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EmpiRx Health 2018 Basic Plus Formulary List

The 2018 Basic Plus Formulary drug list is shown below. The formulary is the list of drugs included in your prescription drug benefit plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription drug benefit program. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY For the member: Generic contain the same active [INJ] – Injectable Drug ingredients as their corresponding brand-name medications, although [OTC] – Over-the-counter Product they may look different in color or shape. They have been FDA-approved [SP] – Specialty Drug under strict standards. Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY For the physician: Please prescribe preferred products and allow generic Generic drugs are listed in lower-case letters. Example: substitutions when medically appropriate.

A adapalene/benzoyl peroxide alyacen apraclonidine eye solution ADCETRIS [INJ] [SP] amabelz abacavir [SP] ADCIRCA [SP] apri abacavir/lamivudine [SP] ADDAMEL N [INJ] AMBISOME [INJ] APTIVUS [SP] abacavir/lamivudine/zidovudine [SP] adefovir AQUASOL A [INJ] ABELCET [INJ] ADEMPAS [SP] amethia ARALAST NP [INJ] [SP] ABILIFY MAINTENA [INJ] adenosine [INJ] amethia lo aranelle ABRAXANE [INJ] [SP] ADVAIR DISKUS amethyst ARANESP [INJ] [SP] ABSORICA ADVAIR HFA AMICAR arbinoxa acamprosate delayed-release advanced am/pm amifostine [INJ] ARCALYST [INJ] [SP] ACANYA ADVATE [INJ] [SP] amikacin [INJ] ARCAPTA NEOHALER acarbose ADYNOVATE [INJ] [SP] amiloride ACCU-CHEK FASTCLIX LANCETS AFINITOR [SP] amiloride/hydrochlorothiazide aripiprazole orally disintegrating tablets [OTC] AFINITOR DISPERZ [SP] amino acid [INJ] ARISTADA [INJ] ACCU-CHEK MULTICLIX LANCET KIT AFLURIA [INJ] aminocaproic acid [INJ] ARISTOSPAN [INJ] [OTC] AFLURIA QUAD [INJ] aminophylline [INJ] armodafinil ACCU-CHEK MULTICLIX LANCETS AFSTYLA [INJ][SP] AMINOSYN [INJ] ARMONAIR RESPICLICK [OTC] AKYNZEO amiodarone ARMOUR THYROID ACCU-CHEK SOFTCLIX LANCET KIT ALBENZA amiodarone [INJ] ARNUITY ELLIPTA [OTC] albumin human [INJ] AMITIZA ARRANON [INJ] [SP] ACCU-CHEK SOFTCLIX LANCETS albuterol ARZERRA [INJ] [SP] [OTC] albuterol ext-release amitriptyline/chlordiazepoxide ASACOL HD acebutolol albuterol nebulization solution amlodipine ascorbic acid [INJ] acetaminophen/ amlodipine/atorvastatin ashlyna acetazolamide ALDURAZYME [INJ] [SP] amlodipine/benazepril ASMANEX HFA acetazolamide ext-release ALECENSA [SP] amlodipine/olmesartan ASMANEX TWISTHALER acetazolamide sodium [INJ] alendronate amlodipine/valsartan /dipyridamole ext-release acetic acid ear solution [INJ] amlodipine/valsartan/hydrochlorothiazide atenolol acetic acid irrigation solution ALFERON N [INJ] ammonium lactate 12% topical atenolol/chlorthalidone acetic acid/aluminum ear alfuzosin ext-release ATGAM [INJ] solution ALIMTA [INJ] amoxicillin atomoxetine acetic acid/ ear solution ALINIA amoxicillin/potassium clavulanate atorvastatin acetic acid/oxyquinoline vaginal allopurinol amoxicillin/potassium clavulanate ext- atovaquone acetylcysteine [INJ] allopurinol sodium [INJ] release atovaquone/proguanil acetylcysteine inhalation solution amphotericin [INJ] ATRIPLA [SP] acitretin ampicillin [INJ] ACTEMRA [INJ] [SP] ALOXI [INJ] ampicillin sodium [INJ] atropine sulfate eye ointment ACTHAR H.P. [INJ] [SP] ALPHAGAN P 0.1% ampicillin sodium/sulbactam [INJ] atropine sulfate eye solution ACTHIB [INJ] ALPHANATE [INJ] [SP] AMPYRA [SP] ATROVENT HFA ACTHREL [INJ] ALPHANINE SD [INJ] [SP] AMYTAL [INJ] aubra ACTIMMUNE [INJ] [SP] alphaquin hp anagrelide AUGMENTIN 125-31.25 MG/5 ML ACTIVASE [INJ] alprazolam anastrozole AVASTIN [INJ] [SP] acyclovir alprazolam ext-release ANDRODERM AVELOX IV [INJ] acyclovir ointment alprazolam orally disintegrating tablets ANDROGEL 1.62% aviane acyclovir sodium [INJ] ALPROLIX [INJ] [SP] ANORO ELLIPTA avo cream ADACEL [INJ] alprostadil [INJ] anthralin AVONEX [INJ] [SP] ADAGEN [INJ] [SP] ALREX APLISOL [INJ] AVYCAZ [INJ] adapalene altavera APOKYN [INJ] [SP] azacitidine [INJ] [SP] EmpiRx Health Basic Plus Formulary AZACTAM-ISO-OSMOTIC DEXTROSE blisovi fe camrese chlorcyclizine/pseudoephedrine/codeine [INJ] BOOSTRIX [INJ] camrese lo chlordiazepoxide AZASITE BOSULIF [SP] CANASA chlordiazepoxide/clidinium azathioprine [SP] BOTOX [INJ] [SP] CANCIDAS [INJ] chlorhexidine gluconate azathioprine sodium [INJ] [SP] bp vit 3 candesartan chloroquine eye solution BREO ELLIPTA candesartan/hydrochlorothiazide chlorothiazide azelastine nasal spray BREVITAL [INJ] CAPASTAT SULFATE [INJ] chlorothiazide sodium [INJ] azithromycin briellyn capecitabine [SP] chlorpheniramine/phenylephrine/ azithromycin [INJ] BRILINTA CAPRELSA [SP] aztreonam [INJ] brimonidine eye solution captopril azuphen mb BRINEURA [INJ] [SP] captopril/hydrochlorothiazide chlorpromazine [INJ] azurette BRISDELLE CARAC chlorthalidone eye solution CARAFATE SUSPENSION B [INJ] CHOLBAM [SP] bacitracin [INJ] /pseudoephedrine/ CARBAGLU [SP] cholestyramine bacitracin eye ointment codeine cholestyramine light bacitracin/polymyxin eye ointment brompheniramine/pseudoephedrine/ carbamazepine ext-release salicylate/ baclofen dextromethorphan carbidopa CHORIONIC GONADOTROPIN [INJ] BAL IN OIL [INJ] ext-release carbidopa/levodopa [SP] balanced salt eye irrigation solution budesonide nebulization suspension carbidopa/levodopa ext-release chromium chloride [INJ] bal-care dha prenatal vitamins bumetanide carbidopa/levodopa orally disintegrating CIALIS balsalazide bumetanide [INJ] tablets ciclopirox balziva bupivacaine [INJ] carbidopa/levodopa/entacapone ciclopirox shampoo BANZEL bupivacaine/dextrose [INJ] cidofovir [INJ] BARACLUDE SOLUTION bupivacaine/epinephrine [INJ] carboplatin [INJ] ciferex BAVENCIO [INJ] [SP] eye solution cilostazol b-complex [INJ] buprenorphine [INJ] carvedilol BEBULIN [INJ] [SP] buprenorphine/naloxone caspofungin [INJ] CINRYZE [INJ] [SP] bekyree CATHFLO ACTIVASE [INJ] CIPRODEX benazepril bupropion ext-release CAVERJECT [INJ] benazepril/hydrochlorothiazide bupropion ext-release (smoking CAYSTON [SP] ciprofloxacin ear solution BENDEKA [INJ] [SP] deterrent) caziant ciprofloxacin ext-release BENEFIX [INJ] [SP] cefaclor ciprofloxacin eye solution BENLYSTA [INJ] [SP] busulfan [INJ] cefaclor ext-release ciprofloxacin lactate [INJ] benoxinate/fluorescein eye solution butalbital/acetaminophen cefadroxil ciprofloxacin lactate/dextrose [INJ] benzonatate butalbital/acetaminophen/caffeine cefazolin [INJ] cisplatin [INJ] benzoyl peroxide butalbital/acetaminophen/caffeine/ cefdinir citalopram benzphetamine codeine cefditoren citric acid/sodium citrate benztropine butalbital/aspirin/caffeine cefepime [INJ] cladribine [INJ] benztropine [INJ] butalbital/aspirin/caffeine/codeine cefepime/dextrose [INJ] clarithromycin BEPREVE [INJ] cefixime clarithromycin ext-release BERINERT [INJ] [SP] butorphanol nasal cefotaxime [INJ] BESPONSA [INJ] [SP] BUTRANS cefotetan [INJ] clindamycin hcl acetate/betamethasone BYDUREON [INJ] cefoxitin [INJ] clindamycin palmitate sodium phosphate [INJ] BYETTA [INJ] cefoxitin/dextrose [INJ] clindamycin phosphate [INJ] betamethasone dipropionate BYSTOLIC cefpodoxime clindamycin phosphate topical betamethasone dipropionate augmented BYVALSON cefprozil clindamycin phosphate vaginal ceftazidime [INJ] clindamycin phosphate/benzoyl peroxide C BETASERON [INJ] [SP] CEFTAZIDIME/DEXTROSE [INJ] clindamycin phosphate/dextrose [INJ] betaxolol ceftibuten clindamycin phosphate/tretinoin betaxolol eye solution CABOMETYX [SP] ceftriaxone [INJ] CLINIMIX [INJ] caffeine citrated ceftriaxone/dextrose [INJ] CLINIMIX E [INJ] BETHKIS [SP] caffeine citrated [INJ] cefuroxime axetil propionate BEVESPI AEROSPHERE caffeine/sodium benzoate [INJ] cefuroxime sodium [INJ] shampoo bexarotene [SP] calcipotriene celacyn clobetasol propionate/emollient BEXSERO [INJ] calcipotriene/betamethasone clofarabine [INJ] bicalutamide dipropionate CELONTIN clomiphene citrate BICILLIN C-R [INJ] calcitonin salmon nasal centratex BICILLIN L-A [INJ] calcitriol cephalexin clonazepam BICNU [INJ] calcitriol [INJ] CEPROTIN [INJ] [SP] clonazepam orally disintegrating tablets BILTRICIDE calcitriol ointment CERDELGA [SP] bimatoprost eye solution calcium acetate CEREZYME [INJ] [SP] clonidine [INJ] BIOTHRAX [INJ] calcium chloride [INJ] syrup clonidine ext-release bisoprolol CALCIUM DISODIUM VERSENATE CETROTIDE [INJ] [SP] clonidine patches bisoprolol/hydrochlorothiazide [INJ] clonidine/chlorthalidone bivalirudin [INJ] calcium gluconate [INJ] CHANTIX clopidogrel blanche calcium-folic acid plus d chateal clorazepate bleomycin [INJ] calcium-pnv 28-1-250 prenatal vitamins CHEMET clotrimazole topical BLINCYTO [INJ] [SP] CALDOLOR [INJ] CHENODAL [SP] clotrimazole troche blisovi 24 fe camila chloramphenicol [INJ] clotrimazole/betamethasone chlorcyclizine/codeine dipropionate

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 2 Basic Plus Comp EmpiRx Health Basic Plus Formulary DARAPRIM [SP] EGRIFTA [INJ] [SP] clozapine orally disintegrating tablets ext-release digoxin ELAPRASE [INJ] [SP] c-nate dha prenatal vitamins DARZALEX [INJ] [SP] digoxin [INJ] electrolyte-48 solution/dextrose [INJ] COAGADEX [INJ] [SP] dasetta /acetaminophen/caffeine ELELYSO [INJ] [SP] COARTEM daunorubicin [INJ] dihydrocodeine/aspirin/caffeine eletone topical solution daysee [INJ] codeine sulfate DAYTRANA dihydroergotamine nasal ELIDEL colchicine/probenecid deblitane DILANTIN 30 MG CAPSULES ELIGARD [INJ] [SP] COLCRYS decitabine [INJ] [SP] DILATRATE-SR elinest colestipol deferoxamine [INJ] diltiazem eliphos colistimethate [INJ] delflex with dextrose [INJ] diltiazem [INJ] ELIQUIS COMBIGAN delyla diltiazem ext-release elite ob prenatal vitamins COMBIPATCH DELZICOL DILUENT FOR REMODULIN [INJ] [SP] ELITEK [INJ] COMBIVENT RESPIMAT demeclocycline [INJ] elite-ob prenatal vitamins COMPLERA [SP] DEMSER ELMIRON complete natal dha prenatal vitamins DEPEN diphenhydramine [INJ] EMCYT completenate prenatal vitamins DEPOCYT [INJ] diphenoxylate/atropine EMEND [INJ] constulose DEPO-ESTRADIOL [INJ] DIPHTHERIA-TETANUS TOXOIDS- EMEND POWDER PACKET COPAXONE 40 MG [INJ] [SP] DEPO-PROVERA 400 MG/ML [INJ] PED [INJ] emoquette copper chloride [INJ] DESCOVY [SP] dipyridamole EMTRIVA [SP] COREG CR dipyridamole [INJ] emulsion sb CORIFACT [INJ] [SP] disulfiram EMVERM CORLANOR desloratadine orally disintegrating tablets divalproex delayed-release enalapril CORTIFOAM desmopressin acetate divalproex ext-release enalapril/hydrochlorothiazide acetate desmopressin acetate [INJ] [SP] DIVIGEL enalaprilat [INJ] corvita desmopressin nasal dobutamine [INJ] ENBREL [INJ] [SP] corvita 150 -ethinyl estradiol dobutamine/dextrose [INJ] ENGERIX-B [INJ] COSENTYX [INJ] [SP] DOCEFREZ [INJ] enoxaparin [INJ] [SP] cosyntropin [INJ] docetaxel [INJ] enpresse COTELLIC [SP] desvenlafaxine succinate ext-release DOCETAXEL 200 MG/10 ML [INJ] enskyce CREON dofetilide ENSTILAR CRESEMBA dexamethasone sodium phosphate [INJ] donepezil entacapone CRESEMBA [INJ] dexamethasone sodium phosphate eye donepezil orally disintegrating tablets entecavir CRINONE 4% solution [INJ] ENTRESTO CRINONE 8% [SP] DEXCOM G4 dopamine/dextrose [INJ] ENTYVIO [INJ] [SP] CRIXIVAN [SP] DEXCOM G5 DORIBAX [INJ] EOVIST [INJ] CROFAB [INJ] dexmedetomidine [INJ] dorzolamide eye solution EPCLUSA [SP] cromolyn sodium eye solution dexmethylphenidate dorzolamide/timolol eye solution ephedrine [INJ] cromolyn sodium nebulization solution dexmethylphenidate ext-release dothelle dha prenatal vitamins EPIDUO cromolyn sodium oral solution dexrazoxane [INJ] doxazosin EPIDUO FORTE cryselle dextran/dextrose [INJ] eye solution cyanocobalamin [INJ] dextran/normal saline [INJ] doxepin cream EPINEPHRINE AUTO-INJECTOR cyclafem dextroamphetamine doxercalciferol (by Mylan) [INJ] dextroamphetamine ext-release doxercalciferol [INJ] epinephrine vial, ampule, syringe [INJ] eye solution dextroamphetamine/ doxorubicin [INJ] EPIPEN [INJ] cyclophosphamide [INJ] dextroamphetamine/amphetamine ext- doxorubicin/liposomal [INJ] EPIPEN JR. [INJ] CYCLOPHOSPHAMIDE CAPSULES release doxycycline hyclate epirubicin [INJ] cyclosporine [INJ] [SP] dextrose/lactated ringers [INJ] doxycycline hyclate [INJ] EPIVIR HBV SOLUTION cyclosporine [SP] dextrose/sodium chloride [INJ] doxycycline hyclate delayed-release eplerenone cyclosporine modified [SP] dextrose/water [INJ] doxycycline monohydrate epoprostenol [INJ] [SP] dialyvite epoprostenol diluent [INJ] [SP] CYRAMZA [INJ] [SP] dialyvite/zinc [INJ] eprosartan cyred diazepam drospirenone-ethinyl estradiol eptifibatide [INJ] CYSTADANE [SP] diazepam [INJ] drospirenone-ethinyl estradiol- ERAXIS [INJ] CYSTAGON [SP] diazepam rectal gel levomefolate ERBITUX [INJ] [SP] CYSTARAN [SP] eye solution DROXIA ergocalciferol cytarabine [INJ] diclofenac potassium DUAVEE ergoloid mesylates CYTOGAM [INJ] [SP] diclofenac sodium delayed-release DULERA tartrate/caffeine cytra-3 diclofenac sodium ext-release duloxetine delayed-release ergotamine tartrate/caffeine diclofenac sodium gel DUPIXENT [INJ] [SP] suppositories D diclofenac sodium topical solution dutasteride ERIVEDGE [SP] dacarbazine [INJ] diclofenac sodium/misoprostol ext- dutasteride/tamsulosin ext-release errin DALIRESP release DYMISTA ERYTHROCIN [INJ] dicloxacillin erythromycin DALVANCE [INJ] E dicyclomine erythromycin delayed-release dantrolene dicyclomine [INJ] econazole erythromycin ethylsuccinate dantrolene [INJ] didanosine delayed-release [SP] EDARBI erythromycin eye ointment dapsone diethylpropion EDARBYCLOR erythromycin stearate DAPTACEL [INJ] diethylpropion ext-release edrophonium [INJ] erythromycin topical daptomycin [INJ] diflorasone EDURANT [SP] erythromycin/benzoyl peroxide diflorasone/emollient ESBRIET [SP]

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 3 Basic Plus Comp EmpiRx Health Basic Plus Formulary escitalopram ferraplus 90 folic acid GENVOYA [SP] esmolol [INJ] ferrex 150 forte folic acid [INJ] gianvi esomeprazole magnesium delayed- ferrex 150 forte plus folic acid/cyanocobalamin/pyridoxine gildagia release ferrex 28 folivane-f GILENYA [SP] esomeprazole sodium [INJ] FERRIPROX [SP] folivane-ob prenatal vitamins GILOTRIF [SP] estarylla ferrocite plus folivane-plus glatopa [INJ] [SP] estazolam ferrogels forte FOLOTYN [INJ] [SP] GLEOSTINE esterified estrogens/methyltestosterone FETZIMA folplex 2.2 glimepiride ESTRACE CREAM FINACEA fomepizole [INJ] glipizide estradiol finasteride fondaparinux [INJ] [SP] glipizide ext-release estradiol patches FIRAZYR [INJ] [SP] FORA LANCING DEVICE [OTC] glipizide/metformin estradiol vaginal FIRMAGON [INJ] [SP] FORACARE 30G LANCETS [OTC] GLUCAGEN [INJ] estradiol valerate [INJ] FORTAZ-ISO-OSMOTIC DEXTROSE GLUCAGON [INJ] estradiol/norethindrone acetate flecainide [INJ] glyburide ESTRING FLECTOR FORTEO [INJ] [SP] glyburide micronized estropipate FLOLAN [INJ] [SP] fosamprenavir [SP] glyburide/metformin eszopiclone FLOLAN DILUENT [INJ] [SP] foscarnet [INJ] glycine irrigation solution ethacrynate [INJ] FLOVENT DISKUS fosinopril glycolax ethacrynic acid FLOVENT HFA fosinopril/hydrochlorothiazide GLYCOPHOS [INJ] ethambutol floxuridine [INJ] fosphenytoin [INJ] glycopyrrolate ETHAMOLIN [INJ] FLUAD [INJ] FRAGMIN [INJ] [SP] glycopyrrolate [INJ] ethosuximide FLUARIX QUAD [INJ] FREAMINE HBC [INJ] GLYXAMBI ethyl [INJ] FLUBLOK [INJ] freamine iii [INJ] GONAL-F [INJ] [SP] ethyl chloride spray FLUBLOK QUAD [INJ] FREESTYLE FREEDOM KIT [OTC] GONAL-F RFF [INJ] [SP] ethynodiol-ethinyl estradiol FLUCELVAX QUAD [INJ] FREESTYLE FREEDOM LITE METER GONAL-F RFF REDI-JECT [INJ] [SP] etidronate fluconazole [OTC] GRALISE fluconazole/dextrose [INJ] FREESTYLE INSULINX GLUCOSE etodolac ext-release fluconazole/normal saline [INJ] SYSTEM [OTC] granisetron [INJ] etomidate [INJ] flucytosine FREESTYLE INSULINX TEST STRIPS GRANIX [INJ] [SP] ETOPOPHOS [INJ] fludarabine [INJ] [OTC] GRASTEK etoposide acetate FREESTYLE LITE METER [OTC] griseofulvin microsize etoposide [INJ] FLULAVAL QUAD [INJ] FREESTYLE LITE TEST STRIPS [OTC] griseofulvin ultramicrosize EUFLEXXA [INJ] [SP] flumazenil [INJ] FREESTYLE TEST STRIPS [OTC] guaifenesin/codeine EVEKEO nasal spray guaifenesin/phenylephrine exemestane furosemide guanfacine EXJADE [SP] oil ear solution furosemide [INJ] guanfacine ext-release EXTAVIA [INJ] [SP] FUZEON [INJ] [SP] guanidine EXTRANEAL ICODEXTRIN DIALYSIS fluocinonide/emollient fyavolv SOLUTION [INJ] fluorescein [INJ] FYCOMPA H EYLEA [INJ] [SP] fluorescein eye strips G HALAVEN [INJ] [SP] ezetimibe eye suspension halobetasol ezetimibe/simvastatin fluorouracil fluorouracil [INJ] F GABITRIL 12 MG, 16 MG [INJ] GABLOFEN [INJ] haloperidol lactate FABRAZYME [INJ] [SP] fluoxetine delayed-release haloperidol lactate [INJ] falmina galantamine ext-release HARVONI [SP] famciclovir decanoate [INJ] GAMASTAN S-D [INJ] [SP] HAVRIX [INJ] fluphenazine hcl GAMMAGARD LIQUID [INJ] [SP] heather famotidine [INJ] fluphenazine hcl [INJ] GAMMAGARD S-D [INJ] [SP] HELIXATE FS [INJ] [SP] famotidine/nacl [INJ] flurandrenolide GAMUNEX-C [INJ] [SP] HEMABATE [INJ] FARESTON flurazepam ganciclovir [INJ] hematinic with folic acid FARXIGA GARDASIL [INJ] hematinic-vitamin-mineral FASLODEX [INJ] flurbiprofen sodium eye solution GARDASIL 9 [INJ] hematogen fayosim flutamide gatifloxacin eye solution hematogen fa fe c plus nasal spray gavilyte h + bisacodyl kit hematogen forte FEIBA NF [INJ] [SP] fluticasone topical gavilyte-c hemenatal ob + dha prenatal vitamins felbamate FLUTICASONE/SALMETEROL gavilyte-g hemenatal ob prenatal vitamins felodipine ext-release fluvastatin gavilyte-n hemetab femynor fluvastatin ext-release GAZYVA [INJ] [SP] HEMOFIL-M [INJ] [SP] fenofibrate FLUVIRIN [INJ] GELNIQUE HEPAGAM B [INJ] fenofibrate micronized fluvoxamine gemcitabine [INJ] heparin lock flush [INJ] fenofibric acid fluvoxamine ext-release gemfibrozil heparin sodium [INJ] fenofibric acid delayed-release FLUZONE [INJ] GENOTROPIN [INJ] [SP] heparin sodium/dextrose [INJ] FLUZONE QUAD [INJ] gentamicin [INJ] heparin sodium/nacl [INJ] citrate [INJ] focalgin 90 dha prenatal vitamins gentamicin eye ointment HEPATAMINE [INJ] fentanyl citrate lozenges focalgin ca prenatal vitamins gentamicin eye solution HERCEPTIN [INJ] [SP] fentanyl citrate/nacl [INJ] focalgin dss gentamicin topical hetastarch/normal saline [INJ] fentanyl patches folbee gentamicin/normal saline [INJ] HEXALEN FERAHEME [INJ] folbee plus GENTAMICIN/NORMAL SALINE HEXTEND LACTATED ELECTROLYTE ferocon folbee plus cz 100 MG/50 ML [INJ] [INJ] folbic

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 4 Basic Plus Comp EmpiRx Health Basic Plus Formulary HIBERIX [INJ] iferex 150 forte J LANTUS [INJ] HIZENTRA [INJ] [SP] ifosfamide [INJ] larin eye solution ifosfamide/mesna [INJ] JADENU [SP] larin fe hpr emollient foam ILARIS [INJ] [SP] JAKAFI [SP] larissia hpr plus ILEVRO JANUMET LARTRUVO [INJ] [SP] hpr plus hydrogel [SP] JANUMET XR latanoprost eye solution HUMALOG [INJ] IMBRUVICA [SP] JANUVIA LATUDA HUMATE-P [INJ] [SP] imipenem/cilastatin [INJ] JARDIANCE layolis fe HUMATROPE [INJ] [SP] hcl jencycla l-cysteine [INJ] HUMIRA [INJ] [SP] imipramine pamoate JENTADUETO leena HUMULIN [INJ] imiquimod JENTADUETO XR leflunomide HUMULIN R 500 UNITS [INJ] IMOGAM RABIES-HT [INJ] JETREA [INJ] [SP] LEMTRADA [INJ] [SP] HYCAMTIN CAPSULES [SP] IMOVAX RABIES VACCINE [INJ] jevantique lo LENVIMA [SP] Hydralazine IMPAVIDO JEVTANA [INJ] [SP] lessina hydralazine [INJ] INCRELEX [INJ] [SP] jinteli LETAIRIS [SP] hydrochlorothiazide INCRUSE ELLIPTA jolessa letrozole /acetaminophen indapamide jolivette leucovorin hydrocodone/chlorpheniramine polistirex indomethacin juleber leucovorin [INJ] ext-release indomethacin ext-release junel LEUKERAN hydrocodone/chlorpheniramine/ indomethacin sodium [INJ] junel fe LEUKINE [INJ] [SP] pseudoephedrine INFANRIX [INJ] JUXTAPID [SP] leuprolide [INJ] [SP] hydrocodone/homatropine infed [INJ] K levalbuterol nebulization solution hydrocodone/ibuprofen INFLECTRA [INJ] [SP] LEVEMIR [INJ] hydrocortisone INFUMORPH [INJ] KADCYLA [INJ] [SP] levetiracetam suppositories INFUVITE [INJ] kaitlib fe levetiracetam [INJ] INLYTA [SP] KALETRA TABLETS [SP] levetiracetam ext-release hydrocortisone butyrate/emollient INTELENCE [SP] KALYDECO [SP] levetiracetam-nacl [INJ] hydrocortisone enema intralipid 20% [INJ] KANUMA [INJ] [SP] levobunolol eye solution hydrocortisone sodium succinate [INJ] INTRON A [INJ] [SP] kariva levocarnitine hydrocortisone topical introvale kelnor INVANZ [INJ] KEPIVANCE [INJ] [SP] levofloxacin hydrocortisone/iodoquinol INVIRASE [SP] [INJ] levofloxacin [INJ] hydrocortisone/iodoquinol/aloe INVOKAMET levofloxacin eye solution hydrocortisone/ INVOKAMET XR ketoconazole shampoo levofloxacin/dextrose [INJ] hydrocortisone/pramoxine INVOKANA ketoconazole topical LEVOLEUCOVORIN [INJ] iodine/potassium iodide levomefolate dha hydromorphone [INJ] IODOPEN [INJ] ketoprofen ext-release levonest hydromorphone ext-release IONOSOL/DEXTROSE [INJ] levonorgestrel-ethinyl estradiol hydromorphone suppositories IPOL [INJ] ketorolac [INJ] levora hydromorphone/nacl [INJ] nasal spray ketorolac eye solution hydroquinone ipratropium bromide nebulization KEYTRUDA [INJ] [SP] levothyroxine sodium hydroquinone microspheres solution kimidess levothyroxine sodium [INJ] hydroxocobalamin [INJ] ipratropium/albuterol sulfate nebulization KINEVAC [INJ] LEVOTHYROXINE SODIUM 100 MCG hydroxychloroquine solution KITABIS PAK [SP] [INJ] hydroxyprogesterone [INJ] irbesartan KOGENATE FS [INJ] [SP] LEVSIN [INJ] hydroxyurea irbesartan/hydrochlorothiazide KOVALTRY [INJ] [SP] LEXISCAN [INJ] hcl IRESSA [SP] k-phos neutral LEXIVA SUSPENSION [SP] hydroxyzine hcl [INJ] irinotecan [INJ] K-PHOS ORIGINAL lidocaine [INJ] hydroxyzine pamoate ISENTRESS [SP] KRYSTEXXA [INJ] [SP] lidocaine hcl/glycerin hyolev mb isibloom kurvelo lidocaine jelly hyophen ISOLYTE [INJ] KUVAN [SP] lidocaine patches isometheptene/caffeine/acetaminophen KYLEENA [SP] lidocaine topical hyoscyamine ext-release isometheptene/dichloralphenazone/ KYPROLIS [INJ] [SP] lidocaine viscous hyoscyamine orally disintegrating tablets acetaminophen lidocaine/dextrose [INJ] HYPERHEP B S-D [INJ] isoniazid L lidocaine/epinephrine [INJ] HYPERRAB S-D [INJ] isoniazid [INJ] labetalol lidocaine/glycerin HYPERRHO S-D [INJ] isoproterenol [INJ] labetalol [INJ] lidocaine/hydrocortisone HYPERTET S-D [INJ] isosorbide dinitrate lactic acid 10% topical lidocaine/prilocaine HYSINGLA ER isosorbide dinitrate ext-release lactulose lillow isosorbide mononitrate lincomycin [INJ] I lamivudine [SP] isosorbide mononitrate ext-release lamivudine hbv lindane shampoo ibandronate isotretinoin lamivudine/zidovudine [SP] linezolid ibandronate [INJ] [SP] isoxsuprine lamotrigine linezolid [INJ] IBRANCE [SP] isradipine lamotrigine ext-release linezolid/nacl [INJ] ibuprofen ISTODAX [INJ] [SP] lamotrigine orally disintegrating tablets LINZESS ibuprofen [INJ] LANOXIN PEDIATRIC [INJ] LIORESAL [INJ] ibutilide [INJ] lansoprazole delayed-release liothyronine ICLUSIG [SP] IXEMPRA [INJ] [SP] lansoprazole delayed-release liothyronine [INJ] idarubicin [INJ] IXIARO [INJ] +amoxicillin+clarithromycin LIPOFEN IDHIFA [SP] IXINITY [INJ] [SP] lanthanum lisinopril lisinopril/hydrochlorothiazide

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 5 Basic Plus Comp EmpiRx Health Basic Plus Formulary lithium carbonate MENOPUR [INJ] [SP] mimvey N lithium carbonate ext-release MEPHYTON mimvey lo lithium citrate mepivacaine [INJ] MINIMED INFUSION SET nadolol LIVALO mercaptopurine MINIMED RESERVOIR nadolol/bendroflumethiazide L-LEUCINE meropenem [INJ] MINIVELLE nafcillin [INJ] LO LOESTRIN FE MEROPENEM/NACL [INJ] MINOCIN [INJ] nafcillin/dextrose [INJ] lomedia 24 fe mesalamine 1.2 GM delayed-release minocycline naftifine LONSURF [SP] mesalamine enema minocycline ext-release NAGLAZYME [INJ] [SP] loperamide mesalamine kit minoxidil [INJ] lopinavir/ritonavir [SP] mesna [INJ] MIRENA [SP] naloxone [INJ] lopreeza MESNEX TABLETS naltrexone MESTINON SYRUP mirtazapine orally disintegrating tablets NAMENDA XR lorazepam [INJ] metaproterenol MIRVASO NAMZARIC loryna metaxalone misoprostol losartan metformin MITIGARE naproxen delayed-release losartan/hydrochlorothiazide metformin ext-release mitomycin [INJ] naproxen sodium LOTEMAX mitoxantrone [INJ] [SP] naproxen sodium ext-release lovastatin methadone [INJ] M-M-R II [INJ] low-ogestrel methamphetamine modafinil NARCAN NASAL SPRAY methazolamide moderiba [SP] NASCOBAL LUCENTIS [INJ] [SP] methenamine hippurate moexipril NATACYN LUMIGAN methenamine mandelate moexipril/hydrochlorothiazide NATAZIA LUMIZYME [INJ] [SP] methenamine/sodium molindone nateglinide LUPRON DEPOT 3.75 MG, 11.25 MG phosphate/methylene NATPARA [INJ] [SP] [INJ] [SP] blue/hyoscyamine mometasone nasal spray NATRECOR [INJ] LUPRON DEPOT-PED [INJ] [SP] methimazole MONOCLATE-P [INJ] [SP] NEBUPENT lutera METHITEST mono-linyah necon luxamend mononessa neomycin LYNPARZA [SP] methocarbamol [INJ] MONONINE [INJ] [SP] neomycin/bacitracin/polymyxin eye LYRICA methotrexate MONOVISC [INJ] [SP] ointment LYSODREN methotrexate [INJ] montelukast neomycin/bacitracin/polymyxin/ lyza methoxsalen sulfate hydrocortisone eye ointment methyclothiazide morphine sulfate [INJ] neomycin/polymyxin irrigation solution M methyldopa morphine sulfate ext-release neomycin/polymyxin/dexamethasone methyldopa/hydrochlorothiazide morphine sulfate suppositories eye ointment m.v.i. adult [INJ] neomycin/polymyxin/dexamethasone M.V.I. PEDIATRIC [INJ] methyldopate [INJ] morphine sulfate/nacl [INJ] methylergonovine MOVANTIK eye suspension M.V.I.-12 [INJ] neomycin/polymyxin/gramicidin eye macnatal cn dha prenatal vitamins methylergonovine [INJ] MOXEZA methylphenidate moxifloxacin solution magnesium chloride [INJ] neomycin/polymyxin/hydrocortisone ear magnesium sulfate [INJ] methylphenidate ext-release MOXIFLOXACIN [INJ] moxifloxacin eye solution solution MAGNESIUM/DEXTROSE neomycin/polymyxin/hydrocortisone ear 1 GM/100 ML [INJ] methylprednisolone acetate [INJ] MOZOBIL [INJ] [SP] methylprednisolone sodium succinate multigen folic suspension MAKENA [INJ] [SP] neomycin/polymyxin/hydrocortisone eye malathion [INJ] multigen plus methyltestosterone MULTI-LANCET DEVICE [OTC] suspension manganese chloride [INJ] neostigmine [INJ] manganese sulfate [INJ] metipranolol eye solution MULTITRACE-4 [INJ] MULTITRACE-5 [INJ] nephplex rx mannitol [INJ] NEPHRAMINE [INJ] metoclopramide [INJ] multivitamins/fluoride metoclopramide orally disintegrating multivitamins/fluoride/iron nephro-vite rx marlissa NERLYNX [SP] MARQIBO [INJ] [SP] tablets mupirocin metolazone MUSE NEULASTA [INJ] [SP] MATULANE [SP] NEUPOGEN [INJ] [SP] mb hydrogel metoprolol succinate ext-release MUSTARGEN [INJ] metoprolol tartrate MYALEPT [INJ] [SP] NEUT [INJ] NEVANAC meclofenamate metoprolol tartrate [INJ] MYCAMINE [INJ] metoprolol/hydrochlorothiazide mycophenolate mofetil [SP] nevirapine [SP] medroxyprogesterone nevirapine ext-release [SP] medroxyprogesterone (contraceptive) metronidazole mycophenolate mofetil hcl [INJ] [SP] metronidazole topical mycophenolic acid delayed-release [SP] newgen prenatal vitamins [INJ] NEXAVAR [SP] metronidazole vaginal MYDAYIS metronidazole/nacl [INJ] myferon-150 forte NEXIUM PACKETS mefloquine NEXPLANON [INJ] [SP] megestrol MYLERAN MIACALCIN [INJ] mynatal advance prenatal vitamins NEXTERONE [INJ] MEKINIST [SP] niacin ext-release melodetta 24 fe mibelas 24 fe mynatal plus prenatal vitamins vaginal mynatal prenatal vitamins nicardipine nicardipine [INJ] melpaque hp microgestin mynatal ultracaplet prenatal vitamins microgestin fe mynatal-z prenatal vitamins nifedipine ext-release melphalan nikki melphalan [INJ] mynate 90 plus prenatal vitamins midazolam [INJ] mynephrocaps nilutamide melquin-3 nimodipine midodrine mynephron miglitol MYOBLOC [INJ] [SP] NINLARO [SP] MENACTRA [INJ] nisoldipine ext-release MENOMUNE-A-C-Y-W-135 [INJ] milrinone [INJ] MYRBETRIQ milrinone/dextrose [INJ] myzilra nitrofurantoin

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 6 Basic Plus Comp EmpiRx Health Basic Plus Formulary nitrofurantoin macrocrystal /fluoxetine P physostigmine [INJ] nitrofurantoin monohydrate/macrocrystal olmesartan phytonadione [INJ] nitroglycerin [INJ] olmesartan/amlodipine/ paclitaxel [INJ] PHYTONADIONE 1 MG/0.5 ML nitroglycerin ext-release hydrochlorothiazide ext-release SYRINGE [INJ] nitroglycerin ointment olmesartan/hydrochlorothiazide pamidronate [INJ] PICATO nitroglycerin patches eye solution PANHEMATIN [INJ] nitroglycerin spray olopatadine nasal spray pantoprazole [INJ] pilocarpine eye solution nitroglycerin/dextrose [INJ] omega-3 ethyl esters pantoprazole delayed-release nitroprusside sodium [INJ] omeprazole delayed-release papaverine [INJ] pimtrea NITYR [SP] omeprazole/sodium bicarbonate PARADIGM INFUSION SETS nivatopic plus OMNIPAQUE [INJ] PARADIGM RESERVOIRS pioglitazone OMNIPOD PARADIGM SILHOUETTE SETS pioglitazone/glimepiride nora-be ONCASPAR [INJ] pioglitazone/metformin NORDITROPIN [INJ] [SP] paricalcitol piperacillin/tazobactam [INJ] norepinephrine [INJ] ondansetron [INJ] paricalcitol [INJ] pirmella norepinephrine/dextrose [INJ] ondansetron orally disintegrating tablets paromomycin norepinephrine/nacl [INJ] ONETOUCH DELICA LANCETS [OTC] hcl PLASMA-LYTE [INJ] norethindrone ONETOUCH ULTRA 2 SYSTEM [OTC] paroxetine hcl ext-release plasmanate [INJ] norethindrone acetate ONETOUCH ULTRA TEST STRIPS paroxetine mesylate PLEGRIDY [INJ] [SP] norethindrone acetate-ethinyl estradiol [OTC] PAZEO PNEUMOVAX 23 [INJ] norethindrone acetate-ethinyl estradiol ONETOUCH ULTRAMINI METER [OTC] PEDIARIX [INJ] pnv 29-1 prenatal vitamins +iron ONETOUCH ULTRASOFT LANCETS PEDITRACE [INJ] pnv ob+dha prenatal vitamins norgestimate-ethinyl estradiol [OTC] PEDVAXHIB [INJ] pnv-dha + docusate prenatal vitamins norlyda ONETOUCH VERIO FLEX [OTC] peg 3350/electrolytes powder for pnv-dha prenatal vitamins norlyroc ONETOUCH VERIO IQ METER [OTC] 4000 ml solution pnv-ferrous fumarate-docu-fa prenatal NORMOSOL-M AND DEXTROSE [INJ] ONETOUCH VERIO METER SYSTEM PEGANONE vitamins NORMOSOL-R AND DEXTROSE [INJ] [OTC] PEGASYS [INJ] [SP] pnv-omega prenatal vitamins NORMOSOL-R PH 7.4 [INJ] ONETOUCH VERIO SYNC SYSTEM peg-prep kit pnv-select prenatal vitamins nortrel [OTC] penicillin g potassium [INJ] pnv-vp-u prenatal vitamins ONETOUCH VERIO TEST STRIPS penicillin g procaine [INJ] podofilox NORVIR [SP] [OTC] penicillin g sodium [INJ] POLOCAINE [INJ] NOVAREL [INJ] [SP] ONEXTON PENICILLIN GK/DEXTROSE [INJ] polyethylene glycol 3350 NOVOEIGHT [INJ] [SP] ONFI penicillin v potassium POLYFIN QR INFUSION SET NOVOFINE 30G, 32G NEEDLES [OTC] ONIVYDE [INJ] [SP] PENTACEL [INJ] poly-iron 150 forte NOVOFINE AUTOCOVER [OTC] OPDIVO [INJ] [SP] PENTACEL ACTHIB COMPONENT polymyxin [INJ] NOVOLIN [INJ] tincture [INJ] polymyxin/trimethoprim eye solution NOVOLOG [INJ] opium/belladonna alkaloids PENTASA POMALYST [SP] NOVOSEVEN RT [INJ] [SP] suppositories [INJ] portia NOVOTWIST 30G, 32G NEEDLE [OTC] OPSUMIT [SP] pentoxifylline ext-release potassium acetate [INJ] NOXAFIL ORACEA PERFOROMIST potassium bicarbonate/citric acid NOXAFIL [INJ] ORBACTIV [INJ] perindopril effervescent tablets NPLATE [INJ] [SP] ORFADIN [SP] PERJETA [INJ] [SP] potassium chloride [INJ] NUCALA [INJ] [SP] ORKAMBI [SP] permethrin potassium chloride ext-release NUCYNTA [INJ] potassium chloride oral solution NUCYNTA ER orphenadrine ext-release perphenazine/amitriptyline potassium chloride powder packets for NUEDEXTA orsythia solution NULOJIX [INJ] [SP] ortho d phendimetrazine potassium chloride/dextrose [INJ] nutrilyte [INJ] ORTHOVISC [INJ] [SP] phendimetrazine ext-release potassium chloride/dextrose/nacl [INJ] NUVARING oseltamivir phenelzine potassium chloride/lactated ringers/ nystatin OTEZLA [SP] phenobarbital dextrose [INJ] nystatin topical OTOVEL phenobarbital sodium [INJ] potassium chloride/nacl [INJ] nystatin/ OTREXUP [INJ] phenobarbital/hyoscyamine/atropine/ potassium citrate ext-release oxacillin [INJ] potassium citrate/citric acid O oxacillin/dextrose [INJ] potassium citrate/sodium citrate/ oxaliplatin [INJ] phentermine citric acid OBIZUR [INJ] [SP] phentolamine [INJ] obstetrix dha prenatal vitamins oxandrolone potassium iodide/iodine solution phenylbutyrate potassium phosphate [INJ] OCALIVA [SP] phenylephrine [INJ] ocella oxazepam POTIGA oxcarbazepine phenylephrine eye solution pr natal 400 ec prenatal vitamins OCREVUS [INJ] [SP] phenylephrine/chlorpheniramine octreotide [INJ] [SP] oxiconazole pr natal 400 prenatal vitamins phenylephrine/dextrose [INJ] pr natal 430 ec prenatal vitamins ODEFSEY [SP] phenylephrine/nacl [INJ] OFEV [SP] oxybutynin ext-release pr natal 430 prenatal vitamins phenytoin PRALUENT [INJ] [SP] OFIRMEV [INJ] phenytoin sodium [INJ] ofloxacin oxycodone/acetaminophen pramipexole oxycodone/aspirin phenytoin sodium extended pramipexole ext-release ofloxacin ear solution philith ofloxacin eye solution oxycodone/ibuprofen prasugrel OXYCONTIN PHOSLYRA pravastatin ogestrel phospha 250 neutral olanzapine prazosin oxymorphone ext-release phosphasal PRECISION XTRA B-KETONE STRIPS olanzapine [INJ] PHOSPHOLINE IODIDE olanzapine orally disintegrating tablets oxytocin [INJ] [OTC] OZURDEX [INJ] [SP] PHOTOFRIN [INJ] PRECISION XTRA MONITOR [OTC]

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 7 Basic Plus Comp EmpiRx Health Basic Plus Formulary PRECISION XTRA TEST STRIPS [OTC] [INJ] RELISTOR [INJ] selegiline propranolol ext-release relnate dha prenatal vitamins selenium [INJ] propranolol/hydrochlorothiazide REMICADE [INJ] [SP] selenium sulfide eye suspension propylthiouracil REMODULIN [INJ] [SP] selenium sulfide shampoo prednisolone sodium phosphate PROQUAD [INJ] RENACIDIN SELZENTRY [SP] prednisolone sodium phosphate PROSOL [INJ] renal caps se-natal 19 prenatal vitamins disintegrating tablets protamine [INJ] rena-vite rx SENSIPAR prednisolone sodium phosphate eye PROTOPAM [INJ] reno caps SENSORCAINE-EPI 0.75%-0.0005% solution REOPRO [INJ] [INJ] PROVENGE [INJ] [SP] repaglinide SEREVENT DISKUS PREMARIN [INJ] pruclair repaglinide/metformin hcl SEROSTIM [INJ] [SP] PREMARIN CREAM prumyx REPATHA [INJ] [SP] sertraline PREMARIN TABLETS prutect RESCRIPTOR [SP] se-tan plus premasol [INJ] pseudoephedrine/chlorpheniramine/ RESECTISOL setlakin PREMASOL 6% [INJ] methscopolamine ext-release RESTASIS sevelamer carbonate PREMPHASE pseudoephedrine/codeine/ RETROVIR [INJ] [SP] sharobel PREMPRO chlorpheniramine REVLIMID [SP] SIGNIFOR [INJ] [SP] prena1 chew prenatal vitamins pseudoephedrine/codeine/guaifenesin REYATAZ [SP] [INJ] [SP] prena1 pearl prenatal vitamins PULMICORT FLEXHALER R-GENE 10 [INJ] sildenafil [SP] prena1 true prenatal vitamins PULMOZYME [SP] RIASTAP [INJ] [SP] SILHOUETTE INFUSION SETS prenaissance plus prenatal vitamins purevit dualfe plus ribavirin [SP] silver nitrate prenaissance prenatal vitamins PURIXAN [SP] ribavirin nebulization solution silver sulfadiazine prenatabs fa prenatal vitamins PYLERA RIDAURA SIMPONI 100 MG [INJ] [SP] prenatabs rx prenatal vitamins pyrazinamide rifabutin SIMULECT [INJ] [SP] prenatal low iron prenatal vitamins pyridostigmine rifampin simvastatin prenatal plus iron prenatal vitamins pyridostigmine [INJ] rifampin [INJ] sirolimus [SP] prenatal plus prenatal vitamins pyridostigmine ext-release riluzole SIRTURO prenatal-u prenatal vitamins pyridoxine [INJ] rimantadine SIVEXTRO [INJ] preplus prenatal vitamins ringers irrigation solution SKYLA [SP] PREPOPIK Q ringers lactated irrigation solution SNAP INSULIN PUMP CONTROLLER pretab 29-1 prenatal vitamins QUADRACEL DTAP-IPV [INJ] ringers solution [INJ] SNAP INSULIN PUMP-INFUSION SET previfem quasense ringers solution lactated [INJ] sodium acetate [INJ] PREVNAR 13 [INJ] quazepam risedronate sodium benzoate/sodium phenylacetate PREZISTA [SP] QUDEXY XR risedronate delayed-release [INJ] PRIALT [INJ] [SP] RISPERDAL CONSTA [INJ] sodium bicarbonate [INJ] PRIFTIN quetiapine ext-release sodium chloride [INJ] PRIMAQUINE QUICK RELEASE TEFLON CANNULA risperidone orally disintegrating tablets sodium chloride 0.45 % [INJ] primidone QUILLICHEW ER RITUXAN [INJ] [SP] sodium chloride 0.9 % [INJ] PRIVIGEN [INJ] [SP] QUILLIVANT XR RITUXAN HYCELA [INJ] [SP] sodium chloride 3 % [INJ] PROAIR HFA quinapril rivastigmine sodium chloride 5 % [INJ] PROAIR RESPICLICK quinapril/hydrochlorothiazide rivastigmine patches sodium chloride irrigation solution probenecid gluconate [INJ] rivelsa sodium chloride nebulization solution procainamide [INJ] quinidine gluconate ext-release sodium chloride, bacteriostatic [INJ] PROCALAMINE [INJ] quinidine sulfate rizatriptan orally disintegrating tablets sodium ferric gluconate complex [INJ] edisylate [INJ] quinine sulfate ropinirole sodium fluoride prochlorperazine maleate QVAR ropinirole ext-release sodium fluoride dental cream, gel prochlorperazine maleate suppositories ropivacaine/nacl [INJ] sodium fluoride dental rinse PROCRIT [INJ] [SP] R rosuvastatin sodium lactate [INJ] PRODIGY INSULIN SYRINGE ROTATEQ sodium phosphate [INJ] PROFILNINE SD [INJ] [SP] RABAVERT [INJ] ROZEREM sodium polystyrene sulfonate in oil [INJ] [SP] rabeprazole delayed-release RUBRACA [SP] sodium polystyrene sulfonate rectal progesterone micronized RADICAVA [INJ] [SP] rulavite dha prenatal vitamins sodium thiosulfate [INJ] PROGLYCEM RAGWITEK RYDAPT [SP] SOF-SET MICRO INFUSION SET PROGRAF [INJ] [SP] rajani SOF-SET ULTIMATE QR SET PROLASTIN C [INJ] [SP] raloxifene S SOFT TOUCH LANCETS [OTC] ramipril PROLENSA SABRIL [SP] SOLIQUA [INJ] PROLEUKIN [INJ] [SP] RANEXA SOLIRIS [INJ] [SP] SAFYRAL PROMACTA [SP] shampoo SOLODYN ranitidine [INJ] SOLU-CORTEF [INJ] RAPAFLO salicylic acid topical promethazine [INJ] SOMATULINE DEPOT [INJ] [SP] promethazine suppositories RAPAMUNE SOLUTION [SP] SOMAVERT [INJ] [SP] RAPIVAB [INJ] SAMSCA [SP] promethazine/codeine SANCUSO sonafine promethazine/dextromethorphan rasagiline SOOLANTRA RASUVO [INJ] SANDIMMUNE SOLUTION [SP] promethazine/phenylephrine SANDOSTATIN LAR DEPOT [INJ] [SP] sotalol promethazine/phenylephrine/codeine RAVICTI [SP] SOTALOL [INJ] REBIF [INJ] [SP] SANTYL propafenone SAVELLA SOTRADECOL [INJ] propafenone ext-release reclipsen SOTYLIZE RECOMBIVAX HB [INJ] SCOPOLAMINE [INJ] proparacaine eye solution scopolamine patches sp antipruritic proparacaine/fluorescein eye solution RECTIV sp scar REGRANEX secobarbital [INJ] SEEBRI NEOHALER spinosad propranolol RELENZA SPINRAZA [INJ] [SP]

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 8 Basic Plus Comp EmpiRx Health Basic Plus Formulary SPIRIVA HANDIHALER taron-prex dha prenatal vitamins TROPHAMINE [INJ] SPIRIVA RESPIMAT TASIGNA [SP] eye solution spironolactone TAYTULLA tolterodine ext-release trospium spironolactone/hydrochlorothiazide tazarotene topiramate trospium ext-release SPORANOX SOLUTION TAZORAC 0.05% CREAM topotecan [INJ] [SP] TRULICITY [INJ] sprintec TAZORAC GEL TORISEL [INJ] [SP] TRUMENBA [INJ] SPRYCEL [SP] TECENTRIQ [INJ] [SP] torsemide trust natal dha prenatal vitamins sronyx TECFIDERA [SP] TOUJEO [INJ] TRUVADA [SP] STAMARIL [INJ] TECHLITE BLOOD LANCETS [OTC] TOVIAZ TUBERSOL [INJ] stavudine [SP] TEFLARO [INJ] TPN ELECTROLYTES [INJ] TUDORZA PRESSAIR STELARA SC [INJ] [SP] TEKTURNA TRACE ELEMENTS-4 [INJ] TWINRIX [INJ] STIMATE [SP] TEKTURNA HCT TRACLEER [SP] TYGACIL [INJ] STIOLTO RESPIMAT telmisartan TRADJENTA TYKERB [SP] STIVARGA [SP] telmisartan/amlodipine TYMLOS [INJ] [SP] STRENSIQ [INJ] [SP] telmisartan/hydrochlorothiazide tramadol ext-release TYPHIM VI [INJ] STREPTOMYCIN SULFATE [INJ] temazepam tramadol/acetaminophen TYSABRI [INJ] [SP] STRIBILD [SP] TEMODAR [INJ] [SP] trandolapril TYVASO [SP] STRIVERDI RESPIMAT temozolomide [SP] trandolapril/verapamil ext-release SUBOXONE SL FILM TENIPOSIDE [INJ] tranexamic acid U SUCRAID [SP] terazosin tranexamic acid [INJ] UCERIS TABLETS sucralfate terbinafine tranylcypromine ULORIC [INJ] terbutaline travasol [INJ] ultimatecare one nf prenatal vitamins sulfacetamide eye ointment terbutaline [INJ] TRAVATAN Z ultimatecare one prenatal vitamins sulfacetamide eye solution terconazole vaginal ULTIVA [INJ] sulfacetamide sodium shampoo testosterone TREANDA [INJ] [SP] UNITUXIN [INJ] [SP] sulfacetamide sodium topical testosterone cypionate [INJ] TRESIBA [INJ] UPTRAVI [SP] sulfacetamide sodium/sulfur testosterone enanthate [INJ] tretinoin ur n-c sulfacetamide sodium/sulfur/urea TETANUS DIPHTHERIA TOXOIDS [INJ] tretinoin microspheres uramit mb sulfacetamide/prednisolone eye solution tetrabenazine [SP] tretinoin topical urea sulfadiazine tetracaine [INJ] tretinoin/emollient urea/lactic acid/salicylic acid sulfamethoxazole/trimethoprim tetracaine eye solution TRETTEN [INJ] [SP] urea/lactic acid/zinc undecylenate sulfamethoxazole/trimethoprim [INJ] tetracycline tri femynor uretron d-s SULFAMYLON THALOMID [SP] triadvance prenatal vitamins urimar-t sulfasalazine theophylline triamcinolone [INJ] urin d.s. sulfasalazine delayed-release theophylline ext-release triamcinolone dental paste uro-458 theophylline/dextrose [INJ] triamcinolone topical urogesic THERACYS [INJ] triamterene/hydrochlorothiazide uro-mp sumatriptan [INJ] thiamine [INJ] triazolam urophen mb sumatriptan nasal tricitrates ursodiol SUPREP thiotepa [INJ] tricon uryl SURE-T INFUSION SET thiothixene tri-estarylla ustell SUSTIVA [SP] thrivite 19 prenatal vitamins UTIBRON NEOHALER SUTENT [SP] THROMBATE III [INJ] trifluridine eye solution utira-c syeda THYMOGLOBULIN [INJ] [SP] trigels-f forte UVADEX [INJ] SYLATRON [INJ] [SP] THYROGEN [INJ] [SP] SYLVANT [INJ] [SP] thyroid tri-legest fe V SYMBICORT tiagabine tri-linyah SYMLINPEN [INJ] TICE BCG [INJ] tri-lo-estarylla valacyclovir SYNAGIS [INJ] [SP] tilia fe tri-lo-marzia VALCHLOR [SP] SYNAREL timolol maleate tri-lo-sprintec valganciclovir SYNERCID [INJ] timolol maleate eye solution trilyte with flavor packets valproate sodium [INJ] SYNJARDY tinidazole valproic acid SYNJARDY XR TIVICAY [SP] trimethoprim valsartan SYNRIBO [INJ] [SP] tizanidine valsartan/hydrochlorothiazide tl gard rx trinatal gt prenatal vitamins VALSTAR [SP] T tl g-fol os trinatal rx 1 prenatal vitamins vancomycin tl icon trinate prenatal vitamins vancomycin [INJ] TABLOID VANCOMYCIN/DEXTROSE TACLONEX SUSPENSION tl-hem 150 trinessa tl-select prenatal vitamins trinessa lo VANCOMYCIN-NS [INJ] tacrolimus [SP] VANTAS [SP] tacrolimus topical TOBI PODHALER [SP] triphrocaps TOBRADEX OINTMENT tri-previfem VAQTA VIALS [INJ] TAFINLAR [SP] VARIVAX [INJ] TAGRISSO [SP] TOBRADEX ST TRISENOX [INJ] tobramycin [INJ] tri-sprintec VARIZIG [INJ] TAMIFLU SUSPENSION VARUBI tamoxifen tobramycin eye solution tri-tabs dha prenatal vitamins tobramycin nebulization solution [SP] TRIUMEQ [SP] VASCEPA tamsulosin ext-release vasopressin [INJ] TARCEVA [SP] tobramycin/dexamethasone eye triveen-duo dha prenatal vitamins suspension triveen-one prenatal vitamins vasopressin/nacl [INJ] TARGRETIN GEL [SP] VAXCHORA VACCINE tarina fe tobramycin/nacl [INJ] triveen-prx rnf prenatal vitamins tolazamide tri-vitamin/fluoride v-c forte taron forte VECTIBIX [INJ] [SP] taron-c dha prenatal vitamins tolbutamide tri-vitamin/iron/fluoride tolcapone trivora VELCADE [INJ] [SP]

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 9 Basic Plus Comp EmpiRx Health Basic Plus Formulary velivet virt-advance prenatal vitamins water for injection, sterile [INJ] zavara VELPHORO virt-c dha prenatal vitamins water for irrigation; sterile ZAVESCA [SP] VELTASSA virt-gard WELCHOL ZEJULA [SP] vemavite-prx 2 prenatal vitamins virt-nate dha prenatal vitamins wera ZELBORAF [SP] VEMLIDY virt-phos 250 neutral WILATE [INJ] [SP] ZEMAIRA [INJ] [SP] vena-bal dha prenatal vitamins virt-pn dha prenatal vitamins wymzya fe zenchent VENCLEXTA [SP] virt-pn plus prenatal vitamins zenchent fe venlafaxine virt-pn prenatal vitamins X ZENPEP venlafaxine ext-release virtrate-3 XALKORI [SP] ZERBAXA [INJ] VENOFER [INJ] virt-select prenatal vitamins XARELTO ZEVALIN [INJ] VENTAVIS [SP] virt-vite XELJANZ [SP] zidovudine [SP] VENTOLIN HFA virt-vite forte XELJANZ XR [SP] zileuton ext-release verapamil virt-vite gt prenatal vitamins XERMELO [SP] zinc chloride [INJ] verapamil [INJ] VISTOGARD [SP] XGEVA [INJ] [SP] zinc sulfate [INJ] verapamil ext-release VISUDYNE [INJ] [SP] XIAFLEX [INJ] [SP] veripred VIVITROL [INJ] [SP] XIFAXAN ZOLADEX [INJ] [SP] VESICARE VIVOTIF XIGDUO XR zolate vestura vol-care rx XIIDRA zoledronic acid [INJ] [SP] VGO vol-nate prenatal vitamins XOFIGO [INJ] [SP] zoledronic acid/mannitol [INJ] [SP] VIAGRA vol-plus prenatal vitamins XOLAIR [INJ] [SP] ZOLINZA [SP] VIBATIV [INJ] vol-tab rx prenatal vitamins XTANDI [SP] VIBERZI VOLUVEN [INJ] xulane patches zolmitriptan orally disintegrating tablets vi-c forte VONVENDI [INJ] [SP] XULTOPHY [INJ] zolpidem VICTOZA [INJ] VORAXAZE [INJ] XURIDEN [SP] zolpidem ext-release VIDEX SOLUTION [SP] voriconazole XYREM [SP] ZOMETA 4 MG/100 ML [INJ] [SP] vienva voriconazole [INJ] ZOMIG NASAL vigabatrin [SP] VOSEVI [SP] Y zonisamide VIIBRYD VOTRIENT [SP] ZONTIVITY VIMIZIM [INJ] [SP] vp-ch plus prenatal vitamins YERVOY [INJ] [SP] ZORTRESS [SP] VIMPAT vp-ch-pnv prenatal vitamins YF-VAX [INJ] ZOSTAVAX [INJ] VIMPAT [INJ] vp-heme ob prenatal vitamins YONDELIS [INJ] [SP] ZOSYN GALAXY BAGS [INJ] vinate care prenatal vitamins vp-heme one prenatal vitamins yuvafem zovia vinate ii prenatal vitamins VPRIV [INJ] [SP] Z ZOVIRAX CREAM vinate one prenatal vitamins vp-vite rx ZUBSOLV vinate-m prenatal vitamins vp-zel zafirlukast ZYDELIG [SP] vinblastine [INJ] vyfemla zaleplon ZYKADIA [SP] vincristine [INJ] VYVANSE ZALTRAP [INJ] [SP] ZYLET vinorelbine [INJ] VYXEOS LIPOSOME [INJ] [SP]X ZANOSAR [INJ] ZYTIGA [SP] VIOKACE zarah viorele W ZARXIO [INJ] [SP] VIRACEPT [SP] warfarin zatean-ch prenatal vitamins VIREAD [SP] water for injection, bacteriostatic [INJ] zatean-pn dha prenatal vitamins virt nate prenatal vitamins zatean-pn plus prenatal vitamins

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 10 Basic Plus Comp Examples of Nonformulary Medications with Selected Formulary Alternatives

The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary. Column 1 lists examples of nonformulary medications. Column 2 lists some alternatives that can be prescribed.

Nonformulary Medications Formulary Alternative(s) ACCU-CHEK METERS/STRIPS FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS ADLYXIN BYDUREON, BYETTA, TRULICITY, VICTOZA AIRDUO RESPICLICK ADVAIR DISKUS/HFA, BREO ELLIPTA, DULERA, SYMBICORT ALVESCO ARMONAIR RESPICLICK, ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR APIDRA HUMALOG, NOVOLOG AUVI-Q EPINEPHRINE AUTO-INJECTOR (by Mylan), EPIPEN, EPIPEN JR BASAGLAR LANTUS, LEVEMIR, TOUJEO, TRESIBA BECONASE AQ budesonide, flunisolide, fluticasone, mometasone, QNASL BREEZE, CONTOUR FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS METERS/STRIPS GEL-ONE EUFLEXXA, MONOVISC, ORTHOVISC GENVISC 850 EUFLEXXA, MONOVISC, ORTHOVISC HYALGAN EUFLEXXA, MONOVISC, ORTHOVISC KADIAN hydromorphone ext-release, morphine sulfate ext-release, oxymorphone ext-release, HYSINGLA ER, NUCYNTA ER, OXYCONTIN KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR LEVITRA CIALIS, VIAGRA NESINA JANUVIA, TRADJENTA NUTROPIN AQ, NUTROPIN AQ GENOTROPIN, HUMATROPE, NORDITROPIN NUSPIN OMNARIS budesonide, flunisolide, fluticasone, mometasone, QNASL OMNITROPE GENOTROPIN, HUMATROPE, NORDITROPIN ONGLYZA JANUVIA, TRADJENTA PROVENTIL HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA SAIZEN, SAIZENPREP GENOTROPIN, HUMATROPE, NORDITROPIN STAXYN CIALIS, VIAGRA STENDRA CIALIS, VIAGRA SUPARTZ, SUPARTZ FX EUFLEXXA, MONOVISC, ORTHOVISC SYNVISC, SYNVISC-ONE EUFLEXXA, MONOVISC, ORTHOVISC TANZEUM BYDUREON, BYETTA, TRULICITY, VICTOZA TRUETEST, TRUETRACK FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS METERS/STRIPS XOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA ZETONNA budesonide, flunisolide, fluticasone, mometasone, QNASL ZOHYDRO ER hydromorphone ext-release, morphine sulfate ext-release, oxymorphone ext-release, HYSINGLA ER, NUCYNTA ER, OXYCONTIN ZOMACTON GENOTROPIN, HUMATROPE, NORDITROPIN

Created 11/15/2017. Please note that this document is subject to change. Any changes/updates to this document can be viewed at www.empirxhealth.com. Page 11 Basic Plus Comp