Department of Human Services Approved PDL for IOWA Medicaid Program ALPHA DRUG LIST trusted, reliable, innovative

Highlighted drugs denote new changes to the Effective Date 01/01/2019 PDL since previous update

Column Header Explanations: P, N, R or NR: B, G or O: P = Preferred B = Brand N = Non-Preferred G = Generic R = Recommended O = OTC NR = Non-Recommended

B Drug Name Drug Category P, N, Comment or R or G NR A G Abacavir Sulfate Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues P G Abacavir Sulfate-Lamivudine-Zidovudine Antiretrovirals - Combinations NR G Abacavir-lamivudine Antiretrovirals - Combinations P B ABILIFY Antipsychotics - Atypicals N PA Required B ABILIFY DISCMELT Antipsychotics - Atypicals NP PA Required B ABILIFY MAINTENA Antipsychotics - Atypicals P B ABSORICA Acne Products: Isotretinoin N PA Required B ABSTRAL Narcotics - Misc. NP PA Required G Acamprosate Calcium Alcohol Deterrents P B ACANYA Topical - Acne Preparations P PA Required G Acarbose Diabetic - Alphaglucosidase P B ACCOLATE Antiasthmatic - Leukotriene Receptor Antagonists NP B ACCUPRIL ACE Inhibitors NP B ACCURETIC ACE and Thiazide Combo's NP G Acebutolol HCl Beta Blockers - Cardio Selective P O Acetaminophen Analgesics - Misc. P G Acetaminophen w/ Codeine Narcotics - Misc. P PA Required < 18 years of age G Acetazolamide Diuretics P G Acetic Acid Urological - Misc. P G Acetic Acid (Otic) Ear P G Acetic Acid-Aluminum Acetate Ear NP G Acetylcysteine Antiasthmatic - Mucolytics P

12/17/2018 9:18:23 AM Page 1 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ACIPHEX Gi - Proton Pump Inhibitor NP PA Required G Acitretin Anti-Psoriatics - Non-Biologicals NP B ACTEMRA Anti-Inflammatories, Non-Nsaid NP PA Required B ACTIGALL Gi - Misc. NP B ACTIMMUNE Interferon Gamma NP B ACTIQ Narcotics - Misc. NP PA Required B ACTIVASE Tissue Plasminogen Activator P B ACTIVELLA Estrogen Combos NP B ACTONEL Osteoporosis NP B ACTOPLUS MET Diabetic - Thiazol / Biguanide Combo NP B ACTOPLUS MET XR Diabetic - Thiazol / Biguanide Combo NP B ACTOS Diabetic - Thiazol NP B ACULAR Op. Nsaid'S NP B ACUVAIL Op. Nsaid'S NP G Acyclovir Herpes Agents P G Acyclovir Sodium Herpes Agents P G Acyclovir SUSP Herpes Agents P G Acyclovir Topical Topical - Antivirals NP B Aczone Topical - Acne Preparations N PA Required B ADALAT CC Calcium Channel Blockers--Nifedipines NP G Adapalene cream Topical - Acne Preparations NP PA Required G Adapalene gel 0.1% Topical - Acne Preparations P PA Required G Adapalene gel 0.3% Topical - Acne Preparations P PA Required G Adapalene lotion Topical - Acne Preparations NP PA Required G adapalene solution Topical - Acne Preparations N PA Required G Adapalene/benzoyl peroxide Topical - Acne Preparations N PA Required B ADCIRCA Pulmonary Anti-Hypertensives NP Grandfather Existing Users B ADDERALL Stimulants - Amphetamines - Short Acting NP PA Required B ADDERALL XR Stimulants - Amphetamines - Long Acting NP PA Required G Adefovir Dipivoxil Hepatitis B Only NP B ADEMPAS Pulmonary Anti-Hypertensives NP PA Required B Adlyxin Diabetic - Non-Insulin Injectables N PA Required B Admelog Diabetic - Insulin N B Admelog Solostar Diabetic - Insulin Penfills N PA Required

12/17/2018 9:18:23 AM Page 2 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ADOXA Tetracyclines NP PA Required B ADRENACLICK Anaphylaxis Therapy NP B ADRENALIN Anaphylaxis Therapy NP B ADVAIR Antiasthmatic - Adrenergic Combos P B ADVAIR HFA Antiasthmatic - Adrenergic Combos P B ADVATE Antihemophilia Factor VIII Agents P B ADVICOR Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B Adynovate Antihemophilia Factor VIII Agents N B Adzenys er oral suspension Stimulants N PA Required B Adzenys XR ODT STIMULANTS NP PA Required B AEROSPAN Antiasthmatic - Steroid Inhalants N B AFINITOR Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B Afluria 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Afluria PF 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Afluria Quad 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B AFREZZA Diabetic - Insulin NP B Afstyla Antihemophilia Factor VIII Agents N B AGGRENOX Platelet Aggr. Inhibitors / Combo's - Misc. P B AGRYLIN Platelet Aggr. Inhibitors / Combo's - Misc. NP B A-HYDROCORT Glucocorticoids - Mineralocorticoids P B Aimovig CGRP Inhibitors N PA Required B Airduo respiclick Antiasthmatic - Adrenergic Combos N B Ajovy CGRP Inhibitors N PA Required B AKNE-MYCIN Topical - Acne Preparations NP PA Required B AKYNZEO Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ALBENZA Anthelmintics P G Albumin, Human Electrolytes/ Nutritionals NP G Albuterol Sulfate NEBU 0.63MG/3 Antiasthmatic - Beta - Adrenergics P Preferred < 2 years of age G Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Syrup 2 MG/5ML Antiasthmatic - Beta - Adrenergics P

12/17/2018 9:18:23 AM Page 3 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A G Albuterol Sulfate Tab 2 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab 4 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab SR 12HR 4 MG Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Tab SR 12HR 8 MG Antiasthmatic - Beta - Adrenergics P B ALCAINE Op. Misc NP G Alclometasone Dipropionate Topical - Corticosteroids - Low Potency N PA Required B ALDACTAZIDE TAB 25/25 Diuretics NP B ALDACTAZIDE TABS 50/50 Diuretics P B ALDACTONE Diuretics NP B ALDARA Topical - Genital Warts NP Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks (112 days). B ALDURAZYME Mucopolysaccharidosis P B Alecensa Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required G Alendronate Sodium Osteoporosis P G Alendronate Sodium SOLN Osteoporosis NP G Alfuzosin HCl BPH P B ALINIA Antiprotozoal Agents P B ALKERAN Antineoplastics - Nitrogen Mustards R G Allopurinol Gout P G Almotriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ALOCRIL Op. Antiallergics - Mast Cell Stabilizers NP G Alogliptin Diabetic - Other N PA Required G Alogliptin-metformin Diabetic - Other N PA Required G Alogliptin-pioglitazone Diabetic - Other N PA Required B ALOMIDE Op. Antiallergics - Mast Cell Stabilizers NP B ALORA Estrogens - Patches P G Alosetron Gi - Irritable Bowel Syndrome Agents NP B ALOXI Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ALPHAGAN P SOL 0.1% Op. Selective Alpha Adrenergic Agonists P B ALPHAGAN P SOLN 0.15% Op. Selective Alpha Adrenergic Agonists P B ALPHANATE Antihemophilia Factor von Willebrand Factor Agents P B ALPHANINE SD Antihemophilia Factor IX Agents P G Alprazolam Anxiolytics - Benzodiazepines P

12/17/2018 9:18:23 AM Page 4 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ALPRAZOLAM INTENSOL Anxiolytics - Benzodiazepines P G Alprazolam Tab SR 24HR 0.5 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 1 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 2 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 3 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tablet Disperse Anxiolytics - Benzodiazepines NP PA Required B ALPROLIX Antihemophilia Factor IX Agents P B ALREX Op. Antiinflammatory / Steroids Ophth. P B ALTABAX Topical - Antibiotic NP B ALTACE ACE Inhibitors NP B ALTOPREV Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B Alunbrig Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B ALVESCO Antiasthmatic - Steroid Inhalants NP G Amantadine HCl Cap 100 MG Anti-Parkinsonian Drugs P G Amantadine HCl Syrup 50 MG/5ML Anti-Parkinsonian Drugs P G Amantadine HCl Tab 100 MG Anti-Parkinsonian Drugs NP B AMARYL Diabetic - Oral Sulfonylureas NP B AMBIEN Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBIEN CR Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBISOME Antifungals - Assorted P PA Required > 90 days G Amcinonide Cream 0.1% Topical - Corticosteroids - High Potency N PA Required G Amcinonide LOTN Topical - Corticosteroids - High Potency N PA Required G Amcinonide OINT Topical - Corticosteroids - High Potency N PA Required B AMERGE Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B Amicar Hemostatic P G Amikacin Sulfate Amino Glycosides P G Amiloride & Hydrochlorothiazide Diuretics P G Amiloride HCl Diuretics P G Amino Acid Electrolyte Infusion Electrolytes/ Nutritionals P G Amino Acid Infusion Electrolytes/ Nutritionals NP G Amino Acid Infusion SOLN 6% Electrolytes/ Nutritionals P G Aminocaproic Acid Hemostatic P G Aminophylline Antiasthmatic - Xanthines P B AMINOSYN Electrolytes/ Nutritionals P

12/17/2018 9:18:23 AM Page 5 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B AMINOSYN II Electrolytes/ Nutritionals P B AMINOSYN-HBC Electrolytes/ Nutritionals NP B AMINOSYN-PF Electrolytes/ Nutritionals NP G Amiodarone HCl Tab 200 MG Antiarrhythmics P G Amiodarone HCl TABS 400MG Antiarrhythmics NP B AMITIZA GI, Constipation - IBS-OIC P PA Required G Amitriptyline HCl Antidepressants - Tri-Cyclics P G Amlodipine Besylate Calcium Channel Blockers--Amlodipines P G Amlodipine Besylate-Atorvastatin Calcium CCB / Lipid NP G Amlodipine Besylate-Benazepril HCl ACE Inhibitors And Calcium Channel Blockers P G Amlodipine Besylate-Valsartan Arb/Ccb P G Amlodipine-olmesartan Arb/Ccb P G Amlodipine-Valsartan-Hydrochlorothiazide ARB/CCB Plus Diuretics P B AMMONUL Urea Cycle Disorder - Agents NP G Amoxapine Antidepressants - Tri-Cyclics P G Amoxicillin & K Clavulanate Chew Tab 200-28.5 MG Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin & K Clavulanate Chew Tab 400-57 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate For Susp 200-28.5 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate For Susp 250-62.5 MG/5ML Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate For Susp 600-42.9 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate Tab 250-125 MG Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin & K Clavulanate Tab 500-125 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate Tab 875-125 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & Pot Clavulanate Tablet ER 12HR Beta-Lactams / Clavulanate Combo'S NP PA Required G Amoxicillin (Trihydrate) Cap 250 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Chew Tab 125 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Chew Tab 250 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 125 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 200 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 250 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 400 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Tab 500 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Tab 875 MG Beta-Lactams / Clavulanate Combo'S P

12/17/2018 9:18:23 AM Page 6 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A G Amoxicillin (Trihydrate) Tab SR 24HR 775 MG Beta-Lactams / Clavulanate Combo'S NP PA required G Amoxicillin-Clarithromycin w/ Lansoprazole Gi - Ulcer Anti-Infective NP G Amphetamine-Dextroamphetamine Stimulants - Amphetamines - Short Acting P PA Required >= 21 yo. G Amphetamine-Dextroamphetamine ER Stimulants - Amphetamines - Long Acting P PA Required >= 21 yo. G Ampicillin Beta-Lactams / Clavulanate Combo'S P G Ampicillin & Sulbactam Sodium Beta-Lactams / Clavulanate Combo'S P B AMPYRA Multiple Sclerosis Agents – Non-Interferons P PA Required B AMRIX Muscle Relaxants NP PA Required B AMTURNIDE Antihypertensive Combos NP B ANAFRANIL Antidepressants - Tri-Cyclics NP Initial fill limited to 15 day supply. G Anagrelide HCl Platelet Aggr. Inhibitors / Combo's - Misc. P B ANAPROX NSAIDS NP PA Required B ANASPAZ Gi - Antidiarrheal / Antacid - Misc. P G Anastrozole Antineoplastics - Aromatase Inhibitors R B ANCOBON Antifungals - Assorted P PA Required > 90 days B ANDRODERM Androgens -Topical P PA Required B Androgel Pump Androgens -Topical N PA Required B ANDROID Androgens - Anabolics N PA Required B ANDROXY Androgens - Anabolics P B ANGELIQ Estrogen Combos P B Angrogel Packets Androgens -Topical N PA Required B ANORO ELLIPTA Antiasthmatic - Adrenergic Combos NP B ANTABUSE Alcohol Deterrents NP B ANTARA Cholesterol - Fibric Acid Derivatives NP G Antipyrine-Benzocaine Ear P B ANUSOL-HC Anorectal - Misc. NP B ANZEMET Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B APIDRA Diabetic - Insulin NP B APIDRA Diabetic - Insulin Penfills NP PA Required B APLENZIN Antidepressants - Selected SSRI's NP PA Required B APOKYN Parkinsons - Selected Dopamin Agonists P G Apraclonidine HCl Op. Selective Alpha Adrenergic Agonists NP G Aprepitant Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin N PA Required B APRISO CAP 0.375GM Gi - Inflammatory Bowel Agents P

12/17/2018 9:18:23 AM Page 7 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B Aptensio XR Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. B APTIOM Anticonvulsants NP B APTIVUS Antiretrovirals - Protease Inhibitors NR O AQUADEKS Vitamins - Misc. P PA Required B ARALAST Alpha-Proteinase Inhibitor NP PA Required B ARANESP ALBUMIN FREE Erythropoeisis Stimulating Agents NP PA Required B ARAVA Rheumatoid Arthritis - Non-Biologicals NP B ARCAPTA NEOHALER Antiasthmatic - Beta - Adrenergics NP B ARICEPT Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B ARICEPT ODT Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B ARIMIDEX Antineoplastics - Aromatase Inhibitors NR G aripiprazole odt Antipsychotics - Atypicals N PA Required G aripiprazole sol Antipsychotics - Atypicals N G aripiprazole tablets Antipsychotics - Atypicals P B ARISTADA Antipsychotics - Atypicals P B ARIXTRA Anticoagulants NP G Armodafinil Stimulants - Other Stimulants / Like Stimulants P PA Required >= 21 yo. B Armonair respiclick Antiasthmatic - Steroid Inhalants N B ARMOUR THYROID Thyroid Hormones NP Grandfather Existing Users B ARNUITY ELLIPTA Antiasthmatic - Steroid Inhalants NP B AROMASIN Antineoplastics - Aromatase Inhibitors NP B ARTHROTEC NSAIDS NP PA Required O Artificial Tear Ointment Op. Misc P O Artificial Tear Solution Op. Misc P B Arymo er Narcotics - Misc. N PA Required G Asa/dipyridamole Platelet Aggr. Inhibitors / Combo's - Misc. NP B ASACOL HD TAB 800MG Gi - Inflammatory Bowel Agents NP B ASMANEX Antiasthmatic - Steroid Inhalants P B Asmanex HFA Antiasthmatic - Steroid Inhalants N O Aspirin Analgesics - Misc. P O Aspirin Buffered Analgesics - Misc. P B ASTAGRAF XL Immunosuppressants NP PA Required B ASTEPRO Antihistamines - Non-Sedating NP

12/17/2018 9:18:23 AM Page 8 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ATACAND ARB'S NP B ATACAND HCT ARB'S And Diuretics NP G Atazanavir Antiretrovirals - Protease Inhibitors P B ATELVIA Osteoporosis NP G Atenolol Beta Blockers - Cardio Selective P G Atenolol & Chlorthalidone Beta Blockers And Diuretic Combo'S P B ATIVAN Anxiolytics - Benzodiazepines NP PA Required G atomoxetine Stimulants - Other Stimulants / Like Stimulants P PA Required >= 21 yo. G Atorvastatin Calcium Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Atovaquone Antiprotozoal Agents P G Atovaquone-proguanil Antimalarial Agents P G Atracurium Besylate Anti-Parkinsonian Drugs NP B ATRALIN Topical - Tretinoids N PA Required B ATRIPLA Antiretrovirals - Combinations R G Atropine Sulfate Gi - Antidiarrheal / Antacid - Misc. P G Atropine Sulfate (Ophthalmic) Op. Cycloplegics P B ATROVENT Antiasthmatic - Nasal Misc. NP B ATROVENT HFA Antiasthmatic - Anti-Cholinergics P B ATROVENT NAS SOL 0.06% Antiasthmatic - Nasal Misc. NP B AUBAGIO Multiple Sclerosis Agents – Non-Interferons P No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months B AUGMENTIN SUS 125/5ML Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN SUS 250/5ML Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN SUS ES-600 Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN TAB 500MG Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN TAB 875MG Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN XR Beta-Lactams / Clavulanate Combo'S NP PA Required B AURYXIA Phosphate Binders NP B Austedo Neurologics - Misc. P PA required B AVALIDE ARB'S And Diuretics NP B AVANDAMET Diabetic - Thiazol / Biguanide Combo NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B AVANDARYL Diabetic - Sulfonylurea / Biguanide NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis

12/17/2018 9:18:23 AM Page 9 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B AVANDIA Diabetic - Thiazol NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B AVAPRO ARB'S NP B AVEED Androgens - Anabolics NP PA Required B AVODART BPH NP Grandfather Existing Users B AVONEX Multiple Sclerosis Agents – Interferons P B AVONEX PEN Multiple Sclerosis Agents – Interferons P B AXERT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B AXID Gi - H2-Antagonists NP B AXIRON Androgens -Topical NP PA Required B AYGESTIN Progestins NP B AZACTAM Antibiotics - Misc. P B AZACTAM IN DEXTROSE Antibiotics - Misc. NP B AZASAN Purine Analog P B AZASITE Op. Antibiotics NP G Azathioprine Purine Analog P G AZELASTINE SPR 0.1% Antihistamines - Non-Sedating P G AZELASTINE SPR 0.15% Antihistamines - Non-Sedating NP G Azelastine HCl (Ophth) Op. Antiallergics - Antihistamines P B AZELEX Topical - Acne Preparations P PA Required B AZILECT Anti-Parkinsonian Drugs NP G Azithromycin For Susp 100 MG/5ML Macrolides / Erythromycin'S / Ketolides P G Azithromycin For Susp 200 MG/5ML Macrolides / Erythromycin'S / Ketolides P G Azithromycin IV For Soln 500 MG Macrolides / Erythromycin'S / Ketolides NP G Azithromycin Powd Pack for Susp 1 GM Macrolides / Erythromycin'S / Ketolides P G Azithromycin Tab 250 MG Macrolides / Erythromycin'S / Ketolides P G Azithromycin Tab 500 MG Macrolides / Erythromycin'S / Ketolides P G Azithromycin Tab 600 MG Macrolides / Erythromycin'S / Ketolides P B AZOPT Op. Carbonic Anhydrase Inhibitors/Combo N B AZOR Arb/Ccb NP G Aztreonam Antibiotics - Misc. NP B AZULFIDINE Gi - Inflammatory Bowel Agents NP B G Bacitracin (Ophthalmic) Op. Antibiotics NP

12/17/2018 9:18:23 AM Page 10 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR B O Bacitracin (Topical) Topical - Antibiotic P G Bacitracin-Polymyxin B (Ophth) Op. Antibiotics P G Bacitracin-Poly-Neomycin-HC Op. Antiinflammatory / Steroids Ophth. P G Baclofen Muscle Relaxants P G bacteriostatic water for injection Compounding Materials P B BACTOCILL IN DEXTROSE Beta-Lactams / Clavulanate Combo'S P B BACTRIM Anti Infective Combo's - Misc. NP B BACTROBAN CRE 2% Topical - Antibiotic NP B BACTROBAN NASAL Topical - Nasal Antibiotics P B BACTROBAN OINT Topical - Antibiotic NP B Balcoltra Contraceptives - Monophasic Combination O/C'S N G Balsalazide Disodium Gi - Inflammatory Bowel Agents P B BANZEL Anticonvulsants NP B BARACLUDE Hepatitis B Only N B Basaglar Diabetic - Insulin Penfills N PA Required B Baxdela Tablets Fluoroquinolones N O B-Complex w/ C & Folic Acid Tab 0.8 MG Vitamins - Misc. N PA Required G B-Complex w/ C & Folic Acid Tab 1 MG Vitamins - Misc. N PA Required B BEBULIN Antihemophilia Factor IX Agents P B BECONASE AQ Nasal Steroids NP B Belbuca Narcotics - Misc. N PA Required B BELSOMRA Sedative/Hypnotics - Non-Benzodiazepines NP PA Required G Benazepril & Hydrochlorothiazide ACE and Thiazide Combo's P G Benazepril HCl ACE Inhibitors P B BENEFIX Antihemophilia Factor IX Agents P B BENICAR ARB'S NP B BENICAR HCT ARB'S And Diuretics NP B Benlysta SLE agents N B BENTYL CAP 10MG Gi - Antidiarrheal / Antacid - Misc. NP B BENTYL INJ 10MG/ML Gi - Antidiarrheal / Antacid - Misc. NP B BENTYL TAB 20MG Gi - Antidiarrheal / Antacid - Misc. NP B BENZACLIN GEL 1-5%PUMP Topical - Acne Preparations N PA Required B BENZACLIN GEL 1-5% Topical - Acne Preparations NP PA Required B BENZAMYCIN Topical - Acne Preparations NP PA Required

12/17/2018 9:18:23 AM Page 11 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR B B BENZAMYCIN GEL PAK Topical - Acne Preparations NP PA Required G Benznidazole Anthelmintics P Preferred for indicated age group (2 to 12 years of age) O Benzoyl Peroxide Topical - Acne Preparations P G Benzoyl Peroxide-Erythromycin Topical - Acne Preparations N PA Required G Benztropine Mesylate Inj 1 MG/ML Parkinsons - Anticholinergics NP G Benztropine Mesylate Tab 0.5 MG Parkinsons - Anticholinergics P G Benztropine Mesylate Tab 1 MG Parkinsons - Anticholinergics P G Benztropine Mesylate Tab 2 MG Parkinsons - Anticholinergics P B BEPREVE Op. Antiallergics - Antihistamines NP B BESIVANCE Op. Quinolones N B BETAGAN Op. Beta - Blockers NP G Betamethasone Dipropionate (Topical) LOTN Topical - Corticosteroids - Medium Potency N PA Required G Betamethasone Dipropionate (Topical) OINT Topical - Corticosteroids - High Potency P G Betamethasone Dipropionate Augmented Cream 0.05% Topical - Corticosteroids - High Potency P G Betamethasone Dipropionate Augmented Gel 0.05% Topical - Corticosteroids - High Potency N PA Required G Betamethasone Dipropionate Augmented Lotion 0.05% Topical - Corticosteroids - High Potency N PA Required G Betamethasone Dipropionate Augmented Oint 0.05% Topical - Corticosteroids - High Potency N PA Required G Betamethasone Dipropionate Cream 0.05% Topical - Corticosteroids - High Potency P G Betamethasone Valerate Topical - Corticosteroids - Medium Potency P G Betamethasone Valerate FOAM Topical - Corticosteroids - Medium Potency N PA Required B BETAPACE Beta Blockers - Non Selective NP B BETAPACE AF Beta Blockers - Non Selective NP B BETASERON Multiple Sclerosis Agents – Interferons P G Betaxolol HCl Beta Blockers - Cardio Selective NP G Betaxolol HCl (Ophth) Op. Beta - Blockers NP G Bethanechol Chloride Cholinergic P B BETHKIS Amino Glycosides N B BETIMOL Op. Beta - Blockers NP B BETOPTIC-S Op. Beta - Blockers P B Bevespi Aerosphere Antiasthmatic - Adrenergic Combos P G Bexarotene Antineoplastics - Selective Retinoid X Receptor Agonists NP B BEYAZ Contraceptives - Monophasic Combination O/C'S NP B BIAXIN SUS 250/5ML Macrolides / Erythromycin'S / Ketolides NP

12/17/2018 9:18:23 AM Page 12 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR B B BIAXIN TAB 250MG Macrolides / Erythromycin'S / Ketolides NP B BIAXIN TAB 500MG Macrolides / Erythromycin'S / Ketolides NP G Bicalutamide Antineoplastics - Antiandrogens R B BICILLIN Beta-Lactams / Clavulanate Combo'S P B BIDIL Antianginals--Isosorbide Nitrate NP B Biktarvy Antiretrovirals - Combinations P B BILTRICIDE Anthelmintics P G BIMATOPROST Op. Prostaglandins NP B BINOSTO Osteoporosis NP PA Required G Bisoprolol & Hydrochlorothiazide Beta Blockers And Diuretic Combo'S P G Bisoprolol Fumarate Beta Blockers - Cardio Selective P B BIVIGAM Immune Serums P B BLEPH-10 Op. Antibiotics NP B BLEPHAMIDE Op. Antiinflammatory / Steroids Ophth. N B Blephamide S.O.P. Op. Antiinflammatory / Steroids Ophth. N B BONIVA Osteoporosis NP B Bonjesta Antiemetic - Anticholinergic / Dopaminergic N B BOSULIF Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B BREO ELLIPTA Antiasthmatic - Adrenergic Combos NP B BREVICON-28 Contraceptives - Monophasic Combination O/C'S N B BRILINTA Platelet Aggregation Inhibitors P G Brimonidine Tartrate Ophth Soln 0.2% Op. Selective Alpha Adrenergic Agonists P G Brimonidine Tartrate SOLN 0.15% Op. Selective Alpha Adrenergic Agonists NP B BRISDELLE Antidepressants - Selected SSRI's NP B Briviact Anticonvulsants N G Bromfenac Sodium (Ophth) Op. Nsaid'S NP G Bromocriptine Mesylate 2.5mg tabs Anti-Parkinsonian Drugs P G Bromocriptine Mesylate 5 MG Cap Anti-Parkinsonian Drugs N B Bromsite Op. Nsaid'S N B BROVANA Antiasthmatic - Beta - Adrenergics NP G Budesonide Glucocorticoids - Mineralocorticoids P G Budesonide (Inhalation) Antiasthmatic - Steroid Inhalants P Preferred < 8yo G Budesonide (Nasal) Nasal Steroids NP G budesonide sus 1mg/2ml Antiasthmatic - Steroid Inhalants NP

12/17/2018 9:18:23 AM Page 13 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR B G Bumetanide Diuretics P B BUNAVAIL Narcotics - Misc. NP PA Required B BUPHENYL Urea Cycle Disorder - Agents P G Bupivacaine in Dextrose Topical - Local Anesthetics NP B BUPRENEX Narcotics - Selected NP PA Required G Buprenorphine HCl Narcotics - Misc. NP PA Required G Buprenorphine HCl Narcotics - Selected NP PA Required G BUPRENORPHINE PATCH Narcotics - Misc. N PA Required G buprenorphine-naloxone sl tabs Narcotics - Misc. P PA Required G Bupropion HCl (Smoking Deterrent) Smoking Cessation (Oral) P PA Required G Bupropion HCl Tab 100 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab 75 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 12HR 100 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 12HR 150 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 12HR 200 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 24HR 150 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 24HR 300 MG Antidepressants - Selected SSRI's P G Buspirone HCl Tab 10 MG Anxiolytics - Misc. P G Buspirone HCl Tab 15 MG Anxiolytics - Misc. P G Buspirone HCl Tab 5 MG Anxiolytics - Misc. P G Buspirone HCl Tab 7.5 MG Anxiolytics - Misc. P G Buspirone HCl TABS 30MG Anxiolytics - Misc. NP BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg tablets G Butalbital-Acetaminophen Tab 50-325 MG Analgesics - Misc. P G Butalbital-Acetaminophen-Caff w/ COD Cap 50-300-40-30 MG Narcotics - Misc. NP PA Required G Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG Narcotics - Misc. P G Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG Analgesics - Misc. P G Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG Analgesics - Misc. P G Butalbital-Aspirin-Caffeine Analgesics - Misc. P G Butalbital-Aspirin-Caffeine w/Cod Narcotics - Misc. NP PA Required B BUTISOL SODIUM Sedative/Hypnotics - Barbiturate NP G Butorphanol Tartrate Narcotics - Selected P PA Required B BUTRANS Narcotics - Misc. NP PA Required B BYDUREON Diabetic - Non-Insulin Injectables P PA Required

12/17/2018 9:18:23 AM Page 14 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR B B Bydureon bcise Diabetic - Non-Insulin Injectables N PA Required B BYETTA Diabetic - Non-Insulin Injectables P PA Required B BYSTOLIC Beta Blockers - Cardio Selective NP PA Required B Byvalson Beta Blockers - Cardio Selective N C G Cabergoline Dopamine Receptor Agonists P B Cabometyx Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B CADUET CCB / Lipid NP B CAFERGOT Migraine - Ergot Combinations NP B Calan Calcium Channel Blockers--Verapamils N B Calan SR Calcium Channel Blockers--Verapamils N G Calcipotriene Anti-Psoriatics - Non-Biologicals P G Calcipotriene-Betamethasone Dipropionate Topical - Steroid Combinations NP G Calcitonin (Salmon) Osteoporosis P G Calcitriol Hyperparathyroid Treatment - Vitamin D Analogs P O Calcium & Phosphorus w/ Vitamin D Tab 105 MG-81 MG-120 Unit Minerals NP G Calcium Acetate Capsules (Phosphate Binder) Phosphate Binders P G Calcium Acetate Tablets (Phosphate Binder) Phosphate Binders P O Calcium Carbonate Minerals P PA Required O calcium carbonate-vitamin d tab Minerals P PA Required O Calcium citrate Minerals P PA Required B CALDOLOR NSAIDS NP PA Required B Calquence Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B CAMBIA NSAIDS NP PA Required B Canasa Gi - Inflammatory Bowel Agents P B CANCIDAS Antifungals - Assorted P PA Required > 90 days G Candesartan Cilexetil ARB'S NP G Candesartan Cilexetil-Hydrochlorothiazide ARB'S And Diuretics NP G Capecitabine Antineoplastics - Antimetabolites NP PA Required B CAPEX Topical - Corticosteroids - Medium Potency P B CAPITAL/CODEINE Narcotics - Misc. NP PA Required B CAPRELSA Antineoplastics - Protein-Tyrosine Kinase Inhibitors R Initial fill limited to 15 day supply. G Captopril ACE Inhibitors P G Captopril & Hydrochlorothiazide ACE and Thiazide Combo's P

12/17/2018 9:18:23 AM Page 15 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C B CARAC Topical - Antineoplastics NP B CARAFATE SUS 1GM/10ML Gi - Misc. Anti-Ulcer NP B CARAFATE TAB 1GM Gi - Misc. Anti-Ulcer NP G Carbamazepine Anticonvulsants P G Carbamazepine Capsule ER 12HR Anticonvulsants P G Carbamazepine SUSP Anticonvulsants NP Grandfather for seizure disorder. G Carbamazepine Tablet ER 12HR Anticonvulsants P B CARBATROL Anticonvulsants NP Grandfather for seizure disorder. G Carbidopa-Levodopa Anti-Parkinsonian Drugs P G Carbidopa-Levodopa-Entacapone Anti-Parkinsonian Drugs P G Carbinoxamine Maleate Antihistamines - Other NP PA Required B CARBOCAINE Topical - Local Anesthetics NP B CARDIZEM Calcium Channel Blockers--Diltiazems NP B CARDIZEM CD Calcium Channel Blockers--Diltiazems NP B CARDIZEM LA Calcium Channel Blockers--Diltiazems NP B CARDURA BPH NP B CARDURA XL BPH NP PA Required B CARIMUNE NANOFILTERED Immune Serums P G Carisoprodol Muscle Relaxants NP PA Required G Carisoprodol w/ Aspirin Muscle Relaxant -Combinations NP PA Required G Carisoprodol w/ Aspirin & Codeine Muscle Relaxant -Combinations NP PA Required B CARNITOR INJ 1GM/5ML Carnitine Replenisher - Agents NP B CARNITOR SOL 1GM/10ML Carnitine Replenisher - Agents P B CARNITOR TAB 330MG Carnitine Replenisher - Agents P B CARNITOR SF SOL 1GM/10ML Carnitine Replenisher - Agents P B Carospir Diuretics N G Carteolol HCl (Ophth) Op. Beta - Blockers P G Carvedilol Beta Blockers - Alpha / Beta P G Carvedilol er Beta Blockers - Alpha / Beta N PA Required B CASODEX Antineoplastics - Antiandrogens NR Requires a Selected Brand Name Drug PA B CATAPRES Antihypertensives - Central NP B CATAPRES-TTS Antihypertensives - Central P B CATHFLO ACTIVASE Tissue Plasminogen Activator P B CAYSTON Antibiotics - Misc. P PA Required < 7 years of age

12/17/2018 9:18:23 AM Page 16 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C B CEDAX Cephalosporins NP G Cefaclor Cap 250 MG Cephalosporins NP G Cefaclor Cap 500 MG Cephalosporins NP G Cefaclor For Susp 125 MG/5ML Cephalosporins NP G Cefaclor For Susp 250 MG/5ML Cephalosporins NP G Cefaclor For Susp 375 MG/5ML Cephalosporins NP G Cefaclor Monohydrate Tab SR 12HR 500 MG Cephalosporins NP G Cefadroxil Cap 500 MG Cephalosporins P G Cefadroxil For Susp 250 MG/5ML Cephalosporins P G Cefadroxil For Susp 500 MG/5ML Cephalosporins P G Cefadroxil Tab 1 GM Cephalosporins NP G Cefazolin in D5W Cephalosporins P G Cefazolin Sodium Cephalosporins P G Cefdinir Cephalosporins P G Cefditoren Pivoxil Cephalosporins NP G Cefepime HCl Cephalosporins P G Cefepime HCl and Dextrose Cephalosporins NP G Cefixime oral suspension Cephalosporins NP G Cefotaxime Sodium Cephalosporins NP G Cefpodoxime Proxetil Cephalosporins NP G Cefprozil Cephalosporins P G Ceftazidime Cephalosporins P G Ceftibuten Cephalosporins NP B CEFTIN Cephalosporins NP G Ceftriaxone Sodium Cephalosporins P G Ceftriaxone Sodium in Dextrose Cephalosporins P G Cefuroxime Axetil Tab 250 MG Cephalosporins P G Cefuroxime Axetil Tab 500 MG Cephalosporins P G Cefuroxime Sodium Cephalosporins P B CELEBREX Cox 2 Inhibitors - Selective NP PA Required G Celecoxib Cox 2 Inhibitors - Selective NP PA Required B CELESTONE-SOLUSPAN Glucocorticoids - Mineralocorticoids NP B CELEXA Antidepressants - Selected SSRI's NP B CELLCEPT Immunosuppressants NP

12/17/2018 9:18:23 AM Page 17 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C B CELLCEPT SUSR Immunosuppressants P B CENESTIN Estrogens - Tabs P B CENTANY AT Topical - Antibiotic NP G Cephalexin Cephalosporins P G Cephalexin CAPS 750MG Cephalosporins P G Cephalexin TABS Cephalosporins NP B CERDELGA Agents For Gaucher Disease NP B CEREZYME Agents For Gaucher Disease NP B CESAMET Antiemetic - Tetrahydrocannabinol (THC) Derivatives NP O Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) Antihistamines - Non-Sedating P O Cetirizine HCl Tab 10 MG Antihistamines - Non-Sedating P O Cetirizine HCl Tab 5 MG Antihistamines - Non-Sedating P G Cevimeline HCl Artificial Saliva/Stimulants NP B CHANTIX Smoking Cessation (Oral) P PA Required B CHANTIX CONTINUING MONTHPAK Smoking Cessation (Oral) P PA Required B CHANTIX STARTING MONTH PAK Smoking Cessation (Oral) P PA Required B CHEMET Antidotes - Chelating Agents P G Chloramphenicol Sodium Succinate Lincosamides / Oxazolidinones / Leprostatics NP G Chlordiazepoxide HCl Anxiolytics - Benzodiazepines P G Chlordiazepoxide-Amitriptyline Psychotherapeutic Combination P G Chlorhexidine Gluconate Soln 0.12% Mouth Antiseptics P G Chloroquine Phosphate Antimalarial Agents P G Chlorothiazide Sodium Diuretics NP G Chlorothiazide Tab Diuretics P O Chlorpheniramine Maleate Antihistamines - Other P G Chlorpromazine HCl Antipsychotics - Typical NP Grandfather Existing Users G Chlorpropamide Diabetic - Oral Sulfonylureas P G Chlorthalidone Diuretics P G Chlorzoxazone Muscle Relaxants P B CHOLBAM Gi - Misc. NP O Cholecalciferol Vitamins P PA required O Cholecalciferol cap 10000 unit Vitamins P PA required O Cholecalciferol Tab 50000 Unit Vitamins N PA Required G Cholestyramine Cholesterol - Bile Sequestrants P

12/17/2018 9:18:23 AM Page 18 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C G Cholestyramine Light Cholesterol - Bile Sequestrants P G Ciclopirox Gel 0.77% Topical - Antifungals NP G Ciclopirox Olamine Topical - Antifungals P G Ciclopirox Shampoo 1% Topical - Antifungals NP G Ciclopirox Solution 8% Topical - Antifungals P G Cidofovir Cyto-Megalovirus Agents N G Cilostazol Platelet Aggr. Inhibitors / Combo's - Misc. P B CILOXAN OIN 0.3% OP Op. Quinolones N B CILOXAN SOL 0.3% OP Op. Quinolones NP B Cimduo Antiretrovirals - Combinations P G Cimetidine Gi - H2-Antagonists P B CIMZIA Anti-Inflammatories, Non-Nsaid NP PA Required B CIPRO (10%) SUS 500MG/5 Fluoroquinolones NP B CIPRO (5%) SUS 250MG/5 Fluoroquinolones NP B CIPRO HC Ear P B CIPRO TABS Fluoroquinolones NP B Cipro XR Fluoroquinolones N PA Required B CIPRODEX Ear P Preferred < 8yo G Ciprofloxacin HCl (Ophth) Op. Quinolones P G Ciprofloxacin HCl Tab 100 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin HCl Tab 250 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin HCl Tab 500 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin HCl Tab 750 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin IV Soln 200 MG/20ML (1%) Fluoroquinolones P G Ciprofloxacin IV Soln 400 MG/40ML (1%) Fluoroquinolones P G ciprofloxacin otic Ear N G Ciprofloxacin-Ciprofloxacin HCl Fluoroquinolones P G Citalopram Hydrobromide Antidepressants - Selected SSRI's P B CLAFORAN Cephalosporins P B CLARINEX Antihistamines - Non-Sedating NP PA Required B CLARINEX-D Antihistamines - Non-Sedating / Decongestants NP PA Required G Clarithromycin For Susp 125 MG/5ML Macrolides / Erythromycin'S / Ketolides P G Clarithromycin For Susp 250 MG/5ML Macrolides / Erythromycin'S / Ketolides P G Clarithromycin Tab 250 MG Macrolides / Erythromycin'S / Ketolides P

12/17/2018 9:18:23 AM Page 19 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C G Clarithromycin Tab 500 MG Macrolides / Erythromycin'S / Ketolides P G Clarithromycin Tab SR 24HR 500 MG Macrolides / Erythromycin'S / Ketolides NP G Clemastine Fumarate Antihistamines - Other NP PA Required B Clenpiq Gi - Misc. N B CLEOCIN CAP 150MG Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN CAP 300MG Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN CAP 75MG Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN CRE 2% VAG Vaginal - Antibacterials NP B CLEOCIN SUP 100MG Vaginal - Antibacterials P B CLEOCIN IN D5W Lincosamides / Oxazolidinones / Leprostatics P B CLEOCIN PED SOL 75MG/5ML Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN-T Topical - Acne Preparations NP PA Required B CLIMARA Estrogens - Patches NP B CLIMARA PRO Estrogen Combos P B CLINDAGEL Topical - Acne Preparations NP PA Required G Clindamycin HCl Cap 150 MG Lincosamides / Oxazolidinones / Leprostatics P G Clindamycin HCl Cap 300 MG Lincosamides / Oxazolidinones / Leprostatics NP G Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base Equiv) Lincosamides / Oxazolidinones / Leprostatics P G Clindamycin Phosphate (Topical) Topical - Acne Preparations P PA Required G Clindamycin Phosphate Vaginal Vaginal - Antibacterials P G Clindamycin Phosphate-Benzoyl Peroxide Topical - Acne Preparations NP PA Required G Clindamycin phosphate-tretinoin Topical - Acne Preparations N PA Required B CLINDESSE Vaginal - Antibacterials N G Clobetasol Propionate Topical - Corticosteroids - High Potency P G Clobetasol Propionate Emollient Base Topical - Corticosteroids - High Potency P G Clobetasol Propionate Emulsion FOAM Topical - Corticosteroids - High Potency P G Clobetasol Propionate Gel Topical - Corticosteroids - High Potency N PA Required G Clobetasol Propionate Lotion Topical - Corticosteroids - High Potency N PA Required G Clobetasol Propionate Shampoo Topical - Corticosteroids - High Potency N PA Required G Clobetasol Propionate Spray Topical - Corticosteroids - High Potency N PA Required B CLOBEX Topical - Corticosteroids - High Potency P B CLOBEX LIQD Topical - Corticosteroids - High Potency N PA Required B CLODERM Topical - Corticosteroids - Medium Potency N PA Required

12/17/2018 9:18:23 AM Page 20 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C G Clomipramine HCl Antidepressants - Tri-Cyclics P Preferred product is authorized generic distributed by labeler 00406 G Clonazepam Anticonvulsants P G Clonazepam Tablet Disperse Anticonvulsants NP PA Required G Clonidine HCl (ADHD) Stimulants - Other Stimulants / Like Stimulants N PA Required G Clonidine HCl Patch Weekly Antihypertensives - Central NP G Clonidine HCl Tab 0.1 MG Antihypertensives - Central P G Clonidine HCl Tab 0.2 MG Antihypertensives - Central P G Clonidine HCl Tab 0.3 MG Antihypertensives - Central P G Clopidogrel Bisulfate Platelet Aggregation Inhibitors P G Clopidogrel Bisulfate TABS 300MG Platelet Aggregation Inhibitors NP G Clorazepate Dipotassium Anxiolytics - Benzodiazepines P PA Required < 9 years of age B CLORPRES Antihypertensive Combos NP G Clotrimazole (Topical) Topical - Antifungals P G Clotrimazole Troche Antifungals - Assorted P PA Required > 90 days O Clotrimazole vaginal cream 1% Vaginal - Anti Fungals P G Clotrimazole w/ Betamethasone Topical - Antifungals P G Clozapine Antipsychotics - Special Atypicals P G CLOZAPINE ODT Antipsychotics - Special Atypicals NP PA Required B CLOZARIL Antipsychotics - Special Atypicals NP B Coagadex Antihemophilia Factor X Agents N G Codeine Sulfate Narcotics - Misc. P PA Required < 18 years of age B COLAZAL Gi - Inflammatory Bowel Agents NP G Colchicine capsules Gout P G Colchicine tablets Gout N G Colchicine w/ Probenecid Gout P B COLCRYS Gout NP G Colesevelam Cholesterol - Bile Sequestrants N B COLESTID Cholesterol - Bile Sequestrants NP G Colestipol HCl Cholesterol - Bile Sequestrants P G Colistimethate Sodium Antibiotics - Misc. P B COLY-MYCIN S Ear P B COLY-MYCIN-M Antibiotics - Misc. NP B COLYTE Gi - Anti - Flatulents / GI Stimulants P

12/17/2018 9:18:23 AM Page 21 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C B COMBIGAN Op. Carbonic Anhydrase Inhibitors/Combo P B COMBIPATCH Estrogen Combos P B COMBIVENT RESPIMAT Antiasthmatic - Adrenergic Combos N B COMBIVIR Antiretrovirals - Combinations NP B COMETRIQ Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B COMPLERA Antiretrovirals - Combinations NP Grandfather Existing Users G Complete Natal DHA Vitamins - Misc. P G Completenate tablet Vitamins - Misc. P B COMTAN Parkinsons - Comt Inhibitors NP B CONCERTA Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. B CONDYLOX Topical - Genital Warts NP B CONZIP Narcotics - Selected NP PA Required B COPAXONE INJ 40MG/ML Multiple Sclerosis Agents – Non-Interferons NP B COPAXONE SOSY 20MG/ML Multiple Sclerosis Agents – Non-Interferons P B COPEGUS Hepatitis C Agents NP B CORDARONE Antiarrhythmics NP B CORDRAN Topical - Corticosteroids - Medium Potency N PA Required B COREG CR Beta Blockers - Alpha / Beta NP PA Required B COREG TABS Beta Blockers - Alpha / Beta NP B CORGARD Beta Blockers - Non Selective NP B CORLANOR Sinus Node Inhibitors NP PA Required B CORTEF Glucocorticoids - Mineralocorticoids P B CORTENEMA Anorectal - Misc. NP B CORTIFOAM Anorectal - Misc. NP G Cortisone Acetate Glucocorticoids - Mineralocorticoids P B CORTISPORIN Topical - Antibiotic NP B CORTISPORIN-TC Ear NP B CORZIDE Beta Blockers And Diuretic Combo'S NP B COSENTYX Anti-Inflammatories, Non-Nsaid P PA required. Preferred for all indicated diagnoses after step through Humira. B COSOPT Op. Carbonic Anhydrase Inhibitors/Combo NP B COSOPT PF Op. Carbonic Anhydrase Inhibitors/Combo NP B Cotellic Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B Cotempla Stimulants - Methylphenidate N PA Required

12/17/2018 9:18:23 AM Page 22 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C B COUMADIN Anticoagulants N Grandfather Existing Users B COUMADIN SOLR Anticoagulants NP B COZAAR ARB'S NP B CREON Gi - Digestive Enzymes P B Cresemba Antifungals - Assorted N PA Required B CRESTOR Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations N B CRIXIVAN Antiretrovirals - Protease Inhibitors NR G Cromolyn Sodium Antiasthmatic - Antiinflammatory Agents P G Cromolyn Sodium (Mastocytosis) Gi - Anti - Flatulents / GI Stimulants P G Cromolyn Sodium (Ophth) Op. Antiallergics - Mast Cell Stabilizers P G Crotan Topical - Scabicides And Pediculicides N B CUBICIN Lincosamides / Oxazolidinones / Leprostatics NP B CUPRIMINE Chelating Agents NP B CUTIVATE Topical - Corticosteroids - Medium Potency N PA Required B Cuvitru Immune Serums N B CUVPOSA Gi - Antidiarrheal / Antacid - Misc. NP G Cyanocobalamin Inj 1000 MCG/ML Vitamins P G Cyanocobalamin Tab 1000 MCG Vitamins NP PA Required G Cyanocobalamin Tab CR 1000 MCG Vitamins NP PA Required B CYCLESSA Contraceptives - Tri-Phasic Combinations NP G Cyclobenzaprine HCl Muscle Relaxants P B CYCLOGYL Op. Cycloplegics NP B CYCLOMYDRIL Op. Cycloplegics NP G Cyclopentolate HCl Op. Cycloplegics P G Cyclophosphamide Antineoplastics - Nitrogen Mustards NR G Cycloserine Antimycobacterials / Antituberculosis NP G Cyclosporine Immunosuppressants P G Cyclosporine Modified (For Microemulsion) Immunosuppressants P B CYMBALTA Antidepressants - Selected SSRI's NP PA Required G Cyproheptadine HCl Antihistamines - Other NP PA Required B CYSTAGON Urological - Misc. NP B CYSTARAN Op. Misc NP B CYTOGAM Immune Serums NP B CYTOMEL Thyroid Hormones P

12/17/2018 9:18:23 AM Page 23 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR C B CYTOTEC Gi - Prostaglandins NP B CYTOVENE Cyto-Megalovirus Agents NP D B D.H.E. 45 Migraine - Ergotamine Derivatives NP B Daklinza Hepatitis C Agents NP PA Required G Dalfampridine er Multiple Sclerosis Agents – Non-Interferons N PA Required B DALIRESP Phosphodiesterase Inhibitors NP PA Required G Danazol Androgens - Anabolics NP B DANTRIUM Muscle Relaxants NP PA Required G Dantrolene Sodium Muscle Relaxants NP PA Required G Dapsone Lincosamides / Oxazolidinones / Leprostatics P G Dapsone gel Topical - Acne Preparations N PA Required B DARAPRIM Antimalarial Agents NP G Darifenacin ER Antispasmodics - Long Acting N B DAYPRO NSAIDS NP PA Required B DAYTRANA Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. B DDAVP INJ 4MCG/ML Vasopressins NP PA Required B DDAVP SOL 0.01% Vasopressins NP PA Required B DDAVP SPR 0.01% Vasopressins NP PA Required B DDAVP TABS Vasopressins NP PA Required G Deferoxamine Mesylate Antidotes P O Dekas Vitamins - Misc. P PA Required B DELESTROGEN Estrogens - Tabs NP B Delstrigo Antiretrovirals - Combinations N B DELZICOL CAP 400MG Gi - Inflammatory Bowel Agents P B DEMADEX Diuretics NP G Demeclocycline HCl Tetracyclines NP B DEMEROL Narcotics - Misc. NP PA Required B DEMSER Agents For Pheochromocytoma NP B DENAVIR Topical - Antivirals NP B DEPACON Anticonvulsants NP B DEPAKENE Anticonvulsants NP B DEPAKOTE Anticonvulsants NP B DEPAKOTE ER Anticonvulsants NP Grandfather for seizure disorder.

12/17/2018 9:18:23 AM Page 24 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR D B DEPAKOTE SPRINKLES Anticonvulsants N Grandfather for seizure disorder. B DEPEN TITRATABS Chelating Agents P B DEPO-ESTRADIOL Estrogens - Tabs P B DEPO-MEDROL Glucocorticoids - Mineralocorticoids N B DEPO-PROVERA Contraceptives - Injectable NP B DEPO-PROVERA Antineoplastics - Progestins R B Depo-Sub Q Provera 104 Endometriosis Agents P B DEPO-TESTOSTERONE Androgens - Anabolics NP PA Required B DERMA-SMOOTHE/FS BODY Topical - Corticosteroids - Medium Potency N PA Required B DERMA-SMOOTHE/FS SCALP Topical - Corticosteroids - Medium Potency N PA Required B DERMATOP Topical - Corticosteroids - Medium Potency N PA Required B DERMOTIC Ear NP B Descovy Antiretrovirals - Combinations P B DESFERAL Antidotes NP G Desipramine HCl Antidepressants - Tri-Cyclics P G Desloratadine Antihistamines - Non-Sedating NP PA Required G Desmopressin Acetate Vasopressins P No PA required for members 6 years of age or older when dosed within established quantity limits G Desmopressin Acetate Refrigerated Vasopressins P PA Required G Desmopressin Acetate Spray Vasopressins P PA Required G Desmopressin Acetate Spray Refrigerated Vasopressins P PA Required B DESOGEN Contraceptives - Monophasic Combination O/C'S P G Desogest-Ethin Est Tab 0.1-0.025/0.125-0.025/0.15-0.025MG-MG Contraceptives - Tri-Phasic Combinations P G Desogestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P G Desogestrel-Ethinyl Estradiol (Biphasic) Contraceptives - Monophasic Combination O/C'S P B DESONATE Topical - Corticosteroids - Low Potency N PA Required G Desonide Topical - Corticosteroids - Low Potency N PA Required B DESOWEN Topical - Corticosteroids - Low Potency N PA Required G Desoximetasone Topical - Corticosteroids - High Potency N PA Required B DESOXYN Stimulants NP PA Required G Desvenlafaxine Antidepressants - Selected SSRI's P Initial fill limited to 15 day supply. B DETROL Antispasmodics NP B DETROL LA Antispasmodics - Long Acting NP G Dexamethasone Glucocorticoids - Mineralocorticoids P

12/17/2018 9:18:23 AM Page 25 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR D B DEXAMETHASONE INTENSOL Glucocorticoids - Mineralocorticoids P G Dexamethasone Sodium Phosphate Glucocorticoids - Mineralocorticoids P G Dexamethasone Sodium Phosphate (Ophth) Op. Antiinflammatory / Steroids Ophth. P G Dexamethasone therapy pack Glucocorticoids - Mineralocorticoids N B DEXEDRINE Stimulants - Amphetamines - Long Acting NP PA Required B DEXILANT Gi - Proton Pump Inhibitor P G dexmethylphenidate er Stimulants - Methylphenidate - Long Acting NP PA Required G Dexmethylphenidate HCl Stimulants - Methylphenidate P PA Required >= 21 yo. B DEXPAK Glucocorticoids - Mineralocorticoids NP G Dextroamphetamine Sulfate Stimulants - Amphetamines - Long Acting NP PA Required G Dextroamphetamine Sulfate Stimulants - Amphetamines - Short Acting NP PA Required O Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML Cough/Cold - Antitussive-Expectorant P G Dextrose Electrolytes/ Nutritionals P G Dextrose in Lactated Ringers Electrolytes/ Nutritionals P G Dextrose w/ Sodium Chloride Electrolytes/ Nutritionals P B DIABETA Diabetic - Oral Sulfonylureas P B DIALYVITE/ TAB ZINC Vitamins - Misc. P PA Required B DIAMOX Diuretics P B DIASTAT Anticonvulsants N G Diazepam Anxiolytics - Benzodiazepines P G Diazepam (Anticonvulsant) Gel Anticonvulsants P B DICLEGIS Antiemetic - Anticholinergic / Dopaminergic P Initial fill limited to 15 day supply. G Diclofenac Potassium NSAIDS P G Diclofenac Sodium NSAIDS P G Diclofenac Sodium (Actinic Keratoses) Topical - Antineoplastics NP G Diclofenac Sodium (Ophth) Op. Nsaid'S P G Diclofenac Sodium (Topical) NSAIDS NP PA Required G Diclofenac Sodium Tablet ER 24HR NSAIDS NP PA Required G Diclofenac w/ Misoprostol NSAIDS NP PA Required G Dicloxacillin Sodium Beta-Lactams / Clavulanate Combo'S P G Dicyclomine HCl Gi - Antidiarrheal / Antacid - Misc. P G Didanosine Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues NR B DIFFERIN CRE 0.1% Topical - Acne Preparations P PA Required B DIFFERIN GEL 0.1% Topical - Acne Preparations P PA Required

12/17/2018 9:18:23 AM Page 26 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR D B DIFFERIN GEL 0.3% Topical - Acne Preparations P PA Required B DIFFERIN LOTN Topical - Acne Preparations P PA Required B DIFICID Macrolides / Erythromycin'S / Ketolides NP G Diflorasone Diacetate Cream 0.05% Topical - Corticosteroids - High Potency N PA Required G Diflorasone Diacetate Oint 0.05% Topical - Corticosteroids - High Potency N PA Required B DIFLUCAN Antifungals - Assorted NP PA Required G Diflunisal Analgesics - Misc. P G Digoxin Cardiac Glycosides P G Digoxin IJ Cardiac Glycosides NP G Dihydroergotamine Mesylate Migraine - Ergotamine Derivatives NP B DILANTIN Anticonvulsants NP Grandfather for seizure disorder. B DILANTIN CAPS 30MG Anticonvulsants P B DILANTIN INFATABS Anticonvulsants N Grandfather for seizure disorder. B DILANTIN SUSP Anticonvulsants NP Grandfather for seizure disorder. B DILATRATE SR Antianginals--Isosorbide Nitrate NP B DILAUDID Narcotics - Misc. NP PA Required G Diltiazem HCl Calcium Channel Blockers--Diltiazems P G Diltiazem HCl Coated Beads Calcium Channel Blockers--Diltiazems NP G Diltiazem HCl Extended Release Beads Calcium Channel Blockers--Diltiazems P B DIOVAN ARB'S NP B DIOVAN HCT ARB'S And Diuretics NP B DIPENTUM Gi - Inflammatory Bowel Agents N O Diphenhydramine HCl Antihistamines - Other P G diphenhydramine inj Antihistamines - Other P G Diphenoxylate w/ Atropine Gi - Antiperistaltic Agents P B DIPROLENE LOT 0.05% Topical - Corticosteroids - Medium Potency N PA Required B DIPROLENE AF CRE 0.05% Topical - Corticosteroids - High Potency N PA Required B DIPROLENE OINT Topical - Corticosteroids - High Potency N PA Required G Dipyridamole Platelet Aggregation Inhibitors P G Disopyramide Phosphate Antiarrhythmics P G Disulfiram Alcohol Deterrents P B DITROPAN XL Antispasmodics - Long Acting NP B DIURIL Diuretics NP G Divalproex Sodium Anticonvulsants P

12/17/2018 9:18:23 AM Page 27 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR D G Divalproex Sodium Cap Sprinkle Anticonvulsants P G Divalproex Sodium Tablet ER 24HR Anticonvulsants P B DIVIGEL Estrogens - Patches NP G Dofetilide Antiarrhythmics P B DOLOPHINE Narcotics -Long Acting NP PA Required G Donepezil Hydrochloride Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. G Donepezil Hydrochloride TABS HCL 23MG Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B DORAL Sedative/Hypnotics - Benzodiazepines NP PA Required B DORYX Tetracyclines NP PA Required G Dorzolamide HCl Op. Carbonic Anhydrase Inhibitors/Combo P G Dorzolamide HCl-Timolol Maleate Op. Carbonic Anhydrase Inhibitors/Combo P G Dorzolamide/timolol pf Op. Carbonic Anhydrase Inhibitors/Combo N B DOVONEX Anti-Psoriatics - Non-Biologicals NP G Doxazosin Mesylate BPH P G Doxepin HCl Antidepressants - Tri-Cyclics P G Doxercalciferol Hyperparathyroid Treatment - Vitamin D Analogs NP G Doxycycline (Monohydrate) Tetracyclines NP G Doxycycline (Monohydrate) CAPS 100MG Tetracyclines P G Doxycycline (Monohydrate) CAPS 50MG Tetracyclines P G Doxycycline Hyclate Tetracyclines NP G Doxycycline Hyclate TBEC Tetracyclines NP PA Required G Dronabinol Antiemetic - Tetrahydrocannabinol (THC) Derivatives NP G Droperidol Anxiolytics - Misc. P G Drosperinone-ethinyl estradiol-levomefolate Contraceptives - Monophasic Combination O/C'S N G Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG Contraceptives - Monophasic Combination O/C'S N G Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG Contraceptives - Monophasic Combination O/C'S P B DROXIA Antineoplastics - Misc. NR B DUAC Topical - Acne Preparations N PA Required B DUAVEE Estrogens - Tabs NP B DUETACT Diabetic - Thiazol NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B DUEXIS NSAIDS NP PA Required B DULERA Antiasthmatic - Adrenergic Combos P

12/17/2018 9:18:23 AM Page 28 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR D G Duloxetine HCl Antidepressants - Selected SSRI's P B DUOPA Anti-Parkinsonian Drugs NP B Dupixent Atopic Dermatitis N PA Required B DURAGESIC Narcotics -Long Acting NP PA Required B DUREZOL Op. Antiinflammatory / Steroids Ophth. N B Durlaza Platelet Aggregation Inhibitors N G Dutasteride BPH N B Dutasteride-Tamsulosin BPH N B DUTOPROL Beta Blockers And Diuretic Combo'S NP B Duzallo Gout N B Dyanavel XR STIMULANTS N PA Required B DYAZIDE Diuretics NP B DYMISTA Nasal Steroid/Antihistamine Combos NP E B E.E.S. GRANULES Macrolides / Erythromycin'S / Ketolides NP B EC-NAPROSYN NSAIDS NP PA Required G Econazole Nitrate Topical - Antifungals NP B EDARBI ARB'S NP B EDARBYCLOR ARB'S And Diuretics NP B EDECRIN Diuretics P B EDLUAR Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B EDURANT Antiretrovirals - Rti - Non - Nucleoside Analogues P PA Required < 18 years of age G Efavirenz Antiretrovirals - Rti - Non - Nucleoside Analogues N B EFFEXOR XR Antidepressants - Selected SSRI's NP B EFFIENT Platelet Aggregation Inhibitors NP B EFUDEX Topical - Antineoplastics P B ELDEPRYL Anti-Parkinsonian Drugs NP B ELELYSO Agents For Gaucher Disease NP B ELESTAT Op. Antiallergics - Antihistamines NP B ELESTRIN Estrogens - Patches NP G Eletriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs N PA Required B ELIDEL Topical - Immunomodulators P PA Required B ELIGARD Antineoplastics - Lhrh Analogs R PA Required < 18 years of age B ELIMITE Topical - Scabicides And Pediculicides NP

12/17/2018 9:18:23 AM Page 29 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR E B ELIPHOS Phosphate Binders P B ELIQUIS Anticoagulants P B ELIXOPHYLLIN Antiasthmatic - Xanthines P B ELLA Contraceptives - Emergency Contraceptive P B ELMIRON Urological - Misc. NP B ELOCON CRE 0.1% Topical - Corticosteroids - Medium Potency N PA Required B ELOCON LOT 0.1% Topical - Corticosteroids - Medium Potency N PA Required B ELOCON OIN 0.1% Topical - Corticosteroids - Medium Potency N PA Required B ELOCTATE Antihemophilia Factor VIII Agents N B EMADINE Op. Antiallergics - Antihistamines NP B Embeda Narcotics -Long Acting P B EMCYT Antineoplastics - Estrogens R B EMEND Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin P PA required for quantities exceeding 12- 40mg capsules and 8-80mg capsules B Emflaza Glucocorticoids - Mineralocorticoids N PA Required B EMSAM Antidepressants - Mao Inhibitors NP Grandfather Existing Users B EMTRIVA Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues R B Emverm Anthelmintics N B ENABLEX Antispasmodics - Long Acting NP G Enalapril Maleate ACE Inhibitors P G Enalapril Maleate & Hydrochlorothiazide ACE and Thiazide Combo's P G Enalaprilat ACE Inhibitors NP B ENBREL Anti-Inflammatories, Non-Nsaid P PA Required B Endari Electrolytes/ Nutritionals N B ENJUVIA Estrogens - Tabs NP G ENOXAPARIN SODIUM SYRINGES Anticoagulants P G ENOXAPARIN SODIUM VIALS Anticoagulants P B Enstilar Topical - Steroid Combinations N G Entacapone Parkinsons - Comt Inhibitors P G Entecavir Hepatitis B Only P B ENTOCORT EC Glucocorticoids - Mineralocorticoids NP B Entresto ARB Combinations P PA Required B Envarsus XR Immunosuppressants N PA Required B EPANED ACE Inhibitors N

12/17/2018 9:18:23 AM Page 30 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR E B Epclusa Hepatitis C Agents P PA Required G Ephedrine Sulfate (Pressors) Pressors NP B EPIDUO Topical - Acne Preparations P PA Required B EPIFOAM Topical - Steroid Local Anesthetics NP G Epinastine HCl (Ophth) Op. Antiallergics - Antihistamines NP G Epinephrine Auto-injector Anaphylaxis Therapy P Preferred product is authorized generic of EpiPen distributed by labeler 49502 G Epinephrine HCl Antiasthmatic - Mixed Adrenergics P B EPIPEN Anaphylaxis Therapy N B EPIVIR Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues N G Eplerenone Diuretics P PA Required B EPOGEN Erythropoeisis Stimulating Agents NP PA Required G Epoprostenol Sodium Pulmonary Anti-Hypertensives P PA Required G Eprosartan Mesylate ARB'S NP B EPZICOM Antiretrovirals - Combinations N B EQUETRO Anticonvulsants NP G Ergocalciferol 50000 Unit Vitamins N PA Required O Ergocalciferol Soln 8000 Unit/ML Vitamins NP PA Required G Ergoloid Mesylates Neurologics - Misc. P B ERIVEDGE Antineoplastics - Antimetabolites NR PA Required B Erleada Antineoplastics - Antiandrogens R PA Required B ERTACZO Topical - Antifungals NP B ERYPED Macrolides / Erythromycin'S / Ketolides NP B ERY-TAB Macrolides / Erythromycin'S / Ketolides NP G Erythromycin (Acne Aid) Topical - Acne Preparations P PA Required G Erythromycin (Ophth) Op. Antibiotics P G Erythromycin Base Macrolides / Erythromycin'S / Ketolides NP G Erythromycin Ethylsuccinate Macrolides / Erythromycin'S / Ketolides NP B ESBRIET Idiopathic Pulmonary Fibrosis NP PA Required G Escitalopram Oxalate Antidepressants - Selected SSRI's P G Esomeprazole Strontium Gi - Proton Pump Inhibitor NP PA Required G Estazolam Sedative/Hypnotics - Benzodiazepines P B ESTRACE Estrogens - Tabs NP B ESTRACE Vaginal - Estrogens NP

12/17/2018 9:18:23 AM Page 31 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR E G Estradiol Estrogens - Tabs P G Estradiol & Norethindrone Acetate Estrogen Combos NP B Estradiol Bi-Weekly Estrogens - Patches NP G Estradiol vaginal cream Vaginal - Estrogens N G Estradiol Valerate Estrogens - Tabs NP G Estradiol Weekly Estrogens - Patches N B ESTRING Vaginal - Estrogens NP G Estropipate Estrogens - Tabs P B ESTROSTEP FE Contraceptives - Tri-Phasic Combinations P G Eszopiclone Sedative/Hypnotics - Non-Benzodiazepines P G Ethacrynic acid Diuretics N G Ethambutol HCl Antimycobacterials / Antituberculosis P G Ethosuximide CAPS Anticonvulsants NP G Ethosuximide Soln 250 MG/5ML Anticonvulsants P G Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P G Etidronate Disodium Osteoporosis NP G Etodolac CAPS NSAIDS NP PA Required G Etodolac Tab 400 MG NSAIDS P G Etodolac Tab 500 MG NSAIDS P G Etodolac Tab SR 24HR 400 MG NSAIDS NP PA Required G Etodolac Tab SR 24HR 500 MG NSAIDS NP PA Required G Etodolac Tab SR 24HR 600 MG NSAIDS NP PA Required G Etoposide Antineoplastics - Mitotic Inhibitors NR B Eucrisa Atopic Dermatitis N PA Required B EURAX Topical - Scabicides And Pediculicides NP B EVAMIST Estrogens - Patches NP B EVEKEO STIMULANTS NP PA Required B EVISTA Osteoporosis NP B EVOCLIN Topical - Acne Preparations NP PA Required B EVOTAZ Antiretrovirals - Combinations P B EVOXAC Artificial Saliva/Stimulants NP B EXALGO Narcotics -Long Acting NP PA Required B EXELDERM Topical - Antifungals NP

12/17/2018 9:18:23 AM Page 32 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR E B EXELON CAP Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B EXELON DIS Alzheimer - Cholinomimetics N Restricted to persons 40 years of age and older. G Exemestane Antineoplastics - Aromatase Inhibitors P B EXFORGE Arb/Ccb N B EXFORGE HCT ARB/CCB Plus Diuretics N B EXJADE Antidotes - Chelating Agents P PA Required B Exondys 51 Muscular Dystrophy Agents N PA Required B EXTAVIA Multiple Sclerosis Agents – Interferons NP B EXTINA Topical - Antifungals NP G Ezetimibe Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations N G Ezetimibe/simvastatin Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations N F B FABIOR Topical - Tretinoids NP PA Required B FABRAZYME Agents For Fabrys Disease P G Famciclovir Herpes Agents NP G Famotidine For Susp 40 MG/5ML Gi - H2-Antagonists NP G Famotidine Tab 20 MG Gi - H2-Antagonists P G Famotidine Tab 40 MG Gi - H2-Antagonists P B FAMVIR Herpes Agents NP B FANAPT Antipsychotics - Atypicals NP Grandfather Existing Users B FARESTON Antineoplastics - Antiestrogens R B FARXIGA Diabetic - Other P PA Required B Farydak Antineoplastics - Misc. NR B FAZACLO Antipsychotics - Special Atypicals N PA Required B FEIBA Antihemophilia Factor IX Agents N G Felbamate Anticonvulsants NP Grandfather for seizure disorder. B FELBATOL Anticonvulsants NP Grandfather for seizure disorder. B FELDENE NSAIDS NP PA Required G Felodipine Calcium Channel Blockers--Felodipines NP B FEMARA Antineoplastics - Aromatase Inhibitors NP B FEMHRT Estrogen Combos NP B FEMRING Vaginal - Estrogens NP G FENOFIBRATE - (All others) Cholesterol - Fibric Acid Derivatives N

12/17/2018 9:18:23 AM Page 33 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR F G Fenofibrate CAPS Cholesterol - Fibric Acid Derivatives NP G Fenofibrate Micronized Cholesterol - Fibric Acid Derivatives NP G FENOFIBRATE NANOCRYSTALLIZED 145MG TABS Cholesterol - Fibric Acid Derivatives P G FENOFIBRATE NANOCRYSTALLIZED 48MG TABS Cholesterol - Fibric Acid Derivatives P G Fenoprofen Calcium NSAIDS NP PA Required G Fentanyl 100mcg Narcotics -Long Acting P G Fentanyl 12mcg Narcotics -Long Acting NP PA Required G Fentanyl 25mcg Narcotics -Long Acting P G Fentanyl 37.5mcg Narcotics -Long Acting NP PA Required G Fentanyl 50mcg Narcotics -Long Acting P G Fentanyl 62.5mcg Narcotics -Long Acting NP PA Required G Fentanyl 75mcg Narcotics -Long Acting P G Fentanyl 87.5mcg Narcotics -Long Acting NP PA Required G Fentanyl Citrate Narcotics - Misc. NP PA Required G Fentanyl Citrate SOLN Narcotics - Misc. P B FENTORA Narcotics - Misc. NP PA Required B FERRIPROX Antidotes NP O Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe) Minerals P G Ferrous Fumarate w/ B12-Vit C-FA-IFC Vitamins - Misc. P PA Required O Ferrous Gluconate Tab 324 MG (38 MG Elemental Iron) Minerals P O Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML Elemental Fe) Minerals P O Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe) Minerals P O Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) Minerals P B FETZIMA Antidepressants - Selected SSRI's NP PA Required B FEXMID Muscle Relaxants NP PA Required B Fiasp Diabetic - Insulin P B Fiasp FlexTouch Diabetic - Insulin Penfills P B FINACEA Topical - Acne Preparations NP PA Required G finasteride BPH P B FIORICET/CODEINE Narcotics - Misc. NP PA Required B FIORINAL/CODEINE #3 Narcotics - Misc. NP PA Required B FIRAZYR Hereditary Angioedema Agents P PA Required B FLAGYL Antibiotics - Misc. NP B FLAGYL ER Antibiotics - Misc. NP PA Required

12/17/2018 9:18:23 AM Page 34 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR F B FLAREX Op. Antiinflammatory / Steroids Ophth. P G Flavoxate HCl Antispasmodics P B FLEBOGAMMA Immune Serums P G Flecainide Acetate Antiarrhythmics P B FLECTOR NSAIDS NP PA Required B FLOLAN Pulmonary Anti-Hypertensives NP PA Required B FLOMAX BPH NP B Flovent Diskus Antiasthmatic - Steroid Inhalants P B Flovent HFA Antiasthmatic - Steroid Inhalants P B Fluad Inj 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Fluarix Quad 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Fluclvx Quad INJ 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. G Fluconazole Antifungals - Assorted P PA Required > 90 days G Fluconazole in Dextrose Antifungals - Assorted P PA Required > 90 days G Fluconazole in NaCl Antifungals - Assorted P PA Required > 90 days G Flucytosine Antifungals - Assorted NP PA Required G Fludrocortisone Acetate Glucocorticoids - Mineralocorticoids P B Flulaval Quad 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FLUMADINE Influenza Agents NP B Flumist 2018-19 Influenza Agents N Those 0-18 should be referred to the Vaccines for Children Program. G Flunisolide (Nasal) Nasal Steroids NP G Fluocinolone Acetonide Topical - Corticosteroids - Medium Potency N PA Required G Fluocinolone Acetonide (Otic) Ear N G Fluocinolone Acetonide Oil 0.01% (Body Oil) Topical - Corticosteroids - Medium Potency N PA Required G Fluocinolone Acetonide Oil 0.01% (Scalp Oil) Topical - Corticosteroids - Medium Potency N PA Required G Fluocinonide Cream 0.05% Topical - Corticosteroids - High Potency P G Fluocinonide Cream 0.1% Topical - Corticosteroids - High Potency N PA Required G Fluocinonide Emulsified Base Topical - Corticosteroids - High Potency P G Fluocinonide Gel 0.05% Topical - Corticosteroids - High Potency P G Fluocinonide Oint 0.05% Topical - Corticosteroids - High Potency P G Fluocinonide Soln 0.05% Topical - Corticosteroids - High Potency P

12/17/2018 9:18:23 AM Page 35 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR F G Fluorometholone (Ophth) Op. Antiinflammatory / Steroids Ophth. P G Fluorouracil Cream 5% Topical - Antineoplastics NP G Fluorouracil Soln 2% Topical - Antineoplastics P G Fluorouracil Soln 5% Topical - Antineoplastics P G Fluoxetine HCl Antidepressants - Selected SSRI's P G Fluoxetine HCl (PMDD) Antidepressants - Selected SSRI's NP Initial fill limited to 15 day supply. G Fluoxetine HCl CAPS 40MG Antidepressants - Selected SSRI's NP PROZAC,FLUOXETINE HCL 40mg CAPS - Use two FLUOXETINE HCL 20mg CAPS instead G Fluoxetine HCl CAPSULE DELAYED RELEASE Antidepressants - Selected SSRI's NP PA Required G Fluoxetine HCl TABS 20MG Antidepressants - Selected SSRI's NP FLUOXETINE HCL 20mg TABS - Use FLUOXETINE HCL 20mg CAPS instead G Fluphenazine Decanoate Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Fluphenazine HCl Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Flurandrenolide Topical - Corticosteroids - Medium Potency N PA Required G Flurazepam HCl Sedative/Hypnotics - Benzodiazepines P PA Required < 15 years of age G Flurbiprofen NSAIDS P G Flurbiprofen Sodium Op. Nsaid'S P G Flutamide Antineoplastics - Antiandrogens NR G Fluticasone Propionate Topical - Corticosteroids - Medium Potency P G Fluticasone Propionate (Nasal) Nasal Steroids P G Fluticasone Propionate LOTN Topical - Corticosteroids - Medium Potency N PA Required G Fluticasone/salmeterol Antiasthmatic - Adrenergic Combos N G Fluvastatin Sodium Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B Fluvirin Inj 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. G fluvoxamine er Antidepressants - Selected SSRI's N PA Required G Fluvoxamine Maleate Antidepressants - Selected SSRI's P B Fluzone HD Inj PF 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Fluzone Quad INJ 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FML Op. Antiinflammatory / Steroids Ophth. P

12/17/2018 9:18:23 AM Page 36 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR F B FML Forte Op. Antiinflammatory / Steroids Ophth. P B FML LIQUIFILM Op. Antiinflammatory / Steroids Ophth. NP B FOCALIN Stimulants - Methylphenidate NP PA Required B FOCALIN XR Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. G Folic Acid Tab 1 MG Vitamins P G Fondaparinux Sodium Anticoagulants NP B FORFIVO XL Antidepressants - Selected SSRI's NP B FORTAMET Diabetic - Oral Biguanides NP PA required B FORTAZ Cephalosporins NP B FORTEO Osteoporosis NP B FORTESTA Androgens -Topical NP PA Required B FORTICAL SPR 200/ACT Osteoporosis NP B FOSAMAX TAB 70MG Osteoporosis NP G Fosamprenavir Antiretrovirals - Protease Inhibitors N G Fosinopril Sodium ACE Inhibitors P G Fosinopril Sodium & Hydrochlorothiazide ACE and Thiazide Combo's NP G Fosphenytoin Sodium Anticonvulsants NP B FOSRENOL Phosphate Binders NP B FRAGMIN Anticoagulants N B FREAMINE III Electrolytes/ Nutritionals NP B FROVA Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required G Frovatriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs N PA Required B Fulphila Granulocyte Csf N PA Required B FURADANTIN Urological - Misc. NP G Furosemide Diuretics P B FUZEON Antiretrovirals - Entry Inhibitors NR G Fyavolv Estrogen Combos N B FYCOMPA Anticonvulsants NP G G Gabapentin Cap 100 MG Anticonvulsants P G Gabapentin Cap 300 MG Anticonvulsants P G Gabapentin Cap 400 MG Anticonvulsants P G Gabapentin Oral Soln 250 MG/5ML Anticonvulsants P G Gabapentin Tab 600 MG Anticonvulsants P

12/17/2018 9:18:23 AM Page 37 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR G G Gabapentin Tab 800 MG Anticonvulsants P B GABITRIL Anticonvulsants P B GABLOFEN Muscle Relaxants P G galantamine er cap Alzheimer - Cholinomimetics N Restricted to persons 40 years of age and older. G galantamine oral solution Alzheimer - Cholinomimetics N Restricted to persons 40 years of age and older. G Galantamine tabs Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. B GAMASTAN S/D Immune Serums NP B GAMMAGARD Immune Serums P B GAMMAKED Immune Serums NP B GAMMAPLEX Immune Serums NP B GAMUNEX-C Immune Serums P G Ganciclovir Sodium Cyto-Megalovirus Agents NP B GASTROCROM Gi - Anti - Flatulents / GI Stimulants P G Gatifloxacin (Ophth) Op. Quinolones Fourth Generation NP B GATTEX Gi - Antiperistaltic Agents NP B GELNIQUE Antispasmodics - Long Acting NP G Gemfibrozil Cholesterol - Fibric Acid Derivatives P B Generess FE Chw Contraceptives - Monophasic Combination O/C'S P G GENGRAF Immunosuppressants P B GENOTROPIN Growth Hormone NP PA Required G Gentamicin in Saline Amino Glycosides P G Gentamicin Sulfate Amino Glycosides P G Gentamicin Sulfate (Ophth) Op. Antibiotics P G Gentamicin Sulfate (Topical) Topical - Antibiotic P B Genvoya Antiretrovirals - Combinations P B GEODON Antipsychotics - Atypicals NP PA Required G Gianvi Contraceptives - Monophasic Combination O/C'S P B GIAZO Gi - Inflammatory Bowel Agents NP B GILENYA Multiple Sclerosis Agents – Non-Interferons P No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months B GILOTRIF Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B GLASSIA Alpha-Proteinase Inhibitor NP PA Required

12/17/2018 9:18:23 AM Page 38 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR G G Glatiramer MULTIPLE SCLEROSIS AGENTS N G Glatopa MULTIPLE SCLEROSIS AGENTS NP B GLEEVEC Antineoplastics - Protein-Tyrosine Kinase Inhibitors P PA Required B Gleostine Antineoplastics - Nitrosoureas NP G Glimepiride Diabetic - Oral Sulfonylureas P G Glipizide Diabetic - Oral Sulfonylureas P G Glipizide-Metformin HCl Diabetic - Sulfonylurea / Biguanide P B GLUCAGEN Diabetic - Other P B GLUCAGON EMERGENCY KIT Diabetic - Other NP B Glucophage Diabetic - Oral Biguanides NP B Glucophage XR Diabetic - Oral Biguanides NP B GLUCOTROL Diabetic - Oral Sulfonylureas NP B GLUCOTROL XL Diabetic - Oral Sulfonylureas NP B GLUCOVANCE Diabetic - Sulfonylurea / Biguanide NP B Glumetza Diabetic - Oral Biguanides N PA Required G Glyburide Diabetic - Oral Sulfonylureas P G Glyburide Micronized Diabetic - Oral Sulfonylureas P G Glyburide-Metformin Diabetic - Sulfonylurea / Biguanide P G Glycopyrrolate Injection Gi - Antidiarrheal / Antacid - Misc. NP G Glycopyrrolate TABS Gi - Antidiarrheal / Antacid - Misc. P B GLYNASE Diabetic - Oral Sulfonylureas NP B GLYSET Diabetic - Alphaglucosidase P B GLYXAMBI Diabetic - Other NP PA Required B Gocovri Anti-Parkinsonian Drugs N PA required B GOLYTELY Gi - Anti - Flatulents / GI Stimulants P B GOLYTELY POWDER PACK Gi - Anti - Flatulents / GI Stimulants N B GoNitro Nitro - Sublingual/ Spray N B GRALISE Anticonvulsants NP PA Required G Granisetron HCl Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B GRANIX Granulocyte Csf P PA Required B GRASTEK Allergenic Extracts NP PA Required G Griseofulvin Microsize TABS Antifungals - Assorted NP PA Required G GRISEOFULVIN SUS Antifungals - Assorted P PA Required > 90 days G Griseofulvin Ultramicrosize Antifungals - Assorted NP PA Required

12/17/2018 9:18:23 AM Page 39 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR G B GRIS-PEG Antifungals - Assorted N PA Required G Guanfacine er Stimulants - Other Stimulants / Like Stimulants P G Guanfacine HCl Antihypertensives - Central P H B H.P. ACTHAR Glucocorticoids - Corticotropin NP PA Required B Haegarda Hereditary Angioedema Agents P PA Required B HALCION Sedative/Hypnotics - Benzodiazepines NP PA Required B HALDOL Antipsychotics - Typical NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B HALDOL DECANOATE 100 Antipsychotics - Typical NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B HALDOL DECANOATE 50 Antipsychotics - Typical NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Halobetasol Propionate Topical - Corticosteroids - High Potency N PA Required B HALOG Topical - Corticosteroids - High Potency N PA Required G Haloperidol Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Haloperidol Decanoate Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Haloperidol Lactate Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B HARVONI Hepatitis C Agents N PA Required B HECTOROL Hyperparathyroid Treatment - Vitamin D Analogs NP Grandfather Existing Users B HEMANGEOL Beta Blockers - Non Selective NP B Hemlibra Antihemophilia Factor VIII Agents P PA required. Preferred for patients with Factor VIII inhibitors only. Non-preferred for all other diagnoses. B HEMOFIL M Antihemophilia Factor VIII Agents P B HEPAGAM B Immune Serums NP G Heparin (Porcine) in Sodium Chloride Anticoagulants P

12/17/2018 9:18:23 AM Page 40 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR H G Heparin Sodium (Porcine) Anticoagulants P B HEPSERA Hepatitis B Only P B HETLIOZ Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B HIPREX Urological - Misc. NP B HIZENTRA Immune Serums NP B HORIZANT Restless Leg Syndrome Agents NP PA Required B HUMALOG Diabetic - Insulin P B HUMALOG Diabetic - Insulin Penfills NP PA Required B HUMALOG MIX 50/50 Diabetic - Insulin P B HUMALOG MIX 50/50 Diabetic - Insulin Penfills NP PA Required B HUMALOG MIX 75/25 Diabetic - Insulin P B HUMALOG MIX 75/25 Diabetic - Insulin Penfills NP PA Required B HUMATE-P Antihemophilia Factor von Willebrand Factor Agents P B HUMATROPE Growth Hormone NP PA Required B HUMIRA Anti-Inflammatories, Non-Nsaid P PA Required B HUMIRA PEN Anti-Inflammatories, Non-Nsaid P PA Required B HUMIRA PEN-CROHNS DISEASESTARTER Anti-Inflammatories, Non-Nsaid P Preferred with Conditions and allow a one time fill. B HUMIRA PEN-PSORIASIS STARTER Anti-Inflammatories, Non-Nsaid P Preferred with Conditions and allow a one time fill. O HUMULIN 70/30 Diabetic - Insulin P O HUMULIN 70/30 PEN Diabetic - Insulin Penfills NP PA Required O HUMULIN N Diabetic - Insulin P O HUMULIN N U-100 PEN Diabetic - Insulin Penfills NP PA Required B HUMULIN R Diabetic - Insulin P B HYCAMTIN Antineoplastics - Topoisomerase I Inhibitors R PA Required G Hydralazine HCl Antihypertensives - Central P B HYDREA Antineoplastics - Misc. NP G Hydrochlorothiazide Diuretics P G Hydrocodone-Acetaminophen Narcotics - Misc. P G Hydrocodone-Acetaminophen TABS 10-300MG Narcotics - Misc. NP PA Required G Hydrocodone-Acetaminophen TABS 5-300MG Narcotics - Misc. NP PA Required G Hydrocodone-Acetaminophen TABS 7.5-300 Narcotics - Misc. NP PA Required G Hydrocodone-Ibuprofen Narcotics - Misc. NP PA Required G Hydrocortisone Glucocorticoids - Mineralocorticoids P

12/17/2018 9:18:23 AM Page 41 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR H G Hydrocortisone (Intrarectal) Anorectal - Misc. P G Hydrocortisone (Rectal) Anorectal - Misc. P G Hydrocortisone Acetate w/ Pramoxine Anorectal - Misc. NP G Hydrocortisone Butyrate Topical - Corticosteroids - Medium Potency N PA Required G Hydrocortisone Cream 1% Topical - Corticosteroids - Low Potency P G Hydrocortisone Cream 2.5% Topical - Corticosteroids - Low Potency P G Hydrocortisone Lotion 2.5% Topical - Corticosteroids - Low Potency P G Hydrocortisone Oint 1% Topical - Corticosteroids - Low Potency P G Hydrocortisone Oint 2.5% Topical - Corticosteroids - Low Potency P G Hydrocortisone Valerate Topical - Corticosteroids - Low Potency N PA Required G Hydrocortisone w/Acetic Acid Ear NP G HYDROMORPHONE HCL INJ Narcotics - Misc. NP PA Required G Hydromorphone HCl Tab 2 MG Narcotics - Misc. P G Hydromorphone HCl Tab 4 MG Narcotics - Misc. P G Hydromorphone HCl Tab 8 MG Narcotics - Misc. P G Hydroxychloroquine Sulfate Antimalarial Agents P G Hydroxyprogesterone caproate Antineoplastics - Progestins R PA Required G Hydroxyurea Antineoplastics - Misc. P G Hydroxyzine HCl SOLN Antihistamines - Other P G Hydroxyzine HCl SYRP Antihistamines - Other P G Hydroxyzine HCl Tab 25 MG Antihistamines - Other P G Hydroxyzine HCl Tab 50 MG Antihistamines - Other P G Hydroxyzine HCl TABS 10MG Antihistamines - Other P G Hydroxyzine Pamoate Antihistamines - Other P G Hydroxyzine Pamoate CAPS 100MG Antihistamines - Other NP PA Required G Hyoscyamine Sulfate Gi - Antidiarrheal / Antacid - Misc. P B HYPERHEP B S/D Immune Serums NP B HYPERHEP B S/D SOLN Immune Serums P B HYPERRHO S/D Immune Serums P B HYPERTET S/D Immune Serums P B HYQVIA Immune Serums P B HYSINGLA ER Narcotics -Long Acting NP PA Required B HYZAAR ARB'S And Diuretics NP

12/17/2018 9:18:23 AM Page 42 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR I G Ibandronate Sodium Osteoporosis NP B IBRANCE Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B IBUDONE Narcotics - Misc. NP PA Required G Ibuprofen Susp 100 MG/5ML NSAIDS NP O Ibuprofen Susp 100 MG/5ML NSAIDS P O Ibuprofen Tab 200 MG NSAIDS P G Ibuprofen Tab 400 MG NSAIDS P G Ibuprofen Tab 600 MG NSAIDS P G Ibuprofen Tab 800 MG NSAIDS P B ICLUSIG Antineoplastics - Misc. NR Initial fill limited to 15 day supply. B Idelvion Antihemophilia Factor IX Agents N B Idhifa Antineoplastics - Misc. NR PA Required B Ilaris Anti-Inflammatories, Non-NSAID N PA Required B ILEVRO Op. Nsaid'S P B Imatinib Antineoplastics - Protein-Tyrosine Kinase Inhibitors N PA Required B IMBRUVICA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required G Imipenem-Cilastatin Carbapenems NP G Imipramine HCl Antidepressants - Tri-Cyclics P G Imipramine Pamoate Antidepressants - Tri-Cyclics NP Imipramine Pamoate - Use Imipramine HCL G Imiquimod Topical - Genital Warts P Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks (112 days). G Imiquimod 3.75% Topical - Genital Warts N B IMITREX Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B IMITREX spray Migraine - Selective Serotonin Agonists (5HT)--Injectables N PA Required B IMITREX STATDOSE REFILL Migraine - Selective Serotonin Agonists (5HT)--Injectables N PA Required B IMITREX STATDOSE SYSTEM Migraine - Selective Serotonin Agonists (5HT)--Injectables N PA Required B IMURAN Purine Analog NP B INCRELEX Growth Hormone NP PA Required B INCRUSE ELLIPTA Antiasthmatic - Anti-Cholinergics NP G Indapamide Diuretics P B INDERAL LA Beta Blockers - Non Selective NP B INDOCIN NSAIDS NP PA Required G Indomethacin NSAIDS P

12/17/2018 9:18:23 AM Page 43 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR I G Indomethacin CPCR NSAIDS NP PA Required B Inflectra Anti-Inflammatories, Non-NSAID N PA Required B Ingrezza Neurologics - Misc. N PA required B INLYTA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B INNOPRAN XL Beta Blockers - Non Selective NP B INSPRA Diuretics NP PA Required B INTELENCE Antiretrovirals - Rti - Non - Nucleoside Analogues NR B INTERMEZZO Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B INTRALIPID Electrolytes/ Nutritionals NP B INTUNIV Stimulants - Other Stimulants / Like Stimulants NP PA Required B INVANZ Carbapenems P B INVEGA Antipsychotics - Atypicals NP PA Required B INVEGA SUSTENNA Antipsychotics - Atypicals P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B INVEGA TRINZA Antipsychotics - Atypicals P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B INVIRASE Antiretrovirals - Protease Inhibitors NR B INVOKAMET Diabetic - Other NP PA Required B Invokamet XR Diabetic - Other N PA Required B INVOKANA Diabetic - Other NP PA Required B IOPIDINE Op. Selective Alpha Adrenergic Agonists NP G Ipratropium Bromide Antiasthmatic - Anti-Cholinergics P G Ipratropium Bromide (Nasal) SOLN 0.03% Antiasthmatic - Nasal Misc. P G Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) Antiasthmatic - Nasal Misc. NP G Ipratropium-Albuterol Antiasthmatic - Adrenergic Combos P G Irbesartan ARB'S P G Irbesartan-Hydrochlorothiazide ARB'S And Diuretics P G Iron Dextran Minerals P B ISENTRESS CHW 100MG Antiretrovirals - Integrase Inhibitors P B ISENTRESS CHW 25MG Antiretrovirals - Integrase Inhibitors P B Isentress HD Antiretrovirals - Integrase Inhibitors N B ISENTRESS TABS Antiretrovirals - Integrase Inhibitors P

12/17/2018 9:18:23 AM Page 44 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR I G Isoniazid Antimycobacterials / Antituberculosis P B ISOPTO CARPINE Op. Miotics - Direct Acting NP B ISORDIL TITRADOSE Antianginals--Isosorbide Nitrate NP G Isosorbide Dinitrate Antianginals--Isosorbide Nitrate P G Isosorbide Mononitrate Antianginals--Isosorbide Nitrate P G Isotretinoin Acne Products: Isotretinoin P PA Required G Isradipine Calcium Channel Blockers--Isradipines NP B ISTALOL Op. Beta - Blockers NP G Itraconazole Antifungals - Assorted NP PA Required G Ivermectin Anthelmintics P B Ixinity Antihemophilia Factor IX Agents N J B JADENU Antidotes - Chelating Agents NP PA Required B JAKAFI Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required < 18 years of age B JALYN BPH NP B JANUMET Diabetic - Other P PA Required B JANUMET XR Diabetic - Other P PA Required B JANUVIA Diabetic - Other P PA Required B JARDIANCE Diabetic - Other P PA Required B JENTADUETO Diabetic - Other P PA Required B Jentadueto XR Diabetic - Other N PA Required B JINTELI Estrogen Combos NP B JUBLIA Topical - Antifungals N PA Required B Juluca Antiretrovirals - Combinations N B JUXTAPID Antihyperlipidemics NP B Jynarque Vasopressins N K B Kadian Narcotics -Long Acting N PA Required B Kalbitor HEREDITARY ANGIOEDEMA AGENTS N B KALETRA Antiretrovirals - Combinations P B KALYDECO Cystic Fibrosis Agents NP PA Required B Kapspargo Beta Blockers - Cardio Selective N PA Required B KAPVAY Stimulants - Other Stimulants / Like Stimulants NP PA Required

12/17/2018 9:18:23 AM Page 45 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR K B KAZANO Diabetic - Other NP PA Required B KEFLEX Cephalosporins NP B KENALOG Glucocorticoids - Mineralocorticoids P B KENALOG Topical - Corticosteroids - Medium Potency N PA Required B KEPPRA Anticonvulsants NP Grandfather for seizure disorder. B KEPPRA XR Anticonvulsants NP Grandfather for seizure disorder. B KERYDIN Topical - Antifungals N PA Required B KETEK Macrolides / Erythromycin'S / Ketolides NP G Ketoconazole Antifungals - Assorted NP PA Required G Ketoconazole (Topical) Topical - Antifungals P G Ketoconazole (Topical) FOAM Topical - Antifungals NP G Ketoprofen NSAIDS P G Ketoprofen Capsule ER 24HR NSAIDS NP PA Required G Ketorolac Tromethamine Cox 2 Inhibitors - Selective NP PA Required G Ketorolac Tromethamine (Ophth) Op. Nsaid'S P G Ketorolac Tromethamine SOLN 60MG/2ML Cox 2 Inhibitors - Selective NP PA Required B Kevzara Anti-Inflammatories, Non-NSAID N PA Required B KHEDEZLA Antidepressants - Selected SSRI's NP PA Required B KINERET Anti-Inflammatories, Non-Nsaid NP PA Required B kisqali Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B Kisqali Pak Femara Antineoplastics - Combinations R PA Required B KITABIS PAK AMINO GLYCOSIDES N B KLARON Topical - Acne Preparations NP PA Required B KLONOPIN Anticonvulsants NP PA Required B KOATE-DVI Antihemophilia Factor VIII Agents P B KOGENATE FS Antihemophilia Factor VIII Agents N B KOGENATE FS BIO-SET Antihemophilia Factor VIII Agents N B KOMBIGLYZE XR Diabetic - Other N PA Required B KORLYM Diabetic - Other NP PA Required B Kovaltry Antihemophilia Factor VIII Agents N B K-PHOS TAB NO 2 Urological - Misc. P B KRISTALOSE Gi - Anti - Flatulents / GI Stimulants NP B KUVAN Phenylketonuria NP PA Required B KYNAMRO Antihyperlipidemics NP

12/17/2018 9:18:23 AM Page 46 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR L G Labetalol HCl Beta Blockers - Alpha / Beta P G Lactated Ringer's Electrolytes/ Nutritionals P G Lactic Acid (Ammonium Lactate) Cream 12% Topical - Emollients NP O Lactic Acid (Ammonium Lactate) Lotion 12% Topical - Emollients P G Lactulose Gi - Anti - Flatulents / GI Stimulants P G Lactulose (Encephalopathy) Gi - Anti - Flatulents / GI Stimulants P B LAMICTAL Anticonvulsants NP Grandfather for seizure disorder. B LAMICTAL XR Anticonvulsants NP PA Required B LAMISIL Antifungals - Assorted NP PA Required G Lamivudine Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues P G Lamivudine-Zidovudine Antiretrovirals - Combinations P G Lamotrigine Anticonvulsants P G Lamotrigine Chewable Tablet Anticonvulsants P G lamotrigine kit Anticonvulsants N G Lamotrigine Tablet Disperse Anticonvulsants N PA required G Lamotrigine Tablet ER 24HR Anticonvulsants NP PA Required B LANOXIN Cardiac Glycosides NP Grandfather Existing Users G Lansoprazole Gi - Proton Pump Inhibitor NP PA Required G Lanthanum Phosphate Binders N B LANTUS INJ 100/ML Diabetic - Insulin P B LANTUS SOLOSTAR Diabetic - Insulin Penfills P B LASIX Diuretics NP B LASTACAFT Op. Antiallergics - Antihistamines NP G Latanoprost Op. Prostaglandins P B LATUDA Antipsychotics - Atypicals NP Grandfather Existing Users B Lazanda Narcotics - Misc. N PA Required G Leflunomide Rheumatoid Arthritis - Non-Biologicals P B Lenvima Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B LESCOL XL Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P B LETAIRIS Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist P PA Required G Letrozole Antineoplastics - Aromatase Inhibitors P Payable for members 50 years of age and older without prior authorization G Leucovorin Calcium Antineoplastics - Folic Acid Antagonists Rescue Agents R B LEUKERAN Antineoplastics - Nitrogen Mustards R

12/17/2018 9:18:23 AM Page 47 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR L B LEUKINE Granulocyte Csf NP PA Required G Leuprolide Acetate Antineoplastics - Lhrh Analogs NR G levalbuterol Antiasthmatic - Beta - Adrenergics N PA Required G Levalbuterol tartrate Antiasthmatic - Beta - Adrenergics N PA Required B LEVAQUIN Fluoroquinolones NP B LEVATOL Beta Blockers - Non Selective P B LEVEMIR Diabetic - Insulin P B LEVEMIR Diabetic - Insulin Penfills P G Levetiracetam Anticonvulsants P G Levetiracetam Tablet ER 24HR Anticonvulsants NP PA Required G Levobunolol HCl Op. Beta - Blockers P G Levocarnitine Inj 200 MG/ML Carnitine Replenisher - Agents P G Levocarnitine Oral Soln 1 GM/10ML (10%) Carnitine Replenisher - Agents NP G Levocarnitine Tab 330 MG Carnitine Replenisher - Agents NP G Levocetirizine Dihydrochloride Antihistamines - Non-Sedating NP PA Required G Levofloxacin Fluoroquinolones P G Levofloxacin Ophth Soln 0.5% Op. Quinolones NP G Levonorgestrel & Ethinyl Estradiol Tab 0.1 MG-20 MCG Contraceptives - Monophasic Combination O/C'S P G Levonorgestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P O Levonorgestrel (Emergency OC) Contraceptives - Emergency Contraceptive P G Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-30MG-MCG Contraceptives - Tri-Phasic Combinations P G Levonorgestrel-Ethinyl Estradiol (91-Day) TABS Contraceptives - Monophasic Combination O/C'S P G Levonorgestrel-Ethinyl Estradiol (Continuous) Contraceptives - Monophasic Combination O/C'S NP G Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab 0.01MG(7) Contraceptives - Monophasic Combination O/C'S NP G Levothyroxine Sodium For IV Inj 500 MCG Thyroid Hormones NP G Levothyroxine Sodium Tab 100 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 112 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 125 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 137 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 150 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 175 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 200 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 25 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 300 MCG Thyroid Hormones P

12/17/2018 9:18:23 AM Page 48 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR L G Levothyroxine Sodium Tab 50 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 75 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 88 MCG Thyroid Hormones P B LEVSIN Gi - Antidiarrheal / Antacid - Misc. NP B LEXAPRO Antidepressants - Selected SSRI's NP B LEXIVA Antiretrovirals - Protease Inhibitors N B LIALDA TAB 1.2GM Gi - Inflammatory Bowel Agents NP G Lidocaine HCl (Cardiac) Antiarrhythmics NP G Lidocaine HCl Cream 3% Topical - Local Anesthetics P G Lidocaine HCl Gel 2% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 1% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 1.5% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 2% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 4% Topical - Local Anesthetics P G Lidocaine HCl Local Preservative Free (PF) Inj 0.5% Topical - Local Anesthetics P G Lidocaine HCl Local Preservative Free (PF) Inj 1% Topical - Local Anesthetics P G Lidocaine HCl Local Preservative Free (PF) Inj 2% Topical - Local Anesthetics P G Lidocaine HCl Lotion 3% Topical - Local Anesthetics P G Lidocaine HCl Soln 4% Topical - Local Anesthetics P G Lidocaine HCl Viscous Soln 2% Mouth - Anesthetics Topical Oral P G Lidocaine Oint 5% Topical - Local Anesthetics P G Lidocaine w/ Epinephrine Topical - Local Anesthetics P G Lidocaine-Hydrocortisone Acetate (Rectal) Anorectal - Misc. NP G Lidocaine-Hydrocortisone Acetate (Rectal) Topical - Steroid Local Anesthetics P G Lidocaine-Prilocaine Topical - Local Anesthetics P B LIDODERM Topical - Local Anesthetics NP PA Required B LINCOCIN Lincosamides / Oxazolidinones / Leprostatics NP G Lindane Topical - Scabicides And Pediculicides NP G Linezolid Lincosamides / Oxazolidinones / Leprostatics P PA Required B LINZESS GI, Constipation - IBS-OIC NP PA Required B LIORESAL INTRATHECAL Muscle Relaxants P G Liothyronine Sodium Thyroid Hormones NP B LIPITOR Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations NP B LIPOFEN Cholesterol - Fibric Acid Derivatives NP

12/17/2018 9:18:23 AM Page 49 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR L B LIPOSYN Electrolytes/ Nutritionals P G Lisinopril ACE Inhibitors P G Lisinopril & Hydrochlorothiazide ACE and Thiazide Combo's P G Lithium Carbonate Cap 150 MG Lithium P G Lithium Carbonate Cap 300 MG Lithium P G Lithium Carbonate Cap 600 MG Lithium NP G Lithium Carbonate Tab 300 MG Lithium P G Lithium Carbonate Tab CR 300 MG Lithium P G Lithium Carbonate Tab CR 450 MG Lithium P B LITHOBID Lithium NP Grandfather Existing Users B LITHOSTAT Urological - Misc. NP B LIVALO Cholesterol - Hmg COA + Absorb Inhibitors NP B LO LOESTRIN FE Contraceptives - Monophasic Combination O/C'S NP B LODOSYN Anti-Parkinsonian Drugs NP B LOESTRIN Contraceptives - Monophasic Combination O/C'S NP B LOESTRIN FE 1.5/30 Contraceptives - Monophasic Combination O/C'S NP B LOESTRIN FE 1/20 Contraceptives - Monophasic Combination O/C'S NP B LOFIBRA Cholesterol - Fibric Acid Derivatives NP B Lokelma K Removing Resins N PA Required B LOMOTIL Gi - Antiperistaltic Agents NP B Lonhala Magnair Antiasthmatic - Anti-Cholinergics N B Lonsurf Antineoplastics - Combinations NR PA Required G Loperamide HCl Cap 2 MG Gi - Antiperistaltic Agents P O Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) Gi - Antiperistaltic Agents P O Loperamide HCl Tab 2 MG Gi - Antiperistaltic Agents P B LOPID Cholesterol - Fibric Acid Derivatives NP G Lopinavir-ritonavir Antiretrovirals - Combinations N B LOPRESSOR Beta Blockers - Cardio Selective NP B LOPRESSOR HCT Beta Blockers And Diuretic Combo'S NP B LOPROX SHAMPOO Topical - Antifungals NP O Loratadine Syrup 5 MG/5ML Antihistamines - Non-Sedating P O Loratadine Tab 10 MG Antihistamines - Non-Sedating P G Lorazepam Anxiolytics - Benzodiazepines P B LORAZEPAM INTENSOL Anxiolytics - Benzodiazepines NP PA Required

12/17/2018 9:18:23 AM Page 50 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR L G Losartan Potassium ARB'S P G Losartan Potassium & Hydrochlorothiazide ARB'S And Diuretics P B LOSEASONIQUE Contraceptives - Monophasic Combination O/C'S NP B LOTEMAX Op. Antiinflammatory / Steroids Ophth. N B LOTENSIN ACE Inhibitors NP B LOTENSIN HCT ACE and Thiazide Combo's NP B LOTREL ACE Inhibitors And Calcium Channel Blockers NP B LOTRISONE Topical - Antifungals NP B LOTRONEX Gi - Irritable Bowel Syndrome Agents P G Lovastatin Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P B LOVAZA Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B LOVENOX SYRINGES Anticoagulants NP B LOVENOX VIALS Anticoagulants NP G Loxapine Succinate Antipsychotics - Typical P B LOXITANE Antipsychotics - Typical NP B Lucemyra OPIOID WITHDRAWAL TREATMENTS N G Luliconazole Topical - Antifungals N B LUMIGAN Op. Prostaglandins NP B LUNESTA Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B LUPANETA PACK Lhrh/Gnrh Agonist Analog Pituitary Suppressants NP B LUPR DEP-PED INJ 11.25MG Central Precocious Puberty Agents P PA Required B LUPR DEP-PED INJ 15MG Central Precocious Puberty Agents P PA Required B LUPR DEP-PED INJ 7.5MG Central Precocious Puberty Agents P PA Required B LUPRON DEPOT Antineoplastics - Lhrh Analogs R PA Required B LUPRON DEPOT-PED KIT 11.25MG Central Precocious Puberty Agents N PA Required B LUPRON DEPOT-PED KIT 30MG Central Precocious Puberty Agents N PA Required B LUXIQ Topical - Corticosteroids - Medium Potency N PA Required B Luzu Topical - Antifungals N B LYNPARZA Antineoplastics - Parp Inhibitors NR PA Required B LYRICA Anticonvulsants NP PA Required B LYSODREN Antineoplastics - Antiadrenals R B LYSTEDA Hemostatic NP M B MACROBID Urological - Misc. NP

12/17/2018 9:18:23 AM Page 51 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR M B MACRODANTIN Urological - Misc. NP B MAGNEBIND 400 Minerals P PA Required O Magnesium Hydroxide Susp 400 MG/5ML Gi - Misc. P O Magnesium Oxide Tab 400 mg Gi - Antidiarrheal / Antacid - Misc. P PA Required G Magnesium Sulfate Inj 4% Minerals P G Magnesium Sulfate Inj 50% Minerals P G Magnesium Sulfate Inj 8% Minerals P B MALARONE Antimalarial Agents N G Malathion Topical - Scabicides And Pediculicides NP G Maprotiline HCl Antidepressants - Selected SSRI's P Initial fill limited to 15 day supply. B MARCAINE Topical - Local Anesthetics P B MARCAINE W/O EPI Topical - Local Anesthetics P B MARINOL Antiemetic - Tetrahydrocannabinol (THC) Derivatives NP B MATULANE Antineoplastics - Misc. R B MAVIK ACE Inhibitors NP B Mavyret Hepatitis C Agents P PA Required B MAXALT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B MAXALT-MLT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B MAXIDEX Op. Antiinflammatory / Steroids Ophth. P B MAXITROL Op. Antiinflammatory / Steroids Ophth. NP B MAXZIDE Diuretics NP O Meclizine HCl Antiemetic - Anticholinergic / Dopaminergic P G Meclizine HCL Antiemetic - Anticholinergic / Dopaminergic P G Meclofenamate Sodium NSAIDS NP PA Required B MEDROL PAK 4MG Glucocorticoids - Mineralocorticoids P B MEDROL TAB 16MG Glucocorticoids - Mineralocorticoids NP B MEDROL TAB 2MG Glucocorticoids - Mineralocorticoids NP B MEDROL TAB 32MG Glucocorticoids - Mineralocorticoids NP B MEDROL TAB 4MG Glucocorticoids - Mineralocorticoids P B MEDROL TAB 8MG Glucocorticoids - Mineralocorticoids NP G Medroxyprogesterone Acetate Progestins P G Medroxyprogesterone Acetate (Contraceptive) Contraceptives - Injectable P G Mefenamic Acid NSAIDS NP PA Required G Mefloquine HCl Antimalarial Agents P

12/17/2018 9:18:23 AM Page 52 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR M B MEGACE ES Progestins NP B MEGACE ORAL Antineoplastics - Progestins NR Requires a Selected Brand Name Drug PA G Megestrol Acetate Antineoplastics - Progestins R B MEKINIST Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required G Meloxicam Cox 2 Inhibitors - Selective P G Melphalan HCl Antineoplastics - Nitrogen Mustards NR G Memantine Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. G Memantine er Alzheimer - Cholinomimetics N Restricted to persons 40 years of age and older. G Memantine oral solution Alzheimer - Cholinomimetics N Restricted to persons 40 years of age and older. B MENEST Estrogens - Tabs N B MENOSTAR Estrogens - Patches NP B MENTAX Topical - Antifungals NP G Meperidine HCl SOLN Narcotics - Misc. NP PA Required G Meperidine HCl Tab 100 MG Narcotics - Misc. P G Meperidine HCl Tab 50 MG Narcotics - Misc. P B MEPHYTON Vitamins P G Mepivacaine HCl Topical - Local Anesthetics NP G Meprobamate Anxiolytics - Misc. P B MEPRON Antiprotozoal Agents N G Mercaptopurine Antineoplastics - Antimetabolites P G Meropenem Carbapenems P B MERREM Carbapenems NP G Mesalamine DR Tablet Gi - Inflammatory Bowel Agents N G mesalamine rectal Gi - Inflammatory Bowel Agents P B MESTINON SYP 60MG/5ML Neurologics - Misc. P B MESTINON TABS Neurologics - Misc. NP B MESTINON TIMESPAN Neurologics - Misc. P B METADATE Stimulants - Methylphenidate - Long Acting N PA Required G Metaproterenol Sulfate Antiasthmatic - Beta - Adrenergics NP G Metaxalone Muscle Relaxants NP PA Required G Metformin HCl Diabetic - Oral Biguanides P G metformin hcl tab sr Diabetic - Oral Biguanides P

12/17/2018 9:18:23 AM Page 53 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR M G metformin hcl tab sr modified release Diabetic - Oral Biguanides N PA Required G metformin hcl tab sr osmotic Diabetic - Oral Biguanides NP G Methadone HCl CONC Narcotics -Long Acting N PA Required G Methadone HCl SOLN Narcotics -Long Acting N PA Required G Methadone HCl Tab 10 MG Narcotics -Long Acting N PA Required G Methadone HCl Tab 5 MG Narcotics -Long Acting N PA Required B METHADOSE CON 10MG/ML Narcotics -Long Acting N PA Required B METHADOSE SF CON 10MG/ML Narcotics -Long Acting N PA Required G Methamphetamine HCl Stimulants NP PA Required G Methazolamide Diuretics NP G Methenamine Hippurate Urological - Misc. NP G Methenamine Mandelate Urological - Misc. P G Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal Urological - Misc. NP G Methimazole Antithyroid Therapies P B METHITEST Androgens - Anabolics P PA Required G Methocarbamol Muscle Relaxants P G Methotrexate Sodium Antineoplastics - Antimetabolites P G Methoxsalen Rapid Anti-Psoriatics - Non-Biologicals NP G Methscopolamine Bromide Gi - Antidiarrheal / Antacid - Misc. P G Methyclothiazide Diuretics P G Methyldopa Antihypertensives - Central P G Methyldopa & Hydrochlorothiazide Antihypertensive Combos P G Methylergonovine Maleate Oxytocics P B Methylin oral solution Stimulants - Methylphenidate P PA Required >= 21 yo. G methylphenidate chew Stimulants - Methylphenidate N PA Required G Methylphenidate er 72mg tablets Stimulants - Methylphenidate - Long Acting N PA Required G Methylphenidate HCl Stimulants - Methylphenidate P PA Required >= 21 yo. G Methylphenidate HCl ER Capsule (cd) Stimulants - Methylphenidate - Long Acting N PA Required G methylphenidate hcl er capsule (la) Stimulants - Methylphenidate - Long Acting N PA Required G methylphenidate hcl tab sa osm Stimulants - Methylphenidate - Long Acting N PA Required G Methylphenidate HCl Tablet ER 10MG ER Stimulants - Methylphenidate - Long Acting NP PA Required G Methylphenidate oral solution Stimulants - Methylphenidate N PA Required G METHYLPHENIDATE TAB 20MG CR Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. G Methylprednisolone Acetate Glucocorticoids - Mineralocorticoids P

12/17/2018 9:18:23 AM Page 54 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR M G Methylprednisolone Sod Succ Glucocorticoids - Mineralocorticoids P G Methylprednisolone Tab 16 MG Glucocorticoids - Mineralocorticoids NP G Methylprednisolone Tab 32 MG Glucocorticoids - Mineralocorticoids NP G Methylprednisolone Tab 4 MG Glucocorticoids - Mineralocorticoids P G Methylprednisolone Tab 8 MG Glucocorticoids - Mineralocorticoids NP B Methyltestosterone Androgens - Anabolics N PA Required G Metipranolol Op. Beta - Blockers P G Metoclopramide HCl Gi - Anti - Flatulents / GI Stimulants P G Metoclopramide odt Gi - Anti - Flatulents / GI Stimulants N PA Required G Metolazone Diuretics P G Metoprolol & Hydrochlorothiazide Beta Blockers And Diuretic Combo'S NP G Metoprolol Succinate Beta Blockers - Cardio Selective P G Metoprolol Tartrate Beta Blockers - Cardio Selective P B METRO IV Antibiotics - Misc. P B METROCREAM Topical - Acne Preparations N PA Required B METROGEL Topical - Acne Preparations P PA Required B METROGEL-VAGINAL Vaginal - Antibacterials N B METROLOTION Topical - Acne Preparations P PA Required G Metronidazole (Topical) LOTN Topical - Acne Preparations NP PA Required G Metronidazole CAPS Antibiotics - Misc. NP G Metronidazole Cream 0.75% Topical - Acne Preparations P PA Required G Metronidazole Gel 0.75% Topical - Acne Preparations NP PA Required G Metronidazole in NaCl Antibiotics - Misc. P G Metronidazole Powder Powders P G Metronidazole Tab 250 MG Antibiotics - Misc. P G Metronidazole Tab 500 MG Antibiotics - Misc. P G Metronidazole Vaginal Vaginal - Antibacterials P G Mexiletine HCl Antiarrhythmics P B MIACALCIN INJ 200/ML Osteoporosis NP B MIACALCIN SPR 200/ACT Osteoporosis NP B MICARDIS ARB'S N B MICARDIS HCT ARB'S And Diuretics N O Miconazole Nitrate Cream 2% Topical - Antifungals P O Miconazole Nitrate Vaginal Cream 2% Vaginal - Anti Fungals P

12/17/2018 9:18:23 AM Page 55 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR M O Miconazole Nitrate Vaginal Suppos 100 MG Vaginal - Anti Fungals P B MICRHOGAM ULTRA-FILTEREDPLUS Immune Serums P B MICRO-K Minerals P B MICROZIDE Diuretics NP G Midazolam HCl Sedative/Hypnotics - Benzodiazepines P G Midazolam HCl SYRP Sedative/Hypnotics - Benzodiazepines P G Midodrine HCl Pressors P B MIGERGOT Migraine - Ergot Combinations P G Miglitol Diabetic - Alphaglucosidase N G Miglustat Agents For Gaucher Disease N B MIGRANAL Migraine - Ergotamine Derivatives N B MILLIPRED SOL 10MG/5ML Glucocorticoids - Mineralocorticoids NP B MILLIPRED TABS Glucocorticoids - Mineralocorticoids NP G Milrinone in Dextrose Phosphodiesterase Inhibitors NP G Milrinone Lactate Phosphodiesterase Inhibitors NP B MINIPRESS Antihypertensives - Central NP B MINIVELLE Estrogens - Patches NP G Minocycline HCl Cap 100 MG Tetracyclines P G Minocycline HCl Cap 50 MG Tetracyclines P G Minocycline HCl Cap 75 MG Tetracyclines P G Minocycline HCl Tab 100 MG Tetracyclines NP G Minocycline HCl Tab 50 MG Tetracyclines NP G Minocycline HCl Tab 75 MG Tetracyclines NP G Minocycline HCl Tablet ER 24HR Tetracyclines NP PA Required G Minoxidil Antihypertensives - Central P B MIRAPEX Parkinsons - Selected Dopamin Agonists NP B MIRAPEX ER Parkinsons - Selected Dopamin Agonists NP PA Required B Mircera Erythropoeisis Stimulating Agents N PA Required B MIRCETTE Contraceptives - Monophasic Combination O/C'S NP G Mirtazapine Antidepressants - Selected SSRI's P G Mirtazapine Tablet Disperse Antidepressants - Selected SSRI's NP PA Required G Misoprostol Gi - Prostaglandins P B mitigare Gout N B MOBIC Cox 2 Inhibitors - Selective NP PA Required

12/17/2018 9:18:23 AM Page 56 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR M G Modafinil Stimulants - Other Stimulants / Like Stimulants P PA Required >= 21 yo. B MODICON Contraceptives - Monophasic Combination O/C'S NP G Moexipril HCl ACE Inhibitors NP G Moexipril-Hydrochlorothiazide ACE and Thiazide Combo's NP G Molindone Antipsychotics - Typical N G Mometasone Furoate Topical - Corticosteroids - Medium Potency P G Mometasone nasal Nasal Steroids N B MONOCLATE-P Antihemophilia Factor VIII Agents P B MONONINE Antihemophilia Factor IX Agents P G Montelukast granules Antiasthmatic - Leukotriene Receptor Antagonists P Preferred < 2 years of age G Montelukast Sodium Chew Tab 4 MG (Base Equiv) Antiasthmatic - Leukotriene Receptor Antagonists P G Montelukast Sodium Chew Tab 5 MG (Base Equiv) Antiasthmatic - Leukotriene Receptor Antagonists P G Montelukast Sodium Tab 10 MG (Base Equiv) Antiasthmatic - Leukotriene Receptor Antagonists P B MONUROL Urological - Misc. N B Morphabond ER Narcotics -Long Acting N PA Required G MORPHINE SUL CAP ER Narcotics -Long Acting NP PA Required G MORPHINE SUL TAB ER Narcotics -Long Acting P G Morphine Sulfate Narcotics -Long Acting P G Morphine Sulfate Narcotics - Misc. P B Movantik GI, Constipation - IBS-OIC NP PA Required B MOVIPREP Gi - Misc. NP B MOXATAG Beta-Lactams / Clavulanate Combo'S NP PA Required B MOXEZA Op. Quinolones Fourth Generation N G Moxifloxacin HCl Fluoroquinolones NP G Moxifloxacin ophthalmic solution Op. Quinolones Fourth Generation P B MS CONTIN Narcotics -Long Acting NP PA Required B Mulpleta Hematopoietics Chronic ITP N PA Required B MULTAQ Antiarrhythmics P G Mupirocin Calcium Cream 2% Topical - Antibiotic NP G Mupirocin Oint Topical - Antibiotic P B MYALEPT Lipodystrophy Agents NP B MYAMBUTOL Antimycobacterials / Antituberculosis N B MYCAMINE Antifungals - Assorted P B MYCOBUTIN Antimycobacterials / Antituberculosis NP

12/17/2018 9:18:23 AM Page 57 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR M G Mycophenolate Mofetil CAPS Immunosuppressants P G Mycophenolate Mofetil oral suspension Immunosuppressants N G Mycophenolate Mofetil Tabs Immunosuppressants P G Mycophenolate Sodium Immunosuppressants NP B Mydayis Stimulants - Amphetamines - Long Acting N PA Required B MYDFRIN Op. Misc P B MYDRIACYL Op. Cycloplegics NP B MYFORTIC Immunosuppressants P B MYLERAN Antineoplastics - Alkylating Agents R B MYRBETRIQ Antispasmodics - Long Acting NP B MYSOLINE Anticonvulsants NP Grandfather Existing Users B Mytesi Gi - Antidiarrheal / Antacid - Misc. N N B NABI-HB Immune Serums P G Nabumetone Cox 2 Inhibitors - Selective P G Nadolol Beta Blockers - Non Selective P G Nadolol & Bendroflumethiazide Beta Blockers And Diuretic Combo'S NP G Nafcillin Sodium Beta-Lactams / Clavulanate Combo'S P G Naftifine Topical - Antifungals N B NAFTIN Topical - Antifungals NP B NAGLAZYME Metabolic Modifiers - Lysosomal Storage Disorder Treatments NP G Nalbuphine HCl Narcotics - Selected P B NALFON NSAIDS NP PA Required G Naloxone HCl Narcotic - Antagonists P G Naltrexone HCl Narcotic - Antagonists P B NAMENDA Alzheimer - Cholinomimetics N Restricted to persons 40 years of age and older. B NAMENDA XR Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B NAMZARIC Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. G Naphazoline HCl Op. Misc P B NAPRELAN NSAIDS NP PA Required B NAPROSYN NSAIDS NP PA Required B NAPROSYN SUSP NSAIDS P

12/17/2018 9:18:23 AM Page 58 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR N G Naproxen NSAIDS P G Naproxen Sodium Tab 550 MG NSAIDS P G Naproxen Sodium TABS 275MG NSAIDS NP PA Required G Naratriptan HCl Migraine - Selective Serotonin Agonists (5HT)--Tabs P PA Required> 12 Units/30 Days supply B Narcan Narcotic - Antagonists P B NARDIL Antidepressants - Mao Inhibitors NP B NASONEX Nasal Steroids N B NATAZIA Contraceptives - Multi-Phasic Combinations NP G Nateglinide Diabetic - Meglitinides P B NATESTO Androgens - Anabolics NP PA Required B NATPARA PTH NP B NATROBA Topical - Scabicides And Pediculicides P B NEBUPENT Antibiotics - Misc. P B NECON 1/50-28 Contraceptives - Monophasic Combination O/C'S P B NECON 10/11-28 Contraceptives - Bi-Phasic Combinations NP G Nefazodone HCl Antidepressants - Selected SSRI's P Initial fill limited to 15 day supply. G Neomycin Sulfate Amino Glycosides P G Neomycin/Polymyxin B GU Urological - Misc. P G Neomycin-Bacitracin Zn-Polymyxin Op. Antibiotics NP O Neomycin-Bacitracin-Polymyxin Topical - Antibiotic P G Neomycin-Polymy-Dexameth Op. Antiinflammatory / Steroids Ophth. P G Neomycin-Polymyxin-Gramicidin Op. Antibiotics NP G Neomycin-Polymyxin-HC (Ophth) Op. Antiinflammatory / Steroids Ophth. NP G Neomycin-Polymyxin-HC (Otic) Ear P B NEORAL Immunosuppressants NP B NEOSPORIN Op. Antibiotics NP B NEOSPORIN GU IRRIGANT Urological - Misc. P B NEPHPLEX RX Vitamins - Misc. P PA Required B NEPTAZANE Diuretics NP B Nerlynx Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B NESINA Diabetic - Other NP PA Required B NEULASTA Granulocyte Csf NP PA Required B NEUMEGA Granulocyte Csf NP PA Required

12/17/2018 9:18:23 AM Page 59 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR N B NEUPOGEN Granulocyte Csf P PA required. Neupogen vials preferred for patients less than 18 years of age. B NEUPRO Parkinsons - Selected Dopamin Agonists NP B NEURONTIN Anticonvulsants NP B NEURONTIN SOLN Anticonvulsants NP Grandfather for seizure disorder. B NEVANAC Op. Nsaid'S N G Nevirapine Antiretrovirals - Rti - Non - Nucleoside Analogues NR G Nevirapine SUSP Antiretrovirals - Rti - Non - Nucleoside Analogues NR B NEXAVAR Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B NEXIUM Gi - Proton Pump Inhibitor NP PA Required G Niacin (Antihyperlipidemic) Cholesterol - Fibric Acid Derivatives NP O Niacin Tab 100 MG Vitamins NP PA Required O Niacin Tab 250 MG Vitamins NP PA Required O Niacin Tab 50 MG Vitamins NP PA Required O Niacin Tab 500 MG Vitamins NP PA Required B NIASPAN Cholesterol - Fibric Acid Derivatives NP Grandfather Existing Users G Nicardipine HCl Nicardipines NP O NICODERM CQ Nicotine Replacement Therapy NP PA required limited to package size of #14 for initial fill O NICORETTE Nicotine Replacement Therapy NP PA required limited to package size of #110 for initial fill O NICORETTE LOZG Nicotine Replacement Therapy NP PA required, Limit of 144 for initial fill O NICORETTE MINI Nicotine Replacement Therapy NP PA required, Limit of 144 for initial fill O NICORETTE STARTER KIT Nicotine Replacement Therapy NP PA required limited to package size of #110 for initial fill O Nicotine Polacrilex Nicotine Replacement Therapy P PA required limited to package size of #110 for initial fill O Nicotine Polacrilex LOZG Nicotine Replacement Therapy P PA required, Limit of 144 for initial fill O Nicotine TD Patch 24HR 14 MG/24HR Nicotine Replacement Therapy P PA required limited to package size of #14 for initial fill O Nicotine TD Patch 24HR 21 MG/24HR Nicotine Replacement Therapy P PA required limited to package size of #14 for initial fill O Nicotine TD Patch 24HR 7 MG/24HR Nicotine Replacement Therapy P PA required limited to package size of #14 for initial fill B NICOTROL Nicotine Replacement Therapy NP PA required limited to package size 168 for intial fill B NICOTROL SOLN Nicotine Replacement Therapy NP PA required limited to package size 40ml for initial fill G Nifedipine Calcium Channel Blockers--Nifedipines P

12/17/2018 9:18:23 AM Page 60 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR N G Nifedipine Tab SR 24HR 30 MG Calcium Channel Blockers--Nifedipines P G Nifedipine Tab SR 24HR 60 MG Calcium Channel Blockers--Nifedipines P G Nifedipine Tab SR 24HR 90 MG Calcium Channel Blockers--Nifedipines P B NILANDRON Antineoplastics - Antiandrogens R B Ninlaro Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required G Nisoldipine Calcium Channel Blockers--Nisoldipine NP B NITRO-BID Nitro - Ointment/Cap/Cr P B NITRO-DUR DIS 0.1MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.2MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.3MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.4MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.6MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.8MG/HR Nitro - Patches P G Nitrofurantoin Macrocrystal 100MG Urological - Misc. P G Nitrofurantoin Macrocrystal 25MG Urological - Misc. N G Nitrofurantoin Macrocrystal 50MG Urological - Misc. P G Nitrofurantoin Monohyd Macro Urological - Misc. P G Nitrofurantoin Suspension Urological - Misc. P G Nitroglycerin Nitro - Ointment/Cap/Cr P G Nitroglycerin Nitro - Patches P G Nitroglycerin Nitro - Sublingual/ Spray P G Nitroglycerin in D5W Nitro - Ointment/Cap/Cr NP G Nitroglycerin SOLN Nitro - Sublingual/ Spray NP B NITROLINGUAL Nitro - Sublingual/ Spray NP B NITROMIST Nitro - Sublingual/ Spray NP B NITROSTAT Nitro - Sublingual/ Spray P B Nityr Hereditary Tyrosinemia Type 1 (HT-1) Treatment - Agents N G Niva-plus tablet Vitamins - Misc. P G Nizatidine Gi - H2-Antagonists NP B NIZORAL SHAMPOO Topical - Antifungals NP B Noctiva Vasopressins N PA Required B NORCO Narcotics - Misc. NP PA Required B NORDITROPIN Growth Hormone P PA Required G Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P

12/17/2018 9:18:23 AM Page 61 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR N G Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P G norethindrone & ethinyl estradiol tab 1 mg-20 mcg Contraceptives - Monophasic Combination O/C'S P G Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P G norethindrone & ethinyl estradiol tab 1.5 mg-30 mcg Contraceptives - Monophasic Combination O/C'S P G Norethindrone & Ethinyl Estradiol-Fe Contraceptives - Monophasic Combination O/C'S NP G Norethindrone & Ethinyl Estradiol-Fe Chew CONTRACEPTIVES - MONOPHASIC COMBINATION O/C'S P G Norethindrone (Contraceptive) Contraceptives - Progestin Only P G Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20 MCG Contraceptives - Monophasic Combination O/C'S P G Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P G Norethindrone Acet & Eth Estra Contraceptives - Monophasic Combination O/C'S NP G Norethindrone Acetate Tab 5 MG Progestins P G Norethindrone Ac-Ethinyl Estrad-Fe Tab 1-20/1-30/1-35 MG-MCG Contraceptives - Tri-Phasic Combinations NP G Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MG-MCG Contraceptives - Tri-Phasic Combinations P G Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG Contraceptives - Tri-Phasic Combinations P G Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35 MG-MCG Contraceptives - Tri-Phasic Combinations P G Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P B NORINYL TAB 1/35 Contraceptives - Monophasic Combination O/C'S NP B NORITATE Topical - Acne Preparations NP PA Required B NORPACE Antiarrhythmics NP B NORPRAMIN Antidepressants - Tri-Cyclics NP B NOR-QD Contraceptives - Progestin Only NP G Nortriptyline HCl Antidepressants - Tri-Cyclics P B NORVASC Calcium Channel Blockers--Amlodipines NP B NORVIR CAP 100MG Antiretrovirals - Protease Inhibitors R B NORVIR SOL 80MG/ML Antiretrovirals - Protease Inhibitors R B Norvir oral powder packets Antiretrovirals - Protease Inhibitors R B NORVIR TABS Antiretrovirals - Protease Inhibitors P B NOVOEIGHT Antihemophilia Factor VIII Agents P O NOVOLIN 70/30 Diabetic - Insulin NP O NOVOLIN N Diabetic - Insulin NP O NOVOLIN R Diabetic - Insulin NP B NOVOLOG Diabetic - Insulin NP B Novolog Flexpen Diabetic - Insulin Penfills P B NOVOLOG MIX 70/30 Diabetic - Insulin NP

12/17/2018 9:18:23 AM Page 62 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR N B NOVOSEVEN Antihemophilia Factor VII Agents P B NOXAFIL Antifungals - Assorted NP PA Required B NPLATE Hematopoietics Chronic ITP NP PA Required B Nucala Antiasthmatic - Antiinflammatory Agents N B NUCYNTA Narcotics - Misc. NP PA Required B NUCYNTA ER Narcotics -Long Acting NP PA Required B NUEDEXTA Neurologics - Misc. NP PA Required B NULYTELY Gi - Anti - Flatulents / GI Stimulants P B Nuplazid Antipsychotics - Atypicals N B Nutrestore Electrolytes/ Nutritionals N B NUTROPIN AQ Growth Hormone P PA Required B NUVARING Contraceptives - Patches/ Vaginal Products P B NUVESSA Vaginal - Antibacterials NP B NUVIGIL Stimulants - Other Stimulants / Like Stimulants NP PA Required B Nuwiq Antihemophilia Factor VIII Agents N B NYMALIZE Calcium Channel Blockers--Nifedipines NP G Nystatin Antifungals - Assorted P G Nystatin Cream 100000 Unit/GM Topical - Antifungals NP G Nystatin Oint 100000 Unit/GM Topical - Antifungals P G Nystatin Susp 100000 Unit/ML Mouth Anti-Infectives P G Nystatin-Triamcinolone Topical - Antifungals NP O B OBIZUR Antihemophilia Factor VIII Agents N B Ocaliva Gi - Misc. N B OCTAGAM Immune Serums NP G Octreotide Acetate Somatostatic Agents N B OCUFEN Op. Nsaid'S NP B OCUFLOX Op. Quinolones NP B Odefsey Antiretrovirals - Combinations P B Odomzo Antineoplastics - Antimetabolites NR PA Required B OFEV Idiopathic Pulmonary Fibrosis NP PA Required G Ofloxacin Fluoroquinolones NP G Ofloxacin (Ophth) Op. Quinolones NP G Ofloxacin (Otic) Ear P

12/17/2018 9:18:23 AM Page 63 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR O B OGESTREL Contraceptives - Monophasic Combination O/C'S NP G olanzapine Antipsychotics - Atypicals P G olanzapine tablet disperse Antipsychotics - Atypicals NP PA Required G Olanzapine-Fluoxetine HCl Psychotherapeutic Combination NP Grandfather Existing Users B OLEPTRO Antidepressants - Selected SSRI's NP PA Required G Olmesartan ARB'S N G Olmesartan-amlodipine-HCTZ ARB/CCB Plus Diuretics N G Olmesartan-HCTZ ARB'S And Diuretics N G olopatadine (ophth) Op. Antiallergics - Antihistamines P Preferred product is authorized generic distributed by labeler 61314 G Olopatadine HCl (Nasal) Antihistamines - Non-Sedating NP B Olumiant Anti-Inflammatories, Non-NSAID N PA Required B OLUX Topical - Corticosteroids - High Potency N PA Required B OLUX-E Topical - Corticosteroids - High Potency N PA Required G Omega-3-acid Ethyl Esters Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP G Omeprazole Gi - Proton Pump Inhibitor P G Omeprazole-Sodium Bicarbonate Gi - Proton Pump Inhibitor NP PA Required B OMNARIS Nasal Steroids NP B OMNIPRED Op. Antiinflammatory / Steroids Ophth. NP B OMNITROPE Growth Hormone NP PA Required G Ondansetron HCl Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin P PA required for quantities exceeding 60- 4mg tabs, 60-8mg tabs, 4-20ml vials, and 8- 2ml vials. G Ondansetron HCl Oral Soln 4 MG/5ML Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required G Ondansetron ODT Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin P PA required for quantities exceeding 60- 4mg tabs, 60-8mg tabs. B Onexton Topical - Acne Preparations NP PA Required B ONFI Anticonvulsants NP PA Required B ONGLYZA Diabetic - Other N PA Required B ONMEL Antifungals - Assorted NP PA Required B Onzetra Xsail Migraine - Selective Serotonin Agonists (5HT)--Tabs N PA Required B OPANA Narcotics - Misc. NP PA Required B OPANA ER (CRUSH RESISTANT) Narcotics -Long Acting NP PA Required G Opium Tincture Gi - Antiperistaltic Agents NP B OPSUMIT Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist NP PA Required B OPTIVAR Op. Antiallergics - Antihistamines NP

12/17/2018 9:18:23 AM Page 64 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR O B ORACEA Tetracyclines NP B ORACIT Urological - Misc. P O Oral Electrolyte Solution Electrolytes/ Nutritionals P B ORALAIR Allergenic Extracts NP PA Required B ORAP Neurologics - Misc. P B ORAPRED Glucocorticoids - Mineralocorticoids NP B ORBACTIV Antibiotics - Misc. NP B ORENCIA Anti-Inflammatories, Non-Nsaid NP PA Required B ORENITRAM Pulmonary Anti-Hypertensives NP PA Required B ORFADIN Hereditary Tyrosinemia Type 1 (HT-1) Treatment - Agents P B Orilissa Endometriosis Agents N B Orkambi Cystic Fibrosis Agents NP PA Required G Orphenadrine Citrate Muscle Relaxants P B ORTHO MICRONOR Contraceptives - Progestin Only P B ORTHO TRI-CYCLEN Contraceptives - Tri-Phasic Combinations P B ORTHO TRI-CYCLEN LO Contraceptives - Tri-Phasic Combinations NP B ORTHO-CEPT Contraceptives - Monophasic Combination O/C'S NP B ORTHO-NOVUM TAB 1/35 Contraceptives - Monophasic Combination O/C'S NP B ORTHO-NOVUM 7/7/7 Contraceptives - Tri-Phasic Combinations NP G Oseltamivir Influenza Agents N B OSENI Diabetic - Other NP PA Required B Osmolex ER Anti-Parkinsonian Drugs N PA Required B OSMOPREP Gi - Anti - Flatulents / GI Stimulants NP B OTEZLA Anti-Inflammatories, Non-Nsaid NP PA Required B Otovel Ear N B OTREXUP Arthritis - Misc. NP PA Required B OVCON-35 Contraceptives - Monophasic Combination O/C'S NP B OVIDE Topical - Scabicides And Pediculicides NP G Oxacillin Sodium Beta-Lactams / Clavulanate Combo'S P G Oxandrolone Androgens - Anabolics NP G Oxaprozin NSAIDS NP PA Required G Oxazepam Anxiolytics - Benzodiazepines P PA Required < 6 years of age G Oxcarbazepine SUSP Anticonvulsants P G Oxcarbazepine Tab 150 MG Anticonvulsants P

12/17/2018 9:18:23 AM Page 65 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR O G Oxcarbazepine Tab 300 MG Anticonvulsants P G Oxcarbazepine Tab 600 MG Anticonvulsants P B OXISTAT Topical - Antifungals NP B OXSORALEN ULTRA Anti-Psoriatics - Non-Biologicals P B OXTELLAR XR Anticonvulsants NP PA Required G OXYBUTYNIN SYP 5MG/5ML Antispasmodics P G OXYBUTYNIN TAB 5MG Antispasmodics P G Oxybutynin Chloride ER Antispasmodics - Long Acting P G Oxycodone HCl Narcotics - Misc. P G Oxycodone HCl ER Narcotics -Long Acting NP PA Required G Oxycodone w/ Acetaminophen Tab 10-325 MG Narcotics - Misc. NP PA Required G Oxycodone w/ Acetaminophen Tab 5-325 MG Narcotics - Misc. P G Oxycodone w/ Acetaminophen TABS 2.5-325 Narcotics - Misc. P G Oxycodone w/ Acetaminophen TABS 7.5-325 Narcotics - Misc. NP G Oxycodone-Aspirin Narcotics - Misc. P G Oxycodone-Ibuprofen Narcotics - Misc. NP B OXYCONTIN Narcotics -Long Acting N PA Required G Oxymorphone HCl Narcotics -Long Acting NP PA Required G Oxymorphone HCl Narcotics - Misc. NP B Oxytrol Antispasmodics - Long Acting NP B Ozempic Diabetic - Non-Insulin Injectables P PA Required P G paliperidone er Antipsychotics - Atypicals N PA Required B Palynziq Phenylketonuria N B PAMELOR Antidepressants - Tri-Cyclics NP G Pamidronate Disodium Osteoporosis NP B PANCREAZE Gi - Digestive Enzymes NP G Pancrelipase (Lipase-Protease-Amylase) Gi - Digestive Enzymes P G Pantoprazole Sodium Gi - Proton Pump Inhibitor P G Papaverine HCl Peripheral Vasodilators P B PARAFON FORTE DSC Muscle Relaxants NP PA Required G Paregoric Gi - Antiperistaltic Agents NP G Parenteral Electrolytes Electrolytes/ Nutritionals NP G Paricalcitol Hyperparathyroid Treatment - Vitamin D Analogs And Calcimimetics NP

12/17/2018 9:18:23 AM Page 66 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR P B PARLODEL Anti-Parkinsonian Drugs P B PARNATE Antidepressants - Mao Inhibitors NP G Paromomycin Sulfate Amino Glycosides P G Paroxetine HCl Antidepressants - Selected SSRI's P G PAROXETINE HCL ER Antidepressants - Selected SSRI's P G Paroxetine mesylate Antidepressants - Selected SSRI's N B PATADAY Op. Antiallergics - Antihistamines N B PATANASE Antihistamines - Non-Sedating P B PATANOL Op. Antiallergics - Antihistamines N B PAXIL Antidepressants - Selected SSRI's NP B PAXIL CR Antidepressants - Selected SSRI's NP Grandfather Existing Users B PAXIL SUSP Antidepressants - Selected SSRI's P B PAZEO Op. Antiallergics - Antihistamines NP B PCE Macrolides / Erythromycin'S / Ketolides NP B PEDIAPRED Glucocorticoids - Mineralocorticoids NP O Pediatric Multiple Vitamin w/ Minerals & C Vitamins - Misc. P PA Required G PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate Gi - Anti - Flatulents / GI Stimulants P G PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride Gi - Anti - Flatulents / GI Stimulants P B PEGANONE Anticonvulsants NP B PEGASYS Hepatitis C Agents P B PEGASYS PROCLICK Hepatitis C Agents P B PEG-INTRON Hepatitis C Agents P G Penicillin G Pot in Dextrose Beta-Lactams / Clavulanate Combo'S P G Penicillin G Potassium Beta-Lactams / Clavulanate Combo'S P G Penicillin V Potassium Beta-Lactams / Clavulanate Combo'S P B PENLAC NAIL LACQUER Topical - Antifungals NP B PENNSAID NSAIDS P B PENTAM 300 Antibiotics - Misc. P B PENTASA CAP 250MG CR Gi - Inflammatory Bowel Agents N B PENTASA CAP 500MG CR Gi - Inflammatory Bowel Agents NP G Pentazocine w/ Naloxone Narcotics - Misc. NP PA Required G Pentoxifylline Platelet Aggr. Inhibitors / Combo's - Misc. P B PEPCID Gi - H2-Antagonists NP B PERCODAN Narcotics - Misc. P

12/17/2018 9:18:23 AM Page 67 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR P B PERFOROMIST Antiasthmatic - Beta - Adrenergics NP G Perindopril Erbumine ACE Inhibitors NP G Permethrin Cream 5% Topical - Scabicides And Pediculicides P O Permethrin Lotion 1% Topical - Scabicides And Pediculicides P G Perphenazine Antipsychotics - Typical P G Perphenazine-Amitriptyline Psychotherapeutic Combination P B PERSANTINE Platelet Aggregation Inhibitors NP B Perseris Antipsychotics - Atypicals P B PERTZYE Gi - Digestive Enzymes N B PEXEVA Antidepressants - Selected SSRI's NP B PFIZERPEN-G Beta-Lactams / Clavulanate Combo'S P G Phenazopyridine HCl Urological - Misc. P G Phenelzine Sulfate Antidepressants - Mao Inhibitors P B PHENERGAN Antiemetic - Anticholinergic / Dopaminergic NP G Phenobarbital Sedative/Hypnotics - Barbiturate P G Phenobarbital Sodium Sedative/Hypnotics - Barbiturate NP B Phenoxybenzamine Agents For Pheochromocytoma NP G Phentolamine Mesylate Agents For Pheochromocytoma P G Phenylephrine HCl (Ophth) Op. Misc P B PHENYTEK Anticonvulsants NP Grandfather Existing Users G Phenytoin Infatab Anticonvulsants P G Phenytoin Sodium Anticonvulsants P G Phenytoin Sodium Extended Cap 100 MG Anticonvulsants P G Phenytoin Sodium Extended CAPS 200MG Anticonvulsants NP Use Multiples of Phenytoin Sodium 100mg Capsules. G Phenytoin Sodium Extended CAPS 300MG Anticonvulsants NP Use Multiples of Phenytoin Sodium 100mg Capsules. G Phenytoin susp Anticonvulsants P B PHOSLO Phosphate Binders NP B PHOSLYRA Phosphate Binders P B PHOSPHOLINE IODIDE Op. Miotics - Direct Acting P G Phytonadione Vitamins P B PICATO Topical - Antineoplastics NP B Pifeltro Antiretrovirals - Rti - Non - Nucleoside Analogues NR G Pilocarpine HCl Op. Miotics - Direct Acting P

12/17/2018 9:18:23 AM Page 68 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR P G Pilocarpine HCl (Oral) Artificial Saliva/Stimulants P B PILOPINE HS Op. Miotics - Direct Acting P G Pimozide Neurologics - Misc. N G Pindolol Beta Blockers - Non Selective P B PINNACAINE OTIC Ear NP G Pioglitazone HCl Diabetic - Thiazol P G Pioglitazone HCl-Glimepiride Diabetic - Thiazol NP G Pioglitazone HCl-Metformin HCl Diabetic - Thiazol / Biguanide Combo NP G Piperacillin Sodium-Tazobactam Sodium Beta-Lactams / Clavulanate Combo'S P G Piroxicam NSAIDS NP PA Required B PITRESSIN SYNTHETIC Vasopressins NP B PLAQUENIL Antimalarial Agents NP B PLAVIX Platelet Aggregation Inhibitors NP B PLEGRIDY Multiple Sclerosis Agents – Interferons NP B PLEGRIDY STARTER PACK Multiple Sclerosis Agents – Interferons NP B Plenvu Gi - Anti - Flatulents / GI Stimulants N B PLETAL Platelet Aggr. Inhibitors / Combo's - Misc. NP B Plixda Pads 0.1% Topical - Acne Preparations N PA Required B Pneumovax Vaccines P Preferred for ages 19 through 64 G PNV 29-1 tablet Vitamins - Misc. P B PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID Vitamins - Misc. P B PNV FOLIC AC TAB + IRON Vitamins - Misc. P B PODOCON 25 Topical - Enzymes / Keratolytics / Urea NP G Podofilox Topical - Genital Warts NP O polyethylene glycol 3350 Gi - Anti - Flatulents / GI Stimulants P Preferred for ages 0-12, PA Required ages 13-18, Not covered ages 19 and above. G polyethylene glycol 3350 PACK 3350 NF Gi - Anti - Flatulents / GI Stimulants P G Polymyxin B Sulfate Antibiotics - Misc. NP G Polymyxin B-Trimethoprim Op. Antibiotics P B POLYTRIM Op. Antibiotics NP B POMALYST Antineoplastics - Misc. NR PA Required B PONSTEL NSAIDS NP PA Required G Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic Minerals P G Potassium Acetate Inj 2 mEq/ML Minerals P

12/17/2018 9:18:23 AM Page 69 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR P G Potassium Bicarbonate Effer Tab 25 mEq Minerals P G potassium chloride cap er 10 meq Minerals P G potassium chloride cap er 8 meq Minerals P G Potassium Chloride in Dextrose Electrolytes/ Nutritionals P G Potassium Chloride in Dextrose & Sodium Chloride Electrolytes/ Nutritionals P G Potassium Chloride in NaCl Electrolytes/ Nutritionals P G Potassium Chloride Inj 10 mEq/100 ML Minerals P G Potassium Chloride Inj 10 mEq/50 ML Minerals P G Potassium Chloride Inj 2 mEq/ML Minerals P G Potassium Chloride Oral Liq 10% (20 MEQ/15ML) Minerals N G Potassium Chloride Oral Liq 20% (40 MEQ/15ML) Minerals N G Potassium Chloride Tab CR 10 mEq Minerals P G Potassium Chloride Tab CR 8 mEq (600 MG) Minerals P G Potassium Chloride Tablet ER 20MEQ ER Minerals P G Potassium Citrate (Alkalinizer) Urological - Misc. P B POTIGA Anticonvulsants NP B PRADAXA Anticoagulants P B Praluent ANTIHYPERLIPIDEMICS P PA Required G Pramipexole Dihydrochloride Parkinsons - Selected Dopamin Agonists P G Pramipexole Dihydrochloride Tablet ER 24HR Parkinsons - Selected Dopamin Agonists NP PA Required B PRANDIMET Diabetic - Other NP B PRANDIN Diabetic - Meglitinides NP G Prasugrel Platelet Aggregation Inhibitors P B PRAVACHOL Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP G Pravastatin Sodium Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P G Praziquantel Anthelmintics N G Prazosin HCl Antihypertensives - Central P B PRECOSE Diabetic - Alphaglucosidase NP B PRED FORTE Op. Antiinflammatory / Steroids Ophth. NP B PRED MILD Op. Antiinflammatory / Steroids Ophth. P B PRED-G Op. Antiinflammatory / Steroids Ophth. P G Prednicarbate Topical - Corticosteroids - Medium Potency N PA Required G Prednisolone Glucocorticoids - Mineralocorticoids P G Prednisolone Acetate (Ophth) Op. Antiinflammatory / Steroids Ophth. P

12/17/2018 9:18:23 AM Page 70 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR P G Prednisolone odt Glucocorticoids - Mineralocorticoids N G Prednisolone Sodium Phosphate Glucocorticoids - Mineralocorticoids P G Prednisolone Sodium Phosphate (Ophth) Op. Antiinflammatory / Steroids Ophth. P G Prednisone Glucocorticoids - Mineralocorticoids P B PREDNISONE INTENSOL Glucocorticoids - Mineralocorticoids NP B PREFEST Estrogen Combos NP B PREMARIN Estrogens - Tabs P B PREMARIN Vaginal - Estrogens P B PREMASOL Electrolytes/ Nutritionals P B PREMPHASE Estrogen Combos P B PREMPRO Estrogen Combos P B PRENATAL VIT TAB PLUS Vitamins - Misc. P G Preplus tablet Vitamins - Misc. P B Prepopik Gi - Misc. N B Prestalia ACE Inhibitors And Calcium Channel Blockers N G Pretab tablet Vitamins - Misc. P B PREVACID Gi - Proton Pump Inhibitor NP PA Required B PREVACID SOLUTAB Gi - Proton Pump Inhibitor NP PA Required B PREVPAC Gi - Ulcer Anti-Infective NP B Prevymis Tablets Cyto-Megalovirus Agents N PA required B PREZCOBIX Antiretrovirals - Combinations P B PREZISTA Antiretrovirals - Protease Inhibitors R B Priftin Antimycobacterials / Antituberculosis P B PRILOSEC Gi - Proton Pump Inhibitor NP PA Required B PRIMAXIN Carbapenems NP G Primidone Anticonvulsants P B PRIMLEV Narcotics - Misc. NP PA Required B PRINIVIL ACE Inhibitors NP B PRISTIQ Antidepressants - Selected SSRI's NP PA Required B PRIVIGEN Immune Serums NP B PROAIR HFA Antiasthmatic - Beta - Adrenergics P B PROAIR RESPICLICK Antiasthmatic - Beta - Adrenergics P G Probenecid Gout P G Procainamide HCl Antiarrhythmics P

12/17/2018 9:18:23 AM Page 71 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR P B PROCALAMINE Electrolytes/ Nutritionals NP B PROCARDIA Calcium Channel Blockers--Nifedipines NP B PROCARDIA XL Calcium Channel Blockers--Nifedipines NP B PROCENTRA Stimulants NP PA Required G Prochlorperazine Edisylate Antihistamines - Other P G Prochlorperazine Maleate Antihistamines - Other P G Prochlorperazine Supp Antihistamines - Other P B PROCRIT Erythropoeisis Stimulating Agents P PA Required B PROCTOFOAM HC Anorectal - Misc. NP B PROCYSBI Urological - Misc. NP B PROFILNINE SD Antihemophilia Factor IX Agents P G Progesterone IM in Oil 50 MG/ML Progestins NP G Progesterone Micronized Progestins NP G Progesterone Micronized Powder Powders P G Progesterone Powder Powders P B PROGLYCEM Diabetic - Other P B PROGRAF Immunosuppressants NP B PROLASTIN C Alpha-Proteinase Inhibitor P PA Required B PROLENSA Op. Nsaid'S NP B PROMACTA Hematopoietics Chronic ITP P PA Required G Promethazine HCl Inj 25 MG/ML Antiemetic - Anticholinergic / Dopaminergic NP G Promethazine HCl Inj 50 MG/ML Antiemetic - Anticholinergic / Dopaminergic NP G Promethazine HCl Suppos 12.5 MG Antiemetic - Anticholinergic / Dopaminergic P G Promethazine HCl Suppos 25 MG Antiemetic - Anticholinergic / Dopaminergic P G Promethazine HCl Syrup 6.25 MG/5ML Antiemetic - Anticholinergic / Dopaminergic P G Promethazine HCl Tab 12.5 MG Antiemetic - Anticholinergic / Dopaminergic NP G Promethazine HCl Tab 25 MG Antiemetic - Anticholinergic / Dopaminergic P G Promethazine HCl Tab 50 MG Antiemetic - Anticholinergic / Dopaminergic P B PROMETRIUM Progestins NP G Propafenone HCl Antiarrhythmics P G Propantheline Bromide Gi - Antidiarrheal / Antacid - Misc. P G Proparacaine HCl Op. Misc P G Propranolol & Hydrochlorothiazide Beta Blockers And Diuretic Combo'S P G Propranolol HCl Beta Blockers - Non Selective P

12/17/2018 9:18:23 AM Page 72 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR P G Propylthiouracil Antithyroid Therapies P B PROSCAR BPH NP B PROTONIX Gi - Proton Pump Inhibitor NP PA Required B PROTOPIC Topical - Immunomodulators P PA Required G Protriptyline HCl Antidepressants - Tri-Cyclics NP B PROVENTIL HFA Antiasthmatic - Beta - Adrenergics P B PROVERA Progestins NP B PROVIGIL Stimulants - Other Stimulants / Like Stimulants N PA Required B PROZAC Antidepressants - Selected SSRI's NP B PROZAC WEEKLY Antidepressants - Selected SSRI's NP PA Required B PRUDOXIN Topical - Antipruritics NP O Pseudoephedrine HCl Liq 30 MG/5ML Cough/Cold - Systemic Decongestants P O Pseudoephedrine HCl Tab 30 MG Cough/Cold - Systemic Decongestants P O Pseudoephedrine HCl Tab 60 MG Cough/Cold - Systemic Decongestants P B PULMICORT INHALER Antiasthmatic - Steroid Inhalants P B PULMICORT SUS Antiasthmatic - Steroid Inhalants N B PULMOZYME Cystic Fibrosis Agents P PA Required B Purixan Antineoplastics - Antimetabolites N B PYLERA Gi - Ulcer Anti-Infective P G Pyrazinamide Antimycobacterials / Antituberculosis P O Pyrethrins-Piperonyl Butoxide Topical - Scabicides And Pediculicides P G Pyridostigmine Bromide Neurologics - Misc. P G Pyridostigmine er Neurologics - Misc. NP Q B Qbrelis ACE Inhibitors N B QNASL Nasal Steroids NP B Qtern Diabetic - Other N PA Required B QUARTETTE Contraceptives - Monophasic Combination O/C'S NP B QUDEXY XR Anticonvulsants NP PA Required B QUESTRAN Cholesterol - Bile Sequestrants NP G Quetiapine ER Antipsychotics - Atypicals P G quetiapine fumarate Antipsychotics - Atypicals P B Quillichew ER Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. B QUILLIVANT XR Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo.

12/17/2018 9:18:23 AM Page 73 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR Q G Quinapril HCl ACE Inhibitors P G Quinapril-Hydrochlorothiazide ACE and Thiazide Combo's NP G Quinidine Gluconate Antiarrhythmics P G Quinidine Sulfate Antiarrhythmics P G Quinidine Sulfate Tablet ER Antiarrhythmics NP B Qvar Redihaler Antiasthmatic - Steroid Inhalants N R G Rabeprazole Sodium Gi - Proton Pump Inhibitor NP PA Required B RAGWITEK Allergenic Extracts NP PA Required G Raloxifene HCl Osteoporosis NP G Ramipril ACE Inhibitors P B RANEXA Antianginals NP G Ranitidine HCl Cap 150 MG Gi - H2-Antagonists NP G Ranitidine HCl Cap 300 MG Gi - H2-Antagonists NP G Ranitidine HCl Inj 150 MG/6ML (25 MG/ML) Gi - H2-Antagonists P G Ranitidine HCl Inj 50 MG/2ML (25 MG/ML) Gi - H2-Antagonists P G Ranitidine HCl Syrup 15 MG/ML (75 MG/5ML) Gi - H2-Antagonists P G Ranitidine HCl Tab 150 MG Gi - H2-Antagonists P G Ranitidine HCl Tab 300 MG Gi - H2-Antagonists P B RAPAFLO BPH NP B RAPAMUNE Immunosuppressants P G Rasagiline Anti-Parkinsonian Drugs N B RASUVO Arthritis - Misc. NP PA Required B RAVICTI Urea Cycle Disorder - Agents NP B Rayaldee Hyperparathyroid Treatment - Vitamin D Analogs N PA Required B RAYOS Glucocorticoids - Mineralocorticoids NP PA Required B RAZADYNE Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B REBETOL Hepatitis C Agents NP B REBIF Multiple Sclerosis Agents – Interferons P B REBIF REBIDOSE Multiple Sclerosis Agents – Interferons P B REBIF REBIDOSE TITRATIONPACK Multiple Sclerosis Agents – Interferons P B Rebinyn Antihemophilia Factor IX Agents N B RECOMBINATE Antihemophilia Factor VIII Agents P

12/17/2018 9:18:23 AM Page 74 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR R B RECTIV Anorectal - Misc. NP B REGLAN Gi - Anti - Flatulents / GI Stimulants NP B REGONOL Neurologics - Misc. P B REGRANEX Topical - Wound / Decubitus Care NP PA Required B RELENZA DISKHALER Influenza Agents P B RELISTOR Gi - Misc. NP B RELPAX Migraine - Selective Serotonin Agonists (5HT)--Tabs N PA Required B REMERON Antidepressants - Selected SSRI's NP B REMERON SOLTAB Antidepressants - Selected SSRI's NP PA Required B REMICADE Anti-Inflammatories, Non-Nsaid NP PA Required B REMODULIN Pulmonary Anti-Hypertensives NP PA Required B RENACIDIN Urological - Misc. P B Renagel Phosphate Binders P B Renagel Tab Phosphate Binders P B RENVELA Phosphate Binders NP B Renvela Pak PHOSPHATE BINDERS N G Repaglinide Diabetic - Meglitinides P B Repatha ANTIHYPERLIPIDEMICS NP PA Required B REQUIP Parkinsons - Selected Dopamin Agonists NP B REQUIP XL Parkinsons - Selected Dopamin Agonists NP PA Required B RESCRIPTOR Antiretrovirals - Rti - Non - Nucleoside Analogues NR B RESCULA Op. Prostaglandins NP G Reserpine Antihypertensives - Central P B RESTASIS Op. Misc P Unit Dose Preferred. No manual PA required if a preferred artificial tear agent is found in member’s pharmacy claims history in past 12 months B RESTORIL Sedative/Hypnotics - Benzodiazepines NP PA Required B RETIN-A Topical - Tretinoids P PA Required B RETIN-A MICRO Topical - Tretinoids NP PA Required B RETIN-A MICRO PUMP Topical - Tretinoids NP PA Required B RETROVIR Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues NR Requires a Selected Brand Name Drug PA B Revatio Pulmonary Anti-Hypertensives NP PA Required B REVATIO SUSR Pulmonary Anti-Hypertensives NP PA Required B REVIA Narcotic - Antagonists NP

12/17/2018 9:18:23 AM Page 75 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR R B REVLIMID Antineoplastics - Misc. R PA Required B REXULTI Antipsychotics - Atypicals NP PA Required B REYATAZ Antiretrovirals - Protease Inhibitors N B RHEUMATREX Arthritis - Misc. NP RHEUMATREX - Write METHOTREXATE instead B RHINOCORT AQUA Nasal Steroids NP B RHOGAM ULTRA-FILTERED PLUS Immune Serums P B RHOPHYLAC Immune Serums P B Rhopressa OP. RHO KINASE INHIBITORS P B RIBASPHERE Hepatitis C Agents NP B RIBASPHERE RIBAPAK Hepatitis C Agents NP G Ribavirin Cap 200 MG Hepatitis C Agents P G Ribavirin Tab 200 MG Hepatitis C Agents P B RIDAURA Arthritis - Misc. P B RIFADIN Antimycobacterials / Antituberculosis NP G Rifampin Antimycobacterials / Antituberculosis P B RILUTEK ALS Drug NP PA Required G Riluzole ALS Drug P PA Required G Rimantadine Hydrochloride Influenza Agents P B RIOMET Diabetic - Oral Biguanides NP G Risedronate Osteoporosis NP B RISPERDAL Antipsychotics - Atypicals NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B RISPERDAL CONSTA Antipsychotics - Atypicals P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B RISPERDAL M-TAB Antipsychotics - Atypicals NP PA Required G risperidone Antipsychotics - Atypicals P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G risperidone tablet disperse Antipsychotics - Atypicals NP PA Required B RITALIN Stimulants - Methylphenidate NP PA Required B RITALIN LA Stimulants - Methylphenidate - Long Acting N PA Required G Ritonavir Antiretrovirals - Protease Inhibitors N

12/17/2018 9:18:23 AM Page 76 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR R G RIVASTIGMINE CAP Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. G RIVASTIGMINE DIS Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B RIXUBIS Antihemophilia Factor IX Agents N G Rizatriptan Benzoate Migraine - Selective Serotonin Agonists (5HT)--Tabs P PA Required> 12 Units/30 Days supply G Rizatriptan Benzoate Tablet Disperse Migraine - Selective Serotonin Agonists (5HT)--Tabs P PA Required> 12 Units/30 Days supply B ROBAXIN Muscle Relaxants NP PA Required B ROBINUL Gi - Antidiarrheal / Antacid - Misc. NP B Rocaltrol Hyperparathyroid Treatment - Vitamin D Analogs N G Ropinirole Hydrochloride Parkinsons - Selected Dopamin Agonists P G Ropinirole Hydrochloride Tablet ER 24HR Parkinsons - Selected Dopamin Agonists NP PA Required G Rosuvastatin Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P B ROXICODONE Narcotics - Misc. NP PA Required B RoxyBond Narcotics - Misc. N PA Required B ROZEREM Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B Rubraca Antineoplastics - Parp Inhibitors NR PA Required B Ruconest Hereditary Angioedema Agents P PA Required B RYBIX ODT Narcotics - Selected NP PA required B Rydapt Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B RYTARY Anti-Parkinsonian Drugs NP PA Required B RYTHMOL SR Antiarrhythmics NP PA Required B RYTHMOL TABS Antiarrhythmics NP S B SABRIL Anticonvulsants NP B SAIZEN Growth Hormone NP PA Required B SALAGEN Artificial Saliva/Stimulants NP B SALEX Topical - Enzymes / Keratolytics / Urea NP G Salicylic Acid Cream 6% Topical - Enzymes / Keratolytics / Urea P G Salicylic Acid Lotion 6% Topical - Enzymes / Keratolytics / Urea P G Salicylic Acid Shampoo 6% Topical - Enzymes / Keratolytics / Urea P G Salicylic Acid Soln 26% Topical - Enzymes / Keratolytics / Urea P G Saline w/ Benzyl Alcohol Minerals P G Saline, Bacteriostatic Compounding Materials P G Salsalate Analgesics - Misc. P

12/17/2018 9:18:23 AM Page 77 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR S B SAMSCA Vasopressins NP B SANCUSO Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B SANDIMMUNE Immunosuppressants P B SANDOSTATIN Somatostatic Agents P B SANTYL Topical - Enzymes / Keratolytics / Urea P B SAPHRIS Antipsychotics - Atypicals NP Grandfather Existing Users B SARAFEM Antidepressants - Selected SSRI's NP Initial fill limited to 15 day supply. B SAVAYSA Anticoagulants NP PA Required B SAVELLA Antidepressants - Selected SSRI's NP PA Required G SCOPOLAMINE PATCH Antiemetic - Anticholinergic / Dopaminergic N B SEASONIQUE Contraceptives - Monophasic Combination O/C'S P B SECONAL Sedative/Hypnotics - Barbiturate NP B SECTRAL Beta Blockers - Cardio Selective NP B SEEBRI NEOHALER Antiasthmatic - Anti-Cholinergics N B Segluromet Diabetic - Other N PA Required G Selegiline HCl Anti-Parkinsonian Drugs P G Selenium Sulfide Topical - Antiseborrheics P G Selenium Sulfide-Pyrithione Zinc in Urea Vehicle Topical - Antiseborrheics P B SELZENTRY Antiretrovirals - Entry Inhibitors NR B SEMPREX-D Antihistamines/Decongestants NP B SE-NATAL 19 CHEW TABLET Vitamins - Misc. P O Sennosides Syrup 8.8 MG/5ML Gi - Misc. P O Sennosides Tab 8.6 MG Gi - Anti - Flatulents / GI Stimulants P O Sennosides-Docusate Sodium Tab 8.6-50 MG Gi - Misc. P B SENSIPAR Hyperparathyroid Treatment - Vitamin D Analogs And Calcimimetics NP B SEREVENT DISKUS Antiasthmatic - Beta - Adrenergics P PA Required < 4 years of age B Sernivo Topical - Corticosteroids - Medium Potency N PA Required B SEROQUEL Antipsychotics - Atypicals NP PA Required B SEROQUEL XR Antipsychotics - Atypicals NP PA Required B SEROSTIM Growth Hormone NP PA Required G Sertraline HCl Antidepressants - Selected SSRI's P G Sevelamer carbonate Pak PHOSPHATE BINDERS N G Sevelamer carbonate Tablets Phosphate Binders N B SFROWASA ENE 4GM Gi - Inflammatory Bowel Agents NP

12/17/2018 9:18:23 AM Page 78 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR S B SIGNIFOR Somatostatic Agents NP B Siklos Sickle Cell Anemia Agents N G Sildenafil Citrate (Pulmonary Hypertension) Pulmonary Anti-Hypertensives P PA Required B SILENOR Antidepressants - Tri-Cyclics NP B Siliq Anti-Inflammatories, Non-Nsaid N PA Required B SILVADENE Topical - Burn Products NP G Silver Nitrate Topical - Cauterizing Agents P G Silver Sulfadiazine Topical - Burn Products P B SIMBRINZA Op. Selective Alpha Adrenergic Agonists P B SIMCOR Cholesterol - Hmg COA + Absorb Inhibitors NP Grandfather Existing Users B SIMPONI Anti-Inflammatories, Non-Nsaid NP PA Required G Simvastatin Tab 10 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin Tab 20 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin Tab 40 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin Tab 5 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin TABS 80MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations NP Grandfather Existing Users B SINEMET Anti-Parkinsonian Drugs NP B SINGULAIR CHW 4MG Antiasthmatic - Leukotriene Receptor Antagonists NP B SINGULAIR CHW 5MG Antiasthmatic - Leukotriene Receptor Antagonists NP B SINGULAIR TAB 10MG Antiasthmatic - Leukotriene Receptor Antagonists NP B SINGULAIR PACK Antiasthmatic - Leukotriene Receptor Antagonists NP G Sirolimus Immunosuppressants P B SIRTURO Antimycobacterials / Antituberculosis NP B SITAVIG Herpes Agents NP PA Required B SIVEXTRO Lincosamides / Oxazolidinones / Leprostatics NP B SKELAXIN Muscle Relaxants NP PA Required B SKLICE Topical - Scabicides And Pediculicides P G Sodium Acetate Inj 2 mEq/ML Minerals P O Sodium Bicarbonate (Antacid) Tabs Gi - Antidiarrheal / Antacid - Misc. P PA Required G Sodium Bicarbonate Inj 4.2% Minerals P G Sodium Bicarbonate Inj 7.5% Minerals P G Sodium Bicarbonate Inj 8.4% Minerals P G Sodium Chloride (GU Irrigant) Urological - Misc. P O Sodium Chloride Hypertonic Ophth Oint 5% Op. Misc P

12/17/2018 9:18:23 AM Page 79 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR S O Sodium Chloride Hypertonic Ophth Soln 5% Op. Misc P G Sodium Chloride Inj 0.45% Minerals P G Sodium Chloride Inj 0.9% Minerals P G Sodium Chloride Inj 3% Minerals P G Sodium Chloride IV Soln 0.9% Minerals P G Sodium Chloride Soln Nebu 0.9% Antiasthmatic - Misc. Respiratory Inhalants P G Sodium Citrate & Citric Acid Urological - Misc. P G Sodium Fluoride (Dental) Dental Products P G Sodium Fluoride Chew Tab 0.25 MG F (from 0.55 MG NaF) Minerals P G Sodium Fluoride Chew Tab 0.5 MG F (from 1.1 MG NaF) Minerals P G Sodium Fluoride Chew Tab 1 MG F (from 2.2 MG NaF) Minerals P G Sodium Fluoride Soln 0.125 MG/DROP F (0.275 MG/DROP NaF) Minerals P G Sodium Fluoride Soln 0.5 MG/ML F (from 1.1 MG/ML NaF) Minerals P G Sodium phenylbutyrate Urea Cycle Disorder - Agents N G Sodium Phosphate Inj 3 MMole/ML Minerals P G Sodium Polystyrene Sulfonate K Removing Resins P B SOLARAZE Topical - Antineoplastics NP B Soliqua Diabetic - Other N PA Required B SOLODYN Tetracyclines NP PA Required B Solosec Antibiotics - Misc. N B SOLTAMOX Antineoplastics - Antiestrogens NR B SOLU-CORTEF Glucocorticoids - Mineralocorticoids P B SOLU-MEDROL Glucocorticoids - Mineralocorticoids P B SOMA Muscle Relaxants NP PA Required B SOMAVERT Somatostatic Agents NP B SONATA Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B SOOLANTRA Topical - Acne Preparations NP PA Required B SORIATANE Anti-Psoriatics - Non-Biologicals NP B SORILUX Anti-Psoriatics - Non-Biologicals NP G Sotalol HCl Beta Blockers - Non Selective P G Sotalol HCl (AFIB/AFL) Beta Blockers - Non Selective P B SOTYLIZE Beta Blockers - Non Selective NP B SOVALDI Hepatitis C Agents N PA Required B SPECTRACEF Cephalosporins NP

12/17/2018 9:18:23 AM Page 80 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR S G Spinosad Topical - Scabicides And Pediculicides NP B SPIRIVA HANDIHALER Antiasthmatic - Anti-Cholinergics P B SPIRIVA RESPIMAT Antiasthmatic - Anti-Cholinergics NP G Spironolactone Diuretics P G Spironolactone & Hydrochlorothiazide Diuretics P B SPORANOX Antifungals - Assorted NP PA Required B Spritam Anticonvulsants N PA Required B SPRIX Cox 2 Inhibitors - Selective NP PA Required B SPRYCEL Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B SPS K Removing Resins NP B SSKI Minerals P B STALEVO Anti-Parkinsonian Drugs NP G Stannous Fluoride Dental Products P B STARLIX Diabetic - Meglitinides NP G Stavudine Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues N B Steglatro Diabetic - Other N PA Required B Steglujan Diabetic - Other N PA Required B STELARA Anti-Inflammatories, Non-Nsaid NP PA Required B STERILE DILU SOL FLOLAN Compounding Materials P B STIMATE Vasopressins P PA Required B Stiolto respimat Antiasthmatic - Adrenergic Combos NP B STIVARGA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B STRATTERA Stimulants - Other Stimulants / Like Stimulants N PA Required B Strensiq Endocrine Metabolic Agents N G Streptomycin Sulfate Amino Glycosides P B STRIANT Androgens -Topical NP PA Required B STRIBILD Antiretrovirals - Combinations NP Grandfather Existing Users B STRIVERDI RESPIMAT Antiasthmatic - Beta - Adrenergics NP B STROMECTOL Anthelmintics NP B SUBLIMAZE Narcotics - Misc. NP PA Required B Suboxone Narcotics - Misc. N PA Required B SUBSYS Narcotics - Misc. NP PA Required G Sucralfate Susp 1 GM/10ML Gi - Misc. Anti-Ulcer NP G Sucralfate Tab 1 GM Gi - Misc. Anti-Ulcer P

12/17/2018 9:18:23 AM Page 81 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR S B SULAR Calcium Channel Blockers--Nisoldipine NP G Sulfacetamide Sodium (Acne) Topical - Acne Preparations NP PA Required G Sulfacetamide Sodium (Ophth) Op. Antibiotics N G Sulfacetamide Sodium Liquid 10% Topical - Antiseborrheics P G Sulfacetamide Sodium w/ Sulfur Topical - Acne Preparations NP PA Required G Sulfacetamide Sod-Prednisolone Op. Antiinflammatory / Steroids Ophth. P G Sulfadiazine Antibiotics - Misc. P G Sulfamethoxazole-Trimethoprim Anti Infective Combo's - Misc. P B SULFAMYLON Topical - Burn Products NP G Sulfasalazine Gi - Inflammatory Bowel Agents P G Sulindac NSAIDS P G Sumatriptan Spray Migraine - Selective Serotonin Agonists (5HT)--Injectables P PA Required> 12 Units/30 Days supply G Sumatriptan Succinate Migraine - Selective Serotonin Agonists (5HT)--Injectables P PA Required> 12 Units/30 Days supply G Sumatriptan Succinate Migraine - Selective Serotonin Agonists (5HT)--Tabs P PA Required> 12 Units/30 Days supply G Sumatriptan-naproxen Migraine - Selective Serotonin Agonists-5HT Combinations N PA Required B SUMAXIN Topical - Acne Preparations NP PA Required B SUMAXIN TS Topical - Acne Preparations NP PA Required B SUPRAX Cephalosporins NP B SUPRAX SUSR 100/5ML Cephalosporins NP B SUPRAX SUSR 200/5ML Cephalosporins NP B Suprep Gi - Misc. P B SURMONTIL Antidepressants - Tri-Cyclics P Initial fill limited to 15 day supply. B SUSTIVA Antiretrovirals - Rti - Non - Nucleoside Analogues P B SUTENT Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B SYLATRON Antineoplastics - Misc. NR B SYMBICORT Antiasthmatic - Adrenergic Combos P B SYMBYAX Psychotherapeutic Combination NP Grandfather Existing Users B Symdeko Cystic Fibrosis Agents N PA Required B Symfi Antiretrovirals - Combinations P B Symfi Lo Antiretrovirals - Combinations P B SYMLINPEN 120 Diabetic - Other NP PA Required B SYMLINPEN 60 Diabetic - Other NP PA Required B Symproic GI, Constipation - IBS-OIC N PA Required B Symtuza Antiretrovirals - Combinations N

12/17/2018 9:18:23 AM Page 82 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR S B SYNAGIS RSV Agents P PA Required B SYNALGOS-DC Narcotics - Misc. NP PA Required B Synarel Endometriosis Agents P B Syndros Antiemetic - Tetrahydrocannabinol (THC) Derivatives N B SYNERA Topical - Local Anesthetics NP B Synjardy Diabetic - Other P PA Required B Synjardy XR Diabetic - Other P PA Required B SYNTHROID Thyroid Hormones NP B SYPRINE Chelating Agents P T B TABLOID Antineoplastics - Antimetabolites R Initial fill limited to 15 day supply. B TACLONEX Topical - Steroid Combinations NP G Tacrolimus Immunosuppressants P G Tacrolimus (Topical) Topical - Immunomodulators NP PA Required G Tadalafil Pulmonary Anti-Hypertensives N PA Required B TAFINLAR Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B Tagrisso Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B Takhzyro HEREDITARY ANGIOEDEMA AGENTS N B Taltz Anti-Inflammatories, Non-Nsaid N PA Required B TAMIFLU Influenza Agents P PA Required: > 14 Units/30Days Supply G Tamoxifen Citrate Antineoplastics - Antiestrogens R G Tamsulosin HCl BPH P B TAPAZOLE Antithyroid Therapies NP B TARCEVA Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B TARGRETIN Antineoplastics - Selective Retinoid X Receptor Agonists P Initial fill limited to 15 day supply. B TARKA ACE Inhibitors And Calcium Channel Blockers NP B TASIGNA Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B TASMAR Parkinsons - Comt Inhibitors NP B Tavalisse Hematopoietics Chronic ITP N PA Required G tazarotene Anti-Psoriatics - Non-Biologicals N PA Required B TAZORAC Anti-Psoriatics - Non-Biologicals P PA Required B TECFIDERA Multiple Sclerosis Agents P No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months

12/17/2018 9:18:23 AM Page 83 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR T B TEGRETOL SUSP Anticonvulsants P B Tegretol Tablets Anticonvulsants N Grandfather for seizure disorder. B TEGRETOL XR Anticonvulsants NP Anticonvulsants B TEKAMLO Direct Renin Inhibitors NP B TEKTURNA Direct Renin Inhibitors NP B TEKTURNA HCT Direct Renin Inhibitors NP G Telmisartan ARB'S NP G Telmisartan-Amlodipine Arb/Ccb NP G Telmisartan-Hydrochlorothiazide ARB'S And Diuretics NP G Temazepam Cap 15 MG Sedative/Hypnotics - Benzodiazepines P G Temazepam Cap 30 MG Sedative/Hypnotics - Benzodiazepines P G Temazepam CAPS 22.5MG Sedative/Hypnotics - Benzodiazepines NP PA Required G Temazepam CAPS 7.5MG Sedative/Hypnotics - Benzodiazepines NP PA Required B TEMODAR Antineoplastics - Imidazotetrazines N PA Required B TEMOVATE Topical - Corticosteroids - High Potency N PA Required G Temozolomide Antineoplastics - Imidazotetrazines P PA Required B TENEX Antihypertensives - Central NP B Tenivac Vaccines P Preferred for ages 19 through 64 G Tenofovir Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues P B TENORETIC Beta Blockers And Diuretic Combo'S NP B TENORMIN Beta Blockers - Cardio Selective NP B Terazol 7 Vaginal - Anti Fungals N G Terazosin HCl BPH P G Terbinafine HCl Antifungals - Assorted P PA Required > 90 days G Terbutaline Sulfate Inj 1 MG/ML Antiasthmatic - Beta - Adrenergics NP G Terbutaline Sulfate Tab 2.5 MG Antiasthmatic - Beta - Adrenergics P G Terbutaline Sulfate Tab 5 MG Antiasthmatic - Beta - Adrenergics P G Terconazole Vaginal Cream 0.4% Vaginal - Anti Fungals P G Terconazole Vaginal Cream 0.8% Vaginal - Anti Fungals P G Terconazole Vaginal Suppos 80 MG Vaginal - Anti Fungals NP B TESTIM Androgens -Topical N PA Required G Testosterone 1% packets Androgens -Topical P PA Required G testosterone 1% pump Androgens -Topical NP PA Required G Testosterone Cypionate Androgens - Anabolics P PA Required

12/17/2018 9:18:23 AM Page 84 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR T G Testosterone Enanthate Androgens - Anabolics P PA Required G TESTOSTERONE GEL Androgens -Topical NP PA Required G testosterone gel 10mg/act Androgens -Topical NP PA Required G TESTOSTERONE SOL Androgens -Topical N PA Required B TESTRED Androgens - Anabolics N PA Required G Tetrabenazine Neurologics - Misc. P PA required G Tetracaine HCl (Ophth) Op. Misc P G Tetracycline HCl Tetracyclines NP B TEVETEN ARB'S NP B TEVETEN HCT ARB'S And Diuretics NP B TEV-TROPIN Growth Hormone NP PA Required B TEXACORT Topical - Corticosteroids - Low Potency N PA Required B THALOMID Antileprotic P B THEO-24 Antiasthmatic - Xanthines P G Theophylline Antiasthmatic - Xanthines P G Thiamine HCl Vitamins P O Thiamine hcl tab Vitamins P PA Required B THIOLA Urological - Misc. NP G Thioridazine HCl Antipsychotics - Typical P G Thiothixene Antipsychotics - Typical P G Thrivite RX tablet Vitamins - Misc. P B THYROLAR Thyroid Hormones P G Tiagabine Anticonvulsants N B TIAZAC Calcium Channel Blockers--Diltiazems NP G Ticlopidine HCl Platelet Aggregation Inhibitors NP B TIGAN Antiemetic - Anticholinergic / Dopaminergic NP G Tigecycline Antibiotics - Misc. N B TIKOSYN Antiarrhythmics N B TIMENTIN Beta-Lactams / Clavulanate Combo'S P G Timolol Maleate Beta Blockers - Non Selective P G Timolol Maleate Ophth Gel Forming Soln 0.25% Op. Beta - Blockers N G Timolol Maleate Ophth Gel Forming Soln 0.5% Op. Beta - Blockers N G Timolol Maleate Ophth Soln 0.25% Op. Beta - Blockers P G Timolol Maleate Ophth Soln 0.5% Op. Beta - Blockers P

12/17/2018 9:18:23 AM Page 85 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR T G Timolol maleate ophthalmic solution (once daily) Op. Beta - Blockers N B TIMOPTIC Op. Beta - Blockers NP B TIMOPTIC-XE Op. Beta - Blockers NP B TINDAMAX Antiprotozoal Agents NP G Tinidazole Antiprotozoal Agents NP B TIROSINT Thyroid Hormones NP B TIVICAY Antiretrovirals - Integrase Inhibitors P B TIVORBEX NSAIDS NP PA Required G Tizanidine HCl Muscle Relaxants P B TOBI Amino Glycosides NP B TOBI PODHALER Amino Glycosides NP B TOBRADEX Op. Antiinflammatory / Steroids Ophth. P B TOBRADEX ST Op. Antiinflammatory / Steroids Ophth. NP G Tobramycin (Ophth) Op. Antibiotics P G Tobramycin Neb Solution Amino Glycosides P G Tobramycin Sulfate Amino Glycosides P G Tobramycin-Dexamethasone Op. Antiinflammatory / Steroids Ophth. NP B TOBREX Op. Antibiotics NP B TOFRANIL Antidepressants - Tri-Cyclics NP B TOFRANIL-PM Antidepressants - Tri-Cyclics NP Imipramine Pamoate - Use Imipramine HCL B Tolak Topical - Antineoplastics N G Tolazamide Diabetic - Oral Sulfonylureas P G Tolbutamide Diabetic - Oral Sulfonylureas NP G TOLCAPONE Parkinsons - Comt Inhibitors NP G Tolmetin Sodium NSAIDS NP PA Required O Tolnaftate Topical - Antifungals P G Tolterodine Tartrate Antispasmodics NP G Tolterodine Tartrate Antispasmodics - Long Acting NP B TOPAMAX Anticonvulsants NP B TOPICORT Topical - Corticosteroids - High Potency N PA Required G Topiramate Anticonvulsants P G Topiramate CS24 Anticonvulsants NP PA Required B TOPROL XL Beta Blockers - Cardio Selective NP G Torsemide Diuretics P

12/17/2018 9:18:23 AM Page 86 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR T B Toujeo Diabetic - Insulin Penfills NP PA Required B TOVIAZ Antispasmodics - Long Acting N G Trace Minerals (Cr-Cu-Mn-Se-Zn) Minerals P B TRACLEER Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist P PA Required B Tracleer soluble tablet Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist N PA Required B TRADJENTA Diabetic - Other P PA Required G Tramadol HCl Narcotics - Selected P PA Required < 18 years of age G Tramadol HCl Tab SR 24HR Biphasic Release Narcotics - Selected NP PA Required G Tramadol HCl Tablet ER 24HR Narcotics - Selected NP PA Required G Tramadol-Acetaminophen Narcotics - Selected NP ULTRACET - Use Tramadol & Acetaminophen separately B TRANDATE Beta Blockers - Alpha / Beta NP G Trandolapril ACE Inhibitors P G Trandolapril-Verapamil HCl ACE Inhibitors And Calcium Channel Blockers P G Tranexamic acid Hemostatic N B TRANSDERM-SCOP Antiemetic - Anticholinergic / Dopaminergic P B TRANXENE Anxiolytics - Benzodiazepines NP PA Required G Tranylcypromine Sulfate Antidepressants - Mao Inhibitors P B TRAVASOL Electrolytes/ Nutritionals P B TRAVATAN Z Op. Prostaglandins P G Travoprost Op. Prostaglandins NP G Trazodone HCl Antidepressants - Selected SSRI's P G Trazodone HCl TABS 300MG Antidepressants - Selected SSRI's NP B TRECATOR Antimycobacterials / Antituberculosis P B Trelegy ellipta Antiasthmatic - Adrenergic Combos N B TRELSTAR Antineoplastics - Lhrh Analogs R B Tremfya Anti-Inflammatories, Non-NSAID N PA Required B Tresiba FlexTouch Diabetic - Insulin Penfills P G Tretinoin Topical - Tretinoids N PA Required G Tretinoin (chemotherapy) antineoplastics - retinoids R PA Required G Tretinoin Microsphere Topical - Tretinoids NP PA Required B TREXALL Antineoplastics - Antimetabolites NP B TREXIMET Migraine - Selective Serotonin Agonists-5HT Combinations NP PA Required G Triamcinolone Acetonide (Nasal) Nasal Steroids NP

12/17/2018 9:18:23 AM Page 87 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR T G Triamcinolone Acetonide (Topical) Topical - Corticosteroids - Medium Potency P G Triamcinolone Acetonide (Topical) LOTN Topical - Corticosteroids - Medium Potency P G Triamcinolone Acetonide Dental Paste 0.1% Mouth - Steroids P G Triamterene & Hydrochlorothiazide Diuretics P B Trianex Topical - Corticosteroids - Medium Potency N PA Required G Triazolam Sedative/Hypnotics - Benzodiazepines NP PA Required B TRIBENZOR ARB/CCB Plus Diuretics NP B TRICOR Cholesterol - Fibric Acid Derivatives NP G Trientine Chelating Agents N G Trifluoperazine HCl Antipsychotics - Typical P G Trifluridine Op. Antibiotics P B TRIGLIDE Cholesterol - Fibric Acid Derivatives NP G Trihexyphenidyl HCl Parkinsons - Anticholinergics P B TRILEPTAL Anticonvulsants NP B TRILEPTAL SUSP Anticonvulsants NP Grandfather for seizure disorder. B TRILIPIX Cholesterol - Fibric Acid Derivatives NP PA Required G Trimethobenzamide HCl Antiemetic - Anticholinergic / Dopaminergic P G Trimethoprim Antibiotics - Misc. P G Trimipramine Antidepressants - Tri-Cyclics N Initial fill limited to 15 day supply. B TRINATAL GT Vitamins - Misc. P B TRINATAL RX 1 Vitamins - Misc. P B TRI-NORINYL 28 Contraceptives - Tri-Phasic Combinations NP B Trintellix Antidepressants - Selected SSRI's P B TRIOSTAT Thyroid Hormones P B TRIUMEQ Antiretrovirals - Combinations NP Grandfather Existing Users G Triveen Duo Vitamins - Misc. P B TRIZIVIR Antiretrovirals - Combinations NR B TROKENDI XR Anticonvulsants NP PA Required B TROPHAMINE Electrolytes/ Nutritionals NP G Tropicamide Op. Cycloplegics P G Trospium Chloride Antispasmodics NP B trulance Gi - Irritable Bowel Syndrome Agents N PA Required B TRULICITY Diabetic - Non-Insulin Injectables NP PA Required B TRUSOPT Op. Carbonic Anhydrase Inhibitors/Combo NP

12/17/2018 9:18:23 AM Page 88 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR T B TRUVADA Antiretrovirals - Combinations P B TUDORZA PRESSAIR Antiasthmatic - Anti-Cholinergics NP B TWYNSTA Arb/Ccb NP B TYBOST ANTIRETROVIRAL BOOSTING AGENT-CYTOCHROME P450 INHIBITOR NR B TYGACIL Antibiotics - Misc. P B TYKERB Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B TYLENOL/CODEINE Narcotics - Misc. NP PA Required B Tymlos Osteoporosis N B TYVASO Pulmonary Anti-Hypertensives NP PA Required B TYZEKA Hepatitis B Only NP U B UCERIS Glucocorticoids - Mineralocorticoids NP B U-CORT Topical - Steroid Combinations NP B ULESFIA Topical - Scabicides And Pediculicides N B ULORIC Gout NP PA Required B ULTRACET Narcotics - Selected NP ULTRACET - Use Tramadol & Acetaminophen separately B ULTRAM Narcotics - Selected NP PA Required B ULTRAVATE Topical - Corticosteroids - High Potency N PA Required B ULTRESA Gi - Digestive Enzymes NP B UMECTA Topical - Emollients NP B UMECTA NAIL FILM Topical - Emollients NP B UNASYN Beta-Lactams / Clavulanate Combo'S NP B UNIVASC ACE Inhibitors NP B Uptravi Pulmonary Anti-Hypertensives N PA Required B URAMAXIN Topical - Emollients NP G Urea Cream 50% Topical - Emollients NP G Urea Foam 40% Topical - Emollients NP G Urea Gel 40% Topical - Emollients NP G Urea Gel 45% Topical - Emollients NP G Urea Lotion 40% Topical - Emollients P G Urea Lotion 45% Topical - Emollients NP B URECHOLINE Cholinergic NP B UROCIT Urological - Misc. P

12/17/2018 9:18:23 AM Page 89 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR U B UROXATRAL BPH NP B URSO Gi - Misc. NP G Ursodiol Gi - Misc. P B UTIBRON NEOHALER Antiasthmatic - Adrenergic Combos N V B VAGIFEM Vaginal - Estrogens NP G Valacyclovir HCl Herpes Agents P G Valcyte oral suspension Cyto-Megalovirus Agents P B Valcyte Tablets Cyto-Megalovirus Agents N G Valganciclovir HCl Tablets Cyto-Megalovirus Agents P G valganciclovir oral suspension Cyto-Megalovirus Agents N G Valproate Sodium Anticonvulsants P G Valproic Acid Anticonvulsants P G Valsartan ARB'S P G Valsartan-Hydrochlorothiazide ARB'S And Diuretics P B VALTREX Herpes Agents NP B VANCOCIN HCL Antibiotics - Misc. N G Vancomycin HCl Antibiotics - Misc. P G Vancomycin HCl CAPS Antibiotics - Misc. P G Vancomycin HCl in Dextrose Antibiotics - Misc. P B VANOS Topical - Corticosteroids - High Potency N PA Required B Varubi Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin N PA Required B VASCEPA Cholesterol - Hmg COA + Absorb Inhibitors NP B VASERETIC ACE and Thiazide Combo's NP G Vasopressin Inj 20 Unit/ML Vasopressins NP B VASOTEC ACE Inhibitors NP B VECTICAL Anti-Psoriatics - Non-Biologicals NP B VELETRI Pulmonary Anti-Hypertensives NP PA Required B VELPHORO Phosphate Binders NP B Veltassa K Removing Resins N PA Required B Venclexta Antineoplastics - CLL 17p Deletion NR PA Required G Venlafaxine HCl Antidepressants - Selected SSRI's P G Venlafaxine HCl Cap SR 24HR 150 MG (Base Equivalent) Antidepressants - Selected SSRI's P G Venlafaxine HCl Cap SR 24HR 37.5 MG (Base Equivalent) Antidepressants - Selected SSRI's P

12/17/2018 9:18:23 AM Page 90 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR V G Venlafaxine HCl Cap SR 24HR 75 MG (Base Equivalent) Antidepressants - Selected SSRI's P G Venlafaxine HCl Tablet ER 24HR Antidepressants - Selected SSRI's NP B VENTAVIS Pulmonary Anti-Hypertensives P PA Required B VENTOLIN HFA Antiasthmatic - Beta - Adrenergics P B VERAMYST Nasal Steroids NP G verapamil hcl Calcium Channel Blockers--Verapamils P G verapamil hcl er cap Calcium Channel Blockers--Verapamils N G verapamil hcl er tab Calcium Channel Blockers--Verapamils P B VEREGEN Topical - Genital Warts P Payable for members who are 18 years of age and older. Quantity limitations of 30 grams/4 weeks (28 days) or a total of 120 grams/16 weeks (112 days) B VERELAN Calcium Channel Blockers--Verapamils NP B Verelan PM Calcium Channel Blockers--Verapamils N B VERIPRED 20 Glucocorticoids - Mineralocorticoids NP B VERSACLOZ Antipsychotics - Special Atypicals NP PA Required B Verzenio Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B VESICARE Antispasmodics - Long Acting P B VEXOL Op. Antiinflammatory / Steroids Ophth. P B VFEND Antifungals - Assorted NP PA Required B VFEND IV Antifungals - Assorted P PA Required > 90 days B VIBATIV Antibiotics - Misc. NP B Viberzi GI, Constipation - IBS-OIC P PA Required B VIBRAMYCIN CAP 100MG Tetracyclines NP B VIBRAMYCIN SUSR Tetracyclines NP B VIBRAMYCIN SYRP Tetracyclines P B VICOPROFEN Narcotics - Misc. NP PA Required B VICTOZA Diabetic - Non-Insulin Injectables P PA Required B VIDEX Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues NR G Vigabatrin Anticonvulsants N B VIGAMOX Op. Quinolones Fourth Generation N B VIIBRYD Antidepressants - Selected SSRI's NP PA Required B VIMOVO Gi - Proton Pump Inhibitor/Nsaid Combo NP PA Required B VIMPAT Anticonvulsants P B VIOKACE Gi - Digestive Enzymes NP

12/17/2018 9:18:23 AM Page 91 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR V B VIRACEPT Antiretrovirals - Protease Inhibitors NR B VIRAMUNE Antiretrovirals - Rti - Non - Nucleoside Analogues NR Requires a Selected Brand Name Drug PA B VIRAMUNE SUSP Antiretrovirals - Rti - Non - Nucleoside Analogues NR B VIRAMUNE XR Antiretrovirals - Rti - Non - Nucleoside Analogues NR B VIREAD Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues P B Viread 300mg tablets Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues N B VIROPTIC Op. Antibiotics NP G Virt-Nate tablet Vitamins - Misc. P B VISTARIL Antihistamines - Other NP PA Required O Vitamin C Vitamins P PA Required B VITEKTA Antiretrovirals - Integrase Inhibitors NR B Vivelle-Dot Estrogens - Patches N B Vivlodex Cox 2 Inhibitors - Selective N PA Required B VOGELXO Androgens -Topical NP PA Required B VOL-NATE Vitamins - Misc. P B VOL-PLUS TAB Vitamins - Misc. P G Vol-tab RX tablet Vitamins - Misc. P B VOLTAREN GEL NSAIDS P B VOLTAREN-XR NSAIDS NP PA Required B Vonvendi Antihemophilia Factor von Willebrand Factor Agents N G Voriconazole Antifungals - Assorted P PA Required > 90 days G Voriconazole SOLR Antifungals - Assorted NP PA Required B Vosevi Hepatitis C Agents N PA Required B VOSPIRE ER Antiasthmatic - Beta - Adrenergics NP B VOTRIENT Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B VPRIV Agents For Gaucher Disease NP B VRAYLAR Antipsychotics - Atypicals N PA Required B VUSION Topical - Antifungals NP PA Required B VYTORIN Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P B VYVANSE Stimulants - Amphetamines - Long Acting P PA Required >= 21 yo. B Vyzulta Op. Prostaglandins N W G Warfarin Sodium Anticoagulants P G Water For Inject, Bacteriostatic Parabens Compounding Materials P

12/17/2018 9:18:23 AM Page 92 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR W B Welchol Pak Cholesterol - Bile Sequestrants N B Welchol Tablets Cholesterol - Bile Sequestrants P B WELLBUTRIN Antidepressants - Selected SSRI's P B WELLBUTRIN XL Antidepressants - Selected SSRI's NP B WILATE Antihemophilia Factor von Willebrand Factor Agents P B WINRHO SDF Immune Serums P X B xadago Anti-Parkinsonian Drugs N B XALATAN Op. Prostaglandins NP B XALKORI Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B XANAX Anxiolytics - Benzodiazepines NP PA Required B XANAX XR Anxiolytics - Long Acting NP PA Required B XARELTO Anticoagulants P B XARTEMIS XR Narcotics -Long Acting NP PA Required B Xatmep Antineoplastics - Antimetabolites N B XELJANZ Anti-Inflammatories, Non-Nsaid NP PA Required B Xeljanz XR Anti-Inflammatories, Non-Nsaid N PA Required B XELODA Antineoplastics - Antimetabolites P PA Required B Xenazine Neurologics - Misc. NP PA required B XERAC AC Topical - Astringents / Protectants P B XERESE Topical - Antivirals NP B Xermelo Gi - Misc. N B Xhance Nasal Steroids N B XIFAXAN Antibiotics - Misc. NP PA Required B XIGDUO XR Diabetic - Other P PA Required B Xiidra Op. Misc N B Ximino Tetracyclines N PA Required B XODOL Narcotics - Misc. NP PA Required B XOPENEX Antiasthmatic - Beta - Adrenergics NP PA Required B Xtampza ER Narcotics -Long Acting N PA Required B XTANDI Antineoplastics - Antiandrogens R PA Required G XULANE Contraceptives - Patches/ Vaginal Products P B Xultophy Diabetic - Other N PA Required B XYLOCAINE Antiarrhythmics NP

12/17/2018 9:18:23 AM Page 93 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR X B XYLOCAINE/EPINEPHRINE Topical - Local Anesthetics P B XYLOCAINE-MPF Topical - Local Anesthetics NP B Xyntha Antihemophilia Factor VIII Agents P B XYREM Anti-Cataplectic Agents NP PA Required B XYZAL Antihistamines - Non-Sedating NP PA Required Y B YASMIN 28 Contraceptives - Monophasic Combination O/C'S NP B YAZ Contraceptives - Monophasic Combination O/C'S NP B Yonsa Antineoplastics - Androgen Biosynthesis Inhibitor. NR PA Required B Yosprala Platelet Aggr. Inhibitors / Combo's - Misc. N G Yuvafem Vaginal - Estrogens N Z G Zafirlukast Antiasthmatic - Leukotriene Receptor Antagonists NP G Zaleplon Sedative/Hypnotics - Non-Benzodiazepines P B ZANAFLEX Muscle Relaxants NP PA Required B ZANTAC Gi - H2-Antagonists NP B ZARONTIN Anticonvulsants P B ZARONTIN SOLN Anticonvulsants NP B ZAROXOLYN Diuretics P B Zarxio Granulocyte Csf NP PA Required B ZAVESCA Agents For Gaucher Disease NP B ZEBETA Beta Blockers - Cardio Selective NP B Zecuity Migraine - Selective Serotonin Agonists (5HT)--Injectables NP PA Required B zejula Antineoplastics - Parp Inhibitors NR PA Required B ZELAPAR Anti-Parkinsonian Drugs NP B ZELBORAF Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B ZEMAIRA Alpha-Proteinase Inhibitor NP PA Required B Zembrace Migraine - Selective Serotonin Agonists (5HT)--Tabs N PA Required B Zemplar capsules Hyperparathyroid Treatment - Vitamin D Analogs And Calcimimetics P B ZENPEP Gi - Digestive Enzymes P B Zepatier Hepatitis C Agents N PA Required B ZERIT Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues NR Requires a Selected Brand Name Drug PA B ZESTORETIC ACE and Thiazide Combo's NP

12/17/2018 9:18:23 AM Page 94 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR Z B ZESTRIL ACE Inhibitors NP B ZETIA Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P No manual PA required if HMG-CoA reductase inhibitor found in member’s pharmacy claims history in past 12 months. B ZETONNA Nasal Steroids NP B ZIAC Beta Blockers And Diuretic Combo'S NP B ZIAGEN Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues N B ZIANA Topical - Acne Preparations NP PA Required G Zidovudine Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues R B ZINACEF Cephalosporins NP B ZIOPTAN Op. Prostaglandins NP G ziprasidone hcl Antipsychotics - Atypicals P B ZIPSOR NSAIDS NP PA Required B ZIRGAN Op. Antibiotics NP B ZITHROMAX INJ 500MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX POW 1GM PAK Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX SUS 100/5ML Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX SUS 200/5ML Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB 250MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB 500MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB 600MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB TRI-PAK Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB Z-PAK Macrolides / Erythromycin'S / Ketolides NP B ZMAX SUS 2GM Macrolides / Erythromycin'S / Ketolides NP B ZOCOR Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations NP B ZOFRAN Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ZOFRAN ODT Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ZOHYDRO ER Narcotics -Long Acting NP PA Required B ZOLADEX Antineoplastics - Lhrh Analogs R B ZOLINZA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR Initial fill limited to 15 day supply. G Zolmitriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ZOLOFT Antidepressants - Selected SSRI's NP G Zolpidem Tartrate Sedative/Hypnotics - Non-Benzodiazepines P G Zolpidem Tartrate Tablet ER Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B ZOLPIMIST Sedative/Hypnotics - Non-Benzodiazepines NP PA Required

12/17/2018 9:18:23 AM Page 95 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR Z B ZOMETA Osteoporosis NP B ZOMIG Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ZOMIG NASAL SPRAY Migraine - Selective Serotonin Agonists (5HT)--Injectables P PA Required> 12 Units/30 Days supply B ZOMIG ZMT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ZONALON Topical - Antipruritics P B ZONEGRAN Anticonvulsants NP Grandfather for seizure disorder. G Zonisamide Anticonvulsants P B ZONTIVITY Platelet Aggr. Inhibitors / Combo's - Misc. NP PA Required B ZORBTIVE Growth Hormone NP PA Required B ZORTRESS Immunosuppressants NP B ZORVOLEX NSAIDS NP PA Required B ZOSTAVAX INJ Vaccines P Payable for members 50 years of age and older without prior authorization B ZOSYN Beta-Lactams / Clavulanate Combo'S P B ZOVIA 1/50E Contraceptives - Monophasic Combination O/C'S P B ZOVIRAX CAP 200MG Herpes Agents NP B ZOVIRAX CRE 5% Topical - Antivirals NP B ZOVIRAX OIN 5% Topical - Antivirals NP B ZOVIRAX SUS 200/5ML Herpes Agents N B ZOVIRAX TAB 400MG Herpes Agents NP B ZOVIRAX TAB 800MG Herpes Agents NP B ZUBSOLV Narcotics - Misc. NP PA Required B Zurampic Gout N PA Required B ZYCLARA Topical - Genital Warts NP B ZYCLARA PUMP Topical - Genital Warts NP B ZYDELIG Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B ZYFLO Antiasthmatic - 5-Lipoxygenase Inhibitors NP B ZYKADIA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B ZYLET Op. Antiinflammatory / Steroids Ophth. P B ZYLOPRIM Gout NP B ZYMAXID Op. Quinolones Fourth Generation NP B Zypitamag Cholesterol - Hmg COA + Absorb Inhibitors N B ZYPREXA Antipsychotics - Atypicals NP PA Required B Zyprexa Relprevv Antipsychotics - Atypicals P

12/17/2018 9:18:23 AM Page 96 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR Z B ZYPREXA ZYDIS Antipsychotics - Atypicals NP PA Required B ZYTIGA Antineoplastics - Androgen Biosynthesis Inhibitor. NR PA Required B ZYVOX Lincosamides / Oxazolidinones / Leprostatics N PA Required

12/17/2018 9:18:23 AM Page 97 Of 98 12/17/2018 9:18:23 AM Page 98 Of 98