Preferred Brand Name Drug List (BCBSVT/TVHP Tier 2)

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1 A ABILIFY MAINTENA ACAM2000 ACTEMRA SC ACTHIB ADACEL TDAP ADDERALL XR ADVAIR HFA ADYNOVATE ADVATE AFLURIA AFLURIA QUAD AFSTYLA AGENERASE AIMOVIG AKYNZEO (oral) ALINIA ALPHAGAN P ALPHANINE ALPROLIX ALUNBRIG (brigatinib) ANDRODERM ANDROGEL ANORO ELLIPTA APRISO ARALAST ARIKAYCE ARNUITY ELLIPTA ASMANEX TWISTHALER AZEDRA AZILECT B BAVENCIO BD INSULIN NEEDLES BD INSULIN SYRINGES BENEFIX BENZIDAZOLE BERINERT BESPONSA BETASERON BEXSERO BIKTARVY BIOTHRAX BOOSTRIX TDAP BREO ELLIPTA BROVANA BYDUREON Preferred Brand Name Drug List (BCBSVT/TVHP Tier 2) Updated: *Effective Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Helpful Tip: To search fo a specific drug, use the find feature (Ctrl + F) Influenza vaccine will continue to take a zero copay for most plans C CALQUENCE CANASA CARAC CEENU CELEBREX CERDELGA CEREZYME CERVARIX CHANTIX CIMDUO CINRYZE CIPRODEX CLIMARA PRO COMBIVENT COMBIVIR COMPLERA COMVAX CONDYLOX GEL CORTIFOAM COSTENYX CREON CRINONE CRIXIVAN CRYSVITA CUPRIMINE D DAPTACEL DTAP DECAVAC DENAVIR DESCOVY DILANTIN KAPSEALS DOPTELET DUAC CS KIT DULERA E EDURANT ELIQUIS ELMIRON EMCYT ENBREL ENGERIX-B ENSTILAR FOAM ENTOCORT EC ENTRESTO EPCLUSA (BCBSVT/TVHP Tier 2) Updated: 06/03/19 Page 1 of 5

2 BYETTA EPIDIOLEX EPIPEN E (continued) EPI-PEN AUTHORIZED GENERIC (GENERIC FOR MYLAN'S EPI-PEN) EPIVIR -HBV EPZICOM ERGAMISOL ERIVEDGE ERLEADA ESBRIET ESTRADERM ESTRATEST ESTRATEST HS EVOXAC EXELON EYLEA F FABRAZYME FARESTON FARYDAK FINACEA FIRDAPSE FLOVENT (ALL FORMS) FLUAD FLUARIX FLUBLOK FLUBLOK QUAD FLUCELVAX QUAD FLULAVAL FLUMIST FLUVIRIN FLUZONE HIGH-DOSE FLUZONE INTRADERM QUAD FLUZONE QUAD FLUZONE QUAD PEDI FORADIL FORTEO FORTOVASE FREESTYLE GLUCOMETER FREESTYLE TEST STRIPS G GAMIFANT GAMMAGARD LIQUID GAMMAGARD S-D GAMUNEX-C GARDASIL GARDASIL 9 GENOTROPIN GILENYA GLASSIA H HARVONI HAVRIX HELIXATE FS HELPLISAVE-B HEMLIBRA HEPSERA HEXALEN HIBERIX HIVID HIZENTRA HUMALOG HUMIRA HUMULIN HYPERRAB I IBRANCE IMBRUVICA IMOGAM RABIES IMOVAX IMPAVIDO INCIVEK INFANRIX DTAP INTAL INHALER INTRON A INVIRASE INVOKANA IPOL ISENTRESS IXIARO IXINITY J JANUMET JANUVIA JARDIANCE JENTADUETO JEVTANA JIVI K KALETRA, CAPSULE AND SOLUTION KINRIX KISQALI KOGENATE FS KOVALTRY KYLEENA KYMRIAH KYPROLIS (BCBSVT/TVHP Tier 2) Updated: 06/03/19 Page 2 of 5

3 GLEEVEC GLEOSTINE GLUCAGON GONALF GRANIX O OCREVUS ODACTRA ODEFSEY L OFEV LANTUS ONE TOUCH GLUCOMETER LARTRUVO ONE TOUCH TEST STRIP LENVIMA ORILISSA LETAIRIS ORKAMBI LEUKERAN OTEZLA LEVEMIR OXERVATE LEXIVA OXSORALEN ULTRA LIBTAYO OZEMPIC * LILETTA LOKELMA P LORBRENA PALYNZIG LOTEMAX PEDIARIX LUCENTIS PEDVAXHIB LUPRON PEGASYS LUXTURNA PENTACEL LYSODREN PERFOROMIST PICATO M PLAN B MAKENA IM * (intramuscular) PNEUMOVAX 23 MEHNIBRIX POTELIGEO MENACTRA POTIGA MENOMUNE PRALUENT MENVEO PRECISION GLUCOMETER MEPHYTON PRECISION TEST STRIPS MEPSEVII PRED MILD METHERGINE PREMARIN MIGRANAL PREMARIN CREAM MIRENA PREMPHASE MITIGARE PREMPRO M-M-R II PREVEN MONONINE PREVNAR 13 MYLERAN PREVYMIS PREZISTA N PRIVIGEN NARCAN PROAIR NASONEX PROAIR HFA NEXAVAR PROCRIT NEXPLANON PRODIGY (SYRINGES & NEEDLES) NILANDRON PROMACTA NORDITROPIN PROQUAD NOVOEIGHT PULMICORT FLEXHALER NOVOFINE (SYRINGES & NEEDLES) PULMICORT RESPULES NOVOLIN PULMOZYME NUCALA (BCBSVT/TVHP Tier 2) Updated: 06/03/19 Page 3 of 5

4 NUVARING NUWIQ Q QVAR R RABAVERT RAPAMUNE REBIF RECOMBIVAX HB RECOVI RELENZA REPATHA RESCRIPTOR RESTASIS REVLIMID REYATAZ RIDAURA RISPERDAL CONSTA ROTARIX ROTATEQ RUBRACA RUCONEST S SAVELLA SELZENTRY SEREVENT (ALL FORMS) SEREVENT DISKUS SHINGRIX SKYLA SKYRIZI SOLIRIS SOMATULINE DEPOT SOMAVERT SPINRAZA SPIRIVA SPIRIVA RESPIMAT SPRYCEL STALEVO STELARA STIBILD STRIVERDI RESPIMAT SUBLOCADE SUSTIVA SUTENT SYLATRON SYMBICORT SYMDEKO THIOGUANINE I TIBSOVO TIVICAY TORGARZO TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TRACLEER TRADJENTA TRAVATAN Z TREMFYA TRESIBA TREXALL TRIPTODUR TRIZIVIR TRUMENBA TRUVADA TWINRIX TYKERB TYPHIM VI TYVASO TYZEKA U ULTRASE ULTRASE MT V VAGIFEM VAQTA VARIVAX VARIZIG VARUBI VAXCHORA VEMLIDY VENTOLIN HFA VEPESID VERZENIO VICTOZA VIDEX VIEKIRA VIRACEPT VIRAMUNE VIREAD VITEKTA VITRAKVI (BCBSVT/TVHP Tier 2) Updated: 06/03/19 Page 4 of 5

5 SYMFI SYMFI LO SYNVISC (ALL FORMS) T TACLONEX SUSPENSION TALZENNA TARCEVA TARGRETIN TAZORAC TECFIDERA TECHNIVIE TEMODAR TENIVAC TESLAC TETANUS TOXOIDS VIVITROL VIVOTIF VOLTAREN GEL (1% TOPICAL) VOSEVI VOTRIENT VYVANSE W WELCHOL X XARELTO XELJANZ/XELJANZ XR XENICAL XIFAXAN (550 MG) XIIDRA (BCBSVT/TVHP Tier 2) Updated: 06/03/19 Page 5 of 5

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Preferred Brand Name Drug List (BCBSVT/TVHP Tier 2)

Preferred Brand Name Drug List (BCBSVT/TVHP Tier 2) A ACAM2000 ACTEMRA SC ACTHIB ADACEL TDAP ADDERALL XR ADVAIR DISKUS ADVAIR HFA ADYNOVATE ADVATE AFLURIA 2017-2018 AFLURIA QUAD 2017-2018 AFSTYLA AGENERASE AIMOVIG AKYNZEO (oral) ALINIA ALPHAGAN P ALPHANINE