Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) ACE Inhibitors benazepril enalapril captopril perindopril fosinopril lisinopril moexipril quinapril ramipril trandolapril Alzheimer’s Agents donepezil Namenda XR galantamine ER capsules Namenda Solution memanine IR tablets Namzeric rivastigmine capsules Rivastigmine capsules rivastigmine patch Anaphylaxis Kits Epinephrine autoinjector (Twinject) EpiPen Angiotensin Blockers candesartan olmesartan losartan olmesartan HCT losartan HCT Edarbi irbesartan eprosartan Irbesartan HCT telmisartan telmisartan HCT valsartan valsartan HCT Anticoagulants – Injectable Post enoxaparin fondaparinux Hip/Knee DVT Prophylaxis heparin Fragmin Anticonvulsants carbamazepine levetiracetam XR divalproex Oxtellar XR gabapentin Trokendi XR lamotrigine oxcarbazepine phenobarbital phenytoin primidone topiramate IR tablets & capsules topiramate ER sprinkle capsules zonisamide Antidepressants – Other bupropion Aplenzin bupropion SR tablets bupropion XL-24H tablets duloxetine Fetzima mirtazapine tablet & ODT Forfivo XL trazodone Oleptro venlafaxine immediate release tablets Pristiq venlafaxine ER Viibryd

Page 1 of 8 Symbria Rx Services Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Antidepressants – Selective Serotonin citalopram escitalopram Reuptake Inhibitors (SSRIs) fluoxetine fluvoxamine ER paroxetine tablet Pexeva sertraline Trintellix Antidiabetic Agents – DPP-4 Inhibitors alogliptin Januvia Tradjenta Janumet Jentadueto Janumet XR Kombiglyze XR Onglyza Oseni Antidiabetic Agents – GLP-1 Receptor Tanzeum Bydureon Agonists Bydureon Byetta Trulicity Victoza Trulicity Antidiabetic Agents - Other glimeperide Farxiga glipizide Metformin ER modified release glipizide/metformin Invokana metformin Jardiance metformin ER Riomet pioglitazone pioglitazone/metformin Antiemetic/Antivertigo Agents meclizine Anzemet metoclopramide dronabinol ondansetron ODT ondansetron solution prochlorperazine Sancuso Zuplenz Antifungals – Topical ciclopirox cream ciclopirox susp, shampoo, gel clotrimazole clotrimazole/betamethasone lotion clotrimazole/betamethasone cream econazole ketoconazole Ertaczo miconazole Exelderm nystatin Luzu 1% terbinafine Mentax Naftin nystatin/triamcinolone Oxistat Antiparkinson Agents carbidopa-levodopa Duopa suspension pramipexole Neupro ropinirole Rytary

*More expensive than other preferred choice(s) but less than most non-formulary items. Page 2 of 8 Symbria Rx Services Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Antipsychotics – 2nd generation quetiapine risperidone aripiprazole ziprasidone Fanapt Latuda Olanzapine Paliperidone ER Rexulti risperidone oral solution Saphris Vraylar Benign Prostatic Hyperplasia (BPH) alfuzosin Cardura XL Agents – Alpha Adrenergic Blockers doxazosin Rapaflo tamsulosin terazosin Beta-Adrenergic Blocking Agents atenolol Bystolic labetalol carvedilol ER capsules metoprolol tartrate metoprolol succinate C. Difficile Treatment vancomycin – oral compound solution Dificid metronidazole vancomycin capsules Xifaxan Chronic Gout Therapy Allopurinol Uloric COX-2 Inhibitors meloxicam celecoxib Vivlodex Glaucoma Agents – Alpha-2 Agonists brimonidine 0.2% brimonidine 0.1% brimonidine 0.15% Simbrinza 1%/0.2% (brinzolamide 1% /brimonidine 0.2%) Glaucoma Agents – Carbonic dorzolamide Azopt Anydrase Inhibitors Glaucoma Agents – Beta-Adrenergic betaxolol 0.5% Betoptic-S 0.25% Antagonists carteolol levobunolol metipranolol timolol Glaucoma Agents – Prostaglandins latanoprost 0.005% bimatoprost 0.03%, 0.01% Travatan Z 0.004% Zioptan 0.0015% Histamine 1 Antagonists (Non- loratadine cetirizine syrup Sedating) cetirizine tablets desloratadine fexofenadine levocetirizine Loratadine ODT Histamine 2 Antagonists famotidine tablets (may be crushed) famotidine suspension ranitidine (may be crushed) ranitidine syrup

*More expensive than other preferred choice(s) but less than most non-formulary items. Page 3 of 8 Symbria Rx Services Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Inhaled Anticholinergic Agents ipratropium 0.02% solution Atrovent HFA ipratropium/albuterol sulfate solution Combivent Respimat Spiriva Handihaler Incruse Ellipta Spiriva Respimat Tudorza Inhaled Beta-Adrenergic (Short albuterol inhalation solution Combivent Respimat Acting) ipratropium/albuterol sulfate solution levalbuterol Ventolin HFA Maxair ProAir HFA Proventil HFA Xopenex HFA Inhaled Long-Acting Beta-Adrenergic Striverdi Respimat Arcapta Agents (LABA) Brovana Perforomist Serevent Diskus Inhaled Long-Acting Beta-Adrenergic Anoro Ellipta Bevespi (LABA) and Long-Acting Muscarinic Stiolto Antagonist (LAMA) Agents Utibron neohaler Insulins Admelog Apidra Basaglar Fiasp Humalog vial 3ML Humalog 200 u/ml Humalog Mix 75/25 vial Humalog Mix 75/25 pens Humulin 70/30 vial 3ML Lantus Levemir Humulin NPH vial 3ML Novolin 70/30 Humulin R vial 3 ML Novolin N Novolin R Novolog Mix 70/30 Novolog Toujeo Tresiba Laxatives Bisacodyl Amitiza Colace Linzess Miralax Movantik Senna Symproic Senna-S Leukocyte Growth Factor (G-CSF) Granix Neupogen Lipotropics – Other cholestyramine Antara colestipol Epanova fenofibrate (48mg, 50mg, 54mg, 67mg, fenofibric acid 105mg 134mg, 145mg, 160mg, 200mg) fenofibrate (40mg, 120mg, 150mg) fenofibrate micronized (43mg, 67mg, fenofibrate micronized 130mg, 135mg 134mg, 200mg) omega-3-acid ethyl ester fenofibric acid 35mg, 45mg Praluent injection gemfibrozil Repatha injection omega 3 fatty acids (fish oil OTC) Vascepa Welchol

*More expensive than other preferred choice(s) but less than most non-formulary items. Page 4 of 8 Symbria Rx Services Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Lipotropics – Statins & Combinations atorvastatin Altoprev lovastatin Ezetimibe/Simvastatin pravastatin Livalo simvastatin rosuvastatin Low Molecular Weight Heparins See Anticoagulants See Anticoagulants (LMWHs) and Related Multiple Sclerosis Agents Extavia Betaseron Muscle Relaxants cyclobenzaprine 10 mg Amrix Narcotic Pain Agents fentanyl transdermal patch (not for fentanyl lozenge intermittent pain) Fentora hydrocodone/acetaminophen Hysingla morphine ER 24H capsule hydromorphone Nucynta morphine sulfate ER 12H tablet Nucynta ER morphine sulfate IR oxycodone ER oxycodone/acetaminophen Zohydro ER oxycodone IR Neuropathic Pain Agents - Oral duloxetine Lyrica gabapentin Neuropathic Pain Agents – Topical lidocaine 4% patch lidocaine 5% patch menthol cream/gel/pach trolamine salicylate cream/lotion Ophthalmics – Antibiotics bacitracin ophthalmic ointment Azasite 1% solution ciprofloxacin 0.3% solution Besivance 0.6% solution erythromycin 0.5% ointment Ciloxan 0.3% ointment gentamicin 0.3% solution & ointment gatifloxacin 0.5% solution levofloxacin 0.5% solution Moxeza 0.5% solution moxifloxacin 0.5% solution Tobrex 0.3% ointment ofloxacin 0.3% solution sulfacetamide sodium 10% solution tobramycin 0.3% solution tobramycin-dexamethasone 0.3%-0.1% Ophthalmics – Anti-inflammatory diclofenac 0.1% Acuvail 0.45% ketorolac 0.4% Bromfenac 0.09% flurbiprofen 0.03% Bromsite 0.09% Ilevro 0.3% ketorolac 0.5% Nevanac 0.1% Prolensa 0.07% Vexol 1%

*More expensive than other preferred choice(s) but less than most non-formulary items. Page 5 of 8 Symbria Rx Services Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Osteoporosis Treatments alendronate oral solution Binosto calcitonin nasal alendronate tablet etidronate Forteo Fosamax Plus D ibandronate Miacalcin Injection Prolia raloxifene risedronate IR & ER Xgeva Other Endocrine/Metabolism megestrol suspension 200 mg/5 ml Megace ES 625 mg/5 ml Phosphate Binders calcium acetate tablets calcium acetate capsules Renvela (2nd line*) Fosrenol Renagel Renvela powder packets Platelet Aggregation Inhibitors clopidogrel aspirin-dipyridamole ER cilostazol Brilinta Effient Zontivity Primary Pulmonary Hypertension sildenafil 20mg Adcirca Agents Cialis Tracleer Uptravi Viagra Proton Pump Inhibitors and Other omeprazole Carafate suspension Gastrointestinals omeprazole OTC Dexilant pantoprazole esomeprazole sucralfate tablets (can be crushed) lansoprazole Zegerid OTC Prevacid solutab rabeprazole Zegerid (omeprazole/sodium bicarbonate) Sedative – Hypnotics temazepam 15mg, 30mg Belsomra zaleplon doxepin 3mg & 6mg zolpidem Edluar (zolpidem sublingual) eszopiclone Intermezzo Rozerem temazepam 7.5mg temazepam 22.5mg zolpidem ER

*More expensive than other preferred choice(s) but less than most non-formulary items. Page 6 of 8 Symbria Rx Services Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Steroids - Inhaled Arnuity Ellipta Advair Breo Ellipta Advair HFA budesonide nebules Alvesco HFA Asmanex Dulera Flovent Pulmicort 1mg/2ml nebs Pulmicort Flexhaler Qvar Symbicort Steroids - Nasal budesonide Beconase AQ Flonase OTC Dymista flunisolide mometasone fluticasone Omnaris Nasacort OTC triamcinolone AQ Veramyst Zetonna Steroids – Topical (High potency) betamethasone valerate 0.1% oint amcinonide 0.1 % cream, lotion, betamethasone dip 0.05% cream ointment triamcinolone 0.5% cream betamethasone diprop augmented 0.05% lotion, creambetamethasone dipropionate 0.05% ointment desoximetasone 0.05% cream, gel, ointment diflorasone 0.05% cream fluocinonide 0.05 % cream, gel, ointment Halog 0.1% cream, ointment Topical Antibiotics metronidazole 0.75% lotion metronidazole 0.75% cream & gel mupirocin 2% ointment metronidazole 1% gel mupirocin 2% cream Noritate 1% cream Ulcerative Colitis Agents balsalazide Apriso budesonide 3mg capsules Asacol HDCanasa suppository mesalamine 4gm enema Delzicol Giazo Humira Lialda Pentasa Uceris

*More expensive than other preferred choice(s) but less than most non-formulary items. Page 7 of 8 Symbria Rx Services Preferred Drug Formulary Effective August 2018

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Urinary Anti-Incontinence Agents oxybutynin XL Enablex Oxytrol for Women patch (OTC) Gelnique tolterodine LA Myrbetriq trospium Oxytrol (Rx) patch tolterodine Toviaz trospium ER Vesicare Vitamins & Minerals potassium Cl 20mEq tablets (dissolve potassium 20mEq powder packets in water)

*More expensive than other preferred choice(s) but less than most non-formulary items. Page 8 of 8