Individual Base Formulary

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INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary abacavir tab300mg alfuzosin tab10mg amlodipine tab10mg ABILIFY SOL1MG/ML ALINIA SUS100MG/5M amlodipine tab2.5mg ABILIFY TAB10MG ALINIA TAB500MG amlodipine tab5mg ABILIFY TAB15MG allopurinol tab100mg ammonium laccre12% ABILIFY TAB20MG allopurinol tab300mg ammonium laclot12% ABILIFY TAB2MG ALORA DIS0.025MG amnesteem cap10mg ABILIFY TAB30MG ALORA DIS0.05MG amnesteem cap20mg ABILIFY TAB5MG ALORA DIS0.075MG amnesteem cap40mg ABILIFY DISCTAB10MG ALORA DIS0.1MG amox/k clav chw200mg ABILIFY DISCTAB15MG alprazolam con1 mg/ml amox/k clav chw400mg acarbose tab100mg alprazolam tab0.25 odt amox/k clav sus200/5ml acarbose tab25mg alprazolam tab0.25mg amox/k clav sus250/5ml acarbose tab50mg alprazolam tab0.5mg amox/k clav sus400/5ml acebutolol cap200mg alprazolam tab0.5mg er amox/k clav sus600/5ml acebutolol cap400mg alprazolam tab0.5mg od amox/k clav tab250mg acetasol hc solotic alprazolam tab0.5mg xr amox/k clav tab500mg acetazolamidcap500mg er alprazolam tab1mg amox/k clav tab875mg acetazolamidtab125mg alprazolam tab1mg er amoxapine tab100mg acetazolamidtab250mg alprazolam tab1mg odt amoxapine tab150mg acetic acid sol2% otic alprazolam tab1mg xr amoxapine tab25mg acetylcyst sol10% alprazolam tab2mg amoxapine tab50mg acetylcyst sol20% alprazolam tab2mg er amoxicillin cap250mg ACTONEL TAB150MG alprazolam tab2mg odt amoxicillin cap500mg ACTONEL TAB30MG alprazolam tab2mg xr amoxicillin chw125mg ACTONEL TAB35MG alprazolam tab3mg er amoxicillin chw250mg ACTONEL TAB5MG alprazolam tab3mg xr amoxicillin sus125/5ml acyclovir cap200mg altavera tab amoxicillin sus200/5ml acyclovir sus200/5ml ALVESCO AER160MCG amoxicillin sus250/5ml acyclovir tab400mg ALVESCO AER80MCG amoxicillin sus400/5ml acyclovir tab800mg alyacen tab1/35 amoxicillin tab500mg adapalene cre0.1% alyacen tab7/7/7 amoxicillin tab875mg adapalene gel0.1% amantadine cap100mg amox-pot clataber ADCIRCA TAB20MG amantadine syp50mg/5ml amphetamine cap10mg er afeditab tab30mg cr amantadine tab100mg amphetamine cap15mg er afeditab tab60mg cr amcinonide cre0.1% amphetamine cap20mg er AFINITOR TAB10MG amcinonide lot0.1% amphetamine cap25mg er AFINITOR TAB2.5MG amcinonide oin0.1% amphetamine cap30mg er AFINITOR TAB5MG amethia tab amphetamine cap5mg er AFINITOR TAB7.5MG amethia lo tab amphetamine tab10mg AGGRENOX CAP25-200MG amethyst tab90-20mcg amphetamine tab12.5mg ala cort cre1% amiloride tab5mg amphetamine tab15mg ALBENZA TAB200MG aminophyllininj25mg/ml amphetamine tab20mg albuterol neb0.083% amiodarone tab200mg amphetamine tab30mg albuterol neb0.5% amiodarone tab400mg amphetamine tab5mg albuterol neb0.63mg/3 AMITIZA CAP24MCG amphetamine tab7.5mg albuterol neb1.25mg/3 AMITIZA CAP8MCG ampicillin cap250mg albuterol syp2mg/5ml amitriptylintab100mg ampicillin cap500mg albuterol tab2mg amitriptylintab10mg ampicillin sus125/5ml albuterol tab4mg amitriptylintab150mg ampicillin sus250/5ml albuterol tab4mg er amitriptylintab25mg AMPYRA TAB10MG albuterol tab8mg er amitriptylintab50mg anagrelide cap0.5mg alclometasoncre0.05% amitriptylintab75mg anagrelide cap1mg alclometasonoin0.05% amlod/benazpcap10-20mg anastrozole tab1mg alendronate tab10mg amlod/benazpcap10-40mg ANDRODERM DIS2MG/24HR alendronate tab35mg amlod/benazpcap2.5-10mg ANDRODERM DIS4MG/24HR alendronate tab40mg amlod/benazpcap5-10mg ANDROGEL GEL1%(50MG) alendronate tab5mg amlod/benazpcap5-20mg ANDROGEL GEL1.62% alendronate tab70mg amlod/benazpcap5-40mg android cap10mg *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 1

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary ANDROXY TAB10MG bacitracin oinop bumetanide tab1mg APIDRA INJSOLOSTAR baclofen tab10mg bumetanide tab2mg APIDRA INJU-100 baclofen tab20mg BUPHENYL TAB500MG apraclonidinsol0.5% op BACTROBAN OINNASAL 2% buprenorphinsub2mg apri tab balsalazide cap750mg buprenorphinsub8mg APRISO CAP0.375GM balziva tab buproban tab150mg APTIVUS CAP250MG BANZEL SUS40MG/ML bupropion tab100mg APTIVUS SOL BANZEL TAB200MG bupropion tab100mg sr aranelle tab BANZEL TAB400MG bupropion tab150mg sr ARANESP INJ100MCG BARACLUDE SOL.05MG/ML bupropion tab200mg sr ARANESP INJ150MCG BARACLUDE TAB0.5MG bupropion tab75mg ARANESP INJ200MCG BARACLUDE TAB1MG buspirone tab10mg ARANESP INJ25MCG BECONASE AQ SUS0.042% buspirone tab15mg ARANESP INJ300MCG benazep/hctztab10-12.5 buspirone tab30mg ARANESP INJ40MCG benazep/hctztab20-12.5 buspirone tab5mg ARANESP INJ500MCG benazep/hctztab20-25mg buspirone tab7.5mg ARANESP INJ60MCG benazep/hctztab5-6.25 butorphanol sol10mg/ml ARCAPTA CAP75MCG benazepril tab10mg cabergoline tab0.5mg ASACOL TAB400MG DR benazepril tab20mg calc acetatecap667mg ASACOL HD TAB800MG benazepril tab40mg calcipotriencre0.005% ASMANEX 120 AER220MCG benazepril tab5mg calcipotriensol0.005% ASMANEX 14 AER220MCG benztropine tab0.5mg calcitonin spr200/act ASMANEX 30 AER110MCG benztropine tab1mg camila tab0.35mg ASMANEX 30 AER220MCG benztropine tab2mg CAMPRAL TAB333MG ASMANEX 60 AER220MCG betameth dipcre0.05% camrese tab atenol/chlortab100-25mg betameth diplot0.05% camrese lo tab atenol/chlortab50-25mg betameth dipoin0.05% CANASA SUP1000MG atenolol tab100mg betameth valcre0.1% candesa/hctztab16-12.5 atenolol tab25mg betameth vallot0.1% candesa/hctztab32-12.5 atenolol tab50mg betameth valoin0.1% candesa/hctztab32-25mg atorvastatintab10mg BETASERON INJ0.3MG CAPRELSA TAB100MG atorvastatintab20mg betaxolol sol0.5% op CAPRELSA TAB300MG atorvastatintab40mg betaxolol tab10mg captopr/hctztab25-15mg atorvastatintab80mg bethanechol tab10mg captopr/hctztab25-25mg atovaq/progutab250-100 bethanechol tab25mg captopr/hctztab50-15mg ATROVENT HFAAER17MCG bethanechol tab50mg captopr/hctztab50-25mg AUBAGIO TAB14MG bethanechol tab5mg captopril tab100mg AUBAGIO TAB7MG bicalutamidetab50mg captopril tab12.5mg aug betamet cre0.05% BILTRICIDE TAB600MG captopril tab25mg aug betamet lot0.05% bisoprl/hctztab10/6.25 captopril tab50mg aug betamet oin0.05% bisoprl/hctztab2.5/6.25 CARAFATE SUS1GM/10ML AVELOX TAB400MG bisoprl/hctztab5-6.25mg carb/levo tab10-100mg AVELOX ABC TAB400MG bisoprol fumtab10mg carb/levo tab25-100mg aviane tab bisoprol fumtab5mg carb/levo tab25-250mg AVONEX KIT30MCG briellyn tab carb/levo ertab25-100mg AVONEX PREFLKIT30MCG BRILINTA TAB90MG carb/levo ertab50-200mg azathioprinetab50mg brimonidine sol0.15% CARBAGLU TAB200MG azelastine dro0.05% brimonidine sol0.2% op carbamazepincap100mg er azelastine spr0.1% bromfenac sol0.09% carbamazepincap200mg er AZILECT TAB0.5MG bromocriptincap5mg carbamazepincap300mg er AZILECT TAB1MG bromocriptintab2.5mg carbamazepinchw100mg azithromycinsus100/5ml BROVANA NEB15MCG carbamazepinsus100/5ml azithromycinsus200/5ml budeprion tab100mg sr carbamazepintab200mg azithromycintab250mg budeprion tab150mg sr carbamazepintab200mg er azithromycintab500mg budesonide cap3mg/24hr carbamazepintab400mg er azithromycintab600mg budesonide sus0.25mg/2 carbinoxaminliq4mg/5ml aztreonam inj1gm budesonide sus0.5mg/2 carbinoxamintab4mg azurette tab28 day bumetanide tab0.5mg carteolol sol1% op *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 2

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary cartia xt cap120/24hr chlorpropam tab250mg cloraz dipottab3.75mg cartia xt cap180/24hr chlorthalid tab25mg cloraz dipottab7.5mg cartia xt cap240/24hr chlorthalid tab50mg clorpres tab0.1-15mg cartia xt cap300/24hr chlorzoxazontab500mg clorpres tab0.2-15mg carvedilol tab12.5mg cholestyram pow4gm lite clorpres tab0.3-15mg carvedilol tab25mg ciclopirox cre0.77% clotrimazoletro10mg carvedilol tab3.125mg ciclopirox gel0.77% clozapine tab100mg carvedilol tab6.25mg ciclopirox sha1% clozapine tab200mg caziant pak ciclopirox sol8% clozapine tab25mg CEENU CAP100MG ciclopirox sus0.77% clozapine tab50mg CEENU CAP10MG cilostazol tab100mg COARTEM TAB20-120MG CEENU CAP40MG cilostazol tab50mg COLCRYS TAB0.6MG cefaclor cap250mg ciprofloxacnsol0.3% op colestipol gra5gm cefaclor cap500mg ciprofloxacntab1000mg colestipol tab1gm cefaclor er tab500mg ciprofloxacntab100mg colocort ene100mg cefadroxil cap500mg ciprofloxacntab250mg compro sup25mg cefadroxil sus250/5ml ciprofloxacntab500mg constulose sol10gm/15 cefadroxil sus500/5ml ciprofloxacntab500mg er COPAXONE KIT20MG/ML cefadroxil tab1gm ciprofloxacntab750mg cortisone actab25mg cefdinir cap300mg citalopram sol10mg/5ml COUMADIN INJ5 MG cefdinir sus125/5ml citalopram tab10mg CREON CAP12000UNT cefdinir sus250/5ml citalopram tab20mg CREON CAP24000UNT cefpodo proxsus100/5ml citalopram tab40mg CREON CAP3000UNIT cefpodo proxsus50mg/5ml claravis cap10mg CREON CAP6000UNIT cefpodoxime tab100mg claravis cap20mg CRINONE GEL4% VAG cefpodoxime tab200mg claravis cap30mg CRINONE GEL8% VAG cefprozil sus125/5ml claravis cap40mg CRIXIVAN CAP200MG cefprozil sus250/5ml clarithromycsus125/5ml CRIXIVAN CAP400MG cefprozil tab250mg clarithromycsus250/5ml cromolyn sodcon100/5ml cefprozil tab500mg clarithromyctab250mg cromolyn sodneb20mg/2ml cefuroxime tab250mg clarithromyctab500mg cromolyn sodsol4% op cefuroxime tab500mg clarithromyctab500mg er cryselle-28 tab28 tabs CELLCEPT SUS200MG/ML clemastine syp0.5/5ml cyclafem tab1/35 cephalexin cap250mg clemastine tab2.68mg cyclafem tab7/7/7 cephalexin cap500mg clindamycin aer1% cyclobenzaprcap15mg er cephalexin sus125/5ml clindamycin cap150mg cyclobenzaprtab10mg cephalexin sus250/5ml clindamycin cap300mg cyclobenzaprtab5mg cephalexin tab250mg clindamycin cre2% vag cyclobenzaprtab7.5mg cephalexin tab500mg clindamycin gel1% cyclophosph tab25mg cevimeline cap30mg clindamycin lot1% cyclophosph tab50mg CHANTIX PAK0.5& 1MG clindamycin pad1% CYCLOSET TAB0.8MG CHANTIX TAB0.5MG clindamycin sol1% cyclosporinecap100mg CHANTIX TAB1MG clobetasol aer0.05% cyclosporinecap100mg md chateal tab0.15/30 clobetasol gel0.05% cyclosporinecap25mg chlordiazep cap10mg clobetasol lot0.05% cyclosporinecap50mg mod chlordiazep cap25mg clobetasol oin0.05% cyclosporinesolmodified chlordiazep cap5mg clobetasol sha0.05% CYMBALTA CAP20MG chlorhex glusol0.12% clobetasol sol0.05% CYMBALTA CAP30MG chloroquine tab250mg clobetasol ecre0.05% CYMBALTA CAP60MG chloroquine tab500mg clonidine dis0.1/24hr cyproheptad syp2mg/5ml chlorothiaz tab250mg clonidine dis0.2/24hr cyproheptad tab4mg chlorothiaz tab500mg clonidine dis0.3/24hr DALIRESP TAB500MCG chlorpromaz tab100mg clonidine tab0.1mg danazol cap100mg chlorpromaz tab10mg clonidine tab0.2mg danazol cap200mg chlorpromaz tab200mg clonidine tab0.3mg danazol cap50mg chlorpromaz tab25mg clopidogrel tab300mg dantrolene cap100mg chlorpromaz tab50mg clopidogrel tab75mg dantrolene cap25mg chlorpropam tab100mg cloraz dipottab15mg dantrolene cap50mg *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 3

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary dapsone tab100mg dicyclomine sol10mg/5ml doxazosin tab8mg dapsone tab25mg dicyclomine tab20mg doxepin hcl cap100mg DARAPRIM TAB25MG didanosine cap125mg doxepin hcl cap10mg dasetta tab1/35 didanosine cap200mg doxepin hcl cap150mg dasetta tab7/7/7 didanosine cap250mg doxepin hcl cap25mg demeclocycl tab150mg didanosine cap400mg doxepin hcl cap50mg demeclocycl tab300mg DIFICID TAB200MG doxepin hcl cap75mg DEPEN TITRA TAB250MG diflorasone cre0.05% doxepin hcl con10mg/ml desipramine tab100mg diflorasone oin0.05% doxycyc monotab150mg desipramine tab10mg DIGOXIN SOL50MCG/ML doxycyc monotab50mg desipramine tab150mg digoxin tab0.125mg doxycyc monotab75mg desipramine tab25mg digoxin tab0.25mg doxycycl hyccap100mg desipramine tab50mg dihydroergotinj1mg/ml doxycycl hyccap50mg desipramine tab75mg dilt-cd cap120mg doxycycl hyctab100mg desmopressinspr0.01% dilt-cd cap300mg doxycycl hyctab75mg desmopressintab0.1mg diltiazem cap120mg cd doxycycline cap75mg desmopressintab0.2mg diltiazem cap120mg er doxycycline tab20mg desonide cre0.05% diltiazem cap180mg/24 drospir/ethitab3-0.03mg desonide lot0.05% diltiazem cap240mg cd DYRENIUM CAP100MG desonide oin0.05% diltiazem cap300mg cd DYRENIUM CAP50MG desoximetas cre0.05% diltiazem cap360mg/24 e.e.s. 400 tab400mg desoximetas cre0.25% diltiazem cap60mg er econazole cre1% desoximetas gel0.05% diltiazem cap90mg er EDURANT TAB25MG desoximetas oin0.25% diltiazem inj50/10ml EFFIENT TAB10MG dexameth phosol0.1% op diltiazem tab120mg EFFIENT TAB5MG dexamethasoncon1mg/ml diltiazem tab30mg ELIDEL CRE1% dexamethasonelx0.5/5ml diltiazem tab60mg elinest tab dexamethasontab0.5mg diltiazem tab90mg eliphos tab667mg dexamethasontab0.75mg dilt-xr cap180mg elixophyllinelx80/15ml dexamethasontab1.5mg dilt-xr cap240mg ELLA TAB30MG dexamethasontab1mg DIOVAN TAB160MG ELMIRON CAP100MG dexamethasontab2mg DIOVAN TAB320MG EMCYT CAP140MG dexamethasontab4mg DIOVAN TAB40MG emoquette tab dexamethasontab6mg DIOVAN TAB80MG EMTRIVA CAP200MG dexmethylph tab10mg DIPENTUM CAP250MG EMTRIVA SOL10MG/ML dexmethylph tab2.5mg diphen/atroptab2.5mg enalapr/hctztab10-25mg dexmethylph tab5mg dipyridamoletab25mg enalapr/hctztab5-12.5mg dextroamphetcap10mg er dipyridamoletab50mg enalapril tab10mg dextroamphetcap15mg er dipyridamoletab75mg enalapril tab2.5mg dextroamphetcap5mg er disopyramidecap100mg enalapril tab20mg dextroamphettab10mg disopyramidecap150mg enalapril tab5mg dextroamphettab5mg disulfiram tab250mg ENBREL INJ25/0.5ML diazepam con5mg/ml disulfiram tab500mg ENBREL INJ25MG diazepam inj5mg/ml DIURIL SUS250/5ML ENBREL INJ50MG/ML diazepam sol1mg/ml divalproex cap125mg ENDOMETRIN SUP100MG diazepam tab10mg divalproex tab125mg dr ENJUVIA TAB0.3MG diazepam tab2mg divalproex tab250mg dr ENJUVIA TAB0.45MG diazepam tab5mg divalproex tab250mg er ENJUVIA TAB0.625MG DIBENZYLINE CAP10MG divalproex tab500mg dr ENJUVIA TAB0.9MG diclofen pottab50mg divalproex tab500mg er ENJUVIA TAB1.25MG diclofenac sol0.1% op donepezil tab10mg enoxaparin inj100mg/ml diclofenac tab100mg er donepezil tab10mg odt enoxaparin inj120/0.8 diclofenac tab25mg dr donepezil tab5mg enoxaparin inj150mg/ml diclofenac tab50mg dr donepezil tab5mg odt enoxaparin inj30/0.3ml diclofenac tab75mg dr dorzolamide sol2% op enoxaparin inj40/0.4ml dicloxacill cap250mg doxazosin tab1mg enoxaparin inj60/0.6ml dicloxacill cap500mg doxazosin tab2mg enoxaparin inj80/0.8ml dicyclomine cap10mg doxazosin tab4mg enpresse-28 tab *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 4

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary enulose sol10gm/15 etidron disdtab200mg FLOVENT HFA AER44MCG epinastine dro0.05% etidron disdtab400mg fluconazole sus10mg/ml epinephrine inj0.1mg/ml etodolac cap200mg fluconazole sus40mg/ml EPIPEN 2-PAKINJ0.3MG etodolac tab400mg fluconazole tab100mg EPIPEN-JR INJ2-PAK etodolac tab500mg fluconazole tab150mg epitol tab200mg etodolac er tab400mg fluconazole tab200mg EPIVIR SOL10MG/ML etodolac er tab500mg fluconazole tab50mg EPIVIR HBV SOL5MG/ML etodolac er tab600mg flucytosine cap250mg EPIVIR HBV TAB100MG ETOPOPHOS INJ100MG flucytosine cap500mg eplerenone tab25mg etoposide inj20mg/ml fludrocort tab0.1mg eplerenone tab50mg EVISTA TAB60MG flunisolide spr0.025% EPOGEN INJ10000/ML exemestane tab25mg fluocin acetcre0.01% EPOGEN INJ2000/ML EXTAVIA INJ0.3MG fluocin acetcre0.025% EPOGEN INJ20000/ML falmina tab fluocin acetoil0.01% EPOGEN INJ3000/ML famciclovir tab125mg fluocin acetoilbody EPOGEN INJ4000/ML famciclovir tab250mg fluocin acetoin0.025% eprosart mestab600mg famciclovir tab500mg fluocin acetsol0.01% EPZICOM TAB FARESTON TAB60MG fluocinonidecre-e 0.05% ergoloid mestab1mg oral felbamate sus600/5ml fluocinonidegel0.05% ergomar sub2mg felbamate tab400mg fluocinonideoin0.05% ERIVEDGE CAP150MG felbamate tab600mg fluocinonidesol0.05% errin tab0.35mg felodipine tab10mg er fluorouracilcre5% ery pad2% felodipine tab2.5mg er fluorouracilsol2% ery-tab tab250mg ec felodipine tab5mg er fluorouracilsol5% ery-tab tab333mg ec FEMRING MIS0.05/24H fluoxetine cap10mg ery-tab tab500mg ec FEMRING MIS0.1MG/24 fluoxetine cap20mg erythrocin tab250mg FEMTRACE TAB0.45MG fluoxetine cap40mg erythromycingel2% FEMTRACE TAB0.9MG fluoxetine cap90mg dr erythromycinoinop fenofibrate cap134mg fluoxetine sol20mg/5ml erythromycinsol2% fenofibrate cap200mg fluoxetine tab10mg erythromycintab250mg bs fenofibrate cap67mg fluoxetine tab20mg erythromycintab500mg bs fenofibrate tab145mg fluphenazinecon5mg/ml escitalopramsol5mg/5ml fenofibrate tab160mg fluphenazineelx2.5/5ml escitalopramtab10mg fenofibrate tab48mg fluphenazinetab10mg escitalopramtab20mg fenofibrate tab54mg fluphenazinetab1mg escitalopramtab5mg fenoprofen tab600mg fluphenazinetab2.5mg estarylla tab0.25-35 fentanyl dis100mcg/h fluphenazinetab5mg ESTRACE VAG CRE0.1MG/GM fentanyl dis12mcg/hr flurbiprofensol0.03% op estrad val inj10mg/ml fentanyl dis25mcg/hr flurbiprofentab100mg estrad val inj200mg/5 fentanyl dis50mcg/hr flurbiprofentab50mg estrad val inj20mg/ml fentanyl dis75mcg/hr flutamide cap125mg estradiol dis0.025mg fentanyl ot loz1200mcg fluticasone cre0.05% estradiol dis0.0375mg fentanyl ot loz1600mcg fluticasone lot0.05% estradiol dis0.05mg fentanyl ot loz200mcg fluticasone oin0.005% estradiol dis0.06mg fentanyl ot loz400mcg fluticasone spr50mcg estradiol dis0.075mg fentanyl ot loz600mcg fluvoxamine tab100mg estradiol dis0.1mg fentanyl ot loz800mcg fluvoxamine tab25mg estradiol tab0.5mg FERRIPROX TAB500MG fluvoxamine tab50mg estradiol tab1mg finasteride tab5mg fondaparinuxsol10/0.8 estradiol tab2mg flavoxate tab100mg fondaparinuxsol2.5/0.5 ESTRING MIS2MG flecainide tab100mg fondaparinuxsol5.0/0.4 estropipate tab0.75mg flecainide tab150mg fondaparinuxsol7.5/0.6 estropipate tab1.5mg flecainide tab50mg FORTESTA GEL10MG/ACT estropipate tab3mg FLOVENT DISKAER100MCG FORTICAL SPR200/ACT ethambutol tab100mg FLOVENT DISKAER250MCG fosinop/hctztab10/12.5 ethambutol tab400mg FLOVENT DISKAER50MCG fosinop/hctztab20/12.5 ethosuximidecap250mg FLOVENT HFA AER110MCG fosinopril tab10mg ethosuximidesol250/5ml FLOVENT HFA AER220MCG fosinopril tab20mg *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 5

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary fosinopril tab40mg GILENYA CAP0.5MG HUMALOG MIX SUS75/25 FOSRENOL CHW1000MG GLEEVEC TAB100MG HUMATROPE INJ12MG FOSRENOL CHW500MG GLEEVEC TAB400MG HUMATROPE INJ24MG FOSRENOL CHW750MG glimepiride tab1mg HUMATROPE INJ5MG FRAGMIN INJ10000/ML glimepiride tab2mg HUMATROPE INJ6MG FRAGMIN INJ12500UNT glimepiride tab4mg HUMIRA KIT20MG/0.4 FRAGMIN INJ15000UNT glipizide tab10mg HUMIRA KIT40MG/0.8 FRAGMIN INJ18000UNT glipizide tab5mg HUMIRA PEN KITCROHNS FRAGMIN INJ2500/0.2 glipizide ertab10mg HUMULIN INJ70/30 FRAGMIN INJ25000/ML glipizide ertab2.5mg HUMULIN N INJU-100 FRAGMIN INJ5000/0.2 glipizide ertab5mg HUMULIN R INJU-100 FRAGMIN INJ7500/0.3 GLUCAGEN INJHYPOKIT HUMULIN R INJU-500 furosemide sol10mg/ml GLUCAGON KIT1MG hydral/hctz cap25/25 furosemide sol8mg/ml glyburid mcrtab1.5mg hydralazine tab100mg furosemide tab20mg glyburid mcrtab3mg hydralazine tab10mg furosemide tab40mg glyburid mcrtab6mg hydralazine tab25mg furosemide tab80mg glyburide tab1.25mg hydralazine tab50mg FUZEON KIT glyburide tab2.5mg hydrochlorotcap12.5mg gabapentin cap100mg glyburide tab5mg hydrochlorottab12.5mg gabapentin cap300mg glycopyrrol tab1mg hydrochlorottab25mg gabapentin cap400mg glycopyrrol tab2mg hydrochlorottab50mg gabapentin sol250/5ml granisetron tab1mg hydrocort cre1% gabapentin tab600mg granisol sol2mg/10ml hydrocort cre2.5% gabapentin tab800mg griseofulvinsus125/5ml hydrocort ene100mg galantamine cap16mg er griseofulvintabmicr 500 hydrocort lot2.5% galantamine cap24mg er griseofulvintabultr 125 hydrocort oin2.5% galantamine cap8mg er griseofulvintabultr 250 hydrocort tab10mg galantamine sol4mg/ml guanfacine tab1mg hydrocort tab20mg galantamine tab12mg guanfacine tab2mg hydrocort tab5mg galantamine tab4mg GUANIDINE TAB125MG hydromorphontab2mg galantamine tab8mg halobetasol cre0.05% hydromorphontab4mg gemfibrozil tab600mg halobetasol oin0.05% hydromorphontab8mg generlac sol10gm/15 haloperidol con2mg/ml hydroxychlortab200mg gengraf cap100mg haloperidol tab0.5mg hydroxyurea cap500mg gengraf cap25mg haloperidol tab10mg hydroxyz hclsol10mg/5ml gengraf sol100mg/ml haloperidol tab1mg hydroxyz hcltab10mg GENOTROPIN INJ0.2MG haloperidol tab20mg hydroxyz hcltab25mg GENOTROPIN INJ0.4MG haloperidol tab2mg hydroxyz hcltab50mg GENOTROPIN INJ0.6MG haloperidol tab5mg hydroxyz pamcap100mg GENOTROPIN INJ0.8MG hc butyrate oin0.1% hydroxyz pamcap25mg GENOTROPIN INJ1.2MG hc butyrate sol0.1% hydroxyz pamcap50mg GENOTROPIN INJ1.4MG hc valerate cre0.2% ibandronate tab150mg GENOTROPIN INJ1.6MG hc valerate oin0.2% ibuprofen tab400mg GENOTROPIN INJ1.8MG hc/acet acidsolotic ibuprofen tab600mg GENOTROPIN INJ12MG heather tab0.35mg ibuprofen tab800mg GENOTROPIN INJ1MG hep sod/d5w inj20000unt imipram hcl tab10mg GENOTROPIN INJ2MG HEP SOD/NACLINJ25000UNT imipram hcl tab25mg GENOTROPIN INJ5MG hep sod/naclinj2unit/ml imipram hcl tab50mg gentak oin0.3% op heparin sod inj1000/ml imipram pam cap100mg GENTAMICIN CRE0.1% heparin sod inj10000/ml imipram pam cap125mg GENTAMICIN OIN0.1% heparin sod inj5000/ml imipram pam cap150mg gentamicin sol0.3% op HEPSERA TAB10MG imipram pam cap75mg gianvi tab3-0.02mg HEXALEN CAP50MG imiquimod cre5% gildagia tab0.4-35 HUMALOG INJ100/ML INCIVEK TAB375MG gildess tab1.5/30 HUMALOG KWIKINJ100/ML INCRELEX INJ40MG/4ML gildess tab1/20 HUMALOG MIX INJ50/50 indapamide tab1.25mg gildess fe tab1.5/30 HUMALOG MIX INJ50/50KWP indapamide tab2.5mg gildess fe tab1/20 HUMALOG MIX INJ75/25KWP indomethacincap25mg *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 6

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary indomethacincap50mg junel fe tab1/20 levetiracetatab750mg indomethacincap75mg er KALETRA SOL levetiracetatab750mg er INFERGEN INJ15MCG KALETRA TAB100-25MG levobunolol sol0.5% op INTELENCE TAB100MG KALETRA TAB200-50MG levofloxacinsol0.5% INTELENCE TAB200MG kariva tab28 day levofloxacinsol25mg/ml INTRON-A INJ10MU kelnor tab1/35 levofloxacintab250mg INTRON-A INJ18MU ketoconazoleaer2% levofloxacintab500mg INTRON-A INJ3MU PEN ketoconazolecre2% levofloxacintab750mg INTRON-A INJ5MU PEN ketoconazolesha2% levonest tab introvale tab ketoconazoletab200mg levonor/ethitab0.1-0.02 INTUNIV TAB1MG ketoprofen cap200mg er levonor/ethitabestradio INTUNIV TAB2MG ketoprofen cap50mg levora-28 tab0.15/30 INTUNIV TAB3MG ketoprofen cap75mg levorphanol tab2mg INTUNIV TAB4MG ketorolac sol0.4% levothyroxintab100mcg INVIRASE CAP200MG ketorolac sol0.5% levothyroxintab112mcg INVIRASE TAB500MG ketorolac tab10mg levothyroxintab125mcg ipratropium sol0.02%inh kionex powusp levothyroxintab137mcg ipratropium spr0.03% klor-con 10 tab10meq er levothyroxintab150mcg ipratropium spr0.06% klor-con 8 tab8meq er levothyroxintab175mcg irbesar/hctztab150-12.5 klor-con m15tab levothyroxintab200mcg irbesar/hctztab300-12.5 klor-con m20tab20meq er levothyroxintab25mcg irbesartan tab150mg kurvelo tab0.15/30 levothyroxintab300mcg irbesartan tab300mg laclotion lot12% levothyroxintab50mcg irbesartan tab75mg lactulose sol10gm/15 levothyroxintab75mcg ISENTRESS CHW100MG lamivud/zidotab150-300 levothyroxintab88mcg ISENTRESS CHW25MG lamivudine tab150mg LEXIVA SUS50MG/ML ISENTRESS TAB400MG lamivudine tab300mg LEXIVA TAB700MG isoniazid syp50mg/5ml lamotrigine chw25mg LIALDA TAB1.2GM isoniazid tab100mg lamotrigine chw5mg lido/prilocncre2.5-2.5% isoniazid tab300mg lamotrigine tab100mg lidocaine gel2% jelly isosorb din sub2.5mg lamotrigine tab150mg lidocaine oin5% isosorb din sub5mg lamotrigine tab200mg lidocaine sol2% visc isosorb din tab10mg lamotrigine tab25mg lidocaine sol4% isosorb din tab20mg LANTUS INJ100/ML LIDODERM DIS5% isosorb din tab30mg LANTUS INJSOLOSTAR lindane lot1% isosorb din tab40mg er latanoprost sol0.005% lindane sha1% isosorb din tab5mg leflunomide tab10mg liothyroninetab25mcg isosorb monotab10mg leflunomide tab20mg liothyroninetab50mcg isosorb monotab120mg er lessina tab liothyroninetab5mcg isosorb monotab20mg LETAIRIS TAB10MG lisinop/hctztab10-12.5 isosorb monotab30mg er LETAIRIS TAB5MG lisinop/hctztab20-12.5 isosorb monotab60mg er letrozole tab2.5mg lisinop/hctztab20-25mg isradipine cap2.5mg leucovor ca tab10mg lisinopril tab10mg isradipine cap5mg leucovor ca tab15mg lisinopril tab2.5mg itraconazolecap100mg leucovor ca tab25mg lisinopril tab20mg jantoven tab10mg leucovor ca tab5mg lisinopril tab30mg jantoven tab1mg LEUKERAN TAB2MG lisinopril tab40mg jantoven tab2.5mg LEUKINE INJ250MCG lisinopril tab5mg jantoven tab2mg LEUKINE INJ500 MCG lithium carbcap150mg jantoven tab3mg leuprolide inj1mg/0.2 lithium carbcap300mg jantoven tab4mg levalbuterolneb1.25/0.5 lithium carbcap600mg jantoven tab5mg LEVEMIR INJ lithium carbtab300mg jantoven tab6mg LEVEMIR INJFLEXPEN lithium carbtab300mg er jantoven tab7.5mg levetiracetasol100mg/ml lithium carbtab450mg er jolessa tab levetiracetatab1000mg LITHIUM CITRSOL8MEQ/5ML junel 1.5/30tab levetiracetatab250mg LODOSYN TAB25MG junel 1/20 tab levetiracetatab500mg lokara lot0.05% junel fe tab1.5/30 levetiracetatab500mg er lorazepam con2mg/ml *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 7

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary lorazepam inj2mg/ml MELOXICAM SUS7.5/5ML methylphenidsol10mg/5ml lorazepam inj4mg/ml meloxicam tab15mg methylphenidsol5mg/5ml lorazepam tab0.5mg meloxicam tab7.5mg methylphenidtab10mg lorazepam tab1mg menest tab0.3mg methylphenidtab20mg lorazepam tab2mg menest tab0.625mg methylphenidtab20mg er loryna tab3-0.02mg menest tab1.25mg methylphenidtab5mg lorzone tab375mg menest tab2.5mg methylpred pak4mg lorzone tab750mg MENOSTAR DIS14MCG methylpred tab16mg losartan pottab100mg meperidine sol50mg/5ml methylpred tab32mg losartan pottab25mg meperitab tab100mg methylpred tab4mg losartan pottab50mg meperitab tab50mg methylpred tab8mg losartan/hcttab100-12.5 mercaptopur tab50mg metipranololsol0.3% oph losartan/hcttab100-25 meropenem inj500mg metoclopram sol5mg/5ml losartan/hcttab50-12.5 mesalamine kit4gm metoclopram tab10mg LOTRONEX TAB0.5MG MESTINON SYP60MG/5ML metoclopram tab5mg LOTRONEX TAB1MG metadate tab20mg er metolazone tab10mg lovastatin tab10mg metaproterensyp10mg/5ml metolazone tab2.5mg lovastatin tab20mg metaproterentab10mg metolazone tab5mg lovastatin tab40mg metaproterentab20mg metoprl/hctztab100-25mg LOVAZA CAP1GM metformin tab1000mg metoprl/hctztab100-50mg low-ogestreltab metformin tab500mg metoprl/hctztab50-25mg loxapine cap10mg metformin tab500mg er metoprol tartab100mg loxapine cap25mg metformin tab750mg er metoprol tartab25mg loxapine cap50mg metformin tab850mg metoprol tartab50mg loxapine cap5mg methadone con10mg/ml metoprolol inj1mg/ml lufyllin tab200mg methadone sol10mg/5ml metoprolol tab100mg er lufyllin tab400mg methadone sol5mg/5ml metoprolol tab200mg er LUMIGAN SOL0.01% methadone tab10mg metoprolol tab25mg er LUMIGAN SOL0.03% methadone tab5mg metoprolol tab50mg er lutera tab methadose tab10mg METROGEL GEL1% LYRICA CAP100MG methamphetamtab5mg metronidazolcap375mg LYRICA CAP150MG methazolamidtab25mg metronidazolcre0.75% LYRICA CAP200MG methazolamidtab50mg metronidazolgel0.75% LYRICA CAP225MG methenam hiptab1gm metronidazolgel0.75%vag LYRICA CAP25MG methimazole tab10mg metronidazollot0.75% LYRICA CAP300MG methimazole tab5mg metronidazoltab250mg LYRICA CAP50MG methitest tab10mg metronidazoltab500mg LYRICA CAP75MG methocarbam tab500mg mexiletine cap150mg LYSODREN TAB500MG methocarbam tab750mg mexiletine cap200mg MALARONE TAB62.5-25 methotrexateinj1gm mexiletine cap250mg malathion lot0.5% methotrexateinj25mg/ml microgestin tab1.5/30 marlissa tab0.15/30 methotrexatetab2.5mg microgestin tab1/20 MARPLAN TAB10MG methscopolamtab2.5mg microgestin tabfe 1/20 MATULANE CAP50MG methscopolamtab5mg microgestin tabfe1.5/30 matzim la tab180mg/24 methyclothiatab5mg midodrine tab10mg matzim la tab240mg/24 methyld/hctztab250/15 midodrine tab2.5mg matzim la tab300mg/24 methyld/hctztab250/25 midodrine tab5mg matzim la tab360mg/24 methyldopa tab250mg millipred sol10mg/5ml matzim la tab420mg/24 methyldopa tab500mg millipred tab5mg meclizine tab25mg METHYLIN CHW10MG minitran dis0.1mg/hr medroxypr actab10mg METHYLIN CHW2.5MG minitran dis0.2mg/hr medroxypr actab2.5mg METHYLIN CHW5MG minitran dis0.4mg/hr medroxypr actab5mg methylphenidcap10mg minitran dis0.6mg/hr mefloquine tab250mg methylphenidcap20mg er MINIVELLE DIS0.0375MG MEGACE ES SUS625/5ML methylphenidcap30mg er MINIVELLE DIS0.05MG megestrol acsus40mg/ml methylphenidcap40mg er MINIVELLE DIS0.075MG megestrol actab20mg methylphenidcap50mg MINIVELLE DIS0.1MG megestrol actab40mg methylphenidcap60mg minocycline cap100mg *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 8

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary minocycline cap50mg NAMENDA SOL10MG/5ML NORDITROPIN INJ10/1.5ML minocycline cap75mg NAMENDA TAB10MG NORDITROPIN INJ15/1.5ML minocycline tab100mg NAMENDA TAB5-10MG NORDITROPIN INJ30/3ML minocycline tab135mg er NAMENDA TAB5MG NORDITROPIN INJ5/1.5ML minocycline tab45mg er naproxen sus125/5ml norethin acetab5mg minocycline tab50mg naproxen tab250mg norethindrontab0.35mg minocycline tab75mg naproxen tab375mg norgest/ethitab0.25/35 minocycline tab90mg er naproxen tab500mg norgest/ethitabestradio minoxidil tab10mg naproxen dr tab375mg NORPACE CAP100MG CR minoxidil tab2.5mg naproxen dr tab500mg NORPACE CAP150MG CR mirtazapine tab15mg naproxen sodtab275mg nortrel tab0.5/35 mirtazapine tab15mg odt naproxen sodtab550mg nortrel tab1/35 mirtazapine tab30mg naratriptan tab1mg nortrel tab7/7/7 mirtazapine tab30mg odt naratriptan tab2.5mg nortriptylincap10mg mirtazapine tab45mg NASONEX SPR50MCG/AC nortriptylincap25mg mirtazapine tab45mg odt nateglinide tab120mg nortriptylincap50mg mirtazapine tab7.5mg nateglinide tab60mg nortriptylincap75mg misoprostol tab200mcg necon tab0.5/35 NORVIR CAP100MG modafinil tab100mg necon tab1/35 NORVIR SOL80MG/ML modafinil tab200mg necon tab1/50-28 NORVIR TAB100MG moexipr/hctztab15-12.5 necon tab10/11-28 NOVOLIN INJ70/30 moexipr/hctztab15-25mg nefazodone tab100mg NOVOLIN N INJU-100 moexipr/hctztab7.5-12.5 nefazodone tab150mg NOVOLIN R INJU-100 moexipril tab15mg nefazodone tab200mg NOVOLOG INJ100/ML moexipril tab7.5mg nefazodone tab250mg NOVOLOG INJFLEXPEN mono-linyah tab0.25-35 nefazodone tab50mg NOVOLOG MIX INJ70/30 montelukast chw4mg neo/poly/hc sol1% otic NOVOLOG MIX INJFLEXPEN montelukast chw5mg neo/poly/hc sus1% otic NUEDEXTA CAP20-10MG montelukast tab10mg neomycin tab500mg NUTROPIN INJ10MG morphine sulcap100mg er NEULASTA INJ6MG/0.6M NUTROPIN AQ INJ10MG/2ML morphine sulcap20mg er NEUPOGEN INJ300/0.5 NUTROPIN AQ INJ20MG/2ML morphine sulcap30mg er NEUPOGEN INJ480/0.8 NUTROPIN AQ INJNUSPIN 5 morphine sulcap50mg er NEUPOGEN INJ480MCG nyamyc pow100000 morphine sulcap60mg er nevirapine tab200mg nystat/triamcre morphine sulcap80mg er NEXAVAR TAB200MG nystat/triamoin morphine sulsol10mg/5ml niacor tab500mg nystatin cre100000 morphine sulsol20mg/ml NIASPAN TAB1000 ER nystatin oin100000 morphine sultab100mg er NIASPAN TAB500MG ER nystatin pow100000 morphine sultab15mg NIASPAN TAB750MG ER nystatin sus100000 morphine sultab15mg er NICOTROL INH nystatin tab500000 morphine sultab200mg er NICOTROL NS SPR10MG/ML nystop pow100000 morphine sultab30mg nifediac cc tab90mg er ocella tab3-0.03mg morphine sultab30mg er nifedical xltab30mg octreotide inj1000mcg morphine sultab60mg er nifedical xltab60mg octreotide inj100mcg mupirocin oin2% NILANDRON TAB150MG octreotide inj200mcg MYCOBUTIN CAP150MG nitro-bid oin2% octreotide inj500mcg mycophenolatcap250mg nitrofur maccap50mg octreotide inj50mcg/ml mycophenolattab500mg nitrofurantncap100mg ofloxacin dro0.3% op MYFORTIC TAB180MG nitrofurantnsus25mg/5ml ofloxacin dro0.3%otic MYFORTIC TAB360MG nitroglycer dis0.1mg/hr ofloxacin tab200mg MYTELASE TAB10MG nitroglycer dis0.2mg/hr ofloxacin tab300mg myzilra tab nitroglycer dis0.4mg/hr ofloxacin tab400mg nabumetone tab500mg nitroglyceridis0.6mg/hr ogestrel tab nabumetone tab750mg NITROLINGUALSPRPUMPSPRA olanzapine tab10mg nadolol/bendtab40-5mg NITROMIST AER400MCG olanzapine tab15mg nadolol/bendtab80-5mg NITROSTAT SUB0.3MG olanzapine tab2.5mg nafcillin inj1gm NITROSTAT SUB0.4MG olanzapine tab20mg naltrexone tab50mg NITROSTAT SUB0.6MG olanzapine tab5mg *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 9

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary olanzapine tab5mg odt paroxetine tab10mg pramipexole tab0.125mg omeprazole cap10mg paroxetine tab20mg pramipexole tab0.25mg omeprazole cap40mg paroxetine tab25mg er pramipexole tab0.5mg OMNARIS SPR paroxetine tab30mg pramipexole tab0.75mg OMNITROPE INJ10/1.5ML paroxetine tab40mg pramipexole tab1.5mg OMNITROPE INJ5.8MG paser gra4gm pramipexole tab1mg OMNITROPE INJ5/1.5ML pedi-dri pow100000 pravastatin tab10mg ondansetron sol4mg/5ml PEGANONE TAB250MG pravastatin tab20mg ondansetron tab24mg PEGASYS INJPROCLICK pravastatin tab40mg ondansetron tab4mg PEGASYS KIT pravastatin tab80mg ondansetron tab4mg odt PEG-INTRON KIT120 RP prazosin hclcap1mg ondansetron tab8mg PEG-INTRON KIT150 RP prazosin hclcap2mg ondansetron tab8mg odt PEG-INTRON KIT50MCG prazosin hclcap5mg ONGLYZA TAB2.5MG PEG-INTRON KIT50MCG RP pred sod phosol1% op ONGLYZA TAB5MG PEG-INTRON KIT80MCG RP pred sod phosol5mg/5ml ORAP TAB1MG penicilln vksol125/5ml prednicarbatcre0.1% ORAP TAB2MG penicilln vksol250/5ml prednicarbatoin0.1% orsythia tab penicilln vktab250mg prednisolonesol15mg/5ml OSMOPREP TAB1.5GM penicilln vktab500mg prednisolonesus1% op oxacillin inj1gm PENTASA CAP250MG CR prednisone con5mg/ml oxandrolone tab10mg PENTASA CAP500MG CR prednisone sol5mg/5ml oxandrolone tab2.5mg pentoxifyllitab400mg er prednisone tab10mg oxazepam cap10mg perindopril tab2mg prednisone tab1mg oxazepam cap15mg perindopril tab4mg prednisone tab2.5mg oxazepam cap30mg perindopril tab8mg prednisone tab20mg oxcarbazepintab150mg periogard sol0.12% prednisone tab50mg oxcarbazepintab300mg permethrin cre5% prednisone tab5mg oxcarbazepintab600mg perphenazinetab16mg PREMARIN TAB0.3MG OXISTAT CRE1% perphenazinetab2mg PREMARIN TAB0.45MG OXISTAT LOT1% perphenazinetab4mg PREMARIN TAB0.625MG OXSORALEN LOT1% perphenazinetab8mg PREMARIN TAB0.9MG OXSORALEN-ULCAP10MG PERTZYE CAP PREMARIN TAB1.25MG oxybutynin syp5mg/5ml phenadoz sup12.5mg PREMARIN VAGCRE0.625MG oxybutynin tab10mg er phenadoz sup25mg prena1 capquatrefo oxybutynin tab15mg er phenelzine tab15mg prena1 chwquatrefo oxybutynin tab5mg phenytoin chw50mg prena1 plus misquatrefo oxybutynin tab5mg er phenytoin excap100mg prenafirst tab oxycod/ibu tab5-400mg phenytoin excap200mg prenat multicap+dha oxycodone tab10mg phenytoin excap300mg prenata chw29-1mg oxycodone tab15mg philith tab0.4-35 prenatabs tabobn oxycodone tab20mg PHISOHEX LIQ3% prenatabs fatab oxycodone tab30mg PHYSIOLYTE SOL prenatabs rxtab oxycodone tab5mg PHYSIOSOL SOLIRRIGAT prenatal tab oxymorphone tab15mg er pilocarpine tab5mg prenatal tab28-0.8mg oxymorphone tab7.5mg er pilocarpine tab7.5mg prenatal tabcomplete oxymorphone tabhcl 10mg pioglitazonetab15mg prenatal tabformula oxymorphone tabhcl 5mg pioglitazonetab30mg prenatal tabforte pacerone tab100mg pioglitazonetab45mg prenatal tablow iron pacerone tab200mg podofilox sol0.5% prenatal tabplus pacerone tab400mg portia-28 tab prenatal tabplus dha palgic liq4mg/5ml pot chloridecap10meq er prenatal tabvitamins PANCREAZE CAP10500UNT pot chloridecap8meq er pre-natal tabformula PANCREAZE CAP16800UNT pot citrate tab1080mg prenatal 1 cap PANCREAZE CAP21000UNT pot citrate tab540mg prenatal 19 chwtab PANCREAZE CAP4200UNIT pot cl microtab10meq er prenatal 19 tab paromomycin cap250mg pot cl microtab20meq er prenatal ad tab paroxetin ertab12.5mg PRADAXA CAP150MG prenatal frmtaba-free paroxetin ertab37.5mg PRADAXA CAP75MG prenatal mulcap+dha *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 10

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary prenatal mv mis+ dha propranolol cap80mg er REVLIMID CAP10MG prenatal onetabdaily propranolol inj1mg/ml REVLIMID CAP15MG prenatal rdacap propranolol sol20mg/5ml REVLIMID CAP25MG prenatal vittabplus propranolol sol40mg/5ml REVLIMID CAP5MG prenatal/fe tab propranolol tab10mg REYATAZ CAP100MG PREPOPIK PAK propranolol tab20mg REYATAZ CAP150MG prevalite pow4gm propranolol tab40mg REYATAZ CAP200MG previfem tab propranolol tab60mg REYATAZ CAP300MG PREZISTA TAB150MG propranolol tab80mg RHEUMATREX TAB2.5MG PREZISTA TAB400MG propylthiourtab50mg RHINOCORT SUSAQUA PREZISTA TAB600MG PROTOPIC OIN0.03% ribapak pak1000/day PREZISTA TAB75MG PROTOPIC OIN0.1% ribapak pak1200/day primidone tab250mg pyridostigm tab60mg ribapak pak800/day primidone tab50mg qnapril/hctztab10-12.5 ribasphere cap200mg proben/colchtab500-0.5 qnapril/hctztab20-12.5 ribasphere tab200mg probenecid tab500mg qnapril/hctztab20-25mg ribasphere tab400mg procainamideinj100mg/ml quasense tab ribasphere tab600mg procainamideinj500mg/ml questran pow4gm ribavirin cap200mg prochlorper sup25mg quetiapine tab100mg ribavirin tab200mg prochlorper tab10mg quetiapine tab200mg RIDAURA CAP3MG prochlorper tab5mg quetiapine tab25mg rifampin cap150mg PROCRIT INJ10000/ML quetiapine tab300mg rifampin cap300mg PROCRIT INJ2000/ML quetiapine tab400mg RIFATER TAB PROCRIT INJ20000/ML quetiapine tab50mg RILUTEK TAB50MG PROCRIT INJ3000/ML quinapril tab10mg rimantadine tab100mg PROCRIT INJ4000/ML quinapril tab20mg risperidone sol1mg/ml PROCRIT INJ40000/ML quinapril tab40mg risperidone tab0.25mg proctocream crehc 2.5% quinapril tab5mg risperidone tab0.5mg procto-pak cre1% quinidine gltab324mg er risperidone tab1mg proctozone cre-hc 2.5% quinidine sutab200mg risperidone tab2mg product_description quinidine sutab300mg risperidone tab3mg progesteronecap100mg quinidine sutab300mg er risperidone tab4mg progesteronecap200mg QVAR AER40MCG RITUXAN INJ500MG PROGLYCEM SUS50MG/ML QVAR AER80MCG rivastigminecap1.5mg PROMACTA TAB12.5MG ramipril cap1.25mg rivastigminecap3mg PROMACTA TAB25MG ramipril cap10mg rivastigminecap4.5mg PROMACTA TAB50MG ramipril cap2.5mg rivastigminecap6mg PROMACTA TAB75MG ramipril cap5mg rizatriptan tab10mg promethazinesup12.5mg RANEXA TAB1000MG rizatriptan tab5mg promethazinesup25mg RANEXA TAB500MG ropinirole tab0.25mg promethazinesyp6.25/5ml ranitidine cap150mg ropinirole tab0.5mg promethazinetab12.5mg ranitidine cap300mg ropinirole tab12mg er promethazinetab25mg ranitidine syp15mg/ml ropinirole tab1mg promethazinetab50mg ranitidine tab300mg ropinirole tab2mg promethegan sup25mg RAPAMUNE SOL1MG/ML ropinirole tab2mg er promethegan sup50mg RAPAMUNE TAB0.5MG ropinirole tab3mg propafenone cap225mg er RAPAMUNE TAB1MG ropinirole tab4mg propafenone cap325mg er RAPAMUNE TAB2MG ropinirole tab4mg er propafenone cap425mg sr REBIF INJ22/0.5 ropinirole tab5mg propafenone tab150mg REBIF INJ44/0.5 ropinirole tab6mg er propafenone tab225mg REBIF TITRTNSOLPACK ropinirole tab8mg er propafenone tab300mg reclipsen tab SABRIL POW500MG proparacainesol0.5% op RELENZA MISDISKHALE SABRIL TAB500MG propran/hctztab40/25 RELISTOR KIT12/0.6ML SAIZEN INJ5MG propran/hctztab80/25 RENAGEL TAB400MG SAIZEN INJ8.8MG propranolol cap120mg er RENAGEL TAB800MG SAMSCA TAB15MG propranolol cap160mg er RESCRIPTOR TAB100 MG SAMSCA TAB30MG propranolol cap60mg er RESCRIPTOR TAB200MG SANDIMMUNE SOL100MG/ML *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 11

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary SAPHRIS SUB10MG stavudine cap30mg TEKTURNA TAB300MG SAPHRIS SUB5MG stavudine cap40mg terazosin cap10mg selegiline cap5mg stavudine sol1mg/ml terazosin cap1mg selegiline tab5mg STIVARGA TAB40MG terazosin cap2mg selenium sullot2.5% STRATTERA CAP100MG terazosin cap5mg SELZENTRY TAB150MG STRATTERA CAP10MG terbinafine tab250mg SELZENTRY TAB300MG STRATTERA CAP18MG terbutaline tab2.5mg SENSIPAR TAB30MG STRATTERA CAP25MG terbutaline tab5mg SENSIPAR TAB60MG STRATTERA CAP40MG terconazole cre0.4% SENSIPAR TAB90MG STRATTERA CAP60MG terconazole cre0.8% SEREVENT DISAER50MCG STRATTERA CAP80MG terconazole sup80mg seromycin cap250mg STRIANT MIS30MG TESTIM GEL1%(50MG) SEROSTIM INJ4MG STRIBILD TAB testost cyp inj100mg/ml SEROSTIM INJ5MG STROMECTOL TAB3MG testost cyp inj200mg/ml SEROSTIM INJ6MG sucralfate tab1gm testost enaninj200mg/ml sertraline con20mg/ml sulfacetamidsus10% testred cap10mg sertraline tab100mg SULFAMYLON CRE85MG/GM tetracyclinecap250mg sertraline tab25mg sulfasalazintab500mg tetracyclinecap500mg sertraline tab50mg sulfazine ectab500mg TEVETEN TAB400MG SFROWASA ENE4GM sulindac tab150mg TEV-TROPIN INJ5MG sildenafil tab20mg sulindac tab200mg THALITONE TAB15MG silver sulfacre1% sumatriptan inj6mg/0.5 THALOMID CAP100MG simvastatin tab10mg sumatriptan tab100mg THALOMID CAP150MG simvastatin tab20mg sumatriptan tab25mg THALOMID CAP200MG simvastatin tab40mg sumatriptan tab50mg THALOMID CAP50MG simvastatin tab5mg SUPREP BOWELSOLPREP theophyllinetab300mg er simvastatin tab80mg SUSTIVA CAP200MG thermazene cre1% smz/tmp ds tab800-160 SUSTIVA CAP50MG thioridazinetab100mg smz-tmp sus200-40/5 SUSTIVA TAB600MG thioridazinetab10mg smz-tmp tab400-80mg SUTENT CAP12.5MG thioridazinetab25mg sod poly sulsus15gm/60 SUTENT CAP25MG thioridazinetab50mg sod sulfacetsol10% op SUTENT CAP50MG thiothixene cap10mg SOMAVERT INJ10MG syeda tab3-0.03mg thiothixene cap1mg SOMAVERT INJ15MG SYMLINPEN 60INJ1000MCG thiothixene cap2mg SOMAVERT INJ20MG SYMLNPEN 120INJ1000MCG thiothixene cap5mg sorine tab120mg TABLOID TAB40MG THYMOGLOBULNINJ25MG sorine tab160mg tacrolimus cap0.5mg tiagabine tab2mg sorine tab240mg tacrolimus cap1mg tiagabine tab4mg sorine tab80mg tacrolimus cap5mg ticlopidine tab250mg sotalol af tab120mg TAMIFLU CAP30MG TIKOSYN CAP125MCG sotalol hcl tab160mg TAMIFLU CAP45MG TIKOSYN CAP250MCG sotalol hcl tab240mg TAMIFLU CAP75MG TIKOSYN CAP500MCG sotalol hcl tab80mg TAMIFLU SUS6MG/ML tilia fe tab SPIRIVA CAPHANDIHLR tamoxifen tab10mg timolol gel sol0.25% op spironolact tab100mg tamoxifen tab20mg timolol gel sol0.5% op spironolact tab25mg tamsulosin cap0.4mg timolol mal sol0.25% op spironolact tab50mg TARCEVA TAB100MG timolol mal sol0.5% op sprintec 28 tab28 day TARCEVA TAB150MG timolol mal tab10mg SPRYCEL TAB100MG TARCEVA TAB25MG timolol mal tab20mg SPRYCEL TAB140MG TASIGNA CAP150MG timolol mal tab5mg SPRYCEL TAB20MG TASIGNA CAP200MG tizanidine cap2mg SPRYCEL TAB50MG TASMAR TAB100MG tizanidine cap4mg SPRYCEL TAB70MG taztia xt cap120mg/24 tizanidine cap6mg SPRYCEL TAB80MG taztia xt cap180mg/24 tizanidine tab2mg sronyx tab taztia xt cap240mg/24 tizanidine tab4mg ssd cre1% taztia xt cap300mg/24 tobramycin sol0.3% op stavudine cap15mg taztia xt cap360mg/24 tolazamide tab250mg stavudine cap20mg TEKTURNA TAB150MG tolazamide tab500mg *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 12

NOTE: Coverage of listed prescription drugs will be subject to the limitations of the PreferredOne prescription drug formulary and the terms of the PreferredOne Contract of coverage for each applicable qualified health plan product. Members should consult their PreferredOne Contract of coverage or contact PreferredOne customer service to determine specific coverage. INDIVIDUAL BASE FORMULARY (MNsure and New Plans) BASE Formulary tolbutamide tab500mg triamcinolonoin0.1% venlafaxine tab25mg tolterodine tab1mg triamcinolonoin0.5% venlafaxine tab37.5mg tolterodine tab2mg triderm cre0.1% venlafaxine tab50mg topicort cre0.05% tri-estarylltab venlafaxine tab75mg topiramate cap15mg trifluoperaztab10mg venlafaxine tab75mg er topiramate cap25mg trifluoperaztab1mg VENTAVIS SOL10MCG/ML topiramate tab100mg trifluoperaztab2mg VENTOLIN HFAAER topiramate tab200mg trifluoperaztab5mg verapamil cap100mg er topiramate tab25mg trifluridinesol1% op verapamil cap120mg er topiramate tab50mg trihexyphen elx0.4mg/ml verapamil cap180mg er toposar inj1gm/50ml trihexyphen tab2mg verapamil cap200mg er topotecan inj4mg trihexyphen tab5mg verapamil cap240mg er torsemide tab100mg tri-legest tabfe verapamil cap300mg er torsemide tab10mg tri-linyah tab verapamil inj2.5mg/ml torsemide tab20mg trimethobenzcap300mg verapamil tab120mg torsemide tab5mg trimethoprimtab100mg verapamil tab120mg er TRACLEER TAB125MG tri-previfemtab verapamil tab180mg er TRACLEER TAB62.5MG tri-sprintectab verapamil tab240mg er tramadol hcltab100mg er trivora-28 tab verapamil tab40mg tramadol hcltab200mg er TRIZIVIR TAB verapamil tab80mg tramadol hcltab300mg er trospium chlcap60mg er veripred 20 sol20mg/5ml tramadol hcltab50mg TRUVADA TAB VICTRELIS CAP200MG trando/veraptab1-240 cr TWINJECT INJ0.15MG VIDEX SOL2GM trando/veraptab2-180 cr TWINJECT INJ0.3MG VIGAMOX DRO0.5% trando/veraptab2-240 cr TYKERB TAB250MG VIIBRYD KIT trando/veraptab4-240 cr TYZEKA TAB600MG VIIBRYD TAB10MG trandolapriltab1mg tyzine sol0.1% VIIBRYD TAB20MG trandolapriltab2mg tyzine ped dro0.05% VIIBRYD TAB40MG trandolapriltab4mg ULORIC TAB40MG VIMPAT SOL10MG/ML tranexamic injacid ULORIC TAB80MG VIMPAT TAB100MG tranylcypromtab10mg ULTRESA CAP13800UNT VIMPAT TAB150MG TRAVATAN Z DRO0.004% ULTRESA CAP20700UNT VIMPAT TAB200MG trazodone tab100mg ULTRESA CAP23000UNT VIMPAT TAB50MG trazodone tab150mg ursodiol cap300mg vinate az tab trazodone tab300mg ursodiol tab250mg vinate az extab trazodone tab50mg ursodiol tab500mg vinate c tab tretinoin cap10mg valacyclovirtab1gm vinate cal tab tretinoin cre0.025% valacyclovirtab500mg vinate dha cap tretinoin cre0.05% VALCYTE SOL50MG/ML vinate ic cap tretinoin cre0.1% VALCYTE TAB450MG vinate ii tab tretinoin gel0.01% valproic acdcap250mg vinate iii tab tretinoin gel0.025% valproic acdsyp250/5ml vinate m tab tretin-x crekit0.025% valsart/hctztab160-12.5 vinate one tab tretin-x crekit0.05% valsart/hctztab160-25mg vinate pn tabcare tretin-x crekit0.1% valsart/hctztab320-12.5 vinate ultratab tretin-x gelkit0.01% valsart/hctztab320-25mg viorele tab tretin-x gelkit0.025% valsart/hctztab80-12.5 VIRACEPT TAB250MG trexall tab10mg vancomycin cap125mg VIRACEPT TAB625MG trexall tab15mg vancomycin cap250mg VIRAMUNE SUS50MG/5ML trexall tab5mg vancomycin inj1000mg VIRAMUNE XR TAB400MG trexall tab7.5mg vancomycin inj10gm VIREAD TAB300MG triamcin/orapst0.1% vancomycin inj500mg VIVELLE-DOT DIS0.025MG triamcinoloncre0.025% velivet pak VIVELLE-DOT DIS0.0375MG triamcinoloncre0.1% venlafaxine cap150mg er VIVELLE-DOT DIS0.05MG triamcinoloncre0.5% venlafaxine cap37.5mg VIVELLE-DOT DIS0.075MG triamcinolonlot0.025% venlafaxine cap75mg er VIVELLE-DOT DIS0.1MG triamcinolonlot0.1% venlafaxine tab100mg vol-plus tab triamcinolonoin0.025% venlafaxine tab150mg er vol-tab rx tab *Generic drugs are listed in lower case letters. **Brand-name drugs are listed in CAPITAL letters. Specialty drugs listed are subject to deductibles and coinsurance. 13