleanser/cmb Cln Cr sodium sulfacetamide-s 9/4.5% cleanser/cream/lotion, sodium Sumaxin CP Kit sulfacetamide-s 10/5% cleanser/cream/lotion, sodium sulfacetamide-s 10/4% medicated pad Synjardy Farxiga or Invokana plus metformin Tanzeum Bydureon, Byetta, Victoza Technivie Harvoni Terbinex terbinafine oral tablet Tirosint levothyroxine, Levoxyl, Synthroid Tivorbex indomethacin oral capsule Toviaz darifenacin ER, oxybutynin, oxybutynin ER, Vesicare Tresiba Flextouch U-100, U-200 Lantus, Levemir Tretinoin Microsphere* Retin-A Micro, Retin-A Micro Pump Tretten Advate SPRx, Xyntha SPRx Treximet sumatriptan QL plus naproxen triamcinolone acetonide nasal spray Trulicity Byetta, Bydureon, Victoza Uptravi Orenitram ER

5 Uta Utibron Neohaler Varubi Vascepa Vecamyl Veltassa Veltin Versacloz Viberzi Viekira Pak Vimovo Vituz Vivlodex Vogelxo Vraylar Xartemis XR Xerese Zecuity Zegerid Zembrace Symtouch Zetonna Ziana Zipsor Zohydro ER Zolpimist Zorvolex Zuplenz Zypram Uretron D-S, Urimar, Ustell Arcapta Neohaler, Brovana, Perforomist Emend oral capsule OTC fish oil, fenofibrate, gemfibrozil generic ACE inhibitor, ARB, beta blocker, or calcium channel blocker sodium polystyrene sulfonate topical clindamycin & tretinoin clozapine PA Xifaxan Harvoni, Sovaldi naproxen & OTC Nexium (esomeprazole) hydrocodone/ chlorpheniramine meloxicam oral tablet PA all aripiprazole, risperidone, ziprasidone oxycodone-apap QL Zovirax topical & OTC hydrocortisone sumatriptan oral tablet/injection QL sumatriptan oral tablet/injection QL topical clindamycin & tretinoin diclofenac potassium oral tablet hydrocodone-apap QL zaleplon, zolpidem, zolpidem ER diclofenac sodium oral tablet ondansetron oral tablet hydrocortisone acetate-pramoxine Legend * Does not apply to co-insurance plans. ** Does not apply to copay plans. # May not be covered by your plan. Check with customer service to determine coverage. PA This drug requires prior authorization. ST Requires other selected drugs to be tried first. QL This drug has quantity limits on amount covered. SPRx Specialty drug. Many plans require you to get this type of drug from a preferred Specialty Pharmacy. Remember: You or your physician may appeal the denial of a drug benefit by faxing supportive documents and information to Please refer to your EOC or member handbook for more information on your grievance rights.

6 This list is subject to change throughout the year. Please call Member Service at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up-to-date information. Spanish: Para obtener ayuda en español, llame al Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese: 如果需要中文的帮助, 请拨打这个号码 Navajo: Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 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. BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN bcbst.com BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association 15PHM3720 (04/16) Essential Formulary Exclusion List

2017 Medicare Part D Step Therapy Requirements. Effective: November 01, 2017

2017 Medicare Part D Step Therapy Requirements Effective: November 01, 2017 Formulary ID 17192, Version 19 Last Updated: 10/24/2017 BISPHOSPHONATE THERAPY FOSAMAX PLUS D 70 MG-2,800 UNIT FOSAMAX PLUS D