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Drug Exclusions July 1, 2020

Why Doesn’t My Health Plan Cover Some Providers Drugs? To request a formulary exception for a drug noted on the list with a (+), call 877-440-0089. To request a From time to time, our pharmacy committee decides formulary exception for all other listed drugs, call the to no longer cover, or exclude, some drugs because precertification number on the member’s ID card. other safe, effective, less costly alternatives are available. The committee is composed of independent Members doctors and pharmacists who regularly review and To request a formulary exception for all drugs listed, compare prescription drugs to ensure the ones we call the Customer Service number on your ID card. cover include proven for treating the Note: Formulary exceptions can only be considered majority of medical conditions. with required documentation from the member’s Newly-launched products and new variations of health care provider. products already on the market are not automatically added to your health plan’s list of covered drugs, also What Happens If I Have A Prescription Filled known as a formulary. A product can be added to the For An Excluded Drug? formulary only if our pharmacy committee decides You will be able to get your drug, but you will pay the that it is clinically appropriate and cost-effective. full cost of it. What Should I Do If My Drug Is Excluded? What Drugs Are Excluded From Coverage? Talk to your doctor to see if a covered alternative drug The drugs on the following pages are excluded from is a good option for treating your condition. Note that coverage as of the date of this list. many excluded brand-name drugs have covered Your pharmacy benefit may not cover certain generic alternatives. categories of drugs, such as those used to treat weight Of course, you and your doctor make the final decision loss or sexual dysfunction. Please check your plan about the medications that are right for you. If your materials for details about coverage for a specific drug doctor believes no alternative drug will work for your category. medical condition, you or your doctor can request a formulary exception to have an excluded drug covered. Just follow these steps:

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. Check your benefit information to verify coverage or view your personal benefit information on our website. This list may contain trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with your health plan. This list may change or expand from time to time without prior notice. BlueChoice Drug Exclusions List – Effective 7/1/20 1

Excluded Drug List Specialty drugs are noted with a (#). A Atralin Caldolor D EpiPen/EpiPen Jr. Abilify (brand) Atrapro spray/gel/kit Cambia D.H.E. (brand) (brand) Abilify Mycite Aurstat Candida Albicans Extract Daklinza (#) EryPed susp. 200 & 400 Absorica/LD Austedo (#) Caplyta Dandelion Allergenic Ext. mg Acanya Auvi-Q Carac (brand & generic) Dapsone-Niacinamide Esomeprazole Aciphex Avar (brand) Carbinoxamine 6 mg Gel Esperoct (#) Acnefree Aveed (brand) Cardizem CD/LA (brand) Dapsone-Niacinamide- esterified Acticlate (brand & gen.) Avenova Carnitor/SF Gel /methyl- Acuicyn Azelex (brand) Carospir Daxbia testosterone Aczone 5% (brand) Azesco Celacyn Defitelio (#) Eucrisa Adagen (#) Azor (brand) Cequa Deflux Eurax lotion Adakveo (#) Azelaic Acid-Niacinamide Ceracade Delstrigo Evekeo/ODT (brand) Adapalene-Benzoyl Cream Cerave Denavir Evenity (#) Peroxide- Azeschew Cetrotide (#) Dermatop (brand) Evivo Cholecal DF Evomela (#+) Clindamycin Gel B Desloratadine Adapalene-Benzoyl Chorionic Dexchlorpheniramine Exondys 51 (#) Peroxide- 5 mg Gonadotropin (#) syrup Ezallor Balcoltra Chlorzoxarone 250 mg Niacinamide Gel Dexeryl F Adderall (brand) Baxdela Cicatrace Pad Dexilant Adhansia XR Beau Rx - Dexpak Fasenra (#+) Adlyxin Belbuca Shampoo Dextenza (#) Fenoglide (brand) Admelog Benicar/HCT (brand) Ciclopirox-Clobetasol- Dexycu fenoprofen (generic) Adzenys XR Bensal HP Shampoo Diclegis (brand and gen.) Fenortho (brand) Aemcolo Benz Per-Clindamycin- Ciclopirox-Salicylic Acid Diclofenac Sodium- Fetroja Aerospan Niacinamide- Shampoo Sodium Hyaluronate- Fexofenadine Afstyla (#) Gel Cimetidine-- Niacinamide Gel fexofenadine- Airduo Benzaclin (brand) Salicylic Acid Cream Diclofono pseudoephedrine Ajovy Benzamycin (brand) Cinqair (#+) Diflorasone cream and -Minoxidil Aklief Benzepro (brand) Clarinex/Clarinex-D oint. Firdapse (#) Alavert -Lidocaine- Claritin/Claritin-D Dimercaptopropane- First Atenolol Alcortin A Oint Clenpiq Sulfonate suspension Aldara (brand) Benzonatate 150 mg Clindagel Diuril First-Lansoprazole Alevicyn Antipruritic/ Beovu (#) Clindamycin Phos- Divigel (brand) (excluded only for Plus Betamethasone Niacinamide- Doptelet (#) members 17 years Allegra/Allegra-D Dipropionate- Tretinoin Cream Doryx/MPC (brand) and older) Allzital Minoxidil Clindamycin Phosphate- cream First-Omeprazole Aloquin Betapace/AF Niacinamide Lotion Doxycycline DR 80mg (excluded only for Alora (brand) Bevacizumab prefilled 1-4% Drizalma members 17 years Altoprev (brand) syr. (#) Clindamycin Phosphate- Duaklir and older) Altreno Bevyxxa Niacinamide Gel Duexis Flolipid Alvesco Biafine Clindamycin-Benzoyl Duobrii Fluconazole-- Alzair Bijuva Peroxide-Niacinamide Durolane (#+) Itraconazole- Ameluz Binosto (brand) Gel Dutoprol Terbinafine Amrix (brand) Bionect Clindamycin-Niacinamid- Duzallo Fluocinolone Amzeeq Bocasal oral rinse Spironolac-Tretinoin Dxevo Acetonide- Andexxa Bonjesta Gel Dyanavel XR (brand) Niacinamide Cream Androgel 1.62% (brand) Bortezemib (#) Clobetasol Propionate- Dyrenium capsule Fluocinonide 0.1% Android-10 (brand) Bravelle (#) Levocetirizine Dihyd cream Annovera Brineura (#) Shampoo E Fluoroplex (brand) Antara (brand) Briviact Clobetasol Propionate- Econazole Nitrate- Fluticasone/salmeterol Apadaz Bromsite Niacinamide Niacinamide Cream inhaler Aplenzin Brukinsa (#) Cream/Oint/Soln Edecrin (brand) Folene Apligraf (#) Bryhali Colcrys (brand) Edex Folika-V Aptensio XR (brand) Budesonide/Formoterol Consensi EES granules Folite Arakoda (#) Bunavail (brand) Conzip (brand) Effexor XR (brand) Follistim AQ (#) Arazlo Bupap (brand) Cortaid max. strength Efudex (brand) Folvite-FE Arestin HCL Cotempla Elestrin (brand) Forfivo XL (brand) Arikayce (#) Butalbital/APAP 50/300 Crysvita (#+) Eletone Fortamet (brand & gen.) Armonair Respiclick Byvalson Cuprimine Emflaza (#) Fulphila (#+) Fungoid-D Arymo ER C Cutaquig (#) Endari Asacol HD (brand) Cuvitru (#+) Enstilar G Asceniv (#) Cafergot tablet Cyclobenzaprine ext rel Entty Spray Emulsion Asparlas (#) Calcipotriene- Cyfolex Envarsus XR (#) Gamifant (#) Atacand/HCT (brand) Betamethasone Cymbalta (brand) Epaned (brand) Ganirelix AC (#) Ativan (brand) Calcipotriene-Clobetasol Cytomel (brand) Epiceram Gatifloxacin Atopiclair Propionate dexamethasone Gelclair Gel BlueChoice Drug Exclusions List – Effective 7/1/20 2

Gelsyn (#+) Innopran XL Lipofen (brand) Naproxen sodium ER Oracea (both brand & Genadur Inrebic (#+) Locoid (brand) (generic Naprelan) generic doxycycline Genvisc (#+) Intrarosa Lodrane D Nascobal (Rosacea) delayed Giazo (brand) Intuniv (brand) Lokelma (#) Nasonex (brand) release capsules are Gloperba Inveltys Lonhala Nayzilam excluded) Glumetza (brand & Iodoquinol- Loprox (brand) Neocera Oravig generic) - Loyon Neosalus/CP Osmolex ER Glycopyrrolate 1.5mg Cream Lucemyra Neutrasal Otiprio Gocovri Ionil liquid Lumoxiti (#) Nevestym Otovel GPL Pak Ivermectin- Lunesta (brand) Nexium Ovace Plus/Wash (brand) Gralise (brand) Metronidazole- Luradrox gel Nexletol Ovidrel (#) Gvoke PFS Niacinamide Gel Lutathera (#) Niacinamide- Oxervate (#) Luxturna (#) Spironolactone Gel Oxtellar XR (brand) H J Luzu Niacinamide- Ozobax Hemlibra (#) Jatenzo Lyrica CR Spironolactone- Herzuma (#) Jivi (#+) Tretinoin Gel P Horizant (brand) Jornay PM M Niacinamide- Palforzia (#) HPR Plus Jublia Macrilen (#) Sulfacetamide Sodium Palynziq (#) HPR Plus MB Hydrogel Juluca Macrodantin capsules Niacinamide- Panzyga (#) Kit Jynarque (#) Mavenclad (#) Oint Parsabiv (#) Hyaluronate Sodium- Mayzent (#) Niacinamide- Pennsaid 1.5% & 2% sol. Niacinamide- K Menopur (#) Triamcinolone Pepcid (brand) Tacrolimus Kadian (brand) Mepsevii (#) Acetonide Cream Pexeva (brand) Hyaluronate Sodium- Kamdoy Metformin ER (only Niacinamide-Tazarotene Phenol Niacinamide- Kanjinti (#+) excluded when Cream Pifeltro Tretinoin Kapspargo prescribed as a Niacinamide-Tretinoin Piqray (#+) Hycofenix (brand) Katerzia generic for brand Cream/Gel Plaquenil (brand) Hydrisalic Kedrab (#) Fortamet or brand Niacinamide- Plavix (brand) Hydrocodone 2.5mg/ Kelarx (silicone) Scar Glumetza) Spironolactone- Plenvu guaifenesin 200mg Care Gel Methionine-Inos- Tretinoin Gel Plexion/Cleanser (brand) hydrocortisone 1% in Kerydin Choline-Levocarn Nilandron Polivy (#) asorbase Ketoconazole 2% foam Methylcobala Nitro-Dur (brand) Portrazza (#) Ketoconazole- Methylphenidate 72 Nitroglycerin lingual Praluent (#) Emulsion Hydrocortisone mg ER (brand) Pred-Gati Hydroquinone- Cream Miacalcin injection/ Nitrolingual Prednisone Intensol Hydrocortisone HCL nasal spray Nitromis (brand) Emulsion Keveyis (#) Micort Nityr (#) Pregenna Hydroquinone- Khapzory (#) Microvix LP Nivatopic Plus Prenara Hydrocortisone- Kinerase Midaz/ketamine troche/ Nivestym (#+) Pretomanid Tretinoin Emulsion Klor-Con oral pack for ondansetron Nocdurna (#) Prevacid Hylatopic Plus solution Midazolam Noctiva Prevymis (#) Hymovis (#+) Kovaltry (#+) Migranal (brand) Noritate Prilopentin Hyperhep B (#) Krintafel Millipred/DP Nourianz Prilosec Hyperrab (#) Kymriah (#) Minastin 24FE (brand) Novacort Primlev Hyperrab S/D (#) Minitran (brand) Novarel (#) Pristiq (brand) L Minivelle (brand) Novolin Relion Probuphine I Lactinol HX Minocin (brand) Nubeqa (#+) Procentra (brand) IBU 600-EZS Lactic Acid-Niacinamide Minocycline ER caps Nucala (#+) Progesterone- Idelvion (#) Cream Minolira ER Nuplazid (#+) Minoxidil Idhifa (#+) Lactulose oral packet Minoxidil-Progesterone- Nurtec ODT Prolate Ilumya (#) 10gm Tretinoin Nutraderm Prolensa Iluvien (#) Lanoxin 125 & 250 mcg Mircera (#) Nutraplus Promiseb Imiquimod- tablet Mitigare (brand) Nutraseb Protexa Levocetirizine Dihcl- Lansoprazole Monodox (brand) Nuvail Prothelial(#) Niacinamide Gel Lazanda Monodoxyne (brand) Nuvigil (brand) Protonix Imiquimod- Levicyn dermal spray Morgidox (brand) Nuwiq (#+) Proventil HFA Levocetirizine Dihcl- Levitra Morphabond ER Nuzyra Provigil (brand) Tretinoin Gel Levorphanol Moxatag (brand) Prozac (brand) Imitrex (brand) Levulan Kerastik Mugard (#) O Pulmicort Respules Imlygic (#) (brand) Mulpleta (#) Ocaliva (#+) (brand) Imogam (#) Lexapro (brand) Mupiricin cream Ocean for Kids Pyridostigmine tablet Impoyz Lexette Mvasi (#+) Odactra 30mg Imvexxy Lialda (brand) Mydayis Ogivri (#) Pyridoxal-5 Phosphate Inbrija Librax (brand) Mylotarg (#) Olysio (#) Pyrimethamine- Inderal LA Libtayo (#) omeprazole (OTC only) Leucovorin Indocin caps./supp./ Lidocaine-Tetracaine N omeprazole/sodium susp. Cream Nabi-HB (#) bicarbonate Q Indomethacin Lidocaine cream 4.12% Nalfon (brand) Onexton Qbrexza pad Infugem (#) Lidoderm (brand) naproxen/ Onzetra Qmiiz ODT Ingrezza (#) Lidotrex (lidocaine) esomeprazole Opana ER Qtern 2% gel Quartette (brand)

BlueChoice Drug Exclusions List – Effective 7/1/20 3

Qudexy XR (brand) Seysara Tepezza (#) Vanoxide-HC lotion Xerese Quillichew ER (brand) Siklos (#) Testopel (brand) Varizig (#) Xhance Quillivant XR (brand) Silenor (brand) Tetravex gel Varubi Ximino Qutenza (#) Siliq (#+) Tetrix Vaseretic (brand) Xofluza Quzyttir Sil-K Pad Thiola EC Vasotec (brand) Xopenex HFA Simvastatin Tiazac (brand) Veltassa (#) Xpovio Pak R Singulair (brand) Tibsovo (#+) Vemlidy (#) Xtampza ER Rabeprazole Sitavig Ticalast Ventavis (#+) Xultophy Rayaldee Sitzmarks Tiglutik (#) Ventolin HFA Xuriden (#) Rayos (brand) Slynd Tirosint capsule/ Verdeso foam 0.05% Xvite Rebinyn (#) Sodium Hyaluronate- solution (brand) Xyosted Reblozyl (#) Hydroquinone Tivorbex (brand) Veregen ointment Recarbrio Emulsion Tobi solution (brand) Vexasyn gel Y Recedo Solaravix Tolak (brand) Viagra Ybuphen Red Algae Solaraze (brand) Tolsura Vibramycin (brand) Yescarta (#) Relafen DS Solesta (#) Topicort Spray Viekira Pak/XR (#) Yonsa (#+) Relistor injection/ Soliqua Tosymra Vimovo Yosprala tablets Solodyn Trazimera (#) Visbiome Yupelri Remedient Solosec Trelegy Ellipta Vitafol strips Yutiq (#) Remodulin (#) Sovaldi (#) Trezix (brand) Vitafol FE+ Renflexis (#+) Spinraza (#+) (excluded Trianex oint. 0.05% Vitasure Z Resveratrol under the pharmacy (brand) Vitrase Zalvit Retacrit (#) benefit; covered Tridesilon (brand) Vivlodex Zavara Retin-A/Micro (brand) under the medical Triglide (brand) Vizimpro (#+) Zegerid (brand & generic) Revcovi (#) benefit) Trijardy XR Voltaren gel (brand) Zelac Revesta Spravato Trikafta (#) Vonvendi (#) Zembrace Reyvow Sprix (brand) Trimo-San gel Vosol HC Zepatier (#) Rexaphenac (brand) Staxyn Trinaz VP-Vite Rx Zerviate Rhofade cream Steglatro Triptodur (#) VSL#3 Zetia (brand) Rhopressa Steglujan Trivisc (#) Vtol LQ Ziana (brand) Riomet ER Stendra Trogarzo Vumerity Ziextenzo (#) Rocklatan Strattera (brand) Trokendi XR Vyepti Zilretta (#) Roxybond Striant (brand) Tronvite Vyleesi Zinbryta (#+) Rozlytrek (#+) Sublocade Trop-Phenyl Vyndagel Zinc Sulfate Ruxience (#) Sumadan wash (brand) Trulance Vyndamax (#) Zinplava Ruzurgi (#) Sumaxin (brand) Truxima (#) Vyondys 53 Zipsor (brand) Rybelsus Sunosi Turalio (#+) Vytorin (brand) Zirabev (#) Rynoderm Symdeko (#) Tussicaps (brand) Vyxeos (#) Zofran/ODT (brand) Symjepi Tuxarin ER Vyzulta Zolgensma (#) S Sympazan Tymlos (#+) Zoloft (brand) S2 Symproic W Zolpimist Salex (brand) Symtuza U Wakix Zonegran 25 & 100 mg Salicylic Acid-Sulfaceta- Synderderm Ubrelvy Wellbutrin SR/XL (brand) caps mide Sodium Syndros Udenyca (#) Wixela Inhub Zonzedi (brand) Salisol Synera (brand) Ultomiris (#) Zorvolex (brand) Salivamax Ultravate lotion X Zovirax Scarcin Gel T Uroxatral tablet Xadago Zuplenz (brand) Scarsilk gel/pad Taclonex Utibron Neohaler Xanax/XR (brand) Zurampic Scenesse (#) Tacrolimus Cream Xaquil XR Zyclara Sebuderm Takhzyro (#+) V Xatmep (#+) Zyflo CR (brand) Secuado Talicia Vabomere Xcopri Zypitamag Segluromet Targdadox (brand) Valium (brand) Xelpros Zyrtec/Zyrtec-D selenium sulfide Tasigna (#+) Valtoco Xembify (#) shampoo 2.25% Tavalisse (#) Valtrex (brand) Xenazine (brand) Sernivo Technivie (#) Vanatol LQ (brand) Xenleta Seroquel/XR (brand) Tegsedi (#) Vanos (brand) Xepi

BlueChoice Drug Exclusions List – Effective 7/1/20 4

Generics Excluded from Certain Manufacturers These generic drugs are excluded from coverage only when produced by certain manufacturers, but can be available from alternate sources — consult your pharmacist for more information. acetic acid/alum cormax scalp neomycin/polymyxin/ proparacaine hcl tobramycin/ acetate application dexamethasone salactic film dexamethasone albuterol sulfate cromolyn sodium neomycin/polymyxin/ sal-plant tropazone anusol-hc cyclopentolate hcl gramicidin sulfacetamide sodium tropicamide atropine sulfate dorzolamide hcl/ opium sulfacetamide sodium/ ureacin bacitracin/neomycin/ timolol m pedi-boro soak pads prednisolone polymyxin flunisolide pedi-dry sulfacetamide sodium/ bacitracin/polymyxin b flurbiprofen sodium phenylephrine hcl tartrate latanaprost podofilox tetracaine hcl carteolol hcl levobunolol hcl polymycin b sulfate/ timolol maleate castellani paint trimethoprim ophthalmic Excluded Compound Bases, Bulk Powders & Compound Kits This list contains many ingredients that are not covered under your prescription benefit coverage when included in certain bases and bulk powders used in compounded drugs, as well as compound kits. Please note that this list is not comprehensive; other compound ingredients are also excluded.

0-9 Base gelatin Gummy Cetaphil moisturizing Dimercapto-1- First-Omeprazole 2-Deoxy-D-Glucose Troche cream Propanesulfo First-Progester-One Vgs 5-Fluorouracil Base X Cetyl Myristoleate Dimercaptosucc-Inic 10/ 20/50 5-Methyltetra- Base-Pcca Mbk (Fatty Cherry syrup Acid First-Testosterone/Mc Hydrofolate Acid) Chloramphenicol Dimethyl Sulfoxide First-Vancomycin 25/50 5-Methyltetra- Beclomethasone Doxepin HCL Flavor blend Hydrofolic A Dipropiona Chorionic Gonadotropin Doxycycline Hyclate Flavor Plus 7-Keto DHEA Benzocaine Chrysaderm Day Drcaps size 1 clear Flavor Sweet-SF Benzoin compound Cimetidine Fluconazole E A tincture Ciprofloxacin HCL Fluocinonide Acacia Benzyl Citric Acid Anhydrous Edetate Disodium Fluorouracil Acetone Betahistine HCL/ Clindamycin HCL/ Dihydrat Flurbiprofen Acetyl Hexapeptide-8 Dihydrochlori Monohydra EGCG F-Melt Acidophilus Betamethasone Sodium Clindamycin Phosphate Emollient cream/base Freedom Derma-N Lactobacillus Phos Clobetasol Propionate/ Empty capsule, all sizes Freedom Poloxitol Albendazole Bethanechol Chloride Micronized & colors G Almond oil, sweet BHRT base Emu oil Alprostadil Biotin HCL Bitter drug powder HCL Ethylsuccina Gentamicin Sulfate Amphotericin B Boric Acid Cocoa butter /Micronized/ Glutamine Apple flavor Bromfenac Sodium Coenzyme Q10 Valerate Glutathione-L Arbem H-Cosmetic Budesonide Copasil Estriol/Micronized Glycerin Ascorbic Acid Bupropion HCL Corn oil Ethoxy Diglycol Glycolic Acid Curcumin Ethyl Alcohol Glycopyrrolate C Auxipro Plasticized Cyanocobalamin Ethyl Oleate Grape flavor Cannabidiol Guaifenesin Avicel Ph 105 Cyclobenzaprine HCL F Microcrysta Capsublend-P Gum base gelatin Capsule Clear Veggie Lo D Fagron Capfill Pro/ Azithromycin H (All) Dehydroepiandroster- Dispersapro/ B Capsule Coni-Snap (All) one Supreme cream Hormone cream base Baclofen Carboxymethylcellu- Dermabase Fattibase Botani Bacteriostatic Water lose So Dexamethasone/ Fattyblend Hrt base (All) Banana creme flavor Carnitine (L) Acetate Anh/Sodium Ferulic Acid Hrt Natural/Supreme Base C Polyethyl-Ene Celecoxib Phos First-Baclofen 5 cream base Glyco Cellulose Microcrystallin Diazepam First-Dukes mouthwash Sodium Sa Base cream with Cellulose/Cmc Na Dichloralphen-Azone First-Lansoprazole Hydrocodone Bitartrate Liposome Microcry Diclofenac Sodium First-Metronida-Zole 50 Hydrocortisone/ HCL First-Mouthwash Blm Acetate/ Micronized

BlueChoice Drug Exclusions List – Effective 7/1/20 5

Hydrogel L-Thyroxine Sodium P Polypeg suppository Supposibase F Hydromorphone HCL Lugols Palmitoyl base Suspendit Hydroquinone Povidone-Iodine Synapsin M Pentapeptide-3 Hydroxyethyl Cellulose Papaverine HCL Praziquantel Syrspend SF/Alka Glycinate 45 Paraffin Pregnenolone/ Mannitol T Hydroxyprogester-One PCCA Anhydrous micronized Marshmallow flavor Tamoxifen Citrate Capro Lipoderm B HCL Mediderm Tea tree oil Hydroxypropyl PCCA cosmetic HRT base Progesterone/Microniz Medi-Rdt base Terbinafine HCL Cellulose 1/ PCCA custom Lipo-Max ed/Ultra Micronized Medium Chain Testosterone/ Methylcellu PCCA DMAE complex Progesterone wettable Triglyceride Cypionate Hydroxyurea PCCA emollient cream HCL Melatonin Testosterone Hypromellose base Mercaptopurine micronized/S/Y Methocel K1 PCCA Emulsifix-205 base E1 Monohydrat Testosterone non- PCCA fixed oil base Purified water I Metformin HCL micronized PCCA gelatin base Pyrantel Pamoate Ibuprofen Methocel E4m Premium Testosterone PCCA Lecithin Isopropyl Pyridoxal-5-Phosphate Imiquimod Methscopolamine Propionate P Mon Isometheptene Mucate Bromide Tetracaine/HCL PCCA Lipoderm base/ Itraconazole Methylcellulose Q Tetracycline HCL HMW Ivermectin Methylcobalamin Quinacrine HCL Thymol PCCA Loxasperse base Methyltestosterone Quinine Sulfate Thyroid Porcine J PCCA Natacream Metoprolol Tartrate Dihydrate Tobramycin/Sulfate PCCA plasticized base N/A Metronidazole/ Tofacitinib Citrate PCCA Pluronic F127 R Benzoate K base /Nitrate Ranitidine HCL Tramadol HCL Ketamine HCL PCCA Polyglycol Troche Midazolam Resveratrol 98+% Transdermal pain base Ketoconazole PCCA Pracasil Tm-Plus Mineral oil light Tretinoin Ketoprofen/Micronized/ base S Mometasone Furoate Triamcinolone Ultra Micronized PCCA rapid-dissolve Salicylic Acid Morphine Sulfate Acetonide Ketotifen Hydrogen tablets Salt durable cream Mucolox Troche base Fumara PCCA Sorbitol lollipop Salt Stable Lo/Ls Mupirocin Tutti Frutti flavor Kinetin base Advanced PCCA Spira-wash base Sermorelin Acetate L N U Nabumetone PCCA Sweet-SF Sesame oil Ubiquinol Lactic Acid Naltrexone HCL/ PCCA syrup vehicle Sildenafil Citrate Ursodiol Lactose/Anhydrous Anhydrous PCCA T3 Sodium Dilution Silica gel Lactose Monohydrate/ V Natapres PCCA T4 Sodium Simethicone spray Niacinamide Dilution Simple syrup Vancomycin HCL Lanolin Anhydrous PCCA vanishing cream/ Sirolimus HCL Lansoprazole Nourivan Antiox cream light/ lotion Sodium Bicarbonate Versabase/foam L-Arginine base PCCA Vanpen base Sodium Chloride/ Versapro Leucovorin Calcium Nystatin/Foreign PCCA Xylifos base Bacterios Versatile cream base Leuprolide Acetate PCCA -Plus Sodium Hyaluronate W Levofloxacin O Penderm Sodium Metabisulfite Hemihydrate Ointment base Pentravan/Plus Solu-K gel Watermelon flavor L-Glutamine emulsifying Peppermint oil Sorbitol Wax paraffin beads Lidocaine/HCL Olive oil Phentermine Spg Supposi-Base White Petrolatum Liothyronine Sodium Omeprazole Hydrochloride Spironolactone Wiley Basic Elements Lipmax Ondansetron HCL Phentolamine Mesylate Sterile water for BHRT Lipopen/Absorption Dihydrate Phytobase injection Witepsol H15/Base F Enhanc Ora-Blend/SF Plo Gel – Mediflo pre- Stevia extract X Lipopen Ultra/base Oral mix flavored susp. Steviol Glycosides mix Xylitol L-Methylfolate Calcium Oral suspension Pluronic F127 Succimer DMSA Lollibase Ora-Plus Polox Sucralfate Y Lollipop base Ora-Sweet/SF Polyethylene Sulfacetamide Sodium Yellow Petrolatum Oxycodone HCL Glycol/blend/ Sulfadiazine Loxoral base Oxytocin 300/400/1450/3350 Sulfamethoxazole Z Lozibase S Sulfapyridine N/A

BlueChoice Drug Exclusions List – Effective 7/1/20 6

Topical Product Exclusions Topical Pain Formulations Excluded Product Categories and Examples Formulary Alternatives Camphomex (CAMPHOR-HISTAMINE--LIQUID SPRAY) • OTC Capsaicin patches, cream, gel Lidocaine HCL cream/lotion 3% • Lidoderm or generic Lidocaine 5% patches Lidocin (LIDOCAINE HCL GEL) • Lidocaine 5% ointment Lidorx (LIDOCAINE HCL GEL) • Lidocaine 2% gel Lidovex (lidocaine cream) • Voltaren 1% gel Livixil Pak (lidocaine-prilocaine kit) • Generic Diclofenac 1.5% solution Medi-Derm/L-RX (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SALICYLATE CREAM) Medi-Derm-RX (CAPSAICIN-MENTHOL-METHYL SALICYLATE CREAM) Mentholix (LIDOCAINE-MENTHOL LIQUID SPRAY) Silmanix Pain Relieving (CAPSAICIN-MENTHOL-HISTAMINE CREAM) Tetramex (TETRACAINE-MENTHOL-CAMPHOR LIQUID SPRAY)

Topical Pain Patches Excluded Product Categories and Examples Formulary Alternatives Anodynerx (CAPSAICIN-LIDOCAINE-MENTHOL) • OTC Capsaicin patches Atendia (LIDOCAINE-MENTHOL) • Lidoderm or generic Lidocaine 5% patches Captracin (CAPSAICIN-MENTHOL) Levatio patch (CAPSAICIN-MENTHOL) Lidenza (LIDOCAINE-MENTHOL) Medi-patch (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SALICYLATE) Menthocin/Lidocaine (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SALICYLATE) Qroxin (CAPSAICIN-MENTHOL) Reciphexamin (LIDOCAINE-MENTHOL) Relyyks (LIDOCAINE-MENTHOL) Relyyt (CAPSAICIN-MENTHOL) Renovo (CAPSAICIN-MENTHOL) Sinelee (CAPSAICIN-MENTHOL) Solaice (CAPSAICIN-MENTHOL) Synvexia (LIDOCAINE-MENTHOL) Velma Pain Relief (METHYL SALICYLATE-LIDOCAINE-MENTHOL)

Ear Pain Formulations and Combinations Excluded Product Categories and Examples Formulary Alternatives Antipyrine/Benzocaine Otic (Generic) • Dexamethasone otic Cortane B-Otic (PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLUTION) • Pediotic Otic Care (ANTIPYRINE-BENZOCAINE-POLYCOSANOL OTIC SOLUTION) • Neomycin/polymyxin/hydrocortisone otic Oticin drops (CHLOROXYLENOL-PRAMOXINE) • Acetic acid/hydrocortisone Oto-End 10 solution (CHLOROXYLENOL-PRAMOXINE- • Ciprodex HYDROCORTISONE) • Cipro otic Otozin drops (BENZOCAINE-ANTIPYRINE-ZINC ACETATE) • Cortisporin Pinnacaine 20% Drops (BENZOCAINE)

BlueChoice Drug Exclusions List – Effective 7/1/20 7

Scar Products Excluded Product Categories and Examples Formulary Alternatives Renuu (ALLANTOIN-LIDOCAINE-PETROLATUM) • Lidoderm or generic Lidocaine 5% patches Scar patch (ALLANTOIN-LIDOCAINE-PETROLATUM) • Lidocaine 5% ointment • Lidocaine 2% gel • Miscellaneous emollients (petrolatum, lanolin, glycerin, mineral oil, aloe vera, dimethicone) Convenience Multi-Product Kits Excluded Product Categories and Examples Formulary Alternatives Active-Medicated specimen (URINE SPECIMEN COLLECTION KIT) • OTC Capsaicin patches, cream, gel Active-PAC/Gabapentin (GABAPENTIN CAPS, LENZAGEL • Lidoderm or generic Lidocaine 5% patches [LIDOCAINE-MENTHOL]) • Lidocaine 5% ointment Advanced DNA Medicated CO (DNA COLLECTION PRODUCT KIT) • Lidocaine 2% gel Analpram Advanced (HC-PRAMOXINE CREAM, DIET MANAGE • Lidocaine 2% or 4% solution PROD TAB, CLEAN WIPE KIT) • Voltaren 1% gel Bupivilog kit (TRIAMCINOLONE INJECTION, BUPIVACAINE HCL • Generic Diclofenac 1.5% solution INJECTION KIT) • Generic topical steroids – alclomethasone, DermacinRX Inflammatral Pak (DICLOFENAC DELAYED-RELEASE betamethasone, clobetasol, desonide, fluocinoline, TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) fluocinonide, fluticasone, halobetasol, mometasone, DermacinRX Kit Silapak (TRIAMCINOLONE ACET CREAM, triamcinolone DIMETHICONE CREAM, SILICONE TAPE) • Chlorhexidine gluconate solution DermacinRX Lexitral (DICLOFENAC SOLUTION, CAPSAICIN CREAM) DermacinRX surgical (CHLORHEXIDINE GLUCONATE 4% SOLUTION) DermacinRX Ticanase Pak (FLUTICASONE NASAL SUSPENSION, SODIUM CHLORIDE SPRAY) Derma SilkRX Anodynexa Pak (DICLOFENAC DELAYED-RELEASE TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) Derma SilkRX Diclopak (DICLOFENAC DELAYED-RELEASE TABLETS, CAPSAICIN CREAM) Derma SilkRX SDS Pak (TRIAMCINOLONE CREAM, DIMETHICONE, SILICONE TAPE) DermaWerx Surgical Plus P (CHLORHEXIDINE SOL 4%- MUPIROCIN, DIMETHICONE, TAPE KIT) DNA collection kit (LIDOCAINE ORAL SOLUTION, GLYCERIN SWAB, BUCCAL SWAB) Genadur kit (DERMATOLOGICAL PRODUCTS MISC TOPICAL/ORAL – KIT) Inflammacin (DICLOFENAC SODIUM, CAPSAICIN CREAM THERA PACK) Morgidox (DOXYCYCLINE HYCLATE CAPSULES WITH CLEANSER KIT) SanadermRX Skin Repair (TRIAMCINOLONE ACET CREAM, DIMETHICONE CREAM, SILICONE TAPE) Silazone PharmaPak (TRIAMCINOLONE ACET CREAM, SILICONE SHEET PACK)

BlueChoice Drug Exclusions List – Effective 7/1/20 8 Rvs 3/13/2017 1 19199-3-2017 Rvs 3/13/2017 2 19199-3-2017