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Formulary(List of covered drugs)UPCOMING CHANGESPremera Blue Cross Medicare AdvantageHMO, Classic (HMO), Classic Plus (HMO), Core (HMO), Core Plus (HMO), Total Health(HMO), Peak Rx (HMO), Sound Rx (HMO), Charter Rx (HMO)Most of the changes in drug coverage happen at the beginning of each year (January 1).However, during the year, we may make changes to the formulary. For example, we may: Add or remove drugs from the formularyMove a drug to a higher or lower cost-sharing tierAdd or remove a restriction on coverage for a drugReplace a brand name drug with a generic drugWe must follow Medicare requirements before we change the plan’s formulary.More information on formulary changes and notice of these changes can be found inChapter 5, Section 6.2 of your Evidence of Coverage.The following drugs will be removed from the Premera Blue Cross Medicare AdvantageHMO, Classic (HMO), Classic Plus (HMO), Core (HMO), Core Plus (HMO), Total Health(HMO), Peak Rx (HMO), Sound Rx (HMO) and Charter Rx (HMO) Formulary.Name ofAffected DrugReason for ChangeAlternative DrugAlternative Effective DateDrugCopayADRUCIL INJ2.5/50MLADRUCIL DiscontinuationFLUOROURACILINJ 2.5/50MLFLUOROURACILINJ 500/10MLTier 207/01/2020Tier 207/01/2020Y0134 PBC2422 C047755 (10-20-2020)

Name ofAffected DrugReason for ChangeAlternative DrugAlternative Effective DateDrugCopayAFINITOR TAB2.5MGAFINITOR TAB5MGAFINITOR TAB7.5MGAMINOSYN-PFINJ 10%CIPROFLOXACINSUSP 500MG/5D5W/NACL INJ0.33%DAPTOMYCINSOLN 350MG(brand)DELYLA TAB 0.10.02DEPEN TITRATAB 250MGFARYDAK CAP15MGFASLODEX INJ250/5MLGeneric AvailableEVEROLIMUSTAB 2.5MGEVEROLIMUSTAB 5MGEVEROLIMUSTAB 7.5MGAMINOSYN IIINJ 10%CIPROFLOXACIN TAB 500MGD5W/NACL INJ0.225%DAPTOMYCINSOLN 350MGTier 505/01/2020Tier 505/01/2020Tier 505/01/2020Tier 408/01/2020Tier 103/01/2020Tier 202/01/2020Tier 501/01/2020AVIANE TABTier 202/01/2020Tier 505/01/2020Tier 505/01/2020Tier 501/01/2020FIRAZYR INJ30MG/3MLFLURBIPROFENTAB 50MGHUMIRAPEDIATRIC INJCROHNSIONOSOL-MBINJ D5WISOSORBIDEDINITRATE TABER 40 MGJADENU TAB360MGJADENU TAB90MGGeneric AvailableTier DiscontinuationPENICILLAMINTAB 250MGFARYDAK CAP20MGFULVESTRANTINJ 250MG/5MLICATIBANT INJ30 MG/3MLFLURBIPROFENTAB 100MGHUMIRA KIT40MG/0.8 MLTier 205/01/2020Tier 504/01/2020Medicare Will NoLonger CoverManufacturerDiscontinuationNORMOSOL -MINJ /D5WISOSORBIDEDINITRATE TABTier 405/01/2020Tier 203/01/2020Generic AvailableDEFERASIROXTAB 360MGDEFERASIROXTAB 90MGTier 505/01/2020Tier 505/01/2020Generic AvailableGeneric AvailableMedicare Will NoLonger tinuationGeneric AvailableManufacturerDiscontinuationGeneric AvailableManufacturerDiscontinuationGeneric AvailableGeneric Available

Name ofAffected DrugReason for ChangeAlternative DrugAlternative Effective DateDrugCopayKCL/D5W/NACLINJ .15/.33%LYRICA CAPManufacturerDiscontinuationGeneric AvailableTier 202/01/2020Tier 201/01/2020LYRICA SOL20MG/MLGeneric AvailableTier 201/01/2020MORGIDOX CAP1X50MGManufacturerDiscontinuationTier 202/01/2020MOXEZA SOLN0.5%Generic AvailableTier 203/01/2020NEBUPENT INH300MGNORLYROC TAB0.35MGNOXAFIL TAB100MGGeneric AvailableTier 205/01/2020Tier 202/01/2020Tier 505/01/2020NUVARINGPENTAM 300INJ 300MGGeneric AvailableGeneric AvailableTier 2Tier 205/01/202005/01/2020RANITIDINE INJMarket RemovalTier 206/01/2020RANITIDINE SYP75MG/5MLRANITIDINE TABMarket RemovalTier 206/01/2020Tier 106/01/2020REBETOL SOLN40MG/MLRESCRIPTORTAB 200MGRIBASPHERECAP 200MGRIBASPHERETAB scontinuationKCL/D5W/NACLINJ .15-.45%PREGABALINCAPPREGABALINSOLN 20MG/MLDOXYCYCLINEHYCLATE CAP50 MGMOXIFLOXACINHCL OPHTHSOLN 0.5%PENTAMIDINEINH 300MGCAMILA TAB0.35MGPOSACONAZOLE TAB 100MGDRELURYNG MISPENTAMIDINEISETHIONATEFOR SOLN 300MGFAMOTIDINEINJFAMOTIDINESUS 40MG/5MLFAMOTIDINETABRIBAVIRIN TAB200MGEFAVIRENZ TAB600MGRIBAVIRIN CAP200MGRIBAVIRIN TAB200MGTier 202/01/2020Tier 506/01/2020Tier 202/01/2020Tier 202/01/2020ManufacturerDiscontinuationGeneric AvailableMarket Removal

Name ofAffected DrugReason for ChangeAlternative DrugAlternative Effective DateDrugCopayRIBASPHERETAB 600MGSILENOR TABSYLATRON KIT600MCGTHEOPHYLLINETAB 100MG CRTHEOPHYLLINETAB 200MG CRTRAVATAN ZDROPS 0.004%VIDEX EC CAP125MGVIDEX SOL 2GMManufacturerDiscontinuationGeneric scontinuationManufacturerDiscontinuationGeneric AvailableRIBAVIRIN CAP200MGDOXEPIN TABSYLATRON KIT300MCGTHEOPHYLLINETAB 400MG ERTHEOPHYLLINETAB 400MG ERTRAVOPROSTDROPS 0.004%DIDANOSINECAP 250MGDIDANOSINECAP 200MGZYKADIA TAB150MGTier 202/01/2020Tier 2Tier 505/01/202004/01/2020Tier 201/01/2020Tier 201/01/2020Tier 205/01/2020Tier 207/01/2020Tier 207/01/2020Tier 502/01/2020ZYKADIA continuationManufacturerDiscontinuationIf your prescriber believes that the alternative drugs listed above are not right for you dueto your medical condition, you may request an exception to our formulary. To file arequest, you may contact us by telephone at 844-449-4723 or fax your request to 855633-7673. You may also make your request via mail by sending your request to: CVSCaremark Part D Appeals and Exceptions, PO Box 52000, MC109, Phoenix, AZ, 850722000. Your doctor or other prescriber must give us a statement that explains the medicalreasons for requesting an exception.If you disagree with our decision to make the above formulary changes, you may file agrievance by calling customer service or notifying us in writing. See Chapter 9 of yourEvidence of Coverage for instructions.If you have any questions please call Customer Service at 888-850-8526 (TTY/TDD: 711)Monday – Friday, 8 a.m. to 8 p.m. (7 days a week, 8 a.m. to 8 p.m., October 1 - March 31.

Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in PremeraBlue Cross depends on contract renewal. This information is not a complete descriptionof benefits. Call Customer Service at 888-850-8526 (TTY/TDD: 711) for more information.Premera Blue Cross is an independent Licensee of the Blue Cross Blue ShieldAssociation. Limitations, copayments, and restrictions may apply. Copayments and/orco-insurance may change on January 1 of each year. This is not a complete list of drugscovered by our plan. For a complete listing, please call customer service or visitpremera.com/ma. The formulary, pharmacy network, and provider network may changeat any time. You will receive notice when necessary.

Discrimination is Against the LawPremera Blue Cross (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis ofrace, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because ofrace, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids andservices to people with disabilities to communicate effectively with us, such as qualified sign language interpreters andwritten information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides freelanguage services to people whose primary language is not English, such as qualified interpreters and information writtenin other languages. If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failedto provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex,you can file a grievance with: Civil Rights Coordinator Complaints and Appeals, Premera Blue Cross MedicareAdvantage Plans - Complaints & Appeals, PO Box 262527, Plano, TX 75026, Phone: 888-850-8526, Fax: 800-889-1076,TTY: 711, Email AppealsDepartmentInquiries@Premera.com. You can file a grievance in person or by mail, fax, oremail. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rightscomplaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Officefor Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S.Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building, Washington, D.C.20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at uage AssistanceATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al888-850-8526 (TTY: 以免費獲得語言援助服務。請致電 888-850-8526（TTY：711）。CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 888-850-8526 (TTY: 711).주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 888-850-8526(TTY: 711) 번으로 전화해 주십시오.ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните888-850-8526 (телетайп: 711).PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walangbayad. Tumawag sa 888-850-8526 (TTY: 711).УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовноїпідтримки. Телефонуйте за номером 888-850-8526 (телетайп: 711).ប្រយ័ត្ន៖ បរើសិនជាអ្ន កនិយាយ ភាសាខ្មែ រ, �ា បោយមិនគិត្ឈ្ន �ំប រ ើអ្ន ក។ ចូ រ ទូ រស័ព្ទ 888-850-8526 (TTY: ��にてご連絡ください。ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥርይደውሉ 888-850-8526 (መስማት ለተሳናቸው: 711).XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa888-850-8526 (TTY: 711).)711 : (رقم هاتف الصم والبكم 888-850-8526 اتصل برقم . فإن خدمات المساعدة اللغوية تتوافر لك بالمجان ، إذا كنت تتحدث اذكر اللغة : ملحوظة ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰ ਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱ ਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 888-850-8526(TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.Rufnummer: 888-850-8526 (TTY: 711).ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, �ືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, �. ໂທຣ 888-850-8526 (TTY: 711).Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on renewal.Y0134 PBC1088 C028023 (08-12-2019)

FASLODEX INJ 250/5ML . Generic Available : FULVESTRANT INJ 250 MG/5ML . Tier 5 : 01/01/2020 . FIRAZYR INJ 30MG/3ML : Generic Available . ICATIBANT INJ 30 MG/3ML : Tier 5 . 01/01/2020 : FLURBIPROFEN TAB 50MG . Manufacturer Discontinuation : FLURBIPROFEN TAB 100MG . Tier 2 : 05/01/2020 . HUMIR