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2019 Controlled Access Formulary List

The 2019 Controlled Access Formulary drug list is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of products that are on the formulary. PLEASE NOTE: Brand-name drugs may move to non-preferred status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY [INJ] – Injectable Drug [SP] – Specialty Drug CR – Controlled Release ER, XR, XL – Extended Release FA – Folic Acid FE – Ferrous (Iron) HCL – Hydrochloride HCTZ – Hydrochlorothiazide LA – Long Acting ODT – Oral Dissolving Tablet

Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA Generic drugs are listed in lower-case letters. Example: ibuprofen

For the member: FDA-approved generic meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.

Addiction ...... 6 Ophthalmic Anti- Tetracyclines ...... 7 Gastrointestinal Adsorbents .. 7 Inflammatories ...... 6 Deterrents/ Anti- Anticonvulsants ...... 7 Antidotes And Specific craving ...... 6 Alzheimer's Disease and All Agents ...... 7 Antagonists ...... 7 Opioid Dependence Treatments Dementia Drugs ...... 6 GABA Modulators ...... 7 All Agents ...... 7 ...... 6 Cholinesterase Inhibitors ...... 6 Valproic Acid ...... 7 Benzodiazepine Antagonists .. 7 Smoking Cessation Agents ..... 6 N-methyl-D-aspartate (NMDA) Antidepressants ...... 7 Antiemetics ...... 7 ADHD Drugs ...... 6 Receptor Antagonist ...... 6 All Agents ...... 7 5-HT3 Receptor Antagonists .. 7 Analeptics ...... 6 Amebicides ...... 6 Antidepressants, Other ...... 7 Antifungals ...... 7 Attention Deficit Hyperactivity All Agents ...... 6 All Agents ...... 7 Disorder Agents, Antibiotics ...... 6 Monoamine Oxidase Inhibitors Amphetamines ...... 6 ...... 7 Imidazole-Related Antifungals 7 Aminoglycosides ...... 6 Attention Deficit Hyperactivity SSRIs/ SNRIs (Selective Antihistamines ...... 7 Disorder Agents, Non- Antibacterials, Other ...... 6 Serotonin Reuptake Inhibitors/ Antihistamines - Alkylamines . 7 amphetamines ...... 6 Beta-Lactam, Cephalosporins . 6 Serotonin and Norepinephrine Reuptake Inhibitor) ...... 7 Antihistamines - Ethanolamines Allergy Drugs ...... 6 Beta-Lactam, Other ...... 6 Tricyclics ...... 7 ...... 7 Allergenic Extracts ...... 6 Beta-Lactam, Penicillins ...... 7 Antidiarrheal/ Probiotic Antihistamines - Antihistamines ...... 6 Macrolides ...... 7 Agents ...... 7 Ethylenediamines ...... 7 Ophthalmic Anti-Allergy Agents Quinolones ...... 7 Antidiarrheal/ Probiotic Agents Antihyperlipidemics ...... 7 ...... 6 Sulfonamides ...... 7 ...... 7 Bile Acid Sequestrants...... 7

Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.

Antihypertensives ...... 7 Antiretrovirals ...... 8 Calcium Channel Blocking Monoclonal Antibodies ...... 11 Agents ...... 9 ACE Inhibitors ...... 7 CMV Agents ...... 8 Retinoids ...... 11 Blood Thinners ...... 9 Antiadrenergic Herpes Agents ...... 8 Chest Pain Drugs ...... 11 Antihypertensives ...... 7 Anticoagulants ...... 9 Influenza Agents ...... 8 Nitrates ...... 11 Vasodilators ...... 7 Heparins And Heparinoid-Like Anxiety Drugs ...... 8 Vasodilators, Direct-acting Agents ...... 9 Arterial ...... 11 Anti-infective Agents ...... 7 Antianxiety Agents ...... 8 In Vitro/ Lock Anticoagulants. 9 Vasodilators, Direct-acting All Agents ...... 7 Anxiolytics, Other ...... 8 Thrombin Inhibitors ...... 9 Arterial/ Venous ...... 11 Anti-infective Misc. - Benzodiazepines ...... 8 Combinations ...... 7 Bowel Treatment Drugs ...... 9 Control Drugs .... 11 Asthma/ Lung Drugs ...... 8 Carbapenems ...... 7 Antispasmodics, Dyslipidemics, Fibric Acid Antiasthmatic - Monoclonal Gastrointestinal ...... 9 Derivatives ...... 11 Glycopeptides ...... 7 Antibodies ...... 8 Gastrointestinal Agents, Other Dyslipidemics, HMG CoA Lincosamides ...... 7 Anti-Inflammatories, Inhaled ...... 10 Reductase Inhibitors ...... 11 Monobactams ...... 8 Corticosteroids ...... 8 Irritable Bowel Syndrome Dyslipidemics, Other ...... 11 Streptogramins ...... 8 Antileukotrienes ...... 8 Agents ...... 10 Contraceptives ...... 11 Antimalarials ...... 8 Bronchodilators, Laxatives ...... 10 Anticholinergic...... 8 Implants ...... 11 All Agents ...... 8 Cardiac Drugs ...... 10 Bronchodilators, Injectable ...... 12 Antimyasthenic/ Cholinergic Cardiovascular Agents, Other10 Sympathomimetic ...... 8 IUD ...... 12 Agents ...... 8 Diuretics, Carbonic Anhydrase Pulmonary Antihypertensives 8 Oral ...... 12 Antimyasthenic/ Cholinergic Inhibitors ...... 10 Agents ...... 8 Respiratory Tract Agents, Other Transdermal ...... 12 ...... 8 Diuretics, Loop ...... 10 Antimycobacterial Agents ..... 8 Vaginal ...... 12 Sympathomimetics ...... 9 Diuretics, Potassium-sparing.10 All Agents ...... 8 Corticosteroids ...... 12 Xanthines ...... 9 Diuretics, ...... 10 Antineoplastics And Glucocorticosteroids ...... 12 Beta Blockers ...... 9 Cardiotonics ...... 10 Adjunctive Therapies ...... 8 Cough/ Cold/ Allergy ...... 12 Beta Blockers Cardio-Selective 9 Cardiac Glycosides ...... 10 Antineoplastic - Hormonal and Antitussives ...... 12 Related Agents ...... 8 Beta Blockers Non-Selective ... 9 Cardiovascular Agents ...... 10 Expectorants ...... 12 Antineoplastic - Bladder Control Drugs ...... 9 Cardioplegic Solutions ...... 10 Immunomodulators ...... 8 Cystic Fibrosis Agents ...... 12 Antispasmodics, Urinary ...... 9 Peripheral Vasodilators ...... 10 Antineoplastic Antibiotics ...... 8 All Agents ...... 12 Bladder, Genital, and Kidney Pulmonary Hypertension - Phosphodiesterase Inhibitors 10 Antineoplastic Enzyme Conditions Drugs ...... 9 Dental and Oral Agents ...... 12 Inhibitors ...... 8 Central Nervous System Drugs All Agents ...... 12 Genitourinary Agents, Other .. 9 Antineoplastic ...... 10 Blood Clotting Drugs ...... 9 Dermatologicals ...... 12 Radiopharmaceuticals ...... 8 Central Nervous System, Other Acne Products ...... 12 Antineoplastics Misc...... 8 Coagulants ...... 9 ...... 10 Antifungals - Topical ...... 12 Chemotherapy Adjuncts ...... 8 Blood Formation Drugs ...... 9 Cephalosporins ...... 10 Antipruritics - Topical ...... 12 Antiparkinson And Related Blood Formation Modifiers .... 9 Cephalosporin Combinations 10 Antipsoriatics ...... 12 Therapy Agents ...... 8 Blood Pressure Drugs...... 9 Chemotherapy Agents ...... 10 Antiseborrheic Products ...... 12 Antiparkinson Dopaminergics 8 Alpha-Adrenergic Agonists .... 9 Alkylating Agents ...... 10 Burn Products ...... 12 Antipsychotics/ Antimanic Alpha-Adrenergic Blocking Antiangiogenic Agents ...... 10 Agents ...... 8 Agents ...... 9 Cauterizing Agents ...... 13 Antiestrogens/ Modifiers ...... 10 Phenothiazines ...... 8 Angiotensin II Receptor Keratolytic/ Antimitotic Agents Antimetabolites ...... 11 Antagonists ...... 9 ...... 13 Quinolinone Derivatives ...... 8 Antineoplastics, Other ...... 11 Angiotensin-converting Enzyme Local - Topical ....13 Antiseptics & Disinfectants .... 8 (ACE) Inhibitors ...... 9 Aromatase Inhibitors, 3rd Misc. Topical ...... 13 All Agents ...... 8 Generation ...... 11 Beta-Adrenergic Blocking Scabicides & Pediculicides .....13 Silver Antiseptics ...... 8 Agents ...... 9 Enzyme Inhibitors ...... 11 Scar Treatment Products ...... 13 Antivirals ...... 8 Molecular Target Inhibitors ..11

Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 2 of 22

Wound Care Products ...... 13 Angioedema (HAE) Agents ....14 Gout Agents ...... 15 Bulk Chemicals - D's ...... 16 Diabetic Drugs ...... 13 Drugs to Treat Viral Infections All Agents ...... 15 Estrogens ...... 16 ...... 14 Antidiabetic Agents ...... 13 Gout Drugs...... 15 Fertility Regulators ...... 16 Anti-Cytomegalovirus (CMV) Antidiabetic Combinations ....13 Antigout Agents...... 15 Growth Hormones ...... 16 Agents ...... 14 DPP-4...... 13 Heart Regulation Drugs ...... 15 Insulin-Like Growth Factors Antivirals ...... 14 (Somatomedins) ...... 16 Glycemic Agents ...... 13 Antiarrhythmics ...... 15 Ear Drugs ...... 14 LHRH/ GnRH Agonist Analog Incretin Mimetic Agents (GLP-1 Antiarrhythmics Type I-B ...... 15 Pituitary Suppressants ...... 16 Receptor Agonists) ...... 13 Otic Agents ...... 14 Antiarrhythmics Type III ...... 15 Posterior Pituitary Hormones 16 Insulins ...... 13 Endocrine And Metabolic Agents ...... 14 Hematological Agents ...... 15 Progestins ...... 16 SGLT2 Inhibitors ...... 13 Metabolic Modifiers ...... 14 Antihemophilic Products ...... 15 Selective Estrogen Receptor Diabetic Supplies ...... 13 Modifying Agents ...... 16 Posterior Pituitary Hormones 14 Plasma Expanders ...... 15 Monitoring Devices & Supplies Hormone Suppressants ...... 16 ...... 13 Enzyme Replacement/ Plasma Proteins ...... 15 Modifying Drugs ...... 14 Platelet Aggregation Inhibitors Antiandrogens ...... 16 Diagnostic Products ...... 13 ...... 15 Enzyme Replacement/ Antineoplastic - Hormonal and Diagnostic Biologicals ...... 13 Modifiers ...... 14 Protamine ...... 15 Related Agents ...... 16 Diagnostic Drugs...... 13 EnzymeReplacement/ Hematopoietic Agents ...... 15 Bulk Chemicals - L's ...... 16 Miscellaneous Contrast Media Modifying Drugs ...... 14 GnRH/ LHRH Antagonists ...... 16 ...... 13 Agents for Gaucher Disease ..15 Enzyme Replacements/ Cobalamins ...... 15 Growth Hormone Receptor Radiographic Contrast Media Modifiers ...... 14 Antagonists ...... 16 ...... 13 Hematopoietic Growth Factors Estrogens ...... 14 ...... 15 Growth Hormone Releasing Dietary Products/ Dietary Hormones (GHRH) ...... 16 Management Products ...... 13 All Agents ...... 14 Hemostatics ...... 15 Hormonal Agents, Suppressant Nutritional Substitutes ...... 13 Eye Drugs ...... 14 Hemostatics - Systemic ...... 15 (Adrenal) ...... 16 Nutritional Supplements ...... 13 Ophthalmic Agents, Other ....14 Hepatitis Drugs ...... 15 Hormonal Agents, Suppressant (Parathyroid) ...... 16 Digestive Aids ...... 13 Fibromyalgia Drugs ...... 14 Anti-hepatitis B (HBV) Agents ...... 15 LHRH/ GnRH Agonist Analog Digestive Enzymes ...... 13 Fibromyalgia Agents ...... 14 Pituitary Suppressants ...... 16 Anti-hepatitis C (HCV) Agents15 Gastric Acidifiers ...... 13 Flu Drugs ...... 14 Prolactin Inhibitors ...... 16 Diuretics ...... 13 Anti-Influenza Agents ...... 14 Herpes Drugs ...... 15 Somatostatic Agents ...... 16 Antiherpetic Agents ...... 15 Carbonic Anhydrase Inhibitors Fluoroquinolones ...... 14 Hypnotics/ Sedatives/ Sleep ...... 13 HIV Drugs ...... 15 All Agents ...... 14 Disorder Agents ...... 16 Loop Diuretics ...... 13 Anti-HIV Agents, Integrase Fungal Infection Drugs ...... 15 Hypnotics ...... 16 Osmotic Diuretics ...... 13 Inhibitors (INSTI) ...... 15 Antifungals ...... 15 Non-Barbiturate Hypnotics ...16 Potassium Sparing Diuretics..14 Anti-HIV Agents, Non- Gastrointestinal Agents ...... 15 nucleoside Reverse Immune System Drugs ...... 16 Drugs to Regulate Hormones14 Transcriptase Inhibitors Inflammatory Bowel Agents .15 Immune Suppressants ...... 16 Hormonal Agents, Stimulant/ (NNRTI) ...... 15 General Anesthetics ...... 15 Immunizing Agents, Passive ..16 Replacement/ Modifying Anti-HIV Agents, Nucleoside (Adrenal) ...... 14 Anesthetics ...... 15 and Nucleotide Reverse Immunomodulators ...... 17 Transcriptase Inhibitors (NRTI) Drugs to Treat Airway Disease Barbiturate Anesthetics ...... 15 Inflammatory Bowel Disease ...... 15 ...... 14 Genitourinary Agents ...... 15 Drugs ...... 17 Anti-HIV Agents, Other ...... 16 Phosphodiesterase Inhibitors, Alkalinizers ...... 15 Aminosalicylates ...... 17 Airways Disease ...... 14 Anti-HIV Agents, Protease Genitourinary Irrigants ...... 15 Inhibitors ...... 16 Glucocorticoids ...... 17 Drugs to Treat Allergies, Laxatives ...... 17 Cough, Cold and Lung Glaucoma Drugs ...... 15 Hormone Replacement/ Conditions ...... 14 Ophthalmic Antiglaucoma Modifying Drugs ...... 16 Laxative Combinations...... 17 Agents ...... 15 Respiratory Tract/ Pulmonary Androgens ...... 16 Lubricant Laxatives ...... 17 Agents ...... 14 Ophthalmic Prostaglandin and Bulk Chemicals - C's...... 16 Local Anesthetics ...... 17 Prostamide Analogs ...... 15 Drugs to Treat Angioedema . 14 Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 3 of 22

All Agents ...... 17 Multiple Sclerosis Drugs ...... 18 Otic Agents ...... 19 Antiprotozoals ...... 19 Local Anesthetics-parenteral 17 Multiple Sclerosis Agents ...... 18 Otic Combinations ...... 19 Psychotherapeutic And Neurological Agents ...... 20 Local Combinations Musculoskeletal Therapy Oxytocics ...... 19 ...... 17 Antidementia Agents ...... 20 Agents ...... 18 Abortifacients/ Agents for Local Anesthetics - Amides ....17 Direct Muscle Relaxants ...... 18 Cervical Ripening ...... 19 Postherpetic Neuralgia (PHN)/ Neuropathic Pain Agents ...... 20 Local Anesthetics - Esters ...... 17 Myasthenia Gravis Drugs ..... 18 All Agents ...... 19 Respiratory Agents ...... 20 Macrolides ...... 17 Parasympathomimetics ...... 18 Pain/ Anti-Inflammatory Drugs ...... 19 Cystic Fibrosis Agents ...... 20 Erythromycins ...... 17 Nausea and Vomiting Drugs 18 Analgesics...... 19 Scabies and Lice Drugs ...... 20 Migraine Drugs ...... 17 Antiemetics, Other ...... 18 Analgesics Other ...... 19 Pediculicides/ Scabicides ...... 20 Ergot Alkaloids ...... 17 Emetogenic Therapy Adjuncts Serotonin (5-HT) 1b/ 1d ...... 18 Nonsteroidal Anti- Sedation and Sleep Drugs .... 20 inflammatory Agents (NSAIDs) Receptor Agonists ...... 17 GABA Receptor Modulators ..20 Neuromuscular Agents ...... 18 ...... 19 Migraine Products ...... 17 Sleep Disorders, Other ...... 20 Depolarizing Muscle Relaxants Nonsteroidal Anti- All Agents ...... 17 ...... 18 Inflammatory Drugs...... 19 Seizure Control Drugs...... 20 Nondepolarizing Muscle Migraine Products - Salicylates...... 19 Anticonvulsants, Other ...... 20 Monoclonal Antibodies ...... 17 Relaxants ...... 18 Pain/ Swelling Management Calcium Channel Modifying Minerals & Electrolytes ...... 17 Neurotoxins ...... 18 Drugs ...... 19 Agents ...... 20 Neuromuscular Blocking Agent Bicarbonates...... 17 Skeletal Muscle Relaxants.....19 Gamma-Aminobutyric Acid - Neurotoxins ...... 18 (GABA) Augmenting Agents ..20 Calcium ...... 17 Parkinson's Disease Drugs ... 19 Nutrients ...... 18 Glutamate Reducing Agents .20 Magnesium ...... 17 Anticholinergics ...... 19 Carbohydrates ...... 18 Agents ...... 20 Manganese ...... 17 Antiparkinson Agents, Other .19 Lipids ...... 18 Skin Agents ...... 20 Phosphate ...... 17 Dopamine Agonists ...... 19 Lipotropics ...... 18 Acne Products ...... 20 Potassium ...... 17 Dopamine Precursors/ L-Amino Proteins ...... 18 Sodium ...... 17 Acid Decarboxylase Inhibitors Agents for Wrinkles/ Ophthalmic Agents ...... 18 ...... 19 Lipoatrophy/ Other Aesthetic Trace Minerals ...... 17 Uses ...... 20 Miotics...... 18 Monoamine Oxidase B (MAO- Zinc ...... 17 B) Inhibitors ...... 19 Antifungals - Topical ...... 20 Ophthalmic Anti-infectives ....18 Miscellaneous Anti-Infectives Passive Immunizing And Anti-inflammatory Agents - Ophthalmic Gene Therapy ....18 ...... 17 Treatment Agents ...... 19 Topical ...... 20 Ophthalmic Kinase Inhibitors 18 Antimycobacterials, Other ....17 Immune Serums ...... 19 Antimetabolites ...... 20 Ophthalmic Surgical Aids ...... 18 Miscellaneous Therapeutic Penicillins...... 19 Antineoplastic or Premalignant Classes ...... 17 Ophthalmics ...... 18 Lesion Agents - Topical ...... 20 Aminopenicillins ...... 19 Chelating Agents ...... 17 Opioid Pain Relievers ...... 18 Antipruritics - Topical ...... 20 Natural Penicillins ...... 19 Enzymes...... 17 Opioid Agonists ...... 18 Antipsoriatics ...... 20 Penicillin Combinations ...... 19 Irrigation Solutions ...... 17 Opioid Analgesics, Long-acting Antiseborrheic Products ...... 20 Penicillinase-Resistant ...... 18 Corticosteroids - Topical ...... 20 Peritoneal Dialysis Solutions .17 Penicillins...... 19 Sclerosing Agents...... 17 Opioid Analgesics, Short-acting Eczema Agents...... 20 ...... 18 Phosphate-Removing Agents Mood Disorder Drugs ...... 17 ...... 19 Emollient/ Keratolytic Agents Opioid Combinations ...... 19 ...... 20 1st Generation/ Typical ...... 17 Phosphate Binders ...... 19 Opioid Partial Agonists ...... 19 Emollients ...... 20 2nd Generation/ Atypical...... 17 Platelet Modifying Drugs ..... 19 Osteoarthritis ...... 19 Enzymes - Topical...... 20 Mood Stabilizers ...... 18 Platelet Modifying Agents ....19 Viscosupplements ...... 19 Immunomodulating Agents - Treatment-Resistant ...... 18 Prostate Enlargement Drugs 19 Topical ...... 21 Osteoporosis (Bone Loss) Mouth/ Throat/ Dental Agents Drugs ...... 19 Benign Prostatic Hypertrophy Immunosuppressive Agents ..21 ...... 18 Agents ...... 19 Metabolic Bone Disease Agents Immunosuppressive Agents - Dental Products ...... 18 ...... 19 Protozoal Infection Drugs .... 19 Topical ...... 21

Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 4 of 22

Inflammatory Bowel Agents .21 Miscellaneous Vaginal Products ...... 21 Keratolytic/ Antimitotic Agents ...... 21 Vasopressors ...... 21 Leprostatics ...... 21 All Agents ...... 21 Local Anesthetics - Topical ....21 Vitamins ...... 21 Metabolic Modifiers ...... 21 Water Soluble Vitamins ...... 21 Nonsteroidal Anti- Vitamins, Minerals, inflammatory Agents (NSAIDs) Electrolytes ...... 21 ...... 21 Electrolyte/ Mineral Modifiers Otic Combinations ...... 21 ...... 21 Rosacea Agents ...... 21 Electrolyte/ Mineral Tricyclic Agents ...... 21 Replacement ...... 22 Wound Care Products ...... 21 Prenatal Vitamins ...... 22 Sulfonamides...... 21 Therapeutic Nutrients/ Minerals/ Electrolytes ...... 22 All Agents ...... 21 Vitamins ...... 22 Tetracyclines ...... 21 Worm Infection Drugs ...... 22 All Agents ...... 21 Anthelmintics ...... 22 Thyroid Agents ...... 21

Thyroid Hormones ...... 21 Thyroid Replacement Drugs 21 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ...... 21 Thyroid Suppressing Drugs .. 21 Antithyroid Agents...... 21 Toxoids ...... 21 Toxoid Combinations ...... 21 Tuberculosis Drugs ...... 21 Antituberculars ...... 21 Ulcer and Stomach Acid Drugs ...... 21 Histamine2 (H2) receptor Antagonists ...... 21 Protectants ...... 21 Proton Pump Inhibitors ...... 21 Ulcer Drugs/ Antispasmodics/ Anticholinergics ...... 21 Antispasmodics ...... 21 Proton Pump Inhibitors ...... 21 Urinary Anti-infectives ...... 21 All Agents ...... 21 Vaccines ...... 21 All Agents ...... 21 Viral Vaccines ...... 21 Vaginal Products ...... 21

Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 5 of 22

Addiction metadate er PROLENSA lincomycin hcl Alcohol Deterrents/ Anti- methylphenidate er lincomycin hcl [INJ] craving methylphenidate hcl Alzheimer's Disease and linezolid acamprosate calcium methylphenidate hcl cd Dementia Drugs lugol's disulfiram methylphenidate la Cholinesterase Inhibitors mafenide acetate naltrexone hydrochloride QUILLICHEW ER donepezil hcl methenamine hippurate VIVITROL [SP] QUILLIVANT XR galantamine methenamine mandelate galantamine er metronidazole Opioid Dependence Treatments Allergy Drugs rivastigmine mupirocin BELBUCA Allergenic Extracts neomycin-polymyxin b ODACTRA N-methyl-D-aspartate (NMDA) nitrofurantoin hydrochloride Receptor Antagonist nitrofurantoin buprenorphine Antihistamines memantine hcl macrocrystal hydrochloride [INJ] azelastine hcl phenol buprenorphine-naloxone carbinoxamine Amebicides polymyxin b sulfate naloxone hcl cetirizine hcl All Agents polymyxin b sulfate [INJ] naloxone hcl [INJ] chlorpheniramine maleate iodoquinol rosadan naltrexone hydrochloride clemastine fumarate silver nitrate NARCAN hcl Antibiotics SILVER NITRATE SUBOXONE APPLICATOR desloratadine Aminoglycosides ZUBSOLV SULFAMYLON hcl amikacin sulfate tigecycline diphenhydramine hcl [INJ] amikacin sulfate [INJ] Smoking Cessation Agents levocetirizine BETHKIS [SP] tinidazole bupropion sr dihydrochloride GENTAK trimethoprim CHANTIX olopatadine hcl gentamicin sulfate vancomycin hcl pharbedryl gentamicin sulfate [INJ] vancomycin-ns ADHD Drugs phenadoz gentamicin sulfate in ns vandazole Analeptics hcl KITABIS PAK [SP] VIBATIV caffeine promethazine hcl [INJ] neomycin sulfate XIFAXAN caffeine & sodium promethegan paromomycin sulfate benzoate [INJ] Beta-Lactam, Cephalosporins streptomycin sulfate Ophthalmic Anti-Allergy Agents cefaclor Attention Deficit Hyperactivity TOBI PODHALER [SP] azelastine hcl cefaclor er Disorder Agents, TOBRADEX cefadroxil Amphetamines BEPREVE tobramycin sulfate [SP] cefazolin sodium dextroamphetamine cromolyn sodium tobramycin sulfate [SP] sulfate epinastine hcl [INJ] cefazolin sodium [INJ] cefdinir dextroamphetamine olopatadine hcl sulfate er PAZEO Antibacterials, Other cefditoren pivoxil cefepime hcl dextroamphetamine- bacitracin amphet er Ophthalmic Anti- benzalkonium chloride cefepime hcl [INJ] dextroamphetamine- Inflammatories chloramphenicol sod cefixime amphetamine ALREX succinate cefotaxime sodium [INJ] EVEKEO bromfenac sodium CLEOCIN PHOSPHATE cefotetan methamphetamine hcl dexamethasone sodium clindacin etz cefotetan [INJ] MYDAYIS phosphate clindacin p cefoxitin PROCENTRA dexamethasone sodium clindamycin hcl cefpodoxime proxetil VYVANSE phosphate [INJ] clindamycin palmitate hcl cefprozil zenzedi diclofenac sodium clindamycin pediatric ceftazidime fluorometholone clindamycin phosphate ceftazidime [INJ] Attention Deficit Hyperactivity flurbiprofen sodium clindamycin phosphate ceftriaxone Disorder Agents, Non- ILEVRO [INJ] ceftriaxone [INJ] amphetamines ketorolac tromethamine colistimethate sodium cefuroxime axetil hcl ketorolac tromethamine colistimethate sodium [INJ] cefuroxime sodium clonidine hcl er [INJ] daptomycin cefuroxime sodium [INJ] DAYTRANA LOTEMAX FEM PH cephalexin dexmethylphenidate hcl OZURDEX [SP] iodine TEFLARO dexmethylphenidate hcl er prednisolone acetate iodoquinol-hydrocortisone-

guanfacine hcl er prednisolone sodium aloe Beta-Lactam, Other phosphate Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 6 of 22

imipenem-cilastatin sulfacetamide sodium desvenlafaxine succinate er 5-HT3 Receptor Antagonists sodium sulfadiazine duloxetine hcl palonosetron hcl INVANZ sulfamethoxazole/trimetho escitalopram oxalate INVANZ [INJ] prim FETZIMA Antifungals meropenem sulfasalazine fluoxetine dr All Agents meropenem-0.9% nacl sulfasalazine dr fluoxetine hcl ABELCET sulfatrim fluvoxamine maleate AMBISOME Beta-Lactam, Penicillins maprotiline hcl amoxicillin Tetracyclines paroxetine er Imidazole-Related Antifungals amoxicillin-clavulanate pot avidoxy paroxetine hcl fluconazole in dextrose er demeclocycline hcl paroxetine mesylate fluconazole in saline amoxicillin-clavulanate doxy 100 sertraline hcl miconazole potass doxycycline hyclate trazodone hcl ampicillin trihydrate doxycycline monohydrate venlafaxine hcl ampicillin/sulbactam Antihistamines MINOCIN venlafaxine hcl er ampicillin/sulbactam [INJ] Antihistamines - Alkylamines minocycline hcl VIIBRYD brompheniramine maleate AUGMENTIN mondoxyne nl dicloxacillin sodium morgidox Tricyclics nafcillin sodium Antihistamines - Ethanolamines okebo hcl nafcillin sodium [INJ] doxylamine succinate ORACEA amoxapine OXACILLIN SODIUM SOLODYN hcl Antihistamines - oxacillin sodium [INJ] tetracycline hcl hcl Ethylenediamines penicillin g potassium [INJ] hcl pyrilamine maleate penicillin g Anticonvulsants hcl tripelennamine hcl penicillin g sodium [INJ] All Agents imipramine pamoate penicillin v potassium levetiracetam-nacl hcl Antihyperlipidemics PFIZERPEN [INJ] roweepra xr protriptyline hcl Bile Acid Sequestrants piperacillin-tazobactam subvenite trimipramine maleate colesevelam hcl ZOSYN

GABA Modulators Antidiarrheal/ Probiotic Antihypertensives Macrolides vigadrone [SP] Agents ACE Inhibitors AZASITE Antidiarrheal/ Probiotic Agents enalaprilat azithromycin Valproic Acid bismuth subgallate clarithromycin sodium Antiadrenergic clarithromycin er Gastrointestinal Adsorbents Antihypertensives E.E.S. Antidepressants kaolin reserpine ery All Agents pectin ERYGEL bupropion hcl er Vasodilators ERY-TAB sodium nitroprusside ERYTHROCIN STEARATE Antidotes And Specific Antidepressants, Other erythromycin Antagonists amitriptyline/chlordiazepo All Agents Anti-infective Agents erythromycin xide ethylsuccinate activated charcoal All Agents amitriptyline-perphenazine BAL IN OIL baci-im bupropion hcl Quinolones calcium disodium metro iv bupropion hcl xl ciprofloxacin versenate [INJ] bupropion sr Anti-infective Misc. - ciprofloxacin er edetate calcium disodium mirtazapine Combinations ciprofloxacin hcl fomepizole olanzapine-fluoxetine hcl smz-tmp ds FLOXIN physostigmine salicylate gatifloxacin Monoamine Oxidase Inhibitors [INJ] Carbapenems levofloxacin hemihydrate phenelzine sulfate PROTOPAM CHLORIDE ertapenem [INJ] MOXEZA tranylcypromine sulfate [INJ] moxifloxacin hcl sodium thiosulfate Glycopeptides ofloxacin SSRIs/ SNRIs (Selective DALVANCE Serotonin Reuptake Inhibitors/ Benzodiazepine Antagonists ORBACTIV Sulfonamides Serotonin and Norepinephrine flumazenil vancomycin-d5w silver sulfadiazine Reuptake Inhibitor)

ssd citalopram hbr Antiemetics Lincosamides Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 7 of 22

clindamycin phosphate- clorazepate dipotassium metaproterenol sulfate d5w Antipsychotics/ Antimanic diazepam PERFOROMIST Agents diazepam [INJ] PROAIR HFA Monobactams Phenothiazines estazolam PROAIR RESPICLICK AZACTAM-ISO-OSMOTIC prochlorperazine edisylate SEREVENT DISKUS DEXTROSE [INJ] lorazepam [INJ] STRIVERDI RESPIMAT aztreonam [INJ] lorazepam intensol terbutaline sulfate Quinolinone Derivatives midazolam hcl VENTOLIN HFA Streptogramins ARISTADA INITIO midazolam hcl [INJ] SYNERCID midazolam hcl-nacl Pulmonary Antihypertensives Antiseptics & Disinfectants triazolam ADEMPAS [SP] Antimalarials All Agents epoprostenol sodium [SP] All Agents hydrogen peroxide Asthma/ Lung Drugs FLOLAN [SP] quinacrine hcl Antiasthmatic - Monoclonal LETAIRIS [SP] Silver Antiseptics Antibodies OPSUMIT [SP] Antimyasthenic/ Cholinergic silver protein FASENRA [SP] REMODULIN [SP] [INJ] Agents sildenafil citrate [SP] Antimyasthenic/ Cholinergic Antivirals Anti-Inflammatories, Inhaled TRACLEER [SP] Agents Antiretrovirals Corticosteroids TYVASO [SP] ENLON [INJ] atazanavir sulfate ARNUITY ELLIPTA UPTRAVI [SP] REGONOL [INJ] BIKTARVY ASMANEX VELETRI [SP] ASMANEX HFA CIMDUO Antimycobacterial Agents efavirenz budesonide Respiratory Tract Agents, Other All Agents ritonavir FLOVENT DISKUS acetylcysteine aminosalicylic acid SYMFI FLOVENT HFA ADVAIR DISKUS SYMFI LO flunisolide ADVAIR HFA Antineoplastics And tenofovir disoproxil fluticasone propionate ANORO ELLIPTA Adjunctive Therapies fumarate mometasone furoate ARALAST NP [SP] Antineoplastic - Hormonal and TROGARZO [SP] QNASL BREO ELLIPTA Related Agents QVAR bromipheniramin- ERLEADA [SP] CMV Agents QVAR REDIHALER pseudoephed-dm YONSA ganciclovir sodium [SP] triamcinolone acetonide brompheniramine PREVYMIS triamcinolone acetonide w/pseudoephed Antineoplastic - [INJ] CAYSTON [SP] Immunomodulators Herpes Agents cromolyn sodium levamisole hcl acyclovir sodium Antileukotrienes DULERA montelukast sodium ESBRIET [SP] Antineoplastic Antibiotics Influenza Agents zafirlukast EXACTUSS dactinomycin RAPIVAB zileuton fluticasone-salmeterol GILTUSS Antineoplastic Enzyme Anxiety Drugs Bronchodilators, GRASTEK Inhibitors Anticholinergic Antianxiety Agents hydrocod-cpm- temsirolimus ATROVENT HFA pseudoephedrine droperidol INCRUSE ELLIPTA hydrocodone- droperidol [INJ] Antineoplastic ipratropium bromide chlorpheniramine Radiopharmaceuticals SPIRIVA iodine Anxiolytics, Other LUTATHERA [SP] SPIRIVA RESPIMAT KALYDECO [SP] buspirone hcl XOFIGO [SP] lugol's hydroxyzine hcl Bronchodilators, NEOTUSS PLUS hydroxyzine pamoate Antineoplastics Misc. Sympathomimetic OFEV [SP] BCG (TICE STRAIN) ADRENALIN CHLORIDE [INJ] ORKAMBI [SP] Benzodiazepines albuterol sulfate PROLASTIN C [SP] Chemotherapy Adjuncts alprazolam ARCAPTA NEOHALER promethazine vc ELITEK alprazolam er epinephrine w/codeine ALPRAZOLAM INTENSOL epinephrine [INJ] promethazine w/codeine Antiparkinson And Related alprazolam odt EPIPEN [INJ] promethazine w/dm Therapy Agents alprazolam xr EPIPEN JR. [INJ] pseudoephedrine hcl Antiparkinson Dopaminergics chlordiazepoxide hcl levalbuterol hcl RAGWITEK levodopa clonazepam SYMBICORT Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 8 of 22

TRELEGY ELLIPTA uro-mp methyldopa besylate ZEMAIRA [SP] ustell methyldopate hcl cartia xt utira-c midodrine hcl 24hr cd Sympathomimetics vilamit mb phenylephrine hcl-ns diltiazem cd ephedrine hcl vilevev mb diltiazem er isoproterenol hcl [INJ] Alpha-Adrenergic Blocking diltiazem hcl Blood Clotting Drugs Agents dilt-xr Xanthines Coagulants doxazosin mesylate er aminophylline ADVATE [SP] phenoxybenzamine hcl theophylline in 5% ADYNOVATE [SP] phentolamine mesylate matzim la dextrose AFSTYLA [SP] phentolamine mesylate hcl [INJ] ALPHANATE [SP] prazosin hcl Beta Blockers ALPHANINE SD [SP] nifedipine er Beta Blockers Cardio-Selective ALPROLIX [SP] Angiotensin II Receptor esmolol hcl AMICAR Antagonists BEBULIN [SP] taztia xt candesartan cilexetil Beta Blockers Non-Selective BENEFIX [SP] er EDARBI sorine COAGADEX [SP] verapamil er pm eprosartan mesylate hcl CORIFACT [SP] verapamil hcl irbesartan FEIBA NF [SP] losartan potassium Bladder Control Drugs HELIXATE FS [SP] Blood Thinners olmesartan medoxomil Antispasmodics, Urinary HEMOFIL-M [SP] Anticoagulants telmisartan darifenacin er HUMATE-P [SP] acd valsartan flavoxate hcl IXINITY [SP] ACD-A GELNIQUE KOGENATE FS [SP] Angiotensin-converting Enzyme ACTIVASE HYOPHEN KOVALTRY [SP] (ACE) Inhibitors CATHFLO ACTIVASE [INJ] me-naphos-mb-hyo 1 MONOCLATE-P [SP] benazepril hcl ELIQUIS MYRBETRIQ MONONINE [SP] captopril enoxaparin sodium [SP] oxybutynin chloride MONSEL'S enalapril maleate fondaparinux sodium [SP] oxybutynin chloride er NOVOEIGHT [SP] fosinopril sodium FRAGMIN [SP] tolterodine tartrate NOVOSEVEN RT [SP] lisinopril heparin sodium tolterodine tartrate er NUWIQ [SP] moexipril hcl heparin sodium [INJ] TOVIAZ OBIZUR [SP] perindopril erbumine heparin sodium in 0.9% nacl trospium chloride PROFILNINE SD [SP] quinapril jantoven UROGESIC RIASTAP [SP] ramipril sodium citrate uryl tranexamic acid trandolapril VESICARE TRETTEN [SP] THROMBATE III

VONVENDI [SP] Beta-Adrenergic Blocking TRICITRASOL [INJ] Bladder, Genital, and Kidney WILATE [SP] Agents warfarin sodium Conditions Drugs acebutolol hcl XARELTO Genitourinary Agents, Other Blood Formation Drugs atenolol aminoacetic acid Blood Formation Modifiers betaxolol hcl Heparins And Heparinoid-Like Agents bethanechol chloride anagrelide hydrochloride bisoprolol fumarate heparin sodium in 0.45% CAVERJECT CEPROTIN [SP] BYSTOLIC nacl CIALIS GRANIX [SP] carvedilol heparin sodium in 5% DEPEN LEUKINE [SP] [INJ] carvedilol er dextrose ELMIRON MOZOBIL [SP] labetalol hcl

glycine NEULASTA [SP] metoprolol succinate In Vitro/ Lock Anticoagulants MUSE NPLATE [SP] metoprolol tartrate CITRATE PHOSPHATE phenazopyridine hcl PROCRIT [SP] [INJ] nadolol DEXTROSE phosphasal PROMACTA [SP] pindolol RENACIDIN SOLIRIS [SP] hcl Thrombin Inhibitors uretron d-s ZARXIO [SP] [INJ] propranolol hcl er bivalirudin URIMAR-T timolol maleate urin d.s. Blood Pressure Drugs Bowel Treatment Drugs uro-458 Alpha-Adrenergic Agonists Calcium Channel Blocking Antispasmodics, uroav-81 clonidine hcl Agents Gastrointestinal uroav-b guanfacine hcl afeditab cr ANASPAZ Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 9 of 22

atropine sulfate glycerol formal NATRECOR tadalafil atropine sulfate [INJ] glycolax olmesartan-amlodipine- belladonna & opium lactulose hctz Central Nervous System belladonna-phenobarbital mineral oil olmesartan- Drugs hydrochlorothiazide clidinium peg 3350-electrolyte Central Nervous System, Other pentoxifylline w/chlordiazepoxide peg-prep benzphetamine hcl propranolol hcl-hctz dicyclomine hcl polyethylene glycol caffeine citrated quinapril- ed-spaz PREPOPIK diethylpropion hcl hydrochlorothiazide glycopyrrolate sorbitol diethylpropion hcl er RANEXA glycopyrrolate [INJ] SUPREP NAMZARIC spironolactone w/hctz hyoscyamine sulfate trilyte with flavor packets NUEDEXTA TEKTURNA hyosyne phendimetrazine tartrate TEKTURNA HCT LEVSIN [INJ] Cardiac Drugs phentermine hcl methscopolamine bromide telmisartan-amlodipine Cardiovascular Agents, Other telmisartan- RADICAVA [SP] oscimin ADRENALIN CHLORIDE [INJ] hydrochlorothiazid oscimin sl hcl w/hctz trandolapril-verapamil serotonin hcl oscimin sr amlodipine besylate- w/hctz succinylcholine chloride phenohytro benazepril valsartan- succinylcholine chloride propantheline bromide amlodipine-atorvastatin hydrochlorothiazide [INJ] symax-sl amlodipine-olmesartan tetrabenazine [SP]

symax-sr amlodipine-valsartan Diuretics, Carbonic Anhydrase amlodipine-valsartan-hctz Inhibitors Cephalosporins Gastrointestinal Agents, Other atenolol w/chlorthalidone acetazolamide Cephalosporin Combinations CHENODAL [SP] benazepril hcl-hctz AVYCAZ CHOLBAM [SP] bisoprolol fumarate/hctz Diuretics, Loop ZERBAXA cromolyn sodium BYVALSON bumetanide diphenoxylate w/atropine candesartan- bumetanide [INJ] Chemotherapy Agents lansoprazol-amoxicil- hydrochlorothiazid ethacrynic acid Alkylating Agents captopril/hydrochlorothiazi clarithro furosemide BENDEKA [SP] de loperamide hcl furosemide [INJ] BICNU CORLANOR magnesium oxide torsemide busulfan DEMSER opium cyclophosphamide digitek paregoric Diuretics, Potassium-sparing dacarbazine digox PYLERA amiloride hcl GLEOSTINE digoxin SEROSTIM [SP] eplerenone HEXALEN digoxin [INJ] simethicone spironolactone ifosfamide EDARBYCLOR sodium bicarbonate LEUKERAN enalapril maleate/hctz ursodiol Diuretics, Thiazide MATULANE [SP] ENTRESTO XERMELO [SP] chlorothiazide melphalan hcl ephedrine sulfate chlorthalidone MUSTARGEN [INJ] Irritable Bowel Syndrome ephedrine sulfate [INJ] hydrochlorothiazide MYLERAN Agents fosinopril- indapamide TEMODAR [SP] alosetron hcl hydrochlorothiazide methyclothiazide temozolomide [SP] AMITIZA irbesartan- metolazone thiotepa LINZESS hydrochlorothiazide thiotepa [INJ] VIBERZI isoxsuprine hcl lisinopril-hctz Cardiotonics TREANDA [SP] Cardiac Glycosides VALCHLOR [SP] Laxatives losartan- hydrochlorothiazide LANOXIN PEDIATRIC [INJ] YONDELIS [SP] bisacodyl methyldopa/hydrochloroth ZANOSAR constulose iazide Cardiovascular Agents docusate sodium metoprolol- Cardioplegic Solutions Antiangiogenic Agents enulose hydrochlorothiazide cardioplegic POMALYST [SP] gavilyte-c milrinone in 5% dextrose REVLIMID [SP] gavilyte-g milrinone lactate Peripheral Vasodilators THALOMID [SP] gavilyte-h and bisacodyl moexipril- nylidrin hcl gavilyte-n hydrochlorothiazide Antiestrogens/ Modifiers generlac nadolol- Pulmonary Hypertension - EMCYT glycerin bendroflumethiazide Phosphodiesterase Inhibitors FARESTON Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 10 of 22

FASLODEX ONCASPAR [INJ] imatinib mesylate [SP] tamoxifen citrate oxaliplatin IMBRUVICA [SP] Vasodilators, Direct-acting paclitaxel INLYTA [SP] Arterial Antimetabolites PHOTOFRIN IRESSA [SP] hydralazine hcl adrucil PROLEUKIN [SP] JAKAFI [SP] hydralazine hcl [INJ] ALIMTA SIPULEUCEL-T PROVENGE LENVIMA [SP] cladribine SYNRIBO [SP] MEKINIST [SP] papaverine hcl clofarabine teniposide NERLYNX [SP] papaverine hcl [INJ] cytarabine [INJ] THERACYS NEXAVAR [SP] DROXIA TICE BCG RYDAPT [SP] Vasodilators, Direct-acting fluorouracil tice bcg [INJ] SPRYCEL [SP] Arterial/ Venous FOLOTYN [SP] TRISENOX STIVARGA [SP] DILATRATE-SR gemcitabine hcl VALSTAR SUTENT [SP] isosorbide dinitrate hydroxyurea VELCADE [SP] [INJ] TAFINLAR [SP] isosorbide mononitrate mercaptopurine VERZENIO [SP] TAGRISSO [SP] NITRO-BID PURIXAN [SP] vinblastine sulfate TARCEVA [SP] nitroglycerin TABLOID vincasar pfs TASIGNA [SP] nitro-time thioguanine vincristine sulfate TYKERB [SP] RECTIV vinorelbine tartrate VENCLEXTA [SP] Antineoplastics, Other VORAXAZE VENCLEXTA STARTING Cholesterol Control Drugs ABRAXANE [SP] VYXEOS LIPOSOME [SP] PACK [SP] Dyslipidemics, Fibric Acid Derivatives ADRIAMYCIN YESCARTA [SP] VOTRIENT [SP] fenofibrate ARRANON [SP] ZALTRAP [SP] XALKORI [SP] fenofibric acid azacitidine [SP] [INJ] ZOLINZA [SP] ZELBORAF [SP] gemfibrozil bleomycin sulfate [INJ] ZYKADIA [SP] LIPOFEN calcium folinate Monoclonal Antibodies capecitabine [SP] Aromatase Inhibitors, 3rd ADCETRIS [SP] Dyslipidemics, HMG CoA carboplatin Generation ARZERRA [SP] Reductase Inhibitors cisplatin anastrozole AVASTIN [SP] atorvastatin calcium daunorubicin hcl exemestane BAVENCIO [SP] fluvastatin er decitabine [SP] letrozole BESPONSA [SP] fluvastatin sodium dexrazoxane BLINCYTO [SP] LIVALO docetaxel Enzyme Inhibitors CYRAMZA [SP] lovastatin doxorubicin hcl ALIQOPA [SP] DARZALEX [SP] pravastatin sodium doxorubicin hcl liposomal ETOPOPHOS ERBITUX [SP] rosuvastatin calcium epirubicin hcl etoposide GAZYVA [SP] simvastatin floxuridine HYCAMTIN [SP] HERCEPTIN [SP]

floxuridine [INJ] LYNPARZA [SP] IMFINZI [SP] Dyslipidemics, Other fludarabine phosphate ONIVYDE [SP] KADCYLA [SP] cholestyramine HALAVEN [SP] RUBRACA [SP] KEYTRUDA [SP] cholestyramine light idarubicin hcl toposar LARTRUVO [SP] colestipol hcl irinotecan hcl topotecan hcl OPDIVO [SP] ezetimibe ISTODAX [SP] ZEJULA [SP] PERJETA [SP] ezetimibe-simvastatin IXEMPRA [SP] ZYDELIG [SP] RITUXAN HYCELA [SP] JUXTAPID [SP] JEVTANA [SP] SYLVANT [SP] niacin er KYMRIAH [SP] Molecular Target Inhibitors TECENTRIQ [SP] omega-3 acid ethyl esters KYPROLIS AFINITOR [SP] UNITUXIN [SP] PRALUENT PEN [SP] leucovorin calcium AFINITOR DISPERZ [SP] VECTIBIX [SP] prevalite ALECENSA [SP] YERVOY [SP] leucovorin calcium [INJ] REPATHA PUSHTRONEX BOSULIF [SP] ZEVALIN levoleucovorin calcium [SP] CABOMETYX [SP] lipodox REPATHA SURECLICK [SP] CAPRELSA [SP] Retinoids LONSURF [SP] REPATHA SYRINGE [SP] COTELLIC [SP] bexarotene MARQIBO VASCEPA mesna ERIVEDGE [SP] TARGRETIN

MESNEX GILOTRIF [SP] Contraceptives IBRANCE [SP] Chest Pain Drugs mitomycin Implants ICLUSIG [SP] Nitrates mitoxantrone [SP] NEXPLANON NINLARO [SP] IDHIFA [SP] nitroglycerin in d5w Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 11 of 22

femynor nortrel methylprednisolone sod Injectable gianvi ocella succ [INJ] medroxyprogesterone gildess fe OGESTREL prednisolone acetate acetate heather orsythia micronize incassia philith IUD introvale pimtrea Cough/ Cold/ Allergy KYLEENA [SP] isibloom pirmella Antitussives MIRENA jencycla portia hydrocodone compound SKYLA jolessa previfem jolivette quasense Expectorants Oral juleber rajani bromhexine hydrochloride altavera junel reclipsen terpin hydrate alyacen junel fe rivelsa amethia kaitlib fe setlakin Cystic Fibrosis Agents amethia lo kariva sharobel All Agents amethyst kelnor 1-35 sprintec KALYDECO [SP] apri kelnor 1-50 sronyx aranelle kurvelo syeda Dental and Oral Agents ashlyna larin tarina fe All Agents aubra larin fe TAYTULLA cevimeline hcl aubra eq larissia tilia fe chlorhexidine gluconate aviane layolis fe tri femynor denta 5000 plus azurette leena tri-estarylla dentagel balziva lessina tri-legest fe FIRST-MOUTHWASH BLM bekyree levonest tri-linyah KEPIVANCE blisovi 24 fe levonorgestrel-eth tri-lo-estarylla oralone blisovi fe estradiol tri-lo-marzia pilocarpine hcl briellyn levonorg-eth estrad eth tri-lo-sprintec sf camila estrad tri-mili sf 5000 plus camrese levora trinessa sodium fluoride camrese lo lillow trinessa lo triamcinolone acetonide caziant LO LOESTRIN FE tri-previfem triamcinolone acetonide chateal loryna tri-sprintec [INJ] chateal eq low-ogestrel trivora cryselle lutera tri-vylibra Dermatologicals cyclafem lyza tulana Acne Products cyred marlissa tydemy isotretinoin dasetta melodetta 24 fe velivet metronidazole benzoate daysee mibelas 24 fe vienva deblitane microgestin viorele Antifungals - Topical delyla microgestin fe vyfemla desogestrel-ethinyl mili vylibra ciclopirox olamine estradiol mono-linyah wera clioquinol desogestr-eth estrad eth mononessa wymzya fe gentian violet estra myzilra zarah iodochlorohydroxyquinolin drospirenone-eth estra- necon e levomef zovia nikki drospirenone-ethinyl nora-be Antipruritics - Topical estradiol Transdermal norethindrone acetate camphor elinest XULANE norethindrone-ethin emoquette estradiol Antipsoriatics enpresse Vaginal norethin-eth estra ferrous anthralin enskyce fum NUVARING

errin norgestimate-ethinyl Antiseborrheic Products estarylla estradiol Corticosteroids glycolic acid ethynodiol-ethinyl NORGESTREL-ETHINY Glucocorticosteroids estradiol ESTRA budesonide er Burn Products falmina norlyda decadron nitrofurazone fayosim norlyroc dexamethasone-0.9% nacl Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 12 of 22

TRESIBA FLEXTOUCH U-200 VARISOFT INFUSION SET Cauterizing Agents VGO 20 chloroacetic acid TRULICITY SGLT2 Inhibitors VGO 30 VICTOZA FARXIGA VGO 40 Keratolytic/ Antimitotic Agents INVOKANA cantharidin Antidiabetic Combinations JARDIANCE Diagnostic Products podophyllum resin -metformin STEGLATRO Diagnostic Biologicals glyburide-metformin hcl APLISOL Local Anesthetics - Topical GLYXAMBI Diabetic Supplies CANDIN glydo INVOKAMET Monitoring Devices & Supplies TUBERSOL lidozion INVOKAMET XR ACCU-CHEK RAPID D pramoxine hcl JANUMET ACCU-CHEK SPIRIT Diagnostic Drugs JANUMET XR ACCU-CHEK TENDER d-xylose Misc. Topical JENTADUETO ACCU-CHEK ULTRAFLEX HISTATROL INTRADERMAL ACUICYN JENTADUETO XR AUTOSOFT 30 IC GREEN [INJ] aluminum chloride pioglitazone- AUTOSOFT 90 INDIGO CARMINE [INJ] arnica flower pioglitazone-metformin AUTOSOFT XC indocyanine green [INJ] ichthammol -metformin hcl cartridge pump isosulfan blue tannic acid SEGLUROMET cartridge stamped KINEVAC [INJ] SOLIQUA 100-33 CLEO 90 INFUSION SET LEXISCAN Scabicides & Pediculicides SYNJARDY COMFORT R-GENE 10 crotan SYNJARDY XR COMFORT SHORT xylose XIGDUO XR CONTACT DETACH Scar Treatment Products XULTOPHY 100-3.6 INFUSION SET Miscellaneous Contrast Media DELTEC COZMO CLEO celacyn EOVIST INFUSION SET DPP-4 Wound Care Products JANUVIA INFUSION SET Radiographic Contrast Media ACTICOAT TRADJENTA INSET 30 INFUSION SET barium sulfate INSET 30 TUBING KENDALL OMNIPAQUE INSET INFUSION SET MEDIHONEY Glycemic Agents RESTORE GLUCAGEN [INJ] insulin cartridge Dietary Products/ Dietary SILVASORB GLUCAGON EMERGENCY MINIMED Management Products MINIMED RESERVOIR SP ANTIPRURITIC KIT [INJ] Nutritional Substitutes MIO INFUSION SET XEROFORM PROGLYCEM sodium saccharin XEROFORM PETROLATUM OMNIPOD

Incretin Mimetic Agents (GLP-1 OMNIPOD DASH DRESSING Nutritional Supplements Receptor Agonists) ONE TOUCH PING FIBERSOURCE HN OZEMPIC PARADIGM Diabetic Drugs NOURISH Antidiabetic Agents PARADIGM INFUSION

Insulins PARADIGM SILHOUETTE acarbose Digestive Aids HUMALOG POLYFIN QR BYDUREON Digestive Enzymes BYDUREON BCISE HUMALOG JUNIOR QUICK RELEASE SOFT KWIKPEN pepsin 3;000 digestion BYDUREON PEN TEFLON HUMALOG MIX 50-50 BYETTA QUICK-SET PARADIGM HUMALOG MIX 75-25 REVEL PROGRAMMABLE Gastric Acidifiers glimepiride HUMULIN R PUMP l-glutamic acid glipizide HUMULIN R U-500 SILHOUETTE glipizide er KWIKPEN SOF-SET Diuretics glipizide xl LANTUS SOF-SET MICRO Carbonic Anhydrase Inhibitors glyburide LANTUS SOLOSTAR SURE-T PARADIGM acetazolamide sodium [INJ] glyburide micronized LEVEMIR T:30 INFUSION SET metformin hcl LEVEMIR FLEXTOUCH T:90 Loop Diuretics metformin hcl er NOVOLOG T:FLEX ethacrynate sodium miglitol NOVOLOG FLEXPEN T:SLIM NOVOLOG MIX 70-30 T:SLIM G4 Osmotic Diuretics pioglitazone hcl TOUJEO MAX SOLOSTAR TRUE METRIX TEST STRIPS mannitol repaglinide TOUJEO SOLOSTAR AND METERS OSMITROL SYMLINPEN 120 TRESIBA FLEXTOUCH U-100 TRUSTEEL INFUSION SET SYMLINPEN 60 Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 13 of 22

Potassium Sparing Diuretics ELIXOPHYLLIN CRYSVITA [SP] flucaine triamterene theochron MEPSEVII [SP] ful-glo theophylline anhydrous PALYNZIQ [SP] green glo Drugs to Regulate sodium phenylacet-sod homatropaire Hormones Drugs to Treat Allergies, benzoate homatropine Hormonal Agents, Stimulant/ Cough, Cold and Lung hydrobromide Replacement/ Modifying Conditions Posterior Pituitary Hormones JETREA [SP] (Adrenal) Respiratory Tract/ Pulmonary vasopressin-ns neo/polymyxin/dexametha anucort-hc Agents sone betamethasone acetate COMBIVENT RESPIMAT Enzyme Replacement/ neomycin/bacitracin/poly/ hc betamethasone acetate- dextromethorphan hbr Modifying Drugs neomycin/bacitracin/poly sod phos [INJ] DYMISTA Enzyme Replacement/ myxin betamethasone sodium guaifenesin Modifiers phosphate neomycin/polymyxin/gram hydrocodone/homatropine ADAGEN [SP] cortisone acetate icidin hydromet ALDURAZYME [SP] deltasone neomycin/polymyxin/hc ipratropium-albuterol CERDELGA [SP] neomycin-polymyxin- desoximetasone nebusal CEREZYME [SP] dexamethaso DEXAMETHASONE NUCALA [SP] CREON neo-polycin dexamethasone acetate promethazine vc CYSTADANE [SP] neo-polycin hc dexamethasone pulmosal CYSTAGON [SP] micronized phenylephrine hcl ELAPRASE [SP] dexamethasone sodium PULMOZYME [SP] phenylephrine hcl [INJ] FABRAZYME [SP] phosphate sodium chloride polycin dexamethasone sodium sodium chloride [INJ] KANUMA [SP] polymyxin b sul- phosphate [INJ] STIOLTO RESPIMAT KUVAN [SP] trimethoprim fludrocortisone acetate XOLAIR [SP] LUMIZYME [SP] proparacaine hcl NAGLAZYME [SP] fluticasone propionate proparacaine-fluorescein fluticasone propionate Drugs to Treat Angioedema NITYR [SP] RESTASIS micro Angioedema (HAE) Agents OCALIVA [SP] RESTASIS MULTIDOSE hemmorex-hc CINRYZE [SP] ORFADIN [SP] sulfacetamide hydrocortisone FIRAZYR [SP] RAVICTI [SP] w/prednisolone sodium phenylbutyrate tetcaine hydrocortisone acetate mercaptopurine Drugs to Treat Viral STRENSIQ [SP] hcl methylprednisolone Infections SUCRAID [SP] tetracaine hcl [INJ] methylprednisolone [INJ] Anti-Cytomegalovirus (CMV) VIMIZIM [SP] TOBRADEX methylprednisolone ac Agents VIOKACE TOBRADEX ST micro cidofovir ZENPEP tobramycin- methylprednisolone dexamethasone valganciclovir hcl acetate [INJ] tropicamide EnzymeReplacement/ MILLIPRED VISUDYNE [SP] Antivirals Modifying Drugs mometasone furoate XIIDRA ribavirin [SP] Enzyme Replacements/ prednisolone Modifiers ZYLET prednisolone sodium phos Ear Drugs BRINEURA [SP] [INJ] odt Fibromyalgia Drugs prednisolone sodium Otic Agents Estrogens Fibromyalgia Agents phosphate acetasol hc All Agents duloxetine hcl prednisone acetic acid ethinyl estradiol LYRICA SOLU-CORTEF [INJ] acetic acid/hydrocortisone SAVELLA triamcinolone CIPRODEX

triamcinolone acetonide ciprofloxacin hcl Eye Drugs Flu Drugs triamcinolone acetonide CORTANE-B Ophthalmic Agents, Other [INJ] exotic-hc altacaine Anti-Influenza Agents triamcinolone diacetate fluocinolone acetonide oil altafluor oseltamivir phosphate VERIPRED 20 neomycin/polymyxin/hc atropine sulfate RELENZA atropine sulfate [INJ] rimantadine hcl otomax-hc Drugs to Treat Airway OTOVEL bacitracin/polymyxin bio glo Fluoroquinolones Disease Phosphodiesterase Inhibitors, Endocrine And Metabolic cyclopentolate hcl All Agents Airways Disease Agents CYSTARAN [SP] ciprofloxacin-d5w DALIRESP Metabolic Modifiers EYLEA [SP] levofloxacin-d5w Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 14 of 22

curity sulfate adefovir dipivoxil Fungal Infection Drugs sotalol BARACLUDE Antifungals Glaucoma Drugs sotalol af entecavir amphotericin b Ophthalmic Antiglaucoma SOTYLIZE EPIVIR HBV amphotericin b [INJ] Agents lamivudine caspofungin acetate ALPHAGAN P Antiarrhythmics Type I-B VEMLIDY ciclodan apraclonidine hcl hcl in dextrose ciclopirox betaxolol hcl Anti-hepatitis C (HCV) Agents clotrimazole bimatoprost Antiarrhythmics Type III EPCLUSA [SP] CRESEMBA brimonidine tartrate fumarate HARVONI [SP] econazole nitrate carteolol hcl NEXTERONE INTRON A [SP] [INJ] ERAXIS(WATER DILUENT) COMBIGAN MAVYRET [SP] fluconazole dorzolamide hcl Hematological Agents moderiba [SP] flucytosine dorzolamide-timolol Antihemophilic Products RIBAPAK [SP] griseofulvin levobunolol hcl HEMLIBRA [SP] ribasphere [SP] griseofulvin ultramicrosize methazolamide ribavirin [SP] itraconazole metipranolol Plasma Expanders SOVALDI [SP] ketoconazole PHOSPHOLINE IODIDE hetastarch w/sodium SYLATRON [SP] MICONAZOLE 3 pilocarpine hcl chloride TECHNIVIE [SP] miconazole nitrate timolol maleate HEXTEND LACTATED VIEKIRA PAK [SP] MYCAMINE ELECTROLYTE VIEKIRA XR [SP] LMD 10% WITH 0.9% naftifine hcl Ophthalmic Prostaglandin and VOSEVI [SP] SODCHLORIDE NATACYN Prostamide Analogs LMD 10% WITH 5% NOXAFIL bimatoprost Herpes Drugs latanoprost DEXTROSE nyamyc VOLUVEN Antiherpetic Agents nystatin LUMIGAN acyclovir TRAVATAN Z nystatin w/triamcinolone Plasma Proteins famciclovir nystatin/triamcinolone trifluridine Gout Agents albumin nystop alburx valacyclovir All Agents oxiconazole nitrate albutein ZOVIRAX allopurinol sodium SPORANOX buminate ALOPRIM terbinafine plasbumin HIV Drugs

terconazole PLASMANATE Anti-HIV Agents, Integrase tolnaftate Gout Drugs Inhibitors (INSTI) Antigout Agents DESCOVY voriconazole Platelet Aggregation Inhibitors allopurinol ISENTRESS eptifibatide colchicine ISENTRESS HD Gastrointestinal Agents REOPRO Inflammatory Bowel Agents COLCRYS STRIBILD KRYSTEXXA [SP] TIVICAY aminosalicylic acid Protamine MITIGARE sulfazine protamine sulfate probenecid Anti-HIV Agents, Non-

General Anesthetics probenecid w/colchicine nucleoside Reverse Hematopoietic Agents Transcriptase Inhibitors Anesthetics ULORIC Agents for Gaucher Disease (NNRTI) etomidate miglustat [SP] COMPLERA hcl Heart Regulation Drugs Antiarrhythmics EDURANT ketamine hcl [INJ] Cobalamins adenosine GENVOYA propofol hydroxocobalamin hcl INTELENCE

nevirapine Barbiturate Anesthetics Hematopoietic Growth Factors acetate nevirapine er BREVITAL SODIUM [INJ] DOPTELET [SP] hcl ODEFSEY

pacerone RESCRIPTOR Genitourinary Agents Hemostatics procainamide hcl Alkalinizers Hemostatics - Systemic procainamide hcl [INJ] Anti-HIV Agents, Nucleoside potassium citrate aminocaproic acid and Nucleotide Reverse propafenone hcl Transcriptase Inhibitors (NRTI) propafenone hcl er Genitourinary Irrigants abacavir quinidine gluconate Hepatitis Drugs aqua care sodium chloride abacavir-lamivudine quinidine gluconate [INJ] Anti-hepatitis B (HBV) Agents Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 15 of 22

abacavir-lamivudine- covaryx megestrol acetate SOMATULINE DEPOT [SP] zidovudine covaryx h.s. norethindrone acetate didanosine DEPO-ESTRADIOL progesterone Hypnotics/ Sedatives/ Sleep EMTRIVA DIVIGEL Disorder Agents lamivudine DUAVEE Selective Estrogen Receptor Barbiturate Hypnotics lamivudine-zidovudine eemt Modifying Agents AMYTAL SODIUM [INJ] RETROVIR eemt hs clomiphene citrate pentobarbital sodium stavudine estradiol raloxifene hcl pentobarbital sodium [INJ] TRIUMEQ estradiol valerate phenobarbital sodium [INJ] TRUVADA Hormone Suppressants estradiol-norethindrone VIDEX acetat Antiandrogens Non-Barbiturate Hypnotics VIREAD ESTRING bicalutamide chloral hydrate zidovudine estrogen & flutamide

methyltestosterone nilutamide Immune System Drugs fyavolv Anti-HIV Agents, Other XTANDI [SP] Immune Suppressants jevantique lo FUZEON [SP] ZYTIGA [SP] azathioprine jinteli SELZENTRY azathioprine sodium [INJ] lopreeza Antineoplastic - Hormonal and cyclosporine Anti-HIV Agents, Protease mimvey Related Agents ENBREL [SP] Inhibitors mimvey lo ELIGARD [SP] gengraf APTIVUS MINIVELLE FIRMAGON [SP] HUMIRA [SP] CRIXIVAN norethindrone-ethin leuprolide acetate [SP] HUMIRA PEDIATRIC [SP] fosamprenavir calcium estradiol LUPRON DEPOT [SP] methotrexate INVIRASE PREMARIN VANTAS [SP] methotrexate [INJ] KALETRA PREMARIN [INJ] ZOLADEX [SP] methotrexate sodium LEXIVA PREMPHASE methotrexate sodium [INJ] lopinavir-ritonavir PREMPRO Bulk Chemicals - L's mycophenolate mofetil NORVIR yuvafem leuprolide acetate [SP] mycophenolic acid PREZISTA NULOJIX [SP] REYATAZ Fertility Regulators GnRH/ LHRH Antagonists OTREXUP VIRACEPT FOLLISTIM AQ [SP] CETROTIDE [SP] MENOPUR [SP] PROGRAF RAPAMUNE Hormone Replacement/ NOVAREL [SP] Growth Hormone Receptor RASUVO Modifying Drugs OVIDREL [SP] Antagonists REMICADE [SP] Androgens SOMAVERT [SP] SANDIMMUNE ANDRODERM Growth Hormones sirolimus ANDROGEL GENOTROPIN [SP] Growth Hormone Releasing tacrolimus danazol Hormones (GHRH) TORISEL [SP] METHITEST Insulin-Like Growth Factors EGRIFTA [SP] (Somatomedins) ZORTRESS methyltestosterone methyltestosterone INCRELEX [SP] Hormonal Agents, Suppressant Immunizing Agents, Passive micronized (Adrenal) ATGAM oxandrolone LHRH/ GnRH Agonist Analog LYSODREN Pituitary Suppressants CYTOGAM [SP] testosterone TRIPTODUR [SP] Hormonal Agents, Suppressant GAMASTAN S-D [SP] testosterone cypionate (Parathyroid) GAMMAGARD LIQUID [SP] testosterone enanthate Posterior Pituitary Hormones SENSIPAR [INJ] testosterone micronized desmopressin acetate GAMMAGARD S-D [SP]

desmopressin acetate [INJ] LHRH/ GnRH Agonist Analog GAMUNEX-C [SP] [INJ] Bulk Chemicals - C's Pituitary Suppressants HEPAGAM B [INJ] chorionic gonadotropin STIMATE [SP] SYNAREL HIZENTRA [SP] [SP] Progestins HYPERHEP B S-D Prolactin Inhibitors HYPERRAB S-D Bulk Chemicals - D's CRINONE cabergoline HYPERRHO S-D [SP] desmopressin acetate DEPO-PROVERA hydroxyprogesterone HYPERTET S-D

caproate [SP] Somatostatic Agents IMOGAM RABIES-HT Estrogens MAKENA [SP] octreotide acetate [SP] PRIVIGEN [SP] amabelz medroxyprogesterone [INJ] THYMOGLOBULIN COMBIPATCH acetate SIGNIFOR [SP] VARIZIG Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 16 of 22

relador pak ZOMIG TRACE ELEMENTS-4 Immunomodulators relador pak plus ACTIMMUNE [SP] SCAR Migraine Products Zinc ALFERON N [INJ] sensorcaine [INJ] All Agents zinc chloride BENLYSTA [SP] sensorcaine-mpf [INJ] ergotamine tartrate ILARIS [SP] zeruvia Miscellaneous Anti- leflunomide Migraine Products - Infectives OTEZLA [SP] Local Anesthetics-parenteral Monoclonal Antibodies Antimycobacterials, Other RIDAURA Combinations AIMOVIG AUTOINJECTOR dapsone SIMULECT hcl- AIMOVIG AUTOINJECTOR rifabutin epinephrine [INJ] (2 PACK) SYNAGIS [SP] lidocaine hcl Miscellaneous Therapeutic Inflammatory Bowel w/epinephrine [INJ] Minerals & Electrolytes Classes SENSORCAINE WITH Disease Drugs Bicarbonates Chelating Agents EPINEPHRINE [INJ] Aminosalicylates NEUT penicillamine(d-) xylocaine dental- sodium acetate APRISO epinephrine [INJ] trientine hcl sodium bicarbonate-water balsalazide disodium sodium lactate CANASA Local Anesthetics - Amides Enzymes mesalamine bupivacaine w/dextrose bromelain Calcium PENTASA [INJ] chymotrypsin calcium chloride CARBOCAINE [INJ] Glucocorticoids lidocaine hcl in 7.5% calcium lactate Irrigation Solutions budesonide ec dextrose calcium phosphate aqua care sterile water irrig colocort polocaine [INJ] calcium phosphate tribasic curity hc pramoxine hcl/pf [INJ] lactated ringers Magnesium hydrocortisone ropivacaine hcl-ns [INJ] magnesium carbonate pramcort Peritoneal Dialysis Solutions procto-med hc Local Anesthetics - Esters magnesium chloride DELFLEX W/DEXTROSE procto-pak hcl [INJ] magnesium chloride [INJ] EXTRANEAL ICODEXTRIN magnesium sulfate in proctosol-hc procaine hcl DIALYSIS dextrose proctozone-hc UCERIS Macrolides Sclerosing Agents Manganese Erythromycins ETHAMOLIN manganese Laxatives ERYTHROCIN SOTRADECOL Laxative Combinations LACTOBIONATE Phosphate CLENPIQ erythromycin stearate Mood Disorder Drugs GLYCOPHOS 1st Generation/ Typical sodium phosphate Lubricant Laxatives Migraine Drugs chlorpromazine hcl mineral oil heavy Ergot Alkaloids chlorpromazine hcl [INJ] Potassium mineral oil light dihydroergotamine fluphenazine decanoate potassium acetate MURI-LUBE MINERAL OIL mesylate fluphenazine decanoate dihydroergotamine [INJ] mesylate [INJ] Sodium Local Anesthetics fluphenazine hcl ergotamine-caffeine monoject 0.9% nacl [INJ] All Agents fluphenazine hcl [INJ] MIGERGOT monoject prefill advanced haloperidol bupivacaine hcl [INJ] haloperidol [INJ] bupivacaine hcl [INJ] normal saline [INJ] Serotonin (5-HT) 1b/ 1d haloperidol decanoate hcl Receptor Agonists saline flush [INJ] haloperidol lactate dermacinrx prizopak almotriptan malate sodium chloride-water haloperidol lactate [INJ] ethyl chloride eletriptan hbr syrex [INJ] loxapine succinate lidocaine frovatriptan succinate lidocaine hcl naratriptan hcl Trace Minerals hcl lidocaine hcl [INJ] rizatriptan chromium thiothixene lidocaine-prilocaine sumatriptan succinate copper chloride trifluoperazine hcl lido-k sumatriptan succ-naproxen cupric sulfate lidopin sod MULTITRACE-4 2nd Generation/ Atypical lidopril zolmitriptan multitrace-5 ABILIFY MAINTENA lorenza zolmitriptan odt selenium MARCAINE [INJ] aripiprazole Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 17 of 22

aripiprazole odt dimenhydrinate [INJ] CLINIMIX E ARISTADA hcl FREAMINE HBC Opioid Analgesics, Long-acting clozapine odt metoclopramide hcl FREAMINE III diskets LATUDA metoclopramide hcl [INJ] HEPATAMINE fentanyl olanzapine metoclopramide hcl odt histidine hcl hydromorphone er olanzapine odt perphenazine l-alanine HYSINGLA ER paliperidone er prochlorperazine maleate l-arginine base INFUMORPH [INJ] quetiapine fumarate trimethobenzamide hcl l-cysteine levorphanol tartrate quetiapine fumarate er l-glutamic acid methadone hcl RISPERDAL CONSTA Emetogenic Therapy Adjuncts l-leucine methadone hcl [INJ] risperidone aprepitant l-proline METHADOSE risperidone odt dronabinol l-threonine morphine sulfate er ziprasidone hcl granisetron hcl l-valine NUCYNTA ER ondansetron hcl NEPHRAMINE OXYCONTIN Mood Stabilizers ondansetron hcl [INJ] phenylalanine (dl) oxymorphone hcl lithium carbonate ondansetron odt plenamine oxymorphone hcl er lithium citrate SANCUSO PREMASOL tramadol hcl er VARUBI PROCALAMINE Treatment-Resistant PROSOL Opioid Analgesics, Short-acting clozapine Neuromuscular Agents taurine acetaminophen w/codeine Depolarizing Muscle Relaxants threonine apap-caffeine- Mouth/ Throat/ Dental ANECTINE [INJ] TRAVASOL dihydrocodeine asa-butalb-caff-cod Agents TROPHAMINE Dental Products Nondepolarizing Muscle tryptophan (l) ascomp with codeine butalbital compound zinc acetate Relaxants atracurium besylate Ophthalmic Agents w/codeine butalbital/caff/apap/codei cisatracurium besylate Miotics Multiple Sclerosis Drugs ne pancuronium bromide MIOSTAT Multiple Sclerosis Agents butorphanol tartrate rocuronium bromide AMPYRA [SP] butorphanol tartrate [INJ] AVONEX ADMINISTRATION vecuronium bromide Ophthalmic Anti-infectives codeine sulfate PACK [SP] ak-poly-bac endocet AVONEX PEN [SP] Neurotoxins fentanyl citrate COPAXONE [SP] Neuromuscular Blocking Agent Ophthalmic Gene Therapy fentanyl citrate [INJ] GILENYA [SP] - Neurotoxins LUXTURNA [SP] fentanyl citrate/ns glatiramer acetate [SP] BOTOX [SP] [INJ] hydrocodone bitartrate glatopa [SP] MYOBLOC [SP] Ophthalmic Kinase Inhibitors hydrocodone bit-ibuprofen OCREVUS [SP] RHOPRESSA Nutrients hydrocodone PLEGRIDY [SP] w/acetaminophen Carbohydrates TECFIDERA [SP] Ophthalmic Surgical Aids hydromorphone hcl dextrose ocucoat hydromorphone hcl [INJ] dextrose in water Musculoskeletal Therapy hydromorphone hcl/ns fructose Agents Ophthalmics lorcet Direct Muscle Relaxants balanced salt lorcet hd Lipids revonto BSS lorcet plus intralipid FLUORESCITE meperidine hcl Myasthenia Gravis Drugs morphine sulfate Lipotropics Parasympathomimetics Opioid Pain Relievers morphine sulfate [INJ] choline bitartrate guanidine hcl Opioid Agonists morphine sulfate/ns MESTINON alfentanil hydrochloride nalbuphine hcl Proteins neostigmine methylsulfate [INJ] nalbuphine hcl [INJ] alanine pyridostigmine bromide codeine phosphate NUCYNTA AMINOSYN pyridostigmine bromide er duramorph [INJ] oxycodone hcl AMINOSYN II morphine sulfate cr oxycodone hcl-ibuprofen AMINOSYN M morphine sulfate in Nausea and Vomiting Drugs oxycodone AMINOSYN WITH dextrose Antiemetics, Other w/acetaminophen ELECTROLYTES remifentanil hcl AKYNZEO oxycodone w/aspirin AMINOSYN-RF sufentanil citrate compro oxymorphone hcl CLINIMIX ULTIVA dimenhydrinate tramadol hcl Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 18 of 22

tramadol hcl- butalbital compound acetyl salicylic acid Penicillins acetaminophen butalbital sodium salicylate Aminopenicillins verdrocet w/acetaminophen ampicillin sodium vicodin butalbital/apap/caffeine Pain/ Swelling Management ampicillin sodium [INJ] vicodin es butalbital-asp-caffeine Drugs vicodin hp phrenilin forte Skeletal Muscle Relaxants Natural Penicillins PRIALT [SP] BICILLIN L-A Opioid Combinations TENCON carisoprodol penicillin gk-iso-osm panlor zebutal dextrose cyclobenzaprine hcl Opioid Partial Agonists Analgesics Other dantrolene sodium Penicillin Combinations SUBLOCADE [SP] OFIRMEV GABLOFEN BICILLIN C-R LIORESAL Osteoarthritis Nonsteroidal Anti- metaxall Penicillinase-Resistant inflammatory Agents (NSAIDs) Viscosupplements metaxalone Penicillins ibuprofen lysine EUFLEXXA [SP] methocarbamol nafcill in dextrose phenylbutazone MONOVISC [SP] methocarbamol [INJ] ORTHOVISC [SP] citrate Phosphate-Removing Nonsteroidal Anti- orphenadrine citrate [INJ] Agents Inflammatory Drugs Osteoporosis (Bone Loss) tizanidine hcl Phosphate Binders aspirin Drugs calcium acetate CALDOLOR Metabolic Bone Disease Agents lanthanum carbonate celecoxib Parkinson's Disease Drugs alendronate sodium PHOSLYRA choline mag trisalicylate Anticholinergics calcitonin-salmon sevelamer carbonate diclofenac potassium benztropine mesylate calcitriol VELPHORO diclofenac sodium benztropine mesylate [INJ] doxercalciferol trihexyphenidyl hcl diclofenac sodium- Platelet Modifying Drugs etidronate disodium misoprostol Platelet Modifying Agents FORTEO [SP] diflunisal Antiparkinson Agents, Other aspirin-dipyridamole er ibandronate sodium etodolac amantadine hcl BRILINTA MIACALCIN [INJ] etodolac er entacapone cilostazol NATPARA [SP] fenoprofen calcium tolcapone clopidogrel pamidronate disodium FLECTOR dipyridamole paricalcitol flurbiprofen Dopamine Agonists prasugrel hcl risedronate sodium ibu APOKYN [SP] ZONTIVITY risedronate sodium dr ibuprofen apomorphine hcl TYMLOS [SP] indomethacin bromocriptine mesylate Prostate Enlargement Drugs XGEVA [SP] ketoprofen pramipexole di-hcl Benign Prostatic Hypertrophy zoledronic acid ketorolac tromethamine pramipexole er Agents ZOMETA ketorolac tromethamine ropinirole hcl alfuzosin hcl er [INJ] CIALIS Otic Agents klofensaid ii Dopamine Precursors/ L-Amino dutasteride Otic Combinations meclofenamate sodium Acid Decarboxylase Inhibitors dutasteride-tamsulosin antibiotic ear solution carbidopa finasteride meloxicam carbidopa/levodopa RAPAFLO Oxytocics nabumetone carbidopa-levodopa er tamsulosin hcl Abortifacients/ Agents for nabumetone micronized carbidopa-levodopa- terazosin hcl Cervical Ripening naproxen entacapone HEMABATE naproxen sodium Monoamine Oxidase B (MAO- naproxen sodium ds Protozoal Infection Drugs B) Inhibitors All Agents naproxen sodium er Antiprotozoals rasagiline mesylate oxytocin [INJ] oxaprozin ALINIA selegiline hcl piroxicam atovaquone Pain/ Anti-Inflammatory profeno atovaquone-proguanil hcl Passive Immunizing And Drugs salsalate chloroquine phosphate Treatment Agents Analgesics sulindac COARTEM Immune Serums acetaminophen tolmetin sodium DARAPRIM [SP] acetaminophen HYPERRAB hydroxychloroquine sulfate w/butalbital Salicylates mefloquine hcl Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 19 of 22

NEBUPENT GRALISE sodium seb-prev primaquine ONFI sulfacetamide/sulfur selenium sulfide quinine sulfate phenobarbital ss 10-2 sodium sulfacetamide sss 10-5 sulfacetamide sodium Psychotherapeutic And SABRIL [SP] sulfacetamide sodium Neurological Agents tiagabine hcl sulfacetamide sodium- Corticosteroids - Topical sulfur Antidementia Agents valproic acid ala-cort sulfacleanse 8/4 memantine hcl er vigabatrin [SP] alclometasone tretinoin dipropionate

Postherpetic Neuralgia (PHN)/ Glutamate Reducing Agents tretinoin acid amcinonide Neuropathic Pain Agents felbamate tretinoin microsphere APEXICON E LYRICA CR zenatane betamethasone dipropionate lamotrigine (blue) Agents for Wrinkles/ Respiratory Agents lamotrigine (green) betamethasone valerate Lipoatrophy/ Other Aesthetic calcipotriene- Cystic Fibrosis Agents lamotrigine (orange) Uses betamethasone dp SYMDEKO [SP] lamotrigine odt REFISSA clobetasol e QUDEXY XR clobetasol emulsion Scabies and Lice Drugs Antifungals - Topical clobetasol propionate Pediculicides/ Scabicides Sodium Channel Agents clotrimazole/betamethaso clodan lindane ne desonide malathion carbamazepine er dermazene cream desoximetasone permethrin epitol hydrocortisone diflorasone diacetate spinosad fosphenytoin sodium [INJ] w/iodoquinol ENSTILAR hydrocortisone-iodoquinol- fluocinolone acetonide Sedation and Sleep Drugs PEGANONE aloe fluocinonide GABA Receptor Modulators fluocinonide-e eszopiclone phenytoin sodium Anti-inflammatory Agents - flurandrenolide flurazepam hcl VIMPAT Topical fluticasone propionate zaleplon diclofenac sodium halobetasol propionate zolpidem tartrate Skin Agents hc pramoxine zolpidem tartrate er Acne Products Antimetabolites hydrocortisone 10-1 fluorouracil hydrocortisone acetate Sleep Disorders, Other ABSORICA Antineoplastic or Premalignant hydrocortisone butyrate armodafinil ACANYA Lesion Agents - Topical hydrocortisone valerate modafinil adapalene CARAC mometasone furoate ROZEREM adapalene-benzoyl diclofenac sodium nolix SECONAL SODIUM peroxide fluorouracil prednicarbate XYREM amnesteem TACLONEX avar PICATO triamcinolone acetonide Seizure Control Drugs avita Antipruritics - Topical TRIANEX Anticonvulsants, Other benzepro doxepin hcl triderm BRIVIACT benzoyl peroxide bp foam PRUDOXIN levetiracetam Eczema Agents BPO roweepra DUPIXENT [SP] claravis Antipsoriatics acitretin Calcium Channel Modifying CLEANSING WASH calcipotriene Emollient/ Keratolytic Agents Agents clindacin etz calcitrene CEM-UREA CELONTIN clindamycin phos-tretinoin calcitriol k50 ethosuximide clindamycin-benzoyl COSENTYX 150MG [SP] rea-lo peroxide dapsone COSENTYX 300MG [SP] umecta urea Gamma-Aminobutyric Acid EPIDUO FORTE DRITHOCREME HP (GABA) Augmenting Agents erythromycin-benzoyl methoxsalen ure-k diazepam peroxide STELARA [SP] diazepam [INJ] myorisan tazarotene Emollients divalproex sodium neuac TAZORAC ammonium lactate divalproex sodium er ONEXTON retinoic acid Antiseborrheic Products Enzymes - Topical Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 20 of 22

collagenase M-M-R II VACCINE SANTYL Tetracyclines Protectants W/DILUENT All Agents CARAFATE PEDVAXHIB Immunomodulating Agents - coremino misoprostol PNEUMOVAX 23 [INJ] Topical minocycline hcl er sucralfate PREVNAR 13 imiquimod oxytetracycline hcl RABAVERT RECOMBIVAX HB Proton Pump Inhibitors Immunosuppressive Agents Thyroid Agents DEXILANT ROTATEQ tacrolimus Thyroid Hormones esomeprazole magnesium SHINGRIX PCCA T3 SODIUM FIRST-LANSOPRAZOLE STAMARIL Immunosuppressive Agents - DILUTION FIRST-OMEPRAZOLE tetanus diphtheria toxoids Topical lansoprazole TICE BCG ELIDEL Thyroid Replacement Drugs omeppi tice bcg [INJ] tacrolimus Hormonal Agents, Stimulant/ omeprazole TRUMENBA Replacement/ Modifying omeprazole-sodium TWINRIX Inflammatory Bowel Agents (Thyroid) bicarbonate TYPHIM VI STELARA [SP] ARMOUR THYROID pantoprazole sodium VARIVAX VACCINE levothyroxine sodium rabeprazole sodium VAXCHORA VACCINE Keratolytic/ Antimitotic Agents levoxyl VIVOTIF podofilox liothyronine sodium Ulcer Drugs/ YF-VAX salicylic acid NATURE-THROID Antispasmodics/ salicylic acid er np thyroid Anticholinergics Viral Vaccines salimez thyroid Antispasmodics AFLURIA QUAD 2018-2019 SALVAX unithroid isopropamide iodide FLUAD 2018-2019 WESTHROID scopolamine FLUBLOK QUAD 2018-2019 Leprostatics hydrobromide PROQUAD dapsone Thyroid Suppressing Drugs Antithyroid Agents Proton Pump Inhibitors Vaginal Products Local Anesthetics - Topical methimazole esomeprazole sodium Miscellaneous Vaginal Products capsaicin propylthiouracil TRIMO-SAN Urinary Anti-infectives Metabolic Modifiers Toxoids All Agents Vasopressors calcitriol Toxoid Combinations nalidixic acid All Agents PEDIARIX dobutamine hcl Nonsteroidal Anti- PENTACEL Vaccines dobutamine hcl in dextrose inflammatory Agents (NSAIDs) QUADRACEL DTAP-IPV All Agents dopamine hcl diclofenac sodium ACTHIB dopamine hcl in 5% Tuberculosis Drugs ADACEL dextrose Otic Combinations Antituberculars AFLURIA epinephrine hcl CORTANE-B CAPASTAT SULFATE [INJ] BEXSERO epinephrine-d5w cycloserine BIOTHRAX norepinephrine bitar-0.9% Rosacea Agents ethambutol hcl BOOSTRIX nacl FINACEA isoniazid DAPTACEL norepinephrine bitartrate MIRVASO norepinephrine bitartrate- isoniazid [INJ] diphtheria-tetanus toxoids- SOOLANTRA d5w PRIFTIN ped phenylephrine hcl-d5w pyrazinamide ENGERIX-B Tricyclic Agents rifampin FLUARIX doxepin hcl Vitamins SIRTURO FLULAVAL FLUZONE Water Soluble Vitamins Wound Care Products aminobenzoic acid Ulcer and Stomach Acid FLUZONE HIGH-DOSE REGRANEX calcium pantothenate Drugs GARDASIL 9 sodium ascorbate Histamine2 (H2) receptor HAVRIX Sulfonamides Antagonists HIBERIX All Agents cimetidine IMOVAX RABIES VACCINE Vitamins, Minerals, sulfamethoxazole famotidine INFANRIX Electrolytes sulfapyridine nizatidine IPOL [INJ] Electrolyte/ Mineral Modifiers sulfathiazole ranitidine hcl IXIARO CHEMET sulfisoxazole ranitidine hcl [INJ] MENACTRA EXJADE [SP] Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Page 21 of 22

FERRIPROX [SP] MYNATAL ADVANCE AQUASOL A JADENU [SP] MYNATAL PLUS ascorbic acid JADENU SPRINKLE [SP] MYNATAL-Z ascorbic acid [INJ] kionex MYNATE 90 PLUS b-complex [INJ] SAMSCA [SP] NEWGEN biotin sodium polystyrene OBSTETRIX DHA calcium ascorbate sulfonate PNV 29-1 cod liver oil sps PNV OB+DHA cyanocobalamin PNV-DHA cyanocobalamin [INJ] Electrolyte/ Mineral PNV-DHA + DOCUSATE d-biotin Replacement PNV-OMEGA ergocalciferol calcium carbonate PNV-SELECT fabb calcium gluconate PR NATAL 400 folic acid CARBAGLU [SP] PR NATAL 400 EC folic acid [INJ] cytra-k PR NATAL 430 FOLTANX effer-k PR NATAL 430 EC INFUVITE FERAHEME PRENA1 CHEW l-methyl-b6-b12 ferrous sulfate PRENA1 PEARL L-METHYLFOLATE- ISOLYTE S PRENA1 TRUE MECOBALAMIN-NAC k effervescent PRENAISSANCE L-METHYL-MC NAC klor-con PRENAISSANCE PLUS M.V.I. ADULT klor-con m PRENATABS RX M.V.I. PEDIATRIC klor-con sprinkle PRENATAL 19 METAFOLBIC klor-con-ef PRENATAL LOW IRON METAFOLBIC PLUS K-PHOS ORIGINAL PRENATAL PLUS n-acetyl-l-cysteine K-TAB PRENATAL VITAMIN PLUS NASCOBAL magnesium sulfate LOW IRON nephronex-sl magnesium sulfate [INJ] PRENATAL-U niacin MULTIGEN PREPLUS niacinamide phospho-trin 250 neutral PRETAB NUTRIVIT PLASMA-LYTE 148 SE-NATAL 19 phytonadione PLASMA-LYTE A PH 7.4 TARON PRENATAL phytonadione [INJ] potassium bicarbonate TARON-BC pyridoxine hcl potassium chl-normal TARON-C DHA pyridoxine hcl [INJ] saline TRINATAL RX 1 SUPPORT potassium chloride TRINATE thiamine hcl potassium citrate er TRI-TABS DHA thiamine hcl [INJ] potassium phosphate TRIVEEN-DUO DHA TL G-FOL OS sod ferric gluconate ULTIMATECARE ONE vitacel complex VINATE II vitamin a sodium chloride VINATE ONE vitamin d2 sodium chloride [INJ] VINATE-M vitamin e sodium fluoride VIRT-C DHA vitamin k [INJ] VELTASSA VIRT-NATE DHA wheat germ oil VENOFER VIRT-PN zinc sulfate VIRT-PN DHA Worm Infection Drugs VIRT-PN PLUS Anthelmintics Prenatal Vitamins VP-HEME OB + DHA ALBENZA BAL-CARE DHA ZATEAN-PN DHA benznidazole C-NATE DHA ZATEAN-PN PLUS EMVERM COMPLETE NATAL DHA ivermectin COMPLETENATE Therapeutic Nutrients/ mebendazole DOTHELLE DHA Minerals/ Electrolytes praziquantel ELITE-OB levocarnitine thiabendazole FOLIVANE-OB ringers HEMENATAL OB tis-u-sol HEMENATAL OB + DHA

MYNATAL Vitamins

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