Commercial Open Formulary Prescription Drugs Not Covered The following drugs are on Paramount’s Commercial non-formulary list, and, therefore, are not covered on any commercial prescription benefit plan. Drugs with generic (G) or over-the-counter (OTC) alternatives available are noted. Generic names are included in parenthesis. OTCs may not be covered by your plan. Paramount reserves the right to add or remove drugs from coverage or from formulary status.

There may be products that are not covered that are not specifically listed. Categories of products that are potentially not covered are listed below.

Non Formulary Drug Alternative

- Convenience paks, compounding kits, some combination brand name products not covered - Dietary supplements, non-FDA approved medications, and topical products for cosmetic use not covered - Many compounds not covered unless contains FDA approved ingredients and strong scientific evidence exists for efficacy and safety of the compounded formulation.

Abstral (fentanyl sublingual) generic fentanyl citrate OTFC Acticlate (doxycycline hyclate tabs) generic doxycycline Adoxa products (doxycycline) generic doxycycline Allegra D 24/Fexofenadine ER (Rx only) OTC fexofenadine/PSE Allergy kit (hydrocortisone cream, etc.) use available OTC products separately All-pax (levocet+loratadine cream) oral items are covered Atendia (lidocaine/methol) OTC not covered. Lido is covered separately Azenase (azelastine NS/fluticasone NS) generic azelastine NS and fluticasone NS s Benzodox (doxycycline/benzoyl peroxide) use medications separately as indicated Budesonide nasal spray (prescription product) Rhinocort Allergy OTC (budesonide) CambiaG (diclofenac powder) generic dicofenac Candin Skin Test contact your physician for diagnostics CaphosolG (supersaturated calcium phosphate) contact Buderer Drug for compound capsaicin/menthol (patches,creams, lotions,ointments) none covered, may purchase OTC products Clindagel (clindamycin1% gel) generic clindamycin gel Convenience Pak (gabapentin tab/lidocaine ointment) use medications separately as indicated Conzip (tramadol ER) generic tramadol IR or tramadol ER Copasil (Anhydrous silicone cream) OTC emolient creams DermacinRx (diclofen/ranit/capsaic/triamcin) use medications separately as indicated Desonate 0.05% gel (desonide) generic desonide lotions, creams DoryxG (doxycycline) generic doxycycline doxycycline hyclate 100mg capsules doxycycline hyclate 100mg tabs or doxycycline monohydrate 100mg capsules DS Prep Pak (diclofenac gel/benzalkonium Cl) generic diclofenac oral tabs, benazlk soln Duexis (famotidine/ibuprofen) generic famotidine + OTC ibuprofen Durlaza (aspirin SR) generic aspirin OTC Dymista (fluticasone/azelastine) fluticasone nasal spray & oral antihistamine Edular (zolpidem) generic zolpidem EnovaRX compound kits use oral medications or FDA approved topical

*Drugs newly added since last revision updated 12-1-2018 ( baclofen, naproxen, tramadol, cyclobenzaprine, amitriptyline, ibuprofen creams) Enstilar (calcipotriene and betamethasone) generic calcipotriene and betamethasone separately Epaned (enalapril solution) generic enalapril tablets esomeprazole prescription formulations Nexium OTC Evzio (naloxone auto-injector) generic vials & syringes, Narcan nasal spray Flonase (fluticasone) generic fluticasone nasal spray FortametG (24-hr metformin) generic metformin ER Freedom Silomac Anhydrous gel (silicone cream) OTC emolient creams GlumetzaG (24-hr metformin) generic metformin ER Glygest (2-fucosyllactose & lacto-n-neotetraose) dietary supplement - no covered alternatives Horizant (gabapentin) generic gabapentin Inflam Pak (diclofen/ranit/capsaic/triamcin, etc) use medications separately as indicated Intermezzo (zolpidem) generic zolpidem Lidothal Pad (lidocaine/ menthol) use medications separately as indicated Lidotral (lidocaine) generic lidocaine Lorvatus (metaxalone/diclofenac solution) ingredients covered separately Metformin ER modified release and osmotic metformin ER tabs , metformin (generic Glumetza and Fortamet) Micort-HC (hydrocortisone acetate 2.5%) generic hydrocortisone rectal cream 2.5% MonodoxG (doxycycline) generic doxycycline MorgidoxG (doxycycline) generic doxycycline Moxatag (amoxicillin ER) generic amoxicillin Nasonex (mometasone) generic mometasone nasal spray Nexium ODT, Nexium granules (esomeprazole) First-omeprazole, First-lansoprazole liquid kit Nitrolingual (nitroglycerin) generic nitroglycerin SL tablets Oleptro (trazodone ER) generic trazodone omeprazole/sodium bicarbonate Rx (generic Zegerid) Zegerid OTC (for 40mg dose add omeprazole 20mg) Oracea (Doxycycline Capsule Delayed Release) generic doxycycline OravigG, OTC (miconazole) nystatin, clotrimazole Pexeva (paroxetine) generic paroxetine Phrenilin Forte (butalbital/apap) generic butalbital/apap Pramlyte (escitalopram/methylfolate/B12) use medications separately as indicated Protonix powder pkts First-omeprazole, First-lansoprazole liquid kit Purefolix (folic acid/vitamin D3) OTC folic acid / vitamin D3 Qbrelis (lisinopril liquid) lisinopril tablets Qutenza patch (capsaicin) OTC capsaicin topicals Rayos (prednisone DR) generic prednisone Rematex cream (capsaicin+menthol cream) use available OTC products separately Renuu Pad (allantoin/petrolatum/lidocaine) use available OTC products separately Restoril 7.5mg, 22.5mg (temazepam) generic temazepam of other strengths Rhinocort Aqua (budesonide) Rhinocort Allergy OTC (budesonide) Rybix (tramadol ODT) generic tramadol IR or tramadol ER Sernivo spray (betamethasone) betamethasone oint.,cream,lotion Silapak (diclofen/ranit/capsaic/triamcin, etc) use medications separately as indicated SilenorG (doxepin) generic doxepin

*Drugs newly added since last revision updated 12-1-2018 Silmanx cream (capsaicin+menthol cream) use available OTC products separately SmartRx Pak Gaba (gabapentin tabs/ lidocaine-menthol cr.) use medications separately as indicated Solodyn ERG (minocycline) generic minocycline Sprix (intranasal ketorolac) generic ketorolac Sumachip Pak (sumatriptan/capsaicin/menthol) use medications separately as indicated Sumavel Dosepro (sumatriptan jet injector) generic sumatriptan injection Targadox (doxycycline) generic doxycycline Temazepam 7.5mg, 22.5mg generic temazepam of other strengths Theramine (suplement/herbal combination) OTC supplements or oral pain medications Ticanase (fluticasone NS/sodium cl NS) use medications separately as indicated Treximet (sumatriptan/naproxen) generic ingredients covered separately triamcinolone nasal spray (prescription formulation) Nasacort Allergy/Nasal Allergy(triamcinolone OTC) Triamsil Kit (triamcinolone/dimethicone/silicone tape) use medications separately as indicated Ultravate lotion 0.05% (halobetasol) halobetasol cream and ointment Velma patch (Methylsalicylate,lidocaine,menthol) lidocaine patch or OTC combination products Veramyst (fluticasone) generic fluticasone nasal spray Vimovo (naproxen/esomeprazole) use available OTC products separately Vivlodex (meloxicam) generic meloxicam Xodol (hydrocodone/acetaminophen) generic hydrocodone/acetamenophen Xrylix Pak (diclofenac solution and adhesive sheets) diclofenac topical solution 1.5% Xyzbac (vitamins and folic acid) folic acid, may purchase OTC vitamins Yosprala (aspirin/omeprazole) generic ingredients separately Zecuity (sumatriptan iontophoretic pad) generic sumatriptan tablets, injection, etc Zegerid and generic Rx(omeprazole/sod bicarb) Zegerid OTC (for 40mg dose add omeprazole 20mg) Zembrace (sumatriptan autoinjector) 3mg sumatriptan 4mg or 6mg auto-injector Ziana Gel (clindamycin gel/tretinoin gel) use medications separately as indicated ZipsorG (diclofenac) generic diclofenac Zolpimist (zolpidem tartrate) generic zolpidem

*Drugs newly added since last revision updated 12-1-2018