BCBSTX RESOURCES : simplebooklet.com

9100009.1120Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an independent Licensee of the Blue Cross and Blue Shield AssociationVirtual Visits may not be available on all plans. Non-emergency medical service in Montana and New Mexico is limited to interactive online video. Non-emergency medical service in Arkansas and Idaho is limited to interactive online video for initial consultation. MDLIVE is a separate company that operates and administers Virtual Visits for Blue Cross and Blue Shield of Texas. MDLIVE is solely responsible for its operations and for those of its contracted providers. MDLIVE® and the MDLIVE logo are registered trademarks of MDLIVE, Inc., and may not be used without permission. Blue Cross® , Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.Activate your MDLIVE account today:• Call MDLIVE at 888-680-8646• Go to MDLIVE.com/bcbstx• Text BCBSTX to 635-483 • Download the MDLIVE appVirtual Visit doctors can even send an e-prescription to your local pharmacy.• Allergies• Cold/Flu• Fever• Headaches• Nausea• Sinus infectionsVirtual Visits with licensed behavioral health therapists are available by appointment. Get virtual care for:• Anxiety• DepressionVirtual Visits, provided by Blue Cross and Blue Shield of Texas (BCBSTX) and powered by MDLIVE®, are a convenient alternative for treatment of more than 80 health conditions, including:• Stress management• And more

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510203040Make Your Fitness Program Membership Work for YouThe Fitness Program gives you exible options to help you live a healthy lifestyle.Since you are a Blue Cross and Blue Shield of Texas (BCBSTX) member, the Fitness Program is available exclusively to you and your covered dependents (age 16 and older).* The program gives you access to a nationwide network of tness locations. Choose one location close to home and one near work, or visit locations while traveling.Other program perks include:• Flexible Gym Network: A choice of gym networks to t your budget and preferences.**Options Digital Only Base Core Power EliteMonthly Fee $10 $19 $29 $39 $99Gym Facility Network Size†Digital Access Only3,000 7,500 12,000 12,400$19 Initiation Fee (No initiation fee for Digital Only Option)• Studio Class Network: Boutique-style classes and specialty gyms with pay-as-you-go option and 30% o every 10th class.• Family Friendly: Expands gym network access to your covered dependents at a bundled price discount. • Convenient Payment: Monthly fees are paid via automatic credit card or bank account withdrawals.† Represents possible network locations. Check local listings for exact network options as some locations may not participate. Network locations are subject to change without notice.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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725214.0222* Individuals must be 18 years old to purchase a membership. Dependents, 16-17 years old, can join but must be accompanied to the location by a parent/guardian who is also a Fitness Program member. Check your preferred location to see their membership age policy. Underage dependents can login and join through the primary member’s account as an “additional member.”**Taxes may apply. Individuals must be at least 18 years old to purchase a membership. ***Member agrees to comply with all applicable federal, state and local laws, including making all disclosures and paying all taxes with respect to their receipt of any reward.The Fitness Program is provided by Tivity HealthTM, an independent contractor that administers the Prime Network of tness locations. The Prime Network is made up of independently owned and operated tness locations. The WholeHealth Living Choices program is administered by Tivity Health™ Services, LLC. This is NOT insurance. Some of the services oered through this program may be covered by a health plan. The relationship between these vendors and Blue Cross and Blue Shield of Texas is that of independent contractors.Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal for more information.BCBSTX makes no endorsement, representations or warranties regarding third-party vendors and the products and services oered by them.Features • Mobile App: Allows members to access location search, studio class registration, location check-in and activity history.Check out the Well onTarget Fitness mobile app, available from Apple® or Google PlayTM. It can help you work on your tness goals — anytime and anywhere.• Real-time Data: Provided to the mobile app and Well onTarget portals.• Complementary and Alternative Medicine (CAM) Discounts Through the WholeHealth Living Choices Program: Save money through a nationwide network of 40,000 health and well-being providers, such as acupuncturists, massage therapists and personal trainers. To take advantage of these discounts, register at www.whlchoices.com.• Blue PointsSM: Get 2,500 points for joining the Fitness Program. Earn additional points for weekly visits. You can redeem points for apparel, books, electronics, health and personal care items, music and sporting goods.***• Web Resources: You can go online to nd tness locations and track your visits.• Digital Fitness: Stay active from the comfort of your own home. Access thousands of digital tness videos and live classes including cardio, bootcamp, barre, yoga, and more through an online platform. Digital access is included with Base, Core, Power and Elite memberships. You can also join the Digital Only plan option if only interested in access to digital tness options.Are You Ready for Fitness?It’s easy to sign up:1. Go to bcbstx.com and log in to Blue Access for MembersSM.2. Select the Wellness tab on the top navigation bar of the Dashboard page. Then scroll down to the Fitness Program section and click on Learn More.3. Complete registration form.4. Verify your personal information and method of payment. Print or download your Fitness Program membership ID card. You may also request to receive the ID card in the mail.5. Visit a tness location today!Find tness buddies, take a digital class and try something new! Join the Fitness Program today to help you reach your health and wellness goals.Prefer to sign up by phone or have questions about the Fitness Program? Just call the toll-free number 888-762-BLUE (2583) Monday through Friday, between 7 a.m. and 7 p.m., CT (6 a.m. and 6 p.m., MT).

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41722-T TX © Prime Therapeutics LLC 10/22 Performance Drug List October 2022 Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug list is regularly updated. You can view the most up-to-date list, or the specialty drug list, at MyPrime.com or bcbstx.com. Contents Introduction .......................................................... I How drug s are selected .......................................... I How member payment is determined........................ I How to use this list................................................ II Drugs used to treat multiple conditions .................... II Generic drugs ..................................................... III Consider talking to your doctor about generic d rugs ............................................................... III Coverage co nsiderations ......................................IV Specialty drugs ...................................................VI Accredo .............................................................VI Abbreviation key................................................. VII Therapeutic Class Drug List Anti-Inf ective Drugs ........................................... 1 Biologicals ....................................................... 9 Antineoplastic Agents .......................................13 Endocrine and Metabolic Drugs ..........................19 Cardiovascular Agents ......................................35 Respiratory Agents ...........................................46 Gastrointestinal Agents .....................................50 Genitourinary Agents ........................................54 Central Nervous System Drugs ..........................55 Analgesics and Anesthetics ...............................68 Neuromuscular Drugs .......................................75 Nutritional Products ..........................................81 Hematological Agents .......................................82 To pical Products ..............................................92 Miscellaneo us Products ....................................98 Index............................................................ 105 To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

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Blue Cross and Blue Shield of Texas October 2022 Performance Drug List I Introduction Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to present the 2022 Drug List. All available covered drugs are shown on this list. Drugs that are not shown are not covered. Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are always between members and their physician. Drug List updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit MyPrime.com or bcbstx.com and log in or call the number on your ID card. Physicians can access the list from the provider portal at bcbstx.com. How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. Newly marketed drugs may not be covered until the committee has had an opportunity to evaluate based on these criteria. How member payment is determined Generally, each prescription drug product is placed into one of up to six member payment tiers: Preferred Generic (Tier 1), Non-Preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-Preferred Brand (Tier 4), Preferred Specialty (Tier 5) and Non-Preferred Specialty (Tier 6). Depending on your benefit plan, drugs can either be in these tiers or you may have fewer tiers, e.g. all generics in one tier. Note: Some brands may be in a generic tier and some generics may be in a brand tier. To verify your payment amount for a drug, visit myprime.com and log in or call the number on your ID card. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that have not received FDA approval may not be covered. Prescription products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA-approved for self-administration may be available through your medical benefit. Check your plan materials for details.

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Blue Cross and Blue Shield of Texas October 2022 Performance Drug List II How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Note: most reference brand drugs (in parentheses) are not covered. Example: atorvastatin (Lipitor – brand is not covered) Brand prescription drugs are shown in all CAPITAL letters followed by the generic name. Example: NOVOLOG – Insulin aspart inj 100 unit/ml • Preferred Generics are marked with a “p” and shown in lower-case boldface type • Non-Preferred Generics are marked with a “np” and shown in lower-case boldface type • Preferred Brands are marked with a “P” and shown in all CAPITAL letters • Non-Preferred Brands are marked with a “NP” and shown in all CAPITAL letters • Preferred Specialty Drugs are marked with a “p, np, or P” and shown as lower-case boldface type or in all CAPITAL letters. These drugs are also marked with a dot in the Specialty column. • Non-Preferred Specialty Drugs are marked with a “NP” and shown in all CAPITAL letters. These drugs are also marked with a dot in the Specialty column. • Drugs that are also marked with a “+” indicate group-specific coverage. Please see your benefit plan materials for coverage details, or call the number on the back of your member ID card. Drugs used to treat multiple conditions Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. Please note: Drugs that need a health care provider to administer them and are often given to you in a hospital, doctor’s office or other health care setting may be covered under your medical benefit. Some types of these drugs are contraceptive implants and chemo infusions. If you are taking or are prescribed a drug that is not on this drug list, call the number on your ID card to see if the drug may be covered.

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Blue Cross and Blue Shield of Texas October 2022 Performance Drug List III Generic drugs Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same standards. There are two types of generic drugs: • A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. • A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: • Is chemically the same • Works just as well in the body • Is as safe and effective • Meets the same standards set by the FDA The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Brand drugs may be removed from or moved to a higher tier on the drug list after a generic equivalent becomes available. You may be responsible for your member cost-share payment amount (copay or coinsurance) plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic equivalent. Generic drugs generally have the lowest member payment amount. Consider talking to your doctor about generic drugs If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.

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Blue Cross and Blue Shield of Texas October 2022 Performance Drug List IV Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction or weight loss. Also, some drugs may only be covered for members within a certain age range due to the drug being used for cosmetic purposes or for safety concerns. Drug coverage may be limited to recommendations based on FDA-approved labeling and recognized evidence-based or clinical practice guidelines. Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan material for details about your particular benefits. Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please see your plan materials or call the number on your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged medications: Repackaged versions of medications already available on the market are not covered. Non FDA-approved drugs: Drugs that have not received FDA approval are not covered. Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication may be covered under your plan. For the medications listed in this document, if a prior authorization is commonly required, it will generally be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. Refer to your benefit plan materials for details about your particular benefits. Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the medications listed in this document, if a step therapy is commonly required, it will generally be noted next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on additional medications beyond those noted in this document. Refer to your benefit plan materials for details about your particular benefits. Dispensing Limits (DL): Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you may be responsible for the full cost of the prescription beyond what your coverage allows.* Some plans may have a dispensing limit on additional medications beyond those noted in this document. For a list of medications and their dispensing limits, visit MyPrime.com or bcbstx.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit.

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Blue Cross and Blue Shield of Texas October 2022 Performance Drug List VI Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be self-administered or administered by a health care professional. Medications administered by a health care professional are not covered under the pharmacy benefit. For a current list of specialty medications, visit MyPrime.com or bcbstx.com. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on your ID card. Accredo® Members who use specialty medications deserve the care and support they need to help manage their therapy. With Accredo, members can have covered specialty medications delivered directly to them or their doctor’s office. When using Accredo for specialty medications, you also receive at no additional charge the following services: • One-on-one support and access to 99.9% of all specialty medications • Condition-specific staff to help answer questions about your medication(s) or condition • 24/7 support • Free shipping with safe, on-time delivery • Refill reminders and other digital tools To order through Accredo: 1. Have your doctor send a new prescription to Accredo electronically, by fax or by phone. Your doctor can find contact information at accredo.com/prescribers. 2. Once the prescription has been received, you will receive a call from Accredo to get signed up and ready for your first prescription fill. 3. You can also call Accredo at 833-721-1619 and an agent will work with you to get a new prescription sent or transferred from another pharmacy. If you have questions, please contact Accredo at 833-721-1619, visit accredo.com, or call the number on your ID card. Blue Cross and Blue Shield of Texas (BCBSTX), is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BCBSTX contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC. Accredo is a specialty pharmacy that is contracted to provide services to members of BCBSTX. The relationship between Accredo and BCBSTX is that of independent contractors. Accredo is a trademark of Express Scripts Strategic Development, Inc.

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Blue Cross and Blue Shield of Texas October 2022 Performance Drug List VII Abbreviation key aer .......................................................... aerosol cap ....................................................... capsules chew .................................................... chewable conc ................................................. concentrate cr..............................................controlled release dr ............................................... delayed release ec ..................................................enteric coated equiv .................................................. equivalent er.............................................. extended release gm ..............................................................gram inhal .........................................................inhaler inj .......................................................... injection liqd ............................................................ liquid mg ........................................................ milligram ml ........................................................... milliliter nebu ..................................................... nebulizer odt. ................................. orally disintegrating tabs oint ....................................................... ointment ophth ................................................. ophthalmic osm ............................................ osmotic release pack ....................................................... packets powd....................................................... powder pttw ........................................ twice-weekly patch sl ........................................................ sublingual soln ....................................................... solution suppos ............................................suppositories susp.................................................. suspension tab ........................................................... tablets td ......................................................transdermal w/................................................................. with Exception Process You, your prescribing health care provider, or your authorized representative, can ask for a Drug List exception if your drug is not on (or is being removed from) the Drug List. To request this exception, you, your prescriber, or your authorized representative, can call the number on your ID card to ask for a review. If the coverage request is denied, BCBSTX will let you and your prescriber (or authorized representative) know why it was denied. Call the number on your ID card if you have any questions.

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If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 855-710-6984. EspañolSpanish Si usted o alguien a quien usted está ayudando tiene preguntas, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 855-710-6984.  Arabic                     .855-710-6984 .        繁體中文 Chinese 如果您, 或您正在協助的對象, 對此有疑問, 您有權利免費以您的母語獲得幫助和訊息。洽詢一位翻譯員, 請撥電話號碼 855-710-6984。 FrançaisFrench Si vous, ou quelqu'un que vous êtes en train d’aider, avez des questions, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 855-710-6984. Deutsch German Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 855-710-6984 an.  Gujarati             ...    ,    ,        .        855-710-6984   . Hindi  ,         ,  ,                    855-710-6984   . Italiano Italian Se tu o qualcuno che stai aiutando avete domande, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare il numero 855-710-6984. 한국어 Korean 만약 귀하 또는 귀하가 돕는 사람이 질문이 있다면 귀하는 무료로 그러한 도움과 정보를 귀하의 언어로 받을 수 있는 권리가 있습니다 . 통역사가 필요하시면 855-710-6984 로 전화하십시오. Diné Navajo T’11 ni, 47 doodago [a’da b7k1 an1n7lwo’7g77, na’7d7[kidgo, ts’7d1 bee n1 ah00ti’i’ t’11 n77k’e n7k1 a’doolwo[ d00 b7na’7d7[kid7g77 bee ni[ h odoonih. Ata’dahalne’7g77 bich’8’ hod77lnih kwe’4 855-710-6984. یسراف Persian                              .         855-710-6984   . Polski Polish Jeśli Ty lub osoba, której pomagasz, macie jakiekolwiek pytania, macie prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń podnumer 855-710-6984. Русский Russian Если у вас или человека, которому вы помогаете, возникли вопросы, у вас есть право на бесплатную помощь и информацию, предоставленную на вашем языке. Чтобы связаться с переводчиком, позвоните по телефону 855-710-6984. TagalogTagalog Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong, may karapatan kang makakuha ngtulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang tagasalin-wika, tumawag sa 855-710-6984.  Urdu                                        855-710-6984    Ting Vit Vietnamese Nu quý v, hoc ngi mà quý v giúp , có câu hi, thì quý v có quyn c giúp  và nhn thông tin bng ngôn ng ca mình min phí.  nói chuyn vi mt thông dch viên, gi 855-710-6984. bcbstx.com

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 1Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN- amoxicillin(trihydrate) chew tab 125 mgNPAMOXICILLIN- amoxicillin(trihydrate) chew tab 250 mgNPamoxicillin (trihydrate) cap250 mgpamoxicillin (trihydrate) cap500 mgpamoxicillin (trihydrate) for susp125 mg/5mlpamoxicillin (trihydrate) for susp200 mg/5mlpamoxicillin (trihydrate) for susp250 mg/5mlpamoxicillin (trihydrate) for susp400 mg/5mlpamoxicillin (trihydrate) tab500 mgpamoxicillin (trihydrate) tab875 mgpamoxicillin & k clavulanate forsusp 200-28.5 mg/5mlpamoxicillin & k clavulanatefor susp 250-62.5 mg/5ml(Augmentin)npamoxicillin & k clavulanate forsusp 400-57 mg/5mlnpamoxicillin & k clavulanatefor susp 600-42.9 mg/5ml(Augmentin es-600)npamoxicillin & k clavulanate tab250-125 mgnpamoxicillin & k clavulanate tab500-125 mg (Augmentin)pamoxicillin & k clavulanate tab875-125 mg (Augmentin)pAMOXICILLIN/CLAVULANATE P-amoxicillin & k clavulanate chewtab 200-28.5 mgNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAAMOXICILLIN/CLAVULANATE P-amoxicillin & k clavulanate chewtab 400-57 mgNPAMOXICILLIN/CLAVULANATE P-amoxicillin & k clavulanate taber 12hr 1000-62.5 mgNPAMPICILLIN- ampicillin cap500 mgNPdicloxacillin sodium cap 250 mgnpdicloxacillin sodium cap 500 mgnpPENICILLIN V POTASSIUM-penicillin v potassium for soln125 mg/5mlNPPENICILLIN V POTASSIUM-penicillin v potassium for soln250 mg/5mlNPpenicillin v potassium tab250 mgppenicillin v potassium tab500 mgpCEPHALOSPORINSCEFACLOR- cefaclor cap 250 mgNPCEFACLOR- cefaclor cap 500 mgNPCEFADROXIL- cefadroxil tab1 gmNPcefadroxil cap 500 mgpcefadroxil for susp 250 mg/5mlnpcefadroxil for susp 500 mg/5mlnpcefdinir cap 300 mgpcefdinir for susp 125 mg/5mlnpcefdinir for susp 250 mg/5mlnpcefixime cap 400 mg (Suprax)npcefixime for susp 100 mg/5ml(Suprax)npcefixime for susp 200 mg/5ml(Suprax)npcefpodoxime proxetil for susp50 mg/5mlnpcefpodoxime proxetil for susp100 mg/5mlnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 2Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAcefpodoxime proxetil tab100 mgnpcefpodoxime proxetil tab200 mgnpcefprozil for susp 125 mg/5mlnpcefprozil for susp 250 mg/5mlnpcefprozil tab 250 mgnpcefprozil tab 500 mgnpcefuroxime axetil tab 250 mgnpcefuroxime axetil tab 500 mgnpCEPHALEXIN- cephalexin cap750 mgNPcephalexin cap 250 mg (Keflex)pcephalexin cap 500 mg (Keflex)pcephalexin for susp 125 mg/5mlnpcephalexin for susp 250 mg/5mlnpMACROLIDESAZITHROMYCIN- azithromycinpowd pack for susp 1 gmPazithromycin for susp100 mg/5ml (Zithromax)npazithromycin for susp200 mg/5ml (Zithromax)npazithromycin tab 250 mg(Zithromax)p•azithromycin tab 500 mg(Zithromax)p•azithromycin tab 600 mg(Zithromax)np•CLARITHROMYCIN-clarithromycin for susp125 mg/5mlNPCLARITHROMYCIN-clarithromycin for susp250 mg/5mlNPclarithromycin tab er 24hr500 mgnp•clarithromycin tab 250 mgnpclarithromycin tab 500 mg(Biaxin)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACADIFICID- fidaxomicin for susp40 mg/mlPDIFICID- fidaxomicin tab 200 mgPE.E.S. 400- erythromycinethylsuccinate tab 400 mgNPERYTHROCIN STEARATE-erythromycin stearate tab250 mgPERYTHROMYCIN- erythromycinw/ delayed release particles cap250 mgNPERYTHROMYCINETHYLSUCCINA- erythromycinethylsuccinate tab 400 mgNPerythromycin ethylsuccinatefor susp 200 mg/5ml(E.e.s. granules)nperythromycin ethylsuccinate forsusp 400 mg/5ml (Eryped 400)nperythromycin tab delayedrelease 250 mgnperythromycin tab delayedrelease 333 mgnperythromycin tab delayedrelease 500 mgnperythromycin tab 250 mgnperythromycin tab 500 mgnpZITHROMAX- azithromycin powdpack for susp 1 gmNPTETRACYCLINESdemeclocycline hcl tab 150 mgnpdemeclocycline hcl tab 300 mgnpdoxycycline hyclate cap 50 mgnpdoxycycline hyclate cap 100 mg(Vibramycin)pdoxycycline hyclate tab 20 mgnpdoxycycline hyclate tab 100 mgpdoxycycline monohydrate cap50 mgp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 3Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdoxycycline monohydrate cap100 mg (Monodox)pdoxycycline monohydrate forsusp 25 mg/5ml (Vibramycin)npdoxycycline monohydrate tab50 mgnpdoxycycline monohydrate tab75 mgnpdoxycycline monohydrate tab100 mgnpdoxycycline monohydrate tab150 mgnp•minocycline hcl cap 50 mg(Minocin)pminocycline hcl cap 75 mg(Minocin)npminocycline hcl cap 100 mg(Minocin)npNUZYRA- omadacycline tosylatetab 150 mg (base equivalent)NP•tetracycline hcl cap 250 mg(Tetracycline hcl)nptetracycline hcl cap 500 mg(Tetracycline hcl)npFLUOROQUINOLONESBAXDELA- delafloxacinmeglumine tab 450 mg (baseequiv)NP•CIPRO- ciprofloxacin for oral susp250 mg/5ml (5%) (5 gm/100ml)NPCIPRO- ciprofloxacin for oralsusp 500 mg/5ml (10%)(10 gm/100ml)NPCIPROFLOXACIN HCL-ciprofloxacin hcl tab 100 mg(base equiv)NPciprofloxacin hcl tab 250 mg(base equiv) (Cipro)pciprofloxacin hcl tab 500 mg(base equiv) (Cipro)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAciprofloxacin hcl tab 750 mg(base equiv)plevofloxacin oral soln 25 mg/mlnplevofloxacin tab 250 mg(Levaquin)plevofloxacin tab 500 mg(Levaquin)plevofloxacin tab 750 mg(Levaquin)pmoxifloxacin hcl tab 400 mg(base equiv) (Avelox)npOFLOXACIN- ofloxacin tab300 mgPofloxacin tab 400 mgnpAMINOGLYCOSIDESARIKAYCE- amikacin sulfateliposome inhal susp590 mg/8.4ml (base eq)NP• • •KITABIS PAK- tobramycin nebusoln 300 mg/5mlNP• • •neomycin sulfate tab 500 mgpparomomycin sulfate cap250 mgnpTOBI PODHALER- tobramycininhal cap 28 mgNP• •TOBRAMYCIN- tobramycin nebusoln 300 mg/5mlNP• • •tobramycin nebu soln300 mg/5ml (Tobi)np• •tobramycin nebu soln300 mg/4ml (Bethkis)np• •SULFONAMIDESSULFADIAZINE- sulfadiazine tab500 mgNPANTIMYCOBACTERIAL AGENTSCYCLOSERINE- cycloserine cap250 mgNPethambutol hcl tab 100 mg(Myambutol)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 4Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAethambutol hcl tab 400 mg(Myambutol)npISONIAZID- isoniazid syrup50 mg/5mlNPISONIAZID- isoniazid tab 100 mgNPisoniazid tab 300 mgpPASER- aminosalicylic acider granules packet 4 gmNPPRETOMANID- pretomanid tab200 mgNPPRIFTIN- rifapentine tab 150 mgPpyrazinamide tab 500 mgnprifabutin cap 150 mg(Mycobutin)nprifampin cap 150 mg (Rifadin)nprifampin cap 300 mgnpSIRTURO- bedaquiline fumaratetab 20 mg (base equiv)NPSIRTURO- bedaquiline fumaratetab 100 mg (base equiv)NPTRECATOR- ethionamide tab250 mgNPANTIFUNGALSCRESEMBA- isavuconazoniumsulfate cap 186 mg(isavuconazole 100 mg)NP•fluconazole for susp 10 mg/ml(Diflucan)npfluconazole for susp 40 mg/ml(Diflucan)npfluconazole tab 50 mg (Diflucan)pfluconazole tab 100 mg(Diflucan)pfluconazole tab 150 mg(Diflucan)pfluconazole tab 200 mg(Diflucan)pflucytosine cap 250 mg(Ancobon)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAflucytosine cap 500 mg(Ancobon)npgriseofulvin microsize susp125 mg/5mlnpgriseofulvin microsize tab500 mgnpgriseofulvin ultramicrosize tab125 mg (Gris-peg)npgriseofulvin ultramicrosize tab250 mg (Gris-peg)npitraconazole cap 100 mg(Sporanox)np•itraconazole oral soln 10 mg/ml(Sporanox)np•ketoconazole tab 200 mgnpNOXAFIL- posaconazole susp40 mg/mlP•nystatin tab 500000 unitnpposaconazole tab delayedrelease 100 mg (Noxafil)np•terbinafine hcl tab 250 mg(Lamisil)pvoriconazole for susp 40 mg/ml(Vfend)np•voriconazole tab 50 mg (Vfend)np•voriconazole tab 200 mg (Vfend)np•ANTIVIRALSabacavir sulfate soln 20 mg/ml(base equiv) (Ziagen)np•abacavir sulfate tab 300 mg(base equiv) (Ziagen)np•abacavir sulfate-lamivudine tab600-300 mg (Epzicom)np•acyclovir cap 200 mg (Zovirax)pacyclovir susp 200 mg/5ml(Zovirax)npacyclovir tab 400 mg (Zovirax)pacyclovir tab 800 mg (Zovirax)padefovir dipivoxil tab 10 mg(Hepsera)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 5Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAAPTIVUS- tipranavir cap 250 mgNP•atazanavir sulfate cap 150 mg(base equiv) (Reyataz)np•atazanavir sulfate cap 200 mg(base equiv) (Reyataz)np•atazanavir sulfate cap 300 mg(base equiv) (Reyataz)np•BARACLUDE- entecavir oral soln0.05 mg/mlPBIKTARVY- bictegravir-emtricitabine-tenofovir af tab30-120-15 mgP•BIKTARVY- bictegravir-emtricitabine-tenofovir af tab50-200-25 mgP•CIMDUO- lamivudine-tenofovirdisoproxil fumarate tab300-300 mgP•COMPLERA- emtricitabine-rilpivirine-tenofovir df tab200-25-300 mgNP•DELSTRIGO- doravirine-lamivudine-tenofovir df tab100-300-300 mgP•DESCOVY- emtricitabine-tenofoviralafenamide fumarate tab120-15 mgP•DESCOVY- emtricitabine-tenofoviralafenamide fumarate tab200-25 mgP•DOVATO- dolutegravir sodium-lamivudine tab 50-300 mg (baseeq)P•EDURANT- rilpivirine hcl tab25 mg (base equivalent)NP•efavirenz cap 50 mg (Sustiva)np•efavirenz cap 200 mg (Sustiva)np•efavirenz tab 600 mg (Sustiva)np•efavirenz-emtricitabine-tenofovir df tab600-200-300 mg (Atripla)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAefavirenz-lamivudine-tenofovirdf tab 400-300-300 mg (Symfilo)np•efavirenz-lamivudine-tenofovirdf tab 600-300-300 mg (Symfi)np•emtricitabine caps 200 mg(Emtriva)np•emtricitabine-tenofovirdisoproxil fumarate tab100-150 mg (Truvada)np•emtricitabine-tenofovirdisoproxil fumarate tab133-200 mg (Truvada)np•emtricitabine-tenofovirdisoproxil fumarate tab167-250 mg (Truvada)np•emtricitabine-tenofovirdisoproxil fumarate tab200-300 mg (Truvada)np• •EMTRIVA- emtricitabine soln10 mg/mlNP•entecavir tab 0.5 mg(Baraclude)npentecavir tab 1 mg (Baraclude)npEPCLUSA- sofosbuvir-velpatasvirpellet pack 150-37.5 mgP• • •EPCLUSA- sofosbuvir-velpatasvirpellet pack 200-50 mgP• • •EPCLUSA- sofosbuvir-velpatasvirtab 200-50 mgP• • •EPCLUSA- sofosbuvir-velpatasvirtab 400-100 mgP• • •EPIVIR HBV- lamivudine oral soln5 mg/ml (hbv)NPetravirine tab 100 mg (Intelence)np•etravirine tab 200 mg (Intelence)np•EVOTAZ- atazanavir sulfate-cobicistat tab 300-150 mg (baseequiv)P•famciclovir tab 125 mgnpfamciclovir tab 250 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 6Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAfamciclovir tab 500 mgnpfosamprenavir calcium tab700 mg (base equiv) (Lexiva)np•FUZEON- enfuvirtide for inj 90 mgNP•GENVOYA- elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mgP•HARVONI- ledipasvir-sofosbuvirpellet pack 33.75-150 mgP• • •HARVONI- ledipasvir-sofosbuvirpellet pack 45-200 mgP• • •HARVONI- ledipasvir-sofosbuvirtab 45-200 mgP• • •HARVONI- ledipasvir-sofosbuvirtab 90-400 mgP• • •INTELENCE- etravirine tab 25 mgP•ISENTRESS- raltegravirpotassium chew tab 25 mg(base equiv)P•ISENTRESS- raltegravirpotassium chew tab 100 mg(base equiv)P•ISENTRESS- raltegravirpotassium packet for susp100 mg (base equiv)P•ISENTRESS- raltegravirpotassium tab 400 mg (baseequiv)P•ISENTRESS HD- raltegravirpotassium tab 600 mg (baseequiv)P•JULUCA- dolutegravir sodium-rilpivirine hcl tab 50-25 mg (baseeq)P•LAGEVRIO- molnupiravir cap200 mgNP•lamivudine oral soln 10 mg/ml(Epivir)np•lamivudine tab 100 mg (hbv)(Epivir hbv)nplamivudine tab 150 mg (Epivir)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAlamivudine tab 300 mg (Epivir)np•lamivudine-zidovudine tab150-300 mg (Combivir)np•LEXIVA- fosamprenavir calciumsusp 50 mg/ml (base equiv)NP•LIVTENCITY- maribavir tab200 mgNP•lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)(Kaletra)np•lopinavir-ritonavir tab100-25 mg (Kaletra)np•lopinavir-ritonavir tab200-50 mg (Kaletra)np•maraviroc tab 150 mg(Selzentry)np•maraviroc tab 300 mg(Selzentry)np•MAVYRET- glecaprevir-pibrentasvir pellet pack50-20 mgP• • •MAVYRET- glecaprevir-pibrentasvir tab 100-40 mgP• • •NEVIRAPINE- nevirapine susp50 mg/5mlNP•NEVIRAPINE ER- nevirapine taber 24hr 100 mgNP•nevirapine tab er 24hr 400 mg(Viramune xr)np•nevirapine tab 200 mg(Viramune)p•NORVIR- ritonavir oral soln80 mg/mlP•NORVIR- ritonavir powder packet100 mgNP•ODEFSEY- emtricitabine-rilpivirine-tenofovir af tab200-25-25 mgP•oseltamivir phosphate cap30 mg (base equiv) (Tamiflu)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 7Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAoseltamivir phosphate cap45 mg (base equiv) (Tamiflu)np•oseltamivir phosphate cap75 mg (base equiv) (Tamiflu)np•oseltamivir phosphate for susp6 mg/ml (base equiv) (Tamiflu)np•PAXLOVID- nirmatrelvir tab 10x 150 mg & ritonavir tab 10 x100 mg pakNP• •PAXLOVID- nirmatrelvir tab 20x 150 mg & ritonavir tab 10 x100 mg pakNP•PEGASYS- peginterferon alfa-2ainj 180 mcg/mlP• •PEGASYS- peginterferon alfa-2asoln prefilled syr 180 mcg/0.5mlP• •PREVYMIS- letermovir tab240 mgNP•PREVYMIS- letermovir tab480 mgNP•PREZCOBIX- darunavir-cobicistattab 800-150 mgP•PREZISTA- darunavir oral susp100 mg/mlP•PREZISTA- darunavir tab 75 mgP•PREZISTA- darunavir tab 150 mgP•PREZISTA- darunavir tab 600 mgP•PREZISTA- darunavir tab 800 mgP•RELENZA DISKHALER-zanamivir aero powder breathactivated 5 mg/blisterNP•REYATAZ- atazanavir sulfate oralpowder packet 50 mg (baseequiv)NP•ribavirin cap 200 mg (Rebetol)np•ribavirin tab 200 mg (Copegus)np•ritonavir tab 100 mg (Norvir)np•RUKOBIA- fostemsavirtromethamine tab er 12hr600 mgNP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACASELZENTRY- maraviroc oral soln20 mg/mlNP•SELZENTRY- maraviroc tab25 mgNP•SELZENTRY- maraviroc tab75 mgNP•SOVALDI- sofosbuvir pellet pack150 mgP• • •SOVALDI- sofosbuvir pellet pack200 mgP• • •SOVALDI- sofosbuvir tab 200 mgP• • •SOVALDI- sofosbuvir tab 400 mgP• • •STAVUDINE- stavudine cap15 mgNP•STAVUDINE- stavudine cap20 mgNP•STAVUDINE- stavudine cap30 mgNP•STAVUDINE- stavudine cap40 mgNP•STRIBILD- elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mgNP•SYMTUZA- darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mgP•tenofovir disoproxil fumaratetab 300 mg (Viread)np•TIVICAY- dolutegravir sodium tab10 mg (base equiv)P•TIVICAY- dolutegravir sodium tab25 mg (base equiv)P•TIVICAY- dolutegravir sodium tab50 mg (base equiv)P•TIVICAY PD- dolutegravir sodiumtab for oral susp 5 mg (baseequiv)P•TRIUMEQ- abacavir-dolutegravir-lamivudine tab 600-50-300 mgP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 8Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACATRIZIVIR- abacavir sulfate-lamivudine-zidovudine tab300-150-300 mgNP•TYBOST- cobicistat tab 150 mgNP•valacyclovir hcl tab 500 mg(Valtrex)pvalacyclovir hcl tab 1 gm(Valtrex)npvalganciclovir hcl for soln50 mg/ml (base equiv)(Valcyte)npvalganciclovir hcl tab 450 mg(base equivalent) (Valcyte)npVEMLIDY- tenofovir alafenamidefumarate tab 25 mgNPVIRACEPT- nelfinavir mesylatetab 250 mgNP•VIRACEPT- nelfinavir mesylatetab 625 mgNP•VIREAD- tenofovir disoproxilfumarate oral powder 40 mg/gmP•VIREAD- tenofovir disoproxilfumarate tab 150 mgP•VIREAD- tenofovir disoproxilfumarate tab 200 mgP•VIREAD- tenofovir disoproxilfumarate tab 250 mgP•VOSEVI- sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mgP• • •XOFLUZA- baloxavir marboxil tabtherapy pack 2 x 20 mg (40 mgdose)NP•XOFLUZA- baloxavir marboxil tabtherapy pack 1 x 40 mg (40 mgdose)NP•XOFLUZA- baloxavir marboxil tabtherapy pack 1 x 80 mg (80 mgdose)NP•zidovudine cap 100 mg(Retrovir)np•zidovudine syrup 10 mg/ml(Retrovir)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAzidovudine tab 300 mgnp•ANTIMALARIALSARAKODA- tafenoquine succinatetab 100 mg (base equivalent)NPatovaquone-proguanil hcl tab62.5-25 mg (Malarone)np•atovaquone-proguanil hcl tab250-100 mg (Malarone)np•CHLOROQUINE PHOSPHATE-chloroquine phosphate tab500 mgNPchloroquine phosphate tab250 mgnpCOARTEM- artemether-lumefantrine tab 20-120 mgNPhydroxychloroquine sulfate tab200 mg (Plaquenil)npKRINTAFEL- tafenoquinesuccinate tab 150 mg (baseequivalent)NPmefloquine hcl tab 250 mgnpprimaquine phosphate tab26.3 mg (15 mg base)(Primaquine phosphate)nppyrimethamine tab 25 mg(Daraprim)np• •quinine sulfate cap 324 mg(Qualaquin)npANTHELMINTICSalbendazole tab 200 mg(Albenza)npBENZNIDAZOLE- benznidazoletab 12.5 mgPBENZNIDAZOLE- benznidazoletab 100 mgPivermectin tab 3 mg(Stromectol)nppraziquantel tab 600 mg(Biltricide)npANTI-INFECTIVE AGENTS - MISC.

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 9Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAALINIA- nitazoxanide for susp100 mg/5mlP•atovaquone susp 750 mg/5ml(Mepron)npCAYSTON- aztreonam lysinefor inhal soln 75 mg (baseequivalent)NP• •clindamycin hcl cap 75 mg(Cleocin)pclindamycin hcl cap 150 mg(Cleocin)pclindamycin hcl cap 300 mg(Cleocin)pclindamycin palmitate hcl forsoln 75 mg/5ml (base equiv)(Cleocin pediatric gr)npdapsone tab 25 mgnpdapsone tab 100 mgnpFIRVANQ- vancomycin hcl for oralsoln 25 mg/ml (base equivalent)NPFIRVANQ- vancomycin hcl for oralsoln 50 mg/ml (base equivalent)NPfosfomycin tromethamine powdpack 3 gm (base equivalent)(Monurol)npIMPAVIDO- miltefosine cap 50 mgPLAMPIT- nifurtimox tab 30 mgNPLAMPIT- nifurtimox tab 120 mgNPlinezolid for susp 100 mg/5ml(Zyvox)np•linezolid tab 600 mg (Zyvox)np•methenamine hippurate tab1 gm (Hiprex)npmetronidazole cap 375 mg(Flagyl)npmetronidazole tab 250 mg(Flagyl)pmetronidazole tab 500 mg(Flagyl)pnitazoxanide tab 500 mg (Alinia)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAnitrofurantoin macrocrystallinecap 25 mg (Macrodantin)npnitrofurantoin macrocrystallinecap 50 mg (Macrodantin)npnitrofurantoin macrocrystallinecap 100 mg (Macrodantin)npnitrofurantoin monohydratemacrocrystalline cap 100 mg(Macrobid)pnitrofurantoin susp 25 mg/5mlnppentamidine isethionate fornebulization soln 300 mg(Nebupent)npSIVEXTRO- tedizolid phosphatetab 200 mgNP•sulfamethoxazole-trimethoprimsusp 200-40 mg/5mlnpsulfamethoxazole-trimethoprimtab 400-80 mg (Bactrim)psulfamethoxazole-trimethoprimtab 800-160 mg (Bactrim ds)ptinidazole tab 250 mgnptinidazole tab 500 mg(Tindamax)npTRIMETHOPRIM- trimethoprimtab 100 mgNPvancomycin hcl cap 125 mg(base equivalent) (Vancocinhcl)np•vancomycin hcl cap 250 mg(base equivalent) (Vancocinhcl)np•XIFAXAN- rifaximin tab 200 mgNP•XIFAXAN- rifaximin tab 550 mgP•BIOLOGICALSVACCINESACTHIB- haemophilus bpolysaccharide conjugatevaccine for injP•AFLURIA QUADRIVALENT2021- influenza virus vac splitP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 10Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAquadrivalent susp pref syr0.25 mlAFLURIA QUADRIVALENT2022- influenza virus vac splitquadrivalent susp pref syr 0.5mlP•AFLURIA QUADRIVALENT 2022-influenza virus vaccine splitquadrivalent im injP•BEXSERO- meningococcal vac b(recomb omv adjuv) inj prefilledsyringeP•COMIRNATY- covid-19 mrnavac tris-sucrose-pfizer im susp30 mcg/0.3mlPENGERIX-B- hepatitis bvaccine (recombinant) susp10 mcg/0.5mlP•ENGERIX-B- hepatitis b vaccine(recombinant) susp 20 mcg/mlP•FLUAD QUADRIVALENT 2022-2-influenza vac type a&b surfaceant adj quad pref syr 0.5 mlP•FLUARIX QUADRIVALENT2022- influenza virus vac splitquadrivalent susp pref syr 0.5mlP•FLUBLOK QUADRIVALENT2022- influenza vac recomb haquad pf soln pref syr 0.5 mlP•FLUCELVAX QUADRIVALENT20- influenza vac tiss-cultsubunt quad susp pref syr0.5 mlP•FLUCELVAX QUADRIVALENT20- influenza vac tissue-culturedsubunit quadrivalent im suspP•FLULAVAL QUADRIVALENT202- influenza virus vac splitquadrivalent susp pref syr 0.5mlP•FLUZONE HIGH-DOSE PF 2022-influenza vac split high-dosequad pf susp pref syr 0.7 mlP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAFLUZONE QUADRIVALENT2022- influenza virus vac splitquadrivalent susp pref syr 0.5mlP•FLUZONE QUADRIVALENT2022- influenza virus vaccinesplit quadrivalent im injP•FLUZONE QUADRIVALENT2022- influenza virus vaccinesplit quadrivalent inj 0.5 mlP•GARDASIL 9- humanpapillomavirus (hpv) 9-valentrecomb vac im suspP•GARDASIL 9- humanpapillomavirus (hpv) 9-valentrecomb vac susp pref syrP•HAVRIX- hepatitis a vaccine injsusp 720 el unit/0.5mlP•HAVRIX- hepatitis a vaccine injsusp 1440 el unit/mlP•HEPLISAV-B- hepatitis b vaccinerecomb adjuvanted pref syr20 mcg/0.5mlP•HIBERIX- haemophilus bpolysaccharide conjugate vacfor inj 10 mcgP•IMOVAX RABIES (H.D.C.V.)-rabies virus vaccine, hdc injPIPOL INACTIVATED IPV-poliovirus vaccine, ipv injectionP•JANSSEN COVID-19 VACCINE-covid-19 (sars-cov-2) ad26vector vaccine-janssen im0.5 mlPM-M-R II- measles-mumps-rubellavirus vaccines for inj solnP•MENACTRA- meningococcal(a, c, y, and w-135) diphthconjugate vaccineP•MENQUADFI- meningococcal(a, c, y, and w-135) tetanusconjugate vaccineP•MENVEO- meningococcal (a, c, y,and w-135) oligo conj vac for injP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 11Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAMODERNA COVID-19 VACCINE-covid-19 mrna vaccine6mo-5y-moderna im susp25 mcg/0.25mlPMODERNA COVID-19 VACCINE-covid-19 (sars-cov-2)mrna vacc-moderna im susp 50 mcg/0.5mlPMODERNA COVID-19 VACCINE-covid-19 (sars-cov-2)mrnavacc-moderna im susp100 mcg/0.5mlPNOVAVAX COVID-19 VACCINE-covid-19 subunit prot recomadjuv vac-novavax im5 mcg/0.5mlPPEDVAX HIB- haemophilus bpolysaccharide conj vac im susp7.5 mcg/0.5 mlP•PFIZER-BIONTECH COVID-19-covid-19 (sars-cov-2)mrna vacc-pfizer im susp30 mcg/0.3mlPPFIZER-BIONTECH COVID-19-covid-19 mrna vac tris-sucrose-pfizer im susp 30 mcg/0.3mlPPFIZER-BIONTECH COVID-19-covid-19 mrna vac tris-s 5-11y-pfizer im susp 10 mcg/0.2mlPPFIZER-BIONTECH COVID-19-covid-19 mrna vac tris-s 6mo-4y-pfizer im susp3 mcg/0.2mlPPNEUMOVAX 23- pneumococcalvaccine polyvalent inj25 mcg/0.5mlP•PNEUMOVAX 23/1 DOSE-pneumococcal vaccinepolyvalent inj 25 mcg/0.5mlP•PREHEVBRIO- hepatitis bvaccine 3-antigen (recombinant)susp 10 mcg/mlP•PREVNAR 13- pneumococcal 13-valent conjugate vaccine injP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPREVNAR 20- pneumococcal 20-valent conjugate vaccine suspref syr 0.5 mlP•PROQUAD- measles-mumps-rubella-varicella virus vaccinesfor suspP•RABAVERT- rabies vaccine, pcecfor injPRECOMBIVAX HB- hepatitis bvaccine (recombinant) susp5 mcg/0.5mlP•RECOMBIVAX HB- hepatitis bvaccine (recombinant) susp10 mcg/mlP•RECOMBIVAX HB- hepatitis bvaccine (recombinant) susp40 mcg/mlP•ROTARIX- rotavirus vaccine, livefor oral suspP•ROTATEQ- rotavirus vaccine, liveoral pentavalent solnP•SHINGRIX- zoster vacrecombinant adjuvanted for iminj 50 mcg/0.5mlP•SPIKEVAX COVID-19 VACCINE-covid-19 (sars-cov-2)mrnavacc-moderna im susp100 mcg/0.5mlPTRUMENBA-meningococcal group b vac(recomb) im susp prefilled syrP•TWINRIX- hep a-hep b vaccinesusp pref syr 720-20 elu-mcg/mlP•VAQTA- hepatitis a vaccine injsusp 25 unit/0.5mlP•VAQTA- hepatitis a vaccine injsusp 50 unit/mlP•VARIVAX- varicella virus vaclive for subcutaneous inj 1350pfu/0.5mlP•VAXNEUVANCE- pneumococcal15-valent conjugate vaccine suspref syr 0.5 mlP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 12Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAVIVOTIF- typhoid vaccine capdelayed releaseNPTOXOIDSADACEL- tet tox-diph-acellpertuss ad inj 5-2-15.5 lf-lf-mcg/0.5mlP•BOOSTRIX- tet tox-diph-acellpertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5mlP•BOOSTRIX- tet-diph-acell pertussad pref syr 5-2.5-18.5 lf-mcg/0.5mlP•DAPTACEL- diph, acellular pert &tet tox inj 15 lf-23 mcg-5 lf/0.5mlP•DIPHTHERIA/TETANUS TOXOID-diphtheria-tetanus tox adsorbed(dt) im inj 25-5 unit/0.5mlP•INFANRIX- diph, acellular pert& tet tox inj 25 lf-58 mcg-10lf/0.5mlP•KINRIX- diph-tetanus-acell pert-polio, ipv vacc susp pref syr0.5 mlP•PEDIARIX- diph-tet tox-acell pert-hep b-polio ipv vac susp pref syrP•PENTACEL- diph-ac per-tet toxad-poliov-haemoph b poly vacfor im suspP•QUADRACEL- diph-tetanus toxad-acell pert & polio virus, ipvvac injP•QUADRACEL- diph-tetanus-acellpert-polio, ipv vacc susp pref syr0.5 mlP•TDVAX- tetanus-diphtheria toxoids(td) inj 2-2 lf/0.5mlP•TENIVAC- tetanus-diphtheriatoxoids (td) inj 5-2 lfuP•VAXELIS- diph-tet tox-ac pert ad-polio ipv-hib-hep b rec susp presyrP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAVAXELIS- diph-tet tox-ac pert ad-polio ipv-hib-hepatitis b recmbsuspP•BIOLOGICALS MISCGRASTEK- timothy grass pollenallergen ext sl tab 2800 bauNPODACTRA- dust mite mixed ext sltab 12 sq-hdmNPORALAIR- grass mixed pollen extsl tab 300 ir (index of reactivity)NPPALFORZIA INITIAL DOSE ES-peanut powder-dnfp starter pack0.5 & 1 & 1.5 & 3 & 6 mgNP• • •PALFORZIA LEVEL 1- peanutpowder-dnfp cap sprinkle pack 3x 1 mg (3 mg dose)NP• • •PALFORZIA LEVEL 10- peanutpowder-dnfp pack 2 x 20 mg & 2x 100 mg (240 mg dose)NP• • •PALFORZIA LEVEL 11 (MAINT-peanut allergen powder-dnfpmaintenance packet 300 mgNP• • •PALFORZIA LEVEL 11 (TITRA-peanut allergen powder-dnfptitration packet 300 mgNP• • •PALFORZIA LEVEL 2- peanutpowder-dnfp cap sprinkle pack 6x 1 mg (6 mg dose)NP• • •PALFORZIA LEVEL 3- peanutpowder-dnfp pack 2 x 1 mg &10 mg (12 mg dose)NP• • •PALFORZIA LEVEL 4- peanutpowder-dnfp cap sprinkle pack20 mg (20 mg dose)NP• • •PALFORZIA LEVEL 5- peanutpowder-dnfp cap sprinkle pack 2x 20 mg (40 mg dose)NP• • •PALFORZIA LEVEL 6- peanutpowder-dnfp cap sprinkle pack 4x 20 mg (80 mg dose)NP• • •PALFORZIA LEVEL 7- peanutpowder-dnfp pack 20 mg &100 mg (120 mg dose)NP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 13Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPALFORZIA LEVEL 8- peanutpowder-dnfp pack 3 x 20 mg &100 mg (160 mg dose)NP• • •PALFORZIA LEVEL 9- peanutpowder-dnfp pack 2 x 100 mg(200 mg dose)NP• • •RAGWITEK- short ragweed pollenallergen extract sl tab 12 amb a1-uNPANTINEOPLASTIC AGENTSANTINEOPLASTICSabiraterone acetate tab 250 mg(Zytiga)np• • •abiraterone acetate tab 500 mg(Zytiga)np• • •ACTIMMUNE-interferon gamma-1b inj100 mcg/0.5ml (2000000unit/0.5ml)P•ALECENSA- alectinib hcl cap150 mg (base equivalent)P• • •ALUNBRIG- brigatinib tabinitiation therapy pack 90 mg &180 mgP• • •ALUNBRIG- brigatinib tab 30 mgP• • •ALUNBRIG- brigatinib tab 90 mgP• • •ALUNBRIG- brigatinib tab 180 mgP• • •anastrozole tab 1 mg (Arimidex)p•AYVAKIT- avapritinib tab 25 mgP• • •AYVAKIT- avapritinib tab 50 mgP• • •AYVAKIT- avapritinib tab 100 mgP• • •AYVAKIT- avapritinib tab 200 mgP• • •AYVAKIT- avapritinib tab 300 mgP• • •BALVERSA- erdafitinib tab 3 mgNP• • •BALVERSA- erdafitinib tab 4 mgNP• • •BALVERSA- erdafitinib tab 5 mgNP• • •BESREMI- ropeginterferonalfa-2b-njft soln prefilled syr500 mcg/mlNP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAbexarotene cap 75 mg(Targretin)np• •bicalutamide tab 50 mg(Casodex)pBOSULIF- bosutinib tab 100 mgP• • •BOSULIF- bosutinib tab 400 mgP• • •BOSULIF- bosutinib tab 500 mgP• • •BRAFTOVI- encorafenib cap75 mgNP• • •BRUKINSA- zanubrutinib cap80 mgNP• • •CABOMETYX- cabozantinibs-malate tab 20 mg (baseequivalent)P• • •CABOMETYX- cabozantinibs-malate tab 40 mg (baseequivalent)P• • •CABOMETYX- cabozantinibs-malate tab 60 mg (baseequivalent)P• • •CALQUENCE- acalabrutinib cap100 mgNP• • •capecitabine tab 150 mg(Xeloda)np• •capecitabine tab 500 mg(Xeloda)np• •CAPRELSA- vandetanib tab100 mgP• • •CAPRELSA- vandetanib tab300 mgP• • •COMETRIQ- cabozantinib s-malcap 1 x 80 mg & 1 x 20 mg (100dose) kitP• • •COMETRIQ- cabozantinib s-malcap 1 x 80 mg & 3 x 20 mg (140dose) kitP• • •COMETRIQ- cabozantinib s-malate cap 3 x 20 mg (60 mgdose) kitP• • •COPIKTRA- duvelisib cap 15 mgNP• • •COPIKTRA- duvelisib cap 25 mgNP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 14Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACACOTELLIC- cobimetinib fumaratetab 20 mg (base equivalent)P• • •CYCLOPHOSPHAMIDE-cyclophosphamide tab 25 mgPCYCLOPHOSPHAMIDE-cyclophosphamide tab 50 mgPcyclophosphamide cap 25 mg(Cyclophosphamide)npcyclophosphamide cap 50 mg(Cyclophosphamide)npDAURISMO- glasdegib maleatetab 25 mg (base equivalent)NP• • •DAURISMO- glasdegib maleatetab 100 mg (base equivalent)NP• • •ELIGARD- leuprolide acetate (3month) for subcutaneous inj kit22.5mgNP•ELIGARD- leuprolide acetate (4month) for subcutaneous inj kit30 mgNP•ELIGARD- leuprolide acetate (6month) for subcutaneous inj kit45 mgNP•ELIGARD- leuprolide acetate forsubcutaneous inj kit 7.5 mgNP•EMCYT- estramustine phosphatesodium cap 140 mgP•ERIVEDGE- vismodegib cap150 mgP• • •ERLEADA- apalutamide tab60 mgP• • •erlotinib hcl tab 25 mg (baseequivalent) (Tarceva)np• • •erlotinib hcl tab 100 mg (baseequivalent) (Tarceva)np• • •erlotinib hcl tab 150 mg (baseequivalent) (Tarceva)np• • •ETOPOSIDE- etoposide cap50 mgP•everolimus tab for oral susp2 mg (Afinitor disperz)np• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAeverolimus tab for oral susp3 mg (Afinitor disperz)np• • •everolimus tab for oral susp5 mg (Afinitor disperz)np• • •everolimus tab 2.5 mg (Afinitor)np• • •everolimus tab 5 mg (Afinitor)np• • •everolimus tab 7.5 mg (Afinitor)np• • •everolimus tab 10 mg (Afinitor)np• • •exemestane tab 25 mg(Aromasin)npEXKIVITY- mobocertinib succinatecap 40 mgNP• • •FLUTAMIDE- flutamide cap125 mgNPFOTIVDA- tivozanib hcl cap0.89 mg (base equivalent)NP• • •FOTIVDA- tivozanib hcl cap1.34 mg (base equivalent)NP• • •GAVRETO- pralsetinib cap100 mgNP• • •GILOTRIF- afatinib dimaleate tab20 mg (base equivalent)P• • •GILOTRIF- afatinib dimaleate tab30 mg (base equivalent)P• • •GILOTRIF- afatinib dimaleate tab40 mg (base equivalent)P• • •GLEOSTINE- lomustine cap10 mgP•GLEOSTINE- lomustine cap40 mgP•GLEOSTINE- lomustine cap100 mgP•HYCAMTIN- topotecan hcl cap0.25 mg (base equiv)P• •HYCAMTIN- topotecan hcl cap1 mg (base equiv)P• •hydroxyurea cap 500 mg(Hydrea)npIBRANCE- palbociclib cap 75 mgP• • •IBRANCE- palbociclib cap 100 mgP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 15Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAIBRANCE- palbociclib cap 125 mgP• • •IBRANCE- palbociclib tab 75 mgP• • •IBRANCE- palbociclib tab 100 mgP• • •IBRANCE- palbociclib tab 125 mgP• • •ICLUSIG- ponatinib hcl tab 10 mg(base equiv)P• • •ICLUSIG- ponatinib hcl tab 15 mg(base equiv)P• • •ICLUSIG- ponatinib hcl tab 30 mg(base equiv)P• • •ICLUSIG- ponatinib hcl tab 45 mg(base equiv)P• • •IDHIFA- enasidenib mesylate tab50 mg (base equivalent)NP• • •IDHIFA- enasidenib mesylate tab100 mg (base equivalent)NP• • •imatinib mesylate tab 100 mg(base equivalent) (Gleevec)np• • •imatinib mesylate tab 400 mg(base equivalent) (Gleevec)np• • •IMBRUVICA- ibrutinib cap 70 mgP• • •IMBRUVICA- ibrutinib cap 140 mgP• • •IMBRUVICA- ibrutinib tab 140 mgP• • •IMBRUVICA- ibrutinib tab 280 mgP• • •IMBRUVICA- ibrutinib tab 420 mgP• • •IMBRUVICA- ibrutinib tab 560 mgP• • •INLYTA- axitinib tab 1 mgP• • •INLYTA- axitinib tab 5 mgP• • •INQOVI- decitabine-cedazuridinetab 35-100 mgNP• • •INREBIC- fedratinib hcl cap100 mgNP• • •INTRON A- interferon alfa-2b forinj 10000000 unitP•INTRON A- interferon alfa-2b forinj 18000000 unitP•INTRON A- interferon alfa-2b forinj 50000000 unitP•IRESSA- gefitinib tab 250 mgP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAJAKAFI- ruxolitinib phosphate tab5 mg (base equivalent)P• • •JAKAFI- ruxolitinib phosphate tab10 mg (base equivalent)P• • •JAKAFI- ruxolitinib phosphate tab15 mg (base equivalent)P• • •JAKAFI- ruxolitinib phosphate tab20 mg (base equivalent)P• • •JAKAFI- ruxolitinib phosphate tab25 mg (base equivalent)P• • •KISQALI- ribociclib succinate tabpack 200 mg daily doseP• • •KISQALI- ribociclib succinate tabpack 400 mg daily dose (200 mgtab)P• • •KISQALI- ribociclib succinate tabpack 600 mg daily dose (200 mgtab)P• • •KISQALI FEMARA 200 DOSE-ribociclib 200 mg dose (200 mgtab) & letrozole 2.5 mg tbpkP• • •KISQALI FEMARA 400 DOSE-ribociclib 400 mg dose (200 mgtab) & letrozole 2.5 mg tbpkP• • •KISQALI FEMARA 600 DOSE-ribociclib 600 mg dose (200 mgtab) & letrozole 2.5 mg tbpkP• • •KOSELUGO- selumetinib sulfatecap 10 mgNP• • •KOSELUGO- selumetinib sulfatecap 25 mgNP• • •lapatinib ditosylate tab 250 mg(base equiv) (Tykerb)np• • •LENVIMA 10 MG DAILY DOSE-lenvatinib cap therapy pack10 mg (10 mg daily dose)P• • •LENVIMA 12MG DAILY DOSE-lenvatinib cap therapy pack 3 x4 mg (12 mg daily dose)P• • •LENVIMA 14 MG DAILY DOSE-lenvatinib cap therapy pack 10 &4 mg (14 mg daily dose)P• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 16Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACALENVIMA 18 MG DAILY DOSE-lenvatinib cap ther pack 10 mg& 2 x 4 mg (18 mg daily dose)P• • •LENVIMA 20 MG DAILY DOSE-lenvatinib cap therapy pack 2 x10 mg (20 mg daily dose)P• • •LENVIMA 24 MG DAILY DOSE-lenvatinib cap ther pack 2 x10 mg & 4 mg (24 mg dailydose)P• • •LENVIMA 4 MG DAILY DOSE-lenvatinib cap therapy pack4 mg (4 mg daily dose)P• • •LENVIMA 8 MG DAILY DOSE-lenvatinib cap therapy pack 2 x4 mg (8 mg daily dose)P• • •letrozole tab 2.5 mg (Femara)pleucovorin calcium tab 5 mgnpleucovorin calcium tab 10 mgnpleucovorin calcium tab 15 mgnpleucovorin calcium tab 25 mgnpLEUKERAN- chlorambucil tab2 mgP•leuprolide acetate inj kit 5 mg/mlnp•LONSURF- trifluridine-tipiracil tab15-6.14 mgP• • •LONSURF- trifluridine-tipiracil tab20-8.19 mgP• • •LORBRENA- lorlatinib tab 25 mgNP• • •LORBRENA- lorlatinib tab 100 mgNP• • •LUMAKRAS- sotorasib tab120 mgNP• • •LUPRON DEPOT (1-MONTH)-leuprolide acetate for inj kit3.75 mgP•LUPRON DEPOT (1-MONTH)-leuprolide acetate for inj kit7.5 mgP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACALUPRON DEPOT (3-MONTH)-leuprolide acetate (3 month) forinj kit 11.25 mgP•LUPRON DEPOT (3-MONTH)-leuprolide acetate (3 month) forinj kit 22.5 mgP•LUPRON DEPOT (4-MONTH)-leuprolide acetate (4 month) forinj kit 30 mgP•LUPRON DEPOT (6-MONTH)-leuprolide acetate (6 month) forinj kit 45 mgP•LYNPARZA- olaparib tab 100 mgP• • •LYNPARZA- olaparib tab 150 mgP• • •LYSODREN- mitotane tab 500 mgP• •MATULANE- procarbazine hcl cap50 mgP• •megestrol acetate susp 40 mg/ml (Megace oral)npmegestrol acetate tab 20 mgpmegestrol acetate tab 40 mgpMEKINIST- trametinib dimethylsulfoxide tab 0.5 mg (baseequivalent)P• • •MEKINIST- trametinib dimethylsulfoxide tab 2 mg (baseequivalent)P• • •MEKTOVI- binimetinib tab 15 mgNP• • •melphalan tab 2 mg (Alkeran)np•mercaptopurine tab 50 mgnpMESNEX- mesna tab 400 mgPMETHOTREXATE SODIUM-methotrexate sodium inj250 mg/10ml (25 mg/ml)NPmethotrexate sodium for inj1 gmnpmethotrexate sodium inj pf50 mg/2ml (25 mg/ml)pmethotrexate sodium inj pf250 mg/10ml (25 mg/ml)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 17Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmethotrexate sodium inj pf1000 mg/40ml (25 mg/ml)npmethotrexate sodium inj50 mg/2ml (25 mg/ml)pmethotrexate sodium tab 2.5 mg(base equiv)npMYLERAN- busulfan tab 2 mgP•NERLYNX- neratinib maleate tab40 mg (base equivalent)NP• • •NEXAVAR- sorafenib tosylate tab200 mg (base equivalent)P• • •nilutamide tab 150 mg(Nilandron)np•NINLARO- ixazomib citrate cap2.3 mg (base equivalent)P• • •NINLARO- ixazomib citrate cap3 mg (base equivalent)P• • •NINLARO- ixazomib citrate cap4 mg (base equivalent)P• • •NUBEQA- darolutamide tab300 mgP• • •ODOMZO- sonidegib phosphatecap 200 mg (base equivalent)P• • •ONUREG- azacitidine tab 200 mgNP• • •ONUREG- azacitidine tab 300 mgNP• • •ORGOVYX- relugolix tab 120 mgNP• • •PEMAZYRE- pemigatinib tab4.5 mgNP• • •PEMAZYRE- pemigatinib tab9 mgNP• • •PEMAZYRE- pemigatinib tab13.5 mgNP• • •PIQRAY 200MG DAILY DOSE-alpelisib tab therapy pack200 mg daily doseP• • •PIQRAY 250MG DAILY DOSE-alpelisib tab pack 250 mg dailydose (200 mg & 50 mg tabs)P• • •PIQRAY 300MG DAILY DOSE-alpelisib tab pack 300 mg dailydose (2x150 mg tab)P• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPOMALYST- pomalidomide cap1 mgP• • •POMALYST- pomalidomide cap2 mgP• • •POMALYST- pomalidomide cap3 mgP• • •POMALYST- pomalidomide cap4 mgP• • •PURIXAN- mercaptopurine susp2000 mg/100ml (20 mg/ml)P•QINLOCK- ripretinib tab 50 mgNP• • •RETEVMO- selpercatinib cap40 mgP• • •RETEVMO- selpercatinib cap80 mgP• • •ROZLYTREK- entrectinib cap100 mgP• • •ROZLYTREK- entrectinib cap200 mgP• • •RUBRACA- rucaparib camsylatetab 200 mg (base equivalent)P• • •RUBRACA- rucaparib camsylatetab 250 mg (base equivalent)P• • •RUBRACA- rucaparib camsylatetab 300 mg (base equivalent)P• • •RYDAPT- midostaurin cap 25 mgP• • •SCEMBLIX- asciminib hcl tab20 mgNP• • •SCEMBLIX- asciminib hcl tab40 mgNP• • •SOLTAMOX- tamoxifen citrateoral soln 10 mg/5ml (baseequivalent)NPsorafenib tosylate tab 200 mg(base equivalent) (Nexavar)np•SPRYCEL- dasatinib tab 20 mgP• • •SPRYCEL- dasatinib tab 50 mgP• • •SPRYCEL- dasatinib tab 70 mgP• • •SPRYCEL- dasatinib tab 80 mgP• • •SPRYCEL- dasatinib tab 100 mgP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 18Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACASPRYCEL- dasatinib tab 140 mgP• • •STIVARGA- regorafenib tab40 mgP• • •sunitinib malate cap 12.5 mg(base equivalent) (Sutent)np• • •sunitinib malate cap 25 mg(base equivalent) (Sutent)np• • •sunitinib malate cap 37.5 mg(base equivalent) (Sutent)np• • •sunitinib malate cap 50 mg(base equivalent) (Sutent)np• • •SYNRIBO- omacetaxinemepesuccinate for inj 3.5 mgPTABLOID- thioguanine tab 40 mgP•TABRECTA- capmatinib hcl tab150 mgP• • •TABRECTA- capmatinib hcl tab200 mgP• • •TAFINLAR- dabrafenib mesylatecap 50 mg (base equivalent)P• • •TAFINLAR- dabrafenib mesylatecap 75 mg (base equivalent)P• • •TAGRISSO- osimertinib mesylatetab 40 mg (base equivalent)P• • •TAGRISSO- osimertinib mesylatetab 80 mg (base equivalent)P• • •TALZENNA- talazoparib tosylatecap 0.25 mg (base equivalent)P• • •TALZENNA- talazoparib tosylatecap 0.5 mg (base equivalent)P• • •TALZENNA- talazoparib tosylatecap 0.75 mg (base equivalent)P• • •TALZENNA- talazoparib tosylatecap 1 mg (base equivalent)P• • •tamoxifen citrate tab 10 mg(base equivalent)p•tamoxifen citrate tab 20 mg(base equivalent)np•TASIGNA- nilotinib hcl cap 50 mg(base equivalent)P• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACATASIGNA- nilotinib hcl cap150 mg (base equivalent)P• • •TASIGNA- nilotinib hcl cap200 mg (base equivalent)P• • •TAZVERIK- tazemetostat hbr tab200 mgNP• • •temozolomide cap 5 mg(Temodar)np• •temozolomide cap 20 mg(Temodar)np• •temozolomide cap 100 mg(Temodar)np• •temozolomide cap 140 mg(Temodar)np• •temozolomide cap 180 mg(Temodar)np• •temozolomide cap 250 mg(Temodar)np• •TEPMETKO- tepotinib hcl tab225 mgNP• • •TIBSOVO- ivosidenib tab 250 mgNP• • •toremifene citrate tab 60 mg(base equivalent) (Fareston)np•tretinoin cap 10 mgnp• •TRUSELTIQ- infigratinib phos cappack 100 & 25 mg (125 mg dailydose)NP• • •TRUSELTIQ- infigratinib phoscap ther pack 2 x 25 mg (50 mgdaily dose)NP• • •TRUSELTIQ- infigratinib phoscap ther pack 3 x 25 mg (75 mgdaily dose)NP• • •TRUSELTIQ- infigratinib phos capther pack 100 mg (100 mg dailydose)NP• • •TUKYSA- tucatinib tab 50 mgNP• • •TUKYSA- tucatinib tab 150 mgNP• • •TURALIO- pexidartinib hcl cap200 mg (base equivalent)NP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 19Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAVENCLEXTA- venetoclax tab10 mgP• • •VENCLEXTA- venetoclax tab50 mgP• • •VENCLEXTA- venetoclax tab100 mgP• • •VENCLEXTA STARTING PACK-venetoclax tab therapy starterpack 10 & 50 & 100 mgP• • •VERZENIO- abemaciclib tab50 mgP• • •VERZENIO- abemaciclib tab100 mgP• • •VERZENIO- abemaciclib tab150 mgP• • •VERZENIO- abemaciclib tab200 mgP• • •VITRAKVI- larotrectinib sulfatecap 25 mg (base equivalent)P• • •VITRAKVI- larotrectinib sulfatecap 100 mg (base equivalent)P• • •VITRAKVI- larotrectinib sulfateoral soln 20 mg/ml (baseequivalent)P• • •VIZIMPRO- dacomitinib tab 15 mgNP• • •VIZIMPRO- dacomitinib tab 30 mgNP• • •VIZIMPRO- dacomitinib tab 45 mgNP• • •VONJO- pacritinib citrate cap100 mgNP• • •VOTRIENT- pazopanib hcl tab200 mg (base equiv)P• • •WELIREG- belzutifan tab 40 mgNP• • •XALKORI- crizotinib cap 200 mgP• • •XALKORI- crizotinib cap 250 mgP• • •XOSPATA- gilteritinib fumaratetablet 40 mg (base equivalent)NP• • •XPOVIO- selinexor tab therapypack 40 mg (40 mg onceweekly)NP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAXPOVIO- selinexor tab therapypack 40 mg (40 mg twiceweekly)NP• • •XPOVIO- selinexor tab therapypack 40 mg (80 mg onceweekly)NP• • •XPOVIO- selinexor tab therapypack 50 mg (100 mg onceweekly)NP• • •XPOVIO- selinexor tab therapypack 60 mg (60 mg onceweekly)NP• • •XPOVIO 60 MG TWICE WEEKLY-selinexor tab therapy pack20 mg (60 mg twice weekly)NP• • •XPOVIO 80 MG TWICE WEEKLY-selinexor tab therapy pack20 mg (80 mg twice weekly)NP• • •XTANDI- enzalutamide cap 40 mgP• • •XTANDI- enzalutamide tab 40 mgP• • •XTANDI- enzalutamide tab 80 mgP• • •YONSA- abiraterone acetate tab125 mgP• • •ZEJULA- niraparib tosylate cap100 mg (base equivalent)P• • •ZELBORAF- vemurafenib tab240 mgP• • •ZOLINZA- vorinostat cap 100 mgP• • •ZYDELIG- idelalisib tab 100 mgP• • •ZYDELIG- idelalisib tab 150 mgP• • •ZYKADIA- ceritinib tab 150 mgP• • •ENDOCRINE AND METABOLIC DRUGSCORTICOSTEROIDSbudesonide delayed releaseparticles cap 3 mg (Entocortec)npDEXAMETHASONE-dexamethasone soln 0.5 mg/5mlNPDEXAMETHASONE-dexamethasone tab 0.5 mgNP

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 20Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACADEXAMETHASONE-dexamethasone tab 0.75 mgNPDEXAMETHASONE-dexamethasone tab 1 mgPDEXAMETHASONE-dexamethasone tab 2 mgPdexamethasone elixir0.5 mg/5mlnpDEXAMETHASONE INTENSOL-dexamethasone conc 1 mg/mlNPdexamethasone tab 1.5 mgpdexamethasone tab 4 mgpdexamethasone tab 6 mgpfludrocortisone acetate tab0.1 mgphydrocortisone tab 5 mg(Cortef)nphydrocortisone tab 10 mg(Cortef)nphydrocortisone tab 20 mg(Cortef)npMEDROL- methylprednisolone tab2 mgNPmethylprednisolone tab therapypack 4 mg (21) (Medroldosepak)pmethylprednisolone tab 4 mg(Medrol)pmethylprednisolone tab 8 mg(Medrol)npmethylprednisolone tab 16 mg(Medrol)pmethylprednisolone tab 32 mg(Medrol)pPREDNISOLONE- prednisolonesyrup 15 mg/5ml (usp solutionequivalent)NPprednisolone sod phosph oralsoln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAprednisolone sod phosphateoral soln 15 mg/5ml (baseequiv)pPREDNISOLONE SODIUMPHOSP- prednisolone sodiumphosphate oral soln 25 mg/5ml(base eq)NPPREDNISONE- prednisone oralsoln 5 mg/5mlPPREDNISONE INTENSOL-prednisone conc 5 mg/mlNPprednisone tab therapy pack5 mg (21)pprednisone tab therapy pack5 mg (48)pprednisone tab therapy pack10 mg (21)npprednisone tab therapy pack10 mg (48)npprednisone tab 1 mgpprednisone tab 2.5 mgpprednisone tab 5 mgpprednisone tab 10 mgpprednisone tab 20 mgpprednisone tab 50 mgpANDROGEN-ANABOLICdanazol cap 50 mgnp•danazol cap 100 mgnp•danazol cap 200 mgnp•METHITEST- methyltestosteroneoral tab 10 mgNP• •methyltestosterone cap 10 mgnp• •oxandrolone tab 2.5 mg(Oxandrin)np•oxandrolone tab 10 mg(Oxandrin)np•testosterone cypionate iminj in oil 100 mg/ml (Depo-testosterone)np• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 21Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAtestosterone cypionate iminj in oil 200 mg/ml (Depo-testosterone)np• •TESTOSTERONE ENANTHATE-testosterone enanthate im inj inoil 200 mg/mlNP• •testosterone td gel 25 mg/2.5gm(1%) (Androgel)np• •testosterone td gel 50 mg/5gm(1%) (Androgel)np• •testosterone td gel 12.5 mg/act(1%)np• •testosterone td gel 20.25 mg/act(1.62%) (Androgel pump)np• •testosterone td soln 30 mg/act(Axiron)np• •ESTROGENSALORA- estradiol td patch twiceweekly 0.025 mg/24hrNP•ALORA- estradiol td patch twiceweekly 0.05 mg/24hrNP•ALORA- estradiol td patch twiceweekly 0.075 mg/24hrNP•ALORA- estradiol td patch twiceweekly 0.1 mg/24hrNP•ANGELIQ- drospirenone-estradioltab 0.25-0.5 mgNPANGELIQ- drospirenone-estradioltab 0.5-1 mgNPCLIMARA PRO- estradiol-levonorgestrel td patch weekly0.045-0.015 mg/dayPCOMBIPATCH- estradiol-norethindrone ace td pttw0.05-0.14 mg/dayNPCOMBIPATCH- estradiol-norethindrone ace td pttw0.05-0.25 mg/dayNPDELESTROGEN- estradiolvalerate im in oil 10 mg/mlNPDEPO-ESTRADIOL- estradiolcypionate im in oil 5 mg/mlNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACADIVIGEL- estradiol td gel0.25 mg/0.25gm (0.1%)PDIVIGEL- estradiol td gel0.5 mg/0.5gm (0.1%)PDIVIGEL- estradiol td gel0.75 mg/0.75gm (0.1%)PDIVIGEL- estradiol td gel 1 mg/gm(0.1%)PDIVIGEL- estradiol td gel1.25 mg/1.25gm (0.1%)PDUAVEE- conjugated estrogens-bazedoxifene tab 0.45-20 mgPELESTRIN- estradiol gel 0.06%(0.52 mg/0.87 gm metered-dosepump)NPestradiol & norethindroneacetate tab 0.5-0.1 mg(Activella)npestradiol & norethindroneacetate tab 1-0.5 mg(Activella)npestradiol tab 0.5 mg (Estrace)pestradiol tab 1 mg (Estrace)pestradiol tab 2 mg (Estrace)pestradiol td patch twice weekly0.025 mg/24hr (Vivelle-dot)np•estradiol td patch twice weekly0.0375 mg/24hr (Vivelle-dot)np•estradiol td patch twice weekly0.05 mg/24hr (Vivelle-dot)np•estradiol td patch twice weekly0.075 mg/24hr (Vivelle-dot)np•estradiol td patch twice weekly0.1 mg/24hr (Vivelle-dot)np•estradiol td patch weekly0.025 mg/24hr (Climara)np•estradiol td patchweekly 0.0375 mg/24hr(37.5 mcg/24hr) (Climara)np•estradiol td patch weekly0.05 mg/24hr (Climara)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 22Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAestradiol td patch weekly0.06 mg/24hr (Climara)np•estradiol td patch weekly0.075 mg/24hr (Climara)np•estradiol td patch weekly0.1 mg/24hr (Climara)np•estradiol valerate im in oil20 mg/ml (Delestrogen)npestradiol valerate im in oil40 mg/ml (Delestrogen)npESTROGEL- estradiol gel 0.06%(0.75 mg/1.25 gm metered-dosepump)PEVAMIST- estradiol transdermalspray 1.53 mg/sprayNPMENEST- esterified estrogens tab0.3 mgNPMENEST- esterified estrogens tab0.625 mgNPMENEST- esterified estrogens tab1.25 mgNPMENOSTAR- estradiol td patchweekly 14 mcg/24hrNP•MYFEMBREE- relugolix-estradiol-norethindrone acetate tab40-1-0.5 mgP• •norethindrone acetate-ethinylestradiol tab 0.5 mg-2.5 mcg(Femhrt low dose)npnorethindrone acetate-ethinylestradiol tab 1 mg-5 mcgnpORIAHNN- elagolix-estrad-noreth300-1-0.5mg & elagolix 300mgcap packP• •PREFEST- estradiol tab 1 mg(15)/estrad-norgestimate tab1-0.09mg(15)NPPREMARIN- estrogens,conjugated tab 0.3 mgPPREMARIN- estrogens,conjugated tab 0.45 mgPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPREMARIN- estrogens,conjugated tab 0.625 mgPPREMARIN- estrogens,conjugated tab 0.9 mgPPREMARIN- estrogens,conjugated tab 1.25 mgPPREMPHASE- conj est 0.625(14)/conj est-medroxypro ac tab0.625-5mg(14)PPREMPRO- conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mgPPREMPRO- conjugated estrogen-medroxyprogest acetate tab0.45-1.5 mgPPREMPRO- conjugated estrogen-medroxyprogest acetate tab0.625-2.5 mgPPREMPRO- conjugated estrogen-medroxyprogest acetate tab0.625-5 mgPCONTRACEPTIVESDEPO-SUBQ PROVERA 104-medroxyprogesterone acetatesusp pref syr 104 mg/0.65mlNPdesogest-eth estrad& eth estrad tab0.15-0.02/0.01 mg(21/5)(Mircette)np• •desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)np• •desogestrel & ethinyl estradioltab 0.15 mg-30 mcg (Desogen)p• •drospirenone-ethinylestrad-levomefolate tab3-0.02-0.451 mg (Beyaz)np• •drospirenone-ethinylestrad-levomefolate tab3-0.03-0.451 mg (Safyral)np• •drospirenone-ethinyl estradioltab 3-0.02 mg (Yaz)np• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 23Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdrospirenone-ethinyl estradioltab 3-0.03 mg (Yasmin 28)np• •ELLA- ulipristal acetate tab 30 mgP• •ethynodiol diacetate & ethinylestradiol tab 1 mg-35 mcgnp• •ethynodiol diacetate & ethinylestradiol tab 1 mg-50 mcgnp• •levonor-eth est tab0.15-0.02/0.025/0.03 mg &ethest 0.01 mg (Quartette)np• •levonorg-eth est tab0.1-0.02mg(84) & eth est tab0.01mg(7) (Loseasonique)np• •levonorg-eth est tab0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)np• •levonorgestrel & ethinylestradiol (91-day) tab0.15-0.03 mgnp• •levonorgestrel & ethinylestradiol tab 0.1 mg-20 mcgp• •levonorgestrel & ethinylestradiol tab 0.15 mg-30 mcgp• •levonorgestrel tab 1.5 mgnp• •levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcgp• •levonorgestrel-ethinyl estradiol(continuous) tab 90-20 mcgnp• •LO LOESTRIN FE- norethin-ethestradiol-fe tab 1 mg-10 mcg(24)/10 mcg (2)NP•medroxyprogesterone acetateim susp prefilled syr 150 mg/ml (Depo-provera contrac)np•medroxyprogesterone acetateim susp 150 mg/ml (Depo-provera contrac)np•NATAZIA- estradiolvalerate-dienogest tab3 mg /2-2 mg/2-3 mg/1 mgNP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAnorelgestromin-ethinyl estradioltd ptwk 150-35 mcg/24hrnp• •norethindrone & ethinylestradiol tab 0.4 mg-35 mcg(Ovcon-35)np• •norethindrone & ethinylestradiol tab 0.5 mg-35 mcg(Brevicon-28)np• •norethindrone & ethinylestradiol tab 1 mg-35 mcg(Norinyl 1+35)p• •norethindrone & ethinylestradiol-fe chew tab0.4 mg-35 mcg (Femcon fe)np• •norethindrone & ethinylestradiol-fe chew tab0.8 mg-25 mcg (Generess fe)np• •norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg(Estrostep fe)np• •norethindrone ace & ethinylestradiol tab 1 mg-20 mcg(Loestrin 1/20-21)p• •norethindrone ace & ethinylestradiol tab 1.5 mg-30 mcg(Loestrin 1.5/30-21)np• •norethindrone ace & ethinylestradiol-fe tab 1 mg-20 mcg(Loestrin fe 1/20)p• •norethindrone ace & ethinylestradiol-fe tab 1.5 mg-30 mcg(Loestrin fe 1.5/30)p• •norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)(Minastrin 24 fe)np• •norethindrone ace-ethinylestradiol-fe tab 1 mg-20 mcg(24)np• •norethindrone tab 0.35 mg(Ortho micronor)p• •norethindrone-eth estradiol tab0.5-35/0.75-35/1-35 mg-mcg(Ortho-novum 7/7/7)np• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 24Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAnorethindrone-eth estradiol tab0.5-35/1-35/0.5-35 mg-mcg(Tri-norinyl 28)np• •norgestimate & ethinyl estradioltab 0.25 mg-35 mcg (Ortho-cyclen)p• •norgestimate-eth estrad tab0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-cyclen lo)p• •norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen)p• •norgestrel & ethinyl estradioltab 0.3 mg-30 mcgnp• •NUVARING- etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hrnp• •TYBLUME- levonorgestrel &ethinyl estradiol chew tab0.1 mg-20 mcgNP•PROGESTINSmedroxyprogesterone acetatetab 2.5 mg (Provera)pmedroxyprogesterone acetatetab 5 mg (Provera)pmedroxyprogesterone acetatetab 10 mg (Provera)pmegestrol acetate susp625 mg/5ml (Megace es)npnorethindrone acetate tab 5 mg(Aygestin)npprogesterone cap 100 mg(Prometrium)npprogesterone cap 200 mg(Prometrium)npprogesterone im in oil 50 mg/mlnpANTIDIABETICSAntidiabeticsacarbose tab 25 mg (Precose)npacarbose tab 50 mg (Precose)npacarbose tab 100 mg (Precose)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACABAQSIMI ONE PACK- glucagonnasal powder 3 mg/dosePBAQSIMI TWO PACK- glucagonnasal powder 3 mg/dosePBD GLUCOSE- glucose chew tab5 gmNPBYDUREON BCISE- exenatideextended release susp auto-injector 2 mg/0.85mlNP•CVS GLUCOSE- glucose chewtab 4 gm (rounded)NPCVS GLUCOSE BITS- glucosechew tab 1 gmNPCVS SOFT GLUCOSE- glucosechew tab 4 gm (rounded)NPDEX4 GLUCOSE- glucose chewtab 4 gm (rounded)NPDEX4 QUICK DISSOLVEGLUCO- glucose chew tab 4 gm(rounded)NPdiazoxide susp 50 mg/ml(Proglycem)npDRUG MART GLUCOSE- glucosechew tab 4 gm (rounded)NPFARXIGA- dapagliflozinpropanediol tab 5 mg (baseequivalent)P•FARXIGA- dapagliflozinpropanediol tab 10 mg (baseequivalent)P•glimepiride tab 1 mg (Amaryl)pglimepiride tab 2 mg (Amaryl)pglimepiride tab 4 mg (Amaryl)pglipizide tab er 24hr 2.5 mg(Glucotrol xl)pglipizide tab er 24hr 5 mg(Glucotrol xl)pglipizide tab er 24hr 10 mg(Glucotrol xl)pglipizide tab 5 mg (Glucotrol)pglipizide tab 10 mg (Glucotrol)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 25Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAglipizide-metformin hcl tab2.5-250 mgnpglipizide-metformin hcl tab2.5-500 mgnpglipizide-metformin hcl tab5-500 mgnpGLUCAGEN HYPOKIT- glucagonhcl (rdna) for inj 1 mg (baseequiv)NPglucagon (rdna) for inj kit 1 mg(Glucagon emergency k)npGLUCAGON EMERGENCY KITFO- glucagon hcl for inj 1 mgPGLUCOSE- glucose chew tab4 gm (rounded)NPglyburide micronized tab 1.5 mg(Glynase)pglyburide micronized tab 3 mg(Glynase)pglyburide micronized tab 6 mg(Glynase)pglyburide tab 1.25 mgpglyburide tab 2.5 mgpglyburide tab 5 mgpglyburide-metformin tab1.25-250 mgpglyburide-metformin tab2.5-500 mg (Glucovance)pglyburide-metformin tab5-500 mg (Glucovance)pGLYXAMBI- empagliflozin-linagliptin tab 10-5 mgP•GLYXAMBI- empagliflozin-linagliptin tab 25-5 mgP•GNP GLUCOSE- glucose chewtab 4 gm (rounded)NPGNP QUICK DISSOLVEGLUCOS- glucose chew tab4 gm (rounded)NPGVOKE HYPOPEN 1-PACK- glucagon subcutaneousPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAsolution auto-injector0.5 mg/0.1mlGVOKE HYPOPEN 1-PACK- glucagon subcutaneoussolution auto-injector 1 mg/0.2mlPGVOKE HYPOPEN 2-PACK- glucagon subcutaneoussolution auto-injector0.5 mg/0.1mlPGVOKE HYPOPEN 2-PACK- glucagon subcutaneoussolution auto-injector 1 mg/0.2mlPGVOKE KIT- glucagonsubcutaneous soln 1 mg/0.2mlPGVOKE PFS- glucagonsubcutaneous soln pref syringe0.5 mg/0.1mlPGVOKE PFS- glucagonsubcutaneous soln pref syringe1 mg/0.2mlPJANUMET- sitagliptin-metforminhcl tab 50-500 mgP•JANUMET- sitagliptin-metforminhcl tab 50-1000 mgP•JANUMET XR- sitagliptin-metformin hcl tab er 24hr50-500 mgP•JANUMET XR- sitagliptin-metformin hcl tab er 24hr50-1000 mgP•JANUMET XR- sitagliptin-metformin hcl tab er 24hr100-1000 mgP•JANUVIA- sitagliptin phosphatetab 25 mg (base equiv)P•JANUVIA- sitagliptin phosphatetab 50 mg (base equiv)P•JANUVIA- sitagliptin phosphatetab 100 mg (base equiv)P•JARDIANCE- empagliflozin tab10 mgP•JARDIANCE- empagliflozin tab25 mgP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 26Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAKORLYM- mifepristone tab300 mgNP• • •KROGER GLUCOSE- glucosechew tab 4 gm (rounded)NPLEADER GLUCOSE- glucosechew tab 4 gm (rounded)NPLEADER QUICK DISSOLVEGLU- glucose chew tab 4 gm(rounded)NPLONGS GLUCOSE- glucose chewtab 4 gm (rounded)NPMEDICINE SHOPPEGLUCOSE- glucose chew tab4 gm (rounded)NPmetformin hcl tab er 24hr500 mg (Glucophage xr)pmetformin hcl tab er 24hr750 mg (Glucophage xr)pmetformin hcl tab 500 mg(Glucophage)pmetformin hcl tab 850 mg(Glucophage)pmetformin hcl tab 1000 mg(Glucophage)pmiglitol tab 25 mgnpmiglitol tab 50 mgnpmiglitol tab 100 mgnpMS QUICK DISSOLVEGLUCOSE- glucose chew tab4 gm (rounded)NPnateglinide tab 60 mg (Starlix)npnateglinide tab 120 mg (Starlix)npOZEMPIC- semaglutide solnpen-inj 0.25 or 0.5 mg/dose(2 mg/1.5ml)P•OZEMPIC- semaglutide soln pen-inj 1 mg/dose (4 mg/3ml)P•OZEMPIC- semaglutide soln pen-inj 2 mg/dose (8 mg/3ml)P•pioglitazone hcl tab 15 mg(base equiv) (Actos)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACApioglitazone hcl tab 30 mg(base equiv) (Actos)ppioglitazone hcl tab 45 mg(base equiv) (Actos)ppioglitazone hcl-metformin hcltab 15-500 mg (Actoplus met)nppioglitazone hcl-metformin hcltab 15-850 mg (Actoplus met)npPREFERRED PLUSGLUCOSE- glucose chew tab4 gm (rounded)NPrepaglinide tab 0.5 mgnprepaglinide tab 1 mg (Prandin)nprepaglinide tab 2 mg (Prandin)npRYBELSUS- semaglutide tab3 mgP•RYBELSUS- semaglutide tab7 mgP•RYBELSUS- semaglutide tab14 mgP•SM GLUCOSE- glucose chew tab4 gm (rounded)NPSOLIQUA 100/33-insulin glargine-lixisenatide solpen-inj 100-33 unit-mcg/mlP•SYNJARDY- empagliflozin-metformin hcl tab 5-500 mgP•SYNJARDY- empagliflozin-metformin hcl tab 5-1000 mgP•SYNJARDY- empagliflozin-metformin hcl tab 12.5-500 mgP•SYNJARDY- empagliflozin-metformin hcl tab 12.5-1000 mgP•SYNJARDY XR- empagliflozin-metformin hcl tab er 24hr5-1000 mgP•SYNJARDY XR- empagliflozin-metformin hcl tab er 24hr10-1000 mgP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 27Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACASYNJARDY XR- empagliflozin-metformin hcl tab er 24hr12.5-1000 mgP•SYNJARDY XR- empagliflozin-metformin hcl tab er 24hr25-1000 mgP•TRIJARDY XR- empagliflozin-linaglip-metformin tab er 24hr12.5-2.5-1000mgP•TRIJARDY XR- empagliflozin-linagliptin-metformin tab er 24hr5-2.5-1000mgP•TRIJARDY XR- empagliflozin-linagliptin-metformin tab er 24hr10-5-1000 mgP•TRIJARDY XR- empagliflozin-linagliptin-metformin tab er 24hr25-5-1000 mgP•TRULICITY- dulaglutide soln pen-injector 0.75 mg/0.5mlP•TRULICITY- dulaglutide soln pen-injector 1.5 mg/0.5mlP•TRULICITY- dulaglutide soln pen-injector 3 mg/0.5mlP•TRULICITY- dulaglutide soln pen-injector 4.5 mg/0.5mlP•VALUE PLUS GLUCOSE- glucosechew tab 4 gm (rounded)NPVICTOZA- liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)P•WALGREENSGLUCOSE- glucose chew tab4 gm (rounded)NPXIGDUO XR- dapagliflozin-metformin hcl tab er 24hr2.5-1000 mgP•XIGDUO XR- dapagliflozin-metformin hcl tab er 24hr5-500 mgP•XIGDUO XR- dapagliflozin-metformin hcl tab er 24hr5-1000 mgP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAXIGDUO XR- dapagliflozin-metformin hcl tab er 24hr10-500 mgP•XIGDUO XR- dapagliflozin-metformin hcl tab er 24hr10-1000 mgP•XULTOPHY 100/3.6- insulindegludec-liraglutide sol pen-inj100-3.6 unit-mg/mlP•ZEGALOGUE- dasiglucagon hclsubcutaneous soln auto-inj0.6 mg/0.6mlPZEGALOGUE- dasiglucagon hclsubcutaneous soln pref syringe0.6 mg/0.6mlPRapid-Acting InsulinsFIASP- insulin aspart (withniacinamide) inj 100 unit/mlP•FIASP FLEXTOUCH- insulinaspart (with niacinamide) solpen-inj 100 unit/mlP•FIASP PENFILL- insulin aspart(with niacinamide) soln cartridge100 unit/mlP•INSULIN ASPART- insulin aspartinj soln 100 unit/mlP•INSULIN ASPART FLEXPEN-insulin aspart soln pen-injector100 unit/mlP•INSULIN ASPART PENFILL-insulin aspart soln cartridge 100unit/mlP•NOVOLOG- insulin aspart inj soln100 unit/mlP•NOVOLOG FLEXPEN- insulinaspart soln pen-injector 100unit/mlP•NOVOLOG FLEXPEN RELION-insulin aspart soln pen-injector100 unit/mlP•NOVOLOG PENFILL- insulinaspart soln cartridge 100 unit/mlP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 28Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANOVOLOG RELION- insulinaspart inj soln 100 unit/mlP•Short-Acting InsulinsHUMULIN R U-500 (CONCENTR-insulin regular (human) inj 500unit/mlP•HUMULIN R U-500 KWIKPEN-insulin regular (human) solnpen-injector 500 unit/mlP•NOVOLIN R- insulin regular(human) inj 100 unit/mlP•NOVOLIN R FLEXPEN- insulinregular (human) soln pen-injector 100 unit/mlP•NOVOLIN R FLEXPEN RELION-insulin regular (human) solnpen-injector 100 unit/mlP•NOVOLIN R RELION- insulinregular (human) inj 100 unit/mlP•Intermediate-Acting InsulinsINSULIN ASPART PROTAMINE/-insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)P•INSULIN ASPART PROTAMINE/-insulin aspart prot & aspart suspen-inj 100 unit/ml (70-30)P•NOVOLIN N- insulin nph (human)(isophane) inj 100 unit/mlP•NOVOLIN N FLEXPEN- insulinnph (human) (isophane) susppen-injector 100 unit/mlP•NOVOLIN N FLEXPEN RELION-insulin nph (human) (isophane)susp pen-injector 100 unit/mlP•NOVOLIN N RELION- insulin nph(human) (isophane) inj 100 unit/mlP•NOVOLIN 70/30- insulin nphisophane & regular human inj100 unit/ml (70-30)P•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANOVOLIN 70/30 FLEXPEN-insulin nph & regular susp pen-inj 100 unit/ml (70-30)P•NOVOLIN 70/30 FLEXPEN REL-insulin nph & regular susp pen-inj 100 unit/ml (70-30)P•NOVOLIN 70/30 RELION- insulinnph isophane & regular humaninj 100 unit/ml (70-30)P•NOVOLOG MIX 70/30- insulinaspart prot & aspart (human) inj100 unit/ml (70-30)P•NOVOLOG MIX 70/30 PREFILL-insulin aspart prot & aspart suspen-inj 100 unit/ml (70-30)P•NOVOLOG MIX 70/30 RELION-insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)P•Basal InsulinsINSULIN GLARGINE-insulin glargine-yfgn inj 100 unit/mlP•INSULIN GLARGINE-insulin glargine-yfgn soln pen-injector 100 unit/mlP•LEVEMIR- insulin detemir inj 100unit/mlP•LEVEMIR FLEXTOUCH- insulindetemir soln pen-injector 100unit/mlP•SEMGLEE- insulin glargine-yfgninj 100 unit/mlP•SEMGLEE- insulin glargine-yfgnsoln pen-injector 100 unit/mlP•TOUJEO MAX SOLOSTAR-insulin glargine soln pen-injector300 unit/ml (2 unit dial)P•TOUJEO SOLOSTAR-insulin glargine soln pen-injector300 unit/ml (1 unit dial)P•TRESIBA- insulin degludec inj 100unit/mlP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 29Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACATRESIBA FLEXTOUCH- insulindegludec soln pen-injector 100unit/mlP•TRESIBA FLEXTOUCH- insulindegludec soln pen-injector 200unit/mlP•THYROID AGENTSARMOUR THYROID- thyroid tab15 mg (1/4 grain)NPARMOUR THYROID- thyroid tab30 mg (1/2 grain)NPARMOUR THYROID- thyroid tab60 mg (1 grain)NPARMOUR THYROID- thyroid tab90 mg (1 1/2 grain)NPARMOUR THYROID- thyroid tab120 mg (2 grain)NPARMOUR THYROID- thyroid tab180 mg (3 grain)NPARMOUR THYROID- thyroid tab240 mg (4 grain)NPARMOUR THYROID- thyroid tab300 mg (5 grain)NPLEVOTHYROXINE SODIUM-levothyroxine sodium cap13 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap25 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap50 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap75 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap88 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap100 mcgNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACALEVOTHYROXINE SODIUM-levothyroxine sodium cap112 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap125 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap137 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap150 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap175 mcgNPLEVOTHYROXINE SODIUM-levothyroxine sodium cap200 mcgNPlevothyroxine sodium tab25 mcg (Synthroid)plevothyroxine sodium tab50 mcg (Synthroid)plevothyroxine sodium tab75 mcg (Synthroid)plevothyroxine sodium tab88 mcg (Synthroid)plevothyroxine sodium tab100 mcg (Synthroid)plevothyroxine sodium tab112 mcg (Synthroid)plevothyroxine sodium tab125 mcg (Synthroid)plevothyroxine sodium tab137 mcg (Synthroid)plevothyroxine sodium tab150 mcg (Synthroid)plevothyroxine sodium tab175 mcg (Synthroid)plevothyroxine sodium tab200 mcg (Synthroid)plevothyroxine sodium tab300 mcg (Synthroid)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 30Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAliothyronine sodium tab 5 mcg(Cytomel)npliothyronine sodium tab 25 mcg(Cytomel)npliothyronine sodium tab 50 mcg(Cytomel)npmethimazole tab 5 mg(Tapazole)pmethimazole tab 10 mg(Tapazole)ppropylthiouracil tab 50 mgnpSYNTHROID- levothyroxinesodium tab 25 mcgPSYNTHROID- levothyroxinesodium tab 50 mcgPSYNTHROID- levothyroxinesodium tab 75 mcgPSYNTHROID- levothyroxinesodium tab 88 mcgPSYNTHROID- levothyroxinesodium tab 100 mcgPSYNTHROID- levothyroxinesodium tab 112 mcgPSYNTHROID- levothyroxinesodium tab 125 mcgPSYNTHROID- levothyroxinesodium tab 137 mcgPSYNTHROID- levothyroxinesodium tab 150 mcgPSYNTHROID- levothyroxinesodium tab 175 mcgPSYNTHROID- levothyroxinesodium tab 200 mcgPSYNTHROID- levothyroxinesodium tab 300 mcgPTHYQUIDITY- levothyroxinesodium oral solution100 mcg/5mlNPthyroid tab 15 mg (1/4 grain)(Armour thyroid)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAthyroid tab 30 mg (1/2 grain)(Armour thyroid)pthyroid tab 60 mg (1 grain)(Armour thyroid)npthyroid tab 90 mg (1 1/2 grain)(Armour thyroid)npthyroid tab 120 mg (2 grain)(Armour thyroid)npTIROSINT- levothyroxine sodiumcap 13 mcgNPTIROSINT- levothyroxine sodiumcap 25 mcgNPTIROSINT- levothyroxine sodiumcap 50 mcgNPTIROSINT- levothyroxine sodiumcap 75 mcgNPTIROSINT- levothyroxine sodiumcap 88 mcgNPTIROSINT- levothyroxine sodiumcap 100 mcgNPTIROSINT- levothyroxine sodiumcap 112 mcgNPTIROSINT- levothyroxine sodiumcap 125 mcgNPTIROSINT- levothyroxine sodiumcap 137 mcgNPTIROSINT- levothyroxine sodiumcap 150 mcgNPTIROSINT- levothyroxine sodiumcap 175 mcgNPTIROSINT- levothyroxine sodiumcap 200 mcgNPTIROSINT-SOL- levothyroxinesodium oral solution 13 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 25 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 37.5 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 44 mcg/mlNP

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 31Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACATIROSINT-SOL- levothyroxinesodium oral solution 50 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 62.5 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 75 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 88 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 100 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 112 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 125 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 137 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 150 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 175 mcg/mlNPTIROSINT-SOL- levothyroxinesodium oral solution 200 mcg/mlNPOXYTOCICSCERVIDIL- dinoprostone vaginalinserts 10 mgNPmethylergonovine maleate tab0.2 mgnpENDOCRINE and METABOLIC AGENTS - MISC.ACTHAR- corticotropin inj gel 80unit/mlNP• •ALENDRONATE SODIUM-alendronate sodium oral soln70 mg/75mlnp•ALENDRONATE SODIUM-alendronate sodium tab 5 mgNP•alendronate sodium tab 10 mgp•alendronate sodium tab 35 mgp•alendronate sodium tab 70 mg(Fosamax)p•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAbetaine powder for oral solution(Cystadane)np•cabergoline tab 0.5 mgnpcalcitonin (salmon) inj 200 unit/ml (Miacalcin)npcalcitonin (salmon) nasal soln200 unit/actnpcalcitriol cap 0.25 mcg(Rocaltrol)pcalcitriol cap 0.5 mcg(Rocaltrol)npcalcitriol oral soln 1 mcg/ml(Rocaltrol)npcarglumic acid soluble tab200 mg (Carbaglu)np•CHORIONIC GONADOTROPIN-chorionic gonadotropin for im inj10000 unitP+• •cinacalcet hcl tab 30 mg (baseequiv)npcinacalcet hcl tab 60 mg (baseequiv)npcinacalcet hcl tab 90 mg (baseequiv)npCLOMID- clomiphene citrate tab50 mgnp+CLOMIPHENE CITRATE-clomiphene citrate tab 50 mgnp+desmopressin acetate inj4 mcg/ml (Ddavp)npdesmopressin acetate nasalspray soln 0.01% (Ddavp)npdesmopressin acetatenasal spray soln 0.01%(refrigerated)npdesmopressin acetatepreservative free (pf) inj4 mcg/ml (Ddavp)npdesmopressin acetate tab0.1 mg (Ddavp)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 32Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdesmopressin acetate tab0.2 mg (Ddavp)npdoxercalciferol cap 0.5 mcg(Hectorol)npdoxercalciferol cap 1 mcg(Hectorol)npdoxercalciferol cap 2.5 mcg(Hectorol)npFOLLISTIM AQ- follitropin beta inj300 unit/0.36mlP+• •FOLLISTIM AQ- follitropin beta inj600 unit/0.72mlP+• •FOLLISTIM AQ- follitropin beta inj900 unit/1.08mlP+• •FORTEO- teriparatide(recombinant) soln pen-inj600 mcg/2.4mlP• • •GALAFOLD- migalastat hcl cap123 mg (base equivalent)NP• • •ganirelix acetate soln prefilledsyringe 250 mcg/0.5ml(Ganirelix acetate)np+• •ibandronate sodium tab 150 mg(base equivalent) (Boniva)p•INCRELEX- mecasermin inj40 mg/4ml (10 mg/ml)P•ISTURISA- osilodrostat phosphatetab 1 mgNP• • •ISTURISA- osilodrostat phosphatetab 5 mgNP• • •ISTURISA- osilodrostat phosphatetab 10 mgNP• • •JYNARQUE- tolvaptan tabtherapy pack 15 mgNP• • •JYNARQUE- tolvaptan tabtherapy pack 30 & 15 mgNP• • •JYNARQUE- tolvaptan tabtherapy pack 45 & 15 mgNP• • •JYNARQUE- tolvaptan tabtherapy pack 60 & 30 mgNP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAJYNARQUE- tolvaptan tabtherapy pack 90 & 30 mgNP• • •JYNARQUE- tolvaptan tab 15 mgNP• • •JYNARQUE- tolvaptan tab 30 mgNP• • •levocarnitine oral soln1 gm/10ml (10%) (Carnitor)nplevocarnitine tab 330 mg(Carnitor)npLUPRON DEPOT-PED (1-MONTH- leuprolide acetate forinj pediatric kit 7.5 mgP•LUPRON DEPOT-PED (1-MONTH- leuprolide acetate forinj pediatric kit 11.25 mgP•LUPRON DEPOT-PED (1-MONTH- leuprolide acetate forinj pediatric kit 15 mgP•LUPRON DEPOT-PED (3-MONTH- leuprolide acetate(3 month) for inj pediatric kit11.25 mgP•LUPRON DEPOT-PED (3-MONTH- leuprolide acetate (3month) for inj pediatric kit 30 mgP•MENOPUR- menotropins forsubcutaneous inj 75 unitNP+• •MYALEPT- metreleptin forsubcutaneous inj 11.3 mgNP• •MYCAPSSA- octreotide acetatecap delayed release 20 mgNP• • •NATPARA- parathyroid hormone(recombinant) for inj cartridge25 mcgNP• • •NATPARA- parathyroid hormone(recombinant) for inj cartridge50 mcgNP• • •NATPARA- parathyroid hormone(recombinant) for inj cartridge75 mcgNP• • •NATPARA- parathyroid hormone(recombinant) for inj cartridge100 mcgNP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 33Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAnitisinone cap 2 mg (Orfadin)np•nitisinone cap 5 mg (Orfadin)np•nitisinone cap 10 mg (Orfadin)np•NITYR- nitisinone tab 2 mgP•NITYR- nitisinone tab 5 mgP•NITYR- nitisinone tab 10 mgP•NORDITROPIN FLEXPRO-somatropin solution pen-injector5 mg/1.5mlP• •NORDITROPIN FLEXPRO-somatropin solution pen-injector10 mg/1.5mlP• •NORDITROPIN FLEXPRO-somatropin solution pen-injector15 mg/1.5mlP• •NORDITROPIN FLEXPRO-somatropin solution pen-injector30 mg/3mlP• •NOVAREL-chorionic gonadotropin for im inj5000 unitP+• •NOVAREL-chorionic gonadotropin for im inj10000 unitP+• •NULIBRY- fosdenopterinhydrobromide for iv soln 9.5 mgNP•OCTREOTIDE ACETATE-octreotide acetate subcutaneoussoln pref syr 50 mcg/mlNP•OCTREOTIDE ACETATE-octreotide acetate subcutaneoussoln pref syr 100 mcg/mlNP•OCTREOTIDE ACETATE-octreotide acetate subcutaneoussoln pref syr 500 mcg/mlNP•octreotide acetate inj 50 mcg/ml(0.05 mg/ml) (Sandostatin)np•octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)np•octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)np•octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)np•ORFADIN- nitisinone cap 20 mgP•ORFADIN- nitisinone susp 4 mg/mlP•ORILISSA- elagolix sodium tab150 mg (base equiv)P• •ORILISSA- elagolix sodium tab200 mg (base equiv)P• •PALYNZIQ- pegvaliase-pqpzsubcutaneous soln pref syringe2.5 mg/0.5mlNP• •PALYNZIQ- pegvaliase-pqpzsubcutaneous soln pref syringe10 mg/0.5mlNP• •PALYNZIQ- pegvaliase-pqpzsubcutaneous soln pref syringe20 mg/mlNP• •paricalcitol cap 1 mcg (Zemplar)npparicalcitol cap 2 mcg (Zemplar)npparicalcitol cap 4 mcgnpPREGNYL W/DILUENT BENZYL-chorionic gonadotropin for im inj10000 unitP+• •raloxifene hcl tab 60 mg (Evista)np•RAVICTI- glycerol phenylbutyrateliquid 1.1 gm/mlNP• •REVCOVI- elapegademase-lvlr imsoln 2.4 mg/1.5ml (1.6 mg/ml)Prisedronate sodium tab delayedrelease 35 mg (Atelvia)np•risedronate sodium tab 5 mg(Actonel)np•risedronate sodium tab 30 mg(Actonel)np•risedronate sodium tab 35 mg(Actonel)np•risedronate sodium tab 150 mg(Actonel)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 34Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAsapropterin dihydrochloridepowder packet 100 mg(Kuvan)np• •sapropterin dihydrochloridepowder packet 500 mg(Kuvan)np• •sapropterin dihydrochloride tab100 mg (Kuvan)np• •SIGNIFOR- pasireotidediaspartate inj 0.3 mg/ml (baseequiv)NP• •SIGNIFOR- pasireotidediaspartate inj 0.6 mg/ml (baseequiv)NP• •SIGNIFOR- pasireotidediaspartate inj 0.9 mg/ml (baseequiv)NP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 3 mgNP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 3.6 mgNP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 4.3 mgNP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 5.2 mgNP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 6.3 mgNP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 7.6 mgNP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 9.1 mgNP• •SKYTROFA- lonapegsomatropin-tcgd for subcutaneous injcartridge 11 mgNP• •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACASKYTROFA- lonapegsomatropin-tcgd for subcutaneous inj cart13.3 mgNP• •sodium phenylbutyrate oralpowder 3 gm/teaspoonful(Buphenyl)np• •sodium phenylbutyrate tab500 mg (Buphenyl)np• •SOMAVERT- pegvisomant for inj10 mg (as protein)NP• • •SOMAVERT- pegvisomant for inj15 mg (as protein)NP• • •SOMAVERT- pegvisomant for inj20 mg (as protein)NP• • •SOMAVERT- pegvisomant for inj25 mg (as protein)NP• • •SOMAVERT- pegvisomant for inj30 mg (as protein)NP• • •STIMATE- desmopressin acetatenasal soln 1.5 mg/mlPSTRENSIQ- asfotase alfasubcutaneous inj 18 mg/0.45mlP• •STRENSIQ- asfotase alfasubcutaneous inj 28 mg/0.7mlP• •STRENSIQ- asfotase alfasubcutaneous inj 40 mg/mlP• •STRENSIQ- asfotase alfasubcutaneous inj 80 mg/0.8mlP• •SYNAREL- nafarelin acetate nasalsoln 2 mg/ml (200 mcg/act)(base eq)NPtolvaptan tab 15 mg (Samsca)np• •tolvaptan tab 30 mg (Samsca)np• •TYMLOS- abaloparatidesubcutaneous soln pen-injector3120 mcg/1.56mlP• • •VOXZOGO- vosoritide forsubcutaneous inj 0.4 mgNP• • •VOXZOGO- vosoritide forsubcutaneous inj 0.56 mgNP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 35Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAVOXZOGO- vosoritide forsubcutaneous inj 1.2 mgNP• • •CARDIOVASCULAR AGENTSCARDIOTONICSDIGOXIN- digoxin oral soln0.05 mg/mlNP•digoxin oral soln 0.05 mg/ml(Digoxin)np•digoxin tab 62.5 mcg(0.0625 mg) (Lanoxin)npdigoxin tab 125 mcg (0.125 mg)(Lanoxin)pdigoxin tab 250 mcg (0.25 mg)(Lanoxin)pLANOXIN- digoxin tab 62.5 mcg(0.0625 mg)NPLANOXIN- digoxin tab 125 mcg(0.125 mg)NPLANOXIN- digoxin tab 250 mcg(0.25 mg)NPANTIANGINAL AGENTSisosorbide dinitrate tab 5 mg(Isordil titradose)npisosorbide dinitrate tab 10 mgnpisosorbide dinitrate tab 20 mgnpisosorbide dinitrate tab 30 mgnpisosorbide mononitrate tab er24hr 30 mgpisosorbide mononitrate tab er24hr 60 mgpisosorbide mononitrate tab er24hr 120 mgpisosorbide mononitrate tab10 mgpisosorbide mononitrate tab20 mgpNITRO-BID- nitroglycerin oint 2%NPNITRO-DUR- nitroglycerin tdpatch 24hr 0.3 mg/hrNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANITRO-DUR- nitroglycerin tdpatch 24hr 0.8 mg/hrNPNITRO-TIME- nitroglycerin cap er2.5 mgNPNITRO-TIME- nitroglycerin cap er6.5 mgNPNITRO-TIME- nitroglycerin cap er9 mgNPnitroglycerin sl tab 0.3 mg(Nitrostat)npnitroglycerin sl tab 0.4 mg(Nitrostat)pnitroglycerin sl tab 0.6 mg(Nitrostat)npnitroglycerin td patch 24hr0.1 mg/hr (Nitro-dur)npnitroglycerin td patch 24hr0.2 mg/hr (Nitro-dur)npnitroglycerin td patch 24hr0.4 mg/hr (Nitro-dur)npnitroglycerin td patch 24hr0.6 mg/hr (Nitro-dur)npnitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)(Nitrolingual pumpspr)npNITROMIST- nitroglycerin lingualaerosol 400 mcg/sprayNPranolazine tab er 12hr 500 mg(Ranexa)npranolazine tab er 12hr 1000 mg(Ranexa)npBETA BLOCKERSacebutolol hcl cap 200 mgnpacebutolol hcl cap 400 mgnpatenolol tab 25 mg (Tenormin)patenolol tab 50 mg (Tenormin)patenolol tab 100 mg (Tenormin)pbetaxolol hcl tab 10 mgnpbetaxolol hcl tab 20 mgnpbisoprolol fumarate tab 5 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 36Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAbisoprolol fumarate tab 10 mgnpcarvedilol tab 3.125 mg (Coreg)pcarvedilol tab 6.25 mg (Coreg)pcarvedilol tab 12.5 mg (Coreg)pcarvedilol tab 25 mg (Coreg)plabetalol hcl tab 100 mgplabetalol hcl tab 200 mgnplabetalol hcl tab 300 mgnpmetoprolol succinate tab er24hr 25 mg (tartrate equiv)(Toprol xl)pmetoprolol succinate tab er24hr 50 mg (tartrate equiv)(Toprol xl)pmetoprolol succinate tab er24hr 100 mg (tartrate equiv)(Toprol xl)pmetoprolol succinate tab er24hr 200 mg (tartrate equiv)(Toprol xl)npmetoprolol tartrate tab 25 mgpmetoprolol tartrate tab 37.5 mgpmetoprolol tartrate tab 50 mg(Lopressor)pmetoprolol tartrate tab 75 mgpmetoprolol tartrate tab 100 mg(Lopressor)pnadolol tab 20 mg (Corgard)npnadolol tab 40 mg (Corgard)npnadolol tab 80 mg (Corgard)nppindolol tab 5 mgnppindolol tab 10 mgnpPROPRANOLOL HCL-propranolol hcl oral soln40 mg/5mlPpropranolol hcl cap er 24hr60 mg (Inderal la)nppropranolol hcl cap er 24hr80 mg (Inderal la)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACApropranolol hcl cap er 24hr120 mg (Inderal la)nppropranolol hcl cap er 24hr160 mg (Inderal la)nppropranolol hcl oral soln20 mg/5mlnppropranolol hcl tab 10 mgppropranolol hcl tab 20 mgppropranolol hcl tab 40 mgppropranolol hcl tab 60 mgnppropranolol hcl tab 80 mgnpsotalol hcl (afib/afl) tab 80 mg(Betapace af)psotalol hcl (afib/afl) tab 120 mg(Betapace af)psotalol hcl (afib/afl) tab 160 mg(Betapace af)npsotalol hcl tab 80 mg (Betapace)psotalol hcl tab 120 mg(Betapace)psotalol hcl tab 160 mg(Betapace)npsotalol hcl tab 240 mgnpCALCIUM CHANNEL BLOCKERSamlodipine besylate tab 2.5 mg(base equivalent) (Norvasc)pamlodipine besylate tab 5 mg(base equivalent) (Norvasc)pamlodipine besylate tab 10 mg(base equivalent) (Norvasc)pCARDIZEM LA- diltiazem hclcoated beads tab er 24hr120 mgNPdiltiazem hcl cap er 12hr 60 mgnpdiltiazem hcl cap er 12hr 90 mgnpdiltiazem hcl cap er 12hr 120 mgnpdiltiazem hcl cap er 24hr 120 mgnpdiltiazem hcl cap er 24hr 180 mgnpdiltiazem hcl cap er 24hr 240 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 37Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdiltiazem hcl coated beads caper 24hr 120 mg (Cardizem cd)pdiltiazem hcl coated beads caper 24hr 180 mg (Cardizem cd)pdiltiazem hcl coated beads caper 24hr 240 mg (Cardizem cd)pdiltiazem hcl coated beads caper 24hr 300 mgnpdiltiazem hcl coated beads caper 24hr 360 mg (Cardizem cd)npdiltiazem hcl coated beads taber 24hr 180 mg (Cardizem la)npdiltiazem hcl coated beads taber 24hr 240 mg (Cardizem la)npdiltiazem hcl coated beads taber 24hr 300 mg (Cardizem la)npdiltiazem hcl coated beads taber 24hr 360 mg (Cardizem la)npdiltiazem hcl coated beads taber 24hr 420 mg (Cardizem la)npdiltiazem hcl extended releasebeads cap er 24hr 120 mg(Tiazac)pdiltiazem hcl extended releasebeads cap er 24hr 180 mg(Tiazac)pdiltiazem hcl extended releasebeads cap er 24hr 240 mg(Tiazac)npdiltiazem hcl extended releasebeads cap er 24hr 300 mg(Tiazac)npdiltiazem hcl extended releasebeads cap er 24hr 360 mg(Tiazac)npdiltiazem hcl extended releasebeads cap er 24hr 420 mg(Tiazac)npdiltiazem hcl tab 30 mg(Cardizem)pdiltiazem hcl tab 60 mg(Cardizem)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdiltiazem hcl tab 90 mgnpdiltiazem hcl tab 120 mg(Cardizem)npfelodipine tab er 24hr 2.5 mgpfelodipine tab er 24hr 5 mgpfelodipine tab er 24hr 10 mgpisradipine cap 2.5 mgnpisradipine cap 5 mgnpnicardipine hcl cap 20 mgnpnicardipine hcl cap 30 mgnpnifedipine cap 10 mg(Procardia)npnifedipine cap 20 mgnpnifedipine tab er 24hr 30 mg(Adalat cc)pnifedipine tab er 24hr 60 mg(Adalat cc)npnifedipine tab er 24hr 90 mg(Adalat cc)npnifedipine tab er 24hr osmoticrelease 30 mg (Procardia xl)pnifedipine tab er 24hr osmoticrelease 60 mg (Procardia xl)npnifedipine tab er 24hr osmoticrelease 90 mg (Procardia xl)npnimodipine cap 30 mgnpNISOLDIPINE ER- nisoldipine taber 24hr 20 mgNPNISOLDIPINE ER- nisoldipine taber 24hr 25.5 mgNPNISOLDIPINE ER- nisoldipine taber 24hr 30 mgNPNISOLDIPINE ER- nisoldipine taber 24hr 40 mgNPNYMALIZE- nimodipine oral soln6 mg/mlNPverapamil hcl cap er 24hr120 mg (Verelan)npverapamil hcl cap er 24hr180 mg (Verelan)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 38Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAverapamil hcl cap er 24hr240 mg (Verelan)npVERAPAMIL HCL ER- verapamilhcl cap er 24hr 100 mgNPVERAPAMIL HCL ER- verapamilhcl cap er 24hr 300 mgNPVERAPAMIL HCL SR- verapamilhcl cap er 24hr 360 mgNPverapamil hcl tab er 120 mg(Calan sr)pverapamil hcl tab er 180 mg(Calan sr)pverapamil hcl tab er 240 mg(Calan sr)pverapamil hcl tab 40 mgpverapamil hcl tab 80 mg (Calan)pverapamil hcl tab 120 mg(Calan)pVERAPAMIL HYDROCHLORIDEE- verapamil hcl cap er 24hr200 mgNPVERELAN PM- verapamil hcl caper 24hr 100 mgNPVERELAN PM- verapamil hcl caper 24hr 200 mgNPVERELAN PM- verapamil hcl caper 24hr 300 mgNPANTIARRHYTHMICSamiodarone hcl tab 100 mgnpamiodarone hcl tab 200 mgpamiodarone hcl tab 400 mgnpdisopyramide phosphate cap100 mg (Norpace)npdisopyramide phosphate cap150 mg (Norpace)npdofetilide cap 125 mcg(0.125 mg) (Tikosyn)npdofetilide cap 250 mcg(0.25 mg) (Tikosyn)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdofetilide cap 500 mcg (0.5 mg)(Tikosyn)npflecainide acetate tab 50 mgnpflecainide acetate tab 100 mgnpflecainide acetate tab 150 mgnpmexiletine hcl cap 150 mgnpmexiletine hcl cap 200 mgnpmexiletine hcl cap 250 mgnpMULTAQ- dronedarone hcl tab400 mg (base equivalent)PNORPACE- disopyramidephosphate cap 100 mgNPNORPACE- disopyramidephosphate cap 150 mgNPNORPACE CR- disopyramidephosphate cap er 12hr 100 mgNPNORPACE CR- disopyramidephosphate cap er 12hr 150 mgNPpropafenone hcl cap er 12hr225 mg (Rythmol sr)nppropafenone hcl cap er 12hr325 mg (Rythmol sr)nppropafenone hcl cap er 12hr425 mg (Rythmol sr)nppropafenone hcl tab 150 mgppropafenone hcl tab 225 mgnppropafenone hcl tab 300 mgnpquinidine gluconate tab er324 mgnpQUINIDINE SULFATE- quinidinesulfate tab 200 mgNPQUINIDINE SULFATE- quinidinesulfate tab 300 mgNPANTIHYPERTENSIVESamlodipine besylate-benazeprilhcl cap 2.5-10 mgpamlodipine besylate-benazeprilhcl cap 5-10 mg (Lotrel)pamlodipine besylate-benazeprilhcl cap 5-20 mg (Lotrel)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 39Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAamlodipine besylate-benazeprilhcl cap 5-40 mgpamlodipine besylate-benazeprilhcl cap 10-20 mg (Lotrel)pamlodipine besylate-benazeprilhcl cap 10-40 mg (Lotrel)pamlodipine besylate-olmesartanmedoxomil tab 5-20 mg (Azor)npamlodipine besylate-olmesartanmedoxomil tab 5-40 mg (Azor)npamlodipine besylate-olmesartanmedoxomil tab 10-20 mg(Azor)npamlodipine besylate-olmesartanmedoxomil tab 10-40 mg(Azor)npamlodipine besylate-valsartantab 5-160 mg (Exforge)npamlodipine besylate-valsartantab 5-320 mg (Exforge)npamlodipine besylate-valsartantab 10-160 mg (Exforge)npamlodipine besylate-valsartantab 10-320 mg (Exforge)npamlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)npamlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg (Exforge hct)npamlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct)npamlodipine-valsartan-hydrochlorothiazide tab10-160-25 mg (Exforge hct)npamlodipine-valsartan-hydrochlorothiazide tab10-320-25 mg (Exforge hct)npatenolol & chlorthalidone tab50-25 mg (Tenoretic 50)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAatenolol & chlorthalidone tab100-25 mg (Tenoretic 100)npbenazepril &hydrochlorothiazide tab10-12.5 mg (Lotensin hct)npbenazepril &hydrochlorothiazide tab20-12.5 mg (Lotensin hct)npbenazepril &hydrochlorothiazide tab20-25 mg (Lotensin hct)npbenazepril hcl tab 5 mgpbenazepril hcl tab 10 mgpbenazepril hcl tab 20 mg(Lotensin)pbenazepril hcl tab 40 mg(Lotensin)pBENAZEPRIL HCL/HYDROCHLOR- benazepril& hydrochlorothiazide tab5-6.25 mgNPbisoprolol &hydrochlorothiazide tab2.5-6.25 mg (Ziac)pbisoprolol &hydrochlorothiazide tab5-6.25 mg (Ziac)pbisoprolol &hydrochlorothiazide tab10-6.25 mg (Ziac)pcandesartan cilexetil tab 4 mg(Atacand)npcandesartan cilexetil tab 8 mg(Atacand)npcandesartan cilexetil tab 16 mg(Atacand)npcandesartan cilexetil tab 32 mg(Atacand)npcandesartan cilexetil-hydrochlorothiazide tab16-12.5 mg (Atacand hct)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 40Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAcandesartan cilexetil-hydrochlorothiazide tab32-12.5 mg (Atacand hct)npcandesartan cilexetil-hydrochlorothiazide tab32-25 mg (Atacand hct)npcaptopril tab 12.5 mgnpcaptopril tab 25 mgnpcaptopril tab 50 mgnpcaptopril tab 100 mgnpclonidine hcl tab 0.1 mg(Catapres)pclonidine hcl tab 0.2 mg(Catapres)pclonidine hcl tab 0.3 mg(Catapres)pclonidine td patch weekly0.1 mg/24hr (Catapres-tts-1)npclonidine td patch weekly0.2 mg/24hr (Catapres-tts-2)npclonidine td patch weekly0.3 mg/24hr (Catapres-tts-3)npdoxazosin mesylate tab 1 mg(Cardura)pdoxazosin mesylate tab 2 mg(Cardura)pdoxazosin mesylate tab 4 mg(Cardura)pdoxazosin mesylate tab 8 mg(Cardura)penalapril maleate &hydrochlorothiazide tab5-12.5 mgpenalapril maleate &hydrochlorothiazide tab10-25 mg (Vaseretic)penalapril maleate oral soln1 mg/ml (Epaned)np• •enalapril maleate tab 2.5 mg(Vasotec)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAenalapril maleate tab 5 mg(Vasotec)penalapril maleate tab 10 mg(Vasotec)penalapril maleate tab 20 mg(Vasotec)peplerenone tab 25 mg (Inspra)npeplerenone tab 50 mg (Inspra)npfosinopril sodium &hydrochlorothiazide tab10-12.5 mgnpfosinopril sodium &hydrochlorothiazide tab20-12.5 mgnpfosinopril sodium tab 10 mgpfosinopril sodium tab 20 mgpfosinopril sodium tab 40 mgpguanfacine hcl tab 1 mgnpguanfacine hcl tab 2 mgnphydralazine hcl tab 10 mgphydralazine hcl tab 25 mgphydralazine hcl tab 50 mgphydralazine hcl tab 100 mgpirbesartan tab 75 mg (Avapro)pirbesartan tab 150 mg (Avapro)pirbesartan tab 300 mg (Avapro)pirbesartan-hydrochlorothiazidetab 150-12.5 mg (Avalide)pirbesartan-hydrochlorothiazidetab 300-12.5 mg (Avalide)plisinopril & hydrochlorothiazidetab 10-12.5 mg (Zestoretic)plisinopril & hydrochlorothiazidetab 20-12.5 mg (Zestoretic)plisinopril & hydrochlorothiazidetab 20-25 mg (Zestoretic)plisinopril tab 2.5 mg (Zestril)plisinopril tab 5 mg (Prinivil)plisinopril tab 10 mg (Prinivil)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 41Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAlisinopril tab 20 mg (Prinivil)plisinopril tab 30 mg (Zestril)plisinopril tab 40 mg (Zestril)plosartan potassium &hydrochlorothiazide tab50-12.5 mg (Hyzaar)plosartan potassium &hydrochlorothiazide tab100-12.5 mg (Hyzaar)plosartan potassium &hydrochlorothiazide tab100-25 mg (Hyzaar)plosartan potassium tab 25 mg(Cozaar)plosartan potassium tab 50 mg(Cozaar)plosartan potassium tab 100 mg(Cozaar)pMETHYLDOPA- methyldopa tab250 mgNPMETHYLDOPA- methyldopa tab500 mgNPmetoprolol &hydrochlorothiazide tab50-25 mg (Lopressor hct)npmetoprolol &hydrochlorothiazide tab100-25 mgnpmetoprolol &hydrochlorothiazide tab100-50 mgNPminoxidil tab 2.5 mgpminoxidil tab 10 mgpmoexipril hcl tab 7.5 mgnpmoexipril hcl tab 15 mgnpolmesartan medoxomil tab 5 mg(Benicar)polmesartan medoxomil tab20 mg (Benicar)polmesartan medoxomil tab40 mg (Benicar)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAolmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg (Benicar hct)polmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg (Benicar hct)polmesartan medoxomil-hydrochlorothiazide tab40-25 mg (Benicar hct)polmesartan-amlodipine-hydrochlorothiazide tab20-5-12.5 mg (Tribenzor)npolmesartan-amlodipine-hydrochlorothiazide tab40-5-12.5 mg (Tribenzor)npolmesartan-amlodipine-hydrochlorothiazide tab40-5-25 mg (Tribenzor)npolmesartan-amlodipine-hydrochlorothiazide tab40-10-12.5 mg (Tribenzor)npolmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg (Tribenzor)npperindopril erbumine tab 2 mgnpperindopril erbumine tab 4 mgnpperindopril erbumine tab 8 mg(Aceon)npphenoxybenzamine hcl cap10 mg (Dibenzyline)npprazosin hcl cap 1 mg(Minipress)npprazosin hcl cap 2 mg(Minipress)npprazosin hcl cap 5 mg(Minipress)npQBRELIS- lisinopril oral soln1 mg/mlNP• •quinapril hcl tab 5 mg (Accupril)pquinapril hcl tab 10 mg(Accupril)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 42Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAquinapril hcl tab 20 mg(Accupril)pquinapril hcl tab 40 mg(Accupril)pquinapril-hydrochlorothiazidetab 10-12.5 mg (Accuretic)npquinapril-hydrochlorothiazidetab 20-12.5 mg (Accuretic)npquinapril-hydrochlorothiazidetab 20-25 mg (Accuretic)npramipril cap 1.25 mg (Altace)pramipril cap 2.5 mg (Altace)pramipril cap 5 mg (Altace)pramipril cap 10 mg (Altace)ptelmisartan tab 20 mg (Micardis)nptelmisartan tab 40 mg (Micardis)nptelmisartan tab 80 mg (Micardis)nptelmisartan-amlodipine tab40-5 mg (Twynsta)nptelmisartan-amlodipine tab40-10 mg (Twynsta)nptelmisartan-amlodipine tab80-5 mg (Twynsta)nptelmisartan-amlodipine tab80-10 mg (Twynsta)nptelmisartan-hydrochlorothiazidetab 40-12.5 mg (Micardis hct)nptelmisartan-hydrochlorothiazidetab 80-12.5 mg (Micardis hct)nptelmisartan-hydrochlorothiazidetab 80-25 mg (Micardis hct)npterazosin hcl cap 1 mg (baseequivalent)pterazosin hcl cap 2 mg (baseequivalent)pterazosin hcl cap 5 mg (baseequivalent)pterazosin hcl cap 10 mg (baseequivalent)ptrandolapril tab 1 mg (Mavik)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAtrandolapril tab 2 mg (Mavik)ptrandolapril tab 4 mgpTRANDOLAPRIL/VERAPAMILHC- trandolapril-verapamil hcltab er 1-240 mgNPTRANDOLAPRIL/VERAPAMILHC- trandolapril-verapamil hcltab er 2-180 mgNPTRANDOLAPRIL/VERAPAMILHC- trandolapril-verapamil hcltab er 2-240 mgNPTRANDOLAPRIL/VERAPAMILHC- trandolapril-verapamil hcltab er 4-240 mgNPvalsartan tab 40 mg (Diovan)pvalsartan tab 80 mg (Diovan)pvalsartan tab 160 mg (Diovan)npvalsartan tab 320 mg (Diovan)npvalsartan-hydrochlorothiazidetab 80-12.5 mg (Diovan hct)pvalsartan-hydrochlorothiazidetab 160-12.5 mg (Diovan hct)npvalsartan-hydrochlorothiazidetab 160-25 mg (Diovan hct)npvalsartan-hydrochlorothiazidetab 320-12.5 mg (Diovan hct)npvalsartan-hydrochlorothiazidetab 320-25 mg (Diovan hct)npVECAMYL- mecamylamine hcl tab2.5 mgNPDIURETICSacetazolamide cap er 12hr500 mg (Diamox)npacetazolamide tab 125 mgnpacetazolamide tab 250 mgnpALDACTAZIDE- spironolactone& hydrochlorothiazide tab50-50 mgNPamiloride & hydrochlorothiazidetab 5-50 mgp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 43Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAamiloride hcl tab 5 mgpbumetanide tab 0.5 mg (Bumex)npbumetanide tab 1 mg (Bumex)npbumetanide tab 2 mg (Bumex)npchlorthalidone tab 25 mgpchlorthalidone tab 50 mgnpDIURIL- chlorothiazide susp250 mg/5mlNPfurosemide oral soln 10 mg/mlpfurosemide tab 20 mg (Lasix)pfurosemide tab 40 mg (Lasix)pfurosemide tab 80 mg (Lasix)phydrochlorothiazide cap12.5 mg (Microzide)phydrochlorothiazide tab 12.5 mgphydrochlorothiazide tab 25 mgphydrochlorothiazide tab 50 mgpindapamide tab 1.25 mgpindapamide tab 2.5 mgpmethazolamide tab 25 mg(Neptazane)npmethazolamide tab 50 mg(Neptazane)npmetolazone tab 2.5 mgnpmetolazone tab 5 mgnpmetolazone tab 10 mgnpspironolactone &hydrochlorothiazide tab25-25 mg (Aldactazide)npspironolactone tab 25 mg(Aldactone)pspironolactone tab 50 mg(Aldactone)pspironolactone tab 100 mg(Aldactone)ptorsemide tab 5 mgptorsemide tab 10 mg (Demadex)ptorsemide tab 20 mg (Demadex)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAtorsemide tab 100 mgptriamterene &hydrochlorothiazide cap37.5-25 mg (Dyazide)ptriamterene &hydrochlorothiazide tab37.5-25 mg (Maxzide-25)ptriamterene &hydrochlorothiazide tab75-50 mg (Maxzide)ptriamterene cap 50 mg(Dyrenium)nptriamterene cap 100 mg(Dyrenium)npVASOPRESSORSepinephrine solution auto-injector 0.15 mg/0.3ml(1:2000) (Epipen-jr 2-pak)npepinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)(Epipen 2-pak)npmidodrine hcl tab 2.5 mgnpmidodrine hcl tab 5 mgnpmidodrine hcl tab 10 mgnpSYMJEPI- epinephrine solnprefilled syringe 0.15 mg/0.3ml(1:2000)PSYMJEPI- epinephrine solutionprefilled syringe 0.3 mg/0.3ml(1:1000)PANTIHYPERLIPIDEMICSatorvastatin calcium tab 10 mg(base equivalent) (Lipitor)p•atorvastatin calcium tab 20 mg(base equivalent) (Lipitor)p•atorvastatin calcium tab 40 mg(base equivalent) (Lipitor)patorvastatin calcium tab 80 mg(base equivalent) (Lipitor)pcholestyramine light powderpackets 4 gmnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 44Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAcholestyramine light powder4 gm/dose (Questran light)npcholestyramine powder packets4 gm (Questran)npcholestyramine powder 4 gm/dose (Questran)npcolesevelam hcl packet for susp3.75 gm (Welchol)np• •colesevelam hcl tab 625 mg(Welchol)npcolestipol hcl granule packets5 gm (Colestid flavored)npcolestipol hcl granules 5 gm(Colestid)npcolestipol hcl tab 1 gm(Colestid)npezetimibe tab 10 mg (Zetia)npezetimibe-simvastatin tab10-10 mg (Vytorin)npezetimibe-simvastatin tab10-20 mg (Vytorin)npezetimibe-simvastatin tab10-40 mg (Vytorin)npezetimibe-simvastatin tab10-80 mg (Vytorin)npfenofibrate micronized cap67 mgp•fenofibrate micronized cap134 mg (Lofibra)np•fenofibrate micronized cap200 mg (Lofibra)np•fenofibrate tab 48 mg (Tricor)p•fenofibrate tab 54 mg (Lofibra)p•fenofibrate tab 145 mg (Tricor)p•fenofibrate tab 160 mgp•gemfibrozil tab 600 mg (Lopid)p•JUXTAPID- lomitapide mesylatecap 5 mg (base equiv)NP• • •JUXTAPID- lomitapide mesylatecap 10 mg (base equiv)NP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAJUXTAPID- lomitapide mesylatecap 20 mg (base equiv)NP• • •JUXTAPID- lomitapide mesylatecap 30 mg (base equiv)NP• • •lovastatin tab 10 mgplovastatin tab 20 mgp•lovastatin tab 40 mgp•NEXLETOL- bempedoic acid tab180 mgP• •NEXLIZET- bempedoic acid-ezetimibe tab 180-10 mgP• •niacin tab er 500 mg(antihyperlipidemic) (Niaspan)npniacin tab er 750 mg(antihyperlipidemic) (Niaspan)npniacin tab er 1000 mg(antihyperlipidemic) (Niaspan)nppravastatin sodium tab 10 mgp•pravastatin sodium tab 20 mg(Pravachol)p•pravastatin sodium tab 40 mg(Pravachol)p•pravastatin sodium tab 80 mg(Pravachol)p•REPATHA- evolocumabsubcutaneous soln prefilledsyringe 140 mg/mlP• •REPATHA PUSHTRONEXSYSTEM- evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5mlP• •REPATHA SURECLICK-evolocumab subcutaneous solnauto-injector 140 mg/mlP• •rosuvastatin calcium tab 5 mg(Crestor)prosuvastatin calcium tab 10 mg(Crestor)prosuvastatin calcium tab 20 mg(Crestor)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 45Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACArosuvastatin calcium tab 40 mg(Crestor)psimvastatin tab 5 mg (Zocor)psimvastatin tab 10 mg (Zocor)psimvastatin tab 20 mg (Zocor)psimvastatin tab 40 mg (Zocor)psimvastatin tab 80 mg (Zocor)pVASCEPA- icosapent ethyl cap0.5 gmP• •VASCEPA- icosapent ethyl cap1 gmnp• •CARDIOVASCULAR AGENTS - MISC.ADEMPAS- riociguat tab 0.5 mgNP• • •ADEMPAS- riociguat tab 1 mgNP• • •ADEMPAS- riociguat tab 1.5 mgNP• • •ADEMPAS- riociguat tab 2 mgNP• • •ADEMPAS- riociguat tab 2.5 mgNP• • •ambrisentan tab 5 mg (Letairis)np• • •ambrisentan tab 10 mg(Letairis)np• • •bosentan tab 62.5 mg (Tracleer)np• • •bosentan tab 125 mg (Tracleer)np• • •CORLANOR- ivabradine hcl oralsoln 5 mg/5ml (base equiv)P• •CORLANOR- ivabradine hcl tab5 mg (base equiv)P• •CORLANOR- ivabradine hcl tab7.5 mg (base equiv)P• •ENTRESTO- sacubitril-valsartantab 24-26 mgPENTRESTO- sacubitril-valsartantab 49-51 mgPENTRESTO- sacubitril-valsartantab 97-103 mgPisosorbide dinitrate-hydralazinehcl tab 20-37.5 mg (Bidil)npOPSUMIT- macitentan tab 10 mgP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAORENITRAM- treprostinildiolamine tab er 0.125 mg (baseequiv)NP• • •ORENITRAM- treprostinildiolamine tab er 0.25 mg (baseequiv)NP• • •ORENITRAM- treprostinildiolamine tab er 1 mg (baseequiv)NP• • •ORENITRAM- treprostinildiolamine tab er 2.5 mg (baseequiv)NP• • •ORENITRAM- treprostinildiolamine tab er 5 mg (baseequiv)NP• • •sildenafil citrate for suspension10 mg/ml (Revatio)np• •sildenafil citrate tab 20 mg(Revatio)np• •tadalafil tab 20 mg (pah)(Adcirca)np• • •TRACLEER- bosentan tab for oralsusp 32 mgP• • •TYVASO- treprostinil inhalationsolution 0.6 mg/mlNP• • •TYVASO REFILL- treprostinilinhalation solution 0.6 mg/mlNP• • •TYVASO STARTER- treprostinilinhalation solution 0.6 mg/mlNP• • •UPTRAVI- selexipag tab therapypack 200 mcg (140) & 800 mcg(60)P• • •UPTRAVI- selexipag tab 200 mcgP• • •UPTRAVI- selexipag tab 400 mcgP• • •UPTRAVI- selexipag tab 600 mcgP• • •UPTRAVI- selexipag tab 800 mcgP• • •UPTRAVI- selexipag tab1000 mcgP• • •UPTRAVI- selexipag tab1200 mcgP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 46Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAUPTRAVI- selexipag tab1400 mcgP• • •UPTRAVI- selexipag tab1600 mcgP• • •VENTAVIS- iloprost inhalationsolution 10 mcg/mlNP• • •VENTAVIS- iloprost inhalationsolution 20 mcg/mlNP• • •VERQUVO- vericiguat tab 2.5 mgP• •VERQUVO- vericiguat tab 5 mgP• •VERQUVO- vericiguat tab 10 mgP• •VYNDAMAX- tafamidis cap 61 mgP• • •VYNDAQEL- tafamidis meglumine(cardiac) cap 20 mgP• • •ERECTILE DYSFUNCTIONCAVERJECT- alprostadil for inj20 mcgNP+• •CAVERJECT- alprostadil for inj40 mcgNP+• •CAVERJECT IMPULSE-alprostadil for inj kit 10 mcgNP+• •CAVERJECT IMPULSE-alprostadil for inj kit 20 mcgNP+• •EDEX- alprostadil for inj kit10 mcgNP+• •EDEX- alprostadil for inj kit20 mcgNP+• •EDEX- alprostadil for inj kit40 mcgNP+• •MUSE- alprostadil urethral pellet250 mcgNP+• •MUSE- alprostadil urethral pellet500 mcgNP+• •MUSE- alprostadil urethral pellet1000 mcgNP+• •sildenafil citrate tab 25 mg(Viagra)p+• •sildenafil citrate tab 50 mg(Viagra)p+• •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAsildenafil citrate tab 100 mg(Viagra)p+• •STENDRA- avanafil tab 50 mgNP+• •STENDRA- avanafil tab 100 mgNP+• •STENDRA- avanafil tab 200 mgNP+• •tadalafil tab 2.5 mg (Cialis)np• •tadalafil tab 5 mg (Cialis)np• •tadalafil tab 10 mg (Cialis)np+• •tadalafil tab 20 mg (Cialis)np+• •vardenafil hcl orallydisintegrating tab 10 mg(Staxyn)np+• •vardenafil hcl tab 2.5 mg(Levitra)np+• •vardenafil hcl tab 5 mg (Levitra)np+• •vardenafil hcl tab 10 mg(Levitra)np+• •vardenafil hcl tab 20 mg(Levitra)np+• •RESPIRATORY AGENTSANTIHISTAMINESCARBINOXAMINE MALEATE-carbinoxamine maleate soln4 mg/5mlNPcarbinoxamine maleate tab4 mgnpCLEMASTINE FUMARATE-clemastine fumarate tab2.68 mgNPcyproheptadine hcl syrup2 mg/5mlnpcyproheptadine hcl tab 4 mgppromethazine hcl suppos12.5 mgnppromethazine hcl suppos 25 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 47Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACApromethazine hcl syrup6.25 mg/5mlppromethazine hcl tab 12.5 mgppromethazine hcl tab 25 mgppromethazine hcl tab 50 mgpPROMETHEGAN- promethazinehcl suppos 50 mgNPNASAL AGENTS - SYSTEMIC and TOPICALazelastine hcl nasal spray 0.1%(137 mcg/spray)p•fluticasone propionate nasalsusp 50 mcg/actp•ipratropium bromide nasal soln0.03% (21 mcg/spray)np•ipratropium bromide nasal soln0.06% (42 mcg/spray)np•XHANCE- fluticasone propionatenasal exhaler susp 93 mcg/actNP• •COUGH/COLD/ALLERGYacetylcysteine inhal soln 10%npacetylcysteine inhal soln 20%npbenzonatate cap 100 mg(Tessalon perles)pbenzonatate cap 200 mgphydrocod polst-chlorphenpolst er susp 10-8 mg/5ml(Tussionex pennkineti)np•hydrocodone bitart-homatropine methylbrom soln5-1.5 mg/5ml (Hycodan)np•hydrocodone bitart-homatropine methylbromidetab 5-1.5 mg (Hycodan)np•promethazine & phenylephrinesyrup 6.25-5 mg/5mlnppromethazine w/ codeine syrup6.25-10 mg/5mlp•promethazine-dm syrup6.25-15 mg/5mlpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACApromethazine-phenylephrine-codeine syrup6.25-5-10 mg/5mlnp•sodium chloride soln nebu 3%psodium chloride soln nebu 7%(Hyper-sal)pANTIASTHMATIC and BRONCHODILATOR AGENTSADVAIR DISKUS- fluticasone-salmeterol aer powder ba100-50 mcg/actnp•ADVAIR DISKUS- fluticasone-salmeterol aer powder ba250-50 mcg/actnp•ADVAIR DISKUS- fluticasone-salmeterol aer powder ba500-50 mcg/actnp•ADVAIR HFA- fluticasone-salmeterol inhal aerosol45-21 mcg/actP•ADVAIR HFA- fluticasone-salmeterol inhal aerosol115-21 mcg/actP•ADVAIR HFA- fluticasone-salmeterol inhal aerosol230-21 mcg/actP•albuterol sulfate inhal aero108 mcg/act (90mcg baseequiv) (Proair hfa)np•albuterol sulfate soln nebu0.083% (2.5 mg/3ml)p•albuterol sulfate soln nebu 0.5%(5 mg/ml)np•albuterol sulfate soln nebu0.63 mg/3ml (base equiv)np•albuterol sulfate soln nebu1.25 mg/3ml (base equiv)np•albuterol sulfate syrup 2 mg/5mlpalbuterol sulfate tab 2 mgnpalbuterol sulfate tab 4 mgnpANORO ELLIPTA- umeclidinium-vilanterol aero powd ba62.5-25 mcg/inhP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 48Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAarformoterol tartrate soln nebu15 mcg/2ml (base equiv)(Brovana)npARNUITY ELLIPTA- fluticasonefuroate aerosol powder breathactiv 50 mcg/actP•ARNUITY ELLIPTA- fluticasonefuroate aerosol powder breathactiv 100 mcg/actP•ARNUITY ELLIPTA- fluticasonefuroate aerosol powder breathactiv 200 mcg/actP•ASMANEX HFA- mometasonefuroate inhal aerosol suspension50 mcg/actP•ASMANEX HFA- mometasonefuroate inhal aerosol suspension100 mcg/actP•ASMANEX HFA- mometasonefuroate inhal aerosol suspension200 mcg/actP•ASMANEX TWISTHALER 120ME- mometasone furoate inhalpowd 220 mcg/inh (breathactivated)P•ASMANEX TWISTHALER 30MET- mometasone furoateinhal powd 110 mcg/inh (breathactivated)P•ASMANEX TWISTHALER 30MET- mometasone furoateinhal powd 220 mcg/inh (breathactivated)P•ASMANEX TWISTHALER 60MET- mometasone furoateinhal powd 220 mcg/inh (breathactivated)P•ATROVENT HFA- ipratropiumbromide hfa inhal aerosol17 mcg/actNP•BREO ELLIPTA- fluticasonefuroate-vilanterol aero powd ba100-25 mcg/inhP•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACABREO ELLIPTA- fluticasonefuroate-vilanterol aero powd ba200-25 mcg/inhP•BREZTRI AEROSPHERE-budesonide-glycopyrrolate-formoterol aers 160-9-4.8 mcg/actP•budesonide inhalation susp0.25 mg/2ml (Pulmicort)np•budesonide inhalation susp0.5 mg/2ml (Pulmicort)np•budesonide inhalation susp1 mg/2ml (Pulmicort)np•COMBIVENT RESPIMAT-ipratropium-albuterol inhalaerosol soln 20-100 mcg/actP•cromolyn sodium soln nebu20 mg/2mlnp•DALIRESP- roflumilast tab250 mcgNPDALIRESP- roflumilast tab500 mcgNPDULERA- mometasone furoate-formoterol fumarate aerosol50-5 mcg/actP•DULERA- mometasone furoate-formoterol fumarate aerosol100-5 mcg/actP•DULERA- mometasone furoate-formoterol fumarate aerosol200-5 mcg/actP•ELIXOPHYLLIN- theophyllineelixir 80 mg/15mlNPFASENRA PEN- benralizumabsubcutaneous soln auto-injector30 mg/mlP• • •FLOVENT DISKUS- fluticasonepropionate aer pow ba 50 mcg/blisterP•FLOVENT DISKUS- fluticasonepropionate aer pow ba 100 mcg/blisterP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 49Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAFLOVENT DISKUS- fluticasonepropionate aer pow ba 250 mcg/blisterP•FLOVENT HFA- fluticasonepropionate hfa inhal aero44 mcg/act (50/valve)P•FLOVENT HFA- fluticasonepropionate hfa inhal aer110 mcg/act (125/valve)P•FLOVENT HFA- fluticasonepropionate hfa inhal aer220 mcg/act (250/valve)P•FLUTICASONE PROPIONATE/SA- fluticasone-salmeterol aerpowder ba 55-14 mcg/actnpFLUTICASONE PROPIONATE/SA- fluticasone-salmeterol aerpowder ba 113-14 mcg/actnpFLUTICASONE PROPIONATE/SA- fluticasone-salmeterol aerpowder ba 232-14 mcg/actnp•INCRUSE ELLIPTA- umeclidiniumbr aero powd breath act62.5 mcg/inh (base eq)P•ipratropium bromide inhal soln0.02%p•ipratropium-albuterol nebu soln0.5-2.5(3) mg/3mlnp•levalbuterol hcl soln nebu conc1.25 mg/0.5ml (base equiv)(Xopenex concentrate)np•levalbuterol hcl soln nebu0.31 mg/3ml (base equiv)(Xopenex)np•levalbuterol hcl soln nebu0.63 mg/3ml (base equiv)(Xopenex)np•levalbuterol hcl soln nebu1.25 mg/3ml (base equiv)(Xopenex)np•montelukast sodium chew tab4 mg (base equiv) (Singulair)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmontelukast sodium chew tab5 mg (base equiv) (Singulair)pmontelukast sodium tab 10 mg(base equiv) (Singulair)pNUCALA- mepolizumabsubcutaneous solution auto-injector 100 mg/mlP• • •NUCALA- mepolizumabsubcutaneous solution prefsyringe 40 mg/0.4mlP• • •NUCALA- mepolizumabsubcutaneous solution prefsyringe 100 mg/mlP• • •QVAR REDIHALER-beclomethasone diprop hfabreath act inh aer 40 mcg/actP•QVAR REDIHALER-beclomethasone diprop hfabreath act inh aer 80 mcg/actP•SEREVENT DISKUS- salmeterolxinafoate aer pow ba 50 mcg/dose (base equiv)P•SPIRIVA HANDIHALER-tiotropium bromide monohydrateinhal cap 18 mcg (base equiv)P•SPIRIVA RESPIMAT- tiotropiumbromide monohydrate inhalaerosol 1.25 mcg/actP•SPIRIVA RESPIMAT- tiotropiumbromide monohydrate inhalaerosol 2.5 mcg/actP•STIOLTO RESPIMAT- tiotropiumbr-olodaterol inhal aero soln2.5-2.5 mcg/actP•STRIVERDI RESPIMAT-olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)P•SYMBICORT- budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/actP•SYMBICORT- budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/actP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 50Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAterbutaline sulfate tab 2.5 mgnpterbutaline sulfate tab 5 mgnpTHEO-24- theophylline cap er24hr 100 mgNPTHEO-24- theophylline cap er24hr 200 mgNPTHEO-24- theophylline cap er24hr 300 mgNPTHEO-24- theophylline cap er24hr 400 mgNPtheophylline soln 80 mg/15mlnptheophylline tab er 12hr 300 mgnptheophylline tab er 12hr 450 mgnptheophylline tab er 24hr 400 mgnptheophylline tab er 24hr 600 mgnpTRELEGY ELLIPTA- fluticasone-umeclidinium-vilanterol aepb100-62.5-25 mcg/inhP•TRELEGY ELLIPTA- fluticasone-umeclidinium-vilanterol aepb200-62.5-25 mcg/inhP•VENTOLIN HFA- albuterol sulfateinhal aero 108 mcg/act (90mcgbase equiv)P•XOLAIR- omalizumabsubcutaneous soln prefilledsyringe 75 mg/0.5mlP• •XOLAIR- omalizumabsubcutaneous soln prefilledsyringe 150 mg/mlP• •zafirlukast tab 10 mg (Accolate)npzafirlukast tab 20 mg (Accolate)npRESPIRATORY AGENTS - MISC.ESBRIET- pirfenidone cap 267 mgNP• • •GLASSIA- alpha1-proteinaseinhibitor (human) inj1000 mg/50mlNP•KALYDECO- ivacaftor packet25 mgP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAKALYDECO- ivacaftor packet50 mgP• • •KALYDECO- ivacaftor packet75 mgP• • •KALYDECO- ivacaftor tab 150 mgP• • •OFEV- nintedanib esylate cap100 mg (base equivalent)NP• • •OFEV- nintedanib esylate cap150 mg (base equivalent)NP• • •ORKAMBI- lumacaftor-ivacaftor granules packet100-125 mgNP• • •ORKAMBI- lumacaftor-ivacaftor granules packet150-188 mgNP• • •ORKAMBI- lumacaftor-ivacaftortab 100-125 mgNP• • •ORKAMBI- lumacaftor-ivacaftortab 200-125 mgNP• • •pirfenidone tab 267 mg (Esbriet)np• • •pirfenidone tab 801 mg (Esbriet)np• • •PULMOZYME- dornase alfa inhalsoln 2.5 mg/2.5mlP•SYMDEKO- tezacaftor-ivacaftor50-75 mg & ivacaftor 75 mg tabtbpkP• • •SYMDEKO- tezacaftor-ivacaftor100-150 mg & ivacaftor 150 mgtab tbpkP• • •TRIKAFTA- elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor75 mg tbpkP• • •TRIKAFTA- elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor150 mg tbpkP• • •GASTROINTESTINAL AGENTSLAXATIVESlactulose solution 10 gm/15mlnppeg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)p•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 51Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACApeg 3350-kcl-nacl-na sulfate-naascorbate-c for soln 100 gm(Moviprep)np•peg 3350-kcl-sod bicarb-nacl forsoln 420 gm (Nulytely/flavorpack)p•PEG-PREP- bisacodyl tab & peg3350-kcl-sod bicarb-nacl for solnkitNPSUPREP BOWEL PREP KIT- sodsulfate-pot sulf-mg sulf oral sol17.5-3.13-1.6 gm/177mlPSUTAB- sod sulfate-mgsulfate-pot chloride tab1479-225-188 mgNPANTIDIARRHEALSdiphenoxylate w/ atropine tab2.5-0.025 mg (Lomotil)npDIPHENOXYLATE/ATROPINE-diphenoxylate w/ atropine liq2.5-0.025 mg/5mlNP• •MOTOFEN- difenoxin w/ atropinetab 1-0.025 mgNPULCER DRUGSdicyclomine hcl cap 10 mg(Bentyl)pdicyclomine hcl oral soln10 mg/5mlnpdicyclomine hcl tab 20 mgpesomeprazole magnesium fordelayed release susp packet10 mg (Nexium)np•esomeprazole magnesium fordelayed release susp packet20 mg (Nexium)np•esomeprazole magnesium fordelayed release susp packet40 mg (Nexium)np•famotidine for susp 40 mg/5mlnpfamotidine tab 40 mg (Pepcid)pglycopyrrolate oral soln1 mg/5ml (Cuvposa)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAglycopyrrolate tab 1 mg(Robinul)npglycopyrrolate tab 2 mg(Robinul forte)npmethscopolamine bromide tab2.5 mg (Pamine)npmethscopolamine bromide tab5 mg (Pamine forte)npmisoprostol tab 100 mcg(Cytotec)pmisoprostol tab 200 mcg(Cytotec)pNEXIUM- esomeprazolemagnesium for delayed releasesusp packet 5 mgP• •NEXIUM- esomeprazolemagnesium for delayed releasesusp pack 2.5 mgP• •omeprazole cap delayed release10 mgp•omeprazole cap delayed release20 mgp•omeprazole cap delayed release40 mgp•pantoprazole sodium ec tab20 mg (base equiv) (Protonix)p•pantoprazole sodium ec tab40 mg (base equiv) (Protonix)p•sucralfate tab 1 gm (Carafate)npANTIEMETICSANZEMET- dolasetron mesylatetab 50 mgNP•aprepitant capsule therapy pack80 & 125 mg (Emend)np•aprepitant capsule 40 mg(Emend)np•aprepitant capsule 80 mg(Emend)np•aprepitant capsule 125 mg(Emend)np•dronabinol cap 2.5 mg (Marinol)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 52Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdronabinol cap 5 mg (Marinol)np•dronabinol cap 10 mg (Marinol)np•EMEND- aprepitant for oral susp125 mg (125 mg/5ml)P•granisetron hcl tab 1 mgnp•ONDANSETRON HCL-ondansetron hcl tab 24 mgNP•ondansetron hcl oral soln4 mg/5ml (Zofran)np•ondansetron hcl tab 4 mg(Zofran)p•ondansetron hcl tab 8 mg(Zofran)p•ondansetron orallydisintegrating tab 4 mg(Zofran odt)p•ondansetron orallydisintegrating tab 8 mg(Zofran odt)p•scopolamine td patch 72hr1 mg/3days (Transderm-scop)nptrimethobenzamide hcl cap300 mg (Tigan)npVARUBI- rolapitant hcl tab therapypack 2 x 90 mg (base equiv)P•DIGESTIVE AIDSCREON- pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000unitPCREON- pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000unitPCREON- pancrelipase(lip-prot-amyl) dr cap12000-38000-60000 unitPCREON- pancrelipase(lip-prot-amyl) dr cap24000-76000-120000 unitPCREON- pancrelipase(lip-prot-amyl) dr cap36000-114000-180000 unitPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACASUCRAID- sacrosidase soln 8500unit/mlNP• • •ZENPEP- pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000unitPZENPEP- pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unitPZENPEP- pancrelipase(lip-prot-amyl) dr cap10000-32000-42000 unitPZENPEP- pancrelipase(lip-prot-amyl) dr cap15000-47000-63000 unitPZENPEP- pancrelipase(lip-prot-amyl) dr cap20000-63000-84000 unitPZENPEP- pancrelipase(lip-prot-amyl) dr cap25000-79000-105000 unitPZENPEP- pancrelipase(lip-prot-amyl) dr cap40000-126000-168000 unitPGASTROINTESTINAL AGENTS- MISC.AURYXIA- ferric citrate tab 1 gm(210 mg ferric iron)NPbalsalazide disodium cap750 mg (Colazal)npBYLVAY- odevixibat cap 400 mcgNP• •BYLVAY- odevixibat cap 1200 mcgNP• •BYLVAY (PELLETS)- odevixibatpellets cap sprinkle 200 mcgNP• •BYLVAY (PELLETS)- odevixibatpellets cap sprinkle 600 mcgNP• •calcium acetate (phosphatebinder) cap 667 mg (169 mgca)npcalcium acetate (phosphatebinder) tab 667 mgnpCHENODAL- chenodiol tab250 mgP•CHOLBAM- cholic acid cap 50 mgNP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 53Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACACHOLBAM- cholic acid cap250 mgNP•CIMZIA- certolizumab pegolprefilled syringe kit 2 x 200 mg/mlNP• • •CIMZIA STARTER KIT-certolizumab pegol prefilledsyringe kit 6 x 200 mg/mlNP• • •cromolyn sodium oral conc100 mg/5ml (Gastrocrom)npFOSRENOL- lanthanumcarbonate oral powder pack750 mg (elemental)NPFOSRENOL- lanthanumcarbonate oral powder pack1000 mg (elemental)NPGATTEX- teduglutide (rdna) for injkit 5 mgNP• •lactulose (encephalopathy)solution 10 gm/15mlnplanthanum carbonate chew tab500 mg (elemental) (Fosrenol)nplanthanum carbonate chew tab750 mg (elemental) (Fosrenol)nplanthanum carbonate chewtab 1000 mg (elemental)(Fosrenol)npLIVMARLI- maralixibat chlorideoral soln 9.5 mg/mlNP• •mesalamine cap dr 400 mg(Delzicol)npmesalamine cap er 24hr0.375 gm (Apriso)npmesalamine enema 4 gmnpmesalamine suppos 1000 mg(Canasa)npmesalamine tab delayed release800 mg (Asacol hd)npmesalamine tab delayed release1.2 gm (Lialda)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmetoclopramide hcl soln5 mg/5ml (10 mg/10ml) (baseequiv)npmetoclopramide hcl tab 5 mg(base equivalent) (Reglan)pmetoclopramide hcl tab 10 mg(base equivalent) (Reglan)pMETOCLOPRAMIDE ODT-metoclopramide hcl orallydisintegrating tab 5 mg (baseeq)NPMETOCLOPRAMIDE ODT-metoclopramide hcl orallydisintegrating tab 10 mg (baseeq)NPMOVANTIK- naloxegol oxalate tab12.5 mg (base equivalent)P•MOVANTIK- naloxegol oxalate tab25 mg (base equivalent)P•OCALIVA- obeticholic acid tab5 mgNP• • •OCALIVA- obeticholic acid tab10 mgNP• • •PHOSLYRA- calcium acetate(phosphate binder) oral soln667 mg/5mlNPsevelamer carbonate packet0.8 gm (Renvela)npsevelamer carbonate packet2.4 gm (Renvela)npsevelamer carbonate tab800 mg (Renvela)npsevelamer hcl tab 800 mg(Renagel)npSEVELAMERHYDROCHLORIDE- sevelamerhcl tab 400 mgNPSFROWASA- mesalamine sulfite-free (sf) enema 4 gm/60mlNPsulfasalazine tab delayedrelease 500 mg (Azulfidine en-tabs)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 54Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAsulfasalazine tab 500 mg(Azulfidine)npSYMPROIC- naldemedinetosylate tab 0.2 mg (baseequivalent)P•TRULANCE- plecanatide tab 3 mgP•ursodiol cap 300 mg (Actigall)npursodiol tab 250 mg (Urso 250)npursodiol tab 500 mg (Urso forte)npVELPHORO- sucroferricoxyhydroxide chew tab 500 mgPVIBERZI- eluxadoline tab 75 mgP•VIBERZI- eluxadoline tab 100 mgP•XERMELO- telotristat ethyl tab250 mg (as telotristat etiprate)NP•GENITOURINARY AGENTSURINARY ANTISPASMODICSbethanechol chloride tab 5 mg(Urecholine)npbethanechol chloride tab 10 mg(Urecholine)npbethanechol chloride tab 25 mg(Urecholine)npbethanechol chloride tab 50 mg(Urecholine)npMYRBETRIQ-mirabegron granules for oralextended release susp 8 mg/mlPMYRBETRIQ- mirabegron tab er24 hr 25 mgPMYRBETRIQ- mirabegron tab er24 hr 50 mgPoxybutynin chloride syrup5 mg/5mlpoxybutynin chloride tab er 24hr5 mg (Ditropan xl)poxybutynin chloride tab er 24hr10 mg (Ditropan xl)poxybutynin chloride tab er 24hr15 mgpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAoxybutynin chloride tab 5 mgpsolifenacin succinate tab 5 mg(Vesicare)npsolifenacin succinate tab 10 mg(Vesicare)nptolterodine tartrate cap er 24hr2 mg (Detrol la)nptolterodine tartrate cap er 24hr4 mg (Detrol la)nptolterodine tartrate tab 1 mg(Detrol)nptolterodine tartrate tab 2 mg(Detrol)nptrospium chloride cap er 24hr60 mgnptrospium chloride tab 20 mgnpVAGINAL PRODUCTSclindamycin phosphate vaginalcream 2% (Cleocin)npCLINDESSE- clindamycinphosphate (one dose) vaginalcream 2%NPENCARE- nonoxynol-9 vaginalsuppos 100 mgP•ENDOMETRIN- progesteronevaginal insert 100 mgP+estradiol vaginal cream 0.1 mg/gm (Estrace)npESTRING- estradiol vaginal ring2 mg (7.5 mcg/24hrs)PGYNAZOLE-1- butoconazolenitrate (one dose) vaginal cream2%NPmetronidazole vaginal gel 0.75%(Metrogel-vaginal)npMICONAZOLE 3- miconazolenitrate vaginal suppos 200 mgNPNUVESSA- metronidazolevaginal gel 1.3%NPOPTIONS GYNOL II VAGINAL-nonoxynol-9 gel 3%P•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 55Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPREMARIN- estrogens,conjugated vaginal cream0.625 mg/gmNPSHUR-SEAL- nonoxynol-9 gel 2%P•terconazole vaginal cream 0.4%(Terazol 7)npterconazole vaginal cream 0.8%npterconazole vaginal suppos80 mgnpTODAY SPONGE- nonoxynol-9vaginal sponge 1000 mgP•VAGIFEM- estradiol vaginal tab10 mcgnpVANDAZOLE- metronidazolevaginal gel 0.75%NPVCF VAGINALCONTRACEPTIVE-nonoxynol-9 gel 4%NPVCF VAGINALCONTRACEPTIVE-nonoxynol-9 film 28%P•VCF VAGINALCONTRACEPTIVE-nonoxynol-9 foam 12.5%P•GENITOURINARY AGENTS - MISC.alfuzosin hcl tab er 24hr 10 mg(Uroxatral)pCYSTAGON- cysteaminebitartrate cap 50 mgP•CYSTAGON- cysteaminebitartrate cap 150 mgP•dutasteride cap 0.5 mg(Avodart)pdutasteride-tamsulosin hcl cap0.5-0.4 mg (Jalyn)npELMIRON- pentosan polysulfatesodium caps 100 mgNPfinasteride tab 5 mg (Proscar)pK-PHOS NO 2- potassium &sodium acid phosphates tab305-700 mgPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACALITHOSTAT- acetohydroxamicacid tab 250 mgNPpotassium citrate tab er 5 meq(540 mg) (Urocit-k 5)nppotassium citrate tab er 10 meq(1080 mg) (Urocit-k 10)nppotassium citrate tab er 15 meq(1620 mg) (Urocit-k 15)npPROCYSBI- cysteamine bitartratecap delayed release 25 mg(base equiv)NP• •PROCYSBI- cysteamine bitartratecap delayed release 75 mg(base equiv)NP• •PROCYSBI- cysteamine bitartratedelayed release granules packet75 mgNP• •PROCYSBI- cysteamine bitartratedelayed release granules packet300 mgNP• •sodium citrate & citric acidsoln 500-334 mg/5ml (Shohlssolution modi)nptamsulosin hcl cap 0.4 mg(Flomax)pTHIOLA EC- tiopronin tab delayedrelease 100 mgNPTHIOLA EC- tiopronin tab delayedrelease 300 mgNPtiopronin tab 100 mg (Thiola)npCENTRAL NERVOUS SYSTEM DRUGSANTIANXIETY AGENTSALPRAZOLAM INTENSOL-alprazolam conc 1 mg/mlNPalprazolam orally disintegratingtab 0.25 mgnpalprazolam orally disintegratingtab 0.5 mgnpalprazolam orally disintegratingtab 1 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 56Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAalprazolam orally disintegratingtab 2 mgnpalprazolam tab er 24hr 0.5 mg(Xanax xr)palprazolam tab er 24hr 1 mg(Xanax xr)palprazolam tab er 24hr 2 mg(Xanax xr)palprazolam tab er 24hr 3 mg(Xanax xr)palprazolam tab 0.25 mg (Xanax)palprazolam tab 0.5 mg (Xanax)palprazolam tab 1 mg (Xanax)palprazolam tab 2 mg (Xanax)pbuspirone hcl tab 5 mgpbuspirone hcl tab 10 mgpbuspirone hcl tab 15 mgpbuspirone hcl tab 30 mgnpchlordiazepoxide hcl cap 5 mgpchlordiazepoxide hcl cap 10 mgpchlordiazepoxide hcl cap 25 mgpclorazepate dipotassium tab3.75 mgnpclorazepate dipotassium tab7.5 mg (Tranxene t)npclorazepate dipotassium tab15 mgnpdiazepam conc 5 mg/mlnpdiazepam oral soln 1 mg/mlnpdiazepam tab 2 mg (Valium)pdiazepam tab 5 mg (Valium)pdiazepam tab 10 mg (Valium)phydroxyzine hcl syrup10 mg/5mlphydroxyzine hcl tab 10 mgphydroxyzine hcl tab 25 mgphydroxyzine hcl tab 50 mgpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAHYDROXYZINE PAMOATE-hydroxyzine pamoate cap100 mgNPhydroxyzine pamoate cap25 mg (Vistaril)phydroxyzine pamoate cap50 mg (Vistaril)plorazepam conc 2 mg/mlnplorazepam tab 0.5 mg (Ativan)p•lorazepam tab 1 mg (Ativan)p•lorazepam tab 2 mg (Ativan)p•oxazepam cap 10 mgnpoxazepam cap 15 mgnpoxazepam cap 30 mgnpANTIDEPRESSANTSamitriptyline hcl tab 10 mgpamitriptyline hcl tab 25 mg(Elavil)pamitriptyline hcl tab 50 mgpamitriptyline hcl tab 75 mgnpamitriptyline hcl tab 100 mgnpamitriptyline hcl tab 150 mgnpbupropion hcl tab er 12hr100 mg (Wellbutrin sr)pbupropion hcl tab er 12hr150 mg (Wellbutrin sr)pbupropion hcl tab er 12hr200 mg (Wellbutrin sr)pbupropion hcl tab er 24hr150 mg (Wellbutrin xl)pbupropion hcl tab er 24hr300 mg (Wellbutrin xl)pbupropion hcl tab 75 mgpbupropion hcl tab 100 mgnpcitalopram hydrobromide oralsoln 10 mg/5mlnpcitalopram hydrobromide tab10 mg (base equiv) (Celexa)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 57Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAcitalopram hydrobromide tab20 mg (base equiv) (Celexa)pcitalopram hydrobromide tab40 mg (base equiv) (Celexa)pclomipramine hcl cap 25 mg(Anafranil)npclomipramine hcl cap 50 mg(Anafranil)npclomipramine hcl cap 75 mg(Anafranil)npdesipramine hcl tab 10 mg(Norpramin)npdesipramine hcl tab 25 mg(Norpramin)npdesipramine hcl tab 50 mgnpdesipramine hcl tab 75 mgnpdesipramine hcl tab 100 mgnpdesipramine hcl tab 150 mgnpdesvenlafaxine succinate taber 24hr 25 mg (base equiv)(Pristiq)npdesvenlafaxine succinate taber 24hr 50 mg (base equiv)(Pristiq)npdesvenlafaxine succinate taber 24hr 100 mg (base equiv)(Pristiq)npdoxepin hcl cap 10 mgpdoxepin hcl cap 25 mgnpdoxepin hcl cap 50 mgnpdoxepin hcl cap 75 mgnpdoxepin hcl cap 100 mgnpdoxepin hcl cap 150 mgnpdoxepin hcl conc 10 mg/mlpduloxetine hcl enteric coatedpellets cap 20 mg (base eq)(Cymbalta)pduloxetine hcl enteric coatedpellets cap 30 mg (base eq)(Cymbalta)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAduloxetine hcl enteric coatedpellets cap 60 mg (base eq)(Cymbalta)pEMSAM- selegiline td patch 24hr6 mg/24hrNPEMSAM- selegiline td patch 24hr9 mg/24hrNPEMSAM- selegiline td patch 24hr12 mg/24hrNPescitalopram oxalate soln5 mg/5ml (base equiv)npescitalopram oxalate tab 5 mg(base equiv) (Lexapro)pescitalopram oxalate tab 10 mg(base equiv) (Lexapro)pescitalopram oxalate tab 20 mg(base equiv) (Lexapro)pFETZIMA- levomilnacipran hcl caper 24hr 20 mg (base equivalent)NP•FETZIMA- levomilnacipran hcl caper 24hr 40 mg (base equivalent)NP•FETZIMA- levomilnacipran hcl caper 24hr 80 mg (base equivalent)NP•FETZIMA- levomilnacipran hclcap er 24hr 120 mg (baseequivalent)NP•FETZIMA TITRATION PACK-levomilnacipran hcl cap er 24hr20 & 40 mg therapy packNP•FLUOXETINE DR- fluoxetine hclcap delayed release 90 mgNP•fluoxetine hcl cap 10 mg(Prozac)pfluoxetine hcl cap 20 mg(Prozac)pfluoxetine hcl cap 40 mg(Prozac)pfluoxetine hcl solution20 mg/5mlnpfluvoxamine maleate tab 25 mgnpfluvoxamine maleate tab 50 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 58Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAfluvoxamine maleate tab 100 mgnpimipramine hcl tab 10 mg(Tofranil)pimipramine hcl tab 25 mg(Tofranil)pimipramine hcl tab 50 mg(Tofranil)pMARPLAN- isocarboxazid tab10 mgNPmirtazapine orallydisintegrating tab 15 mg(Remeron soltab)npmirtazapine orallydisintegrating tab 30 mg(Remeron soltab)npmirtazapine orallydisintegrating tab 45 mg(Remeron soltab)npmirtazapine tab 7.5 mgnpmirtazapine tab 15 mg(Remeron)pmirtazapine tab 30 mg(Remeron)pmirtazapine tab 45 mg(Remeron)pNORTRIPTYLINE HCL-nortriptyline hcl soln 10 mg/5mlNPnortriptyline hcl cap 10 mg(Pamelor)pnortriptyline hcl cap 25 mg(Pamelor)pnortriptyline hcl cap 50 mg(Pamelor)pnortriptyline hcl cap 75 mg(Pamelor)pparoxetine hcl tab 10 mg (Paxil)pparoxetine hcl tab 20 mg (Paxil)pparoxetine hcl tab 30 mg (Paxil)pparoxetine hcl tab 40 mg (Paxil)pphenelzine sulfate tab 15 mg(Nardil)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAprotriptyline hcl tab 5 mgnpprotriptyline hcl tab 10 mgnpsertraline hcl oral concentratefor solution 20 mg/ml (Zoloft)npsertraline hcl tab 25 mg (Zoloft)psertraline hcl tab 50 mg (Zoloft)psertraline hcl tab 100 mg(Zoloft)ptranylcypromine sulfate tab10 mg (Parnate)nptrazodone hcl tab 50 mgptrazodone hcl tab 100 mgptrazodone hcl tab 150 mgptrimipramine maleate cap 25 mg(Surmontil)nptrimipramine maleate cap 50 mg(Surmontil)nptrimipramine maleate cap100 mg (Surmontil)npTRINTELLIX- vortioxetine hbr tab5 mg (base equiv)NP•TRINTELLIX- vortioxetine hbr tab10 mg (base equiv)NP•TRINTELLIX- vortioxetine hbr tab20 mg (base equiv)NP•venlafaxine hcl cap er 24hr37.5 mg (base equivalent)(Effexor xr)pvenlafaxine hcl cap er 24hr75 mg (base equivalent)(Effexor xr)pvenlafaxine hcl cap er 24hr150 mg (base equivalent)(Effexor xr)pvenlafaxine hcl tab 25 mg (baseequivalent)pvenlafaxine hcl tab 37.5 mg(base equivalent)pvenlafaxine hcl tab 50 mg (baseequivalent)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 59Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAvenlafaxine hcl tab 75 mg (baseequivalent)pvenlafaxine hcl tab 100 mg(base equivalent)pVIIBRYD- vilazodone hcl tab10 mgNP•VIIBRYD- vilazodone hcl tab20 mgNP•VIIBRYD- vilazodone hcl tab40 mgNP•VIIBRYD STARTER PACK-vilazodone hcl tab starter kit 10(7) & 20 (23) mgNP•vilazodone hcl tab 10 mg(Viibryd)npvilazodone hcl tab 20 mg(Viibryd)npvilazodone hcl tab 40 mg(Viibryd)npANTIPSYCHOTICSaripiprazole oral solution 1 mg/mlnp•aripiprazole orallydisintegrating tab 10 mgnp•aripiprazole orallydisintegrating tab 15 mgnp•aripiprazole tab 2 mg (Abilify)p•aripiprazole tab 5 mg (Abilify)p•aripiprazole tab 10 mg (Abilify)p•aripiprazole tab 15 mg (Abilify)p•aripiprazole tab 20 mg (Abilify)np•aripiprazole tab 30 mg (Abilify)np•asenapine maleate sl tab 2.5 mg(base equiv) (Saphris)np•asenapine maleate sl tab 5 mg(base equiv) (Saphris)np•asenapine maleate sl tab 10 mg(base equiv) (Saphris)np•chlorpromazine hcl tab 10 mgnpchlorpromazine hcl tab 25 mgnpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAchlorpromazine hcl tab 50 mgnpchlorpromazine hcl tab 100 mgnpchlorpromazine hcl tab 200 mgnpCLOZAPINE ODT- clozapineorally disintegrating tab 12.5 mgNP• •CLOZAPINE ODT- clozapineorally disintegrating tab 150 mgNP• •CLOZAPINE ODT- clozapineorally disintegrating tab 200 mgNP• •clozapine orally disintegratingtab 25 mg (Fazaclo)np•clozapine orally disintegratingtab 100 mg (Fazaclo)np•clozapine tab 25 mg (Clozaril)np• •clozapine tab 50 mgnp•clozapine tab 100 mg (Clozaril)np• •clozapine tab 200 mgnp•EQUETRO- carbamazepine(mood) cap er 12hr 100 mgNPEQUETRO- carbamazepine(mood) cap er 12hr 200 mgNPEQUETRO- carbamazepine(mood) cap er 12hr 300 mgNPFANAPT- iloperidone tab 1 mgNP• •FANAPT- iloperidone tab 2 mgNP• •FANAPT- iloperidone tab 4 mgNP• •FANAPT- iloperidone tab 6 mgNP• •FANAPT- iloperidone tab 8 mgNP• •FANAPT- iloperidone tab 10 mgNP• •FANAPT- iloperidone tab 12 mgNP• •FANAPT TITRATION PACK-iloperidone tab 1 mg & 2 mg &4 mg & 6 mg titration pakNP• •FLUPHENAZINE HCL-fluphenazine hcl oral conc 5 mg/mlNPfluphenazine hcl tab 1 mgnpfluphenazine hcl tab 2.5 mgnpfluphenazine hcl tab 5 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 60Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAfluphenazine hcl tab 10 mgnpFLUPHENAZINEHYDROCHLORID- fluphenazinehcl elixir 2.5 mg/5mlNPhaloperidol lactate oral conc2 mg/mlnphaloperidol tab 0.5 mgphaloperidol tab 1 mgphaloperidol tab 2 mgphaloperidol tab 5 mgnphaloperidol tab 10 mgnphaloperidol tab 20 mgnpLATUDA- lurasidone hcl tab20 mgP•LATUDA- lurasidone hcl tab40 mgP•LATUDA- lurasidone hcl tab60 mgP•LATUDA- lurasidone hcl tab80 mgP•LATUDA- lurasidone hcl tab120 mgP•LITHIUM CARBONATE- lithiumcarbonate cap 150 mgNPLITHIUM CARBONATE- lithiumcarbonate cap 300 mgNPLITHIUM CARBONATE- lithiumcarbonate cap 600 mgNPlithium carbonate cap 150 mg(Lithium carbonate)plithium carbonate cap 300 mgplithium carbonate cap 600 mg(Lithium carbonate)plithium carbonate tab er 300 mg(Lithobid)plithium carbonate tab er 450 mgplithium carbonate tab 300 mgpLITHOBID- lithium carbonate taber 300 mgNPloxapine succinate cap 5 mgnpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAloxapine succinate cap 10 mgnploxapine succinate cap 25 mgnploxapine succinate cap 50 mgnpMOLINDONEHYDROCHLORIDE- molindonehcl tab 5 mgNPMOLINDONEHYDROCHLORIDE- molindonehcl tab 10 mgNPMOLINDONEHYDROCHLORIDE- molindonehcl tab 25 mgNPolanzapine orally disintegratingtab 5 mg (Zyprexa zydis)np•olanzapine orally disintegratingtab 10 mg (Zyprexa zydis)np•olanzapine orally disintegratingtab 15 mg (Zyprexa zydis)np•olanzapine orally disintegratingtab 20 mg (Zyprexa zydis)np•olanzapine tab 2.5 mg (Zyprexa)p•olanzapine tab 5 mg (Zyprexa)p•olanzapine tab 7.5 mg (Zyprexa)p•olanzapine tab 10 mg (Zyprexa)p•olanzapine tab 15 mg (Zyprexa)p•olanzapine tab 20 mg (Zyprexa)p•paliperidone tab er 24hr 1.5 mg(Invega)np•paliperidone tab er 24hr 3 mg(Invega)np•paliperidone tab er 24hr 6 mg(Invega)np•paliperidone tab er 24hr 9 mg(Invega)np•perphenazine tab 2 mgnpperphenazine tab 4 mgnpperphenazine tab 8 mgnpperphenazine tab 16 mgnpprochlorperazine maleate tab5 mg (base equivalent)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 61Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAprochlorperazine maleate tab10 mg (base equivalent)npprochlorperazine suppos 25 mgnpquetiapine fumarate tab er 24hr50 mg (Seroquel xr)np•quetiapine fumarate tab er 24hr150 mg (Seroquel xr)np•quetiapine fumarate tab er 24hr200 mg (Seroquel xr)np•quetiapine fumarate tab er 24hr300 mg (Seroquel xr)np•quetiapine fumarate tab er 24hr400 mg (Seroquel xr)np•quetiapine fumarate tab 25 mg(Seroquel)p•quetiapine fumarate tab 50 mg(Seroquel)p•quetiapine fumarate tab 100 mg(Seroquel)p•quetiapine fumarate tab 200 mg(Seroquel)p•quetiapine fumarate tab 300 mg(Seroquel)p•quetiapine fumarate tab 400 mg(Seroquel)p•REXULTI- brexpiprazole tab0.25 mgNP•REXULTI- brexpiprazole tab0.5 mgNP•REXULTI- brexpiprazole tab 1 mgNP•REXULTI- brexpiprazole tab 2 mgNP•REXULTI- brexpiprazole tab 3 mgNP•REXULTI- brexpiprazole tab 4 mgNP•RISPERIDONE ODT- risperidoneorally disintegrating tab 0.25 mgNP• •risperidone orally disintegratingtab 0.5 mg (Risperdal m-tab)np•risperidone orally disintegratingtab 1 mg (Risperdal m-tab)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACArisperidone orally disintegratingtab 2 mg (Risperdal m-tab)np•risperidone orally disintegratingtab 3 mg (Risperdal m-tab)np•risperidone orally disintegratingtab 4 mg (Risperdal m-tab)np•risperidone soln 1 mg/ml(Risperdal)np•risperidone tab 0.25 mg(Risperdal)p•risperidone tab 0.5 mg(Risperdal)p•risperidone tab 1 mg (Risperdal)p•risperidone tab 2 mg (Risperdal)p•risperidone tab 3 mg (Risperdal)p•risperidone tab 4 mg (Risperdal)p•SECUADO- asenapine td patch24 hr 3.8 mg/24hrNP• •SECUADO- asenapine td patch24 hr 5.7 mg/24hrNP• •SECUADO- asenapine td patch24 hr 7.6 mg/24hrNP• •thiothixene cap 1 mgnpthiothixene cap 2 mgnpthiothixene cap 5 mgnpthiothixene cap 10 mgnptrifluoperazine hcl tab 1 mg(base equivalent)nptrifluoperazine hcl tab 2 mg(base equivalent)nptrifluoperazine hcl tab 5 mg(base equivalent)nptrifluoperazine hcl tab 10 mg(base equivalent)npVERSACLOZ- clozapine susp50 mg/mlNP• •VRAYLAR- cariprazine hcl captherapy pack 1.5 mg (1) & 3 mg(6)NP• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 62Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAVRAYLAR- cariprazine hcl cap1.5 mg (base equivalent)NP• •VRAYLAR- cariprazine hcl cap3 mg (base equivalent)NP• •VRAYLAR- cariprazine hcl cap4.5 mg (base equivalent)NP• •VRAYLAR- cariprazine hcl cap6 mg (base equivalent)NP• •ziprasidone hcl cap 20 mg(Geodon)np•ziprasidone hcl cap 40 mg(Geodon)np•ziprasidone hcl cap 60 mg(Geodon)np•ziprasidone hcl cap 80 mg(Geodon)np•HYPNOTICSestazolam tab 1 mgnpestazolam tab 2 mgnpeszopiclone tab 1 mg (Lunesta)p•eszopiclone tab 2 mg (Lunesta)p•eszopiclone tab 3 mg (Lunesta)p•FLURAZEPAM HCL- flurazepamhcl cap 15 mgNPFLURAZEPAM HCL- flurazepamhcl cap 30 mgNPHETLIOZ- tasimelteon capsule20 mgNP• •HETLIOZ LQ- tasimelteon oralsusp 4 mg/mlNP• •phenobarbital elixir 20 mg/5mlnpphenobarbital tab 15 mgpphenobarbital tab 16.2 mgnpphenobarbital tab 30 mgpphenobarbital tab 32.4 mgnpphenobarbital tab 60 mgpphenobarbital tab 64.8 mgnpphenobarbital tab 97.2 mgnpphenobarbital tab 100 mgpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAtemazepam cap 15 mg (Restoril)ptemazepam cap 30 mg (Restoril)pzaleplon cap 5 mg (Sonata)p•zaleplon cap 10 mg (Sonata)p•zolpidem tartrate tab er 6.25 mg(Ambien cr)np•zolpidem tartrate tab er 12.5 mg(Ambien cr)np•zolpidem tartrate tab 5 mg(Ambien)p•zolpidem tartrate tab 10 mg(Ambien)p•ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSamphetamine-dextroamphetamine cap er24hr 5 mg (Adderall xr)np•amphetamine-dextroamphetamine cap er24hr 10 mg (Adderall xr)np•amphetamine-dextroamphetamine cap er24hr 15 mg (Adderall xr)np•amphetamine-dextroamphetamine cap er24hr 20 mg (Adderall xr)np•amphetamine-dextroamphetamine cap er24hr 25 mg (Adderall xr)np•amphetamine-dextroamphetamine cap er24hr 30 mg (Adderall xr)np•amphetamine-dextroamphetamine tab 5 mg(Adderall)np•amphetamine-dextroamphetamine tab7.5 mg (Adderall)np•amphetamine-dextroamphetamine tab 10 mg(Adderall)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 63Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAamphetamine-dextroamphetamine tab12.5 mg (Adderall)np•amphetamine-dextroamphetamine tab 15 mg(Adderall)np•amphetamine-dextroamphetamine tab 20 mg(Adderall)np•amphetamine-dextroamphetamine tab 30 mg(Adderall)np•armodafinil tab 50 mg (Nuvigil)np•armodafinil tab 150 mg (Nuvigil)np•armodafinil tab 200 mg (Nuvigil)np•armodafinil tab 250 mg (Nuvigil)np•atomoxetine hcl cap 10 mg(base equiv) (Strattera)np•atomoxetine hcl cap 18 mg(base equiv) (Strattera)np•atomoxetine hcl cap 25 mg(base equiv) (Strattera)np•atomoxetine hcl cap 40 mg(base equiv) (Strattera)np•atomoxetine hcl cap 60 mg(base equiv) (Strattera)np•atomoxetine hcl cap 80 mg(base equiv) (Strattera)np•atomoxetine hcl cap 100 mg(base equiv) (Strattera)np•caffeine citrate oral soln60 mg/3ml (10 mg/ml baseequiv)npclonidine hcl tab er 12hr 0.1 mg(Kapvay)np•dexmethylphenidate hcl cap er24 hr 5 mg (Focalin xr)np•dexmethylphenidate hcl cap er24 hr 10 mg (Focalin xr)np•dexmethylphenidate hcl cap er24 hr 15 mg (Focalin xr)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdexmethylphenidate hcl cap er24 hr 20 mg (Focalin xr)np•dexmethylphenidate hcl cap er24 hr 25 mg (Focalin xr)np•dexmethylphenidate hcl cap er24 hr 30 mg (Focalin xr)np•dexmethylphenidate hcl cap er24 hr 35 mg (Focalin xr)np•dexmethylphenidate hcl cap er24 hr 40 mg (Focalin xr)np•dexmethylphenidate hcl tab2.5 mg (Focalin)p•dexmethylphenidate hcl tab5 mg (Focalin)np•dexmethylphenidate hcl tab10 mg (Focalin)np•dextroamphetamine sulfate caper 24hr 5 mg (Dexedrine)np•dextroamphetamine sulfate caper 24hr 10 mg (Dexedrine)np•dextroamphetamine sulfate caper 24hr 15 mg (Dexedrine)np•dextroamphetamine sulfate oralsolution 5 mg/5ml (Procentra)np•dextroamphetamine sulfate tab5 mgnp•dextroamphetamine sulfate tab10 mgnp•guanfacine hcl tab er 24hr 1 mg(base equiv) (Intuniv)np•guanfacine hcl tab er 24hr 2 mg(base equiv) (Intuniv)np•guanfacine hcl tab er 24hr 3 mg(base equiv) (Intuniv)np•guanfacine hcl tab er 24hr 4 mg(base equiv) (Intuniv)np•IMCIVREE- setmelanotide acetatesubcutaneous soln 10 mg/mlNP• • •LOMAIRA- phentermine hcl tab8 mgNP+• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 64Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmethylphenidate hcl cap er10 mg (cd)np•methylphenidate hcl cap er20 mg (cd)np•methylphenidate hcl cap er30 mg (cd)np•methylphenidate hcl cap er40 mg (cd)np•methylphenidate hcl cap er50 mg (cd)np•methylphenidate hcl cap er60 mg (cd)np•methylphenidate hcl cap er 24hr20 mg (la) (Ritalin la)np•methylphenidate hcl cap er 24hr30 mg (la) (Ritalin la)np•methylphenidate hcl cap er 24hr40 mg (la) (Ritalin la)np•methylphenidate hcl chew tab2.5 mgnp•methylphenidate hcl chew tab5 mgnp•methylphenidate hcl chew tab10 mgnp•methylphenidate hcl soln5 mg/5ml (Methylin)np•methylphenidate hcl soln10 mg/5ml (Methylin)np•methylphenidate hcl tab erosmotic release (osm) 18 mg(Concerta)np•methylphenidate hcl tab erosmotic release (osm) 27 mg(Concerta)np•methylphenidate hcl tab erosmotic release (osm) 36 mg(Concerta)np•methylphenidate hcl tab erosmotic release (osm) 54 mg(Concerta)np•methylphenidate hcl tab er10 mgnp•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmethylphenidate hcl tab er20 mgnp•methylphenidate hcl tab 5 mg(Ritalin)p•methylphenidate hcl tab 10 mg(Ritalin)np•methylphenidate hcl tab 20 mg(Ritalin)np•modafinil tab 100 mg (Provigil)np•modafinil tab 200 mg (Provigil)np•phentermine hcl cap 15 mgp+• •phentermine hcl cap 30 mgp+• •phentermine hcl cap 37.5 mg(Adipex-p)p+• •phentermine hcl tab 37.5 mg(Adipex-p)p+• •QSYMIA- phentermine hcl-topiramate cap er 24hr3.75-23 mgNP+• •QSYMIA- phentermine hcl-topiramate cap er 24hr7.5-46 mgNP+• •QSYMIA- phentermine hcl-topiramate cap er 24hr11.25-69 mgNP+• •QSYMIA- phentermine hcl-topiramate cap er 24hr15-92 mgNP+• •SAXENDA- liraglutide (weightmngmt) soln pen-inj 18 mg/3ml(6 mg/ml)NP+• •SUNOSI- solriamfetol hcl tab75 mg (base equiv)P• •SUNOSI- solriamfetol hcl tab150 mg (base equiv)P• •VYVANSE- lisdexamfetaminedimesylate cap 10 mgP•VYVANSE- lisdexamfetaminedimesylate cap 20 mgP•VYVANSE- lisdexamfetaminedimesylate cap 30 mgP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 65Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAVYVANSE- lisdexamfetaminedimesylate cap 40 mgP•VYVANSE- lisdexamfetaminedimesylate cap 50 mgP•VYVANSE- lisdexamfetaminedimesylate cap 60 mgP•VYVANSE- lisdexamfetaminedimesylate cap 70 mgP•VYVANSE- lisdexamfetaminedimesylate chew tab 10 mgP•VYVANSE- lisdexamfetaminedimesylate chew tab 20 mgP•VYVANSE- lisdexamfetaminedimesylate chew tab 30 mgP•VYVANSE- lisdexamfetaminedimesylate chew tab 40 mgP•VYVANSE- lisdexamfetaminedimesylate chew tab 50 mgP•VYVANSE- lisdexamfetaminedimesylate chew tab 60 mgP•WEGOVY- semaglutide (weightmngmt) soln auto-injector0.25 mg/0.5mlNP+• •WEGOVY- semaglutide (weightmngmt) soln auto-injector0.5 mg/0.5mlNP+• •WEGOVY- semaglutide (weightmngmt) soln auto-injector1 mg/0.5mlNP+• •WEGOVY- semaglutide (weightmngmt) soln auto-injector1.7 mg/0.75mlNP+• •WEGOVY- semaglutide (weightmngmt) soln auto-injector2.4 mg/0.75mlNP+• •XENICAL- orlistat cap 120 mgNP+• •PSYCHOTHERAPEUTIC and NEUROLOGICALAGENTS - MISC.acamprosate calcium tabdelayed release 333 mgnpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAADDYI- flibanserin tab 100 mgNP+• •AUBAGIO- teriflunomide tab 7 mgP• • •AUBAGIO- teriflunomide tab14 mgP• • •AUSTEDO- deutetrabenazine tab6 mgNP• • •AUSTEDO- deutetrabenazine tab9 mgNP• • •AUSTEDO- deutetrabenazine tab12 mgNP• • •AVONEX- interferon beta-1aim prefilled syringe kit30 mcg/0.5mlP• • •AVONEX PEN- interferon beta-1aim auto-injector kit 30 mcg/0.5mlP• • •BETASERON- interferon beta-1bfor inj kit 0.3 mgP• • •bupropion hcl (smokingdeterrent) tab er 12hr 150 mg(Zyban)np•CHLORDIAZEPOXIDE/AMITRIPT- chlordiazepoxide-amitriptyline tab 5-12.5 mgNPCHLORDIAZEPOXIDE/AMITRIPT- chlordiazepoxide-amitriptyline tab 10-25 mgNPdalfampridine tab er 12hr 10 mg(Ampyra)np• • •dimethyl fumarate capsuledelayed release 120 mg(Tecfidera)np• •dimethyl fumarate capsuledelayed release 240 mg(Tecfidera)np• •dimethyl fumarate capsule drstarter pack 120 mg & 240 mg(Tecfidera starter pa)np• •disulfiram tab 250 mg(Antabuse)npdisulfiram tab 500 mg(Antabuse)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 66Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdonepezil hydrochloride orallydisintegrating tab 5 mgpdonepezil hydrochloride orallydisintegrating tab 10 mgpdonepezil hydrochloride tab5 mg (Aricept)pdonepezil hydrochloride tab10 mg (Aricept)pdonepezil hydrochloride tab23 mg (Aricept)npGALANTAMINEHYDROBROMIDE- galantaminehydrobromide oral soln 4 mg/mlNPgalantamine hydrobromide caper 24hr 8 mg (Razadyne er)npgalantamine hydrobromide caper 24hr 16 mg (Razadyne er)npgalantamine hydrobromide caper 24hr 24 mg (Razadyne er)npgalantamine hydrobromide tab4 mg (Razadyne)npgalantamine hydrobromide tab8 mg (Razadyne)npgalantamine hydrobromide tab12 mg (Razadyne)npGILENYA- fingolimod hcl cap0.5 mg (base equiv)P• • •glatiramer acetate soln prefilledsyringe 20 mg/ml (MylanProducts) (Copaxone)np• •glatiramer acetate soln prefilledsyringe 40 mg/ml (MylanProducts) (Copaxone)np• •INGREZZA- valbenazine tosylatecap therapy pack 40 mg (7) &80 mg (21)NP• • •INGREZZA- valbenazine tosylatecap 40 mg (base equiv)NP• • •INGREZZA- valbenazine tosylatecap 60 mg (base equiv)NP• • •INGREZZA- valbenazine tosylatecap 80 mg (base equiv)NP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAKESIMPTA- ofatumumab solnauto-injector 20 mg/0.4mlP• • •LUCEMYRA- lofexidine hcl tab0.18 mg (base equivalent)NP•MAVENCLAD- cladribine tabtherapy pack 10 mg (4 tabs)P• • •MAVENCLAD- cladribine tabtherapy pack 10 mg (5 tabs)P• • •MAVENCLAD- cladribine tabtherapy pack 10 mg (6 tabs)P• • •MAVENCLAD- cladribine tabtherapy pack 10 mg (7 tabs)P• • •MAVENCLAD- cladribine tabtherapy pack 10 mg (8 tabs)P• • •MAVENCLAD- cladribine tabtherapy pack 10 mg (9 tabs)P• • •MAVENCLAD- cladribine tabtherapy pack 10 mg (10 tabs)P• • •MAYZENT- siponimod fumaratetab 0.25 mg (base equiv)P• • •MAYZENT- siponimod fumaratetab 1 mg (base equiv)P• • •MAYZENT- siponimod fumaratetab 2 mg (base equiv)P• • •MAYZENT STARTER PACK-siponimod fumarate tab 0.25 mg(7) starter packP• • •MAYZENT STARTER PACK-siponimod fumarate tab 0.25 mg(12) starter packP• • •memantine hcl oral solution2 mg/ml (Namenda)npmemantine hcl tab 5 mg(Namenda)pmemantine hcl tab 10 mg(Namenda)pmemantine hcl tab 28 x 5 mg& 21 x 10 mg titration pack(Namenda titration pa)npnicotine polacrilex gum 2 mgnp•nicotine polacrilex gum 4 mgnp•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 67Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAnicotine polacrilex lozenge2 mgnp•nicotine polacrilex lozenge4 mgnp•nicotine td patch 24hr7 mg/24hrnp•nicotine td patch 24hr14 mg/24hrnp•nicotine td patch 24hr21 mg/24hrnp•NICOTINE TRANSDERMALSYST- nicotine td patch 24 hr kit21-14-7 mg/24hrP•NICOTROL INHALER- nicotineinhaler system 10 mg (4 mgdelivered)P•NICOTROL NS- nicotine nasalspray 10 mg/ml (0.5 mg/spray)P•NUEDEXTA- dextromethorphanhbr-quinidine sulfate cap20-10 mgNP• •PERPHENAZINE/AMITRIPTYLIN-perphenazine-amitriptyline tab2-10 mgNPPERPHENAZINE/AMITRIPTYLIN-perphenazine-amitriptyline tab2-25 mgNPPERPHENAZINE/AMITRIPTYLIN-perphenazine-amitriptyline tab4-10 mgNPPERPHENAZINE/AMITRIPTYLIN-perphenazine-amitriptyline tab4-25 mgNPPERPHENAZINE/AMITRIPTYLIN-perphenazine-amitriptyline tab4-50 mgNPPIMOZIDE- pimozide tab 1 mgNPPIMOZIDE- pimozide tab 2 mgNPPLEGRIDY- peginterferon beta-1asoln pen-injector 125 mcg/0.5mlP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPLEGRIDY- peginterferonbeta-1a soln prefilled syringe125 mcg/0.5mlP• • •PLEGRIDY- peginterferonbeta-1a im soln prefilled syr125 mcg/0.5mlP• • •PLEGRIDY STARTER PACK-peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml packP• • •PLEGRIDY STARTER PACK-peginterferon beta-1a soln prefsyr 63 & 94 mcg/0.5ml packP• • •REBIF- interferon beta-1a solnpref syr 22 mcg/0.5mlP• • •REBIF- interferon beta-1a solnpref syr 44 mcg/0.5mlP• • •REBIF REBIDOSE- interferonbeta-1a soln auto-inj22 mcg/0.5mlP• • •REBIF REBIDOSE- interferonbeta-1a soln auto-inj44 mcg/0.5mlP• • •REBIF REBIDOSE TITRATION-interferon beta-1a auto-inj 6x8.8 mcg/0.2ml &6x22 mcg/0.5mlP• • •REBIF TITRATION PACK-interferon beta-1a prefsyr 6x8.8 mcg/0.2ml &6x22 mcg/0.5mlP• • •rivastigmine tartrate cap 1.5 mg(base equivalent)nprivastigmine tartrate cap 3 mg(base equivalent)nprivastigmine tartrate cap 4.5 mg(base equivalent)nprivastigmine tartrate cap 6 mg(base equivalent)nprivastigmine td patch 24hr4.6 mg/24hr (Exelon)nprivastigmine td patch 24hr9.5 mg/24hr (Exelon)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 68Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACArivastigmine td patch 24hr13.3 mg/24hr (Exelon)npTEGSEDI- inotersen sodsubcutaneous pref syr284 mg/1.5ml (base eq)NP• • •tetrabenazine tab 12.5 mg(Xenazine)np• • •tetrabenazine tab 25 mg(Xenazine)np• • •VARENICLINE STARTINGMONT- varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42packnp•VARENICLINE TARTRATE-varenicline tartrate tab 0.5 mg(base equiv)np•VARENICLINE TARTRATE-varenicline tartrate tab 1 mg(base equiv)np•VYLEESI- bremelanotide acetsubcutaneous soln auto-inj1.75 mg/0.3mlNP+• •XYREM- sodium oxybate oralsolution 500 mg/mlNP• • •XYWAV- calcium, mag,potassium, & sod oxybates oralsoln 500 mg/mlNP• • •ZEPOSIA- ozanimod hcl cap0.92 mgP• • •ZEPOSIA STARTER KIT-ozanimod cap pack 4 x 0.23 mg& 3 x 0.46 mg & 30 x 0.92 mgP• • •ZEPOSIA 7-DAY STARTER PAC-ozanimod cap pack 4 x 0.23 mg& 3 x 0.46 mgP• • •ANALGESICS AND ANESTHETICSANALGESICS - NON-NARCOTICaspirin chew tab 81 mgp•aspirin tab delayed release81 mgp•butalbital-acetaminophen tab50-325 mgnpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAbutalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)npbutalbital-aspirin-caffeine cap50-325-40 mg (Fiorinal)npdiflunisal tab 500 mgnpTENCON- butalbital-acetaminophen tab 50-325 mgNPANALGESICS - NARCOTICacetaminophen w/ codeine soln120-12 mg/5mlp•acetaminophen w/ codeine tab300-15 mg (Tylenol/codeine)p•acetaminophen w/ codeine tab300-30 mg (Tylenol/codeine#3)p•acetaminophen w/ codeine tab300-60 mg (Tylenol/codeine#4)np•BELBUCA- buprenorphine hclbuccal film 75 mcg (baseequivalent)P•BELBUCA- buprenorphine hclbuccal film 150 mcg (baseequivalent)P•BELBUCA- buprenorphine hclbuccal film 300 mcg (baseequivalent)P•BELBUCA- buprenorphine hclbuccal film 450 mcg (baseequivalent)P•BELBUCA- buprenorphine hclbuccal film 600 mcg (baseequivalent)P•BELBUCA- buprenorphine hclbuccal film 750 mcg (baseequivalent)P•BELBUCA- buprenorphine hclbuccal film 900 mcg (baseequivalent)P•buprenorphine hcl sl tab 2 mg(base equiv)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 69Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAbuprenorphine hcl sl tab 8 mg(base equiv)np•buprenorphine hcl-naloxone hclsl film 2-0.5 mg (base equiv)(Suboxone)np•buprenorphine hcl-naloxonehcl sl film 4-1 mg (base equiv)(Suboxone)np•buprenorphine hcl-naloxonehcl sl film 8-2 mg (base equiv)(Suboxone)np•buprenorphine hcl-naloxone hclsl film 12-3 mg (base equiv)(Suboxone)np•buprenorphine hcl-naloxone hclsl tab 2-0.5 mg (base equiv)np•buprenorphine hcl-naloxone hclsl tab 8-2 mg (base equiv)np•butalbital-acetaminophen-caffw/ cod cap 50-325-40-30 mgnp•butalbital-aspirin-caff w/codeine cap 50-325-40-30 mg(Fiorinal/codeine #3)np•butorphanol tartrate nasal soln10 mg/mlnp• •CODEINE SULFATE- codeinesulfate tab 15 mgNP•CODEINE SULFATE- codeinesulfate tab 60 mgNP•codeine sulfate tab 30 mg(Codeine sulfate)np•fentanyl citrate lozenge on ahandle 200 mcg (Actiq)np• •fentanyl citrate lozenge on ahandle 400 mcg (Actiq)np• •fentanyl citrate lozenge on ahandle 600 mcg (Actiq)np• •fentanyl citrate lozenge on ahandle 800 mcg (Actiq)np• •fentanyl citrate lozenge on ahandle 1200 mcg (Actiq)np• •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAfentanyl citrate lozenge on ahandle 1600 mcg (Actiq)np• •fentanyl td patch 72hr 12 mcg/hr (Duragesic)np• •fentanyl td patch 72hr 25 mcg/hr (Duragesic)np• •fentanyl td patch 72hr 50 mcg/hr (Duragesic)np• •fentanyl td patch 72hr 75 mcg/hr (Duragesic)np• •fentanyl td patch 72hr 100 mcg/hr (Duragesic)np• •hydrocodone-acetaminophensoln 7.5-325 mg/15ml (Hycet)np•hydrocodone-acetaminophentab 10-325 mg (Norco)p•hydrocodone-acetaminophentab 5-325 mg (Norco)p•hydrocodone-acetaminophentab 7.5-325 mg (Norco)p•hydrocodone-ibuprofen tab7.5-200 mgnp•HYDROCODONE/IBUPROFEN-hydrocodone-ibuprofen tab5-200 mgNP•HYDROCODONE/IBUPROFEN-hydrocodone-ibuprofen tab10-200 mgnp•hydromorphone hcl liqd 1 mg/ml (Dilaudid)np•hydromorphone hcl tab 2 mg(Dilaudid)p•hydromorphone hcl tab 4 mg(Dilaudid)p•hydromorphone hcl tab 8 mg(Dilaudid)np•methadone hcl conc 10 mg/ml(Methadose)np•methadone hcl soln 5 mg/5ml(Methadone hcl)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 70Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmethadone hcl soln 10 mg/5ml(Methadone hcl)np•methadone hcl tab for oral susp40 mgnp•methadone hcl tab 5 mg(Dolophine)p•methadone hcl tab 10 mg(Dolophine)p•MORPHINE SULFATE- morphinesulfate oral soln 20 mg/5mlNP•MORPHINE SULFATE- morphinesulfate tab 15 mgP•MORPHINE SULFATE- morphinesulfate tab 30 mgP•MORPHINE SULFATE ER-morphine sulfate cap er 24hr10 mgNP• •MORPHINE SULFATE ER-morphine sulfate cap er 24hr20 mgNP• •MORPHINE SULFATE ER-morphine sulfate cap er 24hr30 mgNP• •MORPHINE SULFATE ER-morphine sulfate cap er 24hr50 mgNP• •MORPHINE SULFATE ER-morphine sulfate cap er 24hr60 mgNP• •MORPHINE SULFATE ER-morphine sulfate cap er 24hr80 mgNP• •MORPHINE SULFATE ER-morphine sulfate cap er 24hr100 mgNP• •morphine sulfate oral soln10 mg/5mlp•morphine sulfate oral soln100 mg/5ml (20 mg/ml)np•morphine sulfate tab er 15 mg(Ms contin)p• •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmorphine sulfate tab er 30 mg(Ms contin)np• •morphine sulfate tab er 60 mg(Ms contin)np• •morphine sulfate tab er 100 mg(Ms contin)np• •morphine sulfate tab er 200 mg(Ms contin)np• •morphine sulfate tab 15 mg(Morphine sulfate)np•morphine sulfate tab 30 mg(Morphine sulfate)np•oxycodone hcl cap 5 mgnp•oxycodone hcl conc 100 mg/5ml(20 mg/ml)np•oxycodone hcl soln 5 mg/5mlnp•oxycodone hcl tab 5 mg(Roxicodone)p•oxycodone hcl tab 10 mgp•oxycodone hcl tab 15 mg(Roxicodone)np•oxycodone hcl tab 20 mgnp•oxycodone hcl tab 30 mg(Roxicodone)np•oxycodone w/ acetaminophentab 2.5-325 mg (Percocet)np•oxycodone w/ acetaminophentab 5-325 mg (Percocet)p•oxycodone w/ acetaminophentab 7.5-325 mg (Percocet)np•oxycodone w/ acetaminophentab 10-325 mg (Percocet)np•oxymorphone hcl tab 5 mg(Opana)np•oxymorphone hcl tab 10 mg(Opana)np•OXYMORPHONEHYDROCHLORIDE-oxymorphone hcl tab er 12hr5 mgNP• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 71Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAOXYMORPHONEHYDROCHLORIDE-oxymorphone hcl tab er 12hr7.5 mgNP• •OXYMORPHONEHYDROCHLORIDE-oxymorphone hcl tab er 12hr10 mgNP• •OXYMORPHONEHYDROCHLORIDE-oxymorphone hcl tab er 12hr15 mgNP• •OXYMORPHONEHYDROCHLORIDE-oxymorphone hcl tab er 12hr20 mgNP• •OXYMORPHONEHYDROCHLORIDE-oxymorphone hcl tab er 12hr30 mgNP• •OXYMORPHONEHYDROCHLORIDE-oxymorphone hcl tab er 12hr40 mgNP• •TRAMADOL HCL ER- tramadolhcl tab er 24hr biphasic release100 mgNPTRAMADOL HCL ER- tramadolhcl tab er 24hr biphasic release200 mgNPTRAMADOL HCL ER- tramadolhcl tab er 24hr biphasic release300 mgNPtramadol hcl tab er 24hr 100 mgnp• •tramadol hcl tab er 24hr 200 mgnp• •tramadol hcl tab er 24hr 300 mgnp• •tramadol hcl tab 50 mg (Ultram)p• •tramadol-acetaminophen tab37.5-325 mg (Ultracet)p•XTAMPZA ER- oxycodone cap er12hr abuse-deterrent 9 mgP• •XTAMPZA ER- oxycodone cap er12hr abuse-deterrent 13.5 mgP• •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAXTAMPZA ER- oxycodone cap er12hr abuse-deterrent 18 mgP• •XTAMPZA ER- oxycodone cap er12hr abuse-deterrent 27 mgP• •XTAMPZA ER- oxycodone cap er12hr abuse-deterrent 36 mgP• •ANALGESICS - ANTI-INFLAMMATORYACTEMRA- tocilizumabsubcutaneous soln prefilledsyringe 162 mg/0.9mlP• • •ACTEMRA ACTPEN- tocilizumabsubcutaneous soln auto-injector162 mg/0.9mlP• • •ARCALYST- rilonacept for inj220 mgNP• • •celecoxib cap 50 mg (Celebrex)p•celecoxib cap 100 mg(Celebrex)p•celecoxib cap 200 mg(Celebrex)p•celecoxib cap 400 mg(Celebrex)np•diclofenac potassium tab 50 mgnpdiclofenac sodium tab delayedrelease 25 mgnpdiclofenac sodium tab delayedrelease 50 mgpdiclofenac sodium tab delayedrelease 75 mgpdiclofenac w/ misoprostol tabdelayed release 50-0.2 mg(Arthrotec 50)npdiclofenac w/ misoprostol tabdelayed release 75-0.2 mg(Arthrotec 75)npENBREL- etanerceptsubcutaneous inj 25 mg/0.5mlP• • •ENBREL- etanerceptsubcutaneous soln prefilledsyringe 25 mg/0.5mlP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 72Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAENBREL- etanerceptsubcutaneous soln prefilledsyringe 50 mg/mlP• • •ENBREL MINI- etanerceptsubcutaneous solution cartridge50 mg/mlP• • •ENBREL SURECLICK- etanerceptsubcutaneous solution auto-injector 50 mg/mlP• • •etodolac cap 200 mgnpetodolac cap 300 mgnpetodolac tab er 24hr 400 mgnpetodolac tab er 24hr 500 mgnpetodolac tab er 24hr 600 mgnpetodolac tab 400 mg (Lodine)npetodolac tab 500 mgnpFLURBIPROFEN- flurbiprofen tab50 mgNPflurbiprofen tab 100 mgnpHUMIRA- adalimumab prefilledsyringe kit 10 mg/0.1mlP• • •HUMIRA- adalimumab prefilledsyringe kit 20 mg/0.2mlP• • •HUMIRA- adalimumab prefilledsyringe kit 40 mg/0.8mlP• • •HUMIRA- adalimumab prefilledsyringe kit 40 mg/0.4mlP• • •HUMIRA PEDIATRIC CROHNSD- adalimumab prefilled syringekit 80 mg/0.8mlP• • •HUMIRA PEDIATRIC CROHNSD- adalimumab prefilled syringekit 80 mg/0.8ml & 40 mg/0.4mlP• • •HUMIRA PEN- adalimumab pen-injector kit 40 mg/0.8mlP• • •HUMIRA PEN- adalimumab pen-injector kit 40 mg/0.4mlP• • •HUMIRA PEN- adalimumab pen-injector kit 80 mg/0.8mlP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAHUMIRA PEN-CD/UC/HS START-adalimumab pen-injector kit40 mg/0.8mlP• • •HUMIRA PEN-CD/UC/HS START-adalimumab pen-injector kit80 mg/0.8mlP• • •HUMIRA PEN-PEDIATRIC UCS- adalimumab pen-injector kit80 mg/0.8mlP• • •HUMIRA PEN-PS/UV STARTER-adalimumab pen-injector kit40 mg/0.8mlP• • •HUMIRA PEN-PS/UV STARTER-adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4mlP• • •ibuprofen tab 400 mgpibuprofen tab 600 mgpibuprofen tab 800 mgpindomethacin cap er 75 mgnpindomethacin cap 25 mgpindomethacin cap 50 mgpketorolac tromethamine tab10 mgnp•KEVZARA- sarilumabsubcutaneous soln prefilledsyringe 150 mg/1.14mlNP• • •KEVZARA- sarilumabsubcutaneous soln prefilledsyringe 200 mg/1.14mlNP• • •KEVZARA- sarilumabsubcutaneous solution auto-injector 150 mg/1.14mlNP• • •KEVZARA- sarilumabsubcutaneous solution auto-injector 200 mg/1.14mlNP• • •leflunomide tab 10 mg (Arava)npleflunomide tab 20 mg (Arava)npmeloxicam tab 7.5 mg (Mobic)pmeloxicam tab 15 mg (Mobic)pnabumetone tab 500 mgpnabumetone tab 750 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 73Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAnaproxen sodium tab 275 mgnpnaproxen sodium tab 550 mg(Anaprox ds)npnaproxen tab 250 mgpnaproxen tab 375 mgpnaproxen tab 500 mg(Naprosyn)pORENCIA- abataceptsubcutaneous soln prefilledsyringe 50 mg/0.4mlNP• • •ORENCIA- abataceptsubcutaneous soln prefilledsyringe 87.5 mg/0.7mlNP• • •ORENCIA- abataceptsubcutaneous soln prefilledsyringe 125 mg/mlNP• • •ORENCIA CLICKJECT- abataceptsubcutaneous soln auto-injector125 mg/mlNP• • •OTEZLA- apremilast tab startertherapy pack 10 mg & 20 mg &30 mgP• • •OTEZLA- apremilast tab 30 mgP• • •OTREXUP- methotrexate soln pfauto-injector 10 mg/0.4mlP•OTREXUP- methotrexate soln pfauto-injector 12.5 mg/0.4mlP•OTREXUP- methotrexate soln pfauto-injector 15 mg/0.4mlP•OTREXUP- methotrexate soln pfauto-injector 17.5 mg/0.4mlP•OTREXUP- methotrexate soln pfauto-injector 20 mg/0.4mlP•OTREXUP- methotrexate soln pfauto-injector 22.5 mg/0.4mlP•OTREXUP- methotrexate soln pfauto-injector 25 mg/0.4mlP•oxaprozin tab 600 mg (Daypro)nppiroxicam cap 10 mg (Feldene)nppiroxicam cap 20 mg (Feldene)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAREDITREX- methotrexate solnprefilled syringe 7.5 mg/0.3mlP•REDITREX- methotrexate solnprefilled syringe 10 mg/0.4mlP•REDITREX- methotrexate solnprefilled syringe 12.5 mg/0.5mlP•REDITREX- methotrexate solnprefilled syringe 15 mg/0.6mlP•REDITREX- methotrexate solnprefilled syringe 17.5 mg/0.7mlP•REDITREX- methotrexate solnprefilled syringe 20 mg/0.8mlP•REDITREX- methotrexate solnprefilled syringe 22.5 mg/0.9mlP•REDITREX- methotrexate solnprefilled syringe 25 mg/mlP•RIDAURA- auranofin cap 3 mgNPRINVOQ- upadacitinib tab er 24hr15 mgP• • •RINVOQ- upadacitinib tab er 24hr30 mgP• • •RINVOQ- upadacitinib tab er 24hr45 mgP• • •SIMPONI- golimumabsubcutaneous soln auto-injector100 mg/mlP• • •SIMPONI- golimumabsubcutaneous soln prefilledsyringe 100 mg/mlP• • •sulindac tab 150 mgpsulindac tab 200 mgpXELJANZ- tofacitinib citrate oralsoln 1 mg/ml (base equivalent)P• • •XELJANZ- tofacitinib citrate tab5 mg (base equivalent)P• • •XELJANZ- tofacitinib citrate tab10 mg (base equivalent)P• • •XELJANZ XR- tofacitinib citratetab er 24hr 11 mg (baseequivalent)P• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 74Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAXELJANZ XR- tofacitinib citratetab er 24hr 22 mg (baseequivalent)P• • •MIGRAINE PRODUCTSAIMOVIG- erenumab-aooesubcutaneous soln auto-injector70 mg/mlP• •AIMOVIG- erenumab-aooesubcutaneous soln auto-injector140 mg/mlP• •AJOVY- fremanezumab-vfrmsubcutaneous soln auto-inj225 mg/1.5mlP• •AJOVY- fremanezumab-vfrmsubcutaneous soln pref syr225 mg/1.5mlP• •dihydroergotamine mesylate inj1 mg/ml (D.h.e. 45)np•eletriptan hydrobromide tab20 mg (base equivalent)(Relpax)np•eletriptan hydrobromide tab40 mg (base equivalent)(Relpax)np•EMGALITY- galcanezumab-gnlmsubcutaneous soln auto-injector120 mg/mlP• •EMGALITY- galcanezumab-gnlmsubcutaneous soln prefilled syr100 mg/mlP• •EMGALITY- galcanezumab-gnlmsubcutaneous soln prefilled syr120 mg/mlP• •ERGOMAR- ergotamine tartrate sltab 2 mgNPMIGERGOT- ergotamine w/caffeine suppos 2-100 mgNPnaratriptan hcl tab 1 mg (baseequiv) (Amerge)np•naratriptan hcl tab 2.5 mg (baseequiv) (Amerge)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANURTEC- rimegepant sulfate tabdisint 75 mgP• •QULIPTA- atogepant tab 10 mgP• •QULIPTA- atogepant tab 30 mgP• •QULIPTA- atogepant tab 60 mgP• •REYVOW- lasmiditan succinatetab 50 mgP• •REYVOW- lasmiditan succinatetab 100 mgP• •rizatriptan benzoate oraldisintegrating tab 5 mg (baseeq) (Maxalt-mlt)p•rizatriptan benzoate oraldisintegrating tab 10 mg (baseeq) (Maxalt-mlt)p•rizatriptan benzoate tab 5 mg(base equivalent) (Maxalt)p•rizatriptan benzoate tab 10 mg(base equivalent) (Maxalt)p•sumatriptan nasal spray 5 mg/act (Imitrex)np•sumatriptan nasal spray 20 mg/act (Imitrex)np•sumatriptan succinate inj6 mg/0.5ml (Imitrex)np•SUMATRIPTAN SUCCINATEREF- sumatriptan succinatesolution cartridge 4 mg/0.5mlNP•SUMATRIPTAN SUCCINATEREF- sumatriptan succinatesolution cartridge 6 mg/0.5mlNP•sumatriptan succinate solutionauto-injector 4 mg/0.5ml(Imitrex statdose sys)np•sumatriptan succinate solutionauto-injector 6 mg/0.5ml(Imitrex statdose sys)np•sumatriptan succinate tab25 mg (Imitrex)p•sumatriptan succinate tab50 mg (Imitrex)p•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 75Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAsumatriptan succinate tab100 mg (Imitrex)p•UBRELVY- ubrogepant tab 50 mgP• •UBRELVY- ubrogepant tab100 mgP• •zolmitriptan orallydisintegrating tab 2.5 mg(Zomig zmt)np•zolmitriptan orallydisintegrating tab 5 mg(Zomig zmt)np•zolmitriptan tab 2.5 mg (Zomig)np•zolmitriptan tab 5 mg (Zomig)np•GOUT AGENTSallopurinol tab 100 mg(Zyloprim)pallopurinol tab 300 mg(Zyloprim)pcolchicine tab 0.6 mg (Colcrys)npcolchicine w/ probenecid tab0.5-500 mgnpprobenecid tab 500 mgnpNEUROMUSCULAR DRUGSANTICONVULSANTSAPTIOM- eslicarbazepine acetatetab 200 mgPAPTIOM- eslicarbazepine acetatetab 400 mgPAPTIOM- eslicarbazepine acetatetab 600 mgPAPTIOM- eslicarbazepine acetatetab 800 mgPcarbamazepine cap er 12hr100 mg (Carbatrol)npcarbamazepine cap er 12hr200 mg (Carbatrol)npcarbamazepine cap er 12hr300 mg (Carbatrol)npcarbamazepine chew tab100 mgnpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAcarbamazepine susp100 mg/5ml (Tegretol)npcarbamazepine tab er 12hr100 mg (Tegretol-xr)npcarbamazepine tab er 12hr200 mg (Tegretol-xr)npcarbamazepine tab er 12hr400 mg (Tegretol-xr)npcarbamazepine tab 200 mg(Tegretol)npCARBATROL- carbamazepinecap er 12hr 100 mgNPCARBATROL- carbamazepinecap er 12hr 200 mgNPCARBATROL- carbamazepinecap er 12hr 300 mgNPCELONTIN- methsuximide cap300 mgNPclobazam suspension 2.5 mg/ml(Onfi)npclobazam tab 10 mg (Onfi)npclobazam tab 20 mg (Onfi)npclonazepam orallydisintegrating tab 0.125 mgnpclonazepam orallydisintegrating tab 0.25 mgnpclonazepam orallydisintegrating tab 0.5 mgnpclonazepam orallydisintegrating tab 1 mgnpclonazepam orallydisintegrating tab 2 mgnpclonazepam tab 0.5 mg(Klonopin)pclonazepam tab 1 mg(Klonopin)pclonazepam tab 2 mg(Klonopin)pDIACOMIT- stiripentol cap 250 mgNPDIACOMIT- stiripentol cap 500 mgNP

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 76Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACADIACOMIT- stiripentol packet250 mgNPDIACOMIT- stiripentol packet500 mgNPDIASTAT ACUDIAL- diazepamrectal gel delivery system 10 mgPDIASTAT ACUDIAL- diazepamrectal gel delivery system 20 mgPDIASTAT PEDIATRIC- diazepamrectal gel delivery system2.5 mgPDIAZEPAM RECTAL GEL-diazepam rectal gel deliverysystem 2.5 mgNPDIAZEPAM RECTAL GEL-diazepam rectal gel deliverysystem 10 mgNPDIAZEPAM RECTAL GEL-diazepam rectal gel deliverysystem 20 mgNPDILANTIN- phenytoin sodiumextended cap 30 mgPDILANTIN- phenytoin sodiumextended cap 100 mgNPDILANTIN INFATABS- phenytoinchew tab 50 mgNPDILANTIN-125- phenytoin susp125 mg/5mlNPdivalproex sodium cap delayedrelease sprinkle 125 mg(Depakote sprinkles)npdivalproex sodium tab delayedrelease 125 mg (Depakote)pdivalproex sodium tab delayedrelease 250 mg (Depakote)pdivalproex sodium tab delayedrelease 500 mg (Depakote)pdivalproex sodium tab er 24 hr250 mg (Depakote er)npdivalproex sodium tab er 24 hr500 mg (Depakote er)npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAEPIDIOLEX- cannabidiol soln100 mg/mlP•ethosuximide cap 250 mg(Zarontin)npethosuximide soln 250 mg/5ml(Zarontin)npfelbamate susp 600 mg/5ml(Felbatol)npfelbamate tab 400 mg (Felbatol)npfelbamate tab 600 mg (Felbatol)npFINTEPLA- fenfluramine hcl oralsoln 2.2 mg/mlNP• •FYCOMPA- perampanel susp0.5 mg/mlNPFYCOMPA- perampanel tab 2 mgNPFYCOMPA- perampanel tab 4 mgNPFYCOMPA- perampanel tab 6 mgNPFYCOMPA- perampanel tab 8 mgNPFYCOMPA- perampanel tab10 mgNPFYCOMPA- perampanel tab12 mgNPgabapentin cap 100 mg(Neurontin)pgabapentin cap 300 mg(Neurontin)pgabapentin cap 400 mg(Neurontin)pgabapentin oral soln250 mg/5ml (Neurontin)npgabapentin tab 600 mg(Neurontin)pgabapentin tab 800 mg(Neurontin)placosamide oral solution 10 mg/ml (Vimpat)nplacosamide tab 50 mg (Vimpat)nplacosamide tab 100 mg (Vimpat)nplacosamide tab 150 mg (Vimpat)nplacosamide tab 200 mg (Vimpat)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 77Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACALAMICTAL ODT- lamotrigine tabdisint 21 x 25 mg & 7 x 50 mgtitration kitNPLAMICTAL ODT- lamotrigine tabdisint 42 x 50mg & 14 x 100mgtitration kitNPLAMICTAL XR- lamotrigine tab er24hr 21 x 25 mg & 7 x 50 mgtitration kitNPLAMICTAL XR- lamotrigine taber 24hr 25 (14) & 50 mg (14) &100 mg(7) kitNPLAMICTAL XR- lamotrigine taber 24hr 50 (14) & 100 mg(14) &200 mg(7) kitNPlamotrigine tab chewabledispersible 5 mg (Lamictalchewable di)nplamotrigine tab chewabledispersible 25 mg (Lamictalchewable di)nplamotrigine tab er 24hr 25 mg(Lamictal xr)nplamotrigine tab er 24hr 50 mg(Lamictal xr)nplamotrigine tab er 24hr 100 mg(Lamictal xr)nplamotrigine tab er 24hr 200 mg(Lamictal xr)nplamotrigine tab er 24hr 250 mg(Lamictal xr)nplamotrigine tab er 24hr 300 mg(Lamictal xr)nplamotrigine tab 25 mg (Lamictal)plamotrigine tab 100 mg(Lamictal)plamotrigine tab 150 mg(Lamictal)plamotrigine tab 200 mg(Lamictal)pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAlamotrigine tab 35 x 25 mgstarter kit (Lamictal starter/tak)nplamotrigine tab 25 mg (42) &100 mg (7) starter kit (Lamictalstarter/not)nplamotrigine tab 84 x 25 mg & 14x 100 mg starter kit (Lamictalstarter/tak)nplevetiracetam oral soln 100 mg/ml (Keppra)nplevetiracetam tab er 24hr500 mg (Keppra xr)nplevetiracetam tab er 24hr750 mg (Keppra xr)nplevetiracetam tab 250 mg(Keppra)plevetiracetam tab 500 mg(Keppra)plevetiracetam tab 750 mg(Keppra)nplevetiracetam tab 1000 mg(Keppra)npMYSOLINE- primidone tab 50 mgNPMYSOLINE- primidone tab250 mgNPNAYZILAM- midazolam nasalspray soln 5 mg/0.1 mlNP•oxcarbazepine susp 300 mg/5ml(60 mg/ml) (Trileptal)npoxcarbazepine tab 150 mg(Trileptal)poxcarbazepine tab 300 mg(Trileptal)npoxcarbazepine tab 600 mg(Trileptal)npPHENYTEK- phenytoin sodiumextended cap 200 mgNPPHENYTEK- phenytoin sodiumextended cap 300 mgNP

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 78Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAphenytoin chew tab 50 mg(Dilantin infatabs)npphenytoin sodium extended cap100 mg (Dilantin)npphenytoin sodium extended cap200 mg (Phenytek)npphenytoin sodium extended cap300 mg (Phenytek)npphenytoin susp 125 mg/5ml(Dilantin-125)nppregabalin cap 25 mg (Lyrica)p•pregabalin cap 50 mg (Lyrica)p•pregabalin cap 75 mg (Lyrica)p•pregabalin cap 100 mg (Lyrica)p•pregabalin cap 150 mg (Lyrica)p•pregabalin cap 200 mg (Lyrica)p•pregabalin cap 225 mg (Lyrica)p•pregabalin cap 300 mg (Lyrica)p•pregabalin soln 20 mg/ml(Lyrica)np•primidone tab 50 mg (Mysoline)pprimidone tab 250 mg(Mysoline)nprufinamide susp 40 mg/ml(Banzel)nprufinamide tab 200 mg (Banzel)nprufinamide tab 400 mg (Banzel)npSPRITAM- levetiracetam tabdisintegrating soluble 250 mgNPSPRITAM- levetiracetam tabdisintegrating soluble 500 mgNPSPRITAM- levetiracetam tabdisintegrating soluble 750 mgNPSPRITAM- levetiracetam tabdisintegrating soluble 1000 mgNPTEGRETOL- carbamazepine susp100 mg/5mlNPTEGRETOL- carbamazepine tab200 mgNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACATEGRETOL-XR- carbamazepinetab er 12hr 100 mgNPTEGRETOL-XR- carbamazepinetab er 12hr 200 mgNPTEGRETOL-XR- carbamazepinetab er 12hr 400 mgNPtiagabine hcl tab 2 mg (Gabitril)nptiagabine hcl tab 4 mg (Gabitril)nptiagabine hcl tab 12 mg(Gabitril)nptiagabine hcl tab 16 mg(Gabitril)nptopiramate cap er 24hr sprinkle25 mg (Qudexy xr)np• •topiramate cap er 24hr sprinkle50 mg (Qudexy xr)np• •topiramate cap er 24hr sprinkle100 mg (Qudexy xr)np• •topiramate cap er 24hr sprinkle150 mg (Qudexy xr)np• •topiramate cap er 24hr sprinkle200 mg (Qudexy xr)np• •topiramate sprinkle cap 15 mg(Topamax sprinkle)nptopiramate sprinkle cap 25 mg(Topamax sprinkle)nptopiramate tab 25 mg (Topamax)ptopiramate tab 50 mg (Topamax)ptopiramate tab 100 mg(Topamax)ptopiramate tab 200 mg(Topamax)pTROKENDI XR- topiramate cap er24hr 25 mgNP• •TROKENDI XR- topiramate cap er24hr 50 mgNP• •TROKENDI XR- topiramate cap er24hr 100 mgNP• •TROKENDI XR- topiramate cap er24hr 200 mgNP• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 79Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAvalproate sodium oral soln250 mg/5ml (base equiv)(Depakene)npvalproic acid cap 250 mg(Depakene)npVALTOCO- diazepam nasal sprayther pack 2 x 7.5 mg/0.1ml(15 mg dose)NP•VALTOCO- diazepam nasal sprayther pack 2 x 10 mg/0.1ml(20 mg dose)NP•VALTOCO- diazepam nasal spray5 mg/0.1 mlNP•VALTOCO- diazepam nasal spray10 mg/0.1 mlNP•vigabatrin powd pack 500 mg(Sabril)npvigabatrin tab 500 mg (Sabril)npVIMPAT- lacosamide oral solution10 mg/mlPXCOPRI- cenobamate tab pack100 mg & 150 mg tabs (250 mgdaily dose)NPXCOPRI- cenobamate tab pack150 mg & 200 mg tabs (350 mgdaily dose)NPXCOPRI- cenobamate tab titrationpack 14 x 12.5 mg & 14 x 25 mgNPXCOPRI- cenobamate tab titrationpack 14 x 50 mg & 14 x 100 mgNPXCOPRI- cenobamate tab titrationpack 14 x 150 mg & 14 x200 mgNPXCOPRI- cenobamate tab 50 mgNPXCOPRI- cenobamate tab 100 mgNPXCOPRI- cenobamate tab 150 mgNPXCOPRI- cenobamate tab 200 mgNPZARONTIN- ethosuximide cap250 mgNPZARONTIN- ethosuximide soln250 mg/5mlNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAzonisamide cap 25 mg(Zonegran)pzonisamide cap 50 mgpzonisamide cap 100 mg(Zonegran)npANTIPARKINSON AGENTSamantadine hcl cap 100 mgnpamantadine hcl soln 50 mg/5mlpAPOKYN- apomorphine hcl solncartridge 30 mg/3mlNP•apomorphine hcl soln cartridge30 mg/3ml (Apokyn)np•benztropine mesylate tab0.5 mgpbenztropine mesylate tab 1 mgpbenztropine mesylate tab 2 mgpbromocriptine mesylate cap5 mg (base equivalent)(Parlodel)npbromocriptine mesylate tab2.5 mg (base equivalent)(Parlodel)npcarbidopa & levodopa tab er25-100 mg (Sinemet cr)npcarbidopa & levodopa tab er50-200 mg (Sinemet cr)npcarbidopa & levodopa tab10-100 mg (Sinemet)pcarbidopa & levodopa tab25-100 mg (Sinemet)pcarbidopa & levodopa tab25-250 mg (Sinemet)npcarbidopa tab 25 mg (Lodosyn)npcarbidopa-levodopa-entacapone tabs12.5-50-200 mg (Stalevo 50)npcarbidopa-levodopa-entacapone tabs18.75-75-200 mg (Stalevo 75)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 80Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAcarbidopa-levodopa-entacapone tabs25-100-200 mg (Stalevo 100)npcarbidopa-levodopa-entacapone tabs31.25-125-200 mg (Stalevo125)npcarbidopa-levodopa-entacapone tabs37.5-150-200 mg (Stalevo 150)npcarbidopa-levodopa-entacapone tabs50-200-200 mg (Stalevo 200)npCARBIDOPA/LEVODOPA ODT-carbidopa & levodopa orallydisintegrating tab 10-100 mgNPCARBIDOPA/LEVODOPA ODT-carbidopa & levodopa orallydisintegrating tab 25-100 mgNPCARBIDOPA/LEVODOPA ODT-carbidopa & levodopa orallydisintegrating tab 25-250 mgNPDUOPA- carbidopa-levodopaenteral susp 4.63-20 mg/mlNPentacapone tab 200 mg(Comtan)npINBRIJA- levodopa inhal powdercap 42 mgP•KYNMOBI- apomorphinehydrochloride film 10 mgPKYNMOBI- apomorphinehydrochloride film 15 mgPKYNMOBI- apomorphinehydrochloride film 20 mgPKYNMOBI- apomorphinehydrochloride film 25 mgPKYNMOBI- apomorphinehydrochloride film 30 mgPNEUPRO- rotigotine td patch 24hr1 mg/24hrNPNEUPRO- rotigotine td patch 24hr2 mg/24hrNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANEUPRO- rotigotine td patch 24hr3 mg/24hrNPNEUPRO- rotigotine td patch 24hr4 mg/24hrNPNEUPRO- rotigotine td patch 24hr6 mg/24hrNPNEUPRO- rotigotine td patch 24hr8 mg/24hrNPpramipexole dihydrochloridetab 0.125 mg (Mirapex)ppramipexole dihydrochloridetab 0.25 mg (Mirapex)ppramipexole dihydrochloridetab 0.5 mg (Mirapex)ppramipexole dihydrochloridetab 0.75 mg (Mirapex)ppramipexole dihydrochloridetab 1 mg (Mirapex)ppramipexole dihydrochloridetab 1.5 mg (Mirapex)prasagiline mesylate tab 0.5 mg(base equiv) (Azilect)nprasagiline mesylate tab 1 mg(base equiv) (Azilect)npropinirole hydrochloride tab0.25 mg (Requip)propinirole hydrochloride tab0.5 mg (Requip)propinirole hydrochloride tab1 mg (Requip)propinirole hydrochloride tab2 mg (Requip)propinirole hydrochloride tab3 mg (Requip)propinirole hydrochloride tab4 mg (Requip)propinirole hydrochloride tab5 mg (Requip)pRYTARY- carbidopa & levodopacap er 23.75-95 mgNP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 81Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACARYTARY- carbidopa & levodopacap er 36.25-145 mgNP•RYTARY- carbidopa & levodopacap er 48.75-195 mgNP•RYTARY- carbidopa & levodopacap er 61.25-245 mgNP•selegiline hcl cap 5 mg(Eldepryl)npselegiline hcl tab 5 mgnptolcapone tab 100 mg (Tasmar)npTRIHEXYPHENIDYL HCL-trihexyphenidyl hcl oral soln0.4 mg/mlNPtrihexyphenidyl hcl tab 2 mgptrihexyphenidyl hcl tab 5 mgpNEUROMUSCULAR AGENTSEVRYSDI- risdiplam for soln0.75 mg/mlNP• • •riluzole tab 50 mg (Rilutek)npMUSCULOSKELETAL THERAPY AGENTSbaclofen tab 10 mgpbaclofen tab 20 mgnpchlorzoxazone tab 500 mgnpcyclobenzaprine hcl tab 5 mgpcyclobenzaprine hcl tab 10 mgpdantrolene sodium cap 25 mg(Dantrium)npdantrolene sodium cap 50 mg(Dantrium)npdantrolene sodium cap 100 mgnpmethocarbamol tab 500 mg(Robaxin)pmethocarbamol tab 750 mg(Robaxin-750)porphenadrine citrate tab er 12hr100 mgnptizanidine hcl tab 2 mg (baseequivalent)p•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAtizanidine hcl tab 4 mg (baseequivalent) (Zanaflex)p•ANTIMYASTHENIC AGENTSFIRDAPSE- amifampridinephosphate tab 10 mg (baseequivalent)NP• • •pyridostigmine bromide oralsoln 60 mg/5ml (Mestinon)nppyridostigmine bromide tab er180 mg (Mestinon timespan)nppyridostigmine bromide tab60 mg (Mestinon)npNUTRITIONAL PRODUCTSVITAMINSergocalciferol cap 1.25 mg(50000 unit) (Drisdol)pphytonadione tab 5 mg(Mephyton)npMULTIVITAMINSPRENATABS RX- prenatal vit w/iron carbonyl-fa tab 29-1 mgPPRENATAL PLUS- prenatal vit w/fe fumarate-fa tab 27-1 mgPPRENATAL VITAMINS PLUS LO-prenatal vit w/ fe fumarate-fa tab27-1 mgPPRENATAL 19- prenatal vit w/dss-fe fumarate-fa tab 29-1 mgPPRENATAL 19- prenatal vit w/ fefumarate-fa chew tab 29-1 mgPPRENATAL-U- prenatal w/oa vit w/ fe fumarate-fa cap106.5-1 mgPSE-NATAL 19- prenatal vit w/ dss-fe fumarate-fa tab 29-1 mgPSE-NATAL 19- prenatal vit w/ fefumarate-fa chew tab 29-1 mgPTRINATE- prenatal vit w/ fefumarate-fa tab 28-1 mgP

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 82Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAVINATE II- prenatal vit w/ febisglycinate chelate-fa tab29-1 mgPVINATE ONE- prenatal vit w/ fefumarate-fa tab 60-1 mgPMINERALS and ELECTROLYTESFLORIVA- sodium fluoride-vitamind liqd drops 0.25 mg/ml-400unit/mlNPGALZIN- zinc acetate cap 25 mg(elemental zinc)NPGALZIN- zinc acetate cap 50 mg(elemental zinc)NPK-TAB- potassium chloride tab er8 meq (600 mg)NPpot phos monobasic w/sodphos di & monobas tab155-852-130mg (K-phosneutral)nppotassium chloride cap er 8meq (Micro-k)nppotassium chloride cap er 10meqnpPOTASSIUM CHLORIDE ER-potassium chloride tab er 8 meq(600 mg)NPpotassium chloridemicroencapsulated crys er tab10 meqppotassium chloridemicroencapsulated crys er tab15 meqnppotassium chloridemicroencapsulated crys er tab20 meqppotassium chloride oral soln10% (20 meq/15ml)nppotassium chloride oral soln20% (40 meq/15ml)nppotassium chloride powderpacket 20 meqnpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACApotassium chloride tab er 8 meq(600 mg)ppotassium chloride tab er 10meq (K-tab)ppotassium chloride tab er 20meq (1500 mg) (K-tab)ppotassium phosphatemonobasic tab 500 mg (K-phos)npSODIUM FLUORIDE- sodiumfluoride tab 0.5 mg f (from1.1 mg naf)PSODIUM FLUORIDE- sodiumfluoride tab 1 mg f (from 2.2 mgnaf)Psodium fluoride chew tab0.25 mg f (from 0.55 mg naf)p•sodium fluoride chew tab0.5 mg f (from 1.1 mg naf)p•sodium fluoride chew tab 1 mg f(from 2.2 mg naf)p•sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)np•sodium fluoride soln 0.5 mg/ml f(from 1.1 mg/ml naf)p•DIETARY PRODUCTSWESTAB MAX- folic acid-pyridoxine-cyanocobalamin tab2.5-25-2 mgpHEMATOLOGICAL AGENTSHEMATOPOIETIC AGENTSARANESP ALBUMIN FREE-darbepoetin alfa soln inj 25 mcg/mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln inj 40 mcg/mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln inj 60 mcg/mlP• •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 83Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAARANESP ALBUMIN FREE-darbepoetin alfa soln inj100 mcg/mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln inj200 mcg/mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 10 mcg/0.4mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 25 mcg/0.42mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 40 mcg/0.4mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 60 mcg/0.3mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 100 mcg/0.5mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 150 mcg/0.3mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 200 mcg/0.4mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 300 mcg/0.6mlP• •ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 500 mcg/mlP• •carbonyl iron susp15 mg/1.25ml (elemental iron)np•CERDELGA- eliglustat tartratecap 84 mg (base equivalent)P• • •cyanocobalamin inj 1000 mcg/mlpDOPTELET- avatrombopagmaleate tab 20 mg (base equiv)P• • •DROXIA- hydroxyurea cap200 mgNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACADROXIA- hydroxyurea cap300 mgNPDROXIA- hydroxyurea cap400 mgNPENDARI- glutamine (sickle cell)powd pack 5 gmNP• •EPOGEN- epoetin alfa inj 2000unit/mlNP• •EPOGEN- epoetin alfa inj 3000unit/mlNP• •EPOGEN- epoetin alfa inj 4000unit/mlNP• •EPOGEN- epoetin alfa inj 10000unit/mlNP• •EPOGEN- epoetin alfa inj 20000unit/mlNP• •FERROUS SULFATE- ferroussulfate liquid 220 mg/5ml(44 mg/5ml elemental fe)P•ferrous sulfate elixir 220 mg/5ml(44 mg/5ml elemental fe)p•ferrous sulfate soln 75 mg/ml(15 mg/ml elemental fe)p•ferrous sulfate syrup300 mg/5ml (60 mg/5mlelemental fe)np•folic acid cap 0.8 mgp•folic acid tab 400 mcgp•folic acid tab 800 mcgp•folic acid tab 1 mgpFULPHILA- pegfilgrastim-jmdbsoln prefilled syringe 6 mg/0.6mlP•HYDROXOCOBALAMIN-hydroxocobalamin acetate inj1000 mcg/ml (base equivalent)NPIRON UP- polysaccharide ironcomplex liquid 15 mg/0.5ml (feequiv)P•LEUKINE- sargramostimlyophilized for inj 250 mcgNP•miglustat cap 100 mg (Zavesca)np• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 84Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAMIRCERA- methoxy peg-epoetin beta soln prefilled syr30 mcg/0.3mlNP•MIRCERA- methoxy peg-epoetin beta soln prefilled syr50 mcg/0.3mlNP•MIRCERA- methoxy peg-epoetin beta soln prefilled syr75 mcg/0.3mlNP•MIRCERA- methoxy peg-epoetin beta soln prefilled syr100 mcg/0.3mlNP•MIRCERA- methoxy peg-epoetin beta soln prefilled syr150 mcg/0.3mlNP•MIRCERA- methoxy peg-epoetin beta soln prefilled syr200 mcg/0.3mlNP•MULPLETA- lusutrombopag tab3 mgP• • •NIVESTYM- filgrastim-aafi inj300 mcg/mlP•NIVESTYM- filgrastim-aafi inj480 mcg/1.6ml (300 mcg/ml)P•NIVESTYM- filgrastim-aafi solnprefilled syringe 300 mcg/0.5mlP•NIVESTYM- filgrastim-aafi solnprefilled syringe 480 mcg/0.8mlP•NOVAFERRUM PEDIATRICDROP- polysaccharide ironcomplex liquid 15 mg/ml (feequiv)P•OXBRYTA- voxelotor tab for oralsusp 300 mgNP• • •OXBRYTA- voxelotor tab 500 mgNP• • •PROCRIT- epoetin alfa inj 2000unit/mlP• •PROCRIT- epoetin alfa inj 3000unit/mlP• •PROCRIT- epoetin alfa inj 4000unit/mlP• •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPROCRIT- epoetin alfa inj 10000unit/mlP• •PROCRIT- epoetin alfa inj 20000unit/mlP• •PROCRIT- epoetin alfa inj 40000unit/mlP• •PROMACTA- eltrombopagolamine powder pack for susp25 mg (base equiv)NP• • •PROMACTA- eltrombopagolamine powder pack for susp12.5 mg (base eq)NP• • •PROMACTA- eltrombopagolamine tab 12.5 mg (baseequiv)NP• • •PROMACTA- eltrombopagolamine tab 25 mg (base equiv)NP• • •PROMACTA- eltrombopagolamine tab 50 mg (base equiv)NP• • •PROMACTA- eltrombopagolamine tab 75 mg (base equiv)NP• • •RETACRIT- epoetin alfa-epbx inj2000 unit/mlP• •RETACRIT- epoetin alfa-epbx inj3000 unit/mlP• •RETACRIT- epoetin alfa-epbx inj4000 unit/mlP• •RETACRIT- epoetin alfa-epbx inj10000 unit/mlP• •RETACRIT- epoetin alfa-epbx inj20000 unit/mlP• •RETACRIT- epoetin alfa-epbx inj40000 unit/mlP• •SIKLOS- hydroxyurea tab 100 mgNPSIKLOS- hydroxyurea tab1000 mgNPZARXIO- filgrastim-sndz solnprefilled syringe 300 mcg/0.5mlP•ZARXIO- filgrastim-sndz solnprefilled syringe 480 mcg/0.8mlP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 85Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAZIEXTENZO- pegfilgrastim-bmezsoln prefilled syringe 6 mg/0.6mlP•ANTICOAGULANTSdabigatran etexilate mesylatecap 75 mg (etexilate base eq)(Pradaxa)np•ELIQUIS- apixaban tab 2.5 mgP•ELIQUIS- apixaban tab 5 mgP•ELIQUIS STARTER PACK-apixaban tab starter pack 5 mgP•enoxaparin sodium inj soln prefsyr 30 mg/0.3ml (Lovenox)npenoxaparin sodium inj soln prefsyr 40 mg/0.4ml (Lovenox)npenoxaparin sodium inj soln prefsyr 60 mg/0.6ml (Lovenox)npenoxaparin sodium inj soln prefsyr 80 mg/0.8ml (Lovenox)npenoxaparin sodium inj soln prefsyr 100 mg/ml (Lovenox)npenoxaparin sodium inj soln prefsyr 120 mg/0.8ml (Lovenox)npenoxaparin sodium inj soln prefsyr 150 mg/ml (Lovenox)npenoxaparin sodium inj300 mg/3ml (Lovenox)np•fondaparinux sodiumsubcutaneous inj2.5 mg/0.5ml (Arixtra)np•fondaparinux sodiumsubcutaneous inj 5 mg/0.4ml(Arixtra)np•fondaparinux sodiumsubcutaneous inj7.5 mg/0.6ml (Arixtra)np•fondaparinux sodiumsubcutaneous inj 10 mg/0.8ml(Arixtra)np•FRAGMIN- dalteparin sodium inj95000 unit/3.8mlNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAFRAGMIN- dalteparin sodium solnprefilled syr 2500 unit/0.2mlNPFRAGMIN- dalteparin sodium solnprefilled syr 5000 unit/0.2mlNPFRAGMIN- dalteparin sodium solnprefilled syr 7500 unit/0.3mlNPFRAGMIN- dalteparin sodium solnprefilled syr 10000 unit/mlNPFRAGMIN- dalteparin sodium solnprefilled syr 12500 unit/0.5mlNPFRAGMIN- dalteparin sodium solnprefilled syr 15000 unit/0.6mlNPFRAGMIN- dalteparin sodium solnprefilled syr 18000 unit/0.72mlNPHEPARIN SODIUM- heparinsodium (porcine) pf inj 5000unit/mlNPheparin sodium (porcine) inj1000 unit/mlnpheparin sodium (porcine) inj5000 unit/mlnpheparin sodium (porcine) inj10000 unit/mlnpheparin sodium (porcine) inj20000 unit/mlnpheparin sodium (porcine) pf inj5000 unit/0.5mlnpPRADAXA- dabigatran etexilatemesylate cap 75 mg (etexilatebase eq)NP•PRADAXA- dabigatran etexilatemesylate cap 110 mg (etexilatebase eq)NP•PRADAXA- dabigatran etexilatemesylate cap 150 mg (etexilatebase eq)NP•warfarin sodium tab 1 mg(Coumadin)pwarfarin sodium tab 2 mg(Coumadin)pwarfarin sodium tab 2.5 mg(Coumadin)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 86Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAwarfarin sodium tab 3 mg(Coumadin)pwarfarin sodium tab 4 mg(Coumadin)pwarfarin sodium tab 5 mg(Coumadin)pwarfarin sodium tab 6 mg(Coumadin)pwarfarin sodium tab 7.5 mg(Coumadin)pwarfarin sodium tab 10 mg(Coumadin)pXARELTO- rivaroxaban for susp1 mg/mlP•XARELTO- rivaroxaban tab2.5 mgP•XARELTO- rivaroxaban tab 10 mgP•XARELTO- rivaroxaban tab 15 mgP•XARELTO- rivaroxaban tab 20 mgP•XARELTO STARTER PACK-rivaroxaban tab starter therapypack 15 mg & 20 mgP•HEMOSTATICSaminocaproic acid oral soln0.25 gm/ml (Amicar)npaminocaproic acid tab 500 mg(Amicar)npaminocaproic acid tab 1000 mg(Amicar)npARTISS- fibrin sealant componentsolutionNPRECOTHROM- thrombin(recombinant) for soln 5000 unitNPRECOTHROM- thrombin(recombinant) for soln 20000unitNPRECOTHROM SPRAY KIT-thrombin (recombinant) for soln20000 unitNPRECOTHROM/SPRAYAPPLICATO- thrombinNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACA(recombinant) for soln 20000unitTHROMBIN-JMI DILUENT-thrombin for soln 5000 unitNPTHROMBIN-JMI DILUENT-thrombin for soln 20000 unitNPTHROMBIN-JMI EPISTAXIS-thrombin for soln kit 5000 unitNPTHROMBIN-JMI SYRINGESPRA- thrombin for soln kit5000 unitNPTHROMBIN-JMI SYRINGESPRA- thrombin for soln kit20000 unitNPTHROMBIN-JMI W/DIL SPRAY-thrombin for soln kit 20000 unitNPTISSEEL- fibrin sealantcomponent kit 2 mlNPTISSEEL- fibrin sealantcomponent kit 4 mlNPTISSEEL- fibrin sealantcomponent kit 10 mlNPTISSEEL- fibrin sealantcomponent solutionNPtranexamic acid tab 650 mg(Lysteda)npHEMATOLOGICAL AGENTS - MISC.ADVATE- antihemophilic factorrecomb (rahf-pfm) for inj 250unitP• • •ADVATE- antihemophilic factorrecomb (rahf-pfm) for inj 500unitP• • •ADVATE- antihemophilic factorrecomb (rahf-pfm) for inj 1000unitP• • •ADVATE- antihemophilic factorrecomb (rahf-pfm) for inj 1500unitP• • •ADVATE- antihemophilic factorrecomb (rahf-pfm) for inj 2000unitP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 87Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAADVATE- antihemophilic factorrecomb (rahf-pfm) for inj 3000unitP• • •ADVATE- antihemophilic factorrecomb (rahf-pfm) for inj 4000unitP• • •ADYNOVATE- antihemophilicfactor recomb pegylated for inj250 unitP• • •ADYNOVATE- antihemophilicfactor recomb pegylated for inj500 unitP• • •ADYNOVATE- antihemophilicfactor recomb pegylated for inj750 unitP• • •ADYNOVATE- antihemophilicfactor recomb pegylated for inj1000 unitP• • •ADYNOVATE- antihemophilicfactor recomb pegylated for inj1500 unitP• • •ADYNOVATE- antihemophilicfactor recomb pegylated for inj2000 unitP• • •ADYNOVATE- antihemophilicfactor recomb pegylated for inj3000 unitP• • •AFSTYLA- antihemophilic factrcmb single chain for inj kit 250unitP• • •AFSTYLA- antihemophilic factrcmb single chain for inj kit 500unitP• • •AFSTYLA- antihemophilic factrcmb single chain for inj kit 1000unitP• • •AFSTYLA- antihemophilic factrcmb single chain for inj kit 1500unitP• • •AFSTYLA- antihemophilic factrcmb single chain for inj kit 2000unitP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAAFSTYLA- antihemophilic factrcmb single chain for inj kit 2500unitP• • •AFSTYLA- antihemophilic factrcmb single chain for inj kit 3000unitP• • •ALPHANATE- antihemophilicfactor/vwf (human) for inj 250unitP•ALPHANATE- antihemophilicfactor/vwf (human) for inj 500unitP•ALPHANATE- antihemophilicfactor/vwf (human) for inj 1000unitP•ALPHANATE- antihemophilicfactor/vwf (human) for inj 1500unitP•ALPHANATE- antihemophilicfactor/vwf (human) for inj 2000unitP•ALPHANINE SD- coagulationfactor ix for inj 500 unitP• • •ALPHANINE SD- coagulationfactor ix for inj 1000 unitP• • •ALPHANINE SD- coagulationfactor ix for inj 1500 unitP• • •ALPROLIX- coagulation factor ix(recomb) (rfixfc) for inj 250 unitP• • •ALPROLIX- coagulation factor ix(recomb) (rfixfc) for inj 500 unitP• • •ALPROLIX- coagulation factor ix(recomb) (rfixfc) for inj 1000 unitP• • •ALPROLIX- coagulation factor ix(recomb) (rfixfc) for inj 2000 unitP• • •ALPROLIX- coagulation factor ix(recomb) (rfixfc) for inj 3000 unitP• • •ALPROLIX- coagulation factor ix(recomb) (rfixfc) for inj 4000 unitP• • •anagrelide hcl cap 0.5 mg(Agrylin)npanagrelide hcl cap 1 mgnp

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 88Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAaspirin-dipyridamole cap er12hr 25-200 mg (Aggrenox)npBENEFIX- coagulation factor ix(recombinant) for inj kit 250 unitP• • •BENEFIX- coagulation factor ix(recombinant) for inj kit 500 unitP• • •BENEFIX- coagulation factor ix(recombinant) for inj kit 1000unitP• • •BENEFIX- coagulation factor ix(recombinant) for inj kit 2000unitP• • •BENEFIX- coagulation factor ix(recombinant) for inj kit 3000unitP• • •BERINERT- c1 esterase inhibitor(human) for iv inj kit 500 unitNP• • •BRILINTA- ticagrelor tab 60 mgPBRILINTA- ticagrelor tab 90 mgPcilostazol tab 50 mgpcilostazol tab 100 mgpclopidogrel bisulfate tab 75 mg(base equiv) (Plavix)pclopidogrel bisulfate tab 300 mg(base equiv) (Plavix)npCOAGADEX- coagulation factor x(human) for inj 250 unitP•COAGADEX- coagulation factor x(human) for inj 500 unitP•CORIFACT- factor xiii concentrate(human) for inj kit 1000-1600unitP•dipyridamole tab 25 mgnpdipyridamole tab 50 mgnpdipyridamole tab 75 mgnpELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 250 unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 500 unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 750 unitP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 1000unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 1500unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 2000unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 3000unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 4000unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 5000unitP• • •ELOCTATE- antihemophilic factorrcmb (bdd-rfviiifc) for inj 6000unitP• • •EMPAVELI- pegcetacoplansubcutaneous soln1080 mg/20ml (54 mg/ml)P• • •ESPEROCT- antihemophilic factorrecomb glycopeg-exei for inj 500unitP• • •ESPEROCT- antihemophilic factorrecomb glycopeg-exei for inj1000 unitP• • •ESPEROCT- antihemophilic factorrecomb glycopeg-exei for inj1500 unitP• • •ESPEROCT- antihemophilic factorrecomb glycopeg-exei for inj2000 unitP• • •ESPEROCT- antihemophilic factorrecomb glycopeg-exei for inj3000 unitP• • •FEIBA- antiinhibitor coagulantcomplex for iv soln 500 unitP•FEIBA- antiinhibitor coagulantcomplex for iv soln 1000 unitP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 89Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAFEIBA- antiinhibitor coagulantcomplex for iv soln 2500 unitP•FIBRYGA- fibrinogen conc(human) inj approximately 1 gm(900-1300 mg)P• • •HAEGARDA- c1 esterase inhibitor(human) for subcutaneous inj2000 unitP• • •HAEGARDA- c1 esterase inhibitor(human) for subcutaneous inj3000 unitP• • •HEMLIBRA- emicizumab-kxwhsubcutaneous soln 30 mg/mlP• • •HEMLIBRA- emicizumab-kxwhsubcutaneous soln 60 mg/0.4ml(150 mg/ml)P• • •HEMLIBRA- emicizumab-kxwh subcutaneous soln105 mg/0.7ml (150 mg/ml)P• • •HEMLIBRA- emicizumab-kxwhsubcutaneous soln 150 mg/mlP• • •HEMOFIL M- antihemophilic factor(human) for inj 250 unitP• • •HEMOFIL M- antihemophilic factor(human) for inj 500 unitP• • •HEMOFIL M- antihemophilic factor(human) for inj 1000 unitP• • •HEMOFIL M- antihemophilic factor(human) for inj 1700 unitP• • •HUMATE-P- antihemophilic factor/vwf (human) for inj 250-600 unitP•HUMATE-P- antihemophilic factor/vwf (human) for inj 500-1200unitP•HUMATE-P- antihemophilic factor/vwf (human) for inj 1000-2400unitP•icatibant acetate inj 30 mg/3ml(base equivalent) (Firazyr)np• • •IDELVION- coagulation factor ix(recomb) (rix-fp) for inj 250 unitP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAIDELVION- coagulation factor ix(recomb) (rix-fp) for inj 500 unitP• • •IDELVION- coagulation factor ix(recomb) (rix-fp) for inj 1000 unitP• • •IDELVION- coagulation factor ix(recomb) (rix-fp) for inj 2000 unitP• • •IDELVION- coagulation factor ix(recomb) (rix-fp) for inj 3500 unitP• • •IXINITY- coagulation factor ix(recombinant) for inj 250 unitP• • •IXINITY- coagulation factor ix(recombinant) for inj 500 unitP• • •IXINITY- coagulation factor ix(recombinant) for inj 1000 unitP• • •IXINITY- coagulation factor ix(recombinant) for inj 1500 unitP• • •IXINITY- coagulation factor ix(recombinant) for inj 2000 unitP• • •IXINITY- coagulation factor ix(recombinant) for inj 3000 unitP• • •JIVI- antihemophil fact rcmb(bdd-rfviii peg-aucl) for inj 500 unitP• • •JIVI- antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 1000 unitP• • •JIVI- antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 2000 unitP• • •JIVI- antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 3000 unitP• • •KOATE- antihemophilic factor(human) for inj 250 unitP• • •KOATE- antihemophilic factor(human) for inj 500 unitP• • •KOATE- antihemophilic factor(human) for inj 1000 unitP• • •KOATE-DVI- antihemophilic factor(human) for inj 500 unitP• • •KOATE-DVI- antihemophilic factor(human) for inj 1000 unitP• • •KOGENATE FS- antihemophilicfactor recomb (rfviii) for inj kit250 unitP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 90Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAKOGENATE FS- antihemophilicfactor recomb (rfviii) for inj kit500 unitP• • •KOGENATE FS- antihemophilicfactor recomb (rfviii) for inj kit1000 unitP• • •KOGENATE FS- antihemophilicfactor recomb (rfviii) for inj kit2000 unitP• • •KOGENATE FS- antihemophilicfactor recomb (rfviii) for inj kit3000 unitP• • •KOVALTRY- antihemophilic factorrecomb (rahf-pfm) for inj 250unitP• • •KOVALTRY- antihemophilic factorrecomb (rahf-pfm) for inj 500unitP• • •KOVALTRY- antihemophilic factorrecomb (rahf-pfm) for inj 1000unitP• • •KOVALTRY- antihemophilic factorrecomb (rahf-pfm) for inj 2000unitP• • •KOVALTRY- antihemophilic factorrecomb (rahf-pfm) for inj 3000unitP• • •NOVOEIGHT- antihemophilic factrcmb (bd trunc-rfviii) for inj 250unitP• • •NOVOEIGHT- antihemophilic factrcmb (bd trunc-rfviii) for inj 500unitP• • •NOVOEIGHT- antihemophilic factrcmb (bd trunc-rfviii) for inj 1000unitP• • •NOVOEIGHT- antihemophilic factrcmb (bd trunc-rfviii) for inj 1500unitP• • •NOVOEIGHT- antihemophilic factrcmb (bd trunc-rfviii) for inj 2000unitP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANOVOEIGHT- antihemophilic factrcmb (bd trunc-rfviii) for inj 3000unitP• • •NOVOSEVEN RT- coagulationfactor viia (recomb) for inj 1 mg(1000 mcg)P• • •NOVOSEVEN RT- coagulationfactor viia (recomb) for inj 2 mg(2000 mcg)P• • •NOVOSEVEN RT- coagulationfactor viia (recomb) for inj 5 mg(5000 mcg)P• • •NOVOSEVEN RT- coagulationfactor viia (recomb) for inj 8 mg(8000 mcg)P• • •NUWIQ- antihemophil fact rcmb(bdd-rfviii,sim) for inj kit 250 unitP• • •NUWIQ- antihemophil fact rcmb(bdd-rfviii,sim) for inj kit 500 unitP• • •NUWIQ- antihemophil factrcmb(bdd-rfviii,sim) for inj kit1000 unitP• • •NUWIQ- antihemophil factrcmb(bdd-rfviii,sim) for inj kit1500 unitP• • •NUWIQ- antihemophil factrcmb(bdd-rfviii,sim) for inj kit2000 unitP• • •NUWIQ- antihemophil factrcmb(bdd-rfviii,sim) for inj kit2500 unitP• • •NUWIQ- antihemophil factrcmb(bdd-rfviii,sim) for inj kit3000 unitP• • •NUWIQ- antihemophil factrcmb(bdd-rfviii,sim) for inj kit4000 unitP• • •NUWIQ- antihemophilic fact rcmb(bdd-rfviii,sim) for inj 1000 unitP• • •NUWIQ- antihemophilic fact rcmb(bdd-rfviii,sim) for inj 1500 unitP• • •NUWIQ- antihemophilic fact rcmb(bdd-rfviii,sim) for inj 2000 unitP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 91Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANUWIQ- antihemophilic fact rcmb(bdd-rfviii,sim) for inj 2500 unitP• • •NUWIQ- antihemophilic fact rcmb(bdd-rfviii,sim) for inj 3000 unitP• • •NUWIQ- antihemophilic fact rcmb(bdd-rfviii,sim) for inj 4000 unitP• • •NUWIQ- antihemophilic factorrcmb (bdd-rfviii,sim) for inj 250unitP• • •NUWIQ- antihemophilic factorrcmb (bdd-rfviii,sim) for inj 500unitP• • •OBIZUR- antihemophilic factor(recomb porc) rpfviii for inj 500unitP•pentoxifylline tab er 400 mgnpprasugrel hcl tab 5 mg (baseequiv) (Effient)npprasugrel hcl tab 10 mg (baseequiv) (Effient)npPROFILNINE- factor ix complexfor inj 500 unitP• • •PROFILNINE- factor ix complexfor inj 1000 unitP• • •PROFILNINE- factor ix complexfor inj 1500 unitP• • •PYRUKYND- mitapivat sulfate tab5 mgNP• • •PYRUKYND- mitapivat sulfate tab20 mgNP• • •PYRUKYND- mitapivat sulfate tab50 mgNP• • •PYRUKYND TAPER PACK-mitapivat sulfate tab therapypack 5 mgNP• • •PYRUKYND TAPER PACK-mitapivat sulfate tab therapypack 7 x 20 mg & 7 x 5 mgNP• • •PYRUKYND TAPER PACK-mitapivat sulfate tab therapypack 7 x 50 mg & 7 x 20 mgNP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAREBINYN- coagulation factor ixrecomb glycopegylated for inj500 untP• • •REBINYN- coagulation factor ixrecomb glycopegylated for inj1000 untP• • •REBINYN- coagulation factor ixrecomb glycopegylated for inj2000 untP• • •RECOMBINATE- antihemophilicfactor recomb (rfviii) for inj220-400 unitP• • •RECOMBINATE- antihemophilicfactor recomb (rfviii) for inj401-800 unitP• • •RECOMBINATE- antihemophilicfactor recomb (rfviii) for inj801-1240 unitP• • •RECOMBINATE- antihemophilicfactor recomb (rfviii) for inj1241-1800 unitP• • •RECOMBINATE- antihemophilicfactor recomb (rfviii) for inj1801-2400 unitP• • •RIASTAP- fibrinogen conc(human) inj approximately 1 gm(900-1300 mg)P• • •RIXUBIS- coagulation factor ix(recombinant) for inj 250 unitP• • •RIXUBIS- coagulation factor ix(recombinant) for inj 500 unitP• • •RIXUBIS- coagulation factor ix(recombinant) for inj 1000 unitP• • •RIXUBIS- coagulation factor ix(recombinant) for inj 2000 unitP• • •RIXUBIS- coagulation factor ix(recombinant) for inj 3000 unitP• • •RUCONEST- c1 esterase inhibitor(recombinant) for iv inj 2100 unitNP• • •SEVENFACT- coagulation factorviia (recom)-jncw for inj 1 mg(1000 mcg)NP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 92Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACASEVENFACT- coagulation factorviia (recom)-jncw for inj 5 mg(5000 mcg)NP• • •TAKHZYRO- lanadelumab-flyo inj300 mg/2ml (150 mg/ml)P• • •TAKHZYRO- lanadelumab-flyosoln pref syringe 300 mg/2ml(150 mg/ml)P• • •TAVALISSE- fostamatinibdisodium tab 100 mg (baseequivalent)NP• •TAVALISSE- fostamatinibdisodium tab 150 mg (baseequivalent)NP• •TRETTEN- coagulation factor xiiia-subunit for inj 2000-3125 unitP•VONVENDI- von willebrand factor(recombinant) for inj 650 unitP•VONVENDI- von willebrand factor(recombinant) for inj 1300 unitP•WILATE- antihemophilic factor/vwf(human) for inj 500-500 unit kitP•WILATE- antihemophilic factor/vwf(human) for inj 1000-1000 unitkitP•XYNTHA- antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 250 unitP• • •XYNTHA- antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 500 unitP• • •XYNTHA- antihemophil factrcmb(bdd-rfviii,mor) for inj kit1000 unitP• • •XYNTHA- antihemophil factrcmb(bdd-rfviii,mor) for inj kit2000 unitP• • •XYNTHA SOLOFUSE-antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250 unitP• • •XYNTHA SOLOFUSE-antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 500 unitP• • •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAXYNTHA SOLOFUSE-antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000 unitP• • •XYNTHA SOLOFUSE-antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 2000 unitP• • •XYNTHA SOLOFUSE-antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 3000 unitP• • •ZONTIVITY- vorapaxar sulfate tab2.08 mg (base equivalent)NPTOPICAL PRODUCTSOPHTHALMIC AGENTSAKTEN- lidocaine hcl ophth gel3.5%NPALREX- loteprednol etabonateophth susp 0.2%NPapraclonidine hcl ophth soln0.5% (base equivalent)(Iopidine)npatropine sulfate ophth soln 1%(Atropine sulfate)npazelastine hcl ophth soln 0.05%pBACITRACIN- bacitracin ophthoint 500 unit/gmPbacitracin-polymyxin b ophthointpbacitracin-polymyxin-neomycin-hc ophth oint 1%npbetaxolol hcl ophth soln 0.5%npbrimonidine tartrate ophth soln0.2%pbromfenac sodium ophth soln0.09% (base equiv) (once-daily)npCARTEOLOL HCL- carteolol hclophth soln 1%NPciprofloxacin hcl ophth soln0.3% (base equivalent)(Ciloxan)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 93Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAcromolyn sodium ophth soln4%pCYCLOMYDRIL- cyclopentolatew/ phenylephrine ophth soln0.2-1%NPcyclopentolate hcl ophth soln0.5% (Cyclogyl)npcyclopentolate hcl ophth soln1% (Cyclogyl)pcyclopentolate hcl ophth soln2% (Cyclogyl)npCYSTADROPS- cysteaminehcl ophth soln 0.37% (baseequivalent)NP•CYSTARAN- cysteamine hclophth soln 0.44% (baseequivalent)NP•DEXAMETHASONE SODIUMPHOS- dexamethasone sodiumphosphate ophth soln 0.1%Pdiclofenac sodium ophth soln0.1%pdorzolamide hcl ophth soln 2%(Trusopt)pdorzolamide hcl-timolol maleateophth soln 22.3-6.8 mg/ml(Cosopt)perythromycin ophth oint 5 mg/gmpFLAREX- fluorometholone acetateophth susp 0.1%NPfluorometholone ophth susp0.1% (Fml liquifilm)npFLURBIPROFEN SODIUM-flurbiprofen sodium ophth soln0.03%NPgatifloxacin ophth soln 0.5%(Zymaxid)npGENTAK- gentamicin sulfateophth oint 0.3%NPgentamicin sulfate ophth soln0.3%pDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAISOPTO ATROPINE- atropinesulfate ophth soln 1%NPketorolac tromethamine ophthsoln 0.4% (Acular ls)npketorolac tromethamine ophthsoln 0.5% (Acular)pLACRISERT- artificial tear ophthinsertNPlatanoprost ophth soln 0.005%(Xalatan)p•LEVOBUNOLOL HCL-levobunolol hcl ophth soln 0.5%NPlevofloxacin ophth soln 0.5%npLOTEMAX- loteprednol etabonateophth oint 0.5%PLOTEMAX SM- loteprednoletabonate ophth gel 0.38%Ploteprednol etabonate ophth gel0.5% (Lotemax)nploteprednol etabonate ophthsusp 0.5% (Lotemax)npMAXIDEX- dexamethasone ophthsusp 0.1%NPmoxifloxacin hcl ophth soln0.5% (base equiv) (Vigamox)npNATACYN- natamycin ophth susp5%Pneomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt opoinnpneomycin-polymyxin-dexamethasone ophth oint0.1% (Maxitrol)pneomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)pNEOMYCIN/POLYMYXIN/GRAMIC- neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/mlNPofloxacin ophth soln 0.3%(Ocuflox)p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 94Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAOXERVATE- cenegermin-bkbjophth soln 0.002% (20 mcg/ml)NP• • •phenylephrine hcl ophth soln2.5%npphenylephrine hcl ophth soln10%nppilocarpine hcl ophth soln 1%(Isopto carpine)nppilocarpine hcl ophth soln 2%(Isopto carpine)nppilocarpine hcl ophth soln 4%(Isopto carpine)nppolymyxin b-trimethoprimophth soln 10000 unit/ml-0.1%(Polytrim)pPRED-G- gentamicin-prednisolone ace ophth susp0.3-1%NPPRED-G S.O.P.- gentamicin-prednisolone ace ophth oint0.3-0.6%NPPREDNISOLONE ACETATE-prednisolone acetate ophth susp1%PPREDNISOLONE SODIUMPHOSP- prednisolone sodiumphosphate ophth soln 1%NPproparacaine hcl ophth soln0.5%npSIMBRINZA- brinzolamide-brimonidine tartrate ophth susp1-0.2%PSULFACETAMIDE SODIUM-sulfacetamide sodium ophth oint10%NPsulfacetamide sodium ophthsoln 10% (Bleph-10)npSULFACETAMIDE SODIUM/PRED- sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%NPtetracaine hcl ophth soln 0.5%npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAtimolol maleate ophth soln0.25% (Timoptic)ptimolol maleate ophth soln 0.5%(Timoptic)ptobramycin ophth soln 0.3%(Tobrex)p•tobramycin-dexamethasoneophth susp 0.3-0.1%(Tobradex)npTRIFLURIDINE- trifluridine ophthsoln 1%POTIC AGENTSacetic acid otic soln 2%npCETRAXAL- ciprofloxacin hcl oticsoln 0.2% (base equivalent)NPCIPROFLOXACIN- ciprofloxacinhcl otic soln 0.2% (baseequivalent)NPciprofloxacin-dexamethasoneotic susp 0.3-0.1% (Ciprodex)npfluocinolone acetonide (otic) oil0.01% (Dermotic)nphydrocortisone w/ acetic acidotic soln 1-2%npneomycin-polymyxin-hc oticsoln 1%npneomycin-polymyxin-hc oticsusp 3.5 mg/ml-10000 unit/ml-1%npofloxacin otic soln 0.3% (Floxinotic)npMOUTH/THROAT/DENTAL AGENTScevimeline hcl cap 30 mg(Evoxac)npchlorhexidine gluconate soln0.12% (Peridex)pclotrimazole troche 10 mgnpFLUORIDEX SENSITIVITY REL-sodium fluoride-potassiumnitrate paste 1.1-5%NPlidocaine hcl viscous soln 2%p

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 95Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANAFRINSE DAILY/ACIDULATED-sodium fluoride-phosphoric acidfor soln 1 mg/5ml (f equiv)NPNAFRINSE DAILY/NEUTRAL-sodium fluoride for soln rinse0.05%NPNAFRINSE WEEKLY- sodiumfluoride for soln rinse 0.2%NPnystatin susp 100000 unit/mlnpORAVIG- miconazole buccal tab50 mg (mouth-throat)NPpilocarpine hcl tab 5 mg(Salagen)nppilocarpine hcl tab 7.5 mg(Salagen)npsodium fluoride cream 1.1%(Prevident 5000 plus)p•sodium fluoride gel 1.1% (0.5%f) (Prevident fluoride)p•sodium fluoride paste 1.1%(Prevident 5000 boost)p•sodium fluoride rinse 0.2%(Prevident rinse)np•sodium fluoride-potassiumnitrate gel 1.1-5% (Prevident5000 sensi)p•stannous fluoride conc 0.63%(Gel-kam oral care ri)p•stannous fluoride gel 0.4%np•triamcinolone acetonide dentalpaste 0.1%npANORECTAL AGENTSANALPRAM-HC- hydrocortisoneacetate w/ pramoxine perianallotn 2.5-1%NPCORTIFOAM- hydrocortisoneacetate perianal foam 10%(90 mg/dose)Phydrocortisone acetate suppos25 mgnpDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAhydrocortisone acetate w/pramoxine perianal cream1-1% (Analpram-hc)nphydrocortisone enema100 mg/60ml (Cortenema)nphydrocortisone perianal cream1% (Proctocort)nphydrocortisone perianal cream2.5% (Anusol-hc)npPROCTOFOAM HC-hydrocortisone acetate w/pramoxine perianal foam 1-1%NPRECTIV- nitroglycerin oint 0.4%NPUCERIS- budesonide rectal foam2 mg/actNPDERMATOLOGICALSacitretin cap 10 mg (Soriatane)npacitretin cap 17.5 mg(Soriatane)npacitretin cap 25 mg (Soriatane)npADBRY- tralokinumab-ldrmsubcutaneous soln prefilled syr150 mg/mlP• •alclometasone dipropionatecream 0.05%npalclometasone dipropionateoint 0.05%npAUGMENTEDBETAMETHASONE D-betamethasone dipropionateaugmented gel 0.05%NP•azelaic acid gel 15% (Finacea)npbetamethasone dipropionateaugmented cream 0.05%(Diprolene af)p•betamethasone dipropionateaugmented lotion 0.05%(Diprolene)np•betamethasone dipropionateaugmented oint 0.05%(Diprolene)np•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 96Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAbetamethasone dipropionatecream 0.05%np•betamethasone dipropionatelotion 0.05%np•betamethasone dipropionateoint 0.05%np•betamethasone valerate cream0.1% (base equivalent)npbetamethasone valerate lotion0.1% (base equivalent)npbetamethasone valerate oint0.1% (base equivalent)npcalcipotriene cream 0.005%(Dovonex)npcalcipotriene soln 0.005%(50 mcg/ml)npciclopirox gel 0.77%np•ciclopirox olamine cream 0.77%(base equiv) (Loprox)np•ciclopirox olamine susp 0.77%(base equiv) (Loprox)np•ciclopirox shampoo 1% (Loproxshampoo)npciclopirox solution 8% (PenlacNail Lacquer)np• •clindamycin phosph-benzoylperoxide (refrig) gel 1.2 (1)-5%(Duac)npclindamycin phosphate gel 1%(Cleocin-t)npclindamycin phosphate lotion1% (Cleocin-t)npclindamycin phosphate soln 1%(Cleocin-t)np•clindamycin phosphate swab1% (Cleocin-t)npclobetasol propionate cream0.05% (Temovate)np•clobetasol propionate emollientbase cream 0.05%npDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAclobetasol propionate gel 0.05%(Temovate)npclobetasol propionate oint0.05% (Temovate)np•clobetasol propionate soln0.05% (Temovate)np•clotrimazole w/ betamethasonecream 1-0.05% (Lotrisone)npCOSENTYX- secukinumabsubcutaneous pref syr 150 mg/ml (300 mg dose)P• • •COSENTYX- secukinumabsubcutaneous soln prefilledsyringe 75 mg/0.5mlP• • •COSENTYX- secukinumabsubcutaneous soln prefilledsyringe 150 mg/mlP• • •COSENTYX SENSOREADYPEN- secukinumabsubcutaneous auto-inj 150 mg/ml (300 mg dose)P• • •COSENTYX SENSOREADYPEN- secukinumabsubcutaneous soln auto-injector150 mg/mlP• • •CROTAN- crotamiton lotion 10%NPdesonide cream 0.05%(Desowen)npdesonide oint 0.05%npdesoximetasone cream 0.25%(Topicort)np•desoximetasone oint 0.25%(Topicort)np•diclofenac sodium (actinickeratoses) gel 3% (Solaraze)np• •diclofenac sodium soln 1.5%np•DUPIXENT- dupilumabsubcutaneous soln pen-injector200 mg/1.14mlP• • •DUPIXENT- dupilumabsubcutaneous soln pen-injector300 mg/2mlP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 97Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACADUPIXENT- dupilumabsubcutaneous soln prefilledsyringe 100 mg/0.67mlP• • •DUPIXENT- dupilumabsubcutaneous soln prefilledsyringe 200 mg/1.14mlP• • •DUPIXENT- dupilumabsubcutaneous soln prefilledsyringe 300 mg/2mlP• • •econazole nitrate cream 1%np•ENSTILAR- calcipotriene-betamethasone dipropionatefoam 0.005-0.064%P•ERY- erythromycin pads 2%NPerythromycin gel 2% (Erygel)np•erythromycin soln 2%np•fluocinolone acetonide cream0.01%npfluocinolone acetonide cream0.025% (Synalar)npfluocinolone acetonide oil0.01% (body oil) (Derma-smoothe/fs bod)npfluocinolone acetonide oil0.01% (scalp oil) (Derma-smoothe/fs sca)npfluocinolone acetonide oint0.025% (Synalar)npfluocinolone acetonide soln0.01% (Synalar)npfluocinonide cream 0.05%np•fluocinonide cream 0.1%(Vanos)np• •fluocinonide gel 0.05%np•fluocinonide oint 0.05%np•fluocinonide soln 0.05%np•FLUOROURACIL- fluorouracilsoln 2%NPFLUOROURACIL- fluorouracilsoln 5%NPfluorouracil cream 5% (Efudex)np• •Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAfluticasone propionate cream0.05% (Cutivate)npfluticasone propionate oint0.005%npgentamicin sulfate cream 0.1%np•halobetasol propionate cream0.05% (Ultravate)np•hydrocortisone cream 2.5%phydrocortisone lotion 2.5%nphydrocortisone oint 2.5%pimiquimod cream 5% (Aldara)np•isotretinoin cap 10 mgnp•isotretinoin cap 20 mgnp•isotretinoin cap 30 mgnp•isotretinoin cap 40 mgnp•IVERMECTIN- ivermectin lotion0.5%NPketoconazole cream 2%np•ketoconazole shampoo 2%(Nizoral)plidocaine hcl soln 4%np•lidocaine patch 5% (Lidoderm)np• •lidocaine-prilocaine cream2.5-2.5%npLINDANE- lindane shampoo 1%NPmalathion lotion 0.5% (Ovide)npMETHOXSALEN- methoxsalenrapid cap 10 mgNPmetronidazole cream 0.75%(Metrocream)npmetronidazole gel 0.75%npmetronidazole gel 1% (Metrogel)npMIRVASO- brimonidinetartrate gel 0.33% (baseequivalent)NPmometasone furoate cream0.1% (Elocon)npmometasone furoate oint 0.1%(Elocon)p•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 98Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAmometasone furoate solution0.1% (lotion)npmupirocin oint 2%pNATROBA- spinosad susp 0.9%NPnystatin cream 100000 unit/gmpnystatin oint 100000 unit/gmpnystatin topical powder 100000unit/gmnppermethrin cream 5% (Elimite)nppodofilox soln 0.5% (Condylox)npPREDNICARBATE- prednicarbateoint 0.1%NPREGRANEX- becaplermin gel0.01%NP• •SANTYL- collagenase oint 250unit/gmNPselenium sulfide lotion 2.5%psilver sulfadiazine cream 1%(Silvadene)pSKYRIZI- risankizumab-rzaasol prefilled syringe 2 x75 mg/0.83ml kitP• • •SKYRIZI- risankizumab-rzaa solnprefilled syringe 150 mg/mlP• • •SKYRIZI PEN- risankizumab-rzaasoln auto-injector 150 mg/mlP• • •SOOLANTRA- ivermectin cream1%np•SPINOSAD- spinosad susp 0.9%NPSTELARA- ustekinumab inj45 mg/0.5mlP• • •STELARA- ustekinumab solnprefilled syringe 45 mg/0.5mlP• • •STELARA- ustekinumab solnprefilled syringe 90 mg/mlP• • •sulfacetamide sodium lotion10% (acne) (Klaron)npSULFAMYLON- mafenide acetatecream 85 mg/gmNPtacrolimus oint 0.03% (Protopic)np•Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAtacrolimus oint 0.1% (Protopic)np•tazarotene cream 0.1%(Tazorac)npTAZORAC- tazarotene cream0.05%PTAZORAC- tazarotene gel 0.05%PTAZORAC- tazarotene gel 0.1%PTREMFYA- guselkumab soln pen-injector 100 mg/mlP• • •TREMFYA- guselkumab solnprefilled syringe 100 mg/mlP• • •tretinoin cream 0.025% (Retin-a)nptretinoin cream 0.05% (Retin-a)nptretinoin cream 0.1% (Retin-a)nptretinoin gel 0.01% (Retin-a)nptriamcinolone acetonide cream0.025%ptriamcinolone acetonide cream0.1%ptriamcinolone acetonide cream0.5%ptriamcinolone acetonide lotion0.025%nptriamcinolone acetonide lotion0.1%nptriamcinolone acetonide oint0.025%ptriamcinolone acetonide oint0.1%ptriamcinolone acetonide oint0.5%pVALCHLOR- mechlorethaminehcl gel 0.016% (baseequivalent)P•MISCELLANEOUS PRODUCTSANTIDOTESCHEMET- succimer cap 100 mgPdeferasirox granules packet90 mg (Jadenu sprinkle)np• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 99Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAdeferasirox granules packet180 mg (Jadenu sprinkle)np• • •deferasirox granules packet360 mg (Jadenu sprinkle)np• • •deferasirox tab for oral susp125 mg (Exjade)np• • •deferasirox tab for oral susp250 mg (Exjade)np• • •deferasirox tab for oral susp500 mg (Exjade)np• • •deferasirox tab 90 mg (Jadenu)np• • •deferasirox tab 180 mgnp• • •deferasirox tab 360 mg (Jadenu)np• • •deferiprone tab 500 mg(Ferriprox)np•deferiprone tab 1000 mg(Ferriprox)np•FERRIPROX- deferiprone oralsoln 100 mg/mlNP•KLOXXADO- naloxone hcl nasalspray 8 mg/0.1mlPnaloxone hcl inj 0.4 mg/mlnpnaloxone hcl inj 4 mg/10mlnpnaloxone hcl nasal spray4 mg/0.1ml (Narcan)npnaloxone hcl soln prefilledsyringe 2 mg/2mlnpNALOXONE HYDROCHLORIDE-naloxone hcl soln cartridge0.4 mg/mlNPnaltrexone hcl tab 50 mgnpRADIOGARDASE- prussian blueinsoluble cap 0.5 gmNPZIMHI- naloxone hcl soln prefilledsyringe 5 mg/0.5mlNPDIAGNOSTIC PRODUCTSBINAXNOW COVID-19 AGCARD- covid-19 at homeantigen test kitNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACACARESTART COVID-19 ANTIGE-covid-19 at home antigen test kitNPCELLTRION DIATRUST COVID--covid-19 at home antigen test kitNPCLEARDETECT COVID-19 ANTI-covid-19 at home antigen test kitNPCLINITEST RAPID COVID-19-covid-19 at home antigen test kitNPCONTOUR BLOOD GLUCOSETES- glucose blood test stripP•CONTOUR NEXT BLOODGLUCOS- glucose blood teststripP•COVID-19 AT-HOME TEST KIT-covid-19 at home antigen test kitNPELLUME COVID-19 HOME TEST-covid-19 at home antigen test kitNPFLOWFLEX COVID-19 ANTIGEN-covid-19 at home antigen test kitNPIHEALTH COVID-19 ANTIGEN-covid-19 at home antigen test kitNPINDICAID COVID-19 RAPID A-covid-19 at home antigen test kitNPINTELISWAB COVID-19 RAPID-covid-19 at home antigen test kitNPKETOSTIX- acetone (urine) teststripNPON/GO COVID-19 ANTIGEN SE-covid-19 at home antigen test kitNPON/GO ONE COVID-19 ANTIGE-covid-19 at home antigen test kitNPQUICKVUE AT-HOME COVID-19-covid-19 at home antigen test kitNPMEDICAL DEVICESAEROCHAMBER MINIAEROSOL- spacer/aerosol-holding chambers - devicePAEROCHAMBER MV- spacer/aerosol-holding chambers -deviceP

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 100Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAAEROCHAMBER PLUS FLOW-VU- spacer/aerosol-holdingchambers - devicePAEROCHAMBER PLUS FLOW-VU/- spacer/aerosol-holdingchambers - devicePAEROCHAMBER Z-STAT PLUSV- spacer/aerosol-holdingchambers - devicePAEROCHAMBER Z-STAT PLUS/F- spacer/aerosol-holdingchambers - devicePAEROCHAMBER Z-STAT PLUS/L- spacer/aerosol-holdingchambers - devicePAEROCHAMBER Z-STAT PLUS/M- spacer/aerosol-holdingchambers - devicePAEROCHAMBER Z-STAT PLUS/S- spacer/aerosol-holdingchambers - devicePAEROVENT PLUS HOLDINGCHA- spacer/aerosol-holdingchambers - devicePBREATHE COMFORT ANTI-STAT- spacer/aerosol-holdingchambers - devicePBREATHE EASE/LARGEMASK- spacer/aerosol-holdingchambers - devicePBREATHE EASE/MEDIUMMASK- spacer/aerosol-holdingchambers - devicePBREATHE EASE/SMALLMASK- spacer/aerosol-holdingchambers - devicePCAYA- diaphragm arc-springP•CLEVER CHOICE ANTI-STATIC- spacer/aerosol-holdingchambers - devicePCOMPACT SPACE CHAMBER/ANT- spacer/aerosol-holdingchambers - devicePDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACACONTOUR HIGH CONTROL-blood glucose calibration - liquid- highPCONTOUR LOW CONTROL-blood glucose calibration - liquid- lowPCONTOUR NEXT CONTROLLEVE- blood glucose calibration- liquid - lowPCONTOUR NEXT CONTROLLEVE- blood glucose calibration- liquid - normalPCONTOUR NORMAL CONTROL-blood glucose calibration - liquid- normalPDEXCOM G6 RECEIVER-continuous blood glucosesystem receiverP• •DEXCOM G6 SENSOR-continuous blood glucosesystem sensorP• •DEXCOM G6 TRANSMITTER-continuous blood glucosesystem transmitterP• •EASIVENT- spacer/aerosol-holding chambers - devicePEASIVENT/MASK-LARGE-spacer/aerosol-holdingchambers - devicePEASIVENT/MASK-MEDIUM-spacer/aerosol-holdingchambers - devicePEASIVENT/MASK-SMALL-spacer/aerosol-holdingchambers - devicePEQ SPACE CHAMBER ANTI-STA- spacer/aerosol-holdingchambers - devicePFC2 FEMALE CONDOM-condoms - femaleP•FEMCAP- cervical cap 22 mmP•FEMCAP- cervical cap 26 mmP•

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 101Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAFEMCAP- cervical cap 30 mmP•FLEXICHAMBER- spacer/aerosol-holding chambers - devicePFLEXICHAMBER ADULT MASK/S- spacer/aerosol-holdingchamber supplies - masksPFLEXICHAMBER CHILD MASK/L-spacer/aerosol-holding chambersupplies - masksPFLEXICHAMBER CHILD MASK/S- spacer/aerosol-holdingchamber supplies - masksPINSPIRACHAMBER/ANTI-STATI- spacer/aerosol-holdingchambers - devicePINSPIRACHAMBER/LARGE-spacer/aerosol-holdingchambers - devicePINSPIRACHAMBER/SOOTHERMAS- spacer/aerosol-holding chambers -devicePINSPIREASE DRUG DELIVERY-spacer/aerosol-holdingchambers - devicePINSPIREASE RESERVOIRBAGS- spacer/aerosol-holdingchamber supplies - bagsPINSULIN PEN NEEDLES –VARIOUSP•INSULIN SYRINGES – VARIOUSP•LANCETS – VARIOUSPMASK VORTEX/CHILD/FROG-spacer/aerosol-holding chambersupplies - masksPMASK VORTEX/TODDLER/LADY- spacer/aerosol-holdingchamber supplies - masksPMICROCHAMBER- spacer/aerosol-holding chambers -devicePDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAMICROSPACER- spacer/aerosol-holding chambers - devicePMISC NEEDLES & SYRINGES –VARIOUSPOMNIFLEX DIAPHRAGM-diaphragmsP•OMNIPOD DASH INTRO KIT (G-insulin infusion disposable pumpkitNP• •OMNIPOD DASH PODS (GEN 4)-insulin infusion disposable pumpsuppliesNP• •OMNIPOD 5 G6 INTRO KIT (G-insulin infusion disposable pumpkitNP• •OMNIPOD 5 G6 PODS (GEN 5)-insulin infusion disposable pumpsuppliesNP• •OPTICHAMBER- spacer/aerosol-holding chambers - devicePOPTICHAMBER DIAMOND-spacer/aerosol-holdingchambers - devicePOPTICHAMBER DIAMOND/LARGE- spacer/aerosol-holdingchambers - devicePOPTICHAMBER DIAMOND/MEDIU- spacer/aerosol-holdingchambers - devicePOPTICHAMBER DIAMOND/SMALL- spacer/aerosol-holdingchambers - devicePPANDA MASK LARGE- spacer/aerosol-holding chambersupplies - masksPPANDA MASK MEDIUM- spacer/aerosol-holding chambersupplies - masksPPANDA MASK SMALL- spacer/aerosol-holding chambersupplies - masksP

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 102Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAPEDIATRIC PANDA MASK-spacer/aerosol-holding chambersupplies - masksPPOCKET CHAMBER- spacer/aerosol-holding chambers -devicePPOCKET SPACER- spacer/aerosol-holding chambers -devicePPRO COMFORT INHALERSPACE- spacer/aerosol-holdingchambers - devicePPROCARE SPACER CHAMBERW/- spacer/aerosol-holdingchambers - devicePRITEFLO- spacer/aerosol-holdingchambers - devicePVORTEX VALVED HOLDINGCHA- spacer/aerosol-holdingchambers - devicePWIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 60 mmP•WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 65 mmP•WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 70 mmP•WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 75 mmP•WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 80 mmP•WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 85 mmP•WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 90 mmP•WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 95 mmP•ASSORTED CLASSESASTAGRAF XL- tacrolimus cap er24hr 0.5 mgNPASTAGRAF XL- tacrolimus cap er24hr 1 mgNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAASTAGRAF XL- tacrolimus cap er24hr 5 mgNPazathioprine tab 50 mg (Imuran)npazathioprine tab 75 mgnpazathioprine tab 100 mgnpBENLYSTA- belimumabsubcutaneous solution auto-injector 200 mg/mlNP• • •BENLYSTA- belimumabsubcutaneous solution prefilledsyringe 200 mg/mlNP• • •CELLCEPT- mycophenolatemofetil cap 250 mgNPCELLCEPT- mycophenolatemofetil for oral susp 200 mg/mlNPCELLCEPT- mycophenolatemofetil tab 500 mgNPcyclosporine cap 25 mg(Sandimmune)npcyclosporine cap 100 mg(Sandimmune)npcyclosporine modified cap25 mg (Neoral)npcyclosporine modified cap50 mg (Cyclosporine modifie)npcyclosporine modified cap100 mg (Neoral)npcyclosporine modified oral soln100 mg/ml (Neoral)npENSPRYNG- satralizumab-mwgesubcutaneous soln pref syringe120 mg/mlNP• • •ENVARSUS XR- tacrolimus tab er24hr 0.75 mgNPENVARSUS XR- tacrolimus tab er24hr 1 mgNPENVARSUS XR- tacrolimus tab er24hr 4 mgNPeverolimus tab 0.25 mg(Zortress)np

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 103Drug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACAeverolimus tab 0.5 mg(Zortress)npeverolimus tab 0.75 mg(Zortress)npeverolimus tab 1 mg (Zortress)npIMURAN- azathioprine tab 50 mgNPlenalidomide cap 5 mg(Revlimid)np• • •lenalidomide cap 10 mg(Revlimid)np• • •lenalidomide cap 15 mg(Revlimid)np• • •lenalidomide cap 25 mg(Revlimid)np• • •LOKELMA- sodium zirconiumcyclosilicate for susp packet5 gmPLOKELMA- sodium zirconiumcyclosilicate for susp packet10 gmPLUPKYNIS- voclosporin cap7.9 mgNP• • •mycophenolate mofetil cap250 mg (Cellcept)npmycophenolate mofetil for oralsusp 200 mg/ml (Cellcept)npmycophenolate mofetil tab500 mg (Cellcept)npmycophenolate sodium tab dr180 mg (mycophenolic acidequiv) (Myfortic)npmycophenolate sodium tab dr360 mg (mycophenolic acidequiv) (Myfortic)npMYFORTIC- mycophenolatesodium tab dr 180 mg(mycophenolic acid equiv)NPMYFORTIC- mycophenolatesodium tab dr 360 mg(mycophenolic acid equiv)NPNEORAL- cyclosporine modifiedcap 25 mgNPDrug NameTier DesignationSpecialtyPrior AuthorizationDispensing LimitsStep TherapyACANEORAL- cyclosporine modifiedcap 100 mgNPNEORAL- cyclosporine modifiedoral soln 100 mg/mlNPpenicillamine tab 250 mg(Depen titratabs)np•PROGRAF- tacrolimus cap 0.5 mgNPPROGRAF- tacrolimus cap 1 mgNPPROGRAF- tacrolimus cap 5 mgNPPROGRAF- tacrolimus packet forsusp 0.2 mgNPPROGRAF- tacrolimus packet forsusp 1 mgNPRAPAMUNE- sirolimus oral soln1 mg/mlNPRAPAMUNE- sirolimus tab 0.5 mgNPRAPAMUNE- sirolimus tab 1 mgNPRAPAMUNE- sirolimus tab 2 mgNPRESET- digital therapy applicationP+•RESET FOR IOS OR ANDROID-digital therapy applicationP+•RESET NON-MONETARY CM-digital therapy applicationP+•RESET-O- digital therapyapplicationP+•RESET-O FOR IOS OR ANDROI-digital therapy applicationP+•RESET-O NON-MONETARY CM-digital therapy applicationP+•REVLIMID- lenalidomide caps2.5 mgP• • •REVLIMID- lenalidomide cap 5 mgP• • •REVLIMID- lenalidomide cap10 mgP• • •REVLIMID- lenalidomide cap15 mgP• • •REVLIMID- lenalidomide cap20 mgP• • •REVLIMID- lenalidomide cap25 mgP• • •

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 105INDEXAabacavir sulfate-lamivudine tab 600-300 mg(Epzicom)......................................................................... 4abacavir sulfate soln 20 mg/ml (base equiv)(Ziagen).............................................................................4abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 4abiraterone acetate tab 250 mg (Zytiga)....................... 13abiraterone acetate tab 500 mg (Zytiga)....................... 13acamprosate calcium tab delayed release 333 mg......65acarbose tab 25 mg (Precose)....................................... 24acarbose tab 50 mg (Precose)....................................... 24acarbose tab 100 mg (Precose)..................................... 24acebutolol hcl cap 200 mg............................................. 35acebutolol hcl cap 400 mg............................................. 35acetaminophen w/ codeine soln 120-12 mg/5ml.......... 68acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)..........................................................................68acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3).................................................................... 68acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4).................................................................... 68acetazolamide cap er 12hr 500 mg (Diamox)............... 42acetazolamide tab 125 mg.............................................. 42acetazolamide tab 250 mg.............................................. 42acetic acid otic soln 2%..................................................94acetylcysteine inhal soln 10%........................................47acetylcysteine inhal soln 20%........................................47acitretin cap 10 mg (Soriatane)......................................95acitretin cap 17.5 mg (Soriatane)...................................95acitretin cap 25 mg (Soriatane)......................................95ACTEMRA ACTPEN -tocilizumab subcutaneous solnauto-injector 162 mg/0.9ml.............................................71ACTEMRA -tocilizumab subcutaneous soln prefilledsyringe 162 mg/0.9ml..................................................... 71ACTHAR -corticotropin inj gel 80 unit/ml.......................... 31ACTHIB -haemophilus b polysaccharide conjugatevaccine for inj....................................................................9ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml).......................................................13acyclovir cap 200 mg (Zovirax)........................................4acyclovir susp 200 mg/5ml (Zovirax).............................. 4acyclovir tab 400 mg (Zovirax)........................................ 4acyclovir tab 800 mg (Zovirax)........................................ 4ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml........................................................................ 12ADBRY -tralokinumab-ldrm subcutaneous soln prefilledsyr 150 mg/ml................................................................. 95ADDYI -flibanserin tab 100 mg......................................... 65adefovir dipivoxil tab 10 mg (Hepsera)........................... 4ADEMPAS -riociguat tab 0.5 mg....................................... 45ADEMPAS -riociguat tab 1 mg.......................................... 45ADEMPAS -riociguat tab 1.5 mg....................................... 45ADEMPAS -riociguat tab 2 mg.......................................... 45ADEMPAS -riociguat tab 2.5 mg....................................... 45ADVAIR DISKUS -fluticasone-salmeterol aer powder ba100-50 mcg/act............................................................... 47ADVAIR DISKUS -fluticasone-salmeterol aer powder ba250-50 mcg/act............................................................... 47ADVAIR DISKUS -fluticasone-salmeterol aer powder ba500-50 mcg/act............................................................... 47ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21mcg/act............................................................................ 47ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21mcg/act............................................................................ 47ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21mcg/act............................................................................ 47ADVATE -antihemophilic factor recomb (rahf-pfm) for inj250 unit........................................................................... 86ADVATE -antihemophilic factor recomb (rahf-pfm) for inj500 unit........................................................................... 86ADVATE -antihemophilic factor recomb (rahf-pfm) for inj1000 unit......................................................................... 86ADVATE -antihemophilic factor recomb (rahf-pfm) for inj1500 unit......................................................................... 86ADVATE -antihemophilic factor recomb (rahf-pfm) for inj2000 unit......................................................................... 86ADVATE -antihemophilic factor recomb (rahf-pfm) for inj3000 unit......................................................................... 87ADVATE -antihemophilic factor recomb (rahf-pfm) for inj4000 unit......................................................................... 87ADYNOVATE -antihemophilic factor recomb pegylated forinj 250 unit...................................................................... 87ADYNOVATE -antihemophilic factor recomb pegylated forinj 500 unit...................................................................... 87ADYNOVATE -antihemophilic factor recomb pegylated forinj 750 unit...................................................................... 87ADYNOVATE -antihemophilic factor recomb pegylated forinj 1000 unit.................................................................... 87ADYNOVATE -antihemophilic factor recomb pegylated forinj 1500 unit.................................................................... 87ADYNOVATE -antihemophilic factor recomb pegylated forinj 2000 unit.................................................................... 87ADYNOVATE -antihemophilic factor recomb pegylated forinj 3000 unit.................................................................... 87AEROCHAMBER MINI AEROSOL -spacer/aerosol-holding chambers - device............................................. 99AEROCHAMBER MV -spacer/aerosol-holding chambers -device.............................................................................. 99AEROCHAMBER PLUS FLOW-VU/ -spacer/aerosol-holding chambers - device........................................... 100AEROCHAMBER PLUS FLOW-VU -spacer/aerosol-holding chambers - device........................................... 100AEROCHAMBER Z-STAT PLUS/F -spacer/aerosol-holding chambers - device........................................... 100AEROCHAMBER Z-STAT PLUS/L -spacer/aerosol-holding chambers - device........................................... 100AEROCHAMBER Z-STAT PLUS/M -spacer/aerosol-holding chambers - device........................................... 100AEROCHAMBER Z-STAT PLUS/S -spacer/aerosol-holding chambers - device........................................... 100

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 106AEROCHAMBER Z-STAT PLUS V -spacer/aerosol-holding chambers - device........................................... 100AEROVENT PLUS HOLDING CHA -spacer/aerosol-holding chambers - device........................................... 100AFLURIA QUADRIVALENT 2022 -influenza virus vaccinesplit quadrivalent im inj...................................................10AFLURIA QUADRIVALENT 2021 -influenza virus vac splitquadrivalent susp pref syr 0.25 ml...................................9AFLURIA QUADRIVALENT 2022 -influenza virus vac splitquadrivalent susp pref syr 0.5ml.................................... 10AFSTYLA -antihemophilic fact rcmb single chain for inj kit250 unit........................................................................... 87AFSTYLA -antihemophilic fact rcmb single chain for inj kit500 unit........................................................................... 87AFSTYLA -antihemophilic fact rcmb single chain for inj kit1000 unit......................................................................... 87AFSTYLA -antihemophilic fact rcmb single chain for inj kit1500 unit......................................................................... 87AFSTYLA -antihemophilic fact rcmb single chain for inj kit2000 unit......................................................................... 87AFSTYLA -antihemophilic fact rcmb single chain for inj kit2500 unit......................................................................... 87AFSTYLA -antihemophilic fact rcmb single chain for inj kit3000 unit......................................................................... 87AIMOVIG -erenumab-aooe subcutaneous soln auto-injector 70 mg/ml............................................................ 74AIMOVIG -erenumab-aooe subcutaneous soln auto-injector 140 mg/ml.......................................................... 74AJOVY -fremanezumab-vfrm subcutaneous soln auto-inj225 mg/1.5ml.................................................................. 74AJOVY -fremanezumab-vfrm subcutaneous soln pref syr225 mg/1.5ml.................................................................. 74AKTEN -lidocaine hcl ophth gel 3.5%............................... 92albendazole tab 200 mg (Albenza).................................. 8albuterol sulfate inhal aero 108 mcg/act (90mcg baseequiv) (Proair hfa).........................................................47albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 47albuterol sulfate soln nebu 0.5% (5 mg/ml)..................47albuterol sulfate soln nebu 0.63 mg/3ml (baseequiv).............................................................................. 47albuterol sulfate soln nebu 1.25 mg/3ml (baseequiv).............................................................................. 47albuterol sulfate syrup 2 mg/5ml................................... 47albuterol sulfate tab 2 mg...............................................47albuterol sulfate tab 4 mg...............................................47alclometasone dipropionate cream 0.05%....................95alclometasone dipropionate oint 0.05%........................95ALDACTAZIDE -spironolactone & hydrochlorothiazide tab50-50 mg......................................................................... 42ALECENSA -alectinib hcl cap 150 mg (baseequivalent)....................................................................... 13ALENDRONATE SODIUM -alendronate sodium oral soln70 mg/75ml..................................................................... 31ALENDRONATE SODIUM -alendronate sodium tab 5mg....................................................................................31alendronate sodium tab 10 mg...................................... 31alendronate sodium tab 35 mg...................................... 31alendronate sodium tab 70 mg (Fosamax)................... 31alfuzosin hcl tab er 24hr 10 mg (Uroxatral).................. 55ALINIA -nitazoxanide for susp 100 mg/5ml.........................9allopurinol tab 100 mg (Zyloprim)................................. 75allopurinol tab 300 mg (Zyloprim)................................. 75ALORA -estradiol td patch twice weekly 0.025mg/24hr........................................................................... 21ALORA -estradiol td patch twice weekly 0.05 mg/24hr.....21ALORA -estradiol td patch twice weekly 0.075mg/24hr........................................................................... 21ALORA -estradiol td patch twice weekly 0.1 mg/24hr.......21ALPHANATE -antihemophilic factor/vwf (human) for inj250 unit........................................................................... 87ALPHANATE -antihemophilic factor/vwf (human) for inj500 unit........................................................................... 87ALPHANATE -antihemophilic factor/vwf (human) for inj1000 unit......................................................................... 87ALPHANATE -antihemophilic factor/vwf (human) for inj1500 unit......................................................................... 87ALPHANATE -antihemophilic factor/vwf (human) for inj2000 unit......................................................................... 87ALPHANINE SD -coagulation factor ix for inj 500 unit......87ALPHANINE SD -coagulation factor ix for inj 1000unit................................................................................... 87ALPHANINE SD -coagulation factor ix for inj 1500unit................................................................................... 87ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ml..................................................................................... 55alprazolam orally disintegrating tab 0.25 mg............... 55alprazolam orally disintegrating tab 0.5 mg................. 55alprazolam orally disintegrating tab 1 mg.................... 55alprazolam orally disintegrating tab 2 mg.................... 56alprazolam tab er 24hr 0.5 mg (Xanax xr).....................56alprazolam tab er 24hr 1 mg (Xanax xr)........................56alprazolam tab er 24hr 2 mg (Xanax xr)........................56alprazolam tab er 24hr 3 mg (Xanax xr)........................56alprazolam tab 0.25 mg (Xanax).................................... 56alprazolam tab 0.5 mg (Xanax)...................................... 56alprazolam tab 1 mg (Xanax)..........................................56alprazolam tab 2 mg (Xanax)..........................................56ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj250 unit........................................................................... 87ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj500 unit........................................................................... 87ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj1000 unit......................................................................... 87ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj2000 unit......................................................................... 87ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj3000 unit......................................................................... 87ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj4000 unit......................................................................... 87ALREX -loteprednol etabonate ophth susp 0.2%............. 92ALUNBRIG -brigatinib tab initiation therapy pack 90 mg &180 mg............................................................................ 13ALUNBRIG -brigatinib tab 30 mg......................................13ALUNBRIG -brigatinib tab 90 mg......................................13

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 107ALUNBRIG -brigatinib tab 180 mg.................................... 13amantadine hcl cap 100 mg........................................... 79amantadine hcl soln 50 mg/5ml.....................................79ambrisentan tab 5 mg (Letairis).....................................45ambrisentan tab 10 mg (Letairis)...................................45amiloride & hydrochlorothiazide tab 5-50 mg.............. 42amiloride hcl tab 5 mg.................................................... 43aminocaproic acid oral soln 0.25 gm/ml (Amicar)....... 86aminocaproic acid tab 500 mg (Amicar)....................... 86aminocaproic acid tab 1000 mg (Amicar)..................... 86amiodarone hcl tab 100 mg............................................38amiodarone hcl tab 200 mg............................................38amiodarone hcl tab 400 mg............................................38amitriptyline hcl tab 10 mg.............................................56amitriptyline hcl tab 50 mg.............................................56amitriptyline hcl tab 75 mg.............................................56amitriptyline hcl tab 100 mg...........................................56amitriptyline hcl tab 150 mg...........................................56amitriptyline hcl tab 25 mg (Elavil)................................56amlodipine besylate-benazepril hcl cap 2.5-10 mg......38amlodipine besylate-benazepril hcl cap 5-40 mg.........39amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)............................................................................ 38amlodipine besylate-benazepril hcl cap 5-20 mg(Lotrel)............................................................................ 38amlodipine besylate-benazepril hcl cap 10-20 mg(Lotrel)............................................................................ 39amlodipine besylate-benazepril hcl cap 10-40 mg(Lotrel)............................................................................ 39amlodipine besylate-olmesartan medoxomil tab 5-20mg (Azor)....................................................................... 39amlodipine besylate-olmesartan medoxomil tab 5-40mg (Azor)....................................................................... 39amlodipine besylate-olmesartan medoxomil tab 10-20mg (Azor)....................................................................... 39amlodipine besylate-olmesartan medoxomil tab 10-40mg (Azor)....................................................................... 39amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)........................................................................ 36amlodipine besylate tab 5 mg (base equivalent)(Norvasc)........................................................................ 36amlodipine besylate tab 10 mg (base equivalent)(Norvasc)........................................................................ 36amlodipine besylate-valsartan tab 5-160 mg(Exforge).........................................................................39amlodipine besylate-valsartan tab 5-320 mg(Exforge).........................................................................39amlodipine besylate-valsartan tab 10-160 mg(Exforge).........................................................................39amlodipine besylate-valsartan tab 10-320 mg(Exforge).........................................................................39amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)........................................ 39amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg (Exforge hct)........................................... 39amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct)...................................... 39amlodipine-valsartan-hydrochlorothiazide tab10-160-25 mg (Exforge hct)......................................... 39amlodipine-valsartan-hydrochlorothiazide tab10-320-25 mg (Exforge hct)......................................... 39AMOXICILLIN/CLAVULANATE P -amoxicillin & kclavulanate chew tab 200-28.5 mg.................................. 1AMOXICILLIN/CLAVULANATE P -amoxicillin & kclavulanate chew tab 400-57 mg..................................... 1AMOXICILLIN/CLAVULANATE P -amoxicillin & kclavulanate tab er 12hr 1000-62.5 mg............................. 1amoxicillin & k clavulanate for susp 200-28.5mg/5ml.............................................................................. 1amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin)..................................................................... 1amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)........................................................ 1amoxicillin & k clavulanate tab 250-125 mg................... 1amoxicillin & k clavulanate tab 500-125 mg(Augmentin)..................................................................... 1amoxicillin & k clavulanate tab 875-125 mg(Augmentin)..................................................................... 1AMOXICILLIN -amoxicillin (trihydrate) chew tab 125mg...................................................................................... 1AMOXICILLIN -amoxicillin (trihydrate) chew tab 250mg...................................................................................... 1amoxicillin (trihydrate) cap 250 mg.................................1amoxicillin (trihydrate) cap 500 mg.................................1amoxicillin (trihydrate) for susp 125 mg/5ml..................1amoxicillin (trihydrate) for susp 200 mg/5ml..................1amoxicillin (trihydrate) for susp 250 mg/5ml..................1amoxicillin (trihydrate) for susp 400 mg/5ml..................1amoxicillin (trihydrate) tab 500 mg..................................1amoxicillin (trihydrate) tab 875 mg..................................1amphetamine-dextroamphetamine cap er 24hr 5 mg(Adderall xr)...................................................................62amphetamine-dextroamphetamine cap er 24hr 10 mg(Adderall xr)...................................................................62amphetamine-dextroamphetamine cap er 24hr 15 mg(Adderall xr)...................................................................62amphetamine-dextroamphetamine cap er 24hr 20 mg(Adderall xr)...................................................................62amphetamine-dextroamphetamine cap er 24hr 25 mg(Adderall xr)...................................................................62amphetamine-dextroamphetamine cap er 24hr 30 mg(Adderall xr)...................................................................62amphetamine-dextroamphetamine tab 5 mg(Adderall)........................................................................62amphetamine-dextroamphetamine tab 7.5 mg(Adderall)........................................................................62amphetamine-dextroamphetamine tab 10 mg(Adderall)........................................................................62amphetamine-dextroamphetamine tab 12.5 mg(Adderall)........................................................................63amphetamine-dextroamphetamine tab 15 mg(Adderall)........................................................................63

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 108amphetamine-dextroamphetamine tab 20 mg(Adderall)........................................................................63amphetamine-dextroamphetamine tab 30 mg(Adderall)........................................................................63AMPICILLIN -ampicillin cap 500 mg................................... 1anagrelide hcl cap 1 mg................................................. 87anagrelide hcl cap 0.5 mg (Agrylin).............................. 87ANALPRAM-HC -hydrocortisone acetate w/ pramoxineperianal lotn 2.5-1%........................................................95anastrozole tab 1 mg (Arimidex)................................... 13ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg..........21ANGELIQ -drospirenone-estradiol tab 0.5-1 mg...............21ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba62.5-25 mcg/inh.............................................................. 47ANZEMET -dolasetron mesylate tab 50 mg..................... 51APOKYN -apomorphine hcl soln cartridge 30 mg/3ml......79apomorphine hcl soln cartridge 30 mg/3ml(Apokyn)......................................................................... 79apraclonidine hcl ophth soln 0.5% (base equivalent)(Iopidine)........................................................................ 92aprepitant capsule 40 mg (Emend)............................... 51aprepitant capsule 80 mg (Emend)............................... 51aprepitant capsule 125 mg (Emend)............................. 51aprepitant capsule therapy pack 80 & 125 mg(Emend).......................................................................... 51APTIOM -eslicarbazepine acetate tab 200 mg................. 75APTIOM -eslicarbazepine acetate tab 400 mg................. 75APTIOM -eslicarbazepine acetate tab 600 mg................. 75APTIOM -eslicarbazepine acetate tab 800 mg................. 75APTIVUS -tipranavir cap 250 mg........................................ 5ARAKODA -tafenoquine succinate tab 100 mg (baseequivalent)......................................................................... 8ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25mcg/ml............................................................................. 82ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40mcg/ml............................................................................. 82ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60mcg/ml............................................................................. 82ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100mcg/ml............................................................................. 83ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200mcg/ml............................................................................. 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml....................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml..................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 40 mcg/0.4ml....................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 60 mcg/0.3ml....................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 100 mcg/0.5ml..................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 150 mcg/0.3ml..................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 200 mcg/0.4ml..................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 300 mcg/0.6ml..................................... 83ARANESP ALBUMIN FREE -darbepoetin alfa solnprefilled syringe 500 mcg/ml.......................................... 83ARCALYST -rilonacept for inj 220 mg...............................71arformoterol tartrate soln nebu 15 mcg/2ml (baseequiv) (Brovana)............................................................48ARIKAYCE -amikacin sulfate liposome inhal susp 590mg/8.4ml (base eq)...........................................................3aripiprazole orally disintegrating tab 10 mg.................59aripiprazole orally disintegrating tab 15 mg.................59aripiprazole oral solution 1 mg/ml.................................59aripiprazole tab 2 mg (Abilify)........................................59aripiprazole tab 5 mg (Abilify)........................................59aripiprazole tab 10 mg (Abilify)......................................59aripiprazole tab 15 mg (Abilify)......................................59aripiprazole tab 20 mg (Abilify)......................................59aripiprazole tab 30 mg (Abilify)......................................59armodafinil tab 50 mg (Nuvigil)......................................63armodafinil tab 150 mg (Nuvigil)................................... 63armodafinil tab 200 mg (Nuvigil)................................... 63armodafinil tab 250 mg (Nuvigil)................................... 63ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 29ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 29ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 29ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 29ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 29ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 29ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 29ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 29ARNUITY ELLIPTA -fluticasone furoate aerosol powderbreath activ 50 mcg/act.................................................. 48ARNUITY ELLIPTA -fluticasone furoate aerosol powderbreath activ 100 mcg/act................................................ 48ARNUITY ELLIPTA -fluticasone furoate aerosol powderbreath activ 200 mcg/act................................................ 48ARTISS -fibrin sealant component solution...................... 86asenapine maleate sl tab 2.5 mg (base equiv)(Saphris)......................................................................... 59asenapine maleate sl tab 5 mg (base equiv)(Saphris)......................................................................... 59asenapine maleate sl tab 10 mg (base equiv)(Saphris)......................................................................... 59ASMANEX HFA -mometasone furoate inhal aerosolsuspension 50 mcg/act...................................................48ASMANEX HFA -mometasone furoate inhal aerosolsuspension 100 mcg/act.................................................48ASMANEX HFA -mometasone furoate inhal aerosolsuspension 200 mcg/act.................................................48ASMANEX TWISTHALER 120 ME -mometasone furoateinhal powd 220 mcg/inh (breath activated)....................48ASMANEX TWISTHALER 30 MET -mometasone furoateinhal powd 110 mcg/inh (breath activated).................... 48ASMANEX TWISTHALER 30 MET -mometasone furoateinhal powd 220 mcg/inh (breath activated)....................48ASMANEX TWISTHALER 60 MET -mometasone furoateinhal powd 220 mcg/inh (breath activated)....................48

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 109aspirin chew tab 81 mg...................................................68aspirin-dipyridamole cap er 12hr 25-200 mg(Aggrenox)..................................................................... 88aspirin tab delayed release 81 mg.................................68ASTAGRAF XL -tacrolimus cap er 24hr 0.5 mg..............102ASTAGRAF XL -tacrolimus cap er 24hr 1 mg................ 102ASTAGRAF XL -tacrolimus cap er 24hr 5 mg................ 102atazanavir sulfate cap 150 mg (base equiv)(Reyataz)...........................................................................5atazanavir sulfate cap 200 mg (base equiv)(Reyataz)...........................................................................5atazanavir sulfate cap 300 mg (base equiv)(Reyataz)...........................................................................5atenolol & chlorthalidone tab 50-25 mg (Tenoretic50)....................................................................................39atenolol & chlorthalidone tab 100-25 mg (Tenoretic100)..................................................................................39atenolol tab 25 mg (Tenormin)....................................... 35atenolol tab 50 mg (Tenormin)....................................... 35atenolol tab 100 mg (Tenormin)..................................... 35atomoxetine hcl cap 10 mg (base equiv)(Strattera)....................................................................... 63atomoxetine hcl cap 18 mg (base equiv)(Strattera)....................................................................... 63atomoxetine hcl cap 25 mg (base equiv)(Strattera)....................................................................... 63atomoxetine hcl cap 40 mg (base equiv)(Strattera)....................................................................... 63atomoxetine hcl cap 60 mg (base equiv)(Strattera)....................................................................... 63atomoxetine hcl cap 80 mg (base equiv)(Strattera)....................................................................... 63atomoxetine hcl cap 100 mg (base equiv)(Strattera)....................................................................... 63atorvastatin calcium tab 10 mg (base equivalent)(Lipitor)........................................................................... 43atorvastatin calcium tab 20 mg (base equivalent)(Lipitor)........................................................................... 43atorvastatin calcium tab 40 mg (base equivalent)(Lipitor)........................................................................... 43atorvastatin calcium tab 80 mg (base equivalent)(Lipitor)........................................................................... 43atovaquone-proguanil hcl tab 62.5-25 mg(Malarone)........................................................................ 8atovaquone-proguanil hcl tab 250-100 mg(Malarone)........................................................................ 8atovaquone susp 750 mg/5ml (Mepron)......................... 9atropine sulfate ophth soln 1% (Atropine sulfate).......92ATROVENT HFA -ipratropium bromide hfa inhal aerosol17 mcg/act.......................................................................48AUBAGIO -teriflunomide tab 7 mg.................................... 65AUBAGIO -teriflunomide tab 14 mg..................................65AUGMENTED BETAMETHASONE D -betamethasonedipropionate augmented gel 0.05%............................... 95AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron).......52AUSTEDO -deutetrabenazine tab 6 mg............................65AUSTEDO -deutetrabenazine tab 9 mg............................65AUSTEDO -deutetrabenazine tab 12 mg..........................65AVONEX -interferon beta-1a im prefilled syringe kit 30mcg/0.5ml........................................................................ 65AVONEX PEN -interferon beta-1a im auto-injector kit 30mcg/0.5ml........................................................................ 65AYVAKIT -avapritinib tab 25 mg........................................13AYVAKIT -avapritinib tab 50 mg........................................13AYVAKIT -avapritinib tab 100 mg......................................13AYVAKIT -avapritinib tab 200 mg......................................13AYVAKIT -avapritinib tab 300 mg......................................13azathioprine tab 75 mg................................................. 102azathioprine tab 100 mg............................................... 102azathioprine tab 50 mg (Imuran)..................................102azelaic acid gel 15% (Finacea).......................................95azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 47azelastine hcl ophth soln 0.05%.................................... 92AZITHROMYCIN -azithromycin powd pack for susp 1gm...................................................................................... 2azithromycin for susp 100 mg/5ml (Zithromax)............. 2azithromycin for susp 200 mg/5ml (Zithromax)............. 2azithromycin tab 250 mg (Zithromax)............................. 2azithromycin tab 500 mg (Zithromax)............................. 2azithromycin tab 600 mg (Zithromax)............................. 2BBACITRACIN -bacitracin ophth oint 500 unit/gm.............. 92bacitracin-polymyxin b ophth oint................................ 92bacitracin-polymyxin-neomycin-hc ophth oint 1%......92baclofen tab 10 mg..........................................................81baclofen tab 20 mg..........................................................81balsalazide disodium cap 750 mg (Colazal)................. 52BALVERSA -erdafitinib tab 3 mg.......................................13BALVERSA -erdafitinib tab 4 mg.......................................13BALVERSA -erdafitinib tab 5 mg.......................................13BAQSIMI ONE PACK -glucagon nasal powder 3 mg/dose................................................................................. 24BAQSIMI TWO PACK -glucagon nasal powder 3 mg/dose................................................................................. 24BARACLUDE -entecavir oral soln 0.05 mg/ml....................5BAXDELA -delafloxacin meglumine tab 450 mg (baseequiv)................................................................................. 3BD GLUCOSE -glucose chew tab 5 gm........................... 24BELBUCA -buprenorphine hcl buccal film 75 mcg (baseequivalent)....................................................................... 68BELBUCA -buprenorphine hcl buccal film 150 mcg (baseequivalent)....................................................................... 68BELBUCA -buprenorphine hcl buccal film 300 mcg (baseequivalent)....................................................................... 68BELBUCA -buprenorphine hcl buccal film 450 mcg (baseequivalent)....................................................................... 68BELBUCA -buprenorphine hcl buccal film 600 mcg (baseequivalent)....................................................................... 68BELBUCA -buprenorphine hcl buccal film 750 mcg (baseequivalent)....................................................................... 68BELBUCA -buprenorphine hcl buccal film 900 mcg (baseequivalent)....................................................................... 68

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 110benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)................................................................ 39benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)................................................................ 39benazepril & hydrochlorothiazide tab 20-25 mg(Lotensin hct)................................................................ 39BENAZEPRIL HCL/HYDROCHLOR -benazepril &hydrochlorothiazide tab 5-6.25 mg.................................39benazepril hcl tab 5 mg.................................................. 39benazepril hcl tab 10 mg................................................ 39benazepril hcl tab 20 mg (Lotensin)..............................39benazepril hcl tab 40 mg (Lotensin)..............................39BENEFIX -coagulation factor ix (recombinant) for inj kit250 unit........................................................................... 88BENEFIX -coagulation factor ix (recombinant) for inj kit500 unit........................................................................... 88BENEFIX -coagulation factor ix (recombinant) for inj kit1000 unit......................................................................... 88BENEFIX -coagulation factor ix (recombinant) for inj kit2000 unit......................................................................... 88BENEFIX -coagulation factor ix (recombinant) for inj kit3000 unit......................................................................... 88BENLYSTA -belimumab subcutaneous solution auto-injector 200 mg/ml........................................................ 102BENLYSTA -belimumab subcutaneous solution prefilledsyringe 200 mg/ml........................................................ 102BENZNIDAZOLE -benznidazole tab 12.5 mg..................... 8BENZNIDAZOLE -benznidazole tab 100 mg...................... 8benzonatate cap 200 mg.................................................47benzonatate cap 100 mg (Tessalon perles).................. 47benztropine mesylate tab 0.5 mg.................................. 79benztropine mesylate tab 1 mg..................................... 79benztropine mesylate tab 2 mg..................................... 79BERINERT -c1 esterase inhibitor (human) for iv inj kit 500unit................................................................................... 88BESREMI -ropeginterferon alfa-2b-njft soln prefilled syr500 mcg/ml......................................................................13betaine powder for oral solution (Cystadane)..............31betamethasone dipropionate augmented cream 0.05%(Diprolene af).................................................................95betamethasone dipropionate augmented lotion 0.05%(Diprolene)......................................................................95betamethasone dipropionate augmented oint 0.05%(Diprolene)......................................................................95betamethasone dipropionate cream 0.05%.................. 96betamethasone dipropionate lotion 0.05%................... 96betamethasone dipropionate oint 0.05%...................... 96betamethasone valerate cream 0.1% (baseequivalent)......................................................................96betamethasone valerate lotion 0.1% (baseequivalent)......................................................................96betamethasone valerate oint 0.1% (baseequivalent)......................................................................96BETASERON -interferon beta-1b for inj kit 0.3 mg........... 65betaxolol hcl ophth soln 0.5%........................................92betaxolol hcl tab 10 mg.................................................. 35betaxolol hcl tab 20 mg.................................................. 35bethanechol chloride tab 5 mg (Urecholine)................ 54bethanechol chloride tab 10 mg (Urecholine).............. 54bethanechol chloride tab 25 mg (Urecholine).............. 54bethanechol chloride tab 50 mg (Urecholine).............. 54bexarotene cap 75 mg (Targretin)..................................13BEXSERO -meningococcal vac b (recomb omv adjuv) injprefilled syringe...............................................................10bicalutamide tab 50 mg (Casodex)................................ 13BIKTARVY -bictegravir-emtricitabine-tenofovir af tab30-120-15 mg....................................................................5BIKTARVY -bictegravir-emtricitabine-tenofovir af tab50-200-25 mg....................................................................5BINAXNOW COVID-19 AG CARD -covid-19 at homeantigen test kit.................................................................99bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)............................................................................... 39bisoprolol & hydrochlorothiazide tab 5-6.25 mg(Ziac)............................................................................... 39bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)............................................................................... 39bisoprolol fumarate tab 5 mg.........................................35bisoprolol fumarate tab 10 mg.......................................36BOOSTRIX -tet-diph-acell pertuss ad pref syr 5-2.5-18.5lf-mcg/0.5ml.....................................................................12BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml.....................................................................12bosentan tab 62.5 mg (Tracleer).................................... 45bosentan tab 125 mg (Tracleer)..................................... 45BOSULIF -bosutinib tab 100 mg....................................... 13BOSULIF -bosutinib tab 400 mg....................................... 13BOSULIF -bosutinib tab 500 mg....................................... 13BRAFTOVI -encorafenib cap 75 mg................................. 13BREATHE COMFORT ANTI-STAT -spacer/aerosol-holding chambers - device........................................... 100BREATHE EASE/LARGE MASK -spacer/aerosol-holdingchambers - device........................................................ 100BREATHE EASE/MEDIUM MASK -spacer/aerosol-holding chambers - device........................................... 100BREATHE EASE/SMALL MASK -spacer/aerosol-holdingchambers - device........................................................ 100BREO ELLIPTA -fluticasone furoate-vilanterol aero powdba 100-25 mcg/inh..........................................................48BREO ELLIPTA -fluticasone furoate-vilanterol aero powdba 200-25 mcg/inh..........................................................48BREZTRI AEROSPHERE -budesonide-glycopyrrolate-formoterol aers 160-9-4.8 mcg/act.................................48BRILINTA -ticagrelor tab 60 mg........................................ 88BRILINTA -ticagrelor tab 90 mg........................................ 88brimonidine tartrate ophth soln 0.2%........................... 92bromfenac sodium ophth soln 0.09% (base equiv)(once-daily).................................................................... 92bromocriptine mesylate cap 5 mg (base equivalent)(Parlodel)........................................................................ 79bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)........................................................................ 79BRUKINSA -zanubrutinib cap 80 mg................................ 13

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 111budesonide delayed release particles cap 3 mg(Entocort ec)..................................................................19budesonide inhalation susp 0.25 mg/2ml(Pulmicort)......................................................................48budesonide inhalation susp 0.5 mg/2ml(Pulmicort)......................................................................48budesonide inhalation susp 1 mg/2ml (Pulmicort)......48bumetanide tab 0.5 mg (Bumex)....................................43bumetanide tab 1 mg (Bumex).......................................43bumetanide tab 2 mg (Bumex).......................................43buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv) (Suboxone).........................................................69buprenorphine hcl-naloxone hcl sl film 4-1 mg (baseequiv) (Suboxone).........................................................69buprenorphine hcl-naloxone hcl sl film 8-2 mg (baseequiv) (Suboxone).........................................................69buprenorphine hcl-naloxone hcl sl film 12-3 mg (baseequiv) (Suboxone).........................................................69buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).............................................................................. 69buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).............................................................................. 69buprenorphine hcl sl tab 2 mg (base equiv)................ 68buprenorphine hcl sl tab 8 mg (base equiv)................ 69bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban)............................................................................65bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)........56bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)........56bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)........56bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)........ 56bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)........ 56bupropion hcl tab 75 mg................................................ 56bupropion hcl tab 100 mg.............................................. 56buspirone hcl tab 5 mg...................................................56buspirone hcl tab 10 mg.................................................56buspirone hcl tab 15 mg.................................................56buspirone hcl tab 30 mg.................................................56butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic).............................................................................68butalbital-acetaminophen-caff w/ cod cap50-325-40-30 mg............................................................69butalbital-acetaminophen tab 50-325 mg......................68butalbital-aspirin-caffeine cap 50-325-40 mg(Fiorinal)......................................................................... 68butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3).....................................................69butorphanol tartrate nasal soln 10 mg/ml.................... 69BYDUREON BCISE -exenatide extended release suspauto-injector 2 mg/0.85ml...............................................24BYLVAY -odevixibat cap 400 mcg.....................................52BYLVAY -odevixibat cap 1200 mcg................................... 52BYLVAY (PELLETS) -odevixibat pellets cap sprinkle 200mcg.................................................................................. 52BYLVAY (PELLETS) -odevixibat pellets cap sprinkle 600mcg.................................................................................. 52Ccabergoline tab 0.5 mg................................................... 31CABOMETYX -cabozantinib s-malate tab 20 mg (baseequivalent)....................................................................... 13CABOMETYX -cabozantinib s-malate tab 40 mg (baseequivalent)....................................................................... 13CABOMETYX -cabozantinib s-malate tab 60 mg (baseequivalent)....................................................................... 13caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).............................................................................. 63calcipotriene cream 0.005% (Dovonex).........................96calcipotriene soln 0.005% (50 mcg/ml)......................... 96calcitonin (salmon) inj 200 unit/ml (Miacalcin).............31calcitonin (salmon) nasal soln 200 unit/act..................31calcitriol cap 0.25 mcg (Rocaltrol).................................31calcitriol cap 0.5 mcg (Rocaltrol)...................................31calcitriol oral soln 1 mcg/ml (Rocaltrol)........................31calcium acetate (phosphate binder) cap 667 mg (169mg ca).............................................................................52calcium acetate (phosphate binder) tab 667 mg..........52CALQUENCE -acalabrutinib cap 100 mg......................... 13candesartan cilexetil-hydrochlorothiazide tab 16-12.5mg (Atacand hct).......................................................... 39candesartan cilexetil-hydrochlorothiazide tab 32-12.5mg (Atacand hct).......................................................... 40candesartan cilexetil-hydrochlorothiazide tab 32-25mg (Atacand hct).......................................................... 40candesartan cilexetil tab 4 mg (Atacand)..................... 39candesartan cilexetil tab 8 mg (Atacand)..................... 39candesartan cilexetil tab 16 mg (Atacand)................... 39candesartan cilexetil tab 32 mg (Atacand)................... 39capecitabine tab 150 mg (Xeloda)................................. 13capecitabine tab 500 mg (Xeloda)................................. 13CAPRELSA -vandetanib tab 100 mg................................ 13CAPRELSA -vandetanib tab 300 mg................................ 13captopril tab 12.5 mg...................................................... 40captopril tab 25 mg......................................................... 40captopril tab 50 mg......................................................... 40captopril tab 100 mg....................................................... 40carbamazepine cap er 12hr 100 mg (Carbatrol)...........75carbamazepine cap er 12hr 200 mg (Carbatrol)...........75carbamazepine cap er 12hr 300 mg (Carbatrol)...........75carbamazepine chew tab 100 mg.................................. 75carbamazepine susp 100 mg/5ml (Tegretol).................75carbamazepine tab er 12hr 100 mg (Tegretol-xr)......... 75carbamazepine tab er 12hr 200 mg (Tegretol-xr)......... 75carbamazepine tab er 12hr 400 mg (Tegretol-xr)......... 75carbamazepine tab 200 mg (Tegretol)...........................75CARBATROL -carbamazepine cap er 12hr 100 mg......... 75CARBATROL -carbamazepine cap er 12hr 200 mg......... 75CARBATROL -carbamazepine cap er 12hr 300 mg......... 75CARBIDOPA/LEVODOPA ODT -carbidopa & levodopaorally disintegrating tab 10-100 mg................................80CARBIDOPA/LEVODOPA ODT -carbidopa & levodopaorally disintegrating tab 25-100 mg................................80

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 112CARBIDOPA/LEVODOPA ODT -carbidopa & levodopaorally disintegrating tab 25-250 mg................................80carbidopa & levodopa tab er 25-100 mg (Sinemetcr).................................................................................... 79carbidopa & levodopa tab er 50-200 mg (Sinemetcr).................................................................................... 79carbidopa & levodopa tab 10-100 mg (Sinemet).......... 79carbidopa & levodopa tab 25-100 mg (Sinemet).......... 79carbidopa & levodopa tab 25-250 mg (Sinemet).......... 79carbidopa-levodopa-entacapone tabs 12.5-50-200 mg(Stalevo 50)....................................................................79carbidopa-levodopa-entacapone tabs 18.75-75-200mg (Stalevo 75)............................................................. 79carbidopa-levodopa-entacapone tabs 25-100-200 mg(Stalevo 100)..................................................................80carbidopa-levodopa-entacapone tabs 31.25-125-200mg (Stalevo 125)........................................................... 80carbidopa-levodopa-entacapone tabs 37.5-150-200mg (Stalevo 150)........................................................... 80carbidopa-levodopa-entacapone tabs 50-200-200 mg(Stalevo 200)..................................................................80carbidopa tab 25 mg (Lodosyn).....................................79CARBINOXAMINE MALEATE -carbinoxamine maleatesoln 4 mg/5ml................................................................. 46carbinoxamine maleate tab 4 mg.................................. 46carbonyl iron susp 15 mg/1.25ml (elemental iron)...... 83CARDIZEM LA -diltiazem hcl coated beads tab er 24hr120 mg............................................................................ 36CARESTART COVID-19 ANTIGE -covid-19 at homeantigen test kit.................................................................99carglumic acid soluble tab 200 mg (Carbaglu)............ 31CARTEOLOL HCL -carteolol hcl ophth soln 1%...............92carvedilol tab 3.125 mg (Coreg).....................................36carvedilol tab 6.25 mg (Coreg).......................................36carvedilol tab 12.5 mg (Coreg).......................................36carvedilol tab 25 mg (Coreg)..........................................36CAVERJECT -alprostadil for inj 20 mcg............................46CAVERJECT -alprostadil for inj 40 mcg............................46CAVERJECT IMPULSE -alprostadil for inj kit 10 mcg...... 46CAVERJECT IMPULSE -alprostadil for inj kit 20 mcg...... 46CAYA -diaphragm arc-spring........................................... 100CAYSTON -aztreonam lysine for inhal soln 75 mg (baseequivalent)......................................................................... 9CEFACLOR -cefaclor cap 250 mg...................................... 1CEFACLOR -cefaclor cap 500 mg...................................... 1cefadroxil cap 500 mg.......................................................1CEFADROXIL -cefadroxil tab 1 gm.....................................1cefadroxil for susp 250 mg/5ml....................................... 1cefadroxil for susp 500 mg/5ml....................................... 1cefdinir cap 300 mg...........................................................1cefdinir for susp 125 mg/5ml........................................... 1cefdinir for susp 250 mg/5ml........................................... 1cefixime cap 400 mg (Suprax)......................................... 1cefixime for susp 100 mg/5ml (Suprax).......................... 1cefixime for susp 200 mg/5ml (Suprax).......................... 1cefpodoxime proxetil for susp 50 mg/5ml...................... 1cefpodoxime proxetil for susp 100 mg/5ml....................1cefpodoxime proxetil tab 100 mg.................................... 2cefpodoxime proxetil tab 200 mg.................................... 2cefprozil for susp 125 mg/5ml..........................................2cefprozil for susp 250 mg/5ml..........................................2cefprozil tab 250 mg..........................................................2cefprozil tab 500 mg..........................................................2cefuroxime axetil tab 250 mg........................................... 2cefuroxime axetil tab 500 mg........................................... 2celecoxib cap 50 mg (Celebrex).................................... 71celecoxib cap 100 mg (Celebrex).................................. 71celecoxib cap 200 mg (Celebrex).................................. 71celecoxib cap 400 mg (Celebrex).................................. 71CELLCEPT -mycophenolate mofetil cap 250 mg........... 102CELLCEPT -mycophenolate mofetil for oral susp 200 mg/ml................................................................................... 102CELLCEPT -mycophenolate mofetil tab 500 mg............ 102CELLTRION DIATRUST COVID- -covid-19 at homeantigen test kit.................................................................99CELONTIN -methsuximide cap 300 mg............................75cephalexin cap 250 mg (Keflex).......................................2cephalexin cap 500 mg (Keflex).......................................2CEPHALEXIN -cephalexin cap 750 mg.............................. 2cephalexin for susp 125 mg/5ml......................................2cephalexin for susp 250 mg/5ml......................................2CERDELGA -eliglustat tartrate cap 84 mg (baseequivalent)....................................................................... 83CERVIDIL -dinoprostone vaginal inserts 10 mg............... 31CETRAXAL -ciprofloxacin hcl otic soln 0.2% (baseequivalent)....................................................................... 94cevimeline hcl cap 30 mg (Evoxac)...............................94CHEMET -succimer cap 100 mg...................................... 98CHENODAL -chenodiol tab 250 mg................................. 52CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxide-amitriptyline tab 5-12.5 mg.............................................65CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxide-amitriptyline tab 10-25 mg..............................................65chlordiazepoxide hcl cap 5 mg......................................56chlordiazepoxide hcl cap 10 mg.................................... 56chlordiazepoxide hcl cap 25 mg.................................... 56chlorhexidine gluconate soln 0.12% (Peridex).............94CHLOROQUINE PHOSPHATE -chloroquine phosphatetab 500 mg........................................................................8chloroquine phosphate tab 250 mg................................ 8chlorpromazine hcl tab 10 mg....................................... 59chlorpromazine hcl tab 25 mg....................................... 59chlorpromazine hcl tab 50 mg....................................... 59chlorpromazine hcl tab 100 mg..................................... 59chlorpromazine hcl tab 200 mg..................................... 59chlorthalidone tab 25 mg................................................43chlorthalidone tab 50 mg................................................43chlorzoxazone tab 500 mg..............................................81CHOLBAM -cholic acid cap 50 mg................................... 52CHOLBAM -cholic acid cap 250 mg................................. 53cholestyramine light powder 4 gm/dose (Questranlight)................................................................................ 44cholestyramine light powder packets 4 gm................. 43cholestyramine powder 4 gm/dose (Questran)............44

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 113cholestyramine powder packets 4 gm (Questran).......44CHORIONIC GONADOTROPIN -chorionic gonadotropinfor im inj 10000 unit........................................................31ciclopirox gel 0.77%........................................................ 96ciclopirox olamine cream 0.77% (base equiv)(Loprox).......................................................................... 96ciclopirox olamine susp 0.77% (base equiv)(Loprox).......................................................................... 96ciclopirox shampoo 1% (Loprox shampoo)................. 96ciclopirox solution 8% (Penlac Nail Lacquer).............. 96cilostazol tab 50 mg........................................................ 88cilostazol tab 100 mg...................................................... 88CIMDUO -lamivudine-tenofovir disoproxil fumarate tab300-300 mg....................................................................... 5CIMZIA -certolizumab pegol prefilled syringe kit 2 x 200mg/ml............................................................................... 53CIMZIA STARTER KIT -certolizumab pegol prefilledsyringe kit 6 x 200 mg/ml...............................................53cinacalcet hcl tab 30 mg (base equiv).......................... 31cinacalcet hcl tab 60 mg (base equiv).......................... 31cinacalcet hcl tab 90 mg (base equiv).......................... 31CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5gm/100ml)..........................................................................3CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml)..........................................................................3CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (baseequivalent)....................................................................... 94ciprofloxacin-dexamethasone otic susp 0.3-0.1%(Ciprodex).......................................................................94CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg(base equiv)...................................................................... 3ciprofloxacin hcl ophth soln 0.3% (base equivalent)(Ciloxan)......................................................................... 92ciprofloxacin hcl tab 750 mg (base equiv)..................... 3ciprofloxacin hcl tab 250 mg (base equiv) (Cipro).........3ciprofloxacin hcl tab 500 mg (base equiv) (Cipro).........3citalopram hydrobromide oral soln 10 mg/5ml............ 56citalopram hydrobromide tab 10 mg (base equiv)(Celexa)...........................................................................56citalopram hydrobromide tab 20 mg (base equiv)(Celexa)...........................................................................57citalopram hydrobromide tab 40 mg (base equiv)(Celexa)...........................................................................57CLARITHROMYCIN -clarithromycin for susp 125mg/5ml............................................................................... 2CLARITHROMYCIN -clarithromycin for susp 250mg/5ml............................................................................... 2clarithromycin tab er 24hr 500 mg.................................. 2clarithromycin tab 250 mg................................................2clarithromycin tab 500 mg (Biaxin)................................. 2CLEARDETECT COVID-19 ANTI -covid-19 at homeantigen test kit.................................................................99CLEMASTINE FUMARATE -clemastine fumarate tab 2.68mg....................................................................................46CLEVER CHOICE ANTI-STATIC -spacer/aerosol-holdingchambers - device........................................................ 100CLIMARA PRO -estradiol-levonorgestrel td patch weekly0.045-0.015 mg/day........................................................ 21clindamycin hcl cap 75 mg (Cleocin).............................. 9clindamycin hcl cap 150 mg (Cleocin)............................9clindamycin hcl cap 300 mg (Cleocin)............................9clindamycin palmitate hcl for soln 75 mg/5ml (baseequiv) (Cleocin pediatric gr)..........................................9clindamycin phosphate gel 1% (Cleocin-t)...................96clindamycin phosphate lotion 1% (Cleocin-t).............. 96clindamycin phosphate soln 1% (Cleocin-t).................96clindamycin phosphate swab 1% (Cleocin-t)............... 96clindamycin phosphate vaginal cream 2%(Cleocin)......................................................................... 54clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)................................................................. 96CLINDESSE -clindamycin phosphate (one dose) vaginalcream 2%........................................................................ 54CLINITEST RAPID COVID-19 -covid-19 at home antigentest kit.............................................................................. 99clobazam suspension 2.5 mg/ml (Onfi)........................ 75clobazam tab 10 mg (Onfi)............................................. 75clobazam tab 20 mg (Onfi)............................................. 75clobetasol propionate cream 0.05% (Temovate)..........96clobetasol propionate emollient base cream0.05%...............................................................................96clobetasol propionate gel 0.05% (Temovate)............... 96clobetasol propionate oint 0.05% (Temovate)..............96clobetasol propionate soln 0.05% (Temovate)............. 96CLOMID -clomiphene citrate tab 50 mg........................... 31CLOMIPHENE CITRATE -clomiphene citrate tab 50mg....................................................................................31clomipramine hcl cap 25 mg (Anafranil).......................57clomipramine hcl cap 50 mg (Anafranil).......................57clomipramine hcl cap 75 mg (Anafranil).......................57clonazepam orally disintegrating tab 0.125 mg........... 75clonazepam orally disintegrating tab 0.25 mg............. 75clonazepam orally disintegrating tab 0.5 mg............... 75clonazepam orally disintegrating tab 1 mg.................. 75clonazepam orally disintegrating tab 2 mg.................. 75clonazepam tab 0.5 mg (Klonopin)................................75clonazepam tab 1 mg (Klonopin)...................................75clonazepam tab 2 mg (Klonopin)...................................75clonidine hcl tab er 12hr 0.1 mg (Kapvay)....................63clonidine hcl tab 0.1 mg (Catapres).............................. 40clonidine hcl tab 0.2 mg (Catapres).............................. 40clonidine hcl tab 0.3 mg (Catapres).............................. 40clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1)................................................................................ 40clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2)................................................................................ 40clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3)................................................................................ 40clopidogrel bisulfate tab 75 mg (base equiv)(Plavix)............................................................................88clopidogrel bisulfate tab 300 mg (base equiv)(Plavix)............................................................................88clorazepate dipotassium tab 3.75 mg........................... 56

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 114clorazepate dipotassium tab 15 mg.............................. 56clorazepate dipotassium tab 7.5 mg (Tranxene t)........56clotrimazole troche 10 mg.............................................. 94clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)......................................................................96CLOZAPINE ODT -clozapine orally disintegrating tab 12.5mg....................................................................................59CLOZAPINE ODT -clozapine orally disintegrating tab 150mg....................................................................................59CLOZAPINE ODT -clozapine orally disintegrating tab 200mg....................................................................................59clozapine orally disintegrating tab 25 mg(Fazaclo)......................................................................... 59clozapine orally disintegrating tab 100 mg(Fazaclo)......................................................................... 59clozapine tab 50 mg........................................................ 59clozapine tab 200 mg...................................................... 59clozapine tab 25 mg (Clozaril)........................................59clozapine tab 100 mg (Clozaril)..................................... 59COAGADEX -coagulation factor x (human) for inj 250unit................................................................................... 88COAGADEX -coagulation factor x (human) for inj 500unit................................................................................... 88COARTEM -artemether-lumefantrine tab 20-120 mg......... 8CODEINE SULFATE -codeine sulfate tab 15 mg............. 69CODEINE SULFATE -codeine sulfate tab 60 mg............. 69codeine sulfate tab 30 mg (Codeine sulfate)................69colchicine tab 0.6 mg (Colcrys)..................................... 75colchicine w/ probenecid tab 0.5-500 mg..................... 75colesevelam hcl packet for susp 3.75 gm(Welchol)........................................................................ 44colesevelam hcl tab 625 mg (Welchol)......................... 44colestipol hcl granule packets 5 gm (Colestidflavored)......................................................................... 44colestipol hcl granules 5 gm (Colestid)........................ 44colestipol hcl tab 1 gm (Colestid)..................................44COMBIPATCH -estradiol-norethindrone ace td pttw0.05-0.14 mg/day............................................................21COMBIPATCH -estradiol-norethindrone ace td pttw0.05-0.25 mg/day............................................................21COMBIVENT RESPIMAT -ipratropium-albuterol inhalaerosol soln 20-100 mcg/act.......................................... 48COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mgdose) kit...........................................................................13COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit............................................................13COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit............................................................13COMIRNATY -covid-19 mrna vac tris-sucrose-pfizer imsusp 30 mcg/0.3ml......................................................... 10COMPACT SPACE CHAMBER/ANT -spacer/aerosol-holding chambers - device........................................... 100COMPLERA -emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg..................................................................5CONTOUR BLOOD GLUCOSE TES -glucose blood teststrip.................................................................................. 99CONTOUR HIGH CONTROL -blood glucose calibration -liquid - high................................................................... 100CONTOUR LOW CONTROL -blood glucose calibration -liquid - low.....................................................................100CONTOUR NEXT BLOOD GLUCOS -glucose blood teststrip.................................................................................. 99CONTOUR NEXT CONTROL LEVE -blood glucosecalibration - liquid - low................................................ 100CONTOUR NEXT CONTROL LEVE -blood glucosecalibration - liquid - normal...........................................100CONTOUR NORMAL CONTROL -blood glucosecalibration - liquid - normal...........................................100COPIKTRA -duvelisib cap 15 mg......................................13COPIKTRA -duvelisib cap 25 mg......................................13CORIFACT -factor xiii concentrate (human) for inj kit1000-1600 unit................................................................ 88CORLANOR -ivabradine hcl oral soln 5 mg/5ml (baseequiv)............................................................................... 45CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 45CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 45CORTIFOAM -hydrocortisone acetate perianal foam 10%(90 mg/dose)...................................................................95COSENTYX -secukinumab subcutaneous pref syr 150mg/ml (300 mg dose)..................................................... 96COSENTYX -secukinumab subcutaneous soln prefilledsyringe 75 mg/0.5ml....................................................... 96COSENTYX -secukinumab subcutaneous soln prefilledsyringe 150 mg/ml.......................................................... 96COSENTYX SENSOREADY PEN -secukinumabsubcutaneous auto-inj 150 mg/ml (300 mg dose)..........96COSENTYX SENSOREADY PEN -secukinumabsubcutaneous soln auto-injector 150 mg/ml.................. 96COTELLIC -cobimetinib fumarate tab 20 mg (baseequivalent)....................................................................... 14COVID-19 AT-HOME TEST KIT -covid-19 at homeantigen test kit.................................................................99CREON -pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit.....................................................52CREON -pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit...................................................52CREON -pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit................................................ 52CREON -pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit.............................................. 52CREON -pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit.............................................52CRESEMBA -isavuconazonium sulfate cap 186 mg(isavuconazole 100 mg)................................................... 4cromolyn sodium ophth soln 4%...................................93cromolyn sodium oral conc 100 mg/5ml(Gastrocrom)..................................................................53cromolyn sodium soln nebu 20 mg/2ml....................... 48CROTAN -crotamiton lotion 10%.......................................96CVS GLUCOSE BITS -glucose chew tab 1 gm................24CVS GLUCOSE -glucose chew tab 4 gm (rounded)........ 24CVS SOFT GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 24

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 115cyanocobalamin inj 1000 mcg/ml.................................. 83cyclobenzaprine hcl tab 5 mg........................................ 81cyclobenzaprine hcl tab 10 mg......................................81CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophthsoln 0.2-1%..................................................................... 93cyclopentolate hcl ophth soln 0.5% (Cyclogyl)............93cyclopentolate hcl ophth soln 1% (Cyclogyl)...............93cyclopentolate hcl ophth soln 2% (Cyclogyl)...............93cyclophosphamide cap 25 mg(Cyclophosphamide).................................................... 14cyclophosphamide cap 50 mg(Cyclophosphamide).................................................... 14CYCLOPHOSPHAMIDE -cyclophosphamide tab 25mg....................................................................................14CYCLOPHOSPHAMIDE -cyclophosphamide tab 50mg....................................................................................14CYCLOSERINE -cycloserine cap 250 mg.......................... 3cyclosporine cap 25 mg (Sandimmune)..................... 102cyclosporine cap 100 mg (Sandimmune)................... 102cyclosporine modified cap 50 mg (Cyclosporinemodifie).........................................................................102cyclosporine modified cap 25 mg (Neoral).................102cyclosporine modified cap 100 mg (Neoral)...............102cyclosporine modified oral soln 100 mg/ml(Neoral)......................................................................... 102cyproheptadine hcl syrup 2 mg/5ml..............................46cyproheptadine hcl tab 4 mg......................................... 46CYSTADROPS -cysteamine hcl ophth soln 0.37% (baseequivalent)....................................................................... 93CYSTAGON -cysteamine bitartrate cap 50 mg.................55CYSTAGON -cysteamine bitartrate cap 150 mg...............55CYSTARAN -cysteamine hcl ophth soln 0.44% (baseequivalent)....................................................................... 93Ddabigatran etexilate mesylate cap 75 mg (etexilatebase eq) (Pradaxa)........................................................85dalfampridine tab er 12hr 10 mg (Ampyra)...................65DALIRESP -roflumilast tab 250 mcg.................................48DALIRESP -roflumilast tab 500 mcg.................................48danazol cap 50 mg.......................................................... 20danazol cap 100 mg........................................................ 20danazol cap 200 mg........................................................ 20dantrolene sodium cap 100 mg..................................... 81dantrolene sodium cap 25 mg (Dantrium).................... 81dantrolene sodium cap 50 mg (Dantrium).................... 81dapsone tab 25 mg............................................................9dapsone tab 100 mg..........................................................9DAPTACEL -diph, acellular pert & tet tox inj 15 lf-23mcg-5 lf/0.5ml................................................................. 12DAURISMO -glasdegib maleate tab 25 mg (baseequivalent)....................................................................... 14DAURISMO -glasdegib maleate tab 100 mg (baseequivalent)....................................................................... 14deferasirox granules packet 90 mg (Jadenusprinkle)..........................................................................98deferasirox granules packet 180 mg (Jadenusprinkle)..........................................................................99deferasirox granules packet 360 mg (Jadenusprinkle)..........................................................................99deferasirox tab for oral susp 125 mg (Exjade).............99deferasirox tab for oral susp 250 mg (Exjade).............99deferasirox tab for oral susp 500 mg (Exjade).............99deferasirox tab 180 mg................................................... 99deferasirox tab 90 mg (Jadenu)..................................... 99deferasirox tab 360 mg (Jadenu)...................................99deferiprone tab 500 mg (Ferriprox)............................... 99deferiprone tab 1000 mg (Ferriprox)............................. 99DELESTROGEN -estradiol valerate im in oil 10 mg/ml..................................................................................... 21DELSTRIGO -doravirine-lamivudine-tenofovir df tab100-300-300 mg................................................................5demeclocycline hcl tab 150 mg....................................... 2demeclocycline hcl tab 300 mg....................................... 2DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/ml..................................................................................... 21DEPO-SUBQ PROVERA 104 -medroxyprogesteroneacetate susp pref syr 104 mg/0.65ml.............................22DESCOVY -emtricitabine-tenofovir alafenamide fumaratetab 120-15 mg...................................................................5DESCOVY -emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg...................................................................5desipramine hcl tab 50 mg............................................. 57desipramine hcl tab 75 mg............................................. 57desipramine hcl tab 100 mg........................................... 57desipramine hcl tab 150 mg........................................... 57desipramine hcl tab 10 mg (Norpramin)....................... 57desipramine hcl tab 25 mg (Norpramin)....................... 57desmopressin acetate inj 4 mcg/ml (Ddavp)................31desmopressin acetate nasal spray soln 0.01%(Ddavp)........................................................................... 31desmopressin acetate nasal spray soln 0.01%(refrigerated).................................................................. 31desmopressin acetate preservative free (pf) inj 4 mcg/ml (Ddavp)......................................................................31desmopressin acetate tab 0.1 mg (Ddavp)................... 31desmopressin acetate tab 0.2 mg (Ddavp)................... 32desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (Mircette)........................................................ 22desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg(Cyclessa).......................................................................22desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen)....................................................................... 22desonide cream 0.05% (Desowen)................................ 96desonide oint 0.05%........................................................ 96desoximetasone cream 0.25% (Topicort)......................96desoximetasone oint 0.25% (Topicort)..........................96desvenlafaxine succinate tab er 24hr 25 mg (baseequiv) (Pristiq)...............................................................57desvenlafaxine succinate tab er 24hr 50 mg (baseequiv) (Pristiq)...............................................................57

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 116desvenlafaxine succinate tab er 24hr 100 mg (baseequiv) (Pristiq)...............................................................57DEXAMETHASONE -dexamethasone soln 0.5mg/5ml.............................................................................19DEXAMETHASONE -dexamethasone tab 0.5 mg............19DEXAMETHASONE -dexamethasone tab 0.75 mg..........20DEXAMETHASONE -dexamethasone tab 1 mg...............20DEXAMETHASONE -dexamethasone tab 2 mg...............20dexamethasone elixir 0.5 mg/5ml.................................. 20DEXAMETHASONE INTENSOL -dexamethasone conc 1mg/ml............................................................................... 20DEXAMETHASONE SODIUM PHOS -dexamethasonesodium phosphate ophth soln 0.1%...............................93dexamethasone tab 1.5 mg............................................ 20dexamethasone tab 4 mg............................................... 20dexamethasone tab 6 mg............................................... 20DEXCOM G6 RECEIVER -continuous blood glucosesystem receiver.............................................................100DEXCOM G6 SENSOR -continuous blood glucosesystem sensor...............................................................100DEXCOM G6 TRANSMITTER -continuous blood glucosesystem transmitter........................................................ 100DEX4 GLUCOSE -glucose chew tab 4 gm (rounded)...... 24dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl cap er 24 hr 15 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl cap er 24 hr 20 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl cap er 24 hr 25 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl cap er 24 hr 30 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl cap er 24 hr 35 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl cap er 24 hr 40 mg (Focalinxr).................................................................................... 63dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 63dexmethylphenidate hcl tab 5 mg (Focalin)................. 63dexmethylphenidate hcl tab 10 mg (Focalin)............... 63DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4gm (rounded).................................................................. 24dextroamphetamine sulfate cap er 24hr 5 mg(Dexedrine).....................................................................63dextroamphetamine sulfate cap er 24hr 10 mg(Dexedrine).....................................................................63dextroamphetamine sulfate cap er 24hr 15 mg(Dexedrine).....................................................................63dextroamphetamine sulfate oral solution 5 mg/5ml(Procentra)..................................................................... 63dextroamphetamine sulfate tab 5 mg........................... 63dextroamphetamine sulfate tab 10 mg......................... 63DIACOMIT -stiripentol cap 250 mg................................... 75DIACOMIT -stiripentol cap 500 mg................................... 75DIACOMIT -stiripentol packet 250 mg.............................. 76DIACOMIT -stiripentol packet 500 mg.............................. 76DIASTAT ACUDIAL -diazepam rectal gel delivery system10 mg.............................................................................. 76DIASTAT ACUDIAL -diazepam rectal gel delivery system20 mg.............................................................................. 76DIASTAT PEDIATRIC -diazepam rectal gel deliverysystem 2.5 mg................................................................ 76diazepam conc 5 mg/ml.................................................. 56diazepam oral soln 1 mg/ml........................................... 56DIAZEPAM RECTAL GEL -diazepam rectal gel deliverysystem 2.5 mg................................................................ 76DIAZEPAM RECTAL GEL -diazepam rectal gel deliverysystem 10 mg................................................................. 76DIAZEPAM RECTAL GEL -diazepam rectal gel deliverysystem 20 mg................................................................. 76diazepam tab 2 mg (Valium)........................................... 56diazepam tab 5 mg (Valium)........................................... 56diazepam tab 10 mg (Valium)......................................... 56diazoxide susp 50 mg/ml (Proglycem)..........................24diclofenac potassium tab 50 mg................................... 71diclofenac sodium (actinic keratoses) gel 3%(Solaraze)....................................................................... 96diclofenac sodium ophth soln 0.1%..............................93diclofenac sodium soln 1.5%......................................... 96diclofenac sodium tab delayed release 25 mg.............71diclofenac sodium tab delayed release 50 mg.............71diclofenac sodium tab delayed release 75 mg.............71diclofenac w/ misoprostol tab delayed release 50-0.2mg (Arthrotec 50)..........................................................71diclofenac w/ misoprostol tab delayed release 75-0.2mg (Arthrotec 75)..........................................................71dicloxacillin sodium cap 250 mg..................................... 1dicloxacillin sodium cap 500 mg..................................... 1dicyclomine hcl cap 10 mg (Bentyl).............................. 51dicyclomine hcl oral soln 10 mg/5ml............................ 51dicyclomine hcl tab 20 mg............................................. 51DIFICID -fidaxomicin for susp 40 mg/ml............................. 2DIFICID -fidaxomicin tab 200 mg........................................ 2diflunisal tab 500 mg....................................................... 68DIGOXIN -digoxin oral soln 0.05 mg/ml............................35digoxin oral soln 0.05 mg/ml (Digoxin)......................... 35digoxin tab 62.5 mcg (0.0625 mg) (Lanoxin)................ 35digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 35digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 35dihydroergotamine mesylate inj 1 mg/ml (D.h.e.45)....................................................................................74DILANTIN INFATABS -phenytoin chew tab 50 mg........... 76DILANTIN -phenytoin sodium extended cap 30 mg......... 76DILANTIN -phenytoin sodium extended cap 100 mg........76DILANTIN-125 -phenytoin susp 125 mg/5ml.................... 76diltiazem hcl cap er 12hr 60 mg.....................................36diltiazem hcl cap er 12hr 90 mg.....................................36diltiazem hcl cap er 12hr 120 mg...................................36diltiazem hcl cap er 24hr 120 mg...................................36diltiazem hcl cap er 24hr 180 mg...................................36diltiazem hcl cap er 24hr 240 mg...................................36diltiazem hcl coated beads cap er 24hr 300 mg...........37

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 117diltiazem hcl coated beads cap er 24hr 120 mg(Cardizem cd)................................................................ 37diltiazem hcl coated beads cap er 24hr 180 mg(Cardizem cd)................................................................ 37diltiazem hcl coated beads cap er 24hr 240 mg(Cardizem cd)................................................................ 37diltiazem hcl coated beads cap er 24hr 360 mg(Cardizem cd)................................................................ 37diltiazem hcl coated beads tab er 24hr 180 mg(Cardizem la)................................................................. 37diltiazem hcl coated beads tab er 24hr 240 mg(Cardizem la)................................................................. 37diltiazem hcl coated beads tab er 24hr 300 mg(Cardizem la)................................................................. 37diltiazem hcl coated beads tab er 24hr 360 mg(Cardizem la)................................................................. 37diltiazem hcl coated beads tab er 24hr 420 mg(Cardizem la)................................................................. 37diltiazem hcl extended release beads cap er 24hr 120mg (Tiazac).................................................................... 37diltiazem hcl extended release beads cap er 24hr 180mg (Tiazac).................................................................... 37diltiazem hcl extended release beads cap er 24hr 240mg (Tiazac).................................................................... 37diltiazem hcl extended release beads cap er 24hr 300mg (Tiazac).................................................................... 37diltiazem hcl extended release beads cap er 24hr 360mg (Tiazac).................................................................... 37diltiazem hcl extended release beads cap er 24hr 420mg (Tiazac).................................................................... 37diltiazem hcl tab 90 mg...................................................37diltiazem hcl tab 30 mg (Cardizem)............................... 37diltiazem hcl tab 60 mg (Cardizem)............................... 37diltiazem hcl tab 120 mg (Cardizem)............................. 37dimethyl fumarate capsule delayed release 120 mg(Tecfidera)...................................................................... 65dimethyl fumarate capsule delayed release 240 mg(Tecfidera)...................................................................... 65dimethyl fumarate capsule dr starter pack 120 mg &240 mg (Tecfidera starter pa)...................................... 65DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropineliq 2.5-0.025 mg/5ml....................................................... 51diphenoxylate w/ atropine tab 2.5-0.025 mg(Lomotil)......................................................................... 51DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus toxadsorbed (dt) im inj 25-5 unit/0.5ml............................... 12dipyridamole tab 25 mg.................................................. 88dipyridamole tab 50 mg.................................................. 88dipyridamole tab 75 mg.................................................. 88disopyramide phosphate cap 100 mg (Norpace)......... 38disopyramide phosphate cap 150 mg (Norpace)......... 38disulfiram tab 250 mg (Antabuse)................................. 65disulfiram tab 500 mg (Antabuse)................................. 65DIURIL -chlorothiazide susp 250 mg/5ml......................... 43divalproex sodium cap delayed release sprinkle 125mg (Depakote sprinkles)..............................................76divalproex sodium tab delayed release 125 mg(Depakote)...................................................................... 76divalproex sodium tab delayed release 250 mg(Depakote)...................................................................... 76divalproex sodium tab delayed release 500 mg(Depakote)...................................................................... 76divalproex sodium tab er 24 hr 250 mg (Depakoteer).................................................................................... 76divalproex sodium tab er 24 hr 500 mg (Depakoteer).................................................................................... 76DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 21DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 21DIVIGEL -estradiol td gel 0.75 mg/0.75gm (0.1%)........... 21DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 21DIVIGEL -estradiol td gel 1.25 mg/1.25gm (0.1%)........... 21dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................38dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................38dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................38donepezil hydrochloride orally disintegrating tab 5mg................................................................................... 66donepezil hydrochloride orally disintegrating tab 10mg................................................................................... 66donepezil hydrochloride tab 5 mg (Aricept).................66donepezil hydrochloride tab 10 mg (Aricept)...............66donepezil hydrochloride tab 23 mg (Aricept)...............66DOPTELET -avatrombopag maleate tab 20 mg (baseequiv)............................................................................... 83dorzolamide hcl ophth soln 2% (Trusopt).................... 93dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml (Cosopt)..............................................................93DOVATO -dolutegravir sodium-lamivudine tab 50-300 mg(base eq)........................................................................... 5doxazosin mesylate tab 1 mg (Cardura)....................... 40doxazosin mesylate tab 2 mg (Cardura)....................... 40doxazosin mesylate tab 4 mg (Cardura)....................... 40doxazosin mesylate tab 8 mg (Cardura)....................... 40doxepin hcl cap 10 mg....................................................57doxepin hcl cap 25 mg....................................................57doxepin hcl cap 50 mg....................................................57doxepin hcl cap 75 mg....................................................57doxepin hcl cap 100 mg..................................................57doxepin hcl cap 150 mg..................................................57doxepin hcl conc 10 mg/ml............................................ 57doxercalciferol cap 0.5 mcg (Hectorol).........................32doxercalciferol cap 1 mcg (Hectorol)............................32doxercalciferol cap 2.5 mcg (Hectorol).........................32doxycycline hyclate cap 50 mg....................................... 2doxycycline hyclate cap 100 mg (Vibramycin)...............2doxycycline hyclate tab 20 mg........................................ 2doxycycline hyclate tab 100 mg...................................... 2doxycycline monohydrate cap 50 mg............................. 2doxycycline monohydrate cap 100 mg (Monodox)........3doxycycline monohydrate for susp 25 mg/5ml(Vibramycin).....................................................................3doxycycline monohydrate tab 50 mg..............................3doxycycline monohydrate tab 75 mg..............................3doxycycline monohydrate tab 100 mg............................ 3

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 118doxycycline monohydrate tab 150 mg............................ 3dronabinol cap 2.5 mg (Marinol)....................................51dronabinol cap 5 mg (Marinol).......................................52dronabinol cap 10 mg (Marinol).....................................52drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin28)....................................................................................23drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz).....22drospirenone-ethinyl estrad-levomefolate tab3-0.02-0.451 mg (Beyaz)...............................................22drospirenone-ethinyl estrad-levomefolate tab3-0.03-0.451 mg (Safyral)............................................. 22DROXIA -hydroxyurea cap 200 mg.................................. 83DROXIA -hydroxyurea cap 300 mg.................................. 83DROXIA -hydroxyurea cap 400 mg.................................. 83DRUG MART GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 24DUAVEE -conjugated estrogens-bazedoxifene tab0.45-20 mg...................................................................... 21DULERA -mometasone furoate-formoterol fumarateaerosol 50-5 mcg/act......................................................48DULERA -mometasone furoate-formoterol fumarateaerosol 100-5 mcg/act....................................................48DULERA -mometasone furoate-formoterol fumarateaerosol 200-5 mcg/act....................................................48duloxetine hcl enteric coated pellets cap 20 mg (baseeq) (Cymbalta)............................................................... 57duloxetine hcl enteric coated pellets cap 30 mg (baseeq) (Cymbalta)............................................................... 57duloxetine hcl enteric coated pellets cap 60 mg (baseeq) (Cymbalta)............................................................... 57DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/ml..................................................................................... 80DUPIXENT -dupilumab subcutaneous soln pen-injector200 mg/1.14ml................................................................ 96DUPIXENT -dupilumab subcutaneous soln pen-injector300 mg/2ml..................................................................... 96DUPIXENT -dupilumab subcutaneous soln prefilledsyringe 100 mg/0.67ml................................................... 97DUPIXENT -dupilumab subcutaneous soln prefilledsyringe 200 mg/1.14ml................................................... 97DUPIXENT -dupilumab subcutaneous soln prefilledsyringe 300 mg/2ml........................................................ 97dutasteride cap 0.5 mg (Avodart).................................. 55dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)......55EEASIVENT/MASK-LARGE -spacer/aerosol-holdingchambers - device........................................................ 100EASIVENT/MASK-MEDIUM -spacer/aerosol-holdingchambers - device........................................................ 100EASIVENT/MASK-SMALL -spacer/aerosol-holdingchambers - device........................................................ 100EASIVENT -spacer/aerosol-holding chambers -device............................................................................ 100econazole nitrate cream 1%........................................... 97EDEX -alprostadil for inj kit 10 mcg.................................. 46EDEX -alprostadil for inj kit 20 mcg.................................. 46EDEX -alprostadil for inj kit 40 mcg.................................. 46EDURANT -rilpivirine hcl tab 25 mg (base equivalent).......5E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 2efavirenz cap 50 mg (Sustiva)..........................................5efavirenz cap 200 mg (Sustiva)........................................5efavirenz-emtricitabine-tenofovir df tab 600-200-300mg (Atripla)...................................................................... 5efavirenz-lamivudine-tenofovir df tab 600-300-300 mg(Symfi)...............................................................................5efavirenz-lamivudine-tenofovir df tab 400-300-300 mg(Symfi lo)..........................................................................5efavirenz tab 600 mg (Sustiva)........................................ 5ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gmmetered-dose pump)...................................................... 21eletriptan hydrobromide tab 20 mg (base equivalent)(Relpax).......................................................................... 74eletriptan hydrobromide tab 40 mg (base equivalent)(Relpax).......................................................................... 74ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5mg....................................................................................14ELIGARD -leuprolide acetate (3 month) for subcutaneousinj kit 22.5mg...................................................................14ELIGARD -leuprolide acetate (4 month) for subcutaneousinj kit 30 mg.................................................................... 14ELIGARD -leuprolide acetate (6 month) for subcutaneousinj kit 45 mg.................................................................... 14ELIQUIS -apixaban tab 2.5 mg......................................... 85ELIQUIS -apixaban tab 5 mg............................................ 85ELIQUIS STARTER PACK -apixaban tab starter pack 5mg....................................................................................85ELIXOPHYLLIN -theophylline elixir 80 mg/15ml...............48ELLA -ulipristal acetate tab 30 mg....................................23ELLUME COVID-19 HOME TEST -covid-19 at homeantigen test kit.................................................................99ELMIRON -pentosan polysulfate sodium caps 100mg....................................................................................55ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj250 unit........................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj500 unit........................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj750 unit........................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj1000 unit......................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj1500 unit......................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj2000 unit......................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj3000 unit......................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj4000 unit......................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj5000 unit......................................................................... 88ELOCTATE -antihemophilic factor rcmb (bdd-rfviiifc) for inj6000 unit......................................................................... 88

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 119EMCYT -estramustine phosphate sodium cap 140mg....................................................................................14EMEND -aprepitant for oral susp 125 mg (125mg/5ml)............................................................................52EMGALITY -galcanezumab-gnlm subcutaneous solnauto-injector 120 mg/ml..................................................74EMGALITY -galcanezumab-gnlm subcutaneous solnprefilled syr 100 mg/ml................................................... 74EMGALITY -galcanezumab-gnlm subcutaneous solnprefilled syr 120 mg/ml................................................... 74EMPAVELI -pegcetacoplan subcutaneous soln 1080mg/20ml (54 mg/ml)........................................................88EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 57EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 57EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 57emtricitabine caps 200 mg (Emtriva).............................. 5emtricitabine-tenofovir disoproxil fumarate tab100-150 mg (Truvada).....................................................5emtricitabine-tenofovir disoproxil fumarate tab133-200 mg (Truvada).....................................................5emtricitabine-tenofovir disoproxil fumarate tab167-250 mg (Truvada).....................................................5emtricitabine-tenofovir disoproxil fumarate tab200-300 mg (Truvada).....................................................5EMTRIVA -emtricitabine soln 10 mg/ml.............................. 5enalapril maleate & hydrochlorothiazide tab 5-12.5mg................................................................................... 40enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic)...................................................................... 40enalapril maleate oral soln 1 mg/ml (Epaned)..............40enalapril maleate tab 2.5 mg (Vasotec).........................40enalapril maleate tab 5 mg (Vasotec)............................40enalapril maleate tab 10 mg (Vasotec).......................... 40enalapril maleate tab 20 mg (Vasotec).......................... 40ENBREL -etanercept subcutaneous inj 25 mg/0.5ml........71ENBREL -etanercept subcutaneous soln prefilled syringe25 mg/0.5ml.................................................................... 71ENBREL -etanercept subcutaneous soln prefilled syringe50 mg/ml......................................................................... 72ENBREL MINI -etanercept subcutaneous solutioncartridge 50 mg/ml..........................................................72ENBREL SURECLICK -etanercept subcutaneous solutionauto-injector 50 mg/ml....................................................72ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 54ENDARI -glutamine (sickle cell) powd pack 5 gm............ 83ENDOMETRIN -progesterone vaginal insert 100 mg....... 54ENGERIX-B -hepatitis b vaccine (recombinant) susp 10mcg/0.5ml........................................................................ 10ENGERIX-B -hepatitis b vaccine (recombinant) susp 20mcg/ml............................................................................. 10enoxaparin sodium inj 300 mg/3ml (Lovenox)............. 85enoxaparin sodium inj soln pref syr 30 mg/0.3ml(Lovenox)....................................................................... 85enoxaparin sodium inj soln pref syr 40 mg/0.4ml(Lovenox)....................................................................... 85enoxaparin sodium inj soln pref syr 60 mg/0.6ml(Lovenox)....................................................................... 85enoxaparin sodium inj soln pref syr 80 mg/0.8ml(Lovenox)....................................................................... 85enoxaparin sodium inj soln pref syr 100 mg/ml(Lovenox)....................................................................... 85enoxaparin sodium inj soln pref syr 120 mg/0.8ml(Lovenox)....................................................................... 85enoxaparin sodium inj soln pref syr 150 mg/ml(Lovenox)....................................................................... 85ENSPRYNG -satralizumab-mwge subcutaneous soln prefsyringe 120 mg/ml........................................................ 102ENSTILAR -calcipotriene-betamethasone dipropionatefoam 0.005-0.064%........................................................ 97entacapone tab 200 mg (Comtan)................................. 80entecavir tab 0.5 mg (Baraclude).....................................5entecavir tab 1 mg (Baraclude)........................................5ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 45ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 45ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 45ENVARSUS XR -tacrolimus tab er 24hr 0.75 mg........... 102ENVARSUS XR -tacrolimus tab er 24hr 1 mg................ 102ENVARSUS XR -tacrolimus tab er 24hr 4 mg................ 102EPCLUSA -sofosbuvir-velpatasvir pellet pack 150-37.5mg...................................................................................... 5EPCLUSA -sofosbuvir-velpatasvir pellet pack 200-50mg...................................................................................... 5EPCLUSA -sofosbuvir-velpatasvir tab 200-50 mg.............. 5EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 5EPIDIOLEX -cannabidiol soln 100 mg/ml......................... 76epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000) (Epipen-jr 2-pak)............................................ 43epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000) (Epipen 2-pak)................................................ 43EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)...............5eplerenone tab 25 mg (Inspra)....................................... 40eplerenone tab 50 mg (Inspra)....................................... 40EPOGEN -epoetin alfa inj 2000 unit/ml.............................83EPOGEN -epoetin alfa inj 3000 unit/ml.............................83EPOGEN -epoetin alfa inj 4000 unit/ml.............................83EPOGEN -epoetin alfa inj 10000 unit/ml...........................83EPOGEN -epoetin alfa inj 20000 unit/ml...........................83EQ SPACE CHAMBER ANTI-STA -spacer/aerosol-holding chambers - device........................................... 100EQUETRO -carbamazepine (mood) cap er 12hr 100mg....................................................................................59EQUETRO -carbamazepine (mood) cap er 12hr 200mg....................................................................................59EQUETRO -carbamazepine (mood) cap er 12hr 300mg....................................................................................59ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)........ 81ERGOMAR -ergotamine tartrate sl tab 2 mg.................... 74ERIVEDGE -vismodegib cap 150 mg............................... 14ERLEADA -apalutamide tab 60 mg.................................. 14erlotinib hcl tab 25 mg (base equivalent) (Tarceva).....14erlotinib hcl tab 100 mg (base equivalent)(Tarceva)......................................................................... 14erlotinib hcl tab 150 mg (base equivalent)(Tarceva)......................................................................... 14

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 120ERY -erythromycin pads 2%............................................. 97ERYTHROCIN STEARATE -erythromycin stearate tab250 mg.............................................................................. 2ERYTHROMYCIN -erythromycin w/ delayed releaseparticles cap 250 mg........................................................ 2ERYTHROMYCIN ETHYLSUCCINA -erythromycinethylsuccinate tab 400 mg............................................... 2erythromycin ethylsuccinate for susp 200 mg/5ml(E.e.s. granules).............................................................. 2erythromycin ethylsuccinate for susp 400 mg/5ml(Eryped 400).....................................................................2erythromycin gel 2% (Erygel).........................................97erythromycin ophth oint 5 mg/gm.................................93erythromycin soln 2%..................................................... 97erythromycin tab delayed release 250 mg......................2erythromycin tab delayed release 333 mg......................2erythromycin tab delayed release 500 mg......................2erythromycin tab 250 mg..................................................2erythromycin tab 500 mg..................................................2ESBRIET -pirfenidone cap 267 mg...................................50escitalopram oxalate soln 5 mg/5ml (base equiv)....... 57escitalopram oxalate tab 5 mg (base equiv)(Lexapro)........................................................................ 57escitalopram oxalate tab 10 mg (base equiv)(Lexapro)........................................................................ 57escitalopram oxalate tab 20 mg (base equiv)(Lexapro)........................................................................ 57esomeprazole magnesium for delayed release susppacket 10 mg (Nexium)................................................ 51esomeprazole magnesium for delayed release susppacket 20 mg (Nexium)................................................ 51esomeprazole magnesium for delayed release susppacket 40 mg (Nexium)................................................ 51ESPEROCT -antihemophilic factor recomb glycopeg-exeifor inj 500 unit.................................................................88ESPEROCT -antihemophilic factor recomb glycopeg-exeifor inj 1000 unit...............................................................88ESPEROCT -antihemophilic factor recomb glycopeg-exeifor inj 1500 unit...............................................................88ESPEROCT -antihemophilic factor recomb glycopeg-exeifor inj 2000 unit...............................................................88ESPEROCT -antihemophilic factor recomb glycopeg-exeifor inj 3000 unit...............................................................88estazolam tab 1 mg......................................................... 62estazolam tab 2 mg......................................................... 62estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)....................................................................... 21estradiol & norethindrone acetate tab 1-0.5 mg(Activella)....................................................................... 21estradiol tab 0.5 mg (Estrace)........................................ 21estradiol tab 1 mg (Estrace)........................................... 21estradiol tab 2 mg (Estrace)........................................... 21estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).................................................................................. 21estradiol td patch twice weekly 0.0375 mg/24hr(Vivelle-dot)....................................................................21estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot).................................................................................. 21estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot).................................................................................. 21estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot).................................................................................. 21estradiol td patch weekly 0.025 mg/24hr (Climara)......21estradiol td patch weekly 0.05 mg/24hr (Climara)........21estradiol td patch weekly 0.06 mg/24hr (Climara)........22estradiol td patch weekly 0.075 mg/24hr (Climara)......22estradiol td patch weekly 0.1 mg/24hr (Climara)..........22estradiol td patch weekly 0.0375 mg/24hr (37.5mcg/24hr) (Climara)...................................................... 21estradiol vaginal cream 0.1 mg/gm (Estrace)...............54estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 22estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 22ESTRING -estradiol vaginal ring 2 mg (7.5mcg/24hrs).......................................................................54ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gmmetered-dose pump)...................................................... 22eszopiclone tab 1 mg (Lunesta).................................... 62eszopiclone tab 2 mg (Lunesta).................................... 62eszopiclone tab 3 mg (Lunesta).................................... 62ethambutol hcl tab 100 mg (Myambutol)........................ 3ethambutol hcl tab 400 mg (Myambutol)........................ 4ethosuximide cap 250 mg (Zarontin)............................ 76ethosuximide soln 250 mg/5ml (Zarontin).................... 76ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg................................................................................. 23ethynodiol diacetate & ethinyl estradiol tab 1 mg-50mcg................................................................................. 23etodolac cap 200 mg....................................................... 72etodolac cap 300 mg....................................................... 72etodolac tab er 24hr 400 mg.......................................... 72etodolac tab er 24hr 500 mg.......................................... 72etodolac tab er 24hr 600 mg.......................................... 72etodolac tab 500 mg........................................................72etodolac tab 400 mg (Lodine)........................................ 72ETOPOSIDE -etoposide cap 50 mg..................................14etravirine tab 100 mg (Intelence)..................................... 5etravirine tab 200 mg (Intelence)..................................... 5EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 22everolimus tab for oral susp 2 mg (Afinitordisperz)...........................................................................14everolimus tab for oral susp 3 mg (Afinitordisperz)...........................................................................14everolimus tab for oral susp 5 mg (Afinitordisperz)...........................................................................14everolimus tab 2.5 mg (Afinitor).................................... 14everolimus tab 5 mg (Afinitor)....................................... 14everolimus tab 7.5 mg (Afinitor).................................... 14everolimus tab 10 mg (Afinitor)..................................... 14everolimus tab 0.25 mg (Zortress).............................. 102everolimus tab 0.5 mg (Zortress)................................ 103everolimus tab 0.75 mg (Zortress).............................. 103everolimus tab 1 mg (Zortress)................................... 103

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 121EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg(base equiv)...................................................................... 5EVRYSDI -risdiplam for soln 0.75 mg/ml.......................... 81exemestane tab 25 mg (Aromasin)................................14EXKIVITY -mobocertinib succinate cap 40 mg................. 14ezetimibe-simvastatin tab 10-10 mg (Vytorin).............. 44ezetimibe-simvastatin tab 10-20 mg (Vytorin).............. 44ezetimibe-simvastatin tab 10-40 mg (Vytorin).............. 44ezetimibe-simvastatin tab 10-80 mg (Vytorin).............. 44ezetimibe tab 10 mg (Zetia)............................................ 44Ffamciclovir tab 125 mg......................................................5famciclovir tab 250 mg......................................................5famciclovir tab 500 mg......................................................6famotidine for susp 40 mg/5ml...................................... 51famotidine tab 40 mg (Pepcid)....................................... 51FANAPT -iloperidone tab 1 mg......................................... 59FANAPT -iloperidone tab 2 mg......................................... 59FANAPT -iloperidone tab 4 mg......................................... 59FANAPT -iloperidone tab 6 mg......................................... 59FANAPT -iloperidone tab 8 mg......................................... 59FANAPT -iloperidone tab 10 mg....................................... 59FANAPT -iloperidone tab 12 mg....................................... 59FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg& 4 mg & 6 mg titration pak........................................... 59FARXIGA -dapagliflozin propanediol tab 5 mg (baseequivalent)....................................................................... 24FARXIGA -dapagliflozin propanediol tab 10 mg (baseequivalent)....................................................................... 24FASENRA PEN -benralizumab subcutaneous soln auto-injector 30 mg/ml............................................................ 48FC2 FEMALE CONDOM -condoms - female..................100FEIBA -antiinhibitor coagulant complex for iv soln 500unit................................................................................... 88FEIBA -antiinhibitor coagulant complex for iv soln 1000unit................................................................................... 88FEIBA -antiinhibitor coagulant complex for iv soln 2500unit................................................................................... 89felbamate susp 600 mg/5ml (Felbatol).......................... 76felbamate tab 400 mg (Felbatol).................................... 76felbamate tab 600 mg (Felbatol).................................... 76felodipine tab er 24hr 2.5 mg......................................... 37felodipine tab er 24hr 5 mg............................................ 37felodipine tab er 24hr 10 mg.......................................... 37FEMCAP -cervical cap 22 mm........................................ 100FEMCAP -cervical cap 26 mm........................................ 100FEMCAP -cervical cap 30 mm........................................ 101fenofibrate micronized cap 67 mg.................................44fenofibrate micronized cap 134 mg (Lofibra)............... 44fenofibrate micronized cap 200 mg (Lofibra)............... 44fenofibrate tab 160 mg.................................................... 44fenofibrate tab 54 mg (Lofibra)...................................... 44fenofibrate tab 48 mg (Tricor)........................................ 44fenofibrate tab 145 mg (Tricor)...................................... 44fentanyl citrate lozenge on a handle 200 mcg(Actiq)............................................................................. 69fentanyl citrate lozenge on a handle 400 mcg(Actiq)............................................................................. 69fentanyl citrate lozenge on a handle 600 mcg(Actiq)............................................................................. 69fentanyl citrate lozenge on a handle 800 mcg(Actiq)............................................................................. 69fentanyl citrate lozenge on a handle 1200 mcg(Actiq)............................................................................. 69fentanyl citrate lozenge on a handle 1600 mcg(Actiq)............................................................................. 69fentanyl td patch 72hr 12 mcg/hr (Duragesic)..............69fentanyl td patch 72hr 25 mcg/hr (Duragesic)..............69fentanyl td patch 72hr 50 mcg/hr (Duragesic)..............69fentanyl td patch 72hr 75 mcg/hr (Duragesic)..............69fentanyl td patch 72hr 100 mcg/hr (Duragesic)............69FERRIPROX -deferiprone oral soln 100 mg/ml................ 99ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elementalfe).....................................................................................83FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml(44 mg/5ml elemental fe)............................................... 83ferrous sulfate soln 75 mg/ml (15 mg/ml elementalfe).....................................................................................83ferrous sulfate syrup 300 mg/5ml (60 mg/5mlelemental fe).................................................................. 83FETZIMA -levomilnacipran hcl cap er 24hr 20 mg (baseequivalent)....................................................................... 57FETZIMA -levomilnacipran hcl cap er 24hr 40 mg (baseequivalent)....................................................................... 57FETZIMA -levomilnacipran hcl cap er 24hr 80 mg (baseequivalent)....................................................................... 57FETZIMA -levomilnacipran hcl cap er 24hr 120 mg (baseequivalent)....................................................................... 57FETZIMA TITRATION PACK -levomilnacipran hcl cap er24hr 20 & 40 mg therapy pack...................................... 57FIASP FLEXTOUCH -insulin aspart (with niacinamide) solpen-inj 100 unit/ml.......................................................... 27FIASP -insulin aspart (with niacinamide) inj 100 unit/ml..................................................................................... 27FIASP PENFILL -insulin aspart (with niacinamide) solncartridge 100 unit/ml....................................................... 27FIBRYGA -fibrinogen conc (human) inj approximately 1gm (900-1300 mg).......................................................... 89finasteride tab 5 mg (Proscar)....................................... 55FINTEPLA -fenfluramine hcl oral soln 2.2 mg/ml..............76FIRDAPSE -amifampridine phosphate tab 10 mg (baseequivalent)....................................................................... 81FIRVANQ -vancomycin hcl for oral soln 25 mg/ml (baseequivalent)......................................................................... 9FIRVANQ -vancomycin hcl for oral soln 50 mg/ml (baseequivalent)......................................................................... 9FLAREX -fluorometholone acetate ophth susp 0.1%....... 93flecainide acetate tab 50 mg.......................................... 38flecainide acetate tab 100 mg........................................ 38flecainide acetate tab 150 mg........................................ 38FLEXICHAMBER ADULT MASK/S -spacer/aerosol-holding chamber supplies - masks.............................. 101

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 122FLEXICHAMBER CHILD MASK/L -spacer/aerosol-holding chamber supplies - masks.............................. 101FLEXICHAMBER CHILD MASK/S -spacer/aerosol-holding chamber supplies - masks.............................. 101FLEXICHAMBER -spacer/aerosol-holding chambers -device............................................................................ 101FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/ml-400 unit/ml................................................................. 82FLOVENT DISKUS -fluticasone propionate aer pow ba 50mcg/blister....................................................................... 48FLOVENT DISKUS -fluticasone propionate aer pow ba100 mcg/blister................................................................48FLOVENT DISKUS -fluticasone propionate aer pow ba250 mcg/blister................................................................49FLOVENT HFA -fluticasone propionate hfa inhal aer 110mcg/act (125/valve)........................................................ 49FLOVENT HFA -fluticasone propionate hfa inhal aer 220mcg/act (250/valve)........................................................ 49FLOVENT HFA -fluticasone propionate hfa inhal aero 44mcg/act (50/valve)...........................................................49FLOWFLEX COVID-19 ANTIGEN -covid-19 at homeantigen test kit.................................................................99FLUAD QUADRIVALENT 2022-2 -influenza vac type a&bsurface ant adj quad pref syr 0.5 ml.............................. 10FLUARIX QUADRIVALENT 2022 -influenza virus vac splitquadrivalent susp pref syr 0.5ml.................................... 10FLUBLOK QUADRIVALENT 2022 -influenza vac recombha quad pf soln pref syr 0.5 ml...................................... 10FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cultsubunt quad susp pref syr 0.5 ml.................................. 10FLUCELVAX QUADRIVALENT 20 -influenza vac tissue-cultured subunit quadrivalent im susp........................... 10fluconazole for susp 10 mg/ml (Diflucan).......................4fluconazole for susp 40 mg/ml (Diflucan).......................4fluconazole tab 50 mg (Diflucan).....................................4fluconazole tab 100 mg (Diflucan)................................... 4fluconazole tab 150 mg (Diflucan)................................... 4fluconazole tab 200 mg (Diflucan)................................... 4flucytosine cap 250 mg (Ancobon)................................. 4flucytosine cap 500 mg (Ancobon)................................. 4fludrocortisone acetate tab 0.1 mg............................... 20FLULAVAL QUADRIVALENT 202 -influenza virus vac splitquadrivalent susp pref syr 0.5ml.................................... 10fluocinolone acetonide cream 0.01%............................ 97fluocinolone acetonide cream 0.025% (Synalar)..........97fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod)............................................................97fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca).............................................................97fluocinolone acetonide oint 0.025% (Synalar)..............97fluocinolone acetonide (otic) oil 0.01% (Dermotic)......94fluocinolone acetonide soln 0.01% (Synalar)...............97fluocinonide cream 0.05%.............................................. 97fluocinonide cream 0.1% (Vanos).................................. 97fluocinonide gel 0.05%....................................................97fluocinonide oint 0.05%.................................................. 97fluocinonide soln 0.05%..................................................97FLUORIDEX SENSITIVITY REL -sodium fluoride-potassium nitrate paste 1.1-5%..................................... 94fluorometholone ophth susp 0.1% (Fml liquifilm)....... 93fluorouracil cream 5% (Efudex)..................................... 97FLUOROURACIL -fluorouracil soln 2%............................ 97FLUOROURACIL -fluorouracil soln 5%............................ 97FLUOXETINE DR -fluoxetine hcl cap delayed release 90mg....................................................................................57fluoxetine hcl cap 10 mg (Prozac)................................. 57fluoxetine hcl cap 20 mg (Prozac)................................. 57fluoxetine hcl cap 40 mg (Prozac)................................. 57fluoxetine hcl solution 20 mg/5ml................................. 57FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/ml..................................................................................... 59fluphenazine hcl tab 1 mg.............................................. 59fluphenazine hcl tab 2.5 mg........................................... 59fluphenazine hcl tab 5 mg.............................................. 59fluphenazine hcl tab 10 mg............................................ 60FLUPHENAZINE HYDROCHLORID -fluphenazine hclelixir 2.5 mg/5ml............................................................. 60FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 62FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 62FLURBIPROFEN -flurbiprofen tab 50 mg......................... 72FLURBIPROFEN SODIUM -flurbiprofen sodium ophthsoln 0.03%...................................................................... 93flurbiprofen tab 100 mg.................................................. 72FLUTAMIDE -flutamide cap 125 mg................................. 14FLUTICASONE PROPIONATE/SA -fluticasone-salmeterolaer powder ba 55-14 mcg/act........................................ 49FLUTICASONE PROPIONATE/SA -fluticasone-salmeterolaer powder ba 113-14 mcg/act...................................... 49FLUTICASONE PROPIONATE/SA -fluticasone-salmeterolaer powder ba 232-14 mcg/act...................................... 49fluticasone propionate cream 0.05% (Cutivate)........... 97fluticasone propionate nasal susp 50 mcg/act............ 47fluticasone propionate oint 0.005%...............................97fluvoxamine maleate tab 25 mg..................................... 57fluvoxamine maleate tab 50 mg..................................... 57fluvoxamine maleate tab 100 mg...................................58FLUZONE HIGH-DOSE PF 2022 -influenza vac split high-dose quad pf susp pref syr 0.7 ml................................. 10FLUZONE QUADRIVALENT 2022 -influenza virusvaccine split quadrivalent im inj..................................... 10FLUZONE QUADRIVALENT 2022 -influenza virusvaccine split quadrivalent inj 0.5 ml............................... 10FLUZONE QUADRIVALENT 2022 -influenza virus vacsplit quadrivalent susp pref syr 0.5ml............................ 10folic acid cap 0.8 mg....................................................... 83folic acid tab 400 mcg.....................................................83folic acid tab 800 mcg.....................................................83folic acid tab 1 mg...........................................................83FOLLISTIM AQ -follitropin beta inj 300 unit/0.36ml.......... 32FOLLISTIM AQ -follitropin beta inj 600 unit/0.72ml.......... 32FOLLISTIM AQ -follitropin beta inj 900 unit/1.08ml.......... 32fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml(Arixtra)...........................................................................85

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 123fondaparinux sodium subcutaneous inj 5 mg/0.4ml(Arixtra)...........................................................................85fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml(Arixtra)...........................................................................85fondaparinux sodium subcutaneous inj 10 mg/0.8ml(Arixtra)...........................................................................85FORTEO -teriparatide (recombinant) soln pen-inj 600mcg/2.4ml........................................................................ 32fosamprenavir calcium tab 700 mg (base equiv)(Lexiva)............................................................................. 6fosfomycin tromethamine powd pack 3 gm (baseequivalent) (Monurol)..................................................... 9fosinopril sodium & hydrochlorothiazide tab 10-12.5mg................................................................................... 40fosinopril sodium & hydrochlorothiazide tab 20-12.5mg................................................................................... 40fosinopril sodium tab 10 mg.......................................... 40fosinopril sodium tab 20 mg.......................................... 40fosinopril sodium tab 40 mg.......................................... 40FOSRENOL -lanthanum carbonate oral powder pack 750mg (elemental)................................................................ 53FOSRENOL -lanthanum carbonate oral powder pack1000 mg (elemental).......................................................53FOTIVDA -tivozanib hcl cap 0.89 mg (baseequivalent)....................................................................... 14FOTIVDA -tivozanib hcl cap 1.34 mg (baseequivalent)....................................................................... 14FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml...........85FRAGMIN -dalteparin sodium soln prefilled syr 2500unit/0.2ml......................................................................... 85FRAGMIN -dalteparin sodium soln prefilled syr 5000unit/0.2ml......................................................................... 85FRAGMIN -dalteparin sodium soln prefilled syr 7500unit/0.3ml......................................................................... 85FRAGMIN -dalteparin sodium soln prefilled syr 10000unit/ml.............................................................................. 85FRAGMIN -dalteparin sodium soln prefilled syr 12500unit/0.5ml......................................................................... 85FRAGMIN -dalteparin sodium soln prefilled syr 15000unit/0.6ml......................................................................... 85FRAGMIN -dalteparin sodium soln prefilled syr 18000unit/0.72ml....................................................................... 85FULPHILA -pegfilgrastim-jmdb soln prefilled syringe 6mg/0.6ml..........................................................................83furosemide oral soln 10 mg/ml...................................... 43furosemide tab 20 mg (Lasix)........................................ 43furosemide tab 40 mg (Lasix)........................................ 43furosemide tab 80 mg (Lasix)........................................ 43FUZEON -enfuvirtide for inj 90 mg..................................... 6FYCOMPA -perampanel susp 0.5 mg/ml.......................... 76FYCOMPA -perampanel tab 2 mg.................................... 76FYCOMPA -perampanel tab 4 mg.................................... 76FYCOMPA -perampanel tab 6 mg.................................... 76FYCOMPA -perampanel tab 8 mg.................................... 76FYCOMPA -perampanel tab 10 mg.................................. 76FYCOMPA -perampanel tab 12 mg.................................. 76Ggabapentin cap 100 mg (Neurontin)..............................76gabapentin cap 300 mg (Neurontin)..............................76gabapentin cap 400 mg (Neurontin)..............................76gabapentin oral soln 250 mg/5ml (Neurontin)..............76gabapentin tab 600 mg (Neurontin)...............................76gabapentin tab 800 mg (Neurontin)...............................76GALAFOLD -migalastat hcl cap 123 mg (baseequivalent)....................................................................... 32galantamine hydrobromide cap er 24hr 8 mg(Razadyne er)................................................................ 66galantamine hydrobromide cap er 24hr 16 mg(Razadyne er)................................................................ 66galantamine hydrobromide cap er 24hr 24 mg(Razadyne er)................................................................ 66GALANTAMINE HYDROBROMIDE -galantaminehydrobromide oral soln 4 mg/ml.................................... 66galantamine hydrobromide tab 4 mg (Razadyne)........66galantamine hydrobromide tab 8 mg (Razadyne)........66galantamine hydrobromide tab 12 mg (Razadyne)......66GALZIN -zinc acetate cap 25 mg (elemental zinc)........... 82GALZIN -zinc acetate cap 50 mg (elemental zinc)........... 82ganirelix acetate soln prefilled syringe 250 mcg/0.5ml(Ganirelix acetate).........................................................32GARDASIL 9 -human papillomavirus (hpv) 9-valentrecomb vac im susp....................................................... 10GARDASIL 9 -human papillomavirus (hpv) 9-valentrecomb vac susp pref syr...............................................10gatifloxacin ophth soln 0.5% (Zymaxid)....................... 93GATTEX -teduglutide (rdna) for inj kit 5 mg......................53GAVRETO -pralsetinib cap 100 mg.................................. 14gemfibrozil tab 600 mg (Lopid)...................................... 44GENTAK -gentamicin sulfate ophth oint 0.3%.................. 93gentamicin sulfate cream 0.1%......................................97gentamicin sulfate ophth soln 0.3%..............................93GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg.......................................................... 6GILENYA -fingolimod hcl cap 0.5 mg (base equiv)...........66GILOTRIF -afatinib dimaleate tab 20 mg (baseequivalent)....................................................................... 14GILOTRIF -afatinib dimaleate tab 30 mg (baseequivalent)....................................................................... 14GILOTRIF -afatinib dimaleate tab 40 mg (baseequivalent)....................................................................... 14GLASSIA -alpha1-proteinase inhibitor (human) inj 1000mg/50ml...........................................................................50glatiramer acetate soln prefilled syringe 20 mg/ml(Mylan Products) (Copaxone)..................................... 66glatiramer acetate soln prefilled syringe 40 mg/ml(Mylan Products) (Copaxone)..................................... 66GLEOSTINE -lomustine cap 10 mg.................................. 14GLEOSTINE -lomustine cap 40 mg.................................. 14GLEOSTINE -lomustine cap 100 mg................................ 14glimepiride tab 1 mg (Amaryl)........................................24glimepiride tab 2 mg (Amaryl)........................................24glimepiride tab 4 mg (Amaryl)........................................24

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 124glipizide-metformin hcl tab 2.5-250 mg.........................25glipizide-metformin hcl tab 2.5-500 mg.........................25glipizide-metformin hcl tab 5-500 mg............................25glipizide tab er 24hr 2.5 mg (Glucotrol xl).................... 24glipizide tab er 24hr 5 mg (Glucotrol xl)....................... 24glipizide tab er 24hr 10 mg (Glucotrol xl)..................... 24glipizide tab 5 mg (Glucotrol).........................................24glipizide tab 10 mg (Glucotrol).......................................24GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg(base equiv).................................................................... 25GLUCAGON EMERGENCY KIT FO -glucagon hcl for inj1 mg................................................................................ 25glucagon (rdna) for inj kit 1 mg (Glucagon emergencyk)......................................................................................25GLUCOSE -glucose chew tab 4 gm (rounded).................25glyburide-metformin tab 1.25-250 mg........................... 25glyburide-metformin tab 2.5-500 mg (Glucovance)..... 25glyburide-metformin tab 5-500 mg (Glucovance)........ 25glyburide micronized tab 1.5 mg (Glynase)..................25glyburide micronized tab 3 mg (Glynase).....................25glyburide micronized tab 6 mg (Glynase).....................25glyburide tab 1.25 mg..................................................... 25glyburide tab 2.5 mg....................................................... 25glyburide tab 5 mg.......................................................... 25glycopyrrolate oral soln 1 mg/5ml (Cuvposa).............. 51glycopyrrolate tab 1 mg (Robinul).................................51glycopyrrolate tab 2 mg (Robinul forte)........................51GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 25GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 25GNP GLUCOSE -glucose chew tab 4 gm (rounded)........25GNP QUICK DISSOLVE GLUCOS -glucose chew tab 4gm (rounded).................................................................. 25granisetron hcl tab 1 mg................................................ 52GRASTEK -timothy grass pollen allergen ext sl tab 2800bau...................................................................................12griseofulvin microsize susp 125 mg/5ml........................ 4griseofulvin microsize tab 500 mg.................................. 4griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 4griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 4guanfacine hcl tab er 24hr 1 mg (base equiv)(Intuniv).......................................................................... 63guanfacine hcl tab er 24hr 2 mg (base equiv)(Intuniv).......................................................................... 63guanfacine hcl tab er 24hr 3 mg (base equiv)(Intuniv).......................................................................... 63guanfacine hcl tab er 24hr 4 mg (base equiv)(Intuniv).......................................................................... 63guanfacine hcl tab 1 mg................................................. 40guanfacine hcl tab 2 mg................................................. 40GVOKE HYPOPEN 1-PACK -glucagon subcutaneoussolution auto-injector 0.5 mg/0.1ml................................ 25GVOKE HYPOPEN 1-PACK -glucagon subcutaneoussolution auto-injector 1 mg/0.2ml................................... 25GVOKE HYPOPEN 2-PACK -glucagon subcutaneoussolution auto-injector 0.5 mg/0.1ml................................ 25GVOKE HYPOPEN 2-PACK -glucagon subcutaneoussolution auto-injector 1 mg/0.2ml................................... 25GVOKE KIT -glucagon subcutaneous soln 1mg/0.2ml..........................................................................25GVOKE PFS -glucagon subcutaneous soln pref syringe0.5 mg/0.1ml................................................................... 25GVOKE PFS -glucagon subcutaneous soln pref syringe 1mg/0.2ml..........................................................................25GYNAZOLE-1 -butoconazole nitrate (one dose) vaginalcream 2%........................................................................ 54HHAEGARDA -c1 esterase inhibitor (human) forsubcutaneous inj 2000 unit............................................ 89HAEGARDA -c1 esterase inhibitor (human) forsubcutaneous inj 3000 unit............................................ 89halobetasol propionate cream 0.05% (Ultravate).........97haloperidol lactate oral conc 2 mg/ml...........................60haloperidol tab 0.5 mg.................................................... 60haloperidol tab 1 mg....................................................... 60haloperidol tab 2 mg....................................................... 60haloperidol tab 5 mg....................................................... 60haloperidol tab 10 mg..................................................... 60haloperidol tab 20 mg..................................................... 60HARVONI -ledipasvir-sofosbuvir pellet pack 33.75-150mg...................................................................................... 6HARVONI -ledipasvir-sofosbuvir pellet pack 45-200mg...................................................................................... 6HARVONI -ledipasvir-sofosbuvir tab 45-200 mg................ 6HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 6HAVRIX -hepatitis a vaccine inj susp 720 elunit/0.5ml......................................................................... 10HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml....... 10HEMLIBRA -emicizumab-kxwh subcutaneous soln 30 mg/ml..................................................................................... 89HEMLIBRA -emicizumab-kxwh subcutaneous soln 150mg/ml............................................................................... 89HEMLIBRA -emicizumab-kxwh subcutaneous soln 60mg/0.4ml (150 mg/ml).....................................................89HEMLIBRA -emicizumab-kxwh subcutaneous soln 105mg/0.7ml (150 mg/ml).....................................................89HEMOFIL M -antihemophilic factor (human) for inj 250unit................................................................................... 89HEMOFIL M -antihemophilic factor (human) for inj 500unit................................................................................... 89HEMOFIL M -antihemophilic factor (human) for inj 1000unit................................................................................... 89HEMOFIL M -antihemophilic factor (human) for inj 1700unit................................................................................... 89HEPARIN SODIUM -heparin sodium (porcine) pf inj 5000unit/ml.............................................................................. 85heparin sodium (porcine) inj 1000 unit/ml....................85heparin sodium (porcine) inj 5000 unit/ml....................85heparin sodium (porcine) inj 10000 unit/ml..................85heparin sodium (porcine) inj 20000 unit/ml..................85heparin sodium (porcine) pf inj 5000 unit/0.5ml.......... 85HEPLISAV-B -hepatitis b vaccine recomb adjuvanted prefsyr 20 mcg/0.5ml............................................................ 10HETLIOZ LQ -tasimelteon oral susp 4 mg/ml...................62

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 125HETLIOZ -tasimelteon capsule 20 mg..............................62HIBERIX -haemophilus b polysaccharide conjugate vacfor inj 10 mcg..................................................................10HUMATE-P -antihemophilic factor/vwf (human) for inj250-600 unit.................................................................... 89HUMATE-P -antihemophilic factor/vwf (human) for inj500-1200 unit.................................................................. 89HUMATE-P -antihemophilic factor/vwf (human) for inj1000-2400 unit................................................................ 89HUMIRA -adalimumab prefilled syringe kit 10mg/0.1ml..........................................................................72HUMIRA -adalimumab prefilled syringe kit 20mg/0.2ml..........................................................................72HUMIRA -adalimumab prefilled syringe kit 40mg/0.8ml..........................................................................72HUMIRA -adalimumab prefilled syringe kit 40mg/0.4ml..........................................................................72HUMIRA PEDIATRIC CROHNS D -adalimumab prefilledsyringe kit 80 mg/0.8ml.................................................. 72HUMIRA PEDIATRIC CROHNS D -adalimumab prefilledsyringe kit 80 mg/0.8ml & 40 mg/0.4ml......................... 72HUMIRA PEN -adalimumab pen-injector kit 40mg/0.8ml..........................................................................72HUMIRA PEN -adalimumab pen-injector kit 40mg/0.4ml..........................................................................72HUMIRA PEN -adalimumab pen-injector kit 80mg/0.8ml..........................................................................72HUMIRA PEN-CD/UC/HS START -adalimumab pen-injector kit 40 mg/0.8ml.................................................. 72HUMIRA PEN-CD/UC/HS START -adalimumab pen-injector kit 80 mg/0.8ml.................................................. 72HUMIRA PEN-PEDIATRIC UC S -adalimumab pen-injector kit 80 mg/0.8ml.................................................. 72HUMIRA PEN-PS/UV STARTER -adalimumab pen-injector kit 40 mg/0.8ml.................................................. 72HUMIRA PEN-PS/UV STARTER -adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml......................... 72HUMULIN R U-500 (CONCENTR -insulin regular (human)inj 500 unit/ml..................................................................28HUMULIN R U-500 KWIKPEN -insulin regular (human)soln pen-injector 500 unit/ml.......................................... 28HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 14HYCAMTIN -topotecan hcl cap 1 mg (base equiv)...........14hydralazine hcl tab 10 mg.............................................. 40hydralazine hcl tab 25 mg.............................................. 40hydralazine hcl tab 50 mg.............................................. 40hydralazine hcl tab 100 mg............................................ 40hydrochlorothiazide cap 12.5 mg (Microzide).............. 43hydrochlorothiazide tab 12.5 mg................................... 43hydrochlorothiazide tab 25 mg...................................... 43hydrochlorothiazide tab 50 mg...................................... 43HYDROCODONE/IBUPROFEN -hydrocodone-ibuprofentab 5-200 mg...................................................................69HYDROCODONE/IBUPROFEN -hydrocodone-ibuprofentab 10-200 mg................................................................ 69hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet).............................................................................69hydrocodone-acetaminophen tab 7.5-325 mg(Norco)............................................................................69hydrocodone-acetaminophen tab 5-325 mg(Norco)............................................................................69hydrocodone-acetaminophen tab 10-325 mg(Norco)............................................................................69hydrocodone bitart-homatropine methylbromide tab5-1.5 mg (Hycodan)...................................................... 47hydrocodone bitart-homatropine methylbrom soln5-1.5 mg/5ml (Hycodan)............................................... 47hydrocodone-ibuprofen tab 7.5-200 mg........................69hydrocod polst-chlorphen polst er susp 10-8 mg/5ml(Tussionex pennkineti).................................................47hydrocortisone acetate suppos 25 mg......................... 95hydrocortisone acetate w/ pramoxine perianal cream1-1% (Analpram-hc)...................................................... 95hydrocortisone cream 2.5%............................................97hydrocortisone enema 100 mg/60ml (Cortenema).......95hydrocortisone lotion 2.5%............................................ 97hydrocortisone oint 2.5%................................................97hydrocortisone perianal cream 2.5% (Anusol-hc)....... 95hydrocortisone perianal cream 1% (Proctocort)..........95hydrocortisone tab 5 mg (Cortef).................................. 20hydrocortisone tab 10 mg (Cortef)................................ 20hydrocortisone tab 20 mg (Cortef)................................ 20hydrocortisone w/ acetic acid otic soln 1-2%.............. 94hydromorphone hcl liqd 1 mg/ml (Dilaudid).................69hydromorphone hcl tab 2 mg (Dilaudid).......................69hydromorphone hcl tab 4 mg (Dilaudid).......................69hydromorphone hcl tab 8 mg (Dilaudid).......................69HYDROXOCOBALAMIN -hydroxocobalamin acetate inj1000 mcg/ml (base equivalent)......................................83hydroxychloroquine sulfate tab 200 mg (Plaquenil)......8hydroxyurea cap 500 mg (Hydrea)................................ 14hydroxyzine hcl syrup 10 mg/5ml................................. 56hydroxyzine hcl tab 10 mg............................................. 56hydroxyzine hcl tab 25 mg............................................. 56hydroxyzine hcl tab 50 mg............................................. 56hydroxyzine pamoate cap 25 mg (Vistaril)................... 56hydroxyzine pamoate cap 50 mg (Vistaril)................... 56HYDROXYZINE PAMOATE -hydroxyzine pamoate cap100 mg............................................................................ 56Iibandronate sodium tab 150 mg (base equivalent)(Boniva).......................................................................... 32IBRANCE -palbociclib cap 75 mg..................................... 14IBRANCE -palbociclib cap 100 mg................................... 14IBRANCE -palbociclib cap 125 mg................................... 15IBRANCE -palbociclib tab 75 mg...................................... 15IBRANCE -palbociclib tab 100 mg.................................... 15IBRANCE -palbociclib tab 125 mg.................................... 15ibuprofen tab 400 mg...................................................... 72ibuprofen tab 600 mg...................................................... 72ibuprofen tab 800 mg...................................................... 72icatibant acetate inj 30 mg/3ml (base equivalent)(Firazyr).......................................................................... 89

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 126ICLUSIG -ponatinib hcl tab 10 mg (base equiv)............... 15ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 15ICLUSIG -ponatinib hcl tab 30 mg (base equiv)............... 15ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 15IDELVION -coagulation factor ix (recomb) (rix-fp) for inj250 unit........................................................................... 89IDELVION -coagulation factor ix (recomb) (rix-fp) for inj500 unit........................................................................... 89IDELVION -coagulation factor ix (recomb) (rix-fp) for inj1000 unit......................................................................... 89IDELVION -coagulation factor ix (recomb) (rix-fp) for inj2000 unit......................................................................... 89IDELVION -coagulation factor ix (recomb) (rix-fp) for inj3500 unit......................................................................... 89IDHIFA -enasidenib mesylate tab 50 mg (baseequivalent)....................................................................... 15IDHIFA -enasidenib mesylate tab 100 mg (baseequivalent)....................................................................... 15IHEALTH COVID-19 ANTIGEN -covid-19 at home antigentest kit.............................................................................. 99imatinib mesylate tab 100 mg (base equivalent)(Gleevec)........................................................................ 15imatinib mesylate tab 400 mg (base equivalent)(Gleevec)........................................................................ 15IMBRUVICA -ibrutinib cap 70 mg..................................... 15IMBRUVICA -ibrutinib cap 140 mg................................... 15IMBRUVICA -ibrutinib tab 140 mg.................................... 15IMBRUVICA -ibrutinib tab 280 mg.................................... 15IMBRUVICA -ibrutinib tab 420 mg.................................... 15IMBRUVICA -ibrutinib tab 560 mg.................................... 15IMCIVREE -setmelanotide acetate subcutaneous soln 10mg/ml............................................................................... 63imipramine hcl tab 10 mg (Tofranil).............................. 58imipramine hcl tab 25 mg (Tofranil).............................. 58imipramine hcl tab 50 mg (Tofranil).............................. 58imiquimod cream 5% (Aldara)........................................97IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdcinj..................................................................................... 10IMPAVIDO -miltefosine cap 50 mg......................................9IMURAN -azathioprine tab 50 mg................................... 103INBRIJA -levodopa inhal powder cap 42 mg.................... 80INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........32INCRUSE ELLIPTA -umeclidinium br aero powd breathact 62.5 mcg/inh (base eq)............................................ 49indapamide tab 1.25 mg..................................................43indapamide tab 2.5 mg....................................................43INDICAID COVID-19 RAPID A -covid-19 at home antigentest kit.............................................................................. 99indomethacin cap er 75 mg............................................72indomethacin cap 25 mg................................................ 72indomethacin cap 50 mg................................................ 72INFANRIX -diph, acellular pert & tet tox inj 25 lf-58mcg-10 lf/0.5ml............................................................... 12INGREZZA -valbenazine tosylate cap 40 mg (baseequiv)............................................................................... 66INGREZZA -valbenazine tosylate cap 60 mg (baseequiv)............................................................................... 66INGREZZA -valbenazine tosylate cap 80 mg (baseequiv)............................................................................... 66INGREZZA -valbenazine tosylate cap therapy pack 40 mg(7) & 80 mg (21).............................................................66INLYTA -axitinib tab 1 mg..................................................15INLYTA -axitinib tab 5 mg..................................................15INQOVI -decitabine-cedazuridine tab 35-100 mg............. 15INREBIC -fedratinib hcl cap 100 mg................................. 15INSPIRACHAMBER/ANTI-STATI -spacer/aerosol-holdingchambers - device........................................................ 101INSPIRACHAMBER/LARGE -spacer/aerosol-holdingchambers - device........................................................ 101INSPIRACHAMBER/SOOTHERMAS -spacer/aerosol-holding chambers - device........................................... 101INSPIREASE DRUG DELIVERY -spacer/aerosol-holdingchambers - device........................................................ 101INSPIREASE RESERVOIR BAGS -spacer/aerosol-holding chamber supplies - bags................................. 101INSULIN ASPART FLEXPEN -insulin aspart soln pen-injector 100 unit/ml......................................................... 27INSULIN ASPART -insulin aspart inj soln 100 unit/ml...... 27INSULIN ASPART PENFILL -insulin aspart soln cartridge100 unit/ml.......................................................................27INSULIN ASPART PROTAMINE/ -insulin aspart prot &aspart (human) inj 100 unit/ml (70-30)...........................28INSULIN ASPART PROTAMINE/ -insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)........................... 28INSULIN GLARGINE -insulin glargine-yfgn inj 100 unit/ml..................................................................................... 28INSULIN GLARGINE -insulin glargine-yfgn soln pen-injector 100 unit/ml......................................................... 28INSULIN PEN NEEDLES – VARIOUS............................101INSULIN SYRINGES – VARIOUS...................................101INTELENCE -etravirine tab 25 mg......................................6INTELISWAB COVID-19 RAPID -covid-19 at homeantigen test kit.................................................................99INTRON A -interferon alfa-2b for inj 10000000 unit..........15INTRON A -interferon alfa-2b for inj 18000000 unit..........15INTRON A -interferon alfa-2b for inj 50000000 unit..........15IPOL INACTIVATED IPV -poliovirus vaccine, ipvinjection........................................................................... 10ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 49ipratropium bromide inhal soln 0.02%..........................49ipratropium bromide nasal soln 0.03% (21 mcg/spray).............................................................................. 47ipratropium bromide nasal soln 0.06% (42 mcg/spray).............................................................................. 47irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)..........................................................................40irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)..........................................................................40irbesartan tab 75 mg (Avapro)....................................... 40irbesartan tab 150 mg (Avapro)..................................... 40irbesartan tab 300 mg (Avapro)..................................... 40IRESSA -gefitinib tab 250 mg........................................... 15IRON UP -polysaccharide iron complex liquid 15mg/0.5ml (fe equiv).........................................................83

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 127ISENTRESS HD -raltegravir potassium tab 600 mg (baseequiv)................................................................................. 6ISENTRESS -raltegravir potassium chew tab 25 mg (baseequiv)................................................................................. 6ISENTRESS -raltegravir potassium chew tab 100 mg(base equiv)...................................................................... 6ISENTRESS -raltegravir potassium packet for susp 100mg (base equiv)................................................................6ISENTRESS -raltegravir potassium tab 400 mg (baseequiv)................................................................................. 6ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 4ISONIAZID -isoniazid tab 100 mg.......................................4isoniazid tab 300 mg......................................................... 4ISOPTO ATROPINE -atropine sulfate ophth soln 1%.......93isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg(Bidil)...............................................................................45isosorbide dinitrate tab 10 mg....................................... 35isosorbide dinitrate tab 20 mg....................................... 35isosorbide dinitrate tab 30 mg....................................... 35isosorbide dinitrate tab 5 mg (Isordil titradose).......... 35isosorbide mononitrate tab er 24hr 30 mg................... 35isosorbide mononitrate tab er 24hr 60 mg................... 35isosorbide mononitrate tab er 24hr 120 mg................. 35isosorbide mononitrate tab 10 mg................................ 35isosorbide mononitrate tab 20 mg................................ 35isotretinoin cap 10 mg.................................................... 97isotretinoin cap 20 mg.................................................... 97isotretinoin cap 30 mg.................................................... 97isotretinoin cap 40 mg.................................................... 97isradipine cap 2.5 mg......................................................37isradipine cap 5 mg.........................................................37ISTURISA -osilodrostat phosphate tab 1 mg....................32ISTURISA -osilodrostat phosphate tab 5 mg....................32ISTURISA -osilodrostat phosphate tab 10 mg.................. 32itraconazole cap 100 mg (Sporanox).............................. 4itraconazole oral soln 10 mg/ml (Sporanox).................. 4IVERMECTIN -ivermectin lotion 0.5%...............................97ivermectin tab 3 mg (Stromectol).................................... 8IXINITY -coagulation factor ix (recombinant) for inj 250unit................................................................................... 89IXINITY -coagulation factor ix (recombinant) for inj 500unit................................................................................... 89IXINITY -coagulation factor ix (recombinant) for inj 1000unit................................................................................... 89IXINITY -coagulation factor ix (recombinant) for inj 1500unit................................................................................... 89IXINITY -coagulation factor ix (recombinant) for inj 2000unit................................................................................... 89IXINITY -coagulation factor ix (recombinant) for inj 3000unit................................................................................... 89JJAKAFI -ruxolitinib phosphate tab 5 mg (baseequivalent)....................................................................... 15JAKAFI -ruxolitinib phosphate tab 10 mg (baseequivalent)....................................................................... 15JAKAFI -ruxolitinib phosphate tab 15 mg (baseequivalent)....................................................................... 15JAKAFI -ruxolitinib phosphate tab 20 mg (baseequivalent)....................................................................... 15JAKAFI -ruxolitinib phosphate tab 25 mg (baseequivalent)....................................................................... 15JANSSEN COVID-19 VACCINE -covid-19 (sars-cov-2)ad26 vector vaccine-janssen im 0.5 ml..........................10JANUMET -sitagliptin-metformin hcl tab 50-500 mg.........25JANUMET -sitagliptin-metformin hcl tab 50-1000 mg.......25JANUMET XR -sitagliptin-metformin hcl tab er 24hr50-500 mg....................................................................... 25JANUMET XR -sitagliptin-metformin hcl tab er 24hr50-1000 mg..................................................................... 25JANUMET XR -sitagliptin-metformin hcl tab er 24hr100-1000 mg...................................................................25JANUVIA -sitagliptin phosphate tab 25 mg (baseequiv)............................................................................... 25JANUVIA -sitagliptin phosphate tab 50 mg (baseequiv)............................................................................... 25JANUVIA -sitagliptin phosphate tab 100 mg (baseequiv)............................................................................... 25JARDIANCE -empagliflozin tab 10 mg............................. 25JARDIANCE -empagliflozin tab 25 mg............................. 25JIVI -antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj1000 unit......................................................................... 89JIVI -antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj2000 unit......................................................................... 89JIVI -antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj3000 unit......................................................................... 89JIVI -antihemophil fact rcmb(bdd-rfviii peg-aucl) for inj 500unit................................................................................... 89JULUCA -dolutegravir sodium-rilpivirine hcl tab 50-25 mg(base eq)........................................................................... 6JUXTAPID -lomitapide mesylate cap 5 mg (baseequiv)............................................................................... 44JUXTAPID -lomitapide mesylate cap 10 mg (baseequiv)............................................................................... 44JUXTAPID -lomitapide mesylate cap 20 mg (baseequiv)............................................................................... 44JUXTAPID -lomitapide mesylate cap 30 mg (baseequiv)............................................................................... 44JYNARQUE -tolvaptan tab 15 mg.....................................32JYNARQUE -tolvaptan tab 30 mg.....................................32JYNARQUE -tolvaptan tab therapy pack 30 & 15 mg.......32JYNARQUE -tolvaptan tab therapy pack 45 & 15 mg.......32JYNARQUE -tolvaptan tab therapy pack 60 & 30 mg.......32JYNARQUE -tolvaptan tab therapy pack 90 & 30 mg.......32JYNARQUE -tolvaptan tab therapy pack 15 mg...............32KKALYDECO -ivacaftor packet 25 mg................................ 50KALYDECO -ivacaftor packet 50 mg................................ 50KALYDECO -ivacaftor packet 75 mg................................ 50KALYDECO -ivacaftor tab 150 mg.................................... 50KESIMPTA -ofatumumab soln auto-injector 20mg/0.4ml..........................................................................66

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 128ketoconazole cream 2%.................................................. 97ketoconazole shampoo 2% (Nizoral).............................97ketoconazole tab 200 mg..................................................4ketorolac tromethamine ophth soln 0.5% (Acular)...... 93ketorolac tromethamine ophth soln 0.4% (Acularls).....................................................................................93ketorolac tromethamine tab 10 mg............................... 72KETOSTIX -acetone (urine) test strip............................... 99KEVZARA -sarilumab subcutaneous soln prefilled syringe150 mg/1.14ml................................................................ 72KEVZARA -sarilumab subcutaneous soln prefilled syringe200 mg/1.14ml................................................................ 72KEVZARA -sarilumab subcutaneous solution auto-injector150 mg/1.14ml................................................................ 72KEVZARA -sarilumab subcutaneous solution auto-injector200 mg/1.14ml................................................................ 72KINRIX -diph-tetanus-acell pert-polio, ipv vacc susp prefsyr 0.5 ml........................................................................ 12KISQALI FEMARA 200 DOSE -ribociclib 200 mg dose(200 mg tab) & letrozole 2.5 mg tbpk............................ 15KISQALI FEMARA 400 DOSE -ribociclib 400 mg dose(200 mg tab) & letrozole 2.5 mg tbpk............................ 15KISQALI FEMARA 600 DOSE -ribociclib 600 mg dose(200 mg tab) & letrozole 2.5 mg tbpk............................ 15KISQALI -ribociclib succinate tab pack 200 mg dailydose................................................................................. 15KISQALI -ribociclib succinate tab pack 400 mg daily dose(200 mg tab)................................................................... 15KISQALI -ribociclib succinate tab pack 600 mg daily dose(200 mg tab)................................................................... 15KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 3KLOXXADO -naloxone hcl nasal spray 8 mg/0.1ml..........99KOATE -antihemophilic factor (human) for inj 250 unit.....89KOATE -antihemophilic factor (human) for inj 500 unit.....89KOATE -antihemophilic factor (human) for inj 1000unit................................................................................... 89KOATE-DVI -antihemophilic factor (human) for inj 500unit................................................................................... 89KOATE-DVI -antihemophilic factor (human) for inj 1000unit................................................................................... 89KOGENATE FS -antihemophilic factor recomb (rfviii) forinj kit 250 unit................................................................. 89KOGENATE FS -antihemophilic factor recomb (rfviii) forinj kit 500 unit................................................................. 90KOGENATE FS -antihemophilic factor recomb (rfviii) forinj kit 1000 unit............................................................... 90KOGENATE FS -antihemophilic factor recomb (rfviii) forinj kit 2000 unit............................................................... 90KOGENATE FS -antihemophilic factor recomb (rfviii) forinj kit 3000 unit............................................................... 90KORLYM -mifepristone tab 300 mg.................................. 26KOSELUGO -selumetinib sulfate cap 10 mg....................15KOSELUGO -selumetinib sulfate cap 25 mg....................15KOVALTRY -antihemophilic factor recomb (rahf-pfm) forinj 250 unit...................................................................... 90KOVALTRY -antihemophilic factor recomb (rahf-pfm) forinj 500 unit...................................................................... 90KOVALTRY -antihemophilic factor recomb (rahf-pfm) forinj 1000 unit.................................................................... 90KOVALTRY -antihemophilic factor recomb (rahf-pfm) forinj 2000 unit.................................................................... 90KOVALTRY -antihemophilic factor recomb (rahf-pfm) forinj 3000 unit.................................................................... 90K-PHOS NO 2 -potassium & sodium acid phosphates tab305-700 mg..................................................................... 55KRINTAFEL -tafenoquine succinate tab 150 mg (baseequivalent)......................................................................... 8KROGER GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 26K-TAB -potassium chloride tab er 8 meq (600 mg)...........82KYNMOBI -apomorphine hydrochloride film 10 mg.......... 80KYNMOBI -apomorphine hydrochloride film 15 mg.......... 80KYNMOBI -apomorphine hydrochloride film 20 mg.......... 80KYNMOBI -apomorphine hydrochloride film 25 mg.......... 80KYNMOBI -apomorphine hydrochloride film 30 mg.......... 80Llabetalol hcl tab 100 mg..................................................36labetalol hcl tab 200 mg..................................................36labetalol hcl tab 300 mg..................................................36lacosamide oral solution 10 mg/ml (Vimpat)................76lacosamide tab 50 mg (Vimpat)..................................... 76lacosamide tab 100 mg (Vimpat)................................... 76lacosamide tab 150 mg (Vimpat)................................... 76lacosamide tab 200 mg (Vimpat)................................... 76LACRISERT -artificial tear ophth insert.............................93lactulose (encephalopathy) solution 10 gm/15ml........ 53lactulose solution 10 gm/15ml....................................... 50LAGEVRIO -molnupiravir cap 200 mg................................ 6LAMICTAL ODT -lamotrigine tab disint 21 x 25 mg & 7 x50 mg titration kit............................................................ 77LAMICTAL ODT -lamotrigine tab disint 42 x 50mg & 14 x100mg titration kit........................................................... 77LAMICTAL XR -lamotrigine tab er 24hr 25 (14) & 50 mg(14) & 100 mg(7) kit....................................................... 77LAMICTAL XR -lamotrigine tab er 24hr 50 (14) & 100mg(14) & 200 mg(7) kit.................................................. 77LAMICTAL XR -lamotrigine tab er 24hr 21 x 25 mg & 7 x50 mg titration kit............................................................ 77lamivudine oral soln 10 mg/ml (Epivir)........................... 6lamivudine tab 150 mg (Epivir)........................................ 6lamivudine tab 300 mg (Epivir)........................................ 6lamivudine tab 100 mg (hbv) (Epivir hbv).......................6lamivudine-zidovudine tab 150-300 mg (Combivir)....... 6lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di).................................................................. 77lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di).................................................................. 77lamotrigine tab er 24hr 25 mg (Lamictal xr)................. 77lamotrigine tab er 24hr 50 mg (Lamictal xr)................. 77lamotrigine tab er 24hr 100 mg (Lamictal xr)............... 77lamotrigine tab er 24hr 200 mg (Lamictal xr)............... 77lamotrigine tab er 24hr 250 mg (Lamictal xr)............... 77lamotrigine tab er 24hr 300 mg (Lamictal xr)............... 77

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 129lamotrigine tab 25 mg (42) & 100 mg (7) starter kit(Lamictal starter/not).................................................... 77lamotrigine tab 25 mg (Lamictal)................................... 77lamotrigine tab 100 mg (Lamictal).................................77lamotrigine tab 150 mg (Lamictal).................................77lamotrigine tab 200 mg (Lamictal).................................77lamotrigine tab 84 x 25 mg & 14 x 100 mg starter kit(Lamictal starter/tak).................................................... 77lamotrigine tab 35 x 25 mg starter kit (Lamictalstarter/tak)...................................................................... 77LAMPIT -nifurtimox tab 30 mg............................................ 9LAMPIT -nifurtimox tab 120 mg.......................................... 9LANCETS – VARIOUS.................................................... 101LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 35LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 35LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 35lanthanum carbonate chew tab 500 mg (elemental)(Fosrenol)....................................................................... 53lanthanum carbonate chew tab 750 mg (elemental)(Fosrenol)....................................................................... 53lanthanum carbonate chew tab 1000 mg (elemental)(Fosrenol)....................................................................... 53lapatinib ditosylate tab 250 mg (base equiv)(Tykerb)...........................................................................15latanoprost ophth soln 0.005% (Xalatan)......................93LATUDA -lurasidone hcl tab 20 mg...................................60LATUDA -lurasidone hcl tab 40 mg...................................60LATUDA -lurasidone hcl tab 60 mg...................................60LATUDA -lurasidone hcl tab 80 mg...................................60LATUDA -lurasidone hcl tab 120 mg.................................60LEADER GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 26LEADER QUICK DISSOLVE GLU -glucose chew tab 4gm (rounded).................................................................. 26leflunomide tab 10 mg (Arava).......................................72leflunomide tab 20 mg (Arava).......................................72lenalidomide cap 5 mg (Revlimid)............................... 103lenalidomide cap 10 mg (Revlimid)............................. 103lenalidomide cap 15 mg (Revlimid)............................. 103lenalidomide cap 25 mg (Revlimid)............................. 103LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)...............................15LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapypack 10 mg (10 mg daily dose)..................................... 15LENVIMA 4 MG DAILY DOSE -lenvatinib cap therapypack 4 mg (4 mg daily dose)......................................... 16LENVIMA 12MG DAILY DOSE -lenvatinib cap therapypack 3 x 4 mg (12 mg daily dose)................................. 15LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapypack 2 x 10 mg (20 mg daily dose)............................... 16LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapypack 2 x 4 mg (8 mg daily dose)................................... 16LENVIMA 18 MG DAILY DOSE -lenvatinib cap ther pack10 mg & 2 x 4 mg (18 mg daily dose)........................... 16LENVIMA 24 MG DAILY DOSE -lenvatinib cap ther pack2 x 10 mg & 4 mg (24 mg daily dose)........................... 16letrozole tab 2.5 mg (Femara)........................................ 16leucovorin calcium tab 5 mg..........................................16leucovorin calcium tab 10 mg........................................16leucovorin calcium tab 15 mg........................................16leucovorin calcium tab 25 mg........................................16LEUKERAN -chlorambucil tab 2 mg................................. 16LEUKINE -sargramostim lyophilized for inj 250 mcg........ 83leuprolide acetate inj kit 5 mg/ml.................................. 16levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (baseequiv) (Xopenex concentrate)..................................... 49levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)(Xopenex)....................................................................... 49levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)(Xopenex)....................................................................... 49levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)(Xopenex)....................................................................... 49LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector100 unit/ml.......................................................................28LEVEMIR -insulin detemir inj 100 unit/ml..........................28levetiracetam oral soln 100 mg/ml (Keppra).................77levetiracetam tab er 24hr 500 mg (Keppra xr)..............77levetiracetam tab er 24hr 750 mg (Keppra xr)..............77levetiracetam tab 250 mg (Keppra)............................... 77levetiracetam tab 500 mg (Keppra)............................... 77levetiracetam tab 750 mg (Keppra)............................... 77levetiracetam tab 1000 mg (Keppra)............................. 77LEVOBUNOLOL HCL -levobunolol hcl ophth soln0.5%.................................................................................93levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 32levocarnitine tab 330 mg (Carnitor)...............................32levofloxacin ophth soln 0.5%......................................... 93levofloxacin oral soln 25 mg/ml.......................................3levofloxacin tab 250 mg (Levaquin)................................ 3levofloxacin tab 500 mg (Levaquin)................................ 3levofloxacin tab 750 mg (Levaquin)................................ 3levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est0.01 mg (Quartette).......................................................23levonorgestrel & ethinyl estradiol (91-day) tab0.15-0.03 mg.................................................................. 23levonorgestrel & ethinyl estradiol tab 0.1 mg-20mcg................................................................................. 23levonorgestrel & ethinyl estradiol tab 0.15 mg-30mcg................................................................................. 23levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg...............................23levonorgestrel-ethinyl estradiol (continuous) tab90-20 mcg.......................................................................23levonorgestrel tab 1.5 mg...............................................23levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7) (Loseasonique)........................................... 23levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)............................................... 23LEVOTHYROXINE SODIUM -levothyroxine sodium cap13 mcg............................................................................ 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap25 mcg............................................................................ 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap50 mcg............................................................................ 29

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 130LEVOTHYROXINE SODIUM -levothyroxine sodium cap75 mcg............................................................................ 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap88 mcg............................................................................ 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap100 mcg.......................................................................... 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap112 mcg...........................................................................29LEVOTHYROXINE SODIUM -levothyroxine sodium cap125 mcg.......................................................................... 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap137 mcg.......................................................................... 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap150 mcg.......................................................................... 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap175 mcg.......................................................................... 29LEVOTHYROXINE SODIUM -levothyroxine sodium cap200 mcg.......................................................................... 29levothyroxine sodium tab 25 mcg (Synthroid).............29levothyroxine sodium tab 50 mcg (Synthroid).............29levothyroxine sodium tab 75 mcg (Synthroid).............29levothyroxine sodium tab 88 mcg (Synthroid).............29levothyroxine sodium tab 100 mcg (Synthroid)...........29levothyroxine sodium tab 112 mcg (Synthroid)........... 29levothyroxine sodium tab 125 mcg (Synthroid)...........29levothyroxine sodium tab 137 mcg (Synthroid)...........29levothyroxine sodium tab 150 mcg (Synthroid)...........29levothyroxine sodium tab 175 mcg (Synthroid)...........29levothyroxine sodium tab 200 mcg (Synthroid)...........29levothyroxine sodium tab 300 mcg (Synthroid)...........29LEXIVA -fosamprenavir calcium susp 50 mg/ml (baseequiv)................................................................................. 6lidocaine hcl soln 4%...................................................... 97lidocaine hcl viscous soln 2%....................................... 94lidocaine patch 5% (Lidoderm)...................................... 97lidocaine-prilocaine cream 2.5-2.5%..............................97LINDANE -lindane shampoo 1%.......................................97linezolid for susp 100 mg/5ml (Zyvox)............................ 9linezolid tab 600 mg (Zyvox)............................................ 9liothyronine sodium tab 5 mcg (Cytomel).................... 30liothyronine sodium tab 25 mcg (Cytomel).................. 30liothyronine sodium tab 50 mcg (Cytomel).................. 30lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic).....................................................................40lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic).....................................................................40lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic).....................................................................40lisinopril tab 5 mg (Prinivil)............................................ 40lisinopril tab 10 mg (Prinivil).......................................... 40lisinopril tab 20 mg (Prinivil).......................................... 41lisinopril tab 2.5 mg (Zestril).......................................... 40lisinopril tab 30 mg (Zestril)........................................... 41lisinopril tab 40 mg (Zestril)........................................... 41lithium carbonate cap 300 mg....................................... 60lithium carbonate cap 150 mg (Lithium carbonate).....60lithium carbonate cap 600 mg (Lithium carbonate).....60LITHIUM CARBONATE -lithium carbonate cap 150mg....................................................................................60LITHIUM CARBONATE -lithium carbonate cap 300mg....................................................................................60LITHIUM CARBONATE -lithium carbonate cap 600mg....................................................................................60lithium carbonate tab er 450 mg....................................60lithium carbonate tab er 300 mg (Lithobid).................. 60lithium carbonate tab 300 mg........................................ 60LITHOBID -lithium carbonate tab er 300 mg.................... 60LITHOSTAT -acetohydroxamic acid tab 250 mg...............55LIVMARLI -maralixibat chloride oral soln 9.5 mg/ml......... 53LIVTENCITY -maribavir tab 200 mg................................... 6LOKELMA -sodium zirconium cyclosilicate for susppacket 5 gm.................................................................. 103LOKELMA -sodium zirconium cyclosilicate for susppacket 10 gm................................................................ 103LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10mcg (24)/10 mcg (2)....................................................... 23LOMAIRA -phentermine hcl tab 8 mg............................... 63LONGS GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 26LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 16LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 16lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra)............................................................................ 6lopinavir-ritonavir tab 100-25 mg (Kaletra).....................6lopinavir-ritonavir tab 200-50 mg (Kaletra).....................6lorazepam conc 2 mg/ml.................................................56lorazepam tab 0.5 mg (Ativan)....................................... 56lorazepam tab 1 mg (Ativan).......................................... 56lorazepam tab 2 mg (Ativan).......................................... 56LORBRENA -lorlatinib tab 25 mg......................................16LORBRENA -lorlatinib tab 100 mg....................................16losartan potassium & hydrochlorothiazide tab 50-12.5mg (Hyzaar)....................................................................41losartan potassium & hydrochlorothiazide tab100-12.5 mg (Hyzaar)....................................................41losartan potassium & hydrochlorothiazide tab 100-25mg (Hyzaar)....................................................................41losartan potassium tab 25 mg (Cozaar)........................41losartan potassium tab 50 mg (Cozaar)........................41losartan potassium tab 100 mg (Cozaar)......................41LOTEMAX -loteprednol etabonate ophth oint 0.5%..........93LOTEMAX SM -loteprednol etabonate ophth gel0.38%...............................................................................93loteprednol etabonate ophth gel 0.5% (Lotemax)........93loteprednol etabonate ophth susp 0.5%(Lotemax)....................................................................... 93lovastatin tab 10 mg........................................................44lovastatin tab 20 mg........................................................44lovastatin tab 40 mg........................................................44loxapine succinate cap 5 mg......................................... 60loxapine succinate cap 10 mg....................................... 60loxapine succinate cap 25 mg....................................... 60loxapine succinate cap 50 mg....................................... 60

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 131LUCEMYRA -lofexidine hcl tab 0.18 mg (baseequivalent)....................................................................... 66LUMAKRAS -sotorasib tab 120 mg.................................. 16LUPKYNIS -voclosporin cap 7.9 mg............................... 103LUPRON DEPOT (1-MONTH) -leuprolide acetate for injkit 3.75 mg...................................................................... 16LUPRON DEPOT (1-MONTH) -leuprolide acetate for injkit 7.5 mg........................................................................ 16LUPRON DEPOT (3-MONTH) -leuprolide acetate (3month) for inj kit 11.25 mg............................................. 16LUPRON DEPOT (3-MONTH) -leuprolide acetate (3month) for inj kit 22.5 mg............................................... 16LUPRON DEPOT (4-MONTH) -leuprolide acetate (4month) for inj kit 30 mg.................................................. 16LUPRON DEPOT (6-MONTH) -leuprolide acetate (6month) for inj kit 45 mg.................................................. 16LUPRON DEPOT-PED (1-MONTH -leuprolide acetate forinj pediatric kit 7.5 mg.................................................... 32LUPRON DEPOT-PED (1-MONTH -leuprolide acetate forinj pediatric kit 11.25 mg................................................ 32LUPRON DEPOT-PED (1-MONTH -leuprolide acetate forinj pediatric kit 15 mg..................................................... 32LUPRON DEPOT-PED (3-MONTH -leuprolide acetate (3month) for inj pediatric kit 11.25 mg...............................32LUPRON DEPOT-PED (3-MONTH -leuprolide acetate (3month) for inj pediatric kit 30 mg................................... 32LYNPARZA -olaparib tab 100 mg......................................16LYNPARZA -olaparib tab 150 mg......................................16LYSODREN -mitotane tab 500 mg....................................16Mmalathion lotion 0.5% (Ovide)........................................ 97maraviroc tab 150 mg (Selzentry)....................................6maraviroc tab 300 mg (Selzentry)....................................6MARPLAN -isocarboxazid tab 10 mg............................... 58MASK VORTEX/CHILD/FROG -spacer/aerosol-holdingchamber supplies - masks........................................... 101MASK VORTEX/TODDLER/LADY -spacer/aerosol-holding chamber supplies - masks.............................. 101MATULANE -procarbazine hcl cap 50 mg........................ 16MAVENCLAD -cladribine tab therapy pack 10 mg (4tabs).................................................................................66MAVENCLAD -cladribine tab therapy pack 10 mg (5tabs).................................................................................66MAVENCLAD -cladribine tab therapy pack 10 mg (6tabs).................................................................................66MAVENCLAD -cladribine tab therapy pack 10 mg (7tabs).................................................................................66MAVENCLAD -cladribine tab therapy pack 10 mg (8tabs).................................................................................66MAVENCLAD -cladribine tab therapy pack 10 mg (9tabs).................................................................................66MAVENCLAD -cladribine tab therapy pack 10 mg (10tabs).................................................................................66MAVYRET -glecaprevir-pibrentasvir pellet pack 50-20mg...................................................................................... 6MAVYRET -glecaprevir-pibrentasvir tab 100-40 mg........... 6MAXIDEX -dexamethasone ophth susp 0.1%.................. 93MAYZENT -siponimod fumarate tab 0.25 mg (baseequiv)............................................................................... 66MAYZENT -siponimod fumarate tab 1 mg (baseequiv)............................................................................... 66MAYZENT -siponimod fumarate tab 2 mg (baseequiv)............................................................................... 66MAYZENT STARTER PACK -siponimod fumarate tab0.25 mg (7) starter pack.................................................66MAYZENT STARTER PACK -siponimod fumarate tab0.25 mg (12) starter pack...............................................66MEDICINE SHOPPE GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 26MEDROL -methylprednisolone tab 2 mg.......................... 20medroxyprogesterone acetate im susp 150 mg/ml(Depo-provera contrac)................................................ 23medroxyprogesterone acetate im susp prefilled syr150 mg/ml (Depo-provera contrac).............................23medroxyprogesterone acetate tab 2.5 mg(Provera).........................................................................24medroxyprogesterone acetate tab 5 mg (Provera)...... 24medroxyprogesterone acetate tab 10 mg(Provera).........................................................................24mefloquine hcl tab 250 mg............................................... 8megestrol acetate susp 625 mg/5ml (Megace es)........24megestrol acetate susp 40 mg/ml (Megace oral)......... 16megestrol acetate tab 20 mg..........................................16megestrol acetate tab 40 mg..........................................16MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent)............................................................ 16MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (baseequivalent)....................................................................... 16MEKTOVI -binimetinib tab 15 mg......................................16meloxicam tab 7.5 mg (Mobic)....................................... 72meloxicam tab 15 mg (Mobic)........................................ 72melphalan tab 2 mg (Alkeran)........................................ 16memantine hcl oral solution 2 mg/ml (Namenda)........ 66memantine hcl tab 5 mg (Namenda)............................. 66memantine hcl tab 10 mg (Namenda)........................... 66memantine hcl tab 28 x 5 mg & 21 x 10 mg titrationpack (Namenda titration pa)........................................66MENACTRA -meningococcal (a, c, y, and w-135) diphthconjugate vaccine........................................................... 10MENEST -esterified estrogens tab 0.3 mg....................... 22MENEST -esterified estrogens tab 0.625 mg................... 22MENEST -esterified estrogens tab 1.25 mg..................... 22MENOPUR -menotropins for subcutaneous inj 75unit................................................................................... 32MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 22MENQUADFI -meningococcal (a, c, y, and w-135) tetanusconjugate vaccine........................................................... 10MENVEO -meningococcal (a, c, y, and w-135) oligo conjvac for inj........................................................................ 10mercaptopurine tab 50 mg............................................. 16mesalamine cap dr 400 mg (Delzicol)........................... 53mesalamine cap er 24hr 0.375 gm (Apriso)..................53mesalamine enema 4 gm................................................53

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 132mesalamine suppos 1000 mg (Canasa)........................ 53mesalamine tab delayed release 1.2 gm (Lialda)......... 53mesalamine tab delayed release 800 mg (Asacolhd)................................................................................... 53MESNEX -mesna tab 400 mg........................................... 16metformin hcl tab er 24hr 500 mg (Glucophage xr).....26metformin hcl tab er 24hr 750 mg (Glucophage xr).....26metformin hcl tab 500 mg (Glucophage)...................... 26metformin hcl tab 850 mg (Glucophage)...................... 26metformin hcl tab 1000 mg (Glucophage).................... 26methadone hcl conc 10 mg/ml (Methadose)................ 69methadone hcl soln 5 mg/5ml (Methadone hcl)........... 69methadone hcl soln 10 mg/5ml (Methadone hcl)......... 70methadone hcl tab for oral susp 40 mg........................70methadone hcl tab 5 mg (Dolophine)............................70methadone hcl tab 10 mg (Dolophine)..........................70methazolamide tab 25 mg (Neptazane).........................43methazolamide tab 50 mg (Neptazane).........................43methenamine hippurate tab 1 gm (Hiprex)..................... 9methimazole tab 5 mg (Tapazole).................................. 30methimazole tab 10 mg (Tapazole)................................ 30METHITEST -methyltestosterone oral tab 10 mg............. 20methocarbamol tab 750 mg (Robaxin-750)...................81methocarbamol tab 500 mg (Robaxin)..........................81methotrexate sodium for inj 1 gm................................. 16methotrexate sodium inj 50 mg/2ml (25 mg/ml)...........17methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 16methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)................................................................................... 16methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)................................................................................... 17METHOTREXATE SODIUM -methotrexate sodium inj 250mg/10ml (25 mg/ml)........................................................16methotrexate sodium tab 2.5 mg (base equiv).............17METHOXSALEN -methoxsalen rapid cap 10 mg............. 97methscopolamine bromide tab 2.5 mg (Pamine)......... 51methscopolamine bromide tab 5 mg (Pamineforte)................................................................................51METHYLDOPA -methyldopa tab 250 mg..........................41METHYLDOPA -methyldopa tab 500 mg..........................41methylergonovine maleate tab 0.2 mg..........................31methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla).....................................................................................64methylphenidate hcl cap er 24hr 30 mg (la) (Ritalinla).....................................................................................64methylphenidate hcl cap er 24hr 40 mg (la) (Ritalinla).....................................................................................64methylphenidate hcl cap er 10 mg (cd)........................ 64methylphenidate hcl cap er 20 mg (cd)........................ 64methylphenidate hcl cap er 30 mg (cd)........................ 64methylphenidate hcl cap er 40 mg (cd)........................ 64methylphenidate hcl cap er 50 mg (cd)........................ 64methylphenidate hcl cap er 60 mg (cd)........................ 64methylphenidate hcl chew tab 2.5 mg.......................... 64methylphenidate hcl chew tab 5 mg............................. 64methylphenidate hcl chew tab 10 mg........................... 64methylphenidate hcl soln 5 mg/5ml (Methylin)............ 64methylphenidate hcl soln 10 mg/5ml (Methylin).......... 64methylphenidate hcl tab er 10 mg................................. 64methylphenidate hcl tab er 20 mg................................. 64methylphenidate hcl tab er osmotic release (osm) 18mg (Concerta)................................................................64methylphenidate hcl tab er osmotic release (osm) 27mg (Concerta)................................................................64methylphenidate hcl tab er osmotic release (osm) 36mg (Concerta)................................................................64methylphenidate hcl tab er osmotic release (osm) 54mg (Concerta)................................................................64methylphenidate hcl tab 5 mg (Ritalin)......................... 64methylphenidate hcl tab 10 mg (Ritalin)....................... 64methylphenidate hcl tab 20 mg (Ritalin)....................... 64methylprednisolone tab 4 mg (Medrol).........................20methylprednisolone tab 8 mg (Medrol).........................20methylprednisolone tab 16 mg (Medrol).......................20methylprednisolone tab 32 mg (Medrol).......................20methylprednisolone tab therapy pack 4 mg (21)(Medrol dosepak).......................................................... 20methyltestosterone cap 10 mg...................................... 20metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).............................................................................. 53metoclopramide hcl tab 5 mg (base equivalent)(Reglan).......................................................................... 53metoclopramide hcl tab 10 mg (base equivalent)(Reglan).......................................................................... 53METOCLOPRAMIDE ODT -metoclopramide hcl orallydisintegrating tab 5 mg (base eq).................................. 53METOCLOPRAMIDE ODT -metoclopramide hcl orallydisintegrating tab 10 mg (base eq)................................ 53metolazone tab 2.5 mg....................................................43metolazone tab 5 mg.......................................................43metolazone tab 10 mg.....................................................43metoprolol & hydrochlorothiazide tab 100-25 mg....... 41metoprolol & hydrochlorothiazide tab 100-50 mg....... 41metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)..............................................................41metoprolol succinate tab er 24hr 25 mg (tartrateequiv) (Toprol xl)...........................................................36metoprolol succinate tab er 24hr 50 mg (tartrateequiv) (Toprol xl)...........................................................36metoprolol succinate tab er 24hr 100 mg (tartrateequiv) (Toprol xl)...........................................................36metoprolol succinate tab er 24hr 200 mg (tartrateequiv) (Toprol xl)...........................................................36metoprolol tartrate tab 25 mg........................................ 36metoprolol tartrate tab 37.5 mg..................................... 36metoprolol tartrate tab 75 mg........................................ 36metoprolol tartrate tab 50 mg (Lopressor)................... 36metoprolol tartrate tab 100 mg (Lopressor)................. 36metronidazole cap 375 mg (Flagyl)................................. 9metronidazole cream 0.75% (Metrocream)................... 97metronidazole gel 0.75%.................................................97metronidazole gel 1% (Metrogel)................................... 97metronidazole tab 250 mg (Flagyl).................................. 9metronidazole tab 500 mg (Flagyl).................................. 9

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 133metronidazole vaginal gel 0.75% (Metrogel-vaginal)........................................................................... 54mexiletine hcl cap 150 mg..............................................38mexiletine hcl cap 200 mg..............................................38mexiletine hcl cap 250 mg..............................................38MICONAZOLE 3 -miconazole nitrate vaginal suppos 200mg....................................................................................54MICROCHAMBER -spacer/aerosol-holding chambers -device............................................................................ 101MICROSPACER -spacer/aerosol-holding chambers -device............................................................................ 101midodrine hcl tab 2.5 mg................................................43midodrine hcl tab 5 mg...................................................43midodrine hcl tab 10 mg.................................................43MIGERGOT -ergotamine w/ caffeine suppos 2-100mg....................................................................................74miglitol tab 25 mg............................................................26miglitol tab 50 mg............................................................26miglitol tab 100 mg..........................................................26miglustat cap 100 mg (Zavesca).................................... 83minocycline hcl cap 50 mg (Minocin)............................. 3minocycline hcl cap 75 mg (Minocin)............................. 3minocycline hcl cap 100 mg (Minocin)........................... 3minoxidil tab 2.5 mg........................................................41minoxidil tab 10 mg.........................................................41MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30mcg/0.3ml........................................................................ 84MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50mcg/0.3ml........................................................................ 84MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75mcg/0.3ml........................................................................ 84MIRCERA -methoxy peg-epoetin beta soln prefilled syr100 mcg/0.3ml................................................................ 84MIRCERA -methoxy peg-epoetin beta soln prefilled syr150 mcg/0.3ml................................................................ 84MIRCERA -methoxy peg-epoetin beta soln prefilled syr200 mcg/0.3ml................................................................ 84mirtazapine orally disintegrating tab 15 mg (Remeronsoltab)............................................................................. 58mirtazapine orally disintegrating tab 30 mg (Remeronsoltab)............................................................................. 58mirtazapine orally disintegrating tab 45 mg (Remeronsoltab)............................................................................. 58mirtazapine tab 7.5 mg....................................................58mirtazapine tab 15 mg (Remeron)................................. 58mirtazapine tab 30 mg (Remeron)................................. 58mirtazapine tab 45 mg (Remeron)................................. 58MIRVASO -brimonidine tartrate gel 0.33% (baseequivalent)....................................................................... 97MISC NEEDLES & SYRINGES – VARIOUS.................. 101misoprostol tab 100 mcg (Cytotec)............................... 51misoprostol tab 200 mcg (Cytotec)............................... 51M-M-R II -measles-mumps-rubella virus vaccines for injsoln.................................................................................. 10modafinil tab 100 mg (Provigil)......................................64modafinil tab 200 mg (Provigil)......................................64MODERNA COVID-19 VACCINE -covid-19 mrna vaccine6mo-5y-moderna im susp 25 mcg/0.25ml..................... 11MODERNA COVID-19 VACCINE -covid-19 (sars-cov-2)mrna vacc-moderna im susp 50 mcg/0.5ml.........11MODERNA COVID-19 VACCINE -covid-19 (sars-cov-2)mrna vacc-moderna im susp 100 mcg/0.5ml.......11moexipril hcl tab 7.5 mg................................................. 41moexipril hcl tab 15 mg.................................................. 41MOLINDONE HYDROCHLORIDE -molindone hcl tab 5mg....................................................................................60MOLINDONE HYDROCHLORIDE -molindone hcl tab 10mg....................................................................................60MOLINDONE HYDROCHLORIDE -molindone hcl tab 25mg....................................................................................60mometasone furoate cream 0.1% (Elocon).................. 97mometasone furoate oint 0.1% (Elocon)...................... 97mometasone furoate solution 0.1% (lotion)................. 98montelukast sodium chew tab 4 mg (base equiv)(Singulair).......................................................................49montelukast sodium chew tab 5 mg (base equiv)(Singulair).......................................................................49montelukast sodium tab 10 mg (base equiv)(Singulair).......................................................................49MORPHINE SULFATE ER -morphine sulfate cap er 24hr10 mg.............................................................................. 70MORPHINE SULFATE ER -morphine sulfate cap er 24hr20 mg.............................................................................. 70MORPHINE SULFATE ER -morphine sulfate cap er 24hr30 mg.............................................................................. 70MORPHINE SULFATE ER -morphine sulfate cap er 24hr50 mg.............................................................................. 70MORPHINE SULFATE ER -morphine sulfate cap er 24hr60 mg.............................................................................. 70MORPHINE SULFATE ER -morphine sulfate cap er 24hr80 mg.............................................................................. 70MORPHINE SULFATE ER -morphine sulfate cap er 24hr100 mg............................................................................ 70MORPHINE SULFATE -morphine sulfate oral soln 20mg/5ml.............................................................................70MORPHINE SULFATE -morphine sulfate tab 15 mg........ 70MORPHINE SULFATE -morphine sulfate tab 30 mg........ 70morphine sulfate oral soln 10 mg/5ml.......................... 70morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 70morphine sulfate tab er 15 mg (Ms contin).................. 70morphine sulfate tab er 30 mg (Ms contin).................. 70morphine sulfate tab er 60 mg (Ms contin).................. 70morphine sulfate tab er 100 mg (Ms contin)................ 70morphine sulfate tab er 200 mg (Ms contin)................ 70morphine sulfate tab 15 mg (Morphine sulfate)...........70morphine sulfate tab 30 mg (Morphine sulfate)...........70MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............51MOVANTIK -naloxegol oxalate tab 12.5 mg (baseequivalent)....................................................................... 53MOVANTIK -naloxegol oxalate tab 25 mg (baseequivalent)....................................................................... 53moxifloxacin hcl ophth soln 0.5% (base equiv)(Vigamox)....................................................................... 93

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 134moxifloxacin hcl tab 400 mg (base equiv) (Avelox).......3MS QUICK DISSOLVE GLUCOSE -glucose chew tab 4gm (rounded).................................................................. 26MULPLETA -lusutrombopag tab 3 mg.............................. 84MULTAQ -dronedarone hcl tab 400 mg (baseequivalent)....................................................................... 38mupirocin oint 2%............................................................98MUSE -alprostadil urethral pellet 250 mcg....................... 46MUSE -alprostadil urethral pellet 500 mcg....................... 46MUSE -alprostadil urethral pellet 1000 mcg..................... 46MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 32MYCAPSSA -octreotide acetate cap delayed release 20mg....................................................................................32mycophenolate mofetil cap 250 mg (Cellcept)...........103mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...................................................................... 103mycophenolate mofetil tab 500 mg (Cellcept)............103mycophenolate sodium tab dr 180 mg (mycophenolicacid equiv) (Myfortic)................................................. 103mycophenolate sodium tab dr 360 mg (mycophenolicacid equiv) (Myfortic)................................................. 103MYFEMBREE -relugolix-estradiol-norethindrone acetatetab 40-1-0.5 mg.............................................................. 22MYFORTIC -mycophenolate sodium tab dr 180 mg(mycophenolic acid equiv)............................................103MYFORTIC -mycophenolate sodium tab dr 360 mg(mycophenolic acid equiv)............................................103MYLERAN -busulfan tab 2 mg..........................................17MYRBETRIQ -mirabegron granules for oral extendedrelease susp 8 mg/ml..................................................... 54MYRBETRIQ -mirabegron tab er 24 hr 25 mg..................54MYRBETRIQ -mirabegron tab er 24 hr 50 mg..................54MYSOLINE -primidone tab 50 mg.................................... 77MYSOLINE -primidone tab 250 mg.................................. 77Nnabumetone tab 500 mg................................................. 72nabumetone tab 750 mg................................................. 72nadolol tab 20 mg (Corgard).......................................... 36nadolol tab 40 mg (Corgard).......................................... 36nadolol tab 80 mg (Corgard).......................................... 36NAFRINSE DAILY/ACIDULATED -sodium fluoride-phosphoric acid for soln 1 mg/5ml (f equiv)...................95NAFRINSE DAILY/NEUTRAL -sodium fluoride for solnrinse 0.05%..................................................................... 95NAFRINSE WEEKLY -sodium fluoride for soln rinse0.2%.................................................................................95naloxone hcl inj 0.4 mg/ml............................................. 99naloxone hcl inj 4 mg/10ml............................................ 99naloxone hcl nasal spray 4 mg/0.1ml (Narcan)............ 99naloxone hcl soln prefilled syringe 2 mg/2ml.............. 99NALOXONE HYDROCHLORIDE -naloxone hcl solncartridge 0.4 mg/ml.........................................................99naltrexone hcl tab 50 mg................................................ 99naproxen sodium tab 275 mg........................................ 73naproxen sodium tab 550 mg (Anaprox ds)................. 73naproxen tab 250 mg...................................................... 73naproxen tab 375 mg...................................................... 73naproxen tab 500 mg (Naprosyn).................................. 73naratriptan hcl tab 1 mg (base equiv) (Amerge).......... 74naratriptan hcl tab 2.5 mg (base equiv) (Amerge)....... 74NATACYN -natamycin ophth susp 5%.............................. 93NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2mg/2-3 mg/1 mg............................................................. 23nateglinide tab 60 mg (Starlix)....................................... 26nateglinide tab 120 mg (Starlix).....................................26NATPARA -parathyroid hormone (recombinant) for injcartridge 25 mcg.............................................................32NATPARA -parathyroid hormone (recombinant) for injcartridge 50 mcg.............................................................32NATPARA -parathyroid hormone (recombinant) for injcartridge 75 mcg.............................................................32NATPARA -parathyroid hormone (recombinant) for injcartridge 100 mcg...........................................................32NATROBA -spinosad susp 0.9%.......................................98NAYZILAM -midazolam nasal spray soln 5 mg/0.1 ml......77NEOMYCIN/POLYMYXIN/GRAMIC -neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml........... 93neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin............................... 93neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)........................................................................ 93neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)...............................................................93neomycin-polymyxin-hc otic soln 1%........................... 94neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%...................................................................... 94neomycin sulfate tab 500 mg........................................... 3NEORAL -cyclosporine modified cap 25 mg...................103NEORAL -cyclosporine modified cap 100 mg.................103NEORAL -cyclosporine modified oral soln 100 mg/ml................................................................................... 103NERLYNX -neratinib maleate tab 40 mg (baseequivalent)....................................................................... 17NEUPRO -rotigotine td patch 24hr 1 mg/24hr.................. 80NEUPRO -rotigotine td patch 24hr 2 mg/24hr.................. 80NEUPRO -rotigotine td patch 24hr 3 mg/24hr.................. 80NEUPRO -rotigotine td patch 24hr 4 mg/24hr.................. 80NEUPRO -rotigotine td patch 24hr 6 mg/24hr.................. 80NEUPRO -rotigotine td patch 24hr 8 mg/24hr.................. 80NEVIRAPINE ER -nevirapine tab er 24hr 100 mg..............6NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 6nevirapine tab er 24hr 400 mg (Viramune xr)................. 6nevirapine tab 200 mg (Viramune)...................................6NEXAVAR -sorafenib tosylate tab 200 mg (baseequivalent)....................................................................... 17NEXIUM -esomeprazole magnesium for delayed releasesusp packet 5 mg........................................................... 51NEXIUM -esomeprazole magnesium for delayed releasesusp pack 2.5 mg........................................................... 51NEXLETOL -bempedoic acid tab 180 mg.........................44NEXLIZET -bempedoic acid-ezetimibe tab 180-10mg....................................................................................44

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 135niacin tab er 500 mg (antihyperlipidemic)(Niaspan)........................................................................ 44niacin tab er 750 mg (antihyperlipidemic)(Niaspan)........................................................................ 44niacin tab er 1000 mg (antihyperlipidemic)(Niaspan)........................................................................ 44nicardipine hcl cap 20 mg.............................................. 37nicardipine hcl cap 30 mg.............................................. 37nicotine polacrilex gum 2 mg.........................................66nicotine polacrilex gum 4 mg.........................................66nicotine polacrilex lozenge 2 mg...................................67nicotine polacrilex lozenge 4 mg...................................67nicotine td patch 24hr 7 mg/24hr...................................67nicotine td patch 24hr 14 mg/24hr.................................67nicotine td patch 24hr 21 mg/24hr.................................67NICOTINE TRANSDERMAL SYST -nicotine td patch 24hr kit 21-14-7 mg/24hr....................................................67NICOTROL INHALER -nicotine inhaler system 10 mg (4mg delivered).................................................................. 67NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/spray)...............................................................................67nifedipine cap 20 mg....................................................... 37nifedipine cap 10 mg (Procardia).................................. 37nifedipine tab er 24hr 30 mg (Adalat cc).......................37nifedipine tab er 24hr 60 mg (Adalat cc).......................37nifedipine tab er 24hr 90 mg (Adalat cc).......................37nifedipine tab er 24hr osmotic release 30 mg(Procardia xl)................................................................. 37nifedipine tab er 24hr osmotic release 60 mg(Procardia xl)................................................................. 37nifedipine tab er 24hr osmotic release 90 mg(Procardia xl)................................................................. 37nilutamide tab 150 mg (Nilandron)................................ 17nimodipine cap 30 mg.....................................................37NINLARO -ixazomib citrate cap 2.3 mg (baseequivalent)....................................................................... 17NINLARO -ixazomib citrate cap 3 mg (baseequivalent)....................................................................... 17NINLARO -ixazomib citrate cap 4 mg (baseequivalent)....................................................................... 17NISOLDIPINE ER -nisoldipine tab er 24hr 20 mg............ 37NISOLDIPINE ER -nisoldipine tab er 24hr 25.5 mg......... 37NISOLDIPINE ER -nisoldipine tab er 24hr 30 mg............ 37NISOLDIPINE ER -nisoldipine tab er 24hr 40 mg............ 37nitazoxanide tab 500 mg (Alinia)..................................... 9nitisinone cap 2 mg (Orfadin)........................................ 33nitisinone cap 5 mg (Orfadin)........................................ 33nitisinone cap 10 mg (Orfadin)...................................... 33NITRO-BID -nitroglycerin oint 2%..................................... 35NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 35NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 35nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)...................................................................9nitrofurantoin macrocrystalline cap 50 mg(Macrodantin)...................................................................9nitrofurantoin macrocrystalline cap 100 mg(Macrodantin)...................................................................9nitrofurantoin monohydrate macrocrystalline cap 100mg (Macrobid)................................................................. 9nitrofurantoin susp 25 mg/5ml.........................................9nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 35nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 35nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 35nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur).........35nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur).........35nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur).........35nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur).........35nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)(Nitrolingual pumpspr)................................................. 35NITROMIST -nitroglycerin lingual aerosol 400 mcg/spray................................................................................ 35NITRO-TIME -nitroglycerin cap er 2.5 mg........................ 35NITRO-TIME -nitroglycerin cap er 6.5 mg........................ 35NITRO-TIME -nitroglycerin cap er 9 mg........................... 35NITYR -nitisinone tab 2 mg............................................... 33NITYR -nitisinone tab 5 mg............................................... 33NITYR -nitisinone tab 10 mg............................................. 33NIVESTYM -filgrastim-aafi inj 300 mcg/ml........................84NIVESTYM -filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml)....................................................................................84NIVESTYM -filgrastim-aafi soln prefilled syringe 300mcg/0.5ml........................................................................ 84NIVESTYM -filgrastim-aafi soln prefilled syringe 480mcg/0.8ml........................................................................ 84NORDITROPIN FLEXPRO -somatropin solution pen-injector 5 mg/1.5ml......................................................... 33NORDITROPIN FLEXPRO -somatropin solution pen-injector 10 mg/1.5ml....................................................... 33NORDITROPIN FLEXPRO -somatropin solution pen-injector 15 mg/1.5ml....................................................... 33NORDITROPIN FLEXPRO -somatropin solution pen-injector 30 mg/3ml.......................................................... 33norelgestromin-ethinyl estradiol td ptwk 150-35mcg/24hr.........................................................................23norethindrone & ethinyl estradiol-fe chew tab 0.4mg-35 mcg (Femcon fe)...............................................23norethindrone & ethinyl estradiol-fe chew tab 0.8mg-25 mcg (Generess fe)............................................ 23norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg(Brevicon-28)................................................................. 23norethindrone & ethinyl estradiol tab 1 mg-35 mcg(Norinyl 1+35)................................................................ 23norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg(Ovcon-35)......................................................................23norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg (Loestrin fe 1/20).................................................. 23norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg (Loestrin fe 1.5/30)............................................... 23norethindrone ace & ethinyl estradiol tab 1 mg-20mcg (Loestrin 1/20-21)................................................. 23norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg (Loestrin 1.5/30-21).............................................. 23norethindrone ace-eth estradiol-fe chew tab 1 mg-20mcg (24) (Minastrin 24 fe)............................................23

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 136norethindrone ace-ethinyl estradiol-fe tab 1 mg-20mcg (24)......................................................................... 23norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg................................................................................. 22norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose)................................................22norethindrone acetate tab 5 mg (Aygestin)..................24norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35mg-mcg (Estrostep fe)................................................. 23norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35mg-mcg (Ortho-novum 7/7/7)...................................... 23norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28)...................................................... 24norethindrone tab 0.35 mg (Ortho micronor)............... 23norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg(Ortho-cyclen)................................................................24norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg (Ortho tri-cyclen)........................................... 24norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg (Ortho tri-cyclen lo).......................................24norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........24NORPACE CR -disopyramide phosphate cap er 12hr 100mg....................................................................................38NORPACE CR -disopyramide phosphate cap er 12hr 150mg....................................................................................38NORPACE -disopyramide phosphate cap 100 mg........... 38NORPACE -disopyramide phosphate cap 150 mg........... 38nortriptyline hcl cap 10 mg (Pamelor)...........................58nortriptyline hcl cap 25 mg (Pamelor)...........................58nortriptyline hcl cap 50 mg (Pamelor)...........................58nortriptyline hcl cap 75 mg (Pamelor)...........................58NORTRIPTYLINE HCL -nortriptyline hcl soln 10mg/5ml.............................................................................58NORVIR -ritonavir oral soln 80 mg/ml.................................6NORVIR -ritonavir powder packet 100 mg..........................6NOVAFERRUM PEDIATRIC DROP -polysaccharide ironcomplex liquid 15 mg/ml (fe equiv)................................ 84NOVAREL -chorionic gonadotropin for im inj 5000unit................................................................................... 33NOVAREL -chorionic gonadotropin for im inj 10000unit................................................................................... 33NOVAVAX COVID-19 VACCINE -covid-19 subunit protrecom adjuv vac-novavax im 5 mcg/0.5ml.....................11NOVOEIGHT -antihemophilic fact rcmb (bd trunc-rfviii) forinj 250 unit...................................................................... 90NOVOEIGHT -antihemophilic fact rcmb (bd trunc-rfviii) forinj 500 unit...................................................................... 90NOVOEIGHT -antihemophilic fact rcmb (bd trunc-rfviii) forinj 1000 unit.................................................................... 90NOVOEIGHT -antihemophilic fact rcmb (bd trunc-rfviii) forinj 1500 unit.................................................................... 90NOVOEIGHT -antihemophilic fact rcmb (bd trunc-rfviii) forinj 2000 unit.................................................................... 90NOVOEIGHT -antihemophilic fact rcmb (bd trunc-rfviii) forinj 3000 unit.................................................................... 90NOVOLIN 70/30 FLEXPEN -insulin nph & regular susppen-inj 100 unit/ml (70-30)............................................. 28NOVOLIN 70/30 FLEXPEN REL -insulin nph & regularsusp pen-inj 100 unit/ml (70-30).................................... 28NOVOLIN 70/30 -insulin nph isophane & regular humaninj 100 unit/ml (70-30).................................................... 28NOVOLIN 70/30 RELION -insulin nph isophane & regularhuman inj 100 unit/ml (70-30)........................................ 28NOVOLIN N FLEXPEN -insulin nph (human) (isophane)susp pen-injector 100 unit/ml......................................... 28NOVOLIN N FLEXPEN RELION -insulin nph (human)(isophane) susp pen-injector 100 unit/ml.......................28NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/ml..................................................................................... 28NOVOLIN N RELION -insulin nph (human) (isophane) inj100 unit/ml.......................................................................28NOVOLIN R FLEXPEN -insulin regular (human) soln pen-injector 100 unit/ml......................................................... 28NOVOLIN R FLEXPEN RELION -insulin regular (human)soln pen-injector 100 unit/ml.......................................... 28NOVOLIN R -insulin regular (human) inj 100 unit/ml........28NOVOLIN R RELION -insulin regular (human) inj 100unit/ml.............................................................................. 28NOVOLOG FLEXPEN -insulin aspart soln pen-injector100 unit/ml.......................................................................27NOVOLOG FLEXPEN RELION -insulin aspart soln pen-injector 100 unit/ml......................................................... 27NOVOLOG -insulin aspart inj soln 100 unit/ml................. 27NOVOLOG MIX 70/30 -insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)......................................28NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)........................... 28NOVOLOG MIX 70/30 RELION -insulin aspart prot &aspart (human) inj 100 unit/ml (70-30)...........................28NOVOLOG PENFILL -insulin aspart soln cartridge 100unit/ml.............................................................................. 27NOVOLOG RELION -insulin aspart inj soln 100 unit/ml..................................................................................... 28NOVOSEVEN RT -coagulation factor viia (recomb) for inj1 mg (1000 mcg)............................................................ 90NOVOSEVEN RT -coagulation factor viia (recomb) for inj2 mg (2000 mcg)............................................................ 90NOVOSEVEN RT -coagulation factor viia (recomb) for inj5 mg (5000 mcg)............................................................ 90NOVOSEVEN RT -coagulation factor viia (recomb) for inj8 mg (8000 mcg)............................................................ 90NOXAFIL -posaconazole susp 40 mg/ml............................4NUBEQA -darolutamide tab 300 mg.................................17NUCALA -mepolizumab subcutaneous solution auto-injector 100 mg/ml.......................................................... 49NUCALA -mepolizumab subcutaneous solution prefsyringe 40 mg/0.4ml....................................................... 49NUCALA -mepolizumab subcutaneous solution prefsyringe 100 mg/ml.......................................................... 49NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap20-10 mg......................................................................... 67NULIBRY -fosdenopterin hydrobromide for iv soln 9.5mg....................................................................................33NURTEC -rimegepant sulfate tab disint 75 mg.................74

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 137NUVARING -etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr...................................................... 24NUVESSA -metronidazole vaginal gel 1.3%.....................54NUWIQ -antihemophil fact rcmb(bdd-rfviii,sim) for inj kit1000 unit......................................................................... 90NUWIQ -antihemophil fact rcmb(bdd-rfviii,sim) for inj kit1500 unit......................................................................... 90NUWIQ -antihemophil fact rcmb(bdd-rfviii,sim) for inj kit2000 unit......................................................................... 90NUWIQ -antihemophil fact rcmb(bdd-rfviii,sim) for inj kit2500 unit......................................................................... 90NUWIQ -antihemophil fact rcmb(bdd-rfviii,sim) for inj kit3000 unit......................................................................... 90NUWIQ -antihemophil fact rcmb(bdd-rfviii,sim) for inj kit4000 unit......................................................................... 90NUWIQ -antihemophil fact rcmb (bdd-rfviii,sim) for inj kit250 unit........................................................................... 90NUWIQ -antihemophil fact rcmb (bdd-rfviii,sim) for inj kit500 unit........................................................................... 90NUWIQ -antihemophilic factor rcmb (bdd-rfviii,sim) for inj250 unit........................................................................... 91NUWIQ -antihemophilic factor rcmb (bdd-rfviii,sim) for inj500 unit........................................................................... 91NUWIQ -antihemophilic fact rcmb (bdd-rfviii,sim) for inj1000 unit......................................................................... 90NUWIQ -antihemophilic fact rcmb (bdd-rfviii,sim) for inj1500 unit......................................................................... 90NUWIQ -antihemophilic fact rcmb (bdd-rfviii,sim) for inj2000 unit......................................................................... 90NUWIQ -antihemophilic fact rcmb (bdd-rfviii,sim) for inj2500 unit......................................................................... 91NUWIQ -antihemophilic fact rcmb (bdd-rfviii,sim) for inj3000 unit......................................................................... 91NUWIQ -antihemophilic fact rcmb (bdd-rfviii,sim) for inj4000 unit......................................................................... 91NUZYRA -omadacycline tosylate tab 150 mg (baseequivalent)......................................................................... 3NYMALIZE -nimodipine oral soln 6 mg/ml........................37nystatin cream 100000 unit/gm......................................98nystatin oint 100000 unit/gm.......................................... 98nystatin susp 100000 unit/ml......................................... 95nystatin tab 500000 unit....................................................4nystatin topical powder 100000 unit/gm.......................98OOBIZUR -antihemophilic factor (recomb porc) rpfviii for inj500 unit........................................................................... 91OCALIVA -obeticholic acid tab 5 mg.................................53OCALIVA -obeticholic acid tab 10 mg...............................53octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin)................................................................. 33octreotide acetate inj 100 mcg/ml (0.1 mg/ml)(Sandostatin)................................................................. 33octreotide acetate inj 200 mcg/ml (0.2 mg/ml)(Sandostatin)................................................................. 33octreotide acetate inj 500 mcg/ml (0.5 mg/ml)(Sandostatin)................................................................. 33octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin)................................................................. 33OCTREOTIDE ACETATE -octreotide acetatesubcutaneous soln pref syr 50 mcg/ml.......................... 33OCTREOTIDE ACETATE -octreotide acetatesubcutaneous soln pref syr 100 mcg/ml........................ 33OCTREOTIDE ACETATE -octreotide acetatesubcutaneous soln pref syr 500 mcg/ml........................ 33ODACTRA -dust mite mixed ext sl tab 12 sq-hdm........... 12ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg....................................................................6ODOMZO -sonidegib phosphate cap 200 mg (baseequivalent)....................................................................... 17OFEV -nintedanib esylate cap 100 mg (baseequivalent)....................................................................... 50OFEV -nintedanib esylate cap 150 mg (baseequivalent)....................................................................... 50OFLOXACIN -ofloxacin tab 300 mg.................................... 3ofloxacin ophth soln 0.3% (Ocuflox).............................93ofloxacin otic soln 0.3% (Floxin otic)............................94ofloxacin tab 400 mg.........................................................3olanzapine orally disintegrating tab 5 mg (Zyprexazydis)...............................................................................60olanzapine orally disintegrating tab 10 mg (Zyprexazydis)...............................................................................60olanzapine orally disintegrating tab 15 mg (Zyprexazydis)...............................................................................60olanzapine orally disintegrating tab 20 mg (Zyprexazydis)...............................................................................60olanzapine tab 2.5 mg (Zyprexa)................................... 60olanzapine tab 5 mg (Zyprexa)...................................... 60olanzapine tab 7.5 mg (Zyprexa)................................... 60olanzapine tab 10 mg (Zyprexa).................................... 60olanzapine tab 15 mg (Zyprexa).................................... 60olanzapine tab 20 mg (Zyprexa).................................... 60olmesartan-amlodipine-hydrochlorothiazide tab20-5-12.5 mg (Tribenzor).............................................. 41olmesartan-amlodipine-hydrochlorothiazide tab40-5-12.5 mg (Tribenzor).............................................. 41olmesartan-amlodipine-hydrochlorothiazide tab40-5-25 mg (Tribenzor)................................................. 41olmesartan-amlodipine-hydrochlorothiazide tab40-10-12.5 mg (Tribenzor)............................................ 41olmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg (Tribenzor)............................................... 41olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg (Benicar hct)..............................................41olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg (Benicar hct)..............................................41olmesartan medoxomil-hydrochlorothiazide tab 40-25mg (Benicar hct)........................................................... 41olmesartan medoxomil tab 5 mg (Benicar).................. 41olmesartan medoxomil tab 20 mg (Benicar)................ 41olmesartan medoxomil tab 40 mg (Benicar)................ 41omeprazole cap delayed release 10 mg........................51omeprazole cap delayed release 20 mg........................51omeprazole cap delayed release 40 mg........................51

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 138OMNIFLEX DIAPHRAGM -diaphragms.......................... 101OMNIPOD DASH INTRO KIT (G -insulin infusiondisposable pump kit......................................................101OMNIPOD DASH PODS (GEN 4) -insulin infusiondisposable pump supplies............................................ 101OMNIPOD 5 G6 INTRO KIT (G -insulin infusiondisposable pump kit......................................................101OMNIPOD 5 G6 PODS (GEN 5) -insulin infusiondisposable pump supplies............................................ 101ON/GO COVID-19 ANTIGEN SE -covid-19 at homeantigen test kit.................................................................99ON/GO ONE COVID-19 ANTIGE -covid-19 at homeantigen test kit.................................................................99ONDANSETRON HCL -ondansetron hcl tab 24 mg......... 52ondansetron hcl oral soln 4 mg/5ml (Zofran)...............52ondansetron hcl tab 4 mg (Zofran)................................52ondansetron hcl tab 8 mg (Zofran)................................52ondansetron orally disintegrating tab 4 mg (Zofranodt).................................................................................. 52ondansetron orally disintegrating tab 8 mg (Zofranodt).................................................................................. 52ONUREG -azacitidine tab 200 mg.................................... 17ONUREG -azacitidine tab 300 mg.................................... 17OPSUMIT -macitentan tab 10 mg..................................... 45OPTICHAMBER DIAMOND/LARGE -spacer/aerosol-holding chambers - device........................................... 101OPTICHAMBER DIAMOND/MEDIU -spacer/aerosol-holding chambers - device........................................... 101OPTICHAMBER DIAMOND/SMALL -spacer/aerosol-holding chambers - device........................................... 101OPTICHAMBER DIAMOND -spacer/aerosol-holdingchambers - device........................................................ 101OPTICHAMBER -spacer/aerosol-holding chambers -device............................................................................ 101OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 54ORALAIR -grass mixed pollen ext sl tab 300 ir (index ofreactivity)......................................................................... 12ORAVIG -miconazole buccal tab 50 mg (mouth-throat).............................................................................. 95ORENCIA -abatacept subcutaneous soln prefilled syringe50 mg/0.4ml.................................................................... 73ORENCIA -abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml................................................................. 73ORENCIA -abatacept subcutaneous soln prefilled syringe125 mg/ml....................................................................... 73ORENCIA CLICKJECT -abatacept subcutaneous solnauto-injector 125 mg/ml..................................................73ORENITRAM -treprostinil diolamine tab er 0.125 mg(base equiv).................................................................... 45ORENITRAM -treprostinil diolamine tab er 0.25 mg (baseequiv)............................................................................... 45ORENITRAM -treprostinil diolamine tab er 1 mg (baseequiv)............................................................................... 45ORENITRAM -treprostinil diolamine tab er 2.5 mg (baseequiv)............................................................................... 45ORENITRAM -treprostinil diolamine tab er 5 mg (baseequiv)............................................................................... 45ORFADIN -nitisinone cap 20 mg.......................................33ORFADIN -nitisinone susp 4 mg/ml.................................. 33ORGOVYX -relugolix tab 120 mg..................................... 17ORIAHNN -elagolix-estrad-noreth 300-1-0.5mg & elagolix300mg cap pack............................................................. 22ORILISSA -elagolix sodium tab 150 mg (base equiv).......33ORILISSA -elagolix sodium tab 200 mg (base equiv).......33ORKAMBI -lumacaftor-ivacaftor granules packet 100-125mg....................................................................................50ORKAMBI -lumacaftor-ivacaftor granules packet 150-188mg....................................................................................50ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 50ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 50orphenadrine citrate tab er 12hr 100 mg...................... 81oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu)............................................................................6oseltamivir phosphate cap 45 mg (base equiv)(Tamiflu)............................................................................7oseltamivir phosphate cap 75 mg (base equiv)(Tamiflu)............................................................................7oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu)............................................................................7OTEZLA -apremilast tab 30 mg........................................ 73OTEZLA -apremilast tab starter therapy pack 10 mg & 20mg & 30 mg.................................................................... 73OTREXUP -methotrexate soln pf auto-injector 10mg/0.4ml..........................................................................73OTREXUP -methotrexate soln pf auto-injector 12.5mg/0.4ml..........................................................................73OTREXUP -methotrexate soln pf auto-injector 15mg/0.4ml..........................................................................73OTREXUP -methotrexate soln pf auto-injector 17.5mg/0.4ml..........................................................................73OTREXUP -methotrexate soln pf auto-injector 20mg/0.4ml..........................................................................73OTREXUP -methotrexate soln pf auto-injector 22.5mg/0.4ml..........................................................................73OTREXUP -methotrexate soln pf auto-injector 25mg/0.4ml..........................................................................73oxandrolone tab 2.5 mg (Oxandrin).............................. 20oxandrolone tab 10 mg (Oxandrin)............................... 20oxaprozin tab 600 mg (Daypro)..................................... 73oxazepam cap 10 mg...................................................... 56oxazepam cap 15 mg...................................................... 56oxazepam cap 30 mg...................................................... 56OXBRYTA -voxelotor tab for oral susp 300 mg................ 84OXBRYTA -voxelotor tab 500 mg..................................... 84oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)........................................................................ 77oxcarbazepine tab 150 mg (Trileptal)............................ 77oxcarbazepine tab 300 mg (Trileptal)............................ 77oxcarbazepine tab 600 mg (Trileptal)............................ 77OXERVATE -cenegermin-bkbj ophth soln 0.002% (20mcg/ml)............................................................................94oxybutynin chloride syrup 5 mg/5ml............................ 54oxybutynin chloride tab er 24hr 15 mg.........................54oxybutynin chloride tab er 24hr 5 mg (Ditropan xl).....54

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 139oxybutynin chloride tab er 24hr 10 mg (Ditropanxl).....................................................................................54oxybutynin chloride tab 5 mg........................................ 54oxycodone hcl cap 5 mg................................................ 70oxycodone hcl conc 100 mg/5ml (20 mg/ml)................70oxycodone hcl soln 5 mg/5ml........................................ 70oxycodone hcl tab 10 mg............................................... 70oxycodone hcl tab 20 mg............................................... 70oxycodone hcl tab 5 mg (Roxicodone)......................... 70oxycodone hcl tab 15 mg (Roxicodone)....................... 70oxycodone hcl tab 30 mg (Roxicodone)....................... 70oxycodone w/ acetaminophen tab 2.5-325 mg(Percocet)....................................................................... 70oxycodone w/ acetaminophen tab 5-325 mg(Percocet)....................................................................... 70oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)....................................................................... 70oxycodone w/ acetaminophen tab 10-325 mg(Percocet)....................................................................... 70oxymorphone hcl tab 5 mg (Opana)..............................70oxymorphone hcl tab 10 mg (Opana)............................70OXYMORPHONE HYDROCHLORIDE -oxymorphone hcltab er 12hr 5 mg.............................................................70OXYMORPHONE HYDROCHLORIDE -oxymorphone hcltab er 12hr 7.5 mg..........................................................71OXYMORPHONE HYDROCHLORIDE -oxymorphone hcltab er 12hr 10 mg...........................................................71OXYMORPHONE HYDROCHLORIDE -oxymorphone hcltab er 12hr 15 mg...........................................................71OXYMORPHONE HYDROCHLORIDE -oxymorphone hcltab er 12hr 20 mg...........................................................71OXYMORPHONE HYDROCHLORIDE -oxymorphone hcltab er 12hr 30 mg...........................................................71OXYMORPHONE HYDROCHLORIDE -oxymorphone hcltab er 12hr 40 mg...........................................................71OZEMPIC -semaglutide soln pen-inj 1 mg/dose (4mg/3ml)............................................................................26OZEMPIC -semaglutide soln pen-inj 2 mg/dose (8mg/3ml)............................................................................26OZEMPIC -semaglutide soln pen-inj 0.25 or 0.5 mg/dose(2 mg/1.5ml)....................................................................26PPALFORZIA INITIAL DOSE ES -peanut powder-dnfpstarter pack 0.5 & 1 & 1.5 & 3 & 6 mg...........................12PALFORZIA LEVEL 11 (MAINT -peanut allergen powder-dnfp maintenance packet 300 mg..................................12PALFORZIA LEVEL 4 -peanut powder-dnfp cap sprinklepack 20 mg (20 mg dose).............................................. 12PALFORZIA LEVEL 1 -peanut powder-dnfp cap sprinklepack 3 x 1 mg (3 mg dose)............................................12PALFORZIA LEVEL 2 -peanut powder-dnfp cap sprinklepack 6 x 1 mg (6 mg dose)............................................12PALFORZIA LEVEL 5 -peanut powder-dnfp cap sprinklepack 2 x 20 mg (40 mg dose)........................................12PALFORZIA LEVEL 6 -peanut powder-dnfp cap sprinklepack 4 x 20 mg (80 mg dose)........................................12PALFORZIA LEVEL 7 -peanut powder-dnfp pack 20 mg &100 mg (120 mg dose)...................................................12PALFORZIA LEVEL 3 -peanut powder-dnfp pack 2 x 1 mg& 10 mg (12 mg dose)................................................... 12PALFORZIA LEVEL 8 -peanut powder-dnfp pack 3 x 20mg & 100 mg (160 mg dose)......................................... 13PALFORZIA LEVEL 10 -peanut powder-dnfp pack 2 x 20mg & 2 x 100 mg (240 mg dose)...................................12PALFORZIA LEVEL 9 -peanut powder-dnfp pack 2 x 100mg (200 mg dose).......................................................... 13PALFORZIA LEVEL 11 (TITRA -peanut allergen powder-dnfp titration packet 300 mg...........................................12paliperidone tab er 24hr 1.5 mg (Invega)......................60paliperidone tab er 24hr 3 mg (Invega).........................60paliperidone tab er 24hr 6 mg (Invega).........................60paliperidone tab er 24hr 9 mg (Invega).........................60PALYNZIQ -pegvaliase-pqpz subcutaneous soln prefsyringe 2.5 mg/0.5ml...................................................... 33PALYNZIQ -pegvaliase-pqpz subcutaneous soln prefsyringe 10 mg/0.5ml....................................................... 33PALYNZIQ -pegvaliase-pqpz subcutaneous soln prefsyringe 20 mg/ml............................................................ 33PANDA MASK LARGE -spacer/aerosol-holding chambersupplies - masks...........................................................101PANDA MASK MEDIUM -spacer/aerosol-holding chambersupplies - masks...........................................................101PANDA MASK SMALL -spacer/aerosol-holding chambersupplies - masks...........................................................101pantoprazole sodium ec tab 20 mg (base equiv)(Protonix)........................................................................51pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)........................................................................51paricalcitol cap 4 mcg.....................................................33paricalcitol cap 1 mcg (Zemplar)................................... 33paricalcitol cap 2 mcg (Zemplar)................................... 33paromomycin sulfate cap 250 mg................................... 3paroxetine hcl tab 10 mg (Paxil).................................... 58paroxetine hcl tab 20 mg (Paxil).................................... 58paroxetine hcl tab 30 mg (Paxil).................................... 58paroxetine hcl tab 40 mg (Paxil).................................... 58PASER -aminosalicylic acid er granules packet 4 gm........ 4PAXLOVID -nirmatrelvir tab 10 x 150 mg & ritonavir tab10 x 100 mg pak.............................................................. 7PAXLOVID -nirmatrelvir tab 20 x 150 mg & ritonavir tab10 x 100 mg pak.............................................................. 7PEDIARIX -diph-tet tox-acell pert-hep b-polio ipv vac susppref syr............................................................................ 12PEDIATRIC PANDA MASK -spacer/aerosol-holdingchamber supplies - masks........................................... 102PEDVAX HIB -haemophilus b polysaccharide conj vac imsusp 7.5 mcg/0.5 ml....................................................... 11PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 7PEGASYS -peginterferon alfa-2a soln prefilled syr 180mcg/0.5ml.......................................................................... 7peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236gm (Golytely)................................................................. 50

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 140peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln100 gm (Moviprep)........................................................51peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)................................................... 51PEG-PREP -bisacodyl tab & peg 3350-kcl-sod bicarb-naclfor soln kit....................................................................... 51PEMAZYRE -pemigatinib tab 4.5 mg................................17PEMAZYRE -pemigatinib tab 9 mg...................................17PEMAZYRE -pemigatinib tab 13.5 mg..............................17penicillamine tab 250 mg (Depen titratabs)................103PENICILLIN V POTASSIUM -penicillin v potassium forsoln 125 mg/5ml............................................................... 1PENICILLIN V POTASSIUM -penicillin v potassium forsoln 250 mg/5ml............................................................... 1penicillin v potassium tab 250 mg...................................1penicillin v potassium tab 500 mg...................................1PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b polyvac for im susp............................................................... 12pentamidine isethionate for nebulization soln 300 mg(Nebupent)........................................................................9pentoxifylline tab er 400 mg...........................................91perindopril erbumine tab 2 mg...................................... 41perindopril erbumine tab 4 mg...................................... 41perindopril erbumine tab 8 mg (Aceon)........................41permethrin cream 5% (Elimite)...................................... 98PERPHENAZINE/AMITRIPTYLIN -perphenazine-amitriptyline tab 2-10 mg................................................67PERPHENAZINE/AMITRIPTYLIN -perphenazine-amitriptyline tab 2-25 mg................................................67PERPHENAZINE/AMITRIPTYLIN -perphenazine-amitriptyline tab 4-10 mg................................................67PERPHENAZINE/AMITRIPTYLIN -perphenazine-amitriptyline tab 4-25 mg................................................67PERPHENAZINE/AMITRIPTYLIN -perphenazine-amitriptyline tab 4-50 mg................................................67perphenazine tab 2 mg................................................... 60perphenazine tab 4 mg................................................... 60perphenazine tab 8 mg................................................... 60perphenazine tab 16 mg................................................. 60PFIZER-BIONTECH COVID-19 -covid-19 mrna vac tris-s6mo-4y-pfizer im susp 3 mcg/0.2ml............................... 11PFIZER-BIONTECH COVID-19 -covid-19 mrna vac tris-sucrose-pfizer im susp 30 mcg/0.3ml............................ 11PFIZER-BIONTECH COVID-19 -covid-19 mrna vac tris-s5-11y-pfizer im susp 10 mcg/0.2ml................................ 11PFIZER-BIONTECH COVID-19 -covid-19 (sars-cov-2)mrna vacc-pfizer im susp 30 mcg/0.3ml........................ 11phenelzine sulfate tab 15 mg (Nardil)........................... 58phenobarbital elixir 20 mg/5ml...................................... 62phenobarbital tab 15 mg.................................................62phenobarbital tab 16.2 mg..............................................62phenobarbital tab 30 mg.................................................62phenobarbital tab 32.4 mg..............................................62phenobarbital tab 60 mg.................................................62phenobarbital tab 64.8 mg..............................................62phenobarbital tab 97.2 mg..............................................62phenobarbital tab 100 mg...............................................62phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 41phentermine hcl cap 15 mg............................................64phentermine hcl cap 30 mg............................................64phentermine hcl cap 37.5 mg (Adipex-p)......................64phentermine hcl tab 37.5 mg (Adipex-p).......................64phenylephrine hcl ophth soln 2.5%...............................94phenylephrine hcl ophth soln 10%................................94PHENYTEK -phenytoin sodium extended cap 200mg....................................................................................77PHENYTEK -phenytoin sodium extended cap 300mg....................................................................................77phenytoin chew tab 50 mg (Dilantin infatabs)..............78phenytoin sodium extended cap 100 mg (Dilantin)..... 78phenytoin sodium extended cap 200 mg(Phenytek)...................................................................... 78phenytoin sodium extended cap 300 mg(Phenytek)...................................................................... 78phenytoin susp 125 mg/5ml (Dilantin-125)................... 78PHOSLYRA -calcium acetate (phosphate binder) oral soln667 mg/5ml..................................................................... 53phytonadione tab 5 mg (Mephyton).............................. 81pilocarpine hcl ophth soln 1% (Isopto carpine)........... 94pilocarpine hcl ophth soln 2% (Isopto carpine)........... 94pilocarpine hcl ophth soln 4% (Isopto carpine)........... 94pilocarpine hcl tab 5 mg (Salagen)................................95pilocarpine hcl tab 7.5 mg (Salagen).............................95PIMOZIDE -pimozide tab 1 mg......................................... 67PIMOZIDE -pimozide tab 2 mg......................................... 67pindolol tab 5 mg.............................................................36pindolol tab 10 mg...........................................................36pioglitazone hcl-metformin hcl tab 15-500 mg(Actoplus met)...............................................................26pioglitazone hcl-metformin hcl tab 15-850 mg(Actoplus met)...............................................................26pioglitazone hcl tab 15 mg (base equiv) (Actos)..........26pioglitazone hcl tab 30 mg (base equiv) (Actos)..........26pioglitazone hcl tab 45 mg (base equiv) (Actos)..........26PIQRAY 250MG DAILY DOSE -alpelisib tab pack 250 mgdaily dose (200 mg & 50 mg tabs).................................17PIQRAY 300MG DAILY DOSE -alpelisib tab pack 300 mgdaily dose (2x150 mg tab)..............................................17PIQRAY 200MG DAILY DOSE -alpelisib tab therapy pack200 mg daily dose.......................................................... 17pirfenidone tab 267 mg (Esbriet)................................... 50pirfenidone tab 801 mg (Esbriet)................................... 50piroxicam cap 10 mg (Feldene)..................................... 73piroxicam cap 20 mg (Feldene)..................................... 73PLEGRIDY -peginterferon beta-1a im soln prefilled syr125 mcg/0.5ml................................................................ 67PLEGRIDY -peginterferon beta-1a soln pen-injector 125mcg/0.5ml........................................................................ 67PLEGRIDY -peginterferon beta-1a soln prefilled syringe125 mcg/0.5ml................................................................ 67PLEGRIDY STARTER PACK -peginterferon beta-1a solnpen-inj 63 & 94 mcg/0.5ml pack.................................... 67PLEGRIDY STARTER PACK -peginterferon beta-1a solnpref syr 63 & 94 mcg/0.5ml pack................................... 67

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 141PNEUMOVAX 23/1 DOSE -pneumococcal vaccinepolyvalent inj 25 mcg/0.5ml............................................11PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj25 mcg/0.5ml.................................................................. 11POCKET CHAMBER -spacer/aerosol-holding chambers -device............................................................................ 102POCKET SPACER -spacer/aerosol-holding chambers -device............................................................................ 102podofilox soln 0.5% (Condylox).....................................98polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)........................................................ 94POMALYST -pomalidomide cap 1 mg.............................. 17POMALYST -pomalidomide cap 2 mg.............................. 17POMALYST -pomalidomide cap 3 mg.............................. 17POMALYST -pomalidomide cap 4 mg.............................. 17posaconazole tab delayed release 100 mg (Noxafil)..... 4potassium chloride cap er 10 meq................................ 82potassium chloride cap er 8 meq (Micro-k)..................82POTASSIUM CHLORIDE ER -potassium chloride tab er 8meq (600 mg)................................................................. 82potassium chloride microencapsulated crys er tab 10meq................................................................................. 82potassium chloride microencapsulated crys er tab 15meq................................................................................. 82potassium chloride microencapsulated crys er tab 20meq................................................................................. 82potassium chloride oral soln 10% (20 meq/15ml)........82potassium chloride oral soln 20% (40 meq/15ml)........82potassium chloride powder packet 20 meq................. 82potassium chloride tab er 10 meq (K-tab).................... 82potassium chloride tab er 8 meq (600 mg)...................82potassium chloride tab er 20 meq (1500 mg) (K-tab).................................................................................. 82potassium citrate tab er 5 meq (540 mg) (Urocit-k5)......................................................................................55potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)....................................................................................55potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)....................................................................................55potassium phosphate monobasic tab 500 mg (K-phos)............................................................................... 82pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral).................................82PRADAXA -dabigatran etexilate mesylate cap 75 mg(etexilate base eq).......................................................... 85PRADAXA -dabigatran etexilate mesylate cap 110 mg(etexilate base eq).......................................................... 85PRADAXA -dabigatran etexilate mesylate cap 150 mg(etexilate base eq).......................................................... 85pramipexole dihydrochloride tab 0.125 mg(Mirapex).........................................................................80pramipexole dihydrochloride tab 0.25 mg(Mirapex).........................................................................80pramipexole dihydrochloride tab 0.5 mg (Mirapex).....80pramipexole dihydrochloride tab 0.75 mg(Mirapex).........................................................................80pramipexole dihydrochloride tab 1 mg (Mirapex)........80pramipexole dihydrochloride tab 1.5 mg (Mirapex).....80prasugrel hcl tab 5 mg (base equiv) (Effient)...............91prasugrel hcl tab 10 mg (base equiv) (Effient).............91pravastatin sodium tab 10 mg....................................... 44pravastatin sodium tab 20 mg (Pravachol)...................44pravastatin sodium tab 40 mg (Pravachol)...................44pravastatin sodium tab 80 mg (Pravachol)...................44praziquantel tab 600 mg (Biltricide)................................ 8prazosin hcl cap 1 mg (Minipress)................................ 41prazosin hcl cap 2 mg (Minipress)................................ 41prazosin hcl cap 5 mg (Minipress)................................ 41PRED-G -gentamicin-prednisolone ace ophth susp0.3-1%............................................................................. 94PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint0.3-0.6%.......................................................................... 94PREDNICARBATE -prednicarbate oint 0.1%....................98PREDNISOLONE ACETATE -prednisolone acetate ophthsusp 1%.......................................................................... 94PREDNISOLONE -prednisolone syrup 15 mg/5ml (uspsolution equivalent).........................................................20PREDNISOLONE SODIUM PHOSP -prednisolonesodium phosphate ophth soln 1%..................................94PREDNISOLONE SODIUM PHOSP -prednisolonesodium phosphate oral soln 25 mg/5ml (base eq).........20prednisolone sod phosphate oral soln 15 mg/5ml(base equiv)................................................................... 20prednisolone sod phosph oral soln 6.7 mg/5ml (5mg/5ml base) (Pediapred)............................................20PREDNISONE INTENSOL -prednisone conc 5 mg/ml.....20PREDNISONE -prednisone oral soln 5 mg/5ml................20prednisone tab 1 mg....................................................... 20prednisone tab 2.5 mg.................................................... 20prednisone tab 5 mg....................................................... 20prednisone tab 10 mg..................................................... 20prednisone tab 20 mg..................................................... 20prednisone tab 50 mg..................................................... 20prednisone tab therapy pack 5 mg (21)........................ 20prednisone tab therapy pack 5 mg (48)........................ 20prednisone tab therapy pack 10 mg (21)...................... 20prednisone tab therapy pack 10 mg (48)...................... 20PREFERRED PLUS GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 26PREFEST -estradiol tab 1 mg(15)/estrad-norgestimatetab 1-0.09mg(15)............................................................ 22pregabalin cap 25 mg (Lyrica)....................................... 78pregabalin cap 50 mg (Lyrica)....................................... 78pregabalin cap 75 mg (Lyrica)....................................... 78pregabalin cap 100 mg (Lyrica)..................................... 78pregabalin cap 150 mg (Lyrica)..................................... 78pregabalin cap 200 mg (Lyrica)..................................... 78pregabalin cap 225 mg (Lyrica)..................................... 78pregabalin cap 300 mg (Lyrica)..................................... 78pregabalin soln 20 mg/ml (Lyrica)................................. 78PREGNYL W/DILUENT BENZYL -chorionic gonadotropinfor im inj 10000 unit........................................................33PREHEVBRIO -hepatitis b vaccine 3-antigen(recombinant) susp 10 mcg/ml.......................................11

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 142PREMARIN -estrogens, conjugated tab 0.3 mg............... 22PREMARIN -estrogens, conjugated tab 0.45 mg............. 22PREMARIN -estrogens, conjugated tab 0.625 mg........... 22PREMARIN -estrogens, conjugated tab 0.9 mg............... 22PREMARIN -estrogens, conjugated tab 1.25 mg............. 22PREMARIN -estrogens, conjugated vaginal cream 0.625mg/gm..............................................................................55PREMPHASE -conj est 0.625(14)/conj est-medroxypro actab 0.625-5mg(14).......................................................... 22PREMPRO -conjugated estrogen-medroxyprogestacetate tab 0.3-1.5 mg................................................... 22PREMPRO -conjugated estrogen-medroxyprogestacetate tab 0.45-1.5 mg................................................. 22PREMPRO -conjugated estrogen-medroxyprogestacetate tab 0.625-2.5 mg............................................... 22PREMPRO -conjugated estrogen-medroxyprogestacetate tab 0.625-5 mg.................................................. 22PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1mg....................................................................................81PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1mg....................................................................................81PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1mg....................................................................................81PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab29-1 mg........................................................................... 81PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap106.5-1 mg...................................................................... 81PRENATAL VITAMINS PLUS LO -prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................81PRETOMANID -pretomanid tab 200 mg............................. 4PREVNAR 13 -pneumococcal 13-valent conjugatevaccine inj....................................................................... 11PREVNAR 20 -pneumococcal 20-valent conjugatevaccine sus pref syr 0.5 ml............................................ 11PREVYMIS -letermovir tab 240 mg.................................... 7PREVYMIS -letermovir tab 480 mg.................................... 7PREZCOBIX -darunavir-cobicistat tab 800-150 mg............7PREZISTA -darunavir oral susp 100 mg/ml........................ 7PREZISTA -darunavir tab 75 mg.........................................7PREZISTA -darunavir tab 150 mg.......................................7PREZISTA -darunavir tab 600 mg.......................................7PREZISTA -darunavir tab 800 mg.......................................7PRIFTIN -rifapentine tab 150 mg........................................ 4primaquine phosphate tab 26.3 mg (15 mg base)(Primaquine phosphate).................................................8primidone tab 50 mg (Mysoline).................................... 78primidone tab 250 mg (Mysoline).................................. 78probenecid tab 500 mg................................................... 75PROCARE SPACER CHAMBER W/ -spacer/aerosol-holding chambers - device........................................... 102prochlorperazine maleate tab 5 mg (baseequivalent)......................................................................60prochlorperazine maleate tab 10 mg (baseequivalent)......................................................................61prochlorperazine suppos 25 mg....................................61PRO COMFORT INHALER SPACE -spacer/aerosol-holding chambers - device........................................... 102PROCRIT -epoetin alfa inj 2000 unit/ml............................84PROCRIT -epoetin alfa inj 3000 unit/ml............................84PROCRIT -epoetin alfa inj 4000 unit/ml............................84PROCRIT -epoetin alfa inj 10000 unit/ml..........................84PROCRIT -epoetin alfa inj 20000 unit/ml..........................84PROCRIT -epoetin alfa inj 40000 unit/ml..........................84PROCTOFOAM HC -hydrocortisone acetate w/pramoxine perianal foam 1-1%...................................... 95PROCYSBI -cysteamine bitartrate cap delayed release 25mg (base equiv).............................................................. 55PROCYSBI -cysteamine bitartrate cap delayed release 75mg (base equiv).............................................................. 55PROCYSBI -cysteamine bitartrate delayed releasegranules packet 75 mg...................................................55PROCYSBI -cysteamine bitartrate delayed releasegranules packet 300 mg.................................................55PROFILNINE -factor ix complex for inj 500 unit............... 91PROFILNINE -factor ix complex for inj 1000 unit............. 91PROFILNINE -factor ix complex for inj 1500 unit............. 91progesterone cap 100 mg (Prometrium).......................24progesterone cap 200 mg (Prometrium).......................24progesterone im in oil 50 mg/ml....................................24PROGRAF -tacrolimus cap 0.5 mg.................................103PROGRAF -tacrolimus cap 1 mg.................................... 103PROGRAF -tacrolimus cap 5 mg.................................... 103PROGRAF -tacrolimus packet for susp 0.2 mg.............. 103PROGRAF -tacrolimus packet for susp 1 mg................. 103PROMACTA -eltrombopag olamine powder pack for susp12.5 mg (base eq).......................................................... 84PROMACTA -eltrombopag olamine powder pack for susp25 mg (base equiv)........................................................ 84PROMACTA -eltrombopag olamine tab 12.5 mg (baseequiv)............................................................................... 84PROMACTA -eltrombopag olamine tab 25 mg (baseequiv)............................................................................... 84PROMACTA -eltrombopag olamine tab 50 mg (baseequiv)............................................................................... 84PROMACTA -eltrombopag olamine tab 75 mg (baseequiv)............................................................................... 84promethazine & phenylephrine syrup 6.25-5mg/5ml............................................................................ 47promethazine-dm syrup 6.25-15 mg/5ml.......................47promethazine hcl suppos 12.5 mg................................ 46promethazine hcl suppos 25 mg................................... 46promethazine hcl syrup 6.25 mg/5ml............................ 47promethazine hcl tab 12.5 mg........................................47promethazine hcl tab 25 mg...........................................47promethazine hcl tab 50 mg...........................................47promethazine-phenylephrine-codeine syrup 6.25-5-10mg/5ml............................................................................ 47promethazine w/ codeine syrup 6.25-10 mg/5ml..........47PROMETHEGAN -promethazine hcl suppos 50 mg.........47propafenone hcl cap er 12hr 225 mg (Rythmol sr)...... 38propafenone hcl cap er 12hr 325 mg (Rythmol sr)...... 38propafenone hcl cap er 12hr 425 mg (Rythmol sr)...... 38propafenone hcl tab 150 mg.......................................... 38propafenone hcl tab 225 mg.......................................... 38

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 143propafenone hcl tab 300 mg.......................................... 38proparacaine hcl ophth soln 0.5%.................................94propranolol hcl cap er 24hr 60 mg (Inderal la).............36propranolol hcl cap er 24hr 80 mg (Inderal la).............36propranolol hcl cap er 24hr 120 mg (Inderal la)...........36propranolol hcl cap er 24hr 160 mg (Inderal la)...........36propranolol hcl oral soln 20 mg/5ml............................. 36PROPRANOLOL HCL -propranolol hcl oral soln 40mg/5ml.............................................................................36propranolol hcl tab 10 mg.............................................. 36propranolol hcl tab 20 mg.............................................. 36propranolol hcl tab 40 mg.............................................. 36propranolol hcl tab 60 mg.............................................. 36propranolol hcl tab 80 mg.............................................. 36propylthiouracil tab 50 mg............................................. 30PROQUAD -measles-mumps-rubella-varicella virusvaccines for susp............................................................11protriptyline hcl tab 5 mg............................................... 58protriptyline hcl tab 10 mg............................................. 58PULMOZYME -dornase alfa inhal soln 2.5 mg/2.5ml....... 50PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/ml)....................................................................................17pyrazinamide tab 500 mg..................................................4pyridostigmine bromide oral soln 60 mg/5ml(Mestinon)...................................................................... 81pyridostigmine bromide tab er 180 mg (Mestinontimespan)........................................................................81pyridostigmine bromide tab 60 mg (Mestinon)............ 81pyrimethamine tab 25 mg (Daraprim)............................. 8PYRUKYND -mitapivat sulfate tab 5 mg...........................91PYRUKYND -mitapivat sulfate tab 20 mg.........................91PYRUKYND -mitapivat sulfate tab 50 mg.........................91PYRUKYND TAPER PACK -mitapivat sulfate tab therapypack 5 mg....................................................................... 91PYRUKYND TAPER PACK -mitapivat sulfate tab therapypack 7 x 20 mg & 7 x 5 mg........................................... 91PYRUKYND TAPER PACK -mitapivat sulfate tab therapypack 7 x 50 mg & 7 x 20 mg......................................... 91QQBRELIS -lisinopril oral soln 1 mg/ml...............................41QINLOCK -ripretinib tab 50 mg......................................... 17QSYMIA -phentermine hcl-topiramate cap er 24hr 3.75-23mg....................................................................................64QSYMIA -phentermine hcl-topiramate cap er 24hr 7.5-46mg....................................................................................64QSYMIA -phentermine hcl-topiramate cap er 24hr11.25-69 mg.................................................................... 64QSYMIA -phentermine hcl-topiramate cap er 24hr 15-92mg....................................................................................64QUADRACEL -diph-tetanus-acell pert-polio, ipv vaccsusp pref syr 0.5 ml........................................................12QUADRACEL -diph-tetanus tox ad-acell pert & poliovirus, ipv vac inj.............................................................. 12quetiapine fumarate tab er 24hr 50 mg (Seroquelxr).................................................................................... 61quetiapine fumarate tab er 24hr 150 mg (Seroquelxr).................................................................................... 61quetiapine fumarate tab er 24hr 200 mg (Seroquelxr).................................................................................... 61quetiapine fumarate tab er 24hr 300 mg (Seroquelxr).................................................................................... 61quetiapine fumarate tab er 24hr 400 mg (Seroquelxr).................................................................................... 61quetiapine fumarate tab 25 mg (Seroquel)................... 61quetiapine fumarate tab 50 mg (Seroquel)................... 61quetiapine fumarate tab 100 mg (Seroquel)................. 61quetiapine fumarate tab 200 mg (Seroquel)................. 61quetiapine fumarate tab 300 mg (Seroquel)................. 61quetiapine fumarate tab 400 mg (Seroquel)................. 61QUICKVUE AT-HOME COVID-19 -covid-19 at homeantigen test kit.................................................................99quinapril hcl tab 5 mg (Accupril)................................... 41quinapril hcl tab 10 mg (Accupril)................................. 41quinapril hcl tab 20 mg (Accupril)................................. 42quinapril hcl tab 40 mg (Accupril)................................. 42quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)......................................................................42quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)......................................................................42quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)......................................................................42quinidine gluconate tab er 324 mg................................38QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 38QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 38quinine sulfate cap 324 mg (Qualaquin)......................... 8QULIPTA -atogepant tab 10 mg........................................74QULIPTA -atogepant tab 30 mg........................................74QULIPTA -atogepant tab 60 mg........................................74QVAR REDIHALER -beclomethasone diprop hfa breathact inh aer 40 mcg/act....................................................49QVAR REDIHALER -beclomethasone diprop hfa breathact inh aer 80 mcg/act....................................................49RRABAVERT -rabies vaccine, pcec for inj.......................... 11RADIOGARDASE -prussian blue insoluble cap 0.5gm....................................................................................99RAGWITEK -short ragweed pollen allergen extract sl tab12 amb a 1-u.................................................................. 13raloxifene hcl tab 60 mg (Evista)...................................33ramipril cap 1.25 mg (Altace)......................................... 42ramipril cap 2.5 mg (Altace)........................................... 42ramipril cap 5 mg (Altace).............................................. 42ramipril cap 10 mg (Altace)............................................ 42ranolazine tab er 12hr 500 mg (Ranexa)....................... 35ranolazine tab er 12hr 1000 mg (Ranexa)..................... 35RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 103RAPAMUNE -sirolimus tab 0.5 mg..................................103RAPAMUNE -sirolimus tab 1 mg.....................................103RAPAMUNE -sirolimus tab 2 mg.....................................103rasagiline mesylate tab 0.5 mg (base equiv)(Azilect)...........................................................................80

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 144rasagiline mesylate tab 1 mg (base equiv)(Azilect)...........................................................................80RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........33REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml......67REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml......67REBIF REBIDOSE -interferon beta-1a soln auto-inj 22mcg/0.5ml........................................................................ 67REBIF REBIDOSE -interferon beta-1a soln auto-inj 44mcg/0.5ml........................................................................ 67REBIF REBIDOSE TITRATION -interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 67REBIF TITRATION PACK -interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...............................67REBINYN -coagulation factor ix recomb glycopegylatedfor inj 500 unt..................................................................91REBINYN -coagulation factor ix recomb glycopegylatedfor inj 1000 unt................................................................91REBINYN -coagulation factor ix recomb glycopegylatedfor inj 2000 unt................................................................91RECOMBINATE -antihemophilic factor recomb (rfviii) forinj 220-400 unit............................................................... 91RECOMBINATE -antihemophilic factor recomb (rfviii) forinj 401-800 unit............................................................... 91RECOMBINATE -antihemophilic factor recomb (rfviii) forinj 801-1240 unit............................................................. 91RECOMBINATE -antihemophilic factor recomb (rfviii) forinj 1241-1800 unit........................................................... 91RECOMBINATE -antihemophilic factor recomb (rfviii) forinj 1801-2400 unit........................................................... 91RECOMBIVAX HB -hepatitis b vaccine (recombinant)susp 5 mcg/0.5ml........................................................... 11RECOMBIVAX HB -hepatitis b vaccine (recombinant)susp 10 mcg/ml.............................................................. 11RECOMBIVAX HB -hepatitis b vaccine (recombinant)susp 40 mcg/ml.............................................................. 11RECOTHROM/SPRAY APPLICATO -thrombin(recombinant) for soln 20000 unit.................................. 86RECOTHROM SPRAY KIT -thrombin (recombinant) forsoln 20000 unit............................................................... 86RECOTHROM -thrombin (recombinant) for soln 5000unit................................................................................... 86RECOTHROM -thrombin (recombinant) for soln 20000unit................................................................................... 86RECTIV -nitroglycerin oint 0.4%....................................... 95REDITREX -methotrexate soln prefilled syringe 7.5mg/0.3ml..........................................................................73REDITREX -methotrexate soln prefilled syringe 10mg/0.4ml..........................................................................73REDITREX -methotrexate soln prefilled syringe 12.5mg/0.5ml..........................................................................73REDITREX -methotrexate soln prefilled syringe 15mg/0.6ml..........................................................................73REDITREX -methotrexate soln prefilled syringe 17.5mg/0.7ml..........................................................................73REDITREX -methotrexate soln prefilled syringe 20mg/0.8ml..........................................................................73REDITREX -methotrexate soln prefilled syringe 22.5mg/0.9ml..........................................................................73REDITREX -methotrexate soln prefilled syringe 25 mg/ml..................................................................................... 73REGRANEX -becaplermin gel 0.01%............................... 98RELENZA DISKHALER -zanamivir aero powder breathactivated 5 mg/blister........................................................7repaglinide tab 0.5 mg.................................................... 26repaglinide tab 1 mg (Prandin)...................................... 26repaglinide tab 2 mg (Prandin)...................................... 26REPATHA -evolocumab subcutaneous soln prefilledsyringe 140 mg/ml.......................................................... 44REPATHA PUSHTRONEX SYSTEM -evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml....... 44REPATHA SURECLICK -evolocumab subcutaneous solnauto-injector 140 mg/ml..................................................44RESET -digital therapy application................................. 103RESET FOR IOS OR ANDROID -digital therapyapplication..................................................................... 103RESET NON-MONETARY CM -digital therapyapplication..................................................................... 103RESET-O -digital therapy application............................. 103RESET-O FOR IOS OR ANDROI -digital therapyapplication..................................................................... 103RESET-O NON-MONETARY CM -digital therapyapplication..................................................................... 103RETACRIT -epoetin alfa-epbx inj 2000 unit/ml................. 84RETACRIT -epoetin alfa-epbx inj 3000 unit/ml................. 84RETACRIT -epoetin alfa-epbx inj 4000 unit/ml................. 84RETACRIT -epoetin alfa-epbx inj 10000 unit/ml............... 84RETACRIT -epoetin alfa-epbx inj 20000 unit/ml............... 84RETACRIT -epoetin alfa-epbx inj 40000 unit/ml............... 84RETEVMO -selpercatinib cap 40 mg................................ 17RETEVMO -selpercatinib cap 80 mg................................ 17REVCOVI -elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6mg/ml)..............................................................................33REVLIMID -lenalidomide cap 5 mg.................................103REVLIMID -lenalidomide cap 10 mg...............................103REVLIMID -lenalidomide cap 15 mg...............................103REVLIMID -lenalidomide cap 20 mg...............................103REVLIMID -lenalidomide cap 25 mg...............................103REVLIMID -lenalidomide caps 2.5 mg............................ 103REXULTI -brexpiprazole tab 0.25 mg............................... 61REXULTI -brexpiprazole tab 0.5 mg................................. 61REXULTI -brexpiprazole tab 1 mg.................................... 61REXULTI -brexpiprazole tab 2 mg.................................... 61REXULTI -brexpiprazole tab 3 mg.................................... 61REXULTI -brexpiprazole tab 4 mg.................................... 61REYATAZ -atazanavir sulfate oral powder packet 50 mg(base equiv)...................................................................... 7REYVOW -lasmiditan succinate tab 50 mg...................... 74REYVOW -lasmiditan succinate tab 100 mg.................... 74REZUROCK -belumosudil mesylate tab 200 mg............104RIASTAP -fibrinogen conc (human) inj approximately 1gm (900-1300 mg).......................................................... 91ribavirin cap 200 mg (Rebetol).........................................7ribavirin tab 200 mg (Copegus)....................................... 7

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 145RIDAURA -auranofin cap 3 mg......................................... 73rifabutin cap 150 mg (Mycobutin)....................................4rifampin cap 300 mg..........................................................4rifampin cap 150 mg (Rifadin)..........................................4riluzole tab 50 mg (Rilutek)............................................ 81RINVOQ -upadacitinib tab er 24hr 15 mg.........................73RINVOQ -upadacitinib tab er 24hr 30 mg.........................73RINVOQ -upadacitinib tab er 24hr 45 mg.........................73risedronate sodium tab delayed release 35 mg(Atelvia).......................................................................... 33risedronate sodium tab 5 mg (Actonel)........................ 33risedronate sodium tab 30 mg (Actonel)...................... 33risedronate sodium tab 35 mg (Actonel)...................... 33risedronate sodium tab 150 mg (Actonel).................... 33RISPERIDONE ODT -risperidone orally disintegrating tab0.25 mg........................................................................... 61risperidone orally disintegrating tab 0.5 mg (Risperdalm-tab)..............................................................................61risperidone orally disintegrating tab 1 mg (Risperdalm-tab)..............................................................................61risperidone orally disintegrating tab 2 mg (Risperdalm-tab)..............................................................................61risperidone orally disintegrating tab 3 mg (Risperdalm-tab)..............................................................................61risperidone orally disintegrating tab 4 mg (Risperdalm-tab)..............................................................................61risperidone soln 1 mg/ml (Risperdal)............................61risperidone tab 0.25 mg (Risperdal)..............................61risperidone tab 0.5 mg (Risperdal)................................ 61risperidone tab 1 mg (Risperdal)................................... 61risperidone tab 2 mg (Risperdal)................................... 61risperidone tab 3 mg (Risperdal)................................... 61risperidone tab 4 mg (Risperdal)................................... 61RITEFLO -spacer/aerosol-holding chambers -device............................................................................ 102ritonavir tab 100 mg (Norvir)............................................ 7rivastigmine tartrate cap 1.5 mg (base equivalent)..... 67rivastigmine tartrate cap 3 mg (base equivalent)........ 67rivastigmine tartrate cap 4.5 mg (base equivalent)..... 67rivastigmine tartrate cap 6 mg (base equivalent)........ 67rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 67rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 67rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 68RIXUBIS -coagulation factor ix (recombinant) for inj 250unit................................................................................... 91RIXUBIS -coagulation factor ix (recombinant) for inj 500unit................................................................................... 91RIXUBIS -coagulation factor ix (recombinant) for inj 1000unit................................................................................... 91RIXUBIS -coagulation factor ix (recombinant) for inj 2000unit................................................................................... 91RIXUBIS -coagulation factor ix (recombinant) for inj 3000unit................................................................................... 91rizatriptan benzoate oral disintegrating tab 5 mg (baseeq) (Maxalt-mlt)............................................................. 74rizatriptan benzoate oral disintegrating tab 10 mg(base eq) (Maxalt-mlt).................................................. 74rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)........................................................................... 74rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)........................................................................... 74ropinirole hydrochloride tab 0.25 mg (Requip)............ 80ropinirole hydrochloride tab 0.5 mg (Requip).............. 80ropinirole hydrochloride tab 1 mg (Requip)................. 80ropinirole hydrochloride tab 2 mg (Requip)................. 80ropinirole hydrochloride tab 3 mg (Requip)................. 80ropinirole hydrochloride tab 4 mg (Requip)................. 80ropinirole hydrochloride tab 5 mg (Requip)................. 80rosuvastatin calcium tab 5 mg (Crestor)...................... 44rosuvastatin calcium tab 10 mg (Crestor).................... 44rosuvastatin calcium tab 20 mg (Crestor).................... 44rosuvastatin calcium tab 40 mg (Crestor).................... 45ROTARIX -rotavirus vaccine, live for oral susp.................11ROTATEQ -rotavirus vaccine, live oral pentavalentsoln.................................................................................. 11ROZLYTREK -entrectinib cap 100 mg.............................. 17ROZLYTREK -entrectinib cap 200 mg.............................. 17RUBRACA -rucaparib camsylate tab 200 mg (baseequivalent)....................................................................... 17RUBRACA -rucaparib camsylate tab 250 mg (baseequivalent)....................................................................... 17RUBRACA -rucaparib camsylate tab 300 mg (baseequivalent)....................................................................... 17RUCONEST -c1 esterase inhibitor (recombinant) for iv inj2100 unit......................................................................... 91rufinamide susp 40 mg/ml (Banzel)...............................78rufinamide tab 200 mg (Banzel)..................................... 78rufinamide tab 400 mg (Banzel)..................................... 78RUKOBIA -fostemsavir tromethamine tab er 12hr 600mg...................................................................................... 7RYBELSUS -semaglutide tab 3 mg.................................. 26RYBELSUS -semaglutide tab 7 mg.................................. 26RYBELSUS -semaglutide tab 14 mg................................ 26RYDAPT -midostaurin cap 25 mg..................................... 17RYTARY -carbidopa & levodopa cap er 23.75-95 mg.......80RYTARY -carbidopa & levodopa cap er 36.25-145mg....................................................................................81RYTARY -carbidopa & levodopa cap er 48.75-195mg....................................................................................81RYTARY -carbidopa & levodopa cap er 61.25-245mg....................................................................................81SSANDIMMUNE -cyclosporine cap 25 mg....................... 104SANDIMMUNE -cyclosporine cap 100 mg..................... 104SANDIMMUNE -cyclosporine oral soln 100 mg/ml.........104SANTYL -collagenase oint 250 unit/gm............................ 98sapropterin dihydrochloride powder packet 100 mg(Kuvan)........................................................................... 34sapropterin dihydrochloride powder packet 500 mg(Kuvan)........................................................................... 34sapropterin dihydrochloride tab 100 mg (Kuvan)........34SAXENDA -liraglutide (weight mngmt) soln pen-inj 18mg/3ml (6 mg/ml)............................................................64

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 146SCEMBLIX -asciminib hcl tab 20 mg................................17SCEMBLIX -asciminib hcl tab 40 mg................................17scopolamine td patch 72hr 1 mg/3days (Transderm-scop)............................................................................... 52SECUADO -asenapine td patch 24 hr 3.8 mg/24hr.......... 61SECUADO -asenapine td patch 24 hr 5.7 mg/24hr.......... 61SECUADO -asenapine td patch 24 hr 7.6 mg/24hr.......... 61selegiline hcl cap 5 mg (Eldepryl)................................. 81selegiline hcl tab 5 mg....................................................81selenium sulfide lotion 2.5%.......................................... 98SELZENTRY -maraviroc oral soln 20 mg/ml...................... 7SELZENTRY -maraviroc tab 25 mg.................................... 7SELZENTRY -maraviroc tab 75 mg.................................... 7SEMGLEE -insulin glargine-yfgn inj 100 unit/ml............... 28SEMGLEE -insulin glargine-yfgn soln pen-injector 100unit/ml.............................................................................. 28SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1mg....................................................................................81SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab29-1 mg........................................................................... 81SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50mcg/dose (base equiv)................................................... 49sertraline hcl oral concentrate for solution 20 mg/ml(Zoloft)............................................................................ 58sertraline hcl tab 25 mg (Zoloft).................................... 58sertraline hcl tab 50 mg (Zoloft).................................... 58sertraline hcl tab 100 mg (Zoloft).................................. 58sevelamer carbonate packet 0.8 gm (Renvela)............ 53sevelamer carbonate packet 2.4 gm (Renvela)............ 53sevelamer carbonate tab 800 mg (Renvela)................. 53sevelamer hcl tab 800 mg (Renagel)............................. 53SEVELAMER HYDROCHLORIDE -sevelamer hcl tab 400mg....................................................................................53SEVENFACT -coagulation factor viia (recom)-jncw for inj1 mg (1000 mcg)............................................................ 91SEVENFACT -coagulation factor viia (recom)-jncw for inj5 mg (5000 mcg)............................................................ 92SFROWASA -mesalamine sulfite-free (sf) enema 4gm/60ml...........................................................................53SHINGRIX -zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml.................................................................. 11SHUR-SEAL -nonoxynol-9 gel 2%....................................55SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (baseequiv)............................................................................... 34SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (baseequiv)............................................................................... 34SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (baseequiv)............................................................................... 34SIKLOS -hydroxyurea tab 100 mg.................................... 84SIKLOS -hydroxyurea tab 1000 mg.................................. 84sildenafil citrate for suspension 10 mg/ml(Revatio)......................................................................... 45sildenafil citrate tab 20 mg (Revatio)............................ 45sildenafil citrate tab 25 mg (Viagra).............................. 46sildenafil citrate tab 50 mg (Viagra).............................. 46sildenafil citrate tab 100 mg (Viagra)............................ 46silver sulfadiazine cream 1% (Silvadene)..................... 98SIMBRINZA -brinzolamide-brimonidine tartrate ophthsusp 1-0.2%.................................................................... 94SIMPONI -golimumab subcutaneous soln auto-injector100 mg/ml....................................................................... 73SIMPONI -golimumab subcutaneous soln prefilled syringe100 mg/ml....................................................................... 73simvastatin tab 5 mg (Zocor)......................................... 45simvastatin tab 10 mg (Zocor)....................................... 45simvastatin tab 20 mg (Zocor)....................................... 45simvastatin tab 40 mg (Zocor)....................................... 45simvastatin tab 80 mg (Zocor)....................................... 45sirolimus oral soln 1 mg/ml (Rapamune)....................104sirolimus tab 0.5 mg (Rapamune)............................... 104sirolimus tab 1 mg (Rapamune).................................. 104sirolimus tab 2 mg (Rapamune).................................. 104SIRTURO -bedaquiline fumarate tab 20 mg (baseequiv)................................................................................. 4SIRTURO -bedaquiline fumarate tab 100 mg (baseequiv)................................................................................. 4SIVEXTRO -tedizolid phosphate tab 200 mg......................9SKYRIZI PEN -risankizumab-rzaa soln auto-injector 150mg/ml............................................................................... 98SKYRIZI -risankizumab-rzaa soln prefilled syringe 150mg/ml............................................................................... 98SKYRIZI -risankizumab-rzaa sol prefilled syringe 2 x 75mg/0.83ml kit...................................................................98SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cart 13.3 mg...............................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 3 mg............................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 3.6 mg.........................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 4.3 mg.........................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 5.2 mg.........................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 6.3 mg.........................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 7.6 mg.........................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 9.1 mg.........................................................34SKYTROFA -lonapegsomatropin-tcgd for subcutaneousinj cartridge 11 mg.......................................................... 34SM GLUCOSE -glucose chew tab 4 gm (rounded).......... 26sodium chloride soln nebu 3%...................................... 47sodium chloride soln nebu 7% (Hyper-sal).................. 47sodium citrate & citric acid soln 500-334 mg/5ml(Shohls solution modi)................................................ 55sodium fluoride chew tab 0.25 mg f (from 0.55 mgnaf).................................................................................. 82sodium fluoride chew tab 0.5 mg f (from 1.1 mgnaf).................................................................................. 82sodium fluoride chew tab 1 mg f (from 2.2 mg naf).....82sodium fluoride cream 1.1% (Prevident 5000 plus)..... 95sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride).......................................................................... 95

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 147sodium fluoride paste 1.1% (Prevident 5000boost)..............................................................................95sodium fluoride-potassium nitrate gel 1.1-5%(Prevident 5000 sensi)................................................. 95sodium fluoride rinse 0.2% (Prevident rinse)...............95SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from1.1 mg naf)......................................................................82SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from2.2 mg naf)......................................................................82sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).................................................................................. 82sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/mlnaf).................................................................................. 82sodium phenylbutyrate oral powder 3 gm/teaspoonful(Buphenyl)......................................................................34sodium phenylbutyrate tab 500 mg (Buphenyl)...........34sodium polystyrene sulfonate powder(Kayexalate)................................................................. 104solifenacin succinate tab 5 mg (Vesicare)....................54solifenacin succinate tab 10 mg (Vesicare)..................54SOLIQUA 100/33 -insulin glargine-lixisenatide sol pen-inj100-33 unit-mcg/ml......................................................... 26SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (baseequivalent)....................................................................... 17SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 34SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 34SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 34SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 34SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 34SOOLANTRA -ivermectin cream 1%................................ 98sorafenib tosylate tab 200 mg (base equivalent)(Nexavar)........................................................................ 17sotalol hcl (afib/afl) tab 80 mg (Betapace af)................36sotalol hcl (afib/afl) tab 120 mg (Betapace af)..............36sotalol hcl (afib/afl) tab 160 mg (Betapace af)..............36sotalol hcl tab 240 mg.....................................................36sotalol hcl tab 80 mg (Betapace)...................................36sotalol hcl tab 120 mg (Betapace)................................. 36sotalol hcl tab 160 mg (Betapace)................................. 36SOVALDI -sofosbuvir pellet pack 150 mg...........................7SOVALDI -sofosbuvir pellet pack 200 mg...........................7SOVALDI -sofosbuvir tab 200 mg....................................... 7SOVALDI -sofosbuvir tab 400 mg....................................... 7SPIKEVAX COVID-19 VACCINE -covid-19 (sars-cov-2)mrna vacc-moderna im susp 100 mcg/0.5ml.......11SPINOSAD -spinosad susp 0.9%..................................... 98SPIRIVA HANDIHALER -tiotropium bromide monohydrateinhal cap 18 mcg (base equiv).......................................49SPIRIVA RESPIMAT -tiotropium bromide monohydrateinhal aerosol 1.25 mcg/act............................................. 49SPIRIVA RESPIMAT -tiotropium bromide monohydrateinhal aerosol 2.5 mcg/act............................................... 49spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide).................................................................. 43spironolactone tab 25 mg (Aldactone)..........................43spironolactone tab 50 mg (Aldactone)..........................43spironolactone tab 100 mg (Aldactone)........................43SPRITAM -levetiracetam tab disintegrating soluble 250mg....................................................................................78SPRITAM -levetiracetam tab disintegrating soluble 500mg....................................................................................78SPRITAM -levetiracetam tab disintegrating soluble 750mg....................................................................................78SPRITAM -levetiracetam tab disintegrating soluble 1000mg....................................................................................78SPRYCEL -dasatinib tab 20 mg........................................17SPRYCEL -dasatinib tab 50 mg........................................17SPRYCEL -dasatinib tab 70 mg........................................17SPRYCEL -dasatinib tab 80 mg........................................17SPRYCEL -dasatinib tab 100 mg......................................17SPRYCEL -dasatinib tab 140 mg......................................18SPS -sodium polystyrene sulfonate oral susp 15gm/60ml.........................................................................104stannous fluoride conc 0.63% (Gel-kam oral careri)..................................................................................... 95stannous fluoride gel 0.4%.............................................95STAVUDINE -stavudine cap 15 mg.....................................7STAVUDINE -stavudine cap 20 mg.....................................7STAVUDINE -stavudine cap 30 mg.....................................7STAVUDINE -stavudine cap 40 mg.....................................7STELARA -ustekinumab inj 45 mg/0.5ml..........................98STELARA -ustekinumab soln prefilled syringe 45mg/0.5ml..........................................................................98STELARA -ustekinumab soln prefilled syringe 90 mg/ml..................................................................................... 98STENDRA -avanafil tab 50 mg......................................... 46STENDRA -avanafil tab 100 mg....................................... 46STENDRA -avanafil tab 200 mg....................................... 46STIMATE -desmopressin acetate nasal soln 1.5 mg/ml..................................................................................... 34STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aerosoln 2.5-2.5 mcg/act....................................................... 49STIVARGA -regorafenib tab 40 mg...................................18STRENSIQ -asfotase alfa subcutaneous inj 18mg/0.45ml........................................................................34STRENSIQ -asfotase alfa subcutaneous inj 28mg/0.7ml..........................................................................34STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 34STRENSIQ -asfotase alfa subcutaneous inj 80mg/0.8ml..........................................................................34STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg........................................................ 7STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)................................................49SUCRAID -sacrosidase soln 8500 unit/ml........................ 52sucralfate tab 1 gm (Carafate)....................................... 51SULFACETAMIDE SODIUM/PRED -sulfacetamidesodium-prednisolone ophth soln 10-0.23(0.25)%.......... 94sulfacetamide sodium lotion 10% (acne) (Klaron).......98sulfacetamide sodium ophth soln 10% (Bleph-10)...... 94SULFACETAMIDE SODIUM -sulfacetamide sodium ophthoint 10%.......................................................................... 94SULFADIAZINE -sulfadiazine tab 500 mg.......................... 3

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 148sulfamethoxazole-trimethoprim susp 200-40mg/5ml.............................................................................. 9sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)...........................................................................9sulfamethoxazole-trimethoprim tab 800-160 mg(Bactrim ds)..................................................................... 9SULFAMYLON -mafenide acetate cream 85 mg/gm........ 98sulfasalazine tab delayed release 500 mg (Azulfidineen-tabs)...........................................................................53sulfasalazine tab 500 mg (Azulfidine)........................... 54sulindac tab 150 mg........................................................ 73sulindac tab 200 mg........................................................ 73sumatriptan nasal spray 5 mg/act (Imitrex)..................74sumatriptan nasal spray 20 mg/act (Imitrex)................74sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............74SUMATRIPTAN SUCCINATE REF -sumatriptan succinatesolution cartridge 4 mg/0.5ml......................................... 74SUMATRIPTAN SUCCINATE REF -sumatriptan succinatesolution cartridge 6 mg/0.5ml......................................... 74sumatriptan succinate solution auto-injector 4mg/0.5ml (Imitrex statdose sys)................................. 74sumatriptan succinate solution auto-injector 6mg/0.5ml (Imitrex statdose sys)................................. 74sumatriptan succinate tab 25 mg (Imitrex)...................74sumatriptan succinate tab 50 mg (Imitrex)...................74sumatriptan succinate tab 100 mg (Imitrex).................75sunitinib malate cap 12.5 mg (base equivalent)(Sutent)........................................................................... 18sunitinib malate cap 25 mg (base equivalent)(Sutent)........................................................................... 18sunitinib malate cap 37.5 mg (base equivalent)(Sutent)........................................................................... 18sunitinib malate cap 50 mg (base equivalent)(Sutent)........................................................................... 18SUNOSI -solriamfetol hcl tab 75 mg (base equiv)............ 64SUNOSI -solriamfetol hcl tab 150 mg (base equiv).......... 64SUPREP BOWEL PREP KIT -sod sulfate-pot sulf-mg sulforal sol 17.5-3.13-1.6 gm/177ml.................................... 51SUTAB -sod sulfate-mg sulfate-pot chloride tab1479-225-188 mg............................................................51SYMBICORT -budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act...................................................49SYMBICORT -budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act................................................. 49SYMDEKO -tezacaftor-ivacaftor 50-75 mg & ivacaftor 75mg tab tbpk..................................................................... 50SYMDEKO -tezacaftor-ivacaftor 100-150 mg & ivacaftor150 mg tab tbpk..............................................................50SYMJEPI -epinephrine soln prefilled syringe 0.15mg/0.3ml (1:2000)...........................................................43SYMJEPI -epinephrine solution prefilled syringe 0.3mg/0.3ml (1:1000)...........................................................43SYMPROIC -naldemedine tosylate tab 0.2 mg (baseequivalent)....................................................................... 54SYMTUZA -darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mg.......................................................... 7SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200mcg/act) (base eq)..........................................................34SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000mg....................................................................................26SYNJARDY -empagliflozin-metformin hcl tab 12.5-500mg....................................................................................26SYNJARDY -empagliflozin-metformin hcl tab 5-500mg....................................................................................26SYNJARDY -empagliflozin-metformin hcl tab 5-1000mg....................................................................................26SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr5-1000 mg....................................................................... 26SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr10-1000 mg..................................................................... 26SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr12.5-1000 mg..................................................................27SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr25-1000 mg..................................................................... 27SYNRIBO -omacetaxine mepesuccinate for inj 3.5mg....................................................................................18SYNTHROID -levothyroxine sodium tab 25 mcg.............. 30SYNTHROID -levothyroxine sodium tab 50 mcg.............. 30SYNTHROID -levothyroxine sodium tab 75 mcg.............. 30SYNTHROID -levothyroxine sodium tab 88 mcg.............. 30SYNTHROID -levothyroxine sodium tab 100 mcg............30SYNTHROID -levothyroxine sodium tab 112 mcg............ 30SYNTHROID -levothyroxine sodium tab 125 mcg............30SYNTHROID -levothyroxine sodium tab 137 mcg............30SYNTHROID -levothyroxine sodium tab 150 mcg............30SYNTHROID -levothyroxine sodium tab 175 mcg............30SYNTHROID -levothyroxine sodium tab 200 mcg............30SYNTHROID -levothyroxine sodium tab 300 mcg............30TTABLOID -thioguanine tab 40 mg..................................... 18TABRECTA -capmatinib hcl tab 150 mg........................... 18TABRECTA -capmatinib hcl tab 200 mg........................... 18tacrolimus cap 0.5 mg (Prograf).................................. 104tacrolimus cap 1 mg (Prograf)..................................... 104tacrolimus cap 5 mg (Prograf)..................................... 104tacrolimus oint 0.03% (Protopic)................................... 98tacrolimus oint 0.1% (Protopic)..................................... 98tadalafil tab 2.5 mg (Cialis).............................................46tadalafil tab 5 mg (Cialis)................................................46tadalafil tab 10 mg (Cialis)..............................................46tadalafil tab 20 mg (Cialis)..............................................46tadalafil tab 20 mg (pah) (Adcirca)................................ 45TAFINLAR -dabrafenib mesylate cap 50 mg (baseequivalent)....................................................................... 18TAFINLAR -dabrafenib mesylate cap 75 mg (baseequivalent)....................................................................... 18TAGRISSO -osimertinib mesylate tab 40 mg (baseequivalent)....................................................................... 18TAGRISSO -osimertinib mesylate tab 80 mg (baseequivalent)....................................................................... 18TAKHZYRO -lanadelumab-flyo inj 300 mg/2ml (150 mg/ml)....................................................................................92

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 149TAKHZYRO -lanadelumab-flyo soln pref syringe 300mg/2ml (150 mg/ml)........................................................92TALZENNA -talazoparib tosylate cap 0.25 mg (baseequivalent)....................................................................... 18TALZENNA -talazoparib tosylate cap 0.5 mg (baseequivalent)....................................................................... 18TALZENNA -talazoparib tosylate cap 0.75 mg (baseequivalent)....................................................................... 18TALZENNA -talazoparib tosylate cap 1 mg (baseequivalent)....................................................................... 18tamoxifen citrate tab 10 mg (base equivalent)............. 18tamoxifen citrate tab 20 mg (base equivalent)............. 18tamsulosin hcl cap 0.4 mg (Flomax)............................. 55TASIGNA -nilotinib hcl cap 50 mg (base equivalent)........ 18TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 18TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 18TAVALISSE -fostamatinib disodium tab 100 mg (baseequivalent)....................................................................... 92TAVALISSE -fostamatinib disodium tab 150 mg (baseequivalent)....................................................................... 92tazarotene cream 0.1% (Tazorac)...................................98TAZORAC -tazarotene cream 0.05%................................ 98TAZORAC -tazarotene gel 0.05%..................................... 98TAZORAC -tazarotene gel 0.1%....................................... 98TAZVERIK -tazemetostat hbr tab 200 mg.........................18TDVAX -tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml..... 12TEGRETOL -carbamazepine susp 100 mg/5ml............... 78TEGRETOL -carbamazepine tab 200 mg......................... 78TEGRETOL-XR -carbamazepine tab er 12hr 100 mg...... 78TEGRETOL-XR -carbamazepine tab er 12hr 200 mg...... 78TEGRETOL-XR -carbamazepine tab er 12hr 400 mg...... 78TEGSEDI -inotersen sod subcutaneous pref syr 284mg/1.5ml (base eq).........................................................68telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 42telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 42telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 42telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 42telmisartan-hydrochlorothiazide tab 40-12.5 mg(Micardis hct).................................................................42telmisartan-hydrochlorothiazide tab 80-12.5 mg(Micardis hct).................................................................42telmisartan-hydrochlorothiazide tab 80-25 mg(Micardis hct).................................................................42telmisartan tab 20 mg (Micardis)................................... 42telmisartan tab 40 mg (Micardis)................................... 42telmisartan tab 80 mg (Micardis)................................... 42temazepam cap 15 mg (Restoril)................................... 62temazepam cap 30 mg (Restoril)................................... 62temozolomide cap 5 mg (Temodar)...............................18temozolomide cap 20 mg (Temodar)............................. 18temozolomide cap 100 mg (Temodar)...........................18temozolomide cap 140 mg (Temodar)...........................18temozolomide cap 180 mg (Temodar)...........................18temozolomide cap 250 mg (Temodar)...........................18TENCON -butalbital-acetaminophen tab 50-325 mg........ 68TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 12tenofovir disoproxil fumarate tab 300 mg (Viread)........ 7TEPMETKO -tepotinib hcl tab 225 mg..............................18terazosin hcl cap 1 mg (base equivalent).....................42terazosin hcl cap 2 mg (base equivalent).....................42terazosin hcl cap 5 mg (base equivalent).....................42terazosin hcl cap 10 mg (base equivalent)...................42terbinafine hcl tab 250 mg (Lamisil)................................4terbutaline sulfate tab 2.5 mg........................................ 50terbutaline sulfate tab 5 mg........................................... 50terconazole vaginal cream 0.8%.................................... 55terconazole vaginal cream 0.4% (Terazol 7)................. 55terconazole vaginal suppos 80 mg............................... 55testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone)..................................................................20testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)..................................................................21TESTOSTERONE ENANTHATE -testosterone enanthateim inj in oil 200 mg/ml.................................................... 21testosterone td gel 12.5 mg/act (1%).............................21testosterone td gel 20.25 mg/act (1.62%) (Androgelpump)..............................................................................21testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 21testosterone td gel 50 mg/5gm (1%) (Androgel).......... 21testosterone td soln 30 mg/act (Axiron)....................... 21tetrabenazine tab 12.5 mg (Xenazine)........................... 68tetrabenazine tab 25 mg (Xenazine).............................. 68tetracaine hcl ophth soln 0.5%...................................... 94tetracycline hcl cap 250 mg (Tetracycline hcl)...............3tetracycline hcl cap 500 mg (Tetracycline hcl)...............3THALOMID -thalidomide cap 50 mg............................... 104THALOMID -thalidomide cap 100 mg............................. 104THALOMID -thalidomide cap 150 mg............................. 104THALOMID -thalidomide cap 200 mg............................. 104theophylline soln 80 mg/15ml........................................ 50theophylline tab er 12hr 300 mg.................................... 50theophylline tab er 12hr 450 mg.................................... 50theophylline tab er 24hr 400 mg.................................... 50theophylline tab er 24hr 600 mg.................................... 50THEO-24 -theophylline cap er 24hr 100 mg..................... 50THEO-24 -theophylline cap er 24hr 200 mg..................... 50THEO-24 -theophylline cap er 24hr 300 mg..................... 50THEO-24 -theophylline cap er 24hr 400 mg..................... 50THIOLA EC -tiopronin tab delayed release 100 mg......... 55THIOLA EC -tiopronin tab delayed release 300 mg......... 55thiothixene cap 1 mg.......................................................61thiothixene cap 2 mg.......................................................61thiothixene cap 5 mg.......................................................61thiothixene cap 10 mg.....................................................61THROMBIN-JMI DILUENT -thrombin for soln 5000unit................................................................................... 86THROMBIN-JMI DILUENT -thrombin for soln 20000unit................................................................................... 86THROMBIN-JMI EPISTAXIS -thrombin for soln kit 5000unit................................................................................... 86THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit5000 unit......................................................................... 86THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit20000 unit....................................................................... 86

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 150THROMBIN-JMI W/DIL SPRAY -thrombin for soln kit20000 unit....................................................................... 86THYQUIDITY -levothyroxine sodium oral solution 100mcg/5ml........................................................................... 30thyroid tab 15 mg (1/4 grain) (Armour thyroid)............ 30thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 30thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 30thyroid tab 60 mg (1 grain) (Armour thyroid)............... 30thyroid tab 120 mg (2 grain) (Armour thyroid)............. 30tiagabine hcl tab 2 mg (Gabitril).................................... 78tiagabine hcl tab 4 mg (Gabitril).................................... 78tiagabine hcl tab 12 mg (Gabitril).................................. 78tiagabine hcl tab 16 mg (Gabitril).................................. 78TIBSOVO -ivosidenib tab 250 mg..................................... 18timolol maleate ophth soln 0.25% (Timoptic)...............94timolol maleate ophth soln 0.5% (Timoptic).................94tinidazole tab 250 mg........................................................ 9tinidazole tab 500 mg (Tindamax)....................................9tiopronin tab 100 mg (Thiola).........................................55TIROSINT -levothyroxine sodium cap 13 mcg..................30TIROSINT -levothyroxine sodium cap 25 mcg..................30TIROSINT -levothyroxine sodium cap 50 mcg..................30TIROSINT -levothyroxine sodium cap 75 mcg..................30TIROSINT -levothyroxine sodium cap 88 mcg..................30TIROSINT -levothyroxine sodium cap 100 mcg................30TIROSINT -levothyroxine sodium cap 112 mcg................30TIROSINT -levothyroxine sodium cap 125 mcg................30TIROSINT -levothyroxine sodium cap 137 mcg................30TIROSINT -levothyroxine sodium cap 150 mcg................30TIROSINT -levothyroxine sodium cap 175 mcg................30TIROSINT -levothyroxine sodium cap 200 mcg................30TIROSINT-SOL -levothyroxine sodium oral solution 13mcg/ml............................................................................. 30TIROSINT-SOL -levothyroxine sodium oral solution 25mcg/ml............................................................................. 30TIROSINT-SOL -levothyroxine sodium oral solution 37.5mcg/ml............................................................................. 30TIROSINT-SOL -levothyroxine sodium oral solution 44mcg/ml............................................................................. 30TIROSINT-SOL -levothyroxine sodium oral solution 50mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 62.5mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 75mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 88mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 100mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 112mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 125mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 137mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 150mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 175mcg/ml............................................................................. 31TIROSINT-SOL -levothyroxine sodium oral solution 200mcg/ml............................................................................. 31TISSEEL -fibrin sealant component kit 2 ml..................... 86TISSEEL -fibrin sealant component kit 4 ml..................... 86TISSEEL -fibrin sealant component kit 10 ml................... 86TISSEEL -fibrin sealant component solution.................... 86TIVICAY -dolutegravir sodium tab 10 mg (base equiv).......7TIVICAY -dolutegravir sodium tab 25 mg (base equiv).......7TIVICAY -dolutegravir sodium tab 50 mg (base equiv).......7TIVICAY PD -dolutegravir sodium tab for oral susp 5 mg(base equiv)...................................................................... 7tizanidine hcl tab 2 mg (base equivalent).....................81tizanidine hcl tab 4 mg (base equivalent)(Zanaflex)........................................................................81TOBI PODHALER -tobramycin inhal cap 28 mg.................3tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex)...................................................................... 94tobramycin nebu soln 300 mg/4ml (Bethkis)..................3tobramycin nebu soln 300 mg/5ml (Tobi)....................... 3tobramycin ophth soln 0.3% (Tobrex)...........................94TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............3TODAY SPONGE -nonoxynol-9 vaginal sponge 1000mg....................................................................................55tolcapone tab 100 mg (Tasmar)..................................... 81tolterodine tartrate cap er 24hr 2 mg (Detrol la).......... 54tolterodine tartrate cap er 24hr 4 mg (Detrol la).......... 54tolterodine tartrate tab 1 mg (Detrol)............................ 54tolterodine tartrate tab 2 mg (Detrol)............................ 54tolvaptan tab 15 mg (Samsca)....................................... 34tolvaptan tab 30 mg (Samsca)....................................... 34topiramate cap er 24hr sprinkle 25 mg (Qudexyxr).................................................................................... 78topiramate cap er 24hr sprinkle 50 mg (Qudexyxr).................................................................................... 78topiramate cap er 24hr sprinkle 100 mg (Qudexyxr).................................................................................... 78topiramate cap er 24hr sprinkle 150 mg (Qudexyxr).................................................................................... 78topiramate cap er 24hr sprinkle 200 mg (Qudexyxr).................................................................................... 78topiramate sprinkle cap 15 mg (Topamaxsprinkle)..........................................................................78topiramate sprinkle cap 25 mg (Topamaxsprinkle)..........................................................................78topiramate tab 25 mg (Topamax)...................................78topiramate tab 50 mg (Topamax)...................................78topiramate tab 100 mg (Topamax)................................. 78topiramate tab 200 mg (Topamax)................................. 78toremifene citrate tab 60 mg (base equivalent)(Fareston)....................................................................... 18torsemide tab 5 mg......................................................... 43torsemide tab 100 mg..................................................... 43torsemide tab 10 mg (Demadex)....................................43torsemide tab 20 mg (Demadex)....................................43

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 151TOUJEO MAX SOLOSTAR -insulin glargine soln pen-injector 300 unit/ml (2 unit dial)......................................28TOUJEO SOLOSTAR -insulin glargine soln pen-injector300 unit/ml (1 unit dial)...................................................28TRACLEER -bosentan tab for oral susp 32 mg................45tramadol-acetaminophen tab 37.5-325 mg(Ultracet).........................................................................71TRAMADOL HCL ER -tramadol hcl tab er 24hr biphasicrelease 100 mg...............................................................71TRAMADOL HCL ER -tramadol hcl tab er 24hr biphasicrelease 200 mg...............................................................71TRAMADOL HCL ER -tramadol hcl tab er 24hr biphasicrelease 300 mg...............................................................71tramadol hcl tab er 24hr 100 mg....................................71tramadol hcl tab er 24hr 200 mg....................................71tramadol hcl tab er 24hr 300 mg....................................71tramadol hcl tab 50 mg (Ultram).................................... 71TRANDOLAPRIL/VERAPAMIL HC -trandolapril-verapamilhcl tab er 1-240 mg........................................................ 42TRANDOLAPRIL/VERAPAMIL HC -trandolapril-verapamilhcl tab er 2-180 mg........................................................ 42TRANDOLAPRIL/VERAPAMIL HC -trandolapril-verapamilhcl tab er 2-240 mg........................................................ 42TRANDOLAPRIL/VERAPAMIL HC -trandolapril-verapamilhcl tab er 4-240 mg........................................................ 42trandolapril tab 4 mg....................................................... 42trandolapril tab 1 mg (Mavik)......................................... 42trandolapril tab 2 mg (Mavik)......................................... 42tranexamic acid tab 650 mg (Lysteda).......................... 86tranylcypromine sulfate tab 10 mg (Parnate)............... 58trazodone hcl tab 50 mg................................................. 58trazodone hcl tab 100 mg............................................... 58trazodone hcl tab 150 mg............................................... 58TRECATOR -ethionamide tab 250 mg................................4TRELEGY ELLIPTA -fluticasone-umeclidinium-vilanterolaepb 100-62.5-25 mcg/inh............................................. 50TRELEGY ELLIPTA -fluticasone-umeclidinium-vilanterolaepb 200-62.5-25 mcg/inh............................................. 50TREMFYA -guselkumab soln pen-injector 100 mg/ml...... 98TREMFYA -guselkumab soln prefilled syringe 100 mg/ml..................................................................................... 98TRESIBA FLEXTOUCH -insulin degludec soln pen-injector 100 unit/ml......................................................... 29TRESIBA FLEXTOUCH -insulin degludec soln pen-injector 200 unit/ml......................................................... 29TRESIBA -insulin degludec inj 100 unit/ml....................... 28tretinoin cap 10 mg......................................................... 18tretinoin cream 0.025% (Retin-a)................................... 98tretinoin cream 0.05% (Retin-a)..................................... 98tretinoin cream 0.1% (Retin-a)....................................... 98tretinoin gel 0.01% (Retin-a)........................................... 98TRETTEN -coagulation factor xiii a-subunit for inj2000-3125 unit................................................................ 92triamcinolone acetonide cream 0.025%........................98triamcinolone acetonide cream 0.1%............................ 98triamcinolone acetonide cream 0.5%............................ 98triamcinolone acetonide dental paste 0.1%................. 95triamcinolone acetonide lotion 0.025%.........................98triamcinolone acetonide lotion 0.1%.............................98triamcinolone acetonide oint 0.025%............................ 98triamcinolone acetonide oint 0.1%................................ 98triamcinolone acetonide oint 0.5%................................ 98triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide).........................................................................43triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)...................................................................43triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)........................................................................ 43triamterene cap 50 mg (Dyrenium)................................ 43triamterene cap 100 mg (Dyrenium)..............................43trientine hcl cap 250 mg (Syprine).............................. 104trifluoperazine hcl tab 1 mg (base equivalent).............61trifluoperazine hcl tab 2 mg (base equivalent).............61trifluoperazine hcl tab 5 mg (base equivalent).............61trifluoperazine hcl tab 10 mg (base equivalent)...........61TRIFLURIDINE -trifluridine ophth soln 1%........................94trihexyphenidyl hcl tab 2 mg..........................................81trihexyphenidyl hcl tab 5 mg..........................................81TRIHEXYPHENIDYL HCL -trihexyphenidyl hcl oral soln0.4 mg/ml........................................................................ 81TRIJARDY XR -empagliflozin-linaglip-metformin tab er24hr 12.5-2.5-1000mg.................................................... 27TRIJARDY XR -empagliflozin-linagliptin-metformin tab er24hr 5-2.5-1000mg......................................................... 27TRIJARDY XR -empagliflozin-linagliptin-metformin tab er24hr 10-5-1000 mg......................................................... 27TRIJARDY XR -empagliflozin-linagliptin-metformin tab er24hr 25-5-1000 mg......................................................... 27TRIKAFTA -elexacaf-tezacaf-ivacaf 100-50-75 mg&ivacaftor 150 mg tbpk.................................................. 50TRIKAFTA -elexacaf-tezacaf-ivacaf 50-25-37.5 mg &ivacaftor 75 mg tbpk....................................................... 50trimethobenzamide hcl cap 300 mg (Tigan)................. 52TRIMETHOPRIM -trimethoprim tab 100 mg....................... 9trimipramine maleate cap 25 mg (Surmontil)............... 58trimipramine maleate cap 50 mg (Surmontil)............... 58trimipramine maleate cap 100 mg (Surmontil)............. 58TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg.......81TRINTELLIX -vortioxetine hbr tab 5 mg (base equiv).......58TRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)..... 58TRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)..... 58TRIUMEQ -abacavir-dolutegravir-lamivudine tab600-50-300 mg..................................................................7TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab300-150-300 mg................................................................8TROKENDI XR -topiramate cap er 24hr 25 mg................78TROKENDI XR -topiramate cap er 24hr 50 mg................78TROKENDI XR -topiramate cap er 24hr 100 mg..............78TROKENDI XR -topiramate cap er 24hr 200 mg..............78trospium chloride cap er 24hr 60 mg............................54trospium chloride tab 20 mg.......................................... 54TRULANCE -plecanatide tab 3 mg................................... 54TRULICITY -dulaglutide soln pen-injector 0.75mg/0.5ml..........................................................................27

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 152TRULICITY -dulaglutide soln pen-injector 1.5mg/0.5ml..........................................................................27TRULICITY -dulaglutide soln pen-injector 3 mg/0.5ml......27TRULICITY -dulaglutide soln pen-injector 4.5mg/0.5ml..........................................................................27TRUMENBA -meningococcal group b vac (recomb) imsusp prefilled syr.............................................................11TRUSELTIQ -infigratinib phos cap pack 100 & 25 mg (125mg daily dose)................................................................ 18TRUSELTIQ -infigratinib phos cap ther pack 100 mg (100mg daily dose)................................................................ 18TRUSELTIQ -infigratinib phos cap ther pack 2 x 25 mg(50 mg daily dose)..........................................................18TRUSELTIQ -infigratinib phos cap ther pack 3 x 25 mg(75 mg daily dose)..........................................................18TUKYSA -tucatinib tab 50 mg........................................... 18TUKYSA -tucatinib tab 150 mg......................................... 18TURALIO -pexidartinib hcl cap 200 mg (baseequivalent)....................................................................... 18TWINRIX -hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml............................................................................. 11TYBLUME -levonorgestrel & ethinyl estradiol chew tab0.1 mg-20 mcg................................................................24TYBOST -cobicistat tab 150 mg..........................................8TYMLOS -abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml............................................................ 34TYVASO REFILL -treprostinil inhalation solution 0.6 mg/ml..................................................................................... 45TYVASO STARTER -treprostinil inhalation solution 0.6mg/ml............................................................................... 45TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 45UUBRELVY -ubrogepant tab 50 mg.................................... 75UBRELVY -ubrogepant tab 100 mg.................................. 75UCERIS -budesonide rectal foam 2 mg/act...................... 95UPTRAVI -selexipag tab 200 mcg.....................................45UPTRAVI -selexipag tab 400 mcg.....................................45UPTRAVI -selexipag tab 600 mcg.....................................45UPTRAVI -selexipag tab 800 mcg.....................................45UPTRAVI -selexipag tab 1000 mcg...................................45UPTRAVI -selexipag tab 1200 mcg...................................45UPTRAVI -selexipag tab 1400 mcg...................................46UPTRAVI -selexipag tab 1600 mcg...................................46UPTRAVI -selexipag tab therapy pack 200 mcg (140) &800 mcg (60)...................................................................45ursodiol cap 300 mg (Actigall)....................................... 54ursodiol tab 250 mg (Urso 250)..................................... 54ursodiol tab 500 mg (Urso forte)................................... 54VVAGIFEM -estradiol vaginal tab 10 mcg........................... 55valacyclovir hcl tab 1 gm (Valtrex).................................. 8valacyclovir hcl tab 500 mg (Valtrex).............................. 8VALCHLOR -mechlorethamine hcl gel 0.016% (baseequivalent)....................................................................... 98valganciclovir hcl for soln 50 mg/ml (base equiv)(Valcyte)............................................................................8valganciclovir hcl tab 450 mg (base equivalent)(Valcyte)............................................................................8valproate sodium oral soln 250 mg/5ml (base equiv)(Depakene)..................................................................... 79valproic acid cap 250 mg (Depakene)........................... 79valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).................................................................................. 42valsartan-hydrochlorothiazide tab 160-12.5 mg(Diovan hct)................................................................... 42valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).................................................................................. 42valsartan-hydrochlorothiazide tab 320-12.5 mg(Diovan hct)................................................................... 42valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).................................................................................. 42valsartan tab 40 mg (Diovan)......................................... 42valsartan tab 80 mg (Diovan)......................................... 42valsartan tab 160 mg (Diovan)....................................... 42valsartan tab 320 mg (Diovan)....................................... 42VALTOCO -diazepam nasal spray 5 mg/0.1 ml................ 79VALTOCO -diazepam nasal spray 10 mg/0.1 ml.............. 79VALTOCO -diazepam nasal spray ther pack 2 x 7.5mg/0.1ml (15 mg dose).................................................. 79VALTOCO -diazepam nasal spray ther pack 2 x 10mg/0.1ml (20 mg dose).................................................. 79VALUE PLUS GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 27vancomycin hcl cap 125 mg (base equivalent)(Vancocin hcl)..................................................................9vancomycin hcl cap 250 mg (base equivalent)(Vancocin hcl)..................................................................9VANDAZOLE -metronidazole vaginal gel 0.75%.............. 55VAQTA -hepatitis a vaccine inj susp 25 unit/0.5ml............11VAQTA -hepatitis a vaccine inj susp 50 unit/ml.................11vardenafil hcl orally disintegrating tab 10 mg(Staxyn).......................................................................... 46vardenafil hcl tab 2.5 mg (Levitra).................................46vardenafil hcl tab 5 mg (Levitra)....................................46vardenafil hcl tab 10 mg (Levitra)..................................46vardenafil hcl tab 20 mg (Levitra)..................................46VARENICLINE STARTING MONT -varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack.................................68VARENICLINE TARTRATE -varenicline tartrate tab 0.5mg (base equiv).............................................................. 68VARENICLINE TARTRATE -varenicline tartrate tab 1 mg(base equiv).................................................................... 68VARIVAX -varicella virus vac live for subcutaneous inj1350 pfu/0.5ml................................................................ 11VARUBI -rolapitant hcl tab therapy pack 2 x 90 mg (baseequiv)............................................................................... 52VASCEPA -icosapent ethyl cap 0.5 gm............................ 45VASCEPA -icosapent ethyl cap 1 gm............................... 45VAXELIS -diph-tet tox-ac pert ad-polio ipv-hib-hepatitis brecmb susp......................................................................12

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 153VAXELIS -diph-tet tox-ac pert ad-polio ipv-hib-hep b recsusp pre syr.................................................................... 12VAXNEUVANCE -pneumococcal 15-valent conjugatevaccine sus pref syr 0.5 ml............................................ 11VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 film28%..................................................................................55VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 foam12.5%...............................................................................55VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 gel4%....................................................................................55VECAMYL -mecamylamine hcl tab 2.5 mg.......................42VELPHORO -sucroferric oxyhydroxide chew tab 500mg....................................................................................54VELTASSA -patiromer sorbitex calcium for susp packet8.4 gm (base eq).......................................................... 104VELTASSA -patiromer sorbitex calcium for susp packet16.8 gm (base eq)........................................................ 104VELTASSA -patiromer sorbitex calcium for susp packet25.2 gm (base eq)........................................................ 104VEMLIDY -tenofovir alafenamide fumarate tab 25 mg....... 8VENCLEXTA STARTING PACK -venetoclax tab therapystarter pack 10 & 50 & 100 mg......................................19VENCLEXTA -venetoclax tab 10 mg.................................19VENCLEXTA -venetoclax tab 50 mg.................................19VENCLEXTA -venetoclax tab 100 mg...............................19venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)..................................................................... 58venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)..................................................................... 58venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)..................................................................... 58venlafaxine hcl tab 25 mg (base equivalent)................58venlafaxine hcl tab 37.5 mg (base equivalent)............. 58venlafaxine hcl tab 50 mg (base equivalent)................58venlafaxine hcl tab 75 mg (base equivalent)................59venlafaxine hcl tab 100 mg (base equivalent).............. 59VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 46VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 46VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv)........................................................ 50verapamil hcl cap er 24hr 120 mg (Verelan)................. 37verapamil hcl cap er 24hr 180 mg (Verelan)................. 37verapamil hcl cap er 24hr 240 mg (Verelan)................. 38VERAPAMIL HCL ER -verapamil hcl cap er 24hr 100mg....................................................................................38VERAPAMIL HCL ER -verapamil hcl cap er 24hr 300mg....................................................................................38VERAPAMIL HCL SR -verapamil hcl cap er 24hr 360mg....................................................................................38verapamil hcl tab er 120 mg (Calan sr).........................38verapamil hcl tab er 180 mg (Calan sr).........................38verapamil hcl tab er 240 mg (Calan sr).........................38verapamil hcl tab 40 mg................................................. 38verapamil hcl tab 80 mg (Calan).................................... 38verapamil hcl tab 120 mg (Calan).................................. 38VERAPAMIL HYDROCHLORIDE E -verapamil hcl cap er24hr 200 mg....................................................................38VERELAN PM -verapamil hcl cap er 24hr 100 mg........... 38VERELAN PM -verapamil hcl cap er 24hr 200 mg........... 38VERELAN PM -verapamil hcl cap er 24hr 300 mg........... 38VERQUVO -vericiguat tab 2.5 mg.................................... 46VERQUVO -vericiguat tab 5 mg....................................... 46VERQUVO -vericiguat tab 10 mg..................................... 46VERSACLOZ -clozapine susp 50 mg/ml.......................... 61VERZENIO -abemaciclib tab 50 mg................................. 19VERZENIO -abemaciclib tab 100 mg............................... 19VERZENIO -abemaciclib tab 150 mg............................... 19VERZENIO -abemaciclib tab 200 mg............................... 19VIBERZI -eluxadoline tab 75 mg.......................................54VIBERZI -eluxadoline tab 100 mg.....................................54VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)....................................................................................27vigabatrin powd pack 500 mg (Sabril).......................... 79vigabatrin tab 500 mg (Sabril)........................................79VIIBRYD STARTER PACK -vilazodone hcl tab starter kit10 (7) & 20 (23) mg....................................................... 59VIIBRYD -vilazodone hcl tab 10 mg..................................59VIIBRYD -vilazodone hcl tab 20 mg..................................59VIIBRYD -vilazodone hcl tab 40 mg..................................59vilazodone hcl tab 10 mg (Viibryd)................................59vilazodone hcl tab 20 mg (Viibryd)................................59vilazodone hcl tab 40 mg (Viibryd)................................59VIMPAT -lacosamide oral solution 10 mg/ml.................... 79VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab29-1 mg........................................................................... 82VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1mg....................................................................................82VIRACEPT -nelfinavir mesylate tab 250 mg....................... 8VIRACEPT -nelfinavir mesylate tab 625 mg....................... 8VIREAD -tenofovir disoproxil fumarate oral powder 40mg/gm................................................................................8VIREAD -tenofovir disoproxil fumarate tab 150 mg............ 8VIREAD -tenofovir disoproxil fumarate tab 200 mg............ 8VIREAD -tenofovir disoproxil fumarate tab 250 mg............ 8VITRAKVI -larotrectinib sulfate cap 25 mg (baseequivalent)....................................................................... 19VITRAKVI -larotrectinib sulfate cap 100 mg (baseequivalent)....................................................................... 19VITRAKVI -larotrectinib sulfate oral soln 20 mg/ml (baseequivalent)....................................................................... 19VIVOTIF -typhoid vaccine cap delayed release................12VIZIMPRO -dacomitinib tab 15 mg................................... 19VIZIMPRO -dacomitinib tab 30 mg................................... 19VIZIMPRO -dacomitinib tab 45 mg................................... 19VONJO -pacritinib citrate cap 100 mg.............................. 19VONVENDI -von willebrand factor (recombinant) for inj650 unit........................................................................... 92VONVENDI -von willebrand factor (recombinant) for inj1300 unit......................................................................... 92voriconazole for susp 40 mg/ml (Vfend).........................4voriconazole tab 50 mg (Vfend)....................................... 4voriconazole tab 200 mg (Vfend).....................................4VORTEX VALVED HOLDING CHA -spacer/aerosol-holding chambers - device........................................... 102

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 154VOSEVI -sofosbuvir-velpatasvir-voxilaprevir tab400-100-100 mg................................................................8VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 19VOXZOGO -vosoritide for subcutaneous inj 0.4 mg......... 34VOXZOGO -vosoritide for subcutaneous inj 0.56 mg....... 34VOXZOGO -vosoritide for subcutaneous inj 1.2 mg......... 35VRAYLAR -cariprazine hcl cap 1.5 mg (baseequivalent)....................................................................... 62VRAYLAR -cariprazine hcl cap 3 mg (baseequivalent)....................................................................... 62VRAYLAR -cariprazine hcl cap 4.5 mg (baseequivalent)....................................................................... 62VRAYLAR -cariprazine hcl cap 6 mg (baseequivalent)....................................................................... 62VRAYLAR -cariprazine hcl cap therapy pack 1.5 mg (1) &3 mg (6).......................................................................... 61VYLEESI -bremelanotide acet subcutaneous soln auto-inj1.75 mg/0.3ml................................................................. 68VYNDAMAX -tafamidis cap 61 mg................................... 46VYNDAQEL -tafamidis meglumine (cardiac) cap 20mg....................................................................................46VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 64VYVANSE -lisdexamfetamine dimesylate cap 20 mg....... 64VYVANSE -lisdexamfetamine dimesylate cap 30 mg....... 64VYVANSE -lisdexamfetamine dimesylate cap 40 mg....... 65VYVANSE -lisdexamfetamine dimesylate cap 50 mg....... 65VYVANSE -lisdexamfetamine dimesylate cap 60 mg....... 65VYVANSE -lisdexamfetamine dimesylate cap 70 mg....... 65VYVANSE -lisdexamfetamine dimesylate chew tab 10mg....................................................................................65VYVANSE -lisdexamfetamine dimesylate chew tab 20mg....................................................................................65VYVANSE -lisdexamfetamine dimesylate chew tab 30mg....................................................................................65VYVANSE -lisdexamfetamine dimesylate chew tab 40mg....................................................................................65VYVANSE -lisdexamfetamine dimesylate chew tab 50mg....................................................................................65VYVANSE -lisdexamfetamine dimesylate chew tab 60mg....................................................................................65WWALGREENS GLUCOSE -glucose chew tab 4 gm(rounded)......................................................................... 27warfarin sodium tab 1 mg (Coumadin)......................... 85warfarin sodium tab 2 mg (Coumadin)......................... 85warfarin sodium tab 2.5 mg (Coumadin)...................... 85warfarin sodium tab 3 mg (Coumadin)......................... 86warfarin sodium tab 4 mg (Coumadin)......................... 86warfarin sodium tab 5 mg (Coumadin)......................... 86warfarin sodium tab 6 mg (Coumadin)......................... 86warfarin sodium tab 7.5 mg (Coumadin)...................... 86warfarin sodium tab 10 mg (Coumadin)....................... 86WEGOVY -semaglutide (weight mngmt) soln auto-injector0.25 mg/0.5ml................................................................. 65WEGOVY -semaglutide (weight mngmt) soln auto-injector0.5 mg/0.5ml................................................................... 65WEGOVY -semaglutide (weight mngmt) soln auto-injector1 mg/0.5ml...................................................................... 65WEGOVY -semaglutide (weight mngmt) soln auto-injector1.7 mg/0.75ml................................................................. 65WEGOVY -semaglutide (weight mngmt) soln auto-injector2.4 mg/0.75ml................................................................. 65WELIREG -belzutifan tab 40 mg.......................................19WESTAB MAX -folic acid-pyridoxine-cyanocobalamin tab2.5-25-2 mg.....................................................................82WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60mm.................................................................................102WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65mm.................................................................................102WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70mm.................................................................................102WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75mm.................................................................................102WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80mm.................................................................................102WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85mm.................................................................................102WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90mm.................................................................................102WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95mm.................................................................................102WILATE -antihemophilic factor/vwf (human) for inj500-500 unit kit............................................................... 92WILATE -antihemophilic factor/vwf (human) for inj1000-1000 unit kit........................................................... 92XXALKORI -crizotinib cap 200 mg...................................... 19XALKORI -crizotinib cap 250 mg...................................... 19XARELTO -rivaroxaban for susp 1 mg/ml.........................86XARELTO -rivaroxaban tab 2.5 mg...................................86XARELTO -rivaroxaban tab 10 mg....................................86XARELTO -rivaroxaban tab 15 mg....................................86XARELTO -rivaroxaban tab 20 mg....................................86XARELTO STARTER PACK -rivaroxaban tab startertherapy pack 15 mg & 20 mg........................................ 86XCOPRI -cenobamate tab 50 mg..................................... 79XCOPRI -cenobamate tab 100 mg................................... 79XCOPRI -cenobamate tab 150 mg................................... 79XCOPRI -cenobamate tab 200 mg................................... 79XCOPRI -cenobamate tab pack 100 mg & 150 mg tabs(250 mg daily dose)........................................................79XCOPRI -cenobamate tab pack 150 mg & 200 mg tabs(350 mg daily dose)........................................................79XCOPRI -cenobamate tab titration pack 14 x 12.5 mg &14 x 25 mg......................................................................79XCOPRI -cenobamate tab titration pack 14 x 50 mg & 14x 100 mg......................................................................... 79XCOPRI -cenobamate tab titration pack 14 x 150 mg & 14x 200 mg......................................................................... 79XELJANZ -tofacitinib citrate oral soln 1 mg/ml (baseequivalent)....................................................................... 73

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 155XELJANZ -tofacitinib citrate tab 5 mg (baseequivalent)....................................................................... 73XELJANZ -tofacitinib citrate tab 10 mg (baseequivalent)....................................................................... 73XELJANZ XR -tofacitinib citrate tab er 24hr 11 mg (baseequivalent)....................................................................... 73XELJANZ XR -tofacitinib citrate tab er 24hr 22 mg (baseequivalent)....................................................................... 74XENICAL -orlistat cap 120 mg.......................................... 65XERMELO -telotristat ethyl tab 250 mg (as telotristatetiprate)........................................................................... 54XHANCE -fluticasone propionate nasal exhaler susp 93mcg/act............................................................................ 47XIFAXAN -rifaximin tab 200 mg.......................................... 9XIFAXAN -rifaximin tab 550 mg.......................................... 9XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr2.5-1000 mg....................................................................27XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr5-500 mg......................................................................... 27XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr5-1000 mg....................................................................... 27XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr10-500 mg....................................................................... 27XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr10-1000 mg..................................................................... 27XOFLUZA -baloxavir marboxil tab therapy pack 2 x 20 mg(40 mg dose).....................................................................8XOFLUZA -baloxavir marboxil tab therapy pack 1 x 40 mg(40 mg dose).....................................................................8XOFLUZA -baloxavir marboxil tab therapy pack 1 x 80 mg(80 mg dose).....................................................................8XOLAIR -omalizumab subcutaneous soln prefilled syringe75 mg/0.5ml.................................................................... 50XOLAIR -omalizumab subcutaneous soln prefilled syringe150 mg/ml....................................................................... 50XOSPATA -gilteritinib fumarate tablet 40 mg (baseequivalent)....................................................................... 19XPOVIO 60 MG TWICE WEEKLY -selinexor tab therapypack 20 mg (60 mg twice weekly)................................. 19XPOVIO 80 MG TWICE WEEKLY -selinexor tab therapypack 20 mg (80 mg twice weekly)................................. 19XPOVIO -selinexor tab therapy pack 40 mg (40 mg onceweekly).............................................................................19XPOVIO -selinexor tab therapy pack 40 mg (80 mg onceweekly).............................................................................19XPOVIO -selinexor tab therapy pack 50 mg (100 mg onceweekly).............................................................................19XPOVIO -selinexor tab therapy pack 60 mg (60 mg onceweekly).............................................................................19XPOVIO -selinexor tab therapy pack 40 mg (40 mg twiceweekly).............................................................................19XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9mg....................................................................................71XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent13.5 mg........................................................................... 71XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent18 mg.............................................................................. 71XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent27 mg.............................................................................. 71XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent36 mg.............................................................................. 71XTANDI -enzalutamide cap 40 mg....................................19XTANDI -enzalutamide tab 40 mg.....................................19XTANDI -enzalutamide tab 80 mg.....................................19XULTOPHY 100/3.6 -insulin degludec-liraglutide sol pen-inj 100-3.6 unit-mg/ml.....................................................27XYNTHA -antihemophil fact rcmb(bdd-rfviii,mor) for inj kit1000 unit......................................................................... 92XYNTHA -antihemophil fact rcmb(bdd-rfviii,mor) for inj kit2000 unit......................................................................... 92XYNTHA -antihemophil fact rcmb (bdd-rfviii,mor) for inj kit250 unit........................................................................... 92XYNTHA -antihemophil fact rcmb (bdd-rfviii,mor) for inj kit500 unit........................................................................... 92XYNTHA SOLOFUSE -antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000 unit..........................................92XYNTHA SOLOFUSE -antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 2000 unit..........................................92XYNTHA SOLOFUSE -antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 3000 unit..........................................92XYNTHA SOLOFUSE -antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250 unit............................................92XYNTHA SOLOFUSE -antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 500 unit............................................92XYREM -sodium oxybate oral solution 500 mg/ml........... 68XYWAV -calcium, mag, potassium, & sod oxybates oralsoln 500 mg/ml............................................................... 68YYONSA -abiraterone acetate tab 125 mg......................... 19Zzafirlukast tab 10 mg (Accolate).................................... 50zafirlukast tab 20 mg (Accolate).................................... 50zaleplon cap 5 mg (Sonata)............................................62zaleplon cap 10 mg (Sonata)..........................................62ZARONTIN -ethosuximide cap 250 mg............................ 79ZARONTIN -ethosuximide soln 250 mg/5ml.....................79ZARXIO -filgrastim-sndz soln prefilled syringe 300mcg/0.5ml........................................................................ 84ZARXIO -filgrastim-sndz soln prefilled syringe 480mcg/0.8ml........................................................................ 84ZEGALOGUE -dasiglucagon hcl subcutaneous soln auto-inj 0.6 mg/0.6ml.............................................................. 27ZEGALOGUE -dasiglucagon hcl subcutaneous soln prefsyringe 0.6 mg/0.6ml...................................................... 27ZEJULA -niraparib tosylate cap 100 mg (baseequivalent)....................................................................... 19ZELBORAF -vemurafenib tab 240 mg.............................. 19ZENPEP -pancrelipase (lip-prot-amyl) dr cap3000-10000-14000 unit...................................................52ZENPEP -pancrelipase (lip-prot-amyl) dr cap5000-17000-24000 unit...................................................52

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2022Blue Cross and Blue Shield October 2022 Performance Drug List 156ZENPEP -pancrelipase (lip-prot-amyl) dr cap10000-32000-42000 unit................................................ 52ZENPEP -pancrelipase (lip-prot-amyl) dr cap15000-47000-63000 unit................................................ 52ZENPEP -pancrelipase (lip-prot-amyl) dr cap20000-63000-84000 unit................................................ 52ZENPEP -pancrelipase (lip-prot-amyl) dr cap25000-79000-105000 unit.............................................. 52ZENPEP -pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit............................................ 52ZEPOSIA 7-DAY STARTER PAC -ozanimod cap pack 4 x0.23 mg & 3 x 0.46 mg.................................................. 68ZEPOSIA -ozanimod hcl cap 0.92 mg.............................. 68ZEPOSIA STARTER KIT -ozanimod cap pack 4 x 0.23mg & 3 x 0.46 mg & 30 x 0.92 mg.................................68zidovudine cap 100 mg (Retrovir)................................... 8zidovudine syrup 10 mg/ml (Retrovir).............................8zidovudine tab 300 mg......................................................8ZIEXTENZO -pegfilgrastim-bmez soln prefilled syringe 6mg/0.6ml..........................................................................85ZIMHI -naloxone hcl soln prefilled syringe 5 mg/0.5ml..... 99ziprasidone hcl cap 20 mg (Geodon)............................ 62ziprasidone hcl cap 40 mg (Geodon)............................ 62ziprasidone hcl cap 60 mg (Geodon)............................ 62ziprasidone hcl cap 80 mg (Geodon)............................ 62ZITHROMAX -azithromycin powd pack for susp 1 gm....... 2ZOKINVY -lonafarnib cap 50 mg.................................... 104ZOKINVY -lonafarnib cap 75 mg.................................... 104ZOLINZA -vorinostat cap 100 mg..................................... 19zolmitriptan orally disintegrating tab 2.5 mg (Zomigzmt)................................................................................. 75zolmitriptan orally disintegrating tab 5 mg (Zomigzmt)................................................................................. 75zolmitriptan tab 2.5 mg (Zomig).....................................75zolmitriptan tab 5 mg (Zomig)........................................75zolpidem tartrate tab er 6.25 mg (Ambien cr)...............62zolpidem tartrate tab er 12.5 mg (Ambien cr)...............62zolpidem tartrate tab 5 mg (Ambien).............................62zolpidem tartrate tab 10 mg (Ambien)...........................62zonisamide cap 50 mg.................................................... 79zonisamide cap 25 mg (Zonegran)................................ 79zonisamide cap 100 mg (Zonegran).............................. 79ZONTIVITY -vorapaxar sulfate tab 2.08 mg (baseequivalent)....................................................................... 92ZORTRESS -everolimus tab 0.25 mg............................. 104ZORTRESS -everolimus tab 0.5 mg...............................104ZORTRESS -everolimus tab 0.75 mg............................. 104ZORTRESS -everolimus tab 1 mg.................................. 104ZYDELIG -idelalisib tab 100 mg........................................19ZYDELIG -idelalisib tab 150 mg........................................19ZYKADIA -ceritinib tab 150 mg......................................... 19