508C 2022 Essential Formulary Changes

2022Essential FormularyChanges

Every year, we review our formularies to determine changes based on adrug’s effectiveness, safety, and affordability. While many changes to ourformularies occur at the beginning of the year, formulary changes mayoccur at any time when:›New drugs are released after FDA approval›The FDA removes drugs from the market›New generic drugs are introducedPlease note that the tier structure for the Essential Formulary is differentbased on the type of plan you have. The drug content, exclusions, and rulesare the same for both types of plans. Check with us to determine your typeof coverage at the phone number on the back of your Member ID card.The Essential Formulary is a five tier plan:This list is subject to change throughout the year.Please call us at the Member Service numberlisted on your Member ID card or visit lary.pdffor the most up-to-date information.Tier 1Generic DrugsTier 2Preferred Brand DrugsTier 3Non-Preferred Brand DrugsTier 4Specialty DrugsTier 5Drugs with 0 Cost Share per the Affordable Care Act (ACA) 0 CopayPreventive ListThe Essential Plus Formulary is a six tier plan:Tier 1Generic Drugs with copay based on the BlueCross Preventive ListTier 2Preferred Brand Drugs with copay based on the BlueCross Preventive ListTier 3Non-Preferred Brand Drugs with copay based on the BlueCrossPreventive ListTier 4Specialty Drugs with deductible/coinsuranceTier 5Drugs with 0 Cost Share per the Affordable Care Act (ACA) 0 CopayPreventive ListTier 6Generic or Brand Non-Specialty Drugs with deductible/coinsurancePlease check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. 2022 Essential Formulary Changes1

2022 Essential and Essential Plus Drug ListMulti-Source Brand Drugs Moving toExcluded StatusALINIA 500 MG TABLET2KEPPRA 1,000 MG TABLETATRIPLA TABLETKEPPRA 100 MG/ML ORAL SOLNAZOPT 1% EYE DROPSKEPPRA 250 MG TABLETBANZEL 40 MG/ML SUSPENSIONKEPPRA 500 MG TABLETCARBATROL ER 100 MG CAPSULEKEPPRA 750 MG TABLETCARBATROL ER 200 MG CAPSULEKEPPRA XR 500 MG TABLETCARBATROL ER 300 MG CAPSULEKEPPRA XR 500 MG TABLETCIPRODEX OTIC SUSPENSIONKEPPRA XR 750 MG TABLETCLODERM CREAM 0.1%KLONOPIN 0.5 MG TABLETCOLESTID GRANULESKLONOPIN 1 MG TABLETDEPAKENE 250 MG CAPSULEKLONOPIN 2 MG TABLETDEPAKENE 250 MG/5 ML SOLUTIONK-TAB ER 20 MEQ TABLETDEPAKOTE DR 125 MG SPRINKLE CAPSULEKUVAN 100 MG POWDER PACKETDEPAKOTE DR 125 MG TABLETKUVAN 100 MG TABLETDEPAKOTE DR 250 MG TABLETKUVAN 500 MG POWDER PACKETDEPAKOTE DR 500 MG TABLETLAMICTAL 100 MG TABLETDIASTAT 2.5 MG PEDI SYSTEMLAMICTAL 150 MG TABLETDIASTAT ACUDIAL 12.5-15-20 MGLAMICTAL 200 MG TABLETDIASTAT ACUDIAL 5-7.5-10 MG KITLAMICTAL 25 MG DISPER TABLETDILANTIN 100 MG CAPSULELAMICTAL 25 MG TABLETDILANTIN 125 MG/5 ML SUSPLAMICTAL 5 MG DISPER TABLETDILANTIN 50 MG INFATABLAMICTAL ODT 100 MG TABLETDYRENIUM 100 MG CAPSULELAMICTAL ODT 200 MG TABLETDYRENIUM 50 MG CAPSULELAMICTAL ODT 25 MG TABLETEMTRIVA 200 MG CAPSULELAMICTAL ODT 50 MG TABLETERYGEL GEL 2%LAMICTAL ODT START KIT (BLUE)FELBATOL 400 MG TABLETLAMICTAL ODT START KIT (GREEN)FELBATOL 600 MG TABLETLAMICTAL ODT START KT (ORANGE)FELBATOL 400 MG TABLETLAMICTAL TAB START KIT (BLUE)FELBATOL 600 MG TABLETLAMICTAL TAB START KIT (GREEN)FELBATOL 600 MG/5 ML SUSPLAMICTAL TB START KIT (ORANGE)GABITRIL 12 MG TABLETLAMICTAL XR 100 MG TABLETGABITRIL 2 MG TABLETLAMICTAL XR 200 MG TABLETGABITRIL 4 MG TABLETLAMICTAL XR 25 MG TABLETJADENU 180 MG TABLETLAMICTAL XR 250 MG TABLET2022 Essential Formulary Changes Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.LAMICTAL XR 300 MG TABLETONFI 2.5 MG/ML SUSPENSIONTECFIDERA DR 120 MG CAPSULELAMICTAL XR 50 MG TABLETONFI 20 MG TABLETTECFIDERA DR 240 MG CAPSULELANOXIN 125 MCG TABLETPHENOBARBITAL-BELLADONNA ELIXRTECFIDERA STARTER PACKLANOXIN 250 MCG TABLETPHENYTEK 200 MG CAPSULETEGRETOL 100 MG/5 ML SUSPLYRICA 100 MG CAPSULEPHENYTEK 300 MG CAPSULETEGRETOL 200 MG TABLETLYRICA 150 MG CAPSULEQUDEXY XR 100 MG CAPSULETEGRETOL XR 100 MG TABLETLYRICA 20 MG/ML ORAL SOLUTIONQUDEXY XR 150 MG CAPSULETEGRETOL XR 200 MG TABLETLYRICA 200 MG CAPSULEQUDEXY XR 200 MG CAPSULETEGRETOL XR 400 MG TABLETLYRICA 225 MG CAPSULEQUDEXY XR 200 MG CAPSULETIMOPTIC 0.5% OCUDOSE DROPLYRICA 25 MG CAPSULEQUDEXY XR 25 MG CAPSULETOPAMAX 100 MG TABLETLYRICA 300 MG CAPSULEQUDEXY XR 50 MG CAPSULETOPAMAX 15 MG SPRINKLE CAPLYRICA 50 MG CAPSULERIOMET 500 MG/5 ML SOLUTIONTOPAMAX 200 MG TABLETLYRICA 75 MG CAPSULESABRIL 500 MG POWDER PACKETTOPAMAX 25 MG SPRINKLE CAPLYRICA CR 165 MGSABRIL 500 MG TABLETTOPAMAX 25 MG TABLETLYRICA CR 330 MGSAMSCA 30 MG TABLETTOPAMAX 50 MG TABLETLYRICA CR 82.5 MGSAPHRIS 10 MG TAB SUBLINGUALTRILEPTAL 150 MG TABLETMINIVELLE 0.025 MG PATCHSAPHRIS 2.5 MG TAB SUBLINGUALTRILEPTAL 300 MG TABLETMINIVELLE 0.0375 MG PATCHSAPHRIS 5 MG TAB SUBLINGUALTRILEPTAL 300 MG/5 ML SUSPMINIVELLE 0.05 MG PATCHSKLICE 0.5% LOTIONTRILEPTAL 600 MG TABLETMINIVELLE 0.075 MG PATCHSYMFI 600-300-300 MG TABLETTRUVADA 100 MG-150 MG TABLETMINIVELLE 0.1 MG PATCHSYMFI LO 400-300-300 MG TABLETTRUVADA 133 MG-200 MG TABLETMIRALAX POW 3350 NFSYNTHROID 100 MCG TABLETTRUVADA 167 MG-250 MG TABLETMONUROL 3 GM SACHETSYNTHROID 112 MCG TABLETTRUVADA 200 MG-300 MG TABLETMYSOLINE 250 MG TABLETSYNTHROID 125 MCG TABLETTYKERB 250 MG TABLETMYSOLINE 50 MG TABLETSYNTHROID 137 MCG TABLETVIVELLE-DOT 0.025 MG PATCHNEURONTIN 100 MG CAPSULESYNTHROID 150 MCG TABLETVIVELLE-DOT 0.0375 MG PATCHNEURONTIN 250 MG/5 ML SOLNSYNTHROID 175 MCG TABLETVIVELLE-DOT 0.05 MG PATCHNEURONTIN 250 MG/5 ML SOLUTIONSYNTHROID 200 MCG TABLETVIVELLE-DOT 0.075 MG PATCHNEURONTIN 300 MG CAPSULESYNTHROID 25 MCG TABLETVIVELLE-DOT 0.1 MG PATCHNEURONTIN 400 MG CAPSULESYNTHROID 300 MCG TABLETVUSION OINTMENTNEURONTIN 600 MG TABLETSYNTHROID 50 MCG TABLETZARONTIN 250 MG CAPSULENEURONTIN 800 MG TABLETSYNTHROID 75 MCG TABLETZARONTIN 250 MG/5 ML SOLUTIONNITROSTAT 0.3 MG TABLET SLSYNTHROID 88 MCG TABLETZONEGRAN 100 MG CAPSULENITROSTAT 0.4 MG TABLET SLTACLONEX 0.005%-0.064% SUSPENSZONEGRAN 25 MG CAPSULENITROSTAT 0.6 MG TABLET SLTAMIFLU 30 MG CAPSULEZYTIGA 500 MGNORTHERA 100 MG CAPSULETAMIFLU 45 MG CAPSULEZOMIG 2.5 MG SPRAYNORTHERA 200 MG CAPSULETAMIFLU 6 MG/ML SUSPENSIONZOMIG 5 MG SPRAYONFI 10 MG TABLETTAMIFLU 75 MG CAPSULENOTE: All of these drugs have generic equivalents that are covered on the Essential Formulary. They might have adifferent shape or color, but they have the same active ingredients.Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. 2022 Essential Formulary Changes3

2022 Essential and Essential Plus Drug List2022 Essential and Essential Plus Drug ListFormulary RemovalsFormulary AdditionsFormulary RemovalsFormulary AdditionsNon-Formulary DrugsDrug NameAFREZZAKINERETALBENDAZOLE 200 MG TABLETGEMMILY CAPSULEDICLOFENAC SODIUM 1% GELKITABISBETAXOLOL HCL 0.5% EYE DROPNORE/ETH/FER CAPSULEEDARBIMAVYRETDOXEPIN HCL 3 MG TABLETPLENVUEDARBYCLORNIVESTYMDOXEPIN HCL 6 MG TABLETSUTABIVERMECTIN 0.5% LOTIONOLOPATADINE EYE DROPSKYLEENA IUD 19.5MGSUMATRIPTAN-NAPROXEN 85-500 MGINVOKAMETOLUMIANTLILETTA IUD 52MGTWIRLA PATCHINVOKAMET XRSILIQMIRENA IUD SYSTEMTYBLUME CHEW TABINVOKANAXYREMNEXPLANON IMP 68MGZYLET EYE DROPSPARAGARD IUD T380AZOLMITRIPTAN 2.5 MG SPRAYSKYLA IUD 13.5MGZOLMITRIPTAN 5 MG SPRAYKEVZARAANNOVERA VAGINAL RINGFormulary Removals (Oncology)Non-Formulary ATRON2022 Essential Formulary Changes Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. 2022 Essential Formulary Changes5

2022 Essential and Essential Plus Drug ListNew Prior Authorizations and Quantity LimitsNew Prior Authorizations and Quantity Limitson Multiple Sclerosis MedicationsDrug NameNew Prior Authorizations and Quantity Limitson ADHD MedicationsDrug ERREBIFCOPAXONEGLATOPAVUMERITYDIMETHYL E HENIDATEMETHYLPHENIDATE ERDEXMETHYLPHENIDATE ERMYDAYISADEMLOGINSULIN SSOLIQUADEXTROAMPHETAMINE ETAMINE-AMPHETAMINE ERVYVANSEHUMULINNOVOLINGUANFACINE ERZENZEDIQuantity Limits Added to Oncology MedicationsABIRATERONENew Quantity Limits on Insulin ProductsDrug NameNew Quantity Limits on Medications thatTreat Inflammatory ConditionsDrug NameDrug LJANZ ULAIBRANCESTIVARGAZYDELIGIMATINIBSUTENT2022 Essential Formulary Changes Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.New Quantity LimitsDrug NameXIFAXANNew Prior Authorizations and Quantity Limitson GLP-1 AgonistsDrug NameBYDUREONOZEMPICBYETTARYBELSUSTRULICITYPlease check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. 2022 Essential Formulary Changes7

2022 Essential and Essential Plus Drug ListTier ChangesDrug Name2021 Tier Placement2022 Tier PlacementTier ChangeTRINTELLIXTier 2Tier 3 2022 Essential and Essential Plus Drug ListStep Therapy AddedDrug NamePENTASA2022 Essential and Essential Plus Drug ListPrior Authorization RemovedDrug NameRIBAVIRIN82022 Essential Formulary Changes Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.BlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rightslaws and does not discriminate on the basis of race, color, national origin, age, disability or sex.BlueCross does not exclude people or treat them differently because of race, color, nationalorigin, age, disability or sex.BlueCross: Provides free aids and services to people with disabilities to communicate effectively with us,such as: (1) qualified interpreters and (2) written information in other formats, such as largeprint, audio and accessible electronic formats. Provides free language services to people whose primary language is not English, such as: (1)qualified interpreters and (2) written information in other languages.If you need these services, contact a consumer advisor at the number on the back of yourMember ID card or call 1-800-565-9140 (TTY: 1-800-848-0298 or 711).If you believe that BlueCross has failed to provide these services or discriminated in anotherway on the basis of race, color, national origin, age, disability or sex, you can file a grievance(“Nondiscrimination Grievance”). For help with preparing and submitting your NondiscriminationGrievance, contact a consumer advisor at the number on the back of your Member ID card orcall 1-800-565-9140 (TTY: 1-800-848-0298 or 711). They can provide you with the appropriateform to use in submitting a Nondiscrimination Grievance. You can file a NondiscriminationGrievance in person or by mail, fax or email. Address your Nondiscrimination Grievanceto: Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member BenefitsAdministration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN 37402-0019; (423) 591-9208(fax); Nondiscrimination OfficeGM@bcbst.com (email).You can also file a civil rights complaint with the U.S. Department of Health and Human Services,Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, availableat https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Healthand Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington,DC 20201, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at Cross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShieldAssociation.Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. 2022 Essential Formulary Changes9