CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

Date: June 9, 2015 Market: All fully insured groups,

Consumer Direct members and 100-199 self-insured groups

Clarification: Pharmacy Update – Upcoming Formulary Changes

As a follow up to the Sales Flash released on April 17, please review the information below for clarification about upcoming formulary changes. Communications notifying impacted members and providers of these changes have been sent – you should not reach out to your accounts; there is no action that you need to take. Fully Insured (Groups and Consumer Direct): Effective July 1, 2015, all fully insured groups (regardless of size) and Consumer Direct members in Maryland and Virginia will be transitioning to CareFirst Formulary 2 with prior authorizations (PA). The transition to CareFirst Formulary 2 with PA means 90* additional drugs will require a medical necessity prior authorization before they are covered by our prescription drug benefit. This is the only drug option available to fully insured groups and Consumer Direct members in Maryland and Virginia. Attached you will find a list of the additional 90 drugs that will require prior authorization. 100-199 Self-Insured Groups: Beginning July 1, 2015, all new and renewing 100-199 self-insured groups will move to CareFirst Formulary 2 with exclusions. This means approximately 90* drugs will be excluded from the list of covered drugs starting July 1. CareFirst Formulary 2 with exclusions will be the only option available to 100-199 self-insured groups. A list of the 90 drugs that will be excluded is also attached to this Sales Flash. 200+ Self-Insured Groups: No impact. Self-insured groups can continue to choose between CareFirst Formulary 1, CareFirst Formulary 2 with exclusions, and CareFirst Formulary 3 with exclusions. Note: No paperwork is required to implement these changes. Please keep in mind, formulary management is a proven way to encourage continued savings while minimizing member disruption, which enables accounts to stay ahead of market shifts. By driving employee behavior to lower-cost options, accounts may see improved savings in pharmacy costs. Below are some key messages for reference when talking with your impacted groups. Key messages

Impacted members and their prescribing physicians were notified by mail of this change.

Effective July 1, 2015 there will be two versions of CareFirst Formulary 2 – one with a medical necessity PA requirement on 90 additional drugs (fully insured groups and Consumer Direct in MD & VA) and one with 90 excluded drugs (100-199 self-insured groups).

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

We have enhanced My Account to reflect the member’s formulary. Members can use the Drug Pricing Tool to research whether specific drugs require a PA or if they are excluded.

New ID cards will NOT be issued as a result of these changes. However, every ID card issued after July 1 will display RX, RX2 or RX3 and will include a carrier strip directing the member to log in to My Account to check their formulary.

Fully Insured (Groups and Consumer Direct):

90 additional drugs (out of our open formulary of 5,000 drugs) will now require a medical necessity prior authorization.

Since these additional 90 drugs are on the non-preferred brand tier, impacted members may save money by switching to one of the many available alternatives because they will be on a lower cost-share tier.

Members will still be able to get these drugs with an approved prior authorization IF the drug is found to be medically necessary by CareFirst based on information received from the prescribing physician.

This change impacts about four percent of fully insured members that have CareFirst prescription coverage.

Letters were mailed to all impacted fully insured groups and consumer direct members in Maryland and Virginia the week of April 27. The member letter listed the impacted drug and alternative drug options. Physicians were notified by mail on May 1.

Effective July 1, 2015, the Drug Search Tool on www.carefirst.com/rx will reflect the formulary options for fully insured members.

100-199 Self-Insured Groups:

CareFirst Formulary 2 with exclusions is the only formulary option for 100-199 self-insured groups.

For groups transitioning to CareFirst Formulary 2 effective July 1, letters were mailed to impacted members May 5 and physicians were notified the week of May 25.

All self-insured members will receive a separate Benefit Summary with a unique URL (www.carefirst.com/rxgroup) to view their formulary options.

Prior authorization process The prescribing physician must initiate the prior authorization process by completing an online request through the Provider Portal at http://www.carefirst.com/providerlogin. Should you have any questions, please contact your broker sales representative.

C. Shekar Subramaniam Vice President, Sales Small Medium SBU *The number of drug exclusions or drugs requiring a medical necessity prior authorization for both versions of CareFirst Formulary 2 may change on an annual basis. For July 1, 2015 we know 90 drugs are impacted.

April 2015

Drugs Requiring Prior Authorization for Medical Necessity for Formulary 2 Below is a list of medicines by drug class that require prior authorization for medical necessity on your plan's formulary. If you continue using one of the drugs listed below and identified as a drug requiring prior authorization for medical necessity, your doctor will be required to request prior authorization or you may be required to pay the full cost.

If you are currently using one of the drugs requiring prior authorization for medical necessity, ask your doctor to contact CVS/caremark1

at 1-855-240-0536 to request prior authorization or choose one of the generic or brand formulary options listed below.

Category * Drug Class

Drugs Requiring Prior Authorization for Medical Necessity 2

Formulary Options

Allergic Reaction (Anaphylaxis) Treatment *

ADRENACLICK

AUVI-Q SI, EPIPEN SI, EPIPEN JR SI

Allergies * Nasal Steroids / Combinations

BECONASE AQ OMNARIS QNASL RHINOCORT AQUA VERAMYST ZETONNA

flunisolide spray, fluticasone spray, triamcinolone spray, NASONEX

DYMISTA flunisolide spray, fluticasone spray, triamcinolone spray or NASONEX WITH azelastine spray or olopatadine spray

Allergies * Ophthalmic

LASTACAFT azelastine, cromolyn sodium, PATADAY, PATANOL

Anti-infectives, Antivirals * Hepatitis C Agents

VIEKIRA PAK HARVONI PA SP

Anti-infectives, Antivirals * Herpes Agents

VALTREX acyclovir, valacyclovir

Asthma * Beta Agonists, Short-Acting

PROVENTIL HFA VENTOLIN HFA XOPENEX HFA

PROAIR HFA

Asthma * Steroid Inhalants

AEROSPAN ALVESCO

ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR

Asthma * or Chronic Obstructive Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations

SYMBICORT ADVAIR, DULERA

Attention Deficit Hyperactivity Disorder Agents *

ADDERALL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate, methylphenidate ext-rel, DAYTRANA, QUILLIVANT XR, STRATTERA, VYVANSE

Cardiovascular Antilipemics * Fibrates

TRICOR fenofibrate, fenofibric acid

Cardiovascular Antilipemics * HMG-CoA Reductase Inhibitors (HMGs or Statins) / Combinations

ADVICOR ALTOPREV LESCOL XL LIPITOR LIPTRUZET LIVALO

atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, VYTORIN

Category * Drug Class

Drugs Requiring Prior Authorization for Medical Necessity 2

Formulary Options

Chronic Obstructive Pulmonary Disease (COPD) * Anticholinergics

TUDORZA SPIRIVA

Depression * Antidepressants

OLEPTRO trazodone

Dermatology Skin Inflammation and Hives * Corticosteroids

OLUX-E clobetasol propionate foam 0.05%, CLOBEX SPRAY

APEXICON E desoximetasone, fluocinonide

Diabetes * Biguanides

FORTAMET GLUMETZA RIOMET

metformin, metformin ext-rel

Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

NESINA ONGLYZA

JANUVIA, TRADJENTA

Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

KAZANO KOMBIGLYZE XR OSENI

JANUMET, JANUMET XR, JENTADUETO

Diabetes* Injectable Incretin Mimetics

BYETTA BYDUREON SI, VICTOZA SI

Diabetes * Insulins

APIDRA HUMALOG

NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 NOVOLIN 70/30

HUMULIN N NOVOLIN N

HUMULIN R NOVOLIN R

NOTE: Humulin R U-500 concentrate will not be subject to prior authorization and will continue to be covered.

Diabetes * Insulin Sensitizers

ACTOS pioglitazone

Diabetes * Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors

FARXIGA INVOKANA

Diabetes * Supplies 3, 4

ACCU-CHEK STRIPS AND KITS BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS All other test strips that are not ONETOUCH brand

ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3

Erectile Dysfunction * Phosphodiesterase Inhibitors

LEVITRA CIALIS QL, VIAGRA QL

Gastrointestinal Agents * Proton Pump Inhibitors (PPIs)

PREVACID PROTONIX

lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM

Category * Drug Class

Drugs Requiring Prior Authorization for Medical Necessity 2

Formulary Options

Glaucoma * Prostaglandin Analogs

LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN

Growth Hormones * GENOTROPIN NUTROPIN AQ OMNITROPE SAIZEN TEV-TROPIN

HUMATROPE PA SP SI, NORDITROPIN PA SP SI

Hematologic * Platelet Aggregation Inhibitors

PLAVIX clopidogrel, BRILINTA, EFFIENT

High Blood Pressure * Angiotensin II Receptor Antagonists

ATACAND EDARBI TEVETEN

candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR

High Blood Pressure * Angiotensin II Receptor Antagonist / Diuretic Combinations

ATACAND HCT DIOVAN HCT EDARBYCLOR TEVETEN HCT

candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR HCT

High Blood Pressure * Calcium Channel Blockers

NORVASC amlodipine

Inflammatory Bowel Disease (IBD), Ulcerative Colitis * Aminosalicylates

ASACOL HD DELZICOL

balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS

Multiple Sclerosis Agents* REBIF 5 COPAXONE PA SP SI, EXTAVIA PA SP SI, GILENYA PA SP, PLEGRIDY PA SP SI, TECFIDERA PA SP

Musculoskeletal Agents* AMRIX cyclobenzaprine

Opioid Dependence Agents * SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV

Osteoarthritis * Viscosupplements

EUFLEXXA MB ORTHOVISC MB

GEL-ONE MB, HYALGAN MB, SUPARTZ MB

Overactive Bladder / Incontinence * Urinary Antispasmodics

DETROL LA OXYTROL TOVIAZ

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

Pain and Inflammation * Corticosteroids

RAYOS dexamethasone, methylprednisolone, prednisone

Pain and Inflammation * Nonsteroidal Anti-inflammatory Drugs (NSAIDs) / Combinations

ARTHROTEC DUEXIS VIMOVO

CELEBREX; diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or NEXIUM

FLECTOR PENNSAID

diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL

NAPRELAN diclofenac sodium, meloxicam, naproxen, CELEBREX

Prostate Condition * Benign Prostatic Hyperplasia Agents / Combinations

JALYN finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO

Sleep * Hypnotics, Non-benzodiazepines

INTERMEZZO LUNESTA ROZEREM

eszopiclone, zolpidem, zolpidem ext-rel, SILENOR

Category * Drug Class

Drugs Requiring Prior Authorization for Medical Necessity 2

Formulary Options

Testosterone Replacement * Androgens

testosterone gel 1% 6 ANDROGEL NATESTO TESTIM VOGELXO

ANDRODERM, AXIRON, FORTESTA

Transplant * Immunosuppressants, Calcineurin Inhibitors

Hecoria tacrolimus

Category * Drug Class

Formulary Options

New to Market Agents 2 New to market products and new variations of products already in the marketplace will not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS/caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body).

The listed formulary options are subject to change.

List of Drugs Requiring Prior Authorization for Medical Necessity 2 ACCU-CHEK STRIPS AND KITS 4 ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALTOPREV ALVESCO AMRIX ANDROGEL APEXICON E APIDRA ARTHROTEC ASACOL HD ATACAND ATACAND HCT BECONASE AQ BREEZE 2 STRIPS AND KITS 4 BYETTA CONTOUR NEXT STRIPS AND KITS 4 CONTOUR STRIPS AND KITS 4 DELZICOL DETROL LA DIOVAN HCT DUEXIS DYMISTA EDARBI EDARBYCLOR EUFLEXXA FARXIGA FLECTOR FORTAMET FREESTYLE STRIPS AND KITS 4 GENOTROPIN GLUMETZA

Hecoria HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN 70/30 HUMULIN N HUMULIN R INTERMEZZO JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL LEVITRA LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA NAPRELAN NATESTO NESINA NORVASC NUTROPIN AQ OLEPTRO OLUX-E OMNARIS OMNITROPE ONGLYZA ORTHOVISC OSENI

OXYTROL PENNSAID PLAVIX PREVACID PROTONIX PROVENTIL HFA QNASL RAYOS REBIF 5 RHINOCORT AQUA RIOMET ROZEREM SAIZEN SUBOXONE FILM SYMBICORT TESTIM testosterone gel 1% 6 TEVETEN TEVETEN HCT TEV-TROPIN TOVIAZ TRICOR TUDORZA VALTREX VENTOLIN HFA VERAMYST VIEKIRA PAK VIMOVO VOGELXO XOPENEX HFA ZETONNA

This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available covered options. Go to www.carefirst.com and log in to My Account to check coverage and copay/coinsurance information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CareFirst and CVS/caremark assume no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information. Subject to applicable laws and regulations. * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. MB Covered under the medical benefit. PA Prior authorization required. QL Quantity limits SI Self-injectable product SP Specialty product 1 CVS/caremark is an independent company that provides pharmacy benefit management services. 2 If your doctor believes you have a specific clinical need for one of these products, he or she should contact the Prior Authorization department toll-free at: 1-855-240-0536. 3 A OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than OneTouch. For more information on how

to obtain a blood glucose meter, call toll-free: 1-800-588-4456. Members must have CVS Caremark Mail Service Pharmacy benefits to qualify. 4 OneTouch brand test strips are the only preferred options. 5 Members on existing Rebif therapy will not be subject to exclusions while remaining adherent on these therapies. 6 Listing reflects the authorized generics for Testim and Vogelxo. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. This document contains confidential and proprietary information of CareFirst and CVS/caremark and cannot be reproduced, distributed or printed without written permission from CareFirst. CareFirst may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CareFirst or CVS/caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

©2015. All rights reserved. SUM 2657-1P (04/15)

April 2015

Drug Removals for Formulary 2 Below is a list of medicines by drug class that have been removed from your plan’s formulary. If you continue using one of the drugs listed below and identified as a Formulary Drug Removal, you may be required to pay the full cost.

If you are currently using one of the formulary drug removals, ask your doctor to choose one of the generic or brand formulary options listed below.

Category * Drug Class

Formulary Drug Removals

Formulary Options

Allergic Reaction (Anaphylaxis) Treatment *

ADRENACLICK

AUVI-Q SI, EPIPEN SI, EPIPEN JR SI

Allergies * Nasal Steroids / Combinations

BECONASE AQ OMNARIS QNASL RHINOCORT AQUA VERAMYST ZETONNA

flunisolide spray, fluticasone spray, triamcinolone spray, NASONEX

DYMISTA flunisolide spray, fluticasone spray, triamcinolone spray or NASONEX WITH azelastine spray or olopatadine spray

Allergies * Ophthalmic

LASTACAFT azelastine, cromolyn sodium, PATADAY, PATANOL

Anti-infectives, Antivirals * Hepatitis C Agents

VIEKIRA PAK HARVONI PA SP

Anti-infectives, Antivirals * Herpes Agents VALTREX acyclovir, valacyclovir

Asthma * Beta Agonists, Short-Acting

PROVENTIL HFA VENTOLIN HFA XOPENEX HFA

PROAIR HFA

Asthma * Steroid Inhalants

AEROSPAN ALVESCO

ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR

Asthma * or Chronic Obstructive Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations

SYMBICORT ADVAIR, DULERA

Attention Deficit Hyperactivity Disorder Agents *

ADDERALL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate, methylphenidate ext-rel, DAYTRANA, QUILLIVANT XR, STRATTERA, VYVANSE

Cardiovascular Antilipemics * Fibrates

TRICOR fenofibrate, fenofibric acid

Cardiovascular Antilipemics * HMG-CoA Reductase Inhibitors (HMGs or Statins) / Combinations

ADVICOR ALTOPREV LESCOL XL LIPITOR LIPTRUZET LIVALO

atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, VYTORIN

Chronic Obstructive Pulmonary Disease (COPD) * Anticholinergics

TUDORZA SPIRIVA

Depression * Antidepressants

OLEPTRO trazodone

Category * Drug Class

Formulary Drug Removals

Formulary Options

Dermatology Skin Inflammation and Hives * Corticosteroids

OLUX-E clobetasol propionate foam 0.05%, CLOBEX SPRAY

APEXICON E desoximetasone, fluocinonide

Diabetes * Biguanides

FORTAMET GLUMETZA RIOMET

metformin, metformin ext-rel

Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

NESINA ONGLYZA

JANUVIA, TRADJENTA

Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

KAZANO KOMBIGLYZE XR OSENI

JANUMET, JANUMET XR, JENTADUETO

Diabetes* Injectable Incretin Mimetics

BYETTA BYDUREON SI, VICTOZA SI

Diabetes * Insulins

APIDRA HUMALOG

NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 NOVOLIN 70/30

HUMULIN N NOVOLIN N

HUMULIN R NOVOLIN R

NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered.

Diabetes * Insulin Sensitizers

ACTOS pioglitazone

Diabetes * Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors

FARXIGA INVOKANA

Diabetes * Supplies 1,2

ACCU-CHEK STRIPS AND KITS BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS 3 All other test strips that are not ONETOUCH brand

ONETOUCH ULTRA STRIPS AND KITS 1, ONETOUCH VERIO STRIPS AND KITS 1

Erectile Dysfunction * Phosphodiesterase Inhibitors

LEVITRA CIALIS QL, VIAGRA QL

Gastrointestinal Agents * Proton Pump Inhibitors (PPIs)

PREVACID PROTONIX

lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM

Glaucoma * Prostaglandin Analogs

LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN

Growth Hormones * GENOTROPIN NUTROPIN AQ OMNITROPE SAIZEN TEV-TROPIN

HUMATROPE PA SP SI, NORDITROPIN PA SP SI

Category * Drug Class

Formulary Drug Removals

Formulary Options

Hematologic * Platelet Aggregation Inhibitors

PLAVIX clopidogrel, BRILINTA, EFFIENT

High Blood Pressure * Angiotensin II Receptor Antagonists

ATACAND EDARBI TEVETEN

candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR

High Blood Pressure * Angiotensin II Receptor Antagonist / Diuretic Combinations

ATACAND HCT DIOVAN HCT EDARBYCLOR TEVETEN HCT

candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR HCT

High Blood Pressure * Calcium Channel Blockers

NORVASC amlodipine

Inflammatory Bowel Disease (IBD), Ulcerative Colitis * Aminosalicylates

ASACOL HD DELZICOL

balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS

Multiple Sclerosis Agents* REBIF 4 COPAXONE PA SP SI, EXTAVIA PA SP SI, GILENYA PA SP, PLEGRIDY PA SP SI, TECFIDERA PA SP

Musculoskeletal Agents* AMRIX cyclobenzaprine

Opioid Dependence Agents * SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV

Osteoarthritis * Viscosupplements

EUFLEXXA MB ORTHOVISC MB

GEL-ONE MB, HYALGAN MB, SUPARTZ MB

Overactive Bladder / Incontinence * Urinary Antispasmodics

DETROL LA OXYTROL TOVIAZ

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

Pain and Inflammation * Corticosteroids

RAYOS dexamethasone, methylprednisolone, prednisone

Pain and Inflammation * Nonsteroidal Anti-inflammatory Drugs (NSAIDs) / Combinations

ARTHROTEC DUEXIS VIMOVO

CELEBREX; diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or NEXIUM

FLECTOR PENNSAID

diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL

NAPRELAN diclofenac sodium, meloxicam, naproxen, CELEBREX

Prostate Condition * Benign Prostatic Hyperplasia Agents / Combinations

JALYN finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO

Sleep * Hypnotics, Non-benzodiazepines

INTERMEZZO LUNESTA ROZEREM

eszopiclone, zolpidem, zolpidem ext-rel, SILENOR

Testosterone Replacement * Androgens

testosterone gel 1% 5 ANDROGEL NATESTO TESTIM VOGELXO

ANDRODERM, AXIRON, FORTESTA

Transplant * Immunosuppressants, Calcineurin Inhibitors

Hecoria tacrolimus

Category * Drug Class

Formulary Options

New to Market Agents 3 New to market products and new variations of products already in the marketplace will not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS/caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body).

The listed formulary options are subject to change.

List of Formulary Drug Removals ACCU-CHEK STRIPS AND KITS 2 ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALTOPREV ALVESCO AMRIX ANDROGEL APEXICON E APIDRA ARTHROTEC ASACOL HD ATACAND ATACAND HCT BECONASE AQ BREEZE 2 STRIPS AND KITS 2 BYETTA CONTOUR NEXT STRIPS AND KITS 2 CONTOUR STRIPS AND KITS 2 DELZICOL DETROL LA DIOVAN HCT DUEXIS DYMISTA EDARBI EDARBYCLOR EUFLEXXA FARXIGA FLECTOR FORTAMET FREESTYLE STRIPS AND KITS 2, 3 GENOTROPIN GLUMETZA

Hecoria HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN 70/30 HUMULIN N HUMULIN R INTERMEZZO JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL LEVITRA LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA NAPRELAN NATESTO NESINA NORVASC NUTROPIN AQ OLEPTRO OLUX-E OMNARIS OMNITROPE ONGLYZA ORTHOVISC OSENI

OXYTROL PENNSAID PLAVIX PREVACID PROTONIX PROVENTIL HFA QNASL RAYOS REBIF 4 RHINOCORT AQUA RIOMET ROZEREM SAIZEN SUBOXONE FILM SYMBICORT TESTIM testosterone gel 1% 5 TEVETEN TEVETEN HCT TEV-TROPIN TOVIAZ TRICOR TUDORZA VALTREX VENTOLIN HFA VERAMYST VIEKIRA PAK VIMOVO VOGELXO XOPENEX HFA ZETONNA

This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available covered options. Go to www.carefirst.com and log in to My Account to check coverage and copay/coinsurance information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CareFirst and CVS/caremark6 assume no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information. Subject to applicable laws and regulations. * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. MB Covered under the medical benefit. PA Prior authorization required. QL Quantity limits SI Self-injectable product SP Specialty product 1 A OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than OneTouch. For more information on how

to obtain a blood glucose meter, call toll-free: 1-800-588-4456. Members must have CVS Caremark Mail Service Pharmacy benefits to qualify. 2 OneTouch brand test strips are the only preferred options. 3 An exception process is in place for specific clinical circumstances that may require continued coverage for Freestyle diabetic test strips. If your doctor believes you have a specific

clinical need for this product, he or she should fax an exception request toll-free to: 1-888-487-9257. Your plan may choose to provide an exception process for additional medications on this list and new to market agents.

4 Members on existing Rebif therapy will not be subject to exclusions while remaining adherent on these therapies. 5 Listing reflects the authorized generics for Testim and Vogelxo. 6 CVS/caremark is an independent company that provides pharmacy benefit management services. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. This document contains confidential and proprietary information of CareFirst and CVS/caremark and cannot be reproduced, distributed or printed without written permission from CareFirst. CareFirst may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CareFirst or CVS/caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

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