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FLUOROQUINOLONES QL valacyclovir ANGIOTENSIN II RECEPTOR QL ext-rel QL * ciprofloxacin tabs HIV/AIDS BLOCKERS QL isradipine * ofloxacin Please see BlueCross BlueShield QL candesartan, QL ext-rel MACROLIDES formulary for covered agents. candesartn/HCTZ QL QL azithromycin INFLUENZA QL irbesartan, irbesartan/HCTZ QL verapamil ext-rel QL clarithromycin QL oseltamivir QL losartan, losartan/HCTZ DIURETICS QL (all salt forms) QL zanamivir QL valsartan, valsartan/HCTZ amiloride PENICILLINS MISCELLANEOUS ANTICOAGULANTS amiloride/HCTZ QL amoxicillin albendazole apixaban bumetanide Preferred Drug List QL amoxicillin/clavulanate atovaquone-profuanil PA QL enoxaparin chlorthalidone KEY: QL ampicillin chloroquine phosphate jantoven furosemide * age restrictions apply QL warfarin hydrochlorothiazide PA requires prior QL penicillin VK ethambutol ANTIPLATELET AGENTS indapamide authorization SULFONAMIDES isoniazid QL OTC aspirin metolazone ST requires trial of first sulfadiazine ivermectin cilostazol step product sulfamethoxazole/trimethoprim methenamine QL clopidogrel spironolactone/HCTZ QL daily dosage limits QL mefloquine QL dipyridamole (25/25 mg only) apply doxycycline monohydrate metronidazole tabs BETA BLOCKERS and torsemide RX legend prescription (capsules only) neomycin COMBINATIONS triamterene/HCTZ product minocycline IR QL nitrofurantoin caps acebutolol LIPID LOWERING AGENTS X distribution through praziquantel atenolol QL cholestyramine specialty pharmacy pyrazinamide atenolol/chlorthalidone colestipol network QL troches rifabutin betaxolol QL PA ezetimibe OTC over-the-counter QL fluconazole rifampin caps bisoprolol, bisoprolol/HCTZ QL ST ezetimibe w/ available by prescription QL rifapentine QL fenofibrate QL griseofulvin suspension rifater labetalol QL gemfibrozil ANTIBACTERIALS QL cream, shampoo metoprolol QL ANTIBIOTICS QL nystatin CARDIOVASCULAR QL metoprolol HCTZ QL OTC niacin IR, ER CEPHALOSPORINS QL terbinafine AGENTS metoprolol ext rel QL OTC nicotinic acid First Generation ANTIVIRALS — HEPATITIS C ACE INHIBITORS and nadolol QL pravastatin QL cefadroxil PA QL elbasvir/grazoprevir COMBINATIONS pindolol QL simvastatin QL cephalexin (Zepatier) QL benazepril, benazepril/HCTZ propranolol, PCSK-9 INHIBITORS Second Generation PA glecaprevir/pibrentasvir captopril, captopril/HCTZ propranolol/HCTZ PA evolocumab QL cefaclor (Mavyret) enalapril, enalapril/HCTZ propranolol ext rel MISCELLANEOUS AGENTS QL cefprozil PA peginterferon alfa 2a QL fosinopril, fosinopril/HCTZ sotalol digoxin tab/soln QL cefuroxime axetil PA peginterferon alfa 2b QL lisinopril, lisinopril/HCTZ timolol Third Generation ribavirin moexipril, moexipril/HCTZ CALCIUM CHANNEL CENTRAL NERVOUS SYSTEM QL cefdinir ANTIVIRALS perindopril BLOCKERS ALZHEIMER’S DISEASE QL cefpodoxime acyclovir quinapril, quinapril/HCTZ QL QL donepezil QL famciclovir QL diltiazem ext-rel QL galantamine Version Date 5/1/2018 WEBMWNY-0038-18- Applies to BlueCross BlueShield Medicaid QL galantamine ER QL felbamate QL paroxetine hcl QL lorazepam carbidopa/levodopa ext-rel QL memantine QL gabapentin QL sertraline QL oxazepam QL carbidopa/entacapone/levodopa ANALGESICS QL lamotrigine disper tab, ER, ANTIPSYCHOTICS — oral ATTENTION DEFICIT pramipexole QL * codeine/APAP ODT QL * aripiprazole (tabs only) HYPERACTIVITY DISORDER ropinirole QL PA transdermal QL levetiracetam QL * QL * amphet/dextroamph, ER selegiline caps, tabs QL PA fentanyl citrate lozenge QL oxcarbazepine QL * QL * atomoxetine trihexyphenidyl QL hydrocodone/acetaminophen QL QL * clozapine (except 200 mg) QL * clonidine ER SEDATIVE/HYPNOTICS QL hydrocodone/ibuprofen QL sod ext-rel QL * lithium carbonate QL * dexmethylphenidate QL chloral hydrate QL hydromorphone QL phenytoin tabs, chewable QL * lithium carbonate ext-rel QL * dexmethylphenidate ER QL estazolam QL meperidine QL primidone QL * lithium solution QL * dextroamphetamine, ext-rel QL temazepam (15/30 mg only) QL PA methadone QL roweepra QL * loxapine QL ST * guanfacine QL PA triazolam QL PA morphine tab, soln, QL tiagabine (2 mg and 4 mg) QL * olanzapine tab QL * methylphenidate, ext-rel QL zolpidem suppository QL topiramate QL * perphenazine MIGRAINE QL zaleplon QL PA morphine ER tab QL valproic acid QL * pimozide QL amitriptyline QL oxycodone, QL zonisamide QL * risperidone tab/soln QL butalbital/APAP COUGH & COLD oxycodone/APAP ANTIDEPRESSANTS QL * quetiapine IR QL butalbital/APAP/caff benzonatate HYLAURONICS QL amitriptyline QL * thioridazine QL * butalbital/APAP/caff/codeine QL OTC * dextromethorphan syrup PA hyaluronate sodium QL amitriptyline/perphenazine QL * thiothixene QL butalbital/ASA QL OTC diphenhydramine (Euflexxa) QL amoxapine QL * trifluoperazine QL butalbital/ASA/caff liquid, capsules PA hyaluronate sodium QL bupropion, bupropionSR/XL QL * ziprasidone QL * butalbital/ASA/caff/codeine QL * guaifenesin syrup (Gelsyn) QL chlordiazepoxide/amitriptyline ANTIPSYCHOTICS — injectables QL naratriptan QL * guaifenesIn w/codeine syrup PA hyaluronate sodium (Supartz QL desipramine PA * aripiprazole (Abilify propranolol, ext-rel QL * promethazine w/codeine syrup FX) QL doxepin Maintena) QL sumatriptan tabs QL * promethazine w/DM syrup MISCELLANEOUS QL imipramine PA * aripiprazole lauroxil QL ST sumatriptan inj, spray QL * pseudoehedrine syrup, tablets lidocaine cream QL maprotiline (Aristada) OPIOID/ALCOHOL QL * saline spray, drops lidocaine HC QL mirtazapine QL * fluphenazine decan, inj DEPENDANCE lidocaine jelly, gel QL nortriptyline QL * haloperidol inj QL acamprosate tab DERMATOLOGY QL lidocaine sol QL phenelzine QL * olanzapine inj QL buprenorphine ACNE ORAL QL protriptyline * paliperidone (Invega QL buprenorphine/naloxone lidocaine/pramoxine crm PA PA claravis QL tranylcypromine Sustenna) SL tabs/film (without applicator) minocycline IR QL PA lidocaine topical patch QL trazodone PA * paliperidone (Invega Trinza) disulfiram PA myorisan tramadol; tramadol/APAP * risperidone (Risperdal Consta) QL QL trimipramine PA naloxone inj syr and vials tetracycline ANTICONVULSANTS ANXIETY SNRIs QL naloxone nasal spray PA zenatane * carbamazepine QL QL venlafaxine QL alprazolam naltrexone tab ACNE TOPICAL QL clonazepam tabs QL venlafaxine XR QL buspirone naltrexone inj PA adapalene cream, gel QL diazepam rectal gel SSRIs QL chlordiazepoxide PARKINSON’S DISEASE QL OTC benzoyl peroxide QL divalproex del-rel, ER, QL citalopram QL clonazepam QL amantadine (except tabs) clindamycin 1% gel, pad, soln sprinkle QL escitalopram QL clorazepate benztropine clindamycin-benzoyl peroxide QL diazepam QL epitol QL fluoxetine (except 60 mg) bromocriptine 1.2-5% gel QL ethosuximide QL fluvoxamine QL hydroxyzine HCl, pamoate carbidopa/levodopa OTC Differin 0.1% gel Version Date 5/1/2018 WEBMWNY-0038-18- Applies to BlueCross BlueShield Medicaid

erythromycin 2% pad, soln QL propionate crm, OTC carbamide peroxide 6.5% MONITORING STRIPS AND liothyronine metronidazole 0.75% cream, gel, oint, soln ciprofloxacin 0.2% otic sol KITS/DIABETIC SUPPLIES nature-throid lotion, gel QL halobetasol propionate crm, QL ciprofloxacin hcl QL TrueMetrix (Trividia) np thyroid metronidazole 1% gel, gel oint / QL select lancets, select unithroid pump FUNGAL INFECTIONS neomycin/polymyxinB/hc syringes and needles westhroid rosadan 0.75% cream, gel OTC butenafine hcl QL ofloxacin QL True Metrix control sol GASTROINTESTINAL * tretinoin gel (0.01%, 0.025%) QL PA ciclodan 8% soln ANTIHISTAMINES ORAL AGENTS DIARRHEA * tretinoin gel micro 0.1% tube QL PA ciclopirox 8% soln QL azelastine spray glimepiride diphenoxylate/atropine * tretinoin cream (0.025%, OTC clotrimazole QL cyproheptadine glipizide, glipizide ext-rel OTC QL loperamide (tabs only) 0.05%, 0.1%) ketoconazole QL OTC diphenhydramine QL glyburide, glyburide EMESIS * tretinoin emollient crm 0.05% OTC nitrate QL * fexofenadine micronized QL aprepitant ANTIBACTERIALS nystatin QL OTC QL glyburide/metformin OTC OTC chlorhexidine OTC generic terbinafine hcl INTRANASAL QL linagliptin metoclopramide mupirocin oint cream QL OTC QL linagliptin/metformin QL ondansetron ODT silver sulfadiazine terbinafine tab QL OTC QL metformin, metformin XR prochlorperazine OTC QL nateglinide promethazine Products are grouped based SCABIES AND PEDICULOSIS ELECTROLYTIC AND QL ST metformin; saxagliptin GERD/HEARTBURN/ULCERS upon relative potency. QL 5% cream RENAL AGENTS QL ST metformin; sitagliptin/XR OTC QL acid reducer DR 20mg cap LOW QL OTC permethrin 1% rinse calcium acetate QL ST pioglitazone OTC QL esomeprazole QL RX/OTC crm, OTC pyrethrins/piperonyl PA sucroferric oxyhydroxide QL pioglitazone/glimepiride OTC RX famotidine oral/inj lot, oint butoxide 4% (Velphoro) QL pioglitazone/metformin nizatidine OTC QL hydrocortisone-aloe spinosad 0.9% topical QL repaglinide OTC QL 1% cr suspension ENDOCRINOLOGY QL ST saxagliptin RX QL* omeprazole 20mg capsule VIRAL INFECTIONS MEDIUM ANTIDIABETICS QL ST simvastatin; sitagliptin (for members < 6 years of QL betamethasone valerate crm QL acyclovir ointment INJECTABLE AGENTS QL ST sitaglipitin age) QL crm, QL docosanol topical ST albiglutide ST sitaglipitin/metformin RX QL pantoprazole oint podofilox QL ST liraglutide (XR) OTC QL lansoprazole QL OTC salicylic acid 17% QL furoate crm, QL ST Ozempic dose pen HORMONE THERAPY OTC ranitidine (tabs/caps only) MISCELLANEOUS QL testosterone 1% gel oint, soln INSULINS PA INFLAMMATORY BOWEL QL ammonium lactate 12% PA testosterone cyp inj QL triamcinolone acet crm, oint QL insulin aspart/insulin DISEASE QL emollient ointment PA testosterone enan inj HIGH aspart protamine QL balsalazide (hydrolatum) HUMAN GROWTH QL oint, lot (Nvolog Mix) QL hydrocortisone QL dipr aug crm QL selenium sulfide shampoo HORMONE QL insulin glargine (Basaglar QL mesalamine rectal susp QL betamethasone dipr lotion QL ST oint PA somatropin (Zomacton) Kwikpen) QL mesalamine ER (Apriso) QL oint QL urea crm/gel 40% OSTEOPOROSIS/PAGETS QL insulin glulisine (Apidra) QL mesalamine/5 ASA QL diacetate crm QL alendronate QL insulin isophane & regular QL sulfasalazine QL E cream QL raloxifene EAR, NOSE & THROAT (Humulin, Novolin) PANCREATIC ENZYMES QL triamcinolone acet crm, oint QL acetic acid/aluminum QL insulin lispro/insulin lispro PA X teriparatide QL pancrelipase VERY HIGH acetate protamine (Humalog Mix) THYROID DISEASE MISC AGENTS QL clobetasol E propionate crm benzocaine/antipyrine QL -levoxyl PA sodium phenylbutyrate Version Date 5/1/2018 WEBMWNY-0038-18- Applies to BlueCross BlueShield Medicaid

sulfasalazine metronidazole tabs QL timolol maleate (solution only) LEUKOTRIENE MODIFIERS RHEUMATOLOGY and MISC. IMMUNOSUPRRESIVE metronidazole vaginal gel INFECTIONS QL montelukast MUSCULOSKELETAL cyclosporine OTC miconazole QL bacitracin QL COX II INHIBITORS gengraf nystatin vaginal tablet QL bacitracin/polymyxin B oint NEBULIZER INHALATIONS PA QL celecoxib mycophenolic acid QL ciprofloxacin QL albuterol soln MUSCLE RELAXANTS tioconazole oint QL erythromycin QL * susp QL baclofen tacrolimus gatifloxacin 0.5% drops QL cromolyn soln QL carisoprodol CHELATING AGENTS OPHTHALMIC QL gentamicin QL ipratropium soln carisoprodol/ASA (Wilson’s disease) ALLERGY levofloxacin 0.5% drops QL ipratropium/albuterol soln cyclobenzaprine IR PA Depen QL cromolyn sodium moxifloxacin 0.5% drops XANTHINES (5 mg and 10 mg only) PA Syprine QL OTC ketotifen neomycin/polymyxin theophylline ER tabs chlorzoxazone QL lodoxamide B/gramicidin theophylline soln/elixir QL cyclobenzaprine OB/GYN ANTI-INFLAMMATORIES ofloxacin OTHERS dantrolene CONTRACEPTIVES dexamethasone sodium phos polymyxin B/trimethoprim QL AL albuterol; ipratropium MDI QL methocarbamol All generic oral contraceptives QL diclofenac sulfacetamide 10% QL ST budesonide; formoterol orphenadrine are covered tobramycin QL ST formoterol; mometasone QL tizanidine (tablets only) QL * EE/ QL neomycin/polymyxinB/ QL trifluridine QL ipratropium HFA NSAIDs QL * EE/norgestimate dexamethasone VASOCONSTRICTOR QL tiotropium (Spiriva Respimat) diclofenac QL * estradiol/norethindrone acet acetate DECONGESTANTS QL umeclidinium/vilanterol diclofenac ext-rel QL * /EE vag ring phosphate 1% OTC artificial tears (Anoro Ellipta) etodolac Today Contraceptive Sponge prednisolone naphazoline 0.1% eye drops PA omalizumab (Xolair) etodolac ext-rel EMERGENCY rimexolone phenylephrine 2.5% eye drops PULMONARY ARTERIAL fenoprofen CONTRACEPTIVES sulfacetamide/prednisolone phenylephrine 10% eye drops HYPERTENSION AGENTS ibuprofen (Ella) phos PA indomethacin levonorgestrel 1.5 mg tab tobramycin/dexamethasone RESPIRATORY DRUGS SPACER DEVICES ketoprofen HORMONE THERAPY drops BETA AGONISTS QL Ace Aerosol Cloud Enhancer QL ketorolac tromethamine estradiol tabs DRY EYE QL albuterol tabs, syrup QL Aerotrach Holding Chamber meloxicam ethinyl estradiol/norethindrone OTC artificial tears drops/ointment QL albuterol sulfate (Ventolin QL Aerovent Plus Holding Chamber meclofenamate PA estradiol patch PA Xiidra 5% (lifitegrast) HFA) QL Breatherite Spacer nabumetone estropipate GLAUCOMA QL metaproterenol syrup QL Breathrite Chamber naproxen sodium PA hydroxyprogesterone betaxolol HCL 0.5% QL terbutaline QL Compact Space Chamber piroxicam PA Makena vial QL brimonidine QL Ventolin HFA QL Liteaire sulindac medroxyprogesterone carteolol CORTICOSTEROIDS QL Microchamber MISC. ANTIRHEUMATIC acetate QL dorzolamide QL beclomethasone QL Microspacer auranofin norethindrone QL dorzolamide/timolol QL budesonide Flexhaler QL Optichamber Diamond azathioprine Yuvafem vaginal insert QL latanoprost QL * fluticasone propionate QL Pocket Chamber hydroxychloroquine VAGINAL INFECTIONS QL levobunolol HFA/diskus (Flovent) QL Primeaire Chamber leflunomide clindamycin crm metipranolol QL (Arnuity QL Prochamber Holding Chamber methotrexate 2.5 mg tabs OTC clotrimazole crm QL pilocarpine Ellipta) QL Riteflo Spacer penicillamine fluconazole tabs QL timolol QL mometasone Twisthaler QL Vortex Holding Chamber Version Date 5/1/2018 WEBMWNY-0038-18- Applies to BlueCross BlueShield Medicaid

QL Vortex VHC Frog Child Mask QL Vortex VHC Ladybug Toddler QL Watchhaler Spacer

UROLOGICAL alfuzosin bethanechol darifenacin doxazosin finasteride QL oxybutynin, oxybutynin ext-rel OTC oxytrol for women (patch) tamsulosin terazosin tolterodine, tolterodine ER trospium, trospium ER

SMOKING DETERRENTS QL bupropion SR OTC QL patch, gum, lozenge Nicotrol Inhaler, nasal spray QL varenicline (Chantix)

MISCELLANEOUS ANAPHYLAXIS THERAPY AGENTS QL epinephrine 0.15 mg Auto- Inject QL epinephrine 0.3 mg Auto- Inject epinephrine 0.1 mg/mL syringe epinephrine 1 mg/mL vial METABOLIC DEFICIENCY AGENTS levocarnitine 330 mg tab

Version Date 5/1/2018 WEBMWNY-0038-18- Applies to BlueCross BlueShield Medicaid