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 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 BESPONSA BETASERON BEXSERO BIKTARVY BIOTHRAX BOOSTRIX TDAP BREO ELLIPTA BROVANA BYDUREON BYETTA Preferred Brand Name Drug List (BCBSVT/TVHP Tier 2) Updated: 02.20.19 *Effective 02.27.19 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: 02/20/19 Page 1 of 5
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 FLOVENT (ALL FORMS) FLUAD 2017-2018 FLUARIX FLUBLOK 2017-2018 FLUBLOK QUAD 2017-2018 FLUCELVAX QUAD 2017-2018 FLULAVAL FLUMIST FLUVIRIN FLUZONE HIGH-DOSE FLUZONE INTRADERM QUAD 2017-18 FLUZONE QUAD 2017-2018 FLUZONE QUAD PEDI 2017-2018 FORADIL FORTEO FORTOVASE FREESTYLE GLUCOMETER FREESTYLE TEST STRIPS G GAMMAGARD LIQUID GAMMAGARD S-D GAMUNEX-C GARDASIL GARDASIL 9 GENOTROPIN GILENYA GLASSIA GLEEVEC GLEOSTINE GLUCAGON H HARVONI I HAVRIX HELIXATE FS HELPLISAVE-B HEMLIBRA HEPSERA HEXALEN HIBERIX HIVID HIZENTRA HUMALOG HUMIRA HUMULIN HYPERRAB 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: 02/20/19 Page 2 of 5
GONALF GRANIX O L OCREVUS LANTUS ODACTRA LARTRUVO ODEFSEY LENVIMA OFEV LETAIRIS ONE TOUCH GLUCOMETER LEUKERAN ONE TOUCH TEST STRIP LEVEMIR ORILISSA LEXIVA ORKAMBI LIBTAYO OTEZLA LILETTA OXSORALEN ULTRA LOKELMA OZEMPIC * LOTEMAX LUCENTIS P LUPRON PALYNZIG LUXTURNA PEDIARIX LYSODREN PEDVAXHIB PEGASYS M PENTACEL MAKENA IM * (intramuscular) PERFOROMIST MEHNIBRIX PICATO MENACTRA PLAN B MENOMUNE PNEUMOVAX 23 MENVEO POTELIGEO MEPHYTON POTIGA MEPSEVII PRALUENT METHERGINE PRECISION GLUCOMETER MIGRANAL PRECISION TEST STRIPS MIRENA PRED MILD MITIGARE PREMARIN M-M-R II PREMARIN CREAM MONONINE PREMPHASE MYLERAN PREMPRO PREVEN N PREVNAR 13 NARCAN PREVYMIS NASONEX PREZISTA NEXAVAR PRIVIGEN NEXPLANON PROAIR NILANDRON PROAIR HFA NORDITROPIN PROCRIT NOVOEIGHT PRODIGY (SYRINGES & NEEDLES) NOVOFINE (SYRINGES & NEEDLES) PROMACTA NOVOLIN PROQUAD NUCALA PULMICORT FLEXHALER NUVARING PULMICORT RESPULES NUWIQ PULMOZYME (BCBSVT/TVHP Tier 2) Updated: 02/20/19 Page 3 of 5 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 SOMATULINE DEPOT SOMAVERT SPINRAZA SPIRIVA SPIRIVA RESPIMAT SPRYCEL STALEVO STELARA STIBILD STRIVERDI RESPIMAT SUBLOCADE SUBOXONE SL FILM SUSTIVA SUTENT SYLATRON SYMBICORT SYMDEKO SYMFI SYMFI LO SYNVISC (ALL FORMS) T 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 VIVITROL VIVOTIF (BCBSVT/TVHP Tier 2) Updated: 02/20/19 Page 4 of 5
TACLONEX SUSPENSION TARCEVA TARGRETIN TAZORAC TECFIDERA TECHNIVIE TEMODAR TENIVAC TESLAC TETANUS TOXOIDS VOLTAREN GEL (1% TOPICAL) VOSEVI VOTRIENT VYVANSE W WELCHOL X XARELTO XELJANZ/XELJANZ XR XENICAL XIFAXAN (550 MG) XIIDRA Y YERVOY YESCARTA YF-VAX (BCBSVT/TVHP Tier 2) Updated: 02/20/19 Page 5 of 5