Tenncare Preferred Drug List (PDL)

TennCare Preferred Drug List (PDL) Effective October 1, 2021 PA – Prior Authorization required, subject to specific PA criteria; QL – Quantity Limit (PA & NP agents require a PA before dispensing); B – Budgetary Reduction edit for utilization control (Standard NP PA criteria does not apply); ID – Class PA for patients with Intellectual or Developmental Disability Please note the following: • All agents must be prescribed by a provider with a Tennessee Medicaid Provider ID • Approval of NP agents requires trial and failure, contraindication, or intolerance of 2 preferred agents, unless otherwise indicated • With the exception of the “Branded Drugs Classified as Generics” list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205). Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via an FDA MedWatch form OR contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents. • Unless otherwise noted, all agents listed on the PDL are referencing legend drugs which are prescription-required agents. Coverage of Over-the Counter (OTC) Products is listed at: https://www.optumrx.com/content/dam/openenrollment/pdfs/Tenncare/presciber/program-information/Covered%20OTC%20List.pdf

Preferred Drugs Non-Preferred Drugs I. ANALGESICS Agents for Opioid Use Disorder naltrexone Lucemyra® PA, QL Buprenorphine and Buprenorphine/Naloxone Buprenorphine Enhanced Supportive Medication-Assisted Recovery and Treatment (BESMART) Network Provider only: buprenorphine/naloxone tabs PA, QL Suboxone® film PA, QL Bunavail® PA, QL buprenorphine/naloxone film PA, QL buprenorphine PA, QL Zubsolv® PA, QL All other TennCare Providers: buprenorphine/naloxone tabs PA, QL Bunavail® PA, QL buprenorphine PA, QL Suboxone® film PA, QL buprenorphine/naloxone filmPA, QL Zubsolv® PA, QL COX-II Inhibitors celecoxib (50, 100, & 200 mg) QL Celebrex® QL celecoxib 400 mg PA, QL Transmucosal Fentanyl Products N/A Abstral® PA, QL Fentora® PA, QL Actiq® PA, QL Lazanda ® PA, QL fentanyl lozenge PA, QL Subsys® PA, QL Naloxone Products Narcan® nasal spray QL Kloxxado® nasal spray QL n/a Narcotics Agonist/Antagonists nalbuphine PA, QL butorphanol NS PA, QL pentazocine/naloxone PA, QL pentazocine/APAP PA, QL Long Acting Narcotics fentanyl patch (excluding 37.5mcg/hr, 62.5mcg/hr, and 87.5mcg/hr) PA, QL Arymo ER® PA, QL Morphabond® ER PA, QL morphine sulfate ER tabs PA, QL Belbuca® PA, QL morphine sulfate ER caps PA, QL Nucynta® ER PA, QL buprenorphine patch PA, QL morphine sulfate SA PA, QL Butrans® PA, QL morphine sulfate SR 24hr (generic for Avinza®) PA, QL ConZip® PA, QL MS Contin® PA, QL Dolophine® PA, QL Opana ER® PA, QL Duragesic® PA, QL OxyContin® PA, QL Exalgo® PA, QL oxymorphone ER PA, QL fentanyl patch (37.5mcg/hr, oxycodone ER PA, QL 62.5mcg/hr, and 87.5mcg/hr) PA, QL hydrocodone ER (generic Hysingla ER) PA, tramadol ER 24 hr PA, QL QL hydromorphone ER PA, QL tramadol ER PA, QL (generic Conzip®) Hysingla® ER PA, QL Ultram ER® PA, QL Kadian® PA (≥100 mg), QL Xtampza ER® PA, QL methadone PA, QL Zohydro ER® PA, QL * Note that agents not listed on PDL may be considered non-preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser Proprietary & Confidential to access the files on the TennCare site. Other browsers like Internet © 2021, OptumRx. All rights reserved. Explorer cause issues with functionality and links between files.

Preferred Drugs Non-Preferred Drugs I. ANALGESICS Methadose® PA, QL Short-Acting Narcotics QL codeine/APAP PA (< 19 years old), QL oxycodone tabs QL Apadaz® QL meperidine PA, QL Endocet® QL oxycodone/APAP QL benzhydrocodone/APAP PA, QL morphine suppositories PA, QL hydrocodone/APAP QL oxycodone oral concentrate PA butalbital/APAP/caff/codeine PA, QL Nalocet® PA, QL (excluding generic for Xodol®) hydrocodone/ibuprofen QL oxycodone oral solution butalbital/ASA/caff/codeine PA, QL Norco® PA, QL hydromorphone QL tramadol QL codeine PA, QL Nucynta® PA, QL (excluding suppositories and liquid) morphine IR QL tramadol/APAP QL Demerol® PA, QL Oxaydo® PA, QL (excluding suppositories) morphine sulfate soln 20 mg/ml PA dihydrocodeine/APAP/caffeine PA, QL oxycodone caps PA, QL dihydrocodeine/ASA/caffeine PA, QL oxycodone/ASA PA, QL Dilaudid® PA, QL oxycodone/IBU PA, QL Fioricet® with Codeine PA, QL oxymorphone PA, QL Fiorinal® with Codeine PA, QL Percocet® PA, QL hydrocodone/APAP 5/300 PA, QL Primlev® PA, QL hydrocodone/APAP 10/300 PA, QL Roxicodone® PA, QL hydromorphone liquid PA, QL Tylenol® with Codeine PA, QL hydromorphone suppositories PA Ultracet® PA, QL Ibudone® PA, QL Ultram® PA, QL levorphanol PA, QL Vicodin® PA, QL Lorcet® PA, QL Vicodin HP PA, QL Lortab® PA, QL NSAID/Anti-Ulcer Agents N/A Arthrotec® PA, QL naproxen-esomeprazole PA,QL diclofenac/misoprostol PA, QL Vimovo® PA, QL Duexis® PA, QL Salicylates and Non-Narcotic Combination Agents choline mag trisalicylate QL salsalate QL diflunisal QL

* Note that agents not listed on PDL may be considered non-preferred

Please use Google Chrome, Microsoft Edge, or Firefox as your browser to access the files on the TennCare site. Other browsers like Internet Explorer cause issues with functionality and links between files.

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 2

Preferred Drugs Non-Preferred Drugs I. ANALGESICS Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) diclofenac 1% gel QL ketorolac QL Anaprox® Mobic® diclofenac potassium meloxicam tablets Anaprox DS® Motrin® diclofenac sodium nabumetone Cambia® Nalfon® diclofenac sodium ER sulindac Cataflam® Naprelan® ibuprofen Voltaren® gel QL Clinoril® naproxen tabs and suspension indomethacin Daypro® naproxen sodium ER diclofenac patch PA, QL Naprosyn® diclofenac sodium 1.5% PA Naproxen® CR diclofenac 35mg capsules Oxaprozin EC-Naprosyn® Pennsaid® PA etodolac piroxicam etodolac ER Ponstel® Feldene® Qmiiz ODT® PA, QL fenoprofen Sprix® PA, QL Flector® PA, QL Tolmetin flurbiprofen Toradol® QL indomethacin ER Vivlodex® PA, QL ketoprofen Voltaren® ketoprofen ER Voltaren-XR® ketorolac spray VOPAC MDS Kit PA meclofenamate Zipsor® mefenamic acid Zorvolex® PA meloxicam susp & capsules PA ,QL

Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Cephalosporins First Generation cefadroxil capsules cephalexin capsules cefadroxil tablets Keflex® cefadroxil suspension cephalexin suspension cephalexin tablets Antibiotics: Cephalosporins Second Generation cefaclor capsules cefuroxime tabs cefaclor suspension Ceftin® suspension PA cefprozil cefaclor ER Ceftin® tabs Antibiotics: Cephalosporins Third Generation cefdinir Suprax® chewables cefditoren ceftibuten cefixime capsules and suspension cefpodoxime suspension PA Suprax® capsules and suspension cefpodoxime tablets Antibiotics: Macrolides azithromycin QL Eryped® 400 mg/5mL suspension clarithromycin ER/XL QL erythromycin base tablets azithromycin suspension QL erythromycin generic products Dificid® PA, QL tablet & suspension Zithromax® QL (excluding erythromycin base tabs) clarithromycin tablets & suspension erythromycin ethylsuccinate erythromycin brand products suspension 400 mg/5mL (except Eryped® 400 mg/5mL susp)

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 3

Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Methenamine and Combo all generic combinations of methenamine mandelate all brand combinations of Hiprex® methenamine, phenyl salicylate, methenamine hippurate methenamine, phenyl salicylate, Uroqid Acid #2® hyoscyamine, atropine, etc. hyoscyamine, atropine, etc. Antibiotics: Miscellaneous Agents for UTI Monurol® QL, PA fosfomycin powder packets PA,QL Antibiotics: Agents for Diarrhea vancomycin caps PA Aemcolo® PA, QL vancomycin solution PA,QL Firvanq® PA, QL Vancocin® caps PA Antibiotics: Aminoglycosides neomycin Neo-Fradin® Arikayce® QL Antibiotics: Oral Anti-Tuberculosis ethambutol pyrazinamide Cycloserine Rifadin® isoniazid rifabutin PA Myambutol® Rifamate® PA rifampin Mycobutin® PA Rifater® PA Paser® Trecator® Priftin® Antibiotics: Oral Lincosamines clindamycin caps clindamycin pediatric solution PA Cleocin® Cleocin® Pediatric granules PA Antibiotics: Oral Nitrofurans nitrofurantoin capsules nitrofurantoin suspension PA Furadantin® PA Macrodantin® Macrobid® Antibiotics: Oxazolidinones linezolid tabs PA, QL linezolid suspension QL Zyvox® PA, QL Sivextro® PA, QL Antibiotics: Penicillins amoxicillin dicloxacillin all brand penicillins amoxicillin ER amoxicillin/clavulanate penicillin amoxicillin/clavulanic acid XR ampicillin Antibiotics: Quinolones ciprofloxacin levofloxacin tabs Baxdela® PA, QL Levaquin® tabs Cipro® tablets levofloxacin solution PA Cipro® suspension PA moxifloxacin PA ciprofloxacin suspension PA ofloxacin ciprofloxacin ER QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Tetracyclines doxycycline hyclate 50 and 100mg QL Adoxa® QL minocycline tablets doxycycline monohydrate 50 and 100 mg caps QL demeclocycline PA Minolira ER® PA, QL minocycline capsules Doryx® QL Morgidox® PA, QL tetracycline doxycycline hyclate DR particles Nuzyra® PA, QL tabs QL doxycycline hyclate 20mg PA, QL Ocudox® Kit doxycycline monohydrate 75 mg Oracea® QL and 150 mg caps QL doxycycline monohydrate powder Periostat® PA, QL for suspension PA doxycycline monohydrate tabs QL Solodyn® PA, QL doxycycline 40mg caps QL Dynacin® Vibramycin® QL minocycline ER PA, QL Ximino® ER PA, QL Antibiotics: Sulfonamides, Folate Antagonist sulfadiazine PA trimethoprim (TMP) Bactrim® Primsol® TMP/sulfamethoxazole Sulfatrim® Bactrim DS® Antifungals: Oral clotrimazole troches griseofulvin suspension Ancobon® PA ketoconazole PA fluconazole suspension PA griseofulvin ultramicrosize Cresemba® PA Noxafil® PA fluconazole tablets QL nystatin Diflucan® suspension PA Oravig® PA, QL griseofulvin microsize terbinafine tablets PA, QL Diflucan® tablets QL posaconazole PA flucytosine PA Sporanox® PA, QL Grifulvin V® Tolsura® PA, QL Gris-Peg® Vfend® PA itraconazole PA, QL voriconazole PA Antifungals: Vaginal Gynazole-1® QL terconazole QL AVC® cream QL Terazol® miconazole-3 kit QL miconazole-3 vaginal supp QL Anti-Infectives: Amebicides N/A paromomycin Anti-Infectives: Antimalarials atovaquone/proguanil primaquine Aralen® Malarone® chloroquine quinine sulfate Coartem® Qualaquin® mefloquine Anti-Infectives: Antihelminthics albendazole PA praziquantel Albenza® PA Krintafel® ivermectin tabs QL pyrantel pamoate Biltricide® Stromectol® QL Emverm® PA Anti-Infectives: Miscellaneous Antiprotozoal Agents dapsone metronidazole tabs atovaquone PA Flagyl® ER benznidazole PA, QL Lampit® PA

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Daraprim® Mepron® PA Flagyl® Anti-Infectives: Oral Nitroimidazoles metronidazole tabs Flagyl® metronidazole caps Flagyl® ER Solosec® PA, QL metronidazole caps Tindamax® Tinidazole Anti-Infectives: Vaginal Antibiotics Cleocin® suppositories metronidazole 0.75% gel clindamycin phos 2% cream QL Cleocin® cream QL Nuvessa® QL Clindesse® vaginal cream QL Vandazole®day Antivirals: Cytomegalovirus Agents Valcyte® solution valganciclovir tabs Prevymis® PA, QL valganciclovir solution Valcyte® tabs Antivirals: Hepatitis B entecavir QL Epivir-HBV® solution QL adefovir PA, QL Epivir-HBV® tablets QL lamivudine-HBV QL Baraclude® solution PA, QL Hepsera® PA, QL Baraclude® tablets QL Vemlidy® PA, QL Antivirals: Hepatitis C Pegylated Interferons Pegasys® ProClick PA>24 weeks, QL Pegasys® vials PA>24 weeks, QL PEG-Intron® PA, QL PEG-Intron Redipen® PA, QL Pegasys® syringes PA>24 weeks, QL Antivirals: Hepatitis C Antivirals Epclusa® PA, QL Mavyret® PA, QL Harvoni Pak® PA, QL Vosevi® PA, QL Harvoni® PA, QL sofosbuvir/velpatasvir PA, QL Sovaldi®and Sovaldi Pak® PA, QL Zepatier® PA, QL ledipasvir/sofosbuvir PA, QL Viekira® PA, QL Antivirals: Hepatitis C Ribavirins Ribasphere® 200 mg tablets ribavirin tablets ribavirin capsules Ribasphere® 200mg capsules Ribapak® Ribasphere® 400 and 600 mg tablets Antivirals: Herpes acyclovir caps, suspension, and tabs valacyclovir QL Sitavig® buccal tabs QL Zovirax® caps, suspension, and tabs famciclovir QL Valtrex® QL Antivirals: HIV Attachment Inhibitors Rukobia ® PA, QL Antivirals: HIV CCR5 Antagonists Selzentry® tablets PA, QL Selzentry® solution PA Antivirals: Pharmacokinetic Enhancers Norvir® solution QL ritonavir tablet QL Norvir® tablet QL Tybost®QL Norvir® powder pack PA, QL Antivirals: HIV Fusion Inhibitors Fuzeon® PA, QL N/A

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 6

Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antivirals: HIV Integrase Inhibitors Isentress® PA, QL Tivicay PD® PA, QL Isentress® HD PA, QL Juluca® PA, QL Tivicay® PA, QL Antivirals: HIV NNRTIs Edurant® nevirapine QL nevirapine ER QL Viramune® QL efavirenz QL Pifeltro® QL Rescriptor® QL Viramune® XR QL Intelence® PA, QL Sustiva® QL Antivirals: HIV NRTIs abacavir tablets and solution QL lamivudine tablets and solution QL Epivir® tablets and solution QL Viread®powder didanosine capsules QL stavudine QL Retrovir® QL Zerit® QL emtricitabine QL tenofovir QL Videx® capsules QL Ziagen® tablets and solution QL Emtriva® QL zidovudine QL Viread® tablets QL Antivirals: HIV NRTI Combos abacavir/lamivudine QL efavirenz/emtricitabine/tenofovir QL Cimduo® QL abacavir/lamivudine/ Genvoya® QL efavirenz/lamivudine/tenofovir QL zidovudine PA, QL Atripla® QL lamivudine/zidovudine QL Epzicom® QL Biktarvy® PA, QL Odefsey® QL Symfi® QL Combivir® QL Stribild® QL Symfi® Lo® QL Complera® QL Symtuza® PA, QL Delstrigo® QL Triumeq® QL Descovy® QL Trizivir® PA, QL Dovato® PA, QL Truvada® QL emtricitabine/tenofovir QL Antivirals: HIV Protease Inhibitors Aptivus® PA, QL Lexiva® QL Reyataz® caps QL atazanavir capsules QL lopinavir/ritonavir QL Evotaz® QL Prezcobix® QL fosamprenavir QL Prezista® QL Invirase® QL Reyataz® powder QL Kaletra® QL Viracept® QL Antivirals: Influenza oseltamivir capsules QL Relenza® QL Tamiflu capsules QL Xofluza® PA, QL oseltamivir suspension QL Tamiflu® suspension QL

Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR Alpha/Beta Blockers labetalol carvedilol QL carvedilol ER QL Coreg CR® QL Coreg® QL Alpha-Blockers doxazosin prazosin Cardura® Minipress® terazosin

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR ACE Inhibitors benazepril lisinopril Accupril® perindopril QL enalapril ramipril QL Altace® QL Prinivil® captopril PA Quinapril Epaned® PA trandolapril QL fosinopril Qbrelis® solution PA Lotensin® Vasotec® moexipril QL Zestril® ACEI + Calcium Channel Blocker Combo benazepril/amlodipine QL Lotrel® QL Tarka® PA, QL Prestalia® PA, QL trandolapril/verapamil PA, QL ACEI + Diuretic Combination enalapril/HCTZ lisinopril/HCTZ Accuretic® Lotensin HCT® benazepril/HCTZ PA quinapril/HCTZ captopril/HCTZ Vaseretic® fosinopril/ HCTZ Zestoretic® Angiotensin II Receptor Blockers irbesartan QL olmesartan QL Atacand® QL Diovan® QL losartan QL valsartan QL Avapro® QL Edarbi® QL Benicar® QL eprosartan QL Cozaar QL Micardis® QL candesartan® QL telmisartan QL Angiotensin II Receptor Blockers + Calcium Channel Blocker QL amlodipine /valsartan QL amlodipine/olmesartan QL Exforge HCT® PA, QL amlodipine/valsartan/HCTZ PA, QL amlodipine/olmesartan/HCTZ PA, QL telmisartan/amlodipine QL Azor® QL Tribenzor® PA, QL Exforge® QL Twynsta® QL Angiotensin II Receptor Blockers + Diuretic irbesartan/HCTZ QL olmesartan/HCTZ QL Atacand HCT® QL Edarbyclor® QL losartan/HCTZ® QL valsartan/ HCTZ QL Avalide® QL Hyzaar® QL Benicar HCT® QL Micardis HCT® QL candesartan/HCTZ QL telmisartan/ HCTZ QL Diovan HCT® QL Angiotensin II Receptor Blockers + Neprilysin Inhibitor PA, QL Entresto® PA, QL N/A Anti-Anginal Agents: Miscellaneous N/A Corlanor® PA, QL Ranexa® PA, QL ranolazine ER PA, QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR Anti-Anginal Agents: Nitrates isosorbide dinitrate nitroglycerin (excluding spray) Dilatrate-SR® Nitro-Bid® (excluding 10 mg tabs and SL tabs) isosorbide mononitrate Nitrolingual® GoNitro® powder PA Nitro-Dur® Minitran® Nitrostat® Isordil® nitroglycerin spray Isosorbide dinitrate 10 mg tabs NitroMist® isosorbide dinitrate, sublingual Anti-Arrhythmics, Oral amiodarone mexiletine Betapace® propafenone ER disopyramide propafenone Betapace AF® quinidine gluconate & sulfate dofetilide QL sotalol Cordarone® Rythmol® flecainide sotalol AF Multaq® PA Rythmol SR® Norpace® Sorine® Norpace CR® Tambocor® Pacerone® Tikosyn® QL Anti-Hypertensives, Miscellaneous Catapres-TTS® QL hydralazine Catapres® reserpine clonidine methyldopa clonidine weekly TD patch QL Tenex® guanfacine methyldopa/HCTZ minoxidil PA Vecamyl® PA, QL Beta Blockers and Combinations atenolol nadolol acebutolol Lopressor® bisoprolol fumarate propranolol Betapace® metoprolol tartrate 37.5 & 75 mg metoprolol succinate QL propranolol ER betaxolol pindolol metoprolol tartrate (excluding 37.5 sotalol Bystolic® Sectral® and 75 mg) Corgard® Sorine® Hemangeol® PA Sotylize® PA Inderal LA® Tenormin® Inderal XL® timolol maleate InnoPran XL® QL Toprol XL® PA, QL Kapspargo® Sprinkle® PA, QL Zebeta®

Beta Blockers + Diuretic atenolol/chlorthalidone propranolol HCT Corzide® Tenoretic® bisoprolol HCT Dutoprol® PA, QL Ziac® metoprolol HCT Lopressor HCT®

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 9

Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR

Calcium Channel Blockers (DHP) amlodipine QL Adalat CC® QL Norvasc® QL felodipine ER isradipine QL Nymalize® PA, QL nicardipine Katerzia® QL Procardia® nifedipine ER/SA/XL QL nifedipine IR Procardia XL® QL nimodipine PA Sular® QL nisoldipine QL

Calcium Channel Blockers (Non-DHP) diltiazem ER/SR/XR Calan® diltiazem ER (generic for Cardizem LA) QL diltiazem IR Calan SR® QL Tiazac® verapamil Cardizem® verapamil ER PM verapamil ER/SR QL Cardizem CD® Verelan® Cardizem LA® QL Verelan PM®

Cardiac Glycosides digoxin Lanoxin® PA Direct Renin Inhibitors N/A aliskiren PA, QL Tekturna HCT® PA, QL Tekturna® PA, QL

Diuretics: Carbonic Anhydrase acetazolamide methazolamide Diamox® Sequels Keveyis® PA, QL

Diuretics: Combination Diuretics amiloride/HCTZ triamterene/HCTZ Aldactazide® Maxzide® spironolactone/HCTZ Dyazide®

Diuretics: Loop bumetanide furosemide Demadex® Lasix® ethacrynic acid torsemide Edecrin® PA

Diuretics: Potassium Sparing amiloride spironolactone Aldactone® eplerenone PA CaroSpir® PA, QL Inspra® PA Diuretics: Thiazide and Related Diuretics chlorothiazide indapamide Diuril® Microzide® chlorthalidone metolazone Dyrenium® Thalitone® hydrochlorothiazide methyclothiazide Zaroxolyn®

Hemostatics, Oral Amicar® tranexamic acid PA, QL aminocaproic acid tablets Lysteda® PA, QL

Intermittent Claudication cilostazol pentoxifylline Pletal®

Lipotropics: Bile Acid Sequestrants cholestyramine Prevalite® Colestid® Questran® cholestyramine light Welchol® tablets colesevelam packets PA Questran Light® colesevelam tablets Welchol® packets PA

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR colestipol

Lipotropics: Cholesterol Absorption Inhibitors ezetimibe PA, QL Zetia® PA, QL

Lipotropics: Fibric Acid Derivatives fenofibrate (48 mg & 145 mg) PA gemfibrozil Antara® PA Lipofen® PA fenofibrate 160mg PA fenofibrate (all other strengths) PA Lofibra® PA fenofibric acid PA Lopid® Fenoglide® PA TriCor® PA Fibricor® PA TriLipix® PA Lipotropics: Miscellaneous N/A Juxtapid® QL Nexlizet® PA, QL Nexletol® PA, QL PA Lipotropics: Niacin Derivatives niacin ER PA Niacor® PA Niaspan® PA PA Lipotropics: Omega-3 Fatty Acids N/A Lovaza® PA omega-3 acid ethyl esters PA icosapent ethyl PA,QL Vascepa® PA, QL Lipotropics: PCSK-9 Inhibitors Praluent® PA, QL Repatha® PA, QL N/A Lipotropics: Low Intensity Statins QL lovastatin 10mg to 20mg QL simvastatin 5mg to 10mg QL Altoprev® 10mg to 20mg QL Pravachol®10mg to 20mg QL pravastatin 10mg to 20mg QL fluvastatin 20mg to 40mg QL Zocor® 5 mg to 10 mg QL Livalo®1mg QL Zypitamag® 1mg QL Lipotropics: Moderate Intensity StatinsQL atorvastatin 10mg to 20mg QL rosuvastatin 5mg to 10mg QL Altroprev® 40mg to 60mg QL Livalo® 2 to 4mg QL lovastatin 40mg QL simvastatin 20mg to 40mg QL Ezallor Spinkles® 5mg to 10mg QL pivastatin 2mg to 4mg QL pravastatin 40mg to 80mg QL Flolipid® 20mg to 40mg QL Pravachol® 40mg to 80mg QL fluvastatin 40mg to 80mg QL Zocor® 20mg to 40mg QL fluvastatin ER 80mg QL Zypitamag® 2mg to 4mg QL Lescol XR® 80mg QL

QL Lipotropics: High Intensity Statins atorvastatin 40mg to 80mg QL simvastatin 80 mg PA, QL Crestor®20mg to 40mg PA, QL Lipitor®40mg to 80mg PA, QL rosuvastatin 20mg to 40mg QL Ezallor Sprinkles® 20mg to 40mg PA, Zocor® 80 mg PA, QL QL QL Lipotropics: Combination Antihyperlipidemics N/A ezetimibe/simvastatin PA, QL Vytorin® PA, QL

Lipotropics: Statin + CCB Combination N/A amlodipine/atorvastatin PA, QL Caduet® PA, QL

Injectable Anticoagulants enoxaparin QL heparin Arixtra® QL Lovenox® QL fondaparinux QL Fragmin®

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR

Oral Anticoagulants Jantoven® warfarin Coumadin® Savaysa® PA, QL Pradaxa® PA, QL Xarelto® PA, QL Eliquis® PA, QL

Oral Thrombopoietin Agonists N/A Doptelet® PA, QL Promacta® suspension PA, QL Mulpleta® PA, QL Tavalisse® PA, QL Promacta® PA, QL

Peripheral Vasodilators ergoloid mesylates

Pheochromocytoma Agents N/A Demser® PA metyrosine PA dibenzyline PA, QL phenoxybenzamine PA, QL

Platelet Inhibitors Aggrenox® clopidogrel 75 mg Agrylin® Plavix® anagrelide dipyridamole aspirin/dipyridamole Pletal® Brilinta® PA, QL clopidogrel 300 mg prasugrel PA cilostazol Durlaza® PA, QL Yosprala® PA, QL Effient® PA Zontivity® PA, QL Persantine® PA, QL Pulmonary Arterial Hypertension Agents ambrisentan PA, QL Tracleer® PA, QL Adcirca® PA, QL Orenitram® ER PA, QL sildenafil PA, QL (generic for Revatio®) Tyvaso® PA, QL Adempas® PA, QL Revatio® PA, QL tadalafil PA, QL (generic for Adcirca®) Ventavis® PA, QL bosentan PA, QL Revatio® suspension PA, QL Letairis® PA, QL sildenafil suspension PA, QL Opsumit® PA, QL Uptravi® PA, QL Pulmonary Fibrosis Agents Ofev® PA, QL Esbriet® PA, QL

Vasopressors midodrine Northera® PA, QL droxidopa PA, QL Vasopressor Receptor Antagonists N/A Jynarque® PA, QL Samsca® PA Jynarque Pak® PA, QL

Vasodilator/Nitrate Combinations N/A BiDil® PA

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 12

Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Agents for Neuropathic Pain duloxetine QL Cymbalta® QL Lidoderm® PA gabapentin capsules QL DermacinRx® QL Lyrica® PA lidocaine patch 5% PA, QL duloxetine caps (generic for Irenka®) Lyrica® CR ® PA, QL PA, QL Drizalma DR® PA, QL Neurontin® QL gabapentin solution PA, QL Neurontin® solution PA, QL gabapentin tablets PA, QL pregabalin capsules and solution PA Gralise® PA, QL pregabalin ER PA, QL Horizant® PA, QL Alzheimer’s: Cholinesterase Inhibitors donepezil QL (excluding 23 mg) Exelon® patch QL Aricept® ODT PA, QL galantamine ER QL donepezil ODT PA, QL galantamine tablets Aricept® QL Razadyne® Aricept® 23 mg tablet PA, QL Razadyne ER® QL donepezil 23 mg PA, QL rivastigmine Exelon® rivastigmine patch QL galantamine solution Alzheimer’s: NMDA Receptor Antagonists memantine tablets PA, QL memantine ER PA, QL Namenda XR® PA, QL memantine solution PA, QL Namzaric® PA, QL Namenda® PA, QL

Anti-Parkinson’s Agents: Adenosine A2A Receptor Antagonist N/A Nourianz ® PA, QL Anti-Parkinson’s Agents: Anticholinergics benztropine trihexyphenidyl tablet & solution N/A Anti-Parkinson’s Agents: Decarboxylase Inhibitors carbidopa Lodosyn® Anti-Parkinson’s Agents: Dopamine Precursors/Decarboxylase Inhibitors carbidopa/levodopa carbidopa/levodopa ER/SR Inbrija® PA,QL Sinemet® Rytary® Sinemet® CR Anti-Parkinson’s Agents: COMT Inhibitors and Combos carbidopa/levodopa/entacapone Stalevo® Comtan® Tasmar® entacapone Ongentys® PA, QL tolcapone Antiparkinson’s Agents: Dopamine Agents amantadine capsules amantadine tablets Neupro® PA amantadine syrup Apokyn® PA Osmolex® ER tabs & tablet pack PA, QL pramipexole QL bromocriptine Parlodel® ropinirole Cycloset® pramipexole ER QL Gocovri® PA, QL Requip® Kynmobi® PA, QL Requip® XL Mirapex® QL ropinirole ER Mirapex® ER QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 13

Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Antidepressants: SSRIs ID citalopram QL fluoxetine solution Brisdelle® PA paroxetine CR QL escitalopram tabs QL fluvoxamine QL Celexa® QL Paxil® QL escitalopram solution paroxetine QL fluoxetine tablets QL Paxil CR® QL fluoxetine capsules QL sertraline QL fluoxetine (PMDD) QL Pexeva® QL fluoxetine weekly PA, QL Prozac® QL fluvoxamine ER QL Sarafem® QL Lexapro® solution Viibryd® QL Lexapro® tablets QL Zoloft® QL paroxetine 7.5 mg PA Antidepressants: SSRI/SRMs ID N/A Trintellix® PA, QL Antidepressants: SNRIs ID duloxetine QL Cymbalta® QL Khedezla® PA, QL venlafaxine QL duloxetine caps (generic for Irenka®) PA, QL Pristiq® PA, QL venlafaxine ER caps QL desvenlafaxine ER PA, QL Savella® PA, QL Effexor XR® PA, QL venlafaxine ER tabs PA, QL Fetzima® PA, QL Antidepressants: New Generation ID Aplenzin® mirtazapine bupropion XL (generic Forfivo XL®) trazodone 300 mg bupropion IR/SR mirtazapine rapids PA Forfivo XL® Wellbutrin® bupropion XL (not generic Forfivo XL®) QL trazodone (excluding 300 mg) nefazodone Wellbutrin SR® Remeron® Wellbutrin XL® QL Remeron SolTab® PA Antidepressants: Tricyclics ID amitriptyline amoxapine maprotiline doxepin (excluding generic Silenor®) Anafranil® PA Norpramin® imipramine clomipramine PA Pamelor® nortriptyline desipramine protriptyline imipramine pamoate Antidepressants: MAOIs PA, QL, ID phenelzine PA, QL Emsam® PA, QL Parnate® PA, QL Marplan® PA, QL tranylcypromine PA, QL Nardil® PA, QL Antipsychotics: Typical ID chlorpromazine pimozide molindone fluphenazine thioridazine haloperidol thiothixene loxapine trifluoperazine perphenazine

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 14

Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Antipsychotics: Atypical PA, ID aripiprazole ODT, sol., & tabs PA, QL quetiapine ER PA, QL Abilify® tablets PA, QL Nuplazid ® PA, QL clozapine PA, QL risperidone PA, QL Abilify Maintena® PA, QL paliperidone ER PA, QL Latuda® PA, QL risperidone solution PA, QL Abilify Mycite® PA, QL Perseris® ER PA, QL olanzapine tablets PA, QL risperidone ODT PA, QL asenapine PA, QL Rexulti® PA, QL olanzapine IM PA, QL Vraylar® PA, QL Aristada® PA, QL Risperdal® PA, QL olanzapine ODT PA, QL ziprasidone PA, QL Aristada® Initio® PA, QL Risperdal Consta® PA, QL quetiapine PA, QL Caplyta® PA, QL Saphris® PA, QL clozapine ODT PA, QL Secuado ® PA, QL Clozaril® PA, QL Seroquel® PA, QL Fanapt® PA, QL Seroquel® XR PA, QL Geodon® PA, QL Versacloz® suspension PA Invega® PA, QL Zyprexa® PA, QL Invega® Sustenna® PA, QL Zyprexa® IM PA, QL Invega® Trinza® PA, QL Zyprexa Zydis® PA, QL Atypical Antipsychotic and SSRI Combinations PA, ID N/A fluoxetine/olanzapine PA, QL Symbyax® PA, QL Anti-Migraine: Anti-CGRP Monoclonal Antibodies Aimovig® PA, QL Nurtec ODT® PA, QL Ajovy®autoinjector & prefilled syringe Ubrelvy® PA, QL PA, QL Emgality® pen and syringe PA, QL Anti-Migraine: Barbiturate Combination Agents butalbital/APAP QL Cafergot® QL butalbital/ASA/caff PA, QL Fioricet® with codeine QL butalbital/APAP/caff QL Esgic® capsules QL butalbital/APAP/caff/codeine QL Fiorinal® with codeine QL butalbital/ASA/caff/codeine QL Migergot® QL Esgic® tablets QL Vanatol LQ® QL Anti-Migraine: 5-HT1 Receptor Agonists QL eletriptan QL sumatriptan tabs QL almotriptan QL Relpax® QL rizatriptan QL sumatriptan vials QL Amerge® QL Reyvow® QL rizatriptan ODT QL zolmitriptan nasal spray QL Frova® QL sumatriptan kits PA, QL frovatriptan QL sumatriptan/naproxen QL Imitrex® Injectable QL sumatriptan nasal QL Imitrex® Kit PA, QL Tosymra® PA, QL Imitrex Nasal® QL Treximet® QL Imitrex® tablets QL Zembrace® Symtouch® PA, QL Maxalt® QL zolmitriptan QL Maxalt MLT® QL Zomig® QL Migranow Kit® PA, QL Zomig ZMT® QL naratriptan QL Zomig® nasal spray QL Onzetra Xsail® PA, QL Anti-Migraine: Ergotamine Derivatives N/A Ergomar® PA, QL Migranal® PA, QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 15

Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM dihydroergotamine nasal spray PA, QL

Antihyperkinesis: Stimulants PA ≥ 21 years old amphetamine salt ER comb PA ≥ 21, QL Metadate ER® PA ≥ 21, QL Adderall® QL & Adderall XR® QL Jornay PM® QL amphetamine salt IR comb PA ≥ 21, QL methylphenidate (generic for Adhansia XR® QL methamphetamine QL Ritalin®) PA ≥ 21 amphetamine sulfate (5mg & methylphenidate ER (generic for Adzenys® ER solution QL Methylin® solution 10mg) PA ≥ 21, QL Metadate® ER & Methylin® ER) PA ≥ 21, QL Aptensio® XR PA ≥ 21, QL methylphenidate solution (generic Adzenys® XR ODT QL methylphenidate ER (generic for for Methylin®) PA ≥ 21 Aptensio® XR, Focalin® XR, Ritalin® LA) QL Concerta® PA ≥ 21, QL ProCentra® QL amphetamine ER suspension QL methylphenidate XR ODT (generic for Cotempla XR®ODT) QL dexmethylphenidate PA ≥ 21, QL Vyvanse® capsules PA ≥ 21, QL Cotempla XR®ODT QL methylphenidate chewables (generic for Methylin®) dextroamphetamine PA ≥ 21, QL Vyvanse® chewables PA ≥ 21, QL Daytrana® QL methylphenidate SA OSM (generic for Concerta & Relexxii) QL Focalin XR® PA ≥ 21, QL Desoxyn® QL Mydayis® ER QL Dexedrine Spansule® QL Quillichew ER® QL & Quillivant XR® QL dexmethylphenidate XR QL Relexxii® QL dextroamphetamine soln QL Ritalin® & Ritalin LA® QL Dyanavel® XR QL Zenzedi® QL Evekeo® tab & ODT QL Max cumulative amphetamine dose: Patients ≥ 21: 60 mg/day; Patients ≤ 20: 80 Focalin® mg/day Antihyperkinesis: Non-Stimulants atomoxetine QL guanfacine clonidine ER PA, QL Strattera® QL clonidine guanfacine ER QL Intuniv® PA, QL Agents for Narcolepsy modafinil PA, QL armodafinil PA, QL Wakix®PA, QL Nuvigil® PA, QL Xyrem® PA, QL Provigil® PA, QL Xywav® PA, QL Sunosi® PA, QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 16

Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Anticonvulsants Aptiom® PA levetiracetam Banzel® tablet and suspension PA lamotrigine ER PA carbamazepine ER capsules (generic levetiracetam ER Briviact® tablets and solution PA lamotrigine ODT PA for Carbatrol®) carbamazepine ER Nayzilam® PA, QL carbamazepine tabs and suspension lamotrigine tablet dose pack (generic for Tegretol®) clobazam tablets PA oxcarbazepine Carbatrol® Lyrica® PA clonazepam tablets PA, QL phenobarbital PA Celontin® Mysoline® Diastat® PA, QL phenobarbital elixir PA (< 1 year, PA not clobazam suspension PA Neurontin® QL required) diazepam rectal gel PA, QL phenytoin clonazepam ODT PA, QL Neurontin® solution PA, QL Dilantin Kapseal® 30 mg primidone Depakene® Onfi® PA Dilantin® Infatabs® topiramate Depakote® Oxtellar XR® divalproex Tegretol® (excluding chewables) Depakote® ER Peganone® divalproex extended release valproic acid Depakote® Sprinkles Phenytek® divalproex DR sprinkles Vimpat® PA Diacomit ® QL Qudexy® XR PA, QL Equetro® zonisamide Dilantin-125® rufinamide suspension PA ethosuximide Dilantin Kapseal® 100 mg Sabril® PA gabapentin capsules QL Epidiolex® PA Spritam® PA, QL lamotrigine tablets and chewable Epitol® Sympazan® PA, QL (excluding dose pack) felbamate PA Tegretol® chewables Felbatol® PA Tegretol-XR® Fintepla® PA, QL tiagabine Fycompa® PA, QL Topamax® gabapentin tablets and solution PA, QL topiramate ER PA, QL Gabitril® Trileptal® Keppra® Trokendi XR® PA, QL Keppra® XR Valtoco® PA, QL Klonopin® PA, QL vigabatrin PA Lamictal® tabs and chewable tabs Xcopri® PA, QL Lamictal® ODT PA Zarontin® Lamictal® XR Agents for RLS (Restless Leg Syndrome) pramipexole QL ropinirole Horizant® PA, QL Neupro® PA Mirapex® QL Requip® Amyotrophic Lateral Sclerosis (ALS) riluzole Tiglutik® PA, QL Rilutek®

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 17

Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Anti-Anxiety Agents ID alprazolam PA, QL lorazepam tablets and alprazolam ER PA, QL oxazepam PA, QL concentrate PA, QL buspirone alprazolam ODT PA, QL Tranxene-T® PA, QL chlordiazepoxide PA, QL alprazolam concentrate PA, QL Valium® PA, QL clorazepate PA, QL Ativan® PA, QL Xanax® PA, QL diazepam tablet, solution & meprobamate Xanax® XR PA, QL concentrate PA, QL Cholinergic Muscle Stimulants Mestinon® syrup pyridostigmine Mestinon® 60 mg tab Mestinon® 180mg ER tab Huntington’s Disease Austedo® PA, QL tetrabenazine PA N/A Ingrezza® PA, QL Xenazine® PA MAOI-Bs selegiline Azilect® Xadago® PA, QL rasagiline Zelapar® PA Miscellaneous CNS Agents N/A Nuedexta® PA, QL Mood Stabilizers lamotrigine tabs lithium carbonate SA carbamazepine tabs and suspension Lamictal® XR lamotrigine chewable tabs lithium citrate Depakote® lamotrigine ER levetiracetam oxcarbazepine Depakene® Stavzor® lithium carbonate valproic acid Keppra® Tegretol® Lamictal® tabs Trileptal® Lamictal® chewable tabs Lithobid® Lamictal® ODT PA Sedative Hypnotic Agents QL, ID eszopiclone QL zaleplon QL Ambien® QL Lunesta® QL doxepin concentrate 10mg/mL QL zolpidem QL Ambien CR® QL midazolam PA, QL Rozerem® QL Belsomra® QL quazepam PA, QL Edluar® PA, QL ramelteon QL estazolam PA, QL Restoril® PA, QL Dayvigo PA, QL Silenor® PA, QL Doral PA, QL Sonata® QL doxepin (generic for Silenor) PA, QL temazepam PA, QL flurazepam PA, QL triazolam PA, QL Halcion® PA, QL zolpidem ER QL Hetlioz® capsule & susp PA, QL zolpidem tartrate SL QL Intermezzo® QL Zolpimist® PA, QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 18

Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Skeletal Muscle Relaxants baclofen dantrolene Amrix® PA, QL Norgesic Forte® chlorzoxazone methocarbamol carisoprodol PA, QL orphenadrine cyclobenzaprine tizanidine tablets carisoprodol/ASA PA, QL Robaxin® carisoprodol/ASA/codeine PA Skelaxin® cyclobenzaprine 7.5mg Soma® PA, QL cyclobenzaprine ER PA, QL tizanidine capsules Lorzone® Zanaflex® metaxalone Spinal Muscular Atrophy (SMA) N/A Evrysdi® PA, QL

Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Antipruritics/Antihistamines N/A doxepin cream PA, QL Zonalon® PA, QL Prudoxin® PA, QL Topical Antivirals acyclovir 5% ointment QL acyclovir cream QL Zovirax® cream QL Denavir® cream QL Xerese® PA, QL Zovirax® ointment QL Topical Agents for Burns silver sulfadiazine QL SSD® QL mafenide Sulfamylon® QL Thermazene® Silvadene® QL Antiseborrheic Agents selenium sulfide 2.5% lotion QL Ovace® QL sodium sulfacetamide 10% shampoo Ovace® Plus QL sulfacetamide sodium/urea pads selenium sulfide shampoo sulfacetamide sodium 10% wash selenium sulfide/pyrithione zinc in urea Topical Antibiotic Agents for Skin and Soft Tissue Infections gentamicin mupirocin ointment QL Bactroban® cream QL Centany® QL Bactroban® ointment QL mupirocin cream Topical Antibiotic Agents for Acne (Covered for recipients < 21 years old only) Azelex® 20% cream QL Aczone® QL Amzeeq® PA, QL benzoyl peroxide (2.5%, 5%, benzoyl peroxide (cleanser, gel, microspheres, towelettes, and all 10% excluding cleanser, gel, microspheres, and towelettes) QL strengths not listed as preferred) QL clindamycin phosphate (excluding foam, lotion, & 75 mL bottle of gel) QL benzoyl peroxide kits and other dermatological kits PA clindamycin/benzoyl peroxide gel QL clindamycin phosphate foam, lotion, and gel (75 mL bottle) QL erythromycin (excluding swab & gels) QL dapsone® 5% gel erythromycin/benzoyl peroxide sodium sulfacetamide/sulfur QL erythromycin swab & gel QL sulfacetamide suspension QL All branded single agent and combination products of: benzoyl peroxide, clindamycin, erythromycin, and sodium sulfacetamide QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 19

Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Agents for Rosacea (Covered for recipients < 21 years old only) Finacea® 15% gel QL metronidazole gel 1% QL azelaic acid 15% gel Mirvaso® QL metronidazole 0.75% cream QL Rosadan® 0.75% cream Finacea® 15% foam QL Noritate® 1% cream QL metronidazole 0.75% gel QL Rosadan® 0.75% gel Finacea® Plus gel PA Rhofade® PA, QL metronidazole 0.75% lotion QL MetroCream® QL Rosadan® Kit QL MetroGel® 1% QL Soolantra® QL MetroGel® 1% Kit Zilxi® PA,QL MetroLotion® QL Topical Antifungal Agents ciclopirox (excluding gel) QL clotrimazole/betamethasone QL Bensal HP® QL Loprox® QL ciclopirox solution 8% PA nystatin/triamcinolone QL Ciclodan® Kit PA, QL Lotrisone® clotrimazole 1% cream & soln (OTC) QL ketoconazole ciclopirox gel and suspension QL Luzu® PA (shampoo and cream) QL clotrimazole 1% cream (Rx) QL nystatin QL ciclopirox nail kit PA Mentax® clotrimazole 1% solution (Rx) QL miconazole/zinc/petrolatum PA CNL 8 Nail Kit® PA naftifine gel QL econazole QL Naftin® QL Ertaczo® QL Nizoral® Exelderm® QL oxiconazole QL Extina® QL Oxistat® QL Jublia® PA Pediaderm® AF Ketocon Kit PA Pedipirox-4® Nail PA ketoconazole foam Penlac® PA Ketodan® Kit PA tavaborole solution Kerydin® Vusion® PA luliconazole PA , QL Topical Antipsoriatics PA calcipotriene cream PA, QL tazarotene 1% cream PA calcipotriene ointment PA, QL Duobrii ® PA calcipotriene scalp solution PA Tazorac® 0.5% gel and cream PA, QL calcitriol ointment PA, QL Enstilar® PA, QL Taclonex® suspension/ointment PA Vectical® PA calcipotriene/betamethasone Sorilux® PA, QL ointment & suspension PA, QL Dovonex® PA Tazorac® 1% cream PA Dovonex® scalp solution PA Wynzora® PA, QL Antipsoriatics, Oral PA N/A methoxsalen capsules PA Oxsoralen-Ultra® PA Genital Wart Agents imiquimod QL podofilox Aldara® QL Veregen® QL Condylox® QL Zyclara® QL Emollients ammonium lactate QL lactic acid Lac-Hydrin® LacLotion® lactic acid with vitamin E Topical Anticholinergics N/A Qbrexza® PA,QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 20

Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Retinoids, Oral N/A acitretin PA, QL Myorisan® PA Absorica® & Absorica LD® PA isotretinoin PA Amnesteem® PA Soriatane® QL Claravis® PA Zenatane® PA Retinoids, Topical PA Avita® PA ≥ 21, QL adapalene PA, QL Retin-A® PA , QL Differin® PA ≥ 21, QL adapalene/benzoyl peroxide PA, QL Retin-A Micro® PA, QL tazarotene 0.1% cream PA ≥ 21, QL Altreno® PA, QL Tazorac® 0.1% cream PA Tazorac® 0.05% gel & cream PA ≥ 21, QL Atralin® PA, QL tretinoin gel PA tretinoin PA ≥ 21 Arazlo® PA, QL tretinoin microsphere gel PA clindamycin/tretinoin PA, QL Veltin® PA Epiduo® PA Ziana® PA Epiduo® Forte PA, QL Fabior® PA, QL Pediculocides/Scabicides QL Natroba® QL Crotan® PA, QL malathion QL permethrin QL Elimite® QL Ovide® QL VanaLice® QL Eurax® PA, QL Sklice® QL ivermectin lotion QL (generic Sklice) spinosad QL lindane PA, QL PDE-4 Inhibitors, Topical N/A Eucrisa® PA, QL Keratolytic Agents all generic urea products PA, QL all generic salicylic acid products QL All brand urea products QL All brand salicylic acid products QL Enzyme Preps and Wound Healing Regranex® PA, QL Santyl® QL N/A Topical Anesthetics lidocaine (excluding lotion and All brand lidocaine products LidoPure® PA, QL solution) QL lidocaine viscous EMLA® QL Novacort® gel lidocaine/prilocaine QL hydrocortisone/pramoxine Pliaglis® QL lidocaine patch 5% PA, QL lidocaine lotion and solution Pramosone® 2.5%–1% lotion QL lidocaine/tetracaine Prizotral® QL lidocaine/hydrocortisone QL Zilacaine® PA, QL lidocaine/hydrocortisone/aloe ZTLido ® QL Lidoderm® PA Topical Antineoplastics Carac® QL fluorouracil Aldara® QL Solaraze® PA diclofenac 3% gel PA, QL imiquimod QL Efudex® QL Tolak® PA, QL Fluoroplex® Targretin® QL fluorouracil 5% cream Valchlor® PA, QL Panretin® QL Zyclara® QL Picato® QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 21

Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Steroids: Least Potent hydrocortisone 1% cream and ointment (Rx & OTC) QL Ala-Scalp® 2% lotion QL hydrocortisone 2.5% cream, lotion, and ointment QL Alcortin® A Aqua Glycolic HC® Kit hydrocortisone acetate-aloe vera 2% gel MiCort® HC 2.5% cream QL Pediaderm HC® 2% Kit Texacort® 2.5% solution U-cort® 1% cream Topical Steroids: Mild betamethasone valerate 0.1% lotion QL alclometasone 0.05% cream and ointment Derma-Smoothe/FS® Oil Desonate® 0.05% gel QL desonide 0.05% cream and ointment QL fluocinolone acetonide 0.01% cream, oil and solution QL Synalar® 0.01% solution QL Verdeso® 0.05% foam Topical Steroids: Lower Mid-Strength betamethasone dipropionate 0.05% lotion QL Capex® shampoo betamethasone valerate 0.1% cream QL clocortolone 0.1% cream and pump QL fluticasone propionate 0.05% cream Cloderm® 0.1% cream Cutivate® 0.05% cream and lotion QL Derma-Top® 0.1% cream and ointment QL desonide 0.05% lotion QL Desowen® 0.05% lotion Diprolene® 0.05% lotion fluocinolone acetonide 0.01% shampoo fluocinolone acetonide 0.025% cream fluticasone propionate 0.05% lotion hydrocortisone butyrate 0.1% cream, lotion, ointment, and solution QL hydrocortisone valerate 0.2% cream QL Pandel® 0.1% cream QL prednicarbate 0.1% cream and ointment QL Topical Steroids: Mid-Strength mometasone furoate 0.1% cream and solution (lotion) Elocon® 0.1% cream and lotion QL triamcinolone acetonide 0.1% cream QL fluocinolone acetonide 0.025% ointment flurandrenolide 0.5% cream and lotion flurandrenolide 0.5% ointment QL hydrocortisone valerate 0.2% ointment QL Kenalog® aerosol spray Locoid Lipocream® QL Pediaderm TA® Kit triamcinolone spray

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Steroids: Upper Mid-Strength betamethasone valerate 0.1% ointment QL amcinonide 0.1% cream and lotion QL fluticasone propionate 0.005% ointment QL betamethasone dipropionate 0.05% cream QL triamcinolone acetonide 0.025% cream, lotion and ointment QL betamethasone valerate 0.12% foam QL triamcinolone acetonide 0.05% ointment QL desoximetasone 0.05% cream QL triamcinolone acetonide 0.1% lotion and ointment QL Diprolene AF® 0.05% cream triamcinolone acetonide 0.5% cream and ointment QL Ellzia Pak QL fluocinonide 0.05% emulsified base cream QL Luxiq® 0.12% foam Sernivo® Trianex® 0.05% ointment QL Topical Steroids: Potent betamethasone dipropionate, augmented 0.05% cream QL amcinonide 0.1% ointment mometasone furoate 0.1% ointment Apexicon E® 0.05% cream QL betamethasone dipropionate, augmented 0.05% lotion QL betamethasone dipropionate 0.05% ointment QL desoximetasone 0.05% gel and ointment QL desoximetasone 0.25% cream, ointment, spray QL diflorasone diacetate 0.05% cream and ointment QL Elocon® 0.1% ointment QL fluocinonide 0.05% cream, gel, and ointment QL fluocinonide 0.05% solution Halog® 0.1% ointment, cream, and solution QL Topicort® 0.05% gel and ointment Topicort® 0.25% cream and ointment Topical Steroids: Super Potent clobetasol propionate 0.05% cream, gel, ointment, lotion, & solution QL Bryhali® lotion PA, QL clobetasol propionate emollient base 0.05% cream QL betamethasone dipropionate, augmented 0.05% gel, and ointment QL clobetasol propionate 0.05% foam, shampoo, and spray QL clobetasol propionate emollient base 0.05% foam QL Clobex® 0.05% lotion and shampoo Clobex® 0.05% spray Clodan® Clodan® Kit PA, QL Cordran® tape Diprolene® 0.05% ointment fluocinonide 0.1% cream QL halobetasol propionate 0.05% cream, foam, and ointment QL Impeklo® PA, QL Olux-E® 0.05% aerosol Lexette® PA, QL Ultravate® 0.05% cream, lotion QL, and ointment Olux® 0.05% aerosol Vanos® 0.1% cream Temovate® 0.05% cream and ointment QL Temovate E® 0.05% cream

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 23

Preferred Drugs Non-Preferred Drugs VI. DIABETIC SUPPLIES Diabetic Supplies: Blood Glucose Meters (OTC) QL Abbott Diabetes Care Products QL AgaMatrix Products PA, QL LifeScan Products PA, QL (Covered Meters Include: Freestyle Bayer Healthcare Products PA, QL Roche Diagnostics Products PA, QL InsuLinx Meter, FreeStyle Lite Home Diagnostics Products PA, QL Meter, FreeStyle Freedom Lite Meter, Precision Xtra Meter) Diabetic Supplies: Blood Glucose Test Strips (OTC) Abbott Test Strips QL AgaMatrix Products PA, QL LifeScan Products PA, QL (Covered Strips Include: Precision Bayer Healthcare Products PA, QL Roche Diagnostics Products PA, QL Xtra Test Strips, FreeStyle Test Home Diagnostics Products PA, QL Strips, FreeStyle Lite Test Strips, Freestyle InsuLinx Test Strips) U-500 Insulin Syringes BD U-500 Insulin Syringes PA

Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Agents for Gout allopurinol probenecid colchicine capsules (generic Mitigare® PA Mitigare®) PA colchicine tablets PA probenecid/colchicine Colcrys® PA Uloric® PA Duzallo® PA, QL Zurampic® PA, QL febuxostat PA Zyloprim® Gloperba® PA, QL Anabolic Steroids PA N/A Anadrol-50® PA oxandrolone PA Androgens danazol PA, QL testosterone gel (generic Androgel® Androderm® PA Natesto® nasal gel PA and Vogelxo®)PA, QL testosterone cypionate PA, QL Androgel® 1% and 1.62% packs PA, QL Striant® PA Androgel® pump PA, QL Testim® PA, QL Android® PA Depo-Testosterone® PA, QL Fortesta® PA, QL testosterone enanthate inj. PA, QL Jatenzo® PA, QL Testred® PA Methitest® PA Vogelxo® PA methyltestosterone PA Xyosted® PA, QL Antidiuretic/Vasopressor Agents desmopressin tabs & injection DDAVP Noctiva® PA, QL desmopressin nasal spray Stimate® PA Nocdurna® PA, QL Agents for Dyspareunia N/A Intrarosa® PA Osphena® PA

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Bone: Bisphosphonates alendronate QL Actonel® QL etidronate QL alendronate solution QL Atelvia® QL Fosamax® QL ibandronate QL Binosto® QL Fosamax Plus D® QL Boniva® QL risedronate QL Didronel® Skelid® QL Bone: Calcitonin PA, QL calcitonin nasal spray PA, QL calcitonin injection PA, QL Miacalcin® injection PA, QL Fortical® PA, QL Miacalcin® nasal spray PA, QL Bone: SERMs raloxifene QL Evista® QL Bone: Parathyroid Hormone N/A Forteo® PA, QL teriparatide PA, QL Natpara® PA, QL Tymlos® PA, QL Contraceptives, Non-Oral Depo Provera Contraceptive® QL NuvaRing® QL Annovera ® QL Phexxi ® PA,QL ® QL ® QL Depo SubQ Provera Xulane EluRyng® QL Zafemy® QL medroxyprogesterone Etonogestrel-ethinyl estradiol acetate inj. QL vaginal ring QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Contraceptives, Oral QL Aftera® QL Kaitlib-FE® QL Ortho-Novum® QL Ashlyna® QL Seasonique® QL Altavera® QL Kelnor 1/35® QL Ortho Tri-Cyclen® QL Balziva® QL Slynd® QL Alyacen® QL Kimidess® QL Ortho Tri-Cyclen Lo® QL Generess FE® QL Tilia FE® QL Amethia Lo® QL Kurvelo® QL Ovcon-50® QL Jolessa® QL Tri-Legest FE® QL Amethyst® QL Larin 24® QL Philith® QL Kariva® QL Apri® QL Layolis FE® QL Pirmella® Aranelle® QL Leena® QL Plan B® One-Step QL Aurovela 24 FE® QL Lessina® QL Portia® Aviane® QL levonorgestrel QL Previfem® QL Balcoltra® QL levonorgestrel/ Quartette® QL ethinyl estradiol QL Bekyree® QL Levora® QL Rajani® QL Beyaz® QL Lillow® QL Reclipsen® QL Blisovi FE® QL Lo Loestrin FE® QL Rivelsa® QL Blisovi 24 FE® QL Lo Ovral® QL Safyral® QL Brevicon® QL Loestrin® QL Setlakin® QL Camila® QL Loestrin 24 FE® QL Sharobel® QL Cesia® QL Lomedia 24 FE® Solia® QL Cryselle® QL Low-Ogestrel® QL Sprintec® QL Cyclessa® QL Lo-Zumandimine® QL Sronyx® QL Cyred® QL Lutera® QL Take Action® QL Deblitane® QL Lyza® QL Tarina-FE® QL Desogen® QL Melodetta 24 Fe® QL Taytulla® QL drospirenone/ Tri-Estarylla® QL Mibelas FE 24® QL ethinyl estradiol QL EContra® EZ QL Microgestin® QL Tri-Femynor® QL Elinest® QL Microgestin FE® QL Tri-Lo-Estarylla® QL Ella® QL Minastrin 24 FE® QL Tri-Lo-Marzia® QL Enpresse® QL Mircette® QL Tri-Lo-Mili® QL Errin® QL Modicon® QL Tri-Linyah® QL estradiol QL Mononessa® QL Tri-Norinyl® QL Estrostep FE® QL My Way® QL Tri-Previfem® QL ethynodiol/ Myzilra® QL Tri-Sprintec® QL ethinyl estradiol QL Fayosim® QL Necon® QL TriNessa® QL Femcon FE® QL Natazia® QL TriNessa-Lo® QL Femhrt® QL Nikki® QL Trivora® QL Fyavolv® QL Norg-ee® QL Tri-VyLibra® QL Gemmily® QL Nor-QD® QL Tydemy® QL Gildagia® QL Nora-BE® QL Velivet® QL Gildess® QL Nordette® QL Vestura® QL Gildess 24 FE® QL Norlyda® QL Vienva® QL norethindrone/ VyLibra® QL Heather® QL ethinyl estradiol - FE QL Isibloom® QL Norinyl® QL Wymzya FE® QL Jinteli® QL Nortrel® QL Yasmin® QL Jolivette® QL Opcicon One Step® QL YAZ® QL Juleber® QL Nikki® QL Zeosa® QL * Note that agents not listed on PDL may be considered non-preferred

Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 26

Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Junel® QL Ortho-Cept® QL Zovia® QL Junel FE® QL Ortho-Cyclen® QL Zumandimine® QL Junel FE 24® QL Ortho Micronor® QL Diabetes: Alpha-Glucosidase Inhibitors acarbose PA Glyset® PA miglitol PA Precose® PA Diabetes: Amylin Analogs N/A Symlin® PA Diabetes: Biguanides QL metformin QL Fortamet® QL metformin ER osmotic QL metformin ER QL Glucophage® QL metformin solution PA,QL Glucophage XR® QL Riomet® / Riomet ER® PA, QL Glumetza® QL Diabetes: DPP-4 Inhibitors and Combinations PA, QL Januvia® PA, QL Kombiglyze® XR PA, QL alogliptin PA, QL Kazano® PA, QL Janumet® PA, QL Onglyza® PA, QL alogliptin/metformin PA, QL Nesina® PA, QL Janumet XR® PA, QL Tradjenta® PA, QL alogliptin/pioglitazone PA, QL Oseni® PA, QL Jentadueto® PA, QL Jentadueto® XR PA, QL Diabetes: GLP-1 Receptor Agonists PA, QL Bydureon® Pen & vials PA, QL Ozempic® PA, QL Adlyxin® PA, QL Soliqua® PA, QL Byetta® PA, QL Victoza® PA, QL Bydureon® BCise® PA, QL Trulicity® PA, QL Rybelsus® PA, QL Xultophy® PA, QL Diabetes: Rapid-Acting Insulins Humalog® KwikPen® PA ≥ 21 insulin lispro vial Admelog® Solostar® PA Fiasp® FlexTouch® PA Humalog® Jr KwikPen® PA ≥ 21 insulin lispro Kwikpen® PA ≥ 21 Admelog® vial Humalog® U-200 KwikPen® PA Humalog® vial insulin lispro Kwikpen® Jr. PA ≥ 21 Afrezza® PA, QL Lyumjev® Kwikpen® & vial PA Apidra® Solostar® PA Novolog® FlexPen® PA Apidra® vial Novolog® PenFill® Fiasp® PA Novolog® vial Diabetes: Short-Acting Insulins Humulin® R® U-500 vial Humulin® R® vial Humulin® R® U-500 KwikPen® PA Novolin® R® Diabetes: Intermediate-Acting Insulins Humulin® N® KwikPen® PA ≥ 21 Humulin® N® vial Novolin® N® Diabetes: Mixed Insulins Humalog® Mix 50/50 vial Humalog® Mix 75/25 KwikPen® PA ≥ 21 Novolin ® 70/30® Humalog® Mix 75/25 vial insulin lispro Mix 75/25 KwikPen® PA ≥ 21 Novolog® Mix 70/30® FlexPen® PA Humulin® 70/30® KwikPen® PA ≥ 21 insulin aspart mix 70/30 FlexPen PA≥21 Novolog® Mix 70/30® vial Humulin® 70/30® vial insulin aspart mix 70/30 vial Humalog® Mix 50/50 KwikPen® PA ≥ 21 Diabetes: Long-Acting Insulins Lantus® Solostar® Levemir® FlexTouch® Basaglar® KwikPen® PA Toujeo® Solostar® PA Lantus® vial Levemir® vial Semglee® PA Tresiba® FlexTouch® PA Toujeo® Max Solostar® PA Tresiba® vial PA Diabetes: Meglitinides and Combination QL nateglinide PA, QL Prandin® PA, QL Starlix® PA, QL repaglinide PA, QL repaglinide/metformin PA, QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Diabetes: Sulfonylureas and Combination glimepiride QL glipizide/metformin Amaryl® PA, QL Glynase PresTab® PA glipizide glyburide & glyburide micronized Glucotrol® PA tolbutamide PA glipizide ER/XR glyburide/metformin Glucotrol XL® PA Diabetes: SGLT2 Inhibitors and Combinations PA, QL Farxiga® PA, QL Invokana® PA, QL Invokamet® PA, QL Steglujan® PA, QL Glyxambi® PA, QL Jardiance® PA, QL Invokamet XR PA, QL Synjardy® PA, QL Qtern® PA, QL Synjardy XR® PA, QL Segluromet® PA, QL Trijardy XR® PA, QL Steglatro® PA, QL Xigduo® XR PA, QL Diabetes: Thiazolidinediones and Combinations PA, QL pioglitazone PA, QL Actos® PA, QL Duetact® PA, QL pioglitazone/metformin PA, QL ACTOplus Met® PA, QL pioglitazone-glimepiride PA, QL Diabetes: Glucagon Agents Baqsimi® QL Gvoke® Hypopen & Prefilled Syringe QL N/A glucagon vial and kit Zegalogue ® QL Disease Modifying Anti-Rheumatic Drugs hydroxychloroquine Ridaura® Arava® Plaquenil® leflunomide sulfasalazine QL Azulfidine® QL Rasuvo® PA methotrexate sulfasalazine EC QL Azulfidine EN® QL Rheumatrex® Cuprimine® Trexall® Depen® Xatmep® PA Otrexup® PA, QL Note: Injectable agents for the treatment of RA are located under Immunomodulators Anti-Rheumatic: Kinase Inhibitors Xeljanz® PA, QL Olumiant® PA, QL Xeljanz® XR 11 mg & 22 mg PA, QL Rinvoq® PA, QL Xeljanz® solution PA, QL Fabry Disease N/A Galafold® PA, QL GLP-2 Analogs N/A Gattex® PA Glucocorticoids, Oral dexamethasone prednisolone tab Alkindi Sprinkles® PA, QL Medrol® hydrocortisone prednisone Cortef® Millipred® methylprednisolone cortisone Orapred® ODT PA prednisolone solution dexamethasone intensol prednisolone ODT PA (5mg/5mL, 15 mg/5mL) dexamethasone DS pack prednisolone solution (all other strengths) Dxevo® Rayos® Emflaza® PA TaperDex® Hemady® PA, QL GnRH Antagonist Oriahnn® PA, QL Orilissa® PA, QL N/A Growth Hormone Agents PA Genotropin® PA Humatrope® PA Saizen® PA Norditropin® PA Serostim® PA Nutropin® PA Tev-Tropin® PA Nutropin AQ® PA Zomacton® PA * Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Omnitrope® PA Zorbtive® PA Hematopoietic Agents PA Retacrit® PA Aranesp® PA Procrit® PA Epogen® PA Hormones: Adrenocorticotropic N/A H.P. Acthar® PA, QL Hormones: Anti-Thyroid methimazole propylthiouracil Tapazole® Hormones: LHRH leuprolide PA Synarel® N/A Hormones: Estrogens estradiol tablet Premarin® Depo-Estradiol® injection estradiol cypionate injection Delestrogen® injection estradiol valerate injection Estrace® Menest® Hormones: Oral Estrogen/Progestins estradiol/norethindrone 0.5/2.5 Prefest® Activella® Jinteli® Femhrt® Low Dose Premphase® QL Angeliq® Mimvey® Prempro® QL estradiol/norethindrone 1/5 Lopreeza® Femhrt® 1/5 Hormones: Oral Progestins medroxyprogesterone norethindrone acetate PA Aygestin® PA megestrol acetate 625mg/5ml suspension QL megestrol acetate 40mg/ml progesterone Megace® QL Prometrium® suspension QL megestrol acetate tabs Megace ES® PA, QL Provera® Hormones: Thyroid Cytomel® Levoxyl® Armour Thyroid® Thyrolar® Levo-T® liothyronine NP Thyroid® Tirosint® Levothroid® Synthroid® levothyroxine caps (generic Tirosint) levothyroxine Unithroid® Hormones: Transdermal Estrogens estradiol transdermal biweekly Alora® QL Evamist® patch QL estradiol transdermal weekly patch QL Climara® QL Menostar® QL Divigel® QL Minivelle® QL Elestrin® QL Vivelle-Dot® QL Estrasorb® Hormones: Transdermal Estrogen/Progestins QL CombiPatch® QL Climara Pro® QL Hormones: Vaginal Estrogens Estring® Vagifem® Estrace® QL Imvexxy® Premarin Vaginal Cream® QL estradiol vaginal cream and tab Yuvafem® Femring® Hyperparathyroid Agents Sensipar® PA cinacalcet PA Rayaldee® PA, QL doxercalciferol capsules PA, QL Zemplar® capsules PA, QL paricalcitol capsules PA, QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Hyperinsulinemia Agents diazoxide suspension Proglycem® suspension Insulin-Like Growth Factor-1 PA Increlex® PA N/A Metabolic Agents Cystadane® PA, QL Strensiq® PA, QL Mineralocorticoids, Oral fludrocortisone N/A Progesterone Receptor Antagonists N/A Korlym® PA SERM/Estrogen Combinations N/A Duavee® PA Somatostatic Agents octreotide PA Bynfezia® PA Signifor® PA, QL Isturisa® PA, QL Somatuline Depot® Mycapssa® PA, QL Somavert® Sandostatin® PA Xermelo® PA, QL Urea Cycle Disorders Buphenyl® oral powder & tablet Carbaglu® PA Ravicti® PA sodium phenylbutyrate oral powder

& tablet PA

Preferred Drugs Non-Preferred Drugs VIII. GASTROINTESTINAL 5-ASA Derivatives, Oral QL Apriso® QL Sulfazine® QL Asacol HD® QL Giazo® QL Delzicol® QL sulfasalazine EC QL Azulfidine® QL Lialda® QL sulfasalazine QL Sulfazine EC® QL Azulfidine EN® QL mesalamine ER (generic Apriso) QL balsalazide QL mesalamine DR (generic Delzicol) QL Colazal® QL mesalamine HD (generic Asacol HD) QL Dipentum® QL Pentasa® QL 5-ASA Derivatives, Rectal mesalamine enema Canasa® Rowasa® mesalamine suppository mesalamine kit Rowasa® kit Agents for Irritable Bowel Syndrome (IBS) PA, QL Amitiza® QL Lotronex® PA, QL alosetron PA, QL Viberzi® PA, QL Linzess® QL lubiprostone QL Zelnorm® PA, QL Agents for Chronic Constipation Amitiza® QL Linzess® QL Motegrity® PA, QL Symproic® PA, QL Movantik® PA, QL Trulance® PA, QL lubiprostone QL Xifaxan® PA, QL Antidiarrheals diphenoxylate with atropine Lonox® Lomotil® Fulyzaq® PA Lofene® loperamide tabs, liquid, & loperamide solution & capsules opium tincture suspension Motofen® paregoric

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VIII. GASTROINTESTINAL Anti-Emetics: A-9-THC Derivatives PA N/A Cesamet® PA Marinol® PA dronabinol PA Syndros® PA Anti-Emetics: Anticholinergics meclizine promethazine PA Antivert® Transderm Scōp® PA, QL prochlorperazine scopolamine patches PA, QL Compro® Tigan® Phenergan ® PA trimethobenzamide promethazine 50mg suppositories PA Anti-Emetics: 5-HT3 Antagonists PA ondansetron tabs and ODT PA, QL Anzemet® PA, QL Zofran ODT® PA, QL granisetron PA, QL Zofran® solution PA, QL ondansetron oral soln PA ≥ 6, QL Zofran® PA, QL Sancuso® PA, QL Zuplenz® PA, QL Anti-Emetics: NK-1 Antagonists PA N/A aprepitant PA, QL Emend® PA, QL Akynzeo® PA, QL Varubi® PA, QL Anti-Emetics: Miscellaneous Diclegis® PA, QL Bonjesta® PA, QL doxylamine succinate/vitamin B6 PA, QL Antispasmodics/Anticholinergics dicyclomine propantheline Anaspaz® Librax® glycopyrrolate Symax Fastabs® Bentyl® Levsin® hyoscyamine Symax-SL® Cantil® methscopolamine NuLev® chlordiazepoxide/clidinium Pamine® Cuvposa® PA Pamine Forte® Combination Products for H. pylori PA Pylera® PA, QL lansoprazole/amoxicillin/ Prevpac® PA, QL clarithromycin PA, QL Omeclamox® PA, QL Talicia® PA, QL Gallstone Solubilizing Agents ursodiol QL Actigall® QL Reltone® QL Chenodal® Urso® QL Cholbam® PA Urso Forte® QL Ocaliva® PA, QL Gastrointestinal Agents, Miscellaneous N/A Relistor injectable ® PA Relistor tablets ® PA, QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VIII. GASTROINTESTINAL H2 Receptor Antagonists cimetidine tablets famotidine suspension Axid® Pepcid ® cimetidine solution nizatidine suspension PA nizatidine capsules famotidine tablets Laxatives Colyte® with flavor packs MoviPrep® Clenpiq® PEG 3350 powder packs (generic of Clearlax® powder pack, Miralax® powder pack, etc.) Constulose® OsmoPrep® Entereg® PEG-3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate, ascorbic acid (generic for Moviprep®) Enulose® PEG 3350 powder (generic of GaviLyte-H®/bisacodyl Plenvu® powder packs Clearlax®, Miralax®, etc.) GaviLyte-C®, G®, and N® PEG 3350 electrolyte powder for GoLYTELY® Prepopik® solution (generic of GoLYTELY®) Generlac® HalfLytely® Suclear® lactulose Kristalose® Suprep® NuLYTELY® Sutab® QL PEG 3350 with flavor packs (generic Trilyte® of NuLYTELY®, Trilyte®, GaviLyte) Visicol® Miscellaneous Agents for Inflammatory Bowel Disease Budesonide DR capsules PA Uceris® tablets PA, QL budesonide ER tablets PA, QL Ortikos ER ® PA, QL Entocort® EC PA Uceris® foam PA, QL Motility Agents metoclopramide QL Gimoti® PA, QL Metozolv® ODT PA, QL metoclopramide ODT PA, QL Reglan® QL Mucosal Protectants misoprostol sucralfate tablets Carafate® tablets Cytotec® Carafate® suspension PA sucralfate suspension PA Pancreatic Enzymes Creon® Zenpep® Pertzye® Viokace® Pancreaze® Ultresa® Proton Pump Inhibitors Nexium® Granules PA, QL Aciphex® QL Nexium® QL omeprazole caps and tabs QL Aciphex® sprinkles PA omeprazole/sodium bicarbonate caps and suspension QL omeprazole ODT QL Dexilant® QL Prevacid® QL pantoprazole QL esomeprazole QL Prevacid® SoluTab® PA, QL Protonix® suspension esomeprazole suspension packets QL Prilosec® QL First-Lansoprazole® PA pantoprazole suspension First-Omeprazole® PA Protonix® QL lansoprazole QL rabeprazole QL lansoprazole ODT PA, QL Zegerid® QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs VIII. GASTROINTESTINAL Saliva Stimulating Agents pilocarpine PA, QL cevimeline PA, QL Salagen® PA, QL Evoxac® PA, QL

Preferred Drugs Non-Preferred Drugs IX. IMMUNOLOGIC AGENTS Anti-inflammatory: PDE-4 Inhibitors Otezla® PA, QL N/A Anti-inflammatory: Immunoglobulins N/A Dupixent® PA, QL Nucala® PA, QL Fasenra® PA, QL Xolair® prefilled syringe PA, QL Immunomodulators PA, QL Actimmune® Enbrel® Mini Cartridge® PA, QL Actemra® PA, QL Kineret® PA, QL Enbrel® PA, QL Humira® PA, QL Actemra® ACTPen® PA, QL Orencia® PA, QL Taltz® PA, QL Benlysta® PA, QL Siliq® PA, QL Cimzia® PA, QL Simponi® PA, QL Cosentyx® PA, QL Skyrizi ® PA, QL Enspryng® PA, QL Stelara® PA, QL (applies to syringes only) Kevzara® Pen PA, QL Tremfya® autoinjector & syringe PA, QL Kevzara® syringe PA, QL Immunosuppressants azathioprine Rapamune® tablets and solution PA Astagraf XL® PA mycophenolate mofetil suspension CellCept® suspension Sandimmune® capsules Azasan® PA mycophenolic acid PA cyclosporine microemulsion tacrolimus CellCept® (excluding suspension) PA Myfortic® PA Gengraf® Zortress® PA cyclosporine capsules Neoral® PA mycophenolate mofetil Envarsus® XR PA, QL Prograf® caps and granules for suspension PA everolimus Sandimmune® oral solution Hecoria® PA sirolimus tablets and solution PA Imuran® PA Multiple Sclerosis Agents QL Avonex® QL Copaxone® 20 mg/mL QL Copaxone® 40 mg/mL PA, QL Kesimpta® PA, QL Avonex Administration Pack® QL Extavia® QL Plegridy® PA, QL Betaseron® QL glatiramer 20 mg/ml QL Rebif® QL glatiramer 40 mg/ml PA, QL Zinbryta® PA, QL Glatopa® QL Multiple Sclerosis Agents: Potassium Channel Blockers dalfampridine ER QL Ampyra® QL Multiple Sclerosis Agents: Oral Disease Modifying Agents Aubagio® PA Tecfidera® PA, QL Bafiertam® PA, QL Mayzent® PA, QL Gilenya® PA, QL dimethyl fumarate DR PA, QL Vumerity® PA, QL Mavenclad® PA, QL Topical Immunomodulators PA Elidel® PA, QL pimecrolimus PA tacrolimus ointment PA Protopic® PA, QL * Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs X. MISCELLANEOUS Gaucher’s Disease Agents Zavesca® Cerdelga® QL miglustat Hereditary Angioedema (HAE) Agents icatibant PA Kalbitor® PA Firazyr® PA Takhzyro® PA, QL Haegarda® PA, QL Hereditary Tyrosinemia Agents Orfadin® Orfadin® suspension PA nitisinone PA Lambert-Eaton Myasthenic Syndrome (LEMS) N/A Firdapse® PA,QL Ruzurgi® PA,QL Oral Copper Chelators N/A Syprine® PA,QL Clovique® PA,QL trientine® PA,QL Oral Iron Chelators PA N/A Exjade® PA Ferriprox® /Ferriprox® 2-day pack PA deferiprone PA Jadenu® tablet and granules PA deferasirox tablet and granules PA Sickle Cell Disease PA Droxia® Endari® PA, QL Siklos® PA hydroxyurea Oxbryta® PA, QL

Preferred Drugs Non-Preferred Drugs XI. ONCOLOGY AGENTS abiraterone Imbruvica® capsules Rubraca® QL Afinitor Disperz® PA Koselugo® PA, QL Afinitor® Inlyta® Soltamox® Alkeran® Nilandron® Alecensa® Iressa® Sprycel® Arimidex® Nubeqa® PA, QL Alunbrig® Jakafi® QL Stivarga® Aromasin® Onureg® PA, QL anastrozole Kisqali® PA, QL Sutent® Ayvakit® PA, QL Pemazyre® QL bicalutamide Kisqali/Femara® PA, QL Tabloid® Balversa ® QL Piqray® PA, QL Bosulif® Lenvima® Tafinlar® Calquence® PA, QL Purinethol® Braftovi® PA, QL letrozole Tagrisso® capecitabine Purixan® PA Cabometyx® leucovorin Talzenna® PA, QL Casodex® Retevmo® PA, QL Caprelsa® Leukeran® tamoxifen Copiktra® PA, QL Rozlytrek® QL Cometriq® leuprolide PA Tarceva® Daurismo® PA, QL Temodar® Cotellic® Lonsurf® QL Targretin® Erleada® PA, QL Tabrecta® PA, QL cyclophosphamide Lynparza® QL Tasigna® erlotinib Tazverik® QL Droxia® Lysodren® temozolomide everolimus Tibsovo® PA, QL Eligard® PA Matulane® Thalomid® Femara® toremifene Emcyt® melphalan tretinoin Gavreto® PA, QL Tuksya® PA, QL Erivedge® Mekinist® Tykerb® Gleevec® Vitrakvi® PA, QL etoposide Mektovi® PA, QL Venclexta® QL (See “Note”) Hydrea® Xospata® PA, QL exemestane mercaptopurine Verzenio® lapatinib Xpovio® PA, QL Fareston® Mesnex® Vizimpro® PA, QL Lorbrena® PA, QL Xtandi® tablets PA, QL Farydak® methotrexate Votrient® Imbruvica® tablets Yonsa® PA * Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XI. ONCOLOGY AGENTS flutamide Myleran® Xalkori® Inqovi® PA, QL Zytiga® Gilotrif® Nerlynx® Xeloda® Inrebic® PA, QL Hexalen® Nexavar® Xtandi® capsules Hycamtin® nilutamide Zelboraf® hydroxyurea Ninlaro® Zolinza® Ibrance® Odomzo® Zydelig® Iclusig® Pomalyst® Zykadia® Idhifa® Revlimid® Zejula® QL imatinib Rydapt® Effective March 1, 2014, the initial fill of oncology products will be limited to a 14 days’ supply. If the initial 14 days’ supply is tolerated, the member is eligible to receive the remainder of the first months’ supply without additional co-pay by the pharmacy submitting a Submission Clarification Code (NCPDP D.0 field # 42Ø-DK) of 2. After the initial month, members may continue to receive up to a 31 days’ supply of oncology products per fill. Note: For Ramp-Up Phase Dosing of Venclexta®, please dispense a 7-day supply of 10 mg tablets (for 20 mg dose), followed by a 7- day supply of 50 mg tablets.

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XII. OPHTHALMICS Ophthalmic Antibiotic/Steroid Combinations neomycin/BAC/poly B/HC QL Pred-G® QL Blephamide® QL TobraDex® suspension QL neomycin/poly B/dexamethasone tobramycin/dexamethasone Maxitrol® QL TobraDex® ST suspension QL suspension QL sulfacetamide/prednisolone QL neomycin/poly B/HC QL Zylet® PA, QL TobraDex® ointment QL Ophthalmic Antibiotics bacitracin/poly B polymyxin B/TMP QL AzaSite® QL moxifloxacin 0.5% (generic Vigamox) ciprofloxacin QL sulfacetamide sodium drops QL bacitracin QL Neosporin® Erythromycin QL tobramycin QL Besivance® QL Ocuflox® Gentak® QL Vigamox® Bleph-10® QL Polysporin® moxifloxacin 0.5% (generic Ciloxan® QL Polytrim® Moxeza®) QL neomycin/bac/poly B QL gatifloxacin 0.5% solution QL sulfacetamide ointment QL neomycin/poly B/gramicidin QL gentamicin QL Tobrex® solution QL ofloxacin levofloxacin 0.5% solution QL Tobrex® ointment QL Moxeza® QL Zymaxid® Ophthalmic Antifungals N/A Natacyn® PA, QL Ophthalmic Antivirals trifluridine QL Viroptic® Zirgan® PA > 5yr old, QL Ophthalmic Antihistamines QL azelastine QL bepotastine QL Pataday® QL Bepreve® QL Elestat® QL Pazeo® QL ketotifen QL epinastine QL Zaditor® QL olopatadine drops QL Lastacaft® QL Zerviate® PA, QL Patanol® QL Ophthalmic Alpha-2 Agonists apraclonidine QL Alphagan P® QL brimonidine tartrate 0.15% QL Iopidine® QL brimonidine tartrate 0.2% QL Ophthalmic Beta Blockers carteolol QL timolol maleate QL betaxolol QL timolol gel solution QL Betimol® Timoptic® QL Betoptic-S® QL Timoptic Ocudose® QL Istalol® QL Timoptic-XE® levobunolol QL Ophthalmic Carbonic Anhydrase Inhibitors QL Azopt® QL dorzolamide/timolol QL brinzolamide QL Cosopt PF® QL dorzolamide QL Cosopt® QL Trusopt® QL Ophthalmic Mast Cell Stabilizers cromolyn sodium QL Alocril® QL Alomide® QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XII. OPHTHALMICS Mydriatics and Mydriatic Combos atropine QL tropicamide QL Cyclogyl® QL Mydriacyl® QL cyclopentolate QL Cyclomydril® QL Paremyd® QL Isopto Atropine® Ophthalmic NSAIDs PA diclofenac PA, QL Acular® Ilevro® QL flurbiprofen PA, QL Acular LS® QL Nevanac® QL ketorolac PA, QL Acuvail® QL Ocufen® Bromday® Prolensa® QL bromfenac QL Voltaren® BromSite® QL Ophthalmic Prostaglandin Agonists QL latanoprost QL bimatoprost 0.03% QL Xalatan® QL Lumigan® 0.01% QL Travatan Z® QL Xelpros® PA, QL Vyzulta® PA, QL Zioptan® QL Ophthalmic Steroids Alrex® QL Pred Mild® QL dexamethasone QL Inveltys® Durezol® QL prednisolone acetate QL Eysuvis® PA, QL Lotemax® gel and ointment QL fluorometholone QL Flarex® QL loteprednol drops and gel QL Lotemax® drops QL FML® ointment QL Maxidex® QL FML Forte® QL prednisolone sodium phosphate QL FML Liquifilm® QL Pred Forte® QL Glaucoma Direct Acting Miotics pilocarpine Isopto® Carpine QL Pilopine HS® phospholine iodide QL Glaucoma Combinations Combigan® PA, QL Rocklatan® PA, QL Simbrinza® PA, QL Glaucoma, Miscellaneous Rhopressa® PA, QL N/A Ophthalmic Immunomodulators PA, QL Restasis® PA, QL Restasis® multidose PA, QL Cequa® PA, QL Xiidra® PA, QL Ophthalmic Vasoconstrictors phenylephrine 2.5%, 10% QL N/A Ophthalmic Lubricants and Artificial Tears N/A Lacrisert® PA Miscellaneous Ophthalmics N/A Cystaran® PA, QL Oxervate® PA,QL Cystadrops® PA, QL

Preferred Drugs Non-Preferred Drugs XIII. OTICS Otic Quinolones Ciprodex® QL ciprofloxacin-dexamethasone QL Cipro HC® QL ciprofloxacin otic QL ofloxacin otic QL Otic Steroid/Antibiotic Combinations HC/neomycin/polymyxin B QL Cortisporin® Otic Coly-Mycin® S QL * Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XIII. OTICS Cortisporin®-TC Otic Otovel® Miscellaneous Otics acetic acid acetic acid/HC QL fluocinolone acetonide oil acetic acid/aluminum DermOtic® oil QL

Preferred Drugs Non-Preferred Drugs XIV. RENAL AND GENITOURINARY Alpha Blockers for BPH alfuzosin QL tamsulosin QL Cardura® Rapaflo® doxazosin terazosin Cardura XL® QL silodosin prazosin Flomax® QL Uroxatral® QL Minipress® Androgen Hormone Inhibitors dutasteride QL finasteride QL Avodart® QL Proscar® QL Agents for BPH N/A Cialis® PA, QL Jalyn® PA, QL dutasteride/tamsulosin PA, QL Phosphorus Depleters calcium acetate capsules sevelamer carbonate tablets QL Auryxia® Phoslyra® Renvela® powder for suspension PA, calcium acetate tablets Renagel® QL Eliphos® Renvela® tablets QL Fosrenol® sevelamer carbonate powder packets PA, QL Fosrenol® powder pack PA sevelamer HCl tablets lanthanum carbonate Velphoro® PA PhosLo® Urinary Tract Antispasmodics oxybutynin solifenacin QL darifenacin QL Myrbetriq® QL oxybutynin ER QL Toviaz® QL Detrol® QL Oxytrol® QL Ditropan XL® QL tolterodine QL Detrol LA® QL tolterodine ER QL Enablex® QL trospium QL flavoxate QL trospium XR QL Gelnique® QL VESIcare® tablet & suspension QL Urinary Alkalizing Agents potassium citrate ER potassium citrate/citric acid Cytra-K® crystals packet Urocit-K® Oracit® Urinary Acidifying Agents K-Phos Original® K-Phos #2® Renacidin® PA Urinary Analgesics phenazopyridine (Rx & OTC) Phenazo® Pyridium® Urinary Interstitial Cystitis Agents Elmiron® RIMSO-50® N/A

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XV. RESPIRATORY Anaphylaxis Therapy Agents epinephrine QL Symjepi® QL EpiPen® QL epinephrine auto injector QL EpiPen, Jr.® QL Antiallergens, Oral N/A Grastek® PA, QL Ragwitek® PA, QL Oralair® PA, QL Anticholinergics and Anticholinergic Combinations, Inhaled QL Anoro Ellipta® PA, QL ipratropium solution QL Bevespi Aerosphere® PA, QL Spiriva Respimat® PA, QL albuterol/ipratropium QL Spiriva® QL Breztri Aerosphere® PA, QL Stiolto Respimat® PA, QL Atrovent® HFA QL Combivent Respimat® PA, QL Trelegy Ellipta® PA, QL Duaklir Pressair ® PA, QL Tudorza® PA, QL Incruse Ellipta® PA, QL Utibron Neohaler® PA, QL Lonhala Magnair® PA, QL Yupelri® PA, QL Anticholinergics, Nasal QL ipratropium 0.3%, 0.6% QL N/A Antihistamines, First Generation (Covered for recipients < 21 years old only unless otherwise noted) Bromspiro® cyproheptadine (Covered for all all formulations of brompheniramine tannate ages) carbinoxamine maleate diphenhydramine HCl (see OTC list) all formulations of chlorpheniramine tannate chlorpheniramine maleate hydroxyzine (Covered for all ages) all formulations of diphenhydramine tannate clemastine LoHist-12® Aldex AN® J-Tan PD Benadryl® Palgic® dexchlorpheniramine Vazol® Doxytex® Vistaril® Karbinal® ER Antihistamines, Non-Sedating (Covered for recipients < 21 years old only) cetirizine chewable PA, QL Allegra® QL Clarinex-D 24 Hr® QL cetirizine solution Allegra-D 12 Hr® QL desloratadine QL cetirizine syrup Allegra-D 24 Hr® QL desloratadine ODT PA, QL cetirizine tabs QL Allegra ODT® PA, QL fexofenadine QL cetirizine/PSE QL Claritin®QL fexofenadine/PSE QL levocetirizine tablets QL Claritin® chewable PA, QL levocetirizine solution QL loratadine tablet QL Claritin-D 12 Hr® QL Semprex®-D QL loratadine RDT PA, QL Claritin-D 24 Hr® QL Xyzal® QL loratadine/PSE QL Claritin RediTabs® PA, QL Zyrtec® QL loratadine chewables QL Clarinex® QL Zyrtec® chewable PA, QL loratadine syrup QL Clarinex RediTabs® PA, QL Zyrtec® ODT PA, QL Clarinex-D 12 Hr® QL Zyrtec-D® QL Antihistamines, Nasal QL azelastine QL Astepro® PA, QL Patanase® QL olopatadine QL Dymista® PA, QL Beta Agonist - Corticosteroid Combination Products PA, QL Advair HFA® PA, QL Dulera® PA, QL AirDuo RespiClick/Digihaler® PA, QL fluticasone/salmeterol PA, QL Advair Diskus® PA, QL Symbicort® PA, QL Breo Ellipta® PA, QL Wixela® PA, QL budesonide/formoterol PA, QL Beta Agonists: Long Acting MDI PA, QL Serevent Diskus® PA, QL Arcapta® QL Striverdi® Respimat QL * Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XV. RESPIRATORY Beta Agonists: Nebulizer albuterol inhalation solution QL arformoterol PA,QL Perforomist® PA, QL Brovana® PA, QL Xopenex® PA, QL levalbuterol PA, QL Beta Agonists: Short Acting MDI QL ProAir® HFA QL Ventolin® HFA QL albuterol HFA QL ProAir Digihaler® PA, QL levalbuterol HFA PA, QL Proventil® HFA QL ProAir Respiclick® PA, QL Xopenex® HFAPA, QL Beta Agonist: Oral albuterol syrup terbutaline tabs albuterol tabs metaproterenol albuterol ER Cystic Fibrosis Agents TOBI® Podhaler® and inhalation Bethkis® PA, QL Pulmozyme® PA, QL Cayston® PA, QL solution PA, QL tobramycin solution tobramycin solution tobramycin vial PA (excluding 1.2g Kitabis® PA, QL 300mg/4mL PA, QL (generic for 300mg/5mL PA, QL vials) Bethkis®) Cystic Fibrosis Agents: CFTR Potentiators N/A Kalydeco® PA, QL Symdeko® PA, QL Orkambi® PA, QL Trikafta® PA, QL Expectorants SSKI N/A Leukotriene Modifiers QL montelukast tabs Accolate® QL zafirlukast QL and chewables QL montelukast granules PA, QL zileuton CR QL Singulair® tabs and Zyflo® QL chewables PA, QL Singulair® granules PA, QL Mast Cell Stabilizers cromolyn QL N/A Mucolytics acetylcysteine Cetylev® Non-Narcotic Antitussives PA benzonatate PA ≤ 10, QL Tessalon® PA Zonatuss® PA Tessalon Perles® PA, QL

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XV. RESPIRATORY Steroids, Orally Inhaled QL Asmanex Twisthaler® QL Alvesco® QL budesonide respules QL Flovent HFA® QL ArmonAir Digihaler® QL Pulmicort Flexhaler® QL Flovent Diskus® QL Arnuity Ellipta® QL Pulmicort Respules® PA, QL Asmanex HFA® QL QVAR® Redihaler® QL Steroids, Intranasal QL budesonide nasal QL Beconase AQ® QL Omnaris® QL fluticasone propionate QL budesonide nasal (Rx only) QL Qnasl® QL Nasacort® QL Flonase® QL Rhinocort Aqua® QL flunisolide QL triamcinolone acetonide QL mometasone furoate QL Veramyst® QL Nasacort® AQ QL Xhance® PA, QL Nasonex® QL Zetonna® QL Xanthine Derivatives aminophylline theophylline solution N/A Elixophyllin® theophylline ER tabs and capsules Theo-24® Phosphodiesterase 4 Inhibitor N/A Daliresp® PA Vasoconstrictors, Intranasal Adrenalin® Tyzine® N/A

Preferred Drugs Non-Preferred Drugs XVI. SMOKING CESSATION AGENTS Smoking Cessation Agents QL (OTC) bupropion SR QL nicotine polacrilex lozenge QL Nicotrol® inhaler QL Chantix® QL nicotine transdermal patch QL Nicotrol® nasal spray QL nicotine polacrilex gum QL Zyban® QL

Preferred Drugs Non-Preferred Drugs XVIII. VITAMINS AND ELECTROLYTES Cystine Depleting Agent Cystagon® Procysbi® PA Procysbi DR® PA Fluoride Products Denta 5000® Plus cream QL SF 1.1% gel N/A Dentagel® 1.1% gel QL SF 5000 Plus cream Folic Acid Preparations folic acid l-methylfolate PA Denovo® PA Kidney Stone Agents Lithostat® Thiola® Thiola EC® PA tiopronin tablet Multivitamins with Iron (Covered for recipients < 21 years old only) Generic prescription products All brand prescription products

* Note that agents not listed on PDL may be considered non-preferred

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Preferred Drugs Non-Preferred Drugs XVIII. VITAMINS AND ELECTROLYTES Select OTC products (see OTC list for NDCs) Potassium Depletors Kalexate sodium polystyrene sulfonate Kayexalate® SPS® Kionex® Lokelma® PA, QL Veltassa® QL Potassium Supplements Effer-K® K-Effervescent® Epiklor® Micro K® Kaon-CL® K-Vescent® K-tabs® potassium chloride caps Klor-Con® potassium bicarbonate Klor-Con® powder Klor-Con/EF® potassium chloride tabs and solution Klor-Con M® potassium chloride, microencapsulated Prenatal Vitamins generic prescription products (various manufacturers) All brand prescription products (various manufacturers) Renal Vitamins generic prescription products (various manufacturers) All brand prescription products (various manufacturers) Triglycerides Dojolvi ® PA, QL Vitamin B Products cyanocobalamin injection PA hydroxocobalamin injection PA N/A cyanocobalamin, OTC PA Nascobal® Nasal Spray PA Vitamin D/Vitamin D Analogs calcitriol Vitamin D Drisdol® Rocaltrol® Vitamin K Products Mephyton® QL phytonadione QL Zinc Supplements zinc sulfate Zincate® Galzin® PA

* Note that agents not listed on PDL may be considered non-preferred

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