Drug Exclusions April 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 medications 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 4/1/20 1

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

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

BlueChoice Drug Exclusions List – Effective 4/1/20 3

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

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 sulfur brimonidine tartrate latanaprost podofilox tetracaine hcl carteolol hcl levobunolol hcl polymycin b sulfate/ timolol maleate castellani paint trimethoprim ophthalmic

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

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 BHRT base D First-Progester-One I 2-Deoxy-D-Glucose Biotin Dehydroepiandroster- Vgs 10/ 20/50 Ibuprofen 5-Fluorouracil Bitter drug powder one First-Testosterone/Mc Imiquimod 5-Methyltetra- Boric Acid Dermabase First-Vancomycin Isometheptene Hydrofolate Bromfenac Sodium Dexamethasone/ 25/50 Mucate 5-Methyltetra- Budesonide Acetate Anh/Sodium Flavor blend Itraconazole Hydrofolic A Bupropion HCL Phos Flavor Plus Ivermectin Flavor Sweet-SF 7-Keto DHEA C Diazepam J Dichloralphen-Azone Fluconazole A Cannabidiol Diclofenac Sodium Fluocinonide N/A Capsublend-P Acacia Diltiazem HCL Fluorouracil Capsule Clear Veggie K Acetone Dimercapto-1- Flurbiprofen Lo (All) Ketamine HCL Acetyl Hexapeptide-8 Propanesulfo F-Melt Capsule Coni-Snap (All) Ketoconazole Acidophilus Dimercaptosucc-Inic Freedom Derma-N Carboxymethylcellu- Ketoprofen/Micronized/ Lactobacillus Acid Freedom Poloxitol lose So Ultra Micronized Albendazole Dimethyl Sulfoxide Carnitine (L) G Ketotifen Hydrogen Almond oil, sweet Doxepin HCL Celecoxib Gabapentin Fumara Alprostadil Doxycycline Hyclate Cellulose Gentamicin Sulfate Kinetin Amitriptyline HCL Drcaps size 1 clear Amphotericin B Microcrystallin Glutamine L Cellulose/Cmc Na E Glutathione-L Apple flavor Lactic Acid Microcry Glycerin Arbem H-Cosmetic Edetate Disodium Lactose/Anhydrous Cetaphil moisturizing Glycolic Acid Ascorbic Acid Dihydrat Lactose cream Glycopyrrolate Aspirin EGCG Monohydrate/spray Cetyl Myristoleate Grape flavor Auxipro Plasticized Emollient cream/base Lanolin Anhydrous Cherry syrup Guaifenesin Avicel Ph 105 Empty capsule, all sizes Lansoprazole Chloramphenicol Gum base gelatin Microcrysta & colors L-Arginine Cholesterol Azithromycin Emu oil H Leucovorin Calcium Chorionic Erythromycin Leuprolide Acetate B Gonadotropin Hormone cream base Ethylsuccina Levofloxacin Baclofen Chrysaderm Day Botani Estradiol/Micronized/ Hemihydrate Bacteriostatic Water Cimetidine Hrt base (All) Valerate L-Glutamine Banana creme flavor Ciprofloxacin HCL Hrt Natural/Supreme Estriol/Micronized Lidocaine/HCL Base C Polyethyl-Ene Citric Acid Anhydrous cream base Ethoxy Diglycol Liothyronine Sodium Glyco Clindamycin Hyaluronic Acid Ethyl Alcohol Lipmax Base cream with HCL/Monohydra Sodium Sa Ethyl Oleate Lipopen/Absorption Liposome Clindamycin Hydrocodone Enhanc Base gelatin Gummy Phosphate F Bitartrate Lipopen Ultra/base Troche Clobetasol Propionate/ Fagron Capfill Pro/ Hydrocortisone/ L-Methylfolate Calcium Base X Micronized Dispersapro/ Acetate/ Micronized Lollibase Base-Pcca Mbk (Fatty Clotrimazole Supreme cream Hydrogel Lollipop base Acid) Coal Tar Fattibase Hydromorphone HCL Lorazepam Beclomethasone Cocaine HCL Fattyblend Hydroquinone Loxoral base Dipropiona Cocoa butter Ferulic Acid Hydroxyethyl Cellulose Lozibase S Benzocaine Coenzyme Q10 First-Baclofen 5 45 L-Thyroxine Sodium Benzoin compound Copasil First-Dukes Hydroxyprogester-One Lugols tincture Corn oil mouthwash Capro Benzyl alcohol Curcumin First-Lansoprazole Hydroxypropyl M Cellulose 1/ Betahistine HCL/ Cyanocobalamin First-Metronida-Zole Magnesium Glycinate Methylcellu Dihydrochlori Cyclobenzaprine HCL 50 Mannitol Hydroxyurea Betamethasone First-Mouthwash Blm Marshmallow flavor Hypromellose Sodium Phos First-Omeprazole Mediderm Bethanechol Chloride Methocel K1

BlueChoice Drug Exclusions List – Effective 4/1/20 5

Medi-Rdt base Oral suspension PCCA vanishing cream/ S Testosterone Medium Chain Ora-Plus light/ lotion Salicylic Acid Propionate Triglyceride Ora-Sweet/SF PCCA Vanpen base Salt durable cream Tetracaine/HCL Melatonin Oxycodone HCL PCCA Xylifos base Salt Stable Lo/Ls Tetracycline HCL Mercaptopurine Oxytocin PCCA -Plus Advanced Thymol Monohydrat P Penderm Sermorelin Acetate Thyroid Porcine Metformin HCL Pentravan/Plus Sesame oil Tobramycin/Sulfate Palmitoyl Methocel E4m Peppermint oil Sildenafil Citrate Tofacitinib Citrate Pentapeptide-3 Premium Phentermine Silica gel Topiramate Papaverine HCL Methscopolamine Hydrochloride Simethicone Tramadol HCL Paraffin Bromide Phentolamine Simple syrup Transdermal pain base PCCA Anhydrous Methylcellulose Mesylate Sirolimus Tretinoin Lipoderm B Methylcobalamin Phytobase Sodium Bicarbonate Triamcinolone PCCA cosmetic HRT Methyltestosterone Plo Gel – Mediflo pre- Sodium Chloride/ Acetonide base Metoprolol Tartrate mix Bacterios Troche base PCCA custom Lipo-Max Metronidazole/ Pluronic F127 Sodium Hyaluronate Tutti Frutti flavor PCCA DMAE complex Benzoate Polox Sodium Metabisulfite PCCA emollient cream U Miconazole/Nitrate Polyethylene Solu-K gel base Ubiquinol Midazolam Glycol/blend/ Sorbitol PCCA Emulsifix-205 Ursodiol Mineral oil light 300/400/1450/3350 Spg Supposi-Base base Mometasone Furoate Polypeg suppository Spironolactone V PCCA fixed oil base Morphine Sulfate base Sterile water for PCCA gelatin base Vancomycin HCL Mucolox Povidone-Iodine injection PCCA Lecithin Verapamil HCL Mupirocin Praziquantel Stevia extract Isopropyl P Versabase/foam Pregnenolone/ Steviol Glycosides N PCCA Lipoderm Versapro micronized Succimer DMSA Nabumetone base/HMW Versatile cream base Prilocaine HCL Sucralfate Naltrexone PCCA Loxasperse base Progesterone/Microniz Sulfacetamide Sodium W HCL/Anhydrous PCCA Natacream ed/ Ultra Micronized Sulfadiazine Watermelon flavor Natapres PCCA plasticized base Progesterone wettable Sulfamethoxazole Wax paraffin beads Niacinamide PCCA Pluronic F127 Promethazine HCL Sulfapyridine White Petrolatum Nifedipine base Propylene Glycol Supposibase F Wiley Basic Elements Nourivan Antiox cream PCCA Polyglycol Troche Prostaglandin E1 Suspendit BHRT base PCCA Pracasil Tm-Plus Purified water Synapsin Witepsol H15/Base F Nystatin/Foreign base Pyrantel Pamoate Syrspend SF/Alka X O PCCA rapid-dissolve Pyridoxal-5-Phosphate tablets T Xylitol Ointment base Mon PCCA Sorbitol lollipop Tamoxifen Citrate emulsifying Q Y base Tea tree oil Olive oil Yellow Petrolatum PCCA Spira-wash base Quinacrine HCL Terbinafine HCL Omeprazole PCCA Sweet-SF Quinine Sulfate Testosterone/ Z Ondansetron HCL PCCA syrup vehicle Dihydrate Cypionate Dihydrate N/A PCCA T3 Sodium Testosterone Ora-Blend/SF R Dilution micronized/S/Y Oral mix flavored Ranitidine HCL PCCA T4 Sodium Testosterone non- suspension Resveratrol 98+% Dilution micronized

BlueChoice Drug Exclusions List – Effective 4/1/20 6

Topical Product Exclusions Topical Pain Formulations Excluded Product Categories and Examples Formulary Alternatives Camphomex (CAMPHOR-HISTAMINE-MENTHOL-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 4/1/20 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 4/1/20 8 Rvs 3/13/2017 1 19199-3-2017 Rvs 3/13/2017 2 19199-3-2017