APWU Health Plan: Consumer Driven Option January 2020 Preferred Drug List Exclusions

The medications covered on this list are not covered by the CDH plan. In most cases, if you fill a prescription for one of these drugs, you will pay the full price of the medication.

Take action to avoid paying full price. If you are currently utilizing one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the preferred alternatives. Compare drug prices at www.myuhc.com® or the UnitedHealthcareTM Mobile App.

Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Acne Absorica Brand isotretinoin [Amnesteem, Claravis, Myorisan, Zenatane (branded generics for Accutane)] clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin (generic Cleocin-T) plus Acanya Brand & Generic OTC benzoyl peroxide benzoyl peroxide 5%/erythromycin 3% gel (generic Benzamycin), erythromycin gel (generic Aktipak Brand Erygel) Altreno Brand OTC Differin gel, tretinoin cream (generic Retin-A) Avar Brand sulfacetamide sodium/sulfur 10-5% Avar LS Brand sulfacetamide sodium/sulfur 10-5% Avita 0.025% Generic Only OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Benzac, Desquam, Panoxyl, Brevoxyl Brand & Generic OTC benzoyl peroxide clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Benzaclin jar Brand & Generic T) plus OTC benzoyl peroxide clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Benzaclin pump Brand & Generic T) plus OTC benzoyl peroxide Clindacin Kit/Pac Brand clindamycin 1% gel, solution (generic Cleocin T) Clindagel Brand & Generic clindamycin 1% gel, solution (generic Cleocin T) Differin 0.1% cream, gel, lotion Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Differin 0.3% gel Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Doryx Brand & Generic Monodox) clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Duac Brand T) plus OTC benzoyl peroxide Epiduo Brand OTC Differin 0.1% gel plus OTC benzoyl peroxide Epiduo Forte Brand OTC Differin 0.1% gel plus OTC benzoyl peroxide Fabior Brand OTC Differin 0.1% gel, tretinoin cream (generic Retin-A), Tazorac minocycline tablet (generic Dynacin) Generic Only minocycline immediate-release capsules (generic Minocin) Minolira Brand minocycline immediate-release capsules (generic Minocin) doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Morgidox Kit Brand Monodox) clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Neuac 1.2%-5% Kit Brand T) plus OTC benzoyl peroxide clindamycin topical solution (generic Cleocin T) + OTC benzoyl peroxide or clindamycin/benzoyl Onexton Brand peroxide (generic Duac) 1.2%-5% Plexion Brand sulfacetamide sodium/sulfur 10-5% Retin-A cream Brand OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Retin-A gel Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Retin-A Micro Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg and 100 mg (generic Seysara Brand Monodox), minocycline immediate-release capsules (generic Minocin) Solodyn4 Brand & Generic minocycline immediate-release capsules (generic Minocin) Sumadan Brand & Generic sulfacetamide soldium/sulfur 10-5%

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Acne (Continued) Sumadan Kit Brand & Generic sodium sulfacetamide/sulfur 10-5% Sumadan XLT Kit Brand sulfacetamide sodium/sulfur 10-5% Sumaxin CP Brand sodium sulfacetamide/sulfur 10-5% Sumaxin TS Brand & Generic sodium sulfacetamide/sulfur 10-5% Targadox Brand doxycycline hyclate (generic Vibramycin), doxycycline monohydrate (generic Monodox) tazarotene 0.1% cream (generic Tazorac) Generic Only OTC Differin, tretinoin cream (generic Retin-A), Tazorac 0.1% cream clindamycin solution (generic Cleocin-T) plus tretinoin cream (generic Retin-A) or OTC Differin Veltin Brand 0.1% Ximino Brand minocycline immediate-release capsules (generic Minocin) clindamycin solution (generic Cleocin-T) plus tretinoin cream (generic Retin-A) or OTC Differin Ziana Brand & Generic 0.1% ADHD Adderall Brand amphetamine/dextroamphetamine immediate-release (generic Adderall) methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Adzenys Brand Concerta, Vyvanse amphetamine/dextroamphetamine extended-release (generic Generic Only Adderall XR methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Aptensio XR Brand Concerta, Vyvanse methylphenidate extended-release (generic Metadate CD, Ritalin LA), Adderall XR, Concerta, Cotempla XR-ODT Brand Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Daytrana Brand Concerta, Vyvanse Dexedrine (Brand Only) Brand dextroamphetamine extended-release (generic Dexedrine), Adderall XR methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Dyanavel XR Brand Concerta, Vyvanse amphetamine/dextroamphetamine immediate-release (generic Adderall), dextroamphetamine Evekeo Brand & Generic immediate-release (generic Dexedrine) methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Focalin XR Brand Concerta, Vyvanse Intuniv Brand guanfacine extended-release (generic Intuniv) guanfacine extended-release (generic Intuniv) Kapvay Brand & Generic methylphenidate extended-release tablet (generic Concerta) Generic Only Concerta methylphenidate extended-release (generic Metadate CD, Ritalin LA), Adderall XR, Concerta, Mydayis Brand Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Quillichew ER Brand Concerta, Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Quillivant XR Brand Concerta, Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Ritalin LA Brand Concerta, Vyvanse Strattera Brand atomoxetine (generic Strattera) Zenzedi Brand amphetamine/dextroamphetamine (generic Adderall), dextroamphetamine (generic Dexedrine) Allergic Reactions Auvi-Q Brand epinephrine auto-injector (generic EpiPen/EpiPen Jr.), Symjepi EpiPen/Epipen Jr Brand epinephrine auto-injector (generic EpiPen/EpiPen Jr.), Symjepi Allergies Allegra Brand & Generic OTC Allegra Astepro Brand & Generic azelastine (g0.1% nasal spray ) (generic Astelin) (g ) Beconase AQ Brand Rhinocort Benadryl Brand & Generic OTC Benadryl () p (gp)p Bepreve Brand ophthalmic solution (generic Patanol), Lastacaft Clarinex Brand & Generic levocetirizine (g(generic Xyzal), y ) OTC - pAllegra, pClaritin, Xyzal (g, Zyrtec ) g Clarinex-D Brand & Generic Claritin D, Zyrtec D fluticasone (generic Flonase), azelastine 0.1% (generic Astelin), OTC - Flonase, Nasacort, Dymista Brand Rhinocort OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Elestat Brand & Generic ophthalmic solution (generic Patanol), Lastacaft

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Allergies (Continued) Emadine Brand ophthalmic solution (generic Patanol), Lastacaft Histex Brand & Generic n/a Karbinal ER Brand carbinoxamine tablets (generic Palgic) flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Nasacort AQ Brand & Generic Rhinocort flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Nasonex Brand & Generic Rhinocort flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Omnaris Brand Rhinocort OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Optivar Brand ophthalmic solution (generic Patanol), Lastacaft OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Pataday Brand & Generic ophthalmic solution (generic Patanol), Lastacaft OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Patanol Brand ophthalmic solution (generic Patanol), Lastacaft OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine ophthalmic Pazeo Brand solution (generic Patanol), Lastacaft flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Qnasl Brand Rhinocort flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Rhinocort Aqua Brand & Generic Rhinocort Ryclora Brand & Generic OTC chlorpheniramine (generic Chlor-Trimeton) RyVent Brand carbinoxamine tablets (generic Palgic) Singulair Chewable Tablet Brand montelukast chewable tablet (generic Singulair) Singulair Tablet Brand montelukast tablet (generic Singulair) Zyrtec oral solution Brand & Generic OTC Children’s Zyrtec Allergy Syrup Zyrtec Tablet Brand & Generic OTC Zyrtec Alzheimer's Disease Aricept 23mg Brand & Generic donepezil 10 mg (generic Aricept) Exelon Patch Brand rivastigmine transdermal patch (generic Exelon), rivastigmine capsules (generic Exelon) Namenda XR Brand & Generic memantine immediate-release (generic Namenda) Namzaric Brand donepezil (generic Aricept) plus memantine immediate-release (generic Namenda) Anemia Epogen Brand Retacrit Procrit Brand Retacrit Angina Ranexa (Brand Only) Brand ranolazine (generic Ranexa) Anxiety Ativan Brand lorazepam (generic Ativan) Valium Brand diazepam (generic Valium) Xanax Brand alprazolam (generic Xanax) Xanax XR Brand alprazolam extended-release (generic Xanax XR) Arrhythmias Betapace Brand sotalol (generic Betapace)

Asthma Albuterol HFA [Ventolin HFA authorized generic (Prasco)] Authorized Generic Ventolin HFA fluticasone/salmeterol powder for inhalation (generic AirDuo Respiclick), Advair Diskus/HFA, Breo Dulera Brand Ellipta, Symbicort fluticasone/salmeterol powder for inhalation (generic AirDuo Respiclick), Advair Diskus/HFA, Breo Asthma/COPD AirDuo Respiclick Brand Ellipta, Symbicort Pulmicort inhalation suspension (Brand Only) Brand budesonide inhalation suspension (generic Pulmicort) Xopenex Nebs Brand albuterol nebs (generic Proventil) Benign Prostatic Hypertrophy Avodart Brand dutasteride (generic Avodart), finasteride (generic Proscar) Flomax Brand tamsulosin (generic Flomax) Jalyn Brand & Generic dutasteride (generic Avodart) PLUS tamsulosin (generic Flomax) Birthmark (Hemangioma) Hemangeol Brand propranolol tablet (generic Inderal), propranolol oral solution (generic Inderal) Blood Clots Lovenox (Brand Only) Brand enoxaparin (generic Lovenox) Blood Disorders trientine (generic Syprine) Generic Only Syprine Breast Cancer Arimidex Brand anastrozole (generic Arimidex)

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Breast Cancer (Continued) Femara Brand letrozole (generic Femara) Soltamox Brand tamoxifen (generic Nolvadex) Cancer bexarotene caps (generic for Targretin) Generic Only Targretin capsules capecitabine (generic Xeloda) Generic Only Xeloda Gleevec Brand imatinib (generic Gleevec) Yonsa Brand Zytiga Cancer Pain Abstral Brand fentanyl citrate lozenges (generic Actiq), Lazanda Actiq Brand fentanyl citrate lozenges (generic Actiq), Lazanda Fentora Brand fentanyl citrate lozenges (generic Actiq), Lazanda Subsys Brand fentanyl citrate lozenges (generic Actiq), Lazanda Chest Pain GoNitro Brand nitroglycerin spray (generic NitroMist), nitroglycerin sublingual tablets (generic Nitrostat) Nitrolingual PumpSpray Brand & Generic nitroglycerin spray (generic NitroMist), nitroglycerin sublingual tablets (generic Nitrostat) atorvastatin (generic Lipitor), lovastatin (generic Mevacor), pravastatin (generic Pravachol), Cholesterol Zypitamag Brand rosuvastatin (generic Crestor), simvastatin (generic Zocor) Cholesterol/Lipid Lowering Altoprev Brand lovastatin (generic Mevacor) Antara 30 mg, 90 mg Brand fenofibrate 54 mg, 160 mg tablet (generic Lofibra tablet, Triglide) Antara 43 mg, 130 mg Brand & Generic fenofibrate 54 mg, 160 mg tablet (generic Lofibra tablet, Triglide) Crestor Brand rosuvastatin (generic Crestor) Fenoglide Brand & Generic fenofibrate 54 mg, 160 mg tablet (generic Lofibra tablet, Triglide) Fibricor Brand & Generic fenofibrate 54 mg, 160 mg tablet (generic Lofibra tablet, Triglide) atorvastatin (generic Lipitor), fluvastatin extended-release (generic Lescol XL), lovastatin (generic Mevacor), pravastatin (generic Pravachol), rosuvastatin (generic Crestor), simvastatin (generic Lescol XL Brand Zocor)

Lipitor Brand atorvastatin (generic Lipitor) Lipofen Brand & Generic fenofibrate 54 mg, 160 mg tablet (generic Lofibra tablet, Triglide) atorvastatin (generic Lipitor), lovastatin (generic Mevacor), pravastatin (generic Pravachol), Livalo Brand rosuvastatin (generic Crestor), simvastatin (generic Zocor) Lofibra capsules Brand & Generic fenofibrate 54 mg, 160 mg tablet (generic Lofibra tablet, Triglide) Lovaza Brand omega-3-acid ethyl esters (generic Lovaza) Tricor 48 mg and 145 mg Brand & Generic fenofibrate 54mg, 160 mg tablet (generic Lofibra, Triglide) Triglide (Brand only) Brand fenofibrate 54 mg, 160 mg tablet (generic Lofibra tablet, Triglide) Trilipix Brand & Generic fenofibrate 54mg, 160 mg tablet (generic Lofibra, Triglide) Vytorin Brand simvastatin/ezetimibe (generic Vytorin) Zetia Brand ezetimibe tablet (generic Zetia) Constipation PCP 100 Kit Brand metoclopramide (generic Reglan) + OTC medications for constipation Contraceptive Balcoltra Brand levonorgestrel 0.1 mg/ethinyl estradiol 0.02 mg (generics for Alesse) Beyaz Brand & Generic Yaz + folic acid norethindrone/ethinyl estradiol FE 1/0.02 mg [Aurovela FE, Blisovi FE, Junel FE, Larin FE, Generess FE Brand & Generic Microgestin FE, Tarina FE (branded generics for Loestrin FE)] norethindrone/ethinyl estradiol FE 1/0.02 mg [Aurovela FE, Blisovi FE, Junel FE, Larin FE, Minastrin 24 FE Brand & Generic Microgestin FE, Tarina FE (branded generics for Loestrin FE)] norgestimate/ethinyl estradiol Lo 0.18-0.215-0.25/0.025 mg [Tri-Lo-Estarylla, Tri-Lo-Marzia, Tri-Lo- Sprintec, Trinessa Lo Ortho Tri-Cyclen Lo Brand (branded generics Ortho Tri-Cyclen Lo)] levonorgestrel/ethinyl estradiol 0.15/0.03 mg [Introvale, Jolessa, Quasense, Setlakin (branded Quartette Brand & Generic generic Seasonale)] Safyral Brand & Generic Yasmin + folic acid norethindrone/ethinyl estradiol 24 FE 1/0.02 mg [Aurovela 24 FE, Blisovi 24 FE, Junel 24 FE, Larin 24 FE, LoMedia 24 FE, (branded generic Loestrin 24 FE)], norethindone/ethinyl estradiol FE 1/0.02 mg [Aurovela FE, Blisovi FE, Junel FE, Larin FE, Microgestin FE, Tarina FE (branded Taytulla Brand generic Loestrin FE)]

COPD Lonhala Magnair Brand Incruse Ellipta, Spiriva Handihaler/Resipmat, Yupelri Stiolto Respimat Brand Anoro Ellipta, Bevespi Aerosphere

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 COPD (Continued) Tudorza Pressair Brand Incruse Ellipta, Spiriva Handihaler/Resipmat Utibron Neohaler Brand Anoro Ellipta, Bevespi Aerosphere

Cough & Cold Tuzistra XR Brand hydrocodone polistirex/chlorpheniramine polistirex (generic Tussionex Pennkinetic), Z-Tuss AC Hydrocodone/Guaifenesin 2.5 mg/200 mg/5 mL Brand guaifenesin/codeine solution (Cheratussin AC) Diabetes Actos Brand pioglitazone (generic Actos) Admelog Brand Humalog Afrezza Brand Humalog Alogliptin (Nesina authorized generic) Authorized Generic Nesina Alogliptin/metformin (Kazano authorized generic) Authorized Generic Kazano Alogliptin/pioglitazone (Oseni authorized generic) Authorized Generic Oseni Apidra Brand Humalog Farxiga Brand Invokana, Jardiance Fiasp4 Brand Humalog Fortamet Brand & Generic metformin (generic Glucophage), metformin extended-release (generic Glucophage XR) Glumetza Brand & Generic metformin (generic Glucophage), metformin extended-release (generic Glucophage XR) Lantus, Lantus SoloStar Brand Basaglar, Tresiba Levemir4 Brand Basaglar, Tresiba Novolin 70/30 (includes Relion) Brand Humulin 70/30 Novolin N (includes Relion) Brand Humulin N Novolin R (includes Relion) Brand Humulin R Novolog Brand Humalog Novolog 70/30 Brand Humalog 75/25 Qtern Brand Glyxambi Segluromet Brand Invokamet, Invokamet XR, Synjardy, Synjardy XR Select Diabetic Meters4 Brand OneTouch Meters, Contour Next Meter, Contour Next EZ Meter, Contour Next One Meter Select Diabetic Test Strips4 Brand OneTouch Test Strips, Contour Next Test Strips Steglatro Brand Invokana, Jardiance Steglujan Brand Glyxambi Toujeo Solostar Brand Basaglar, Tresiba Xigduo XR Brand Invokamet, Invokamet XR, Synjardy, Synjardy XR Xultophy Brand Soliqua Diaper Rash Vusion Brand and Authorized Generic nystatin Cream (generic Mycostatin), OTC - miconazole Diarrhea Imodium Brand & Generic OTC Imodium Motofen Brand OTC loperamide (generic Imodium A-D), diphenoxylate/atropine (generic Lomotil) Dry Eye Disease Restasis MultiDose Brand Restasis (single use vials), Xiidra Dry Skin Lac-Hydrin 12% Brand & Generic OTC Lac-Hydrin Duchenne Muscular Dystrophy Emflaza Brand prednisone Elevated Parathyroid Hormone Rayaldee Brand calcitriol (generic Rocaltrol), doxercalciferol (generic Hectorol), paricalcitol (generic Zemplar) Elevated Phosphate Levels Fosrenol Brand lanthanum chewable tablets (generic Fosrenol) Renvela tablets Brand sevelamer tablets (generic Renvela) Endocrine Disorders Orfadin Brand Nityr Sandostatin Brand octreotide (generic Sandostatin) Erectile Dysfunction Cialis (Brand only) Brand tadalafil (generic Cialis) Levitra (Brand only) Brand vardenafil (generic Levitra) Staxyn Brand vardenafil (generic Levitra) Viagra Brand sildenafil (generic Viagra) Excessive Nighttime Urination Noctiva Brand Nocdurna Excessive Secretions Glycate Brand glycopyrrolate (generic Robinul) Eye Infections Tobradex ST Brand tobramycin/dexamethasone (generic Tobradex)

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Eye Inflammation Lotemax gel Brand prednisolone (generic Pred Forte), Lotemax Ointment, Lotemax Suspension, Maxidex, Vexol Eye Pain & Inflammation Acuvail Brand ketorolac ophthalmic solution (generic Acular) bromfenac ophthalmic solution (generic Bromday, Xibrom), diclofenac ophthalmic solution Ilevro Brand (generic Voltaren), ketorolac ophthalmic solution (generic Acular), Nevanac bromfenac ophthalmic solution (generic Bromday, Xibrom), diclofenac ophthalmic solution Prolensa Brand (generic Voltaren), ketorolac ophthalmic solution (generic Acular), Nevanac bromfenac ophthalmic solution (generic Bromday, Xibrom), diclofenac ophthalmic solution BromSite Brand (generic Voltaren), ketorolac ophthalmic solution (generic Acular), Nevanac Fever, Pain & Swelling Motrin Suspension, Pedia-Profen Brand & Generic OTC Motrin Fungal Infections Ciclodan Kit Brand & Generic ciclopirox solution (generic Loprox) Ciclodan/Loprox Cream Kit Brand ciclopirox (generic Loprox) ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral), OTC - Ecoza Brand clotrimazole, miconazole, terbinafine ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral), OTC - Ertaczo Brand clotrimazole, miconazole, terbinafine Lotrimin 1% Brand & Generic OTC Lotrimin ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral), OTC - Luzu Brand and Authorized Generic clotrimazole, miconazole, terbinafine ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral), OTC - Naftin 1% and 2% gel Brand clotrimazole, miconazole, terbinafine ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral), OTC - Naftin 1% and 2% cream Brand & Generic clotrimazole, miconazole, terbinafine nystatin/triamcinolone (generic Mycolog II) cream, ointment Generic Only nystatin cream (generic Mycostatin) + triamcinolone 0.1% cream (generic Kenalog) ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral), OTC - Oxistat Lotion Brand clotrimazole, miconazole, terbinafine Gaucher Disease Zavesca Brand miglustat (generic Zavesca) Glaucoma bimatoprost 0.03% (generic Lumigan) Generic Only latanoprost (generic Xalatan), Lumigan 0.01%, Travatan Z Cosopt PF Brand & Generic dorzolamide/timolol (generic Cosopt) Rhopressa Brand latanoprost (Xalatan), timolol (generic Timoptic), Lumigan, Travatan Z Simbrinza Brand brimonidine (generic Alphagan) plus Azopt Vyzulta Brand latanoprost (Xalatan), Lumigan, Travatan Z Xalatan (Brand Only) Brand latanoprost (generic Xalatan) Gout colchicine capsule (Mitigare authorized generic) Authorized Generic Mitigare Colcrys4 Brand and Authorized Generic Mitigare Growth Hormone Humatrope Brand Nutropin AQ, Nutropin AQ NuSpin Norditropin Brand Nutropin AQ, Nutropin AQ NuSpin Omnitrope Brand Nutropin AQ, Nutropin AQ NuSpin Saizen Brand Nutropin AQ, Nutropin AQ NuSpin Zomacton Brand Nutropin AQ, Nutropin AQ NuSpin Genotropin Brand Nutropin AQ, Nutropin AQ NuSpin Headache Butalbital/Acetaminophen 50/300 mg capsule Brand butalbital/acetaminophen 50 mg/325 mg (generic Phrenilin) Allzital Brand butalbital/acetaminophen 50mg/325 mg (generic Phenrilin) Heart attack/Stroke prevention Effient Brand prasugrel (generic Effient) Hemophilia Adynovate Brand Kogenate FS, Kovaltry, Novoeight, Nuwiq Ixinity Brand BeneFIX, Rixubis Rebinyn Brand Alprolix, Benefix, Idelvion, Rixubus Hemorrhoids Anusol HC Supp Brand hydrocortisone cream (generic Anusol-HC), hydrocortisone suppository (generic Anusol-HC) Hepatitis B Baraclude tablets Brand entecavir tablet (generic Baraclude) Hepatitis B/HIV Viread tablets Brand tenofovir tablets (generic Viread) Hepatitis C Moderiba Tablet, Pak Generic Only ribavirin (generic Copegus) Ribasphere Ribapak Generic Only ribavirin (generic Copegus, Rebetol) Hereditary Angioedema Cinryze Brand Haegarda, Takhzyro

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 amlodipine/valsartan (generic Exforge) or amlodipine (generic Norvasc) PLUS olmesartan High Blood Pressure Azor Brand & Generic (generic Benicar) Benicar Brand olmesartan (generic Benicar) Benicar HCT Brand olmesartan HCT (generic Benicar HCT) Cardizem Brand diltiazem (generic Cardizem) Cardizem CD Brand diltiazem extended-release (generic Cardizem CD) Cardizem LA Brand diltiazem extended-release (generic Cardizem LA) Dibenzyline Brand phenoxybenzamine (generic Dibenzyline) Diovan Brand valsartan (generic Diovan) Diovan HCT Brand valsartan/hydrochlorothiazide (generic Diovan HCT) Dutoprol Brand & Authorized Generic metoprolol (generic Toprol-XL) plus hydrochlorothiazide Exforge Brand amlodipine/valsartan (generic Exforge) Exforge HCT4 Brand & Generic amlodipine/valsartan (generic Exforge) PLUS hydrochlorothiazide Inderal LA Brand propranolol extended-release capsule (generic Inderal LA) metoprolol tartrate 37.5, 75 mg Generic Only metoprolol (25, 50, 100 mg strengths) (generic Lopressor) Micardis Brand telmisartan (generic Micardis) Micardis HCT Brand telmisartan/hydrochlorothiazide (generic Micardis HCT) Norvasc (Brand Only) Brand amlodipine (generic Norvasc) Prestalia Brand amlodipine (generic Norvasc) plus perindopril (generic Aceon) Tenoretic Brand atenolol/chlorthalidone (generic Tenoretic 50, Tenoretic 100) Tenormin Brand atenolol (generic Tenormin) Tribenzor Brand & Generic amlodipine (generic Norvasc) PLUS olmesartan/HCTZ (generic Benicar HCT) amlodipine/valsartan (generic Exforge) or amlodipine (generic Norvasc) PLUS telmisartan Twynsta Brand & Generic (generic Micardis) Vaseretic Brand enalapril/hydrochlorothiazide (generic Vaseretic) Vasotec Brand enalapril (generic Vasotec) Zestoretic Brand lisinopril/hydrochlorothiazide (generic Zestoretic) Zestril Brand lisinopril (generic Zestril) High Blood Pressure/Heart Failure Coreg CR Brand & Generic carvedilol immediate-release (generic Coreg) High Cholesterol/High Blood Pressure Caduet Brand & Generic amlodipine (geneic Norvasc) plus atorvastatin (generic Lipitor) HIV Atripla Brand Cimduo, Isentress, Juluca, Symfi, Symfi Lo,Tivicay, Triumeq Epzicom Brand abacavir/lamivudine (generic Epzicom) Norvir tablets Brand ritonavir tablets (generic Norvir) Reyataz capsules Brand atazanavir capsules (Reyataz) Symtuza Brand Prezcobix plus Cimduo, Prezcobix plus Descovy Viramune Brand nevirapine (generic Viramune) Viramune XR Brand & Generic nevirapine (generic Viramune) Hormone Replacement Climara Brand estradiol transdermal patch (generic Climara) estradiol transdermal patches (generic for Vivelle-Dot) Generic Only Vivelle-Dot Minivelle (Brand Only) Brand estradiol patch (generic Minivelle), Vivelle-Dot Prometrium (Brand Only) Brand progesterone (generic Prometrium) Vagifem Brand estradiol vaginal tablet [Yuvafem (generic Vagifem)] Huntington's Disease Xenazine Brand tetrabenazine (generic Xenazine) doxycycline hyclate (generic Vibramycin, Vibra-tab), doxycycline monohydrate 50 mg or 100 mg Infections Acticlate Brand & Generic (generic Monodox) Augmentin Brand amoxicillin/clavulanic acid (generic Augmentin) Augmentin ES-600 Brand amoxicillin/clavulanic acid (generic Augmentin) Augmentin XR Brand & Generic amoxicillin/clavulanic acid (generic Augmentin) Avelox tablet Brand moxifloxacin tablets (generic Avelox) Centany AT Brand mupirocin ointment (generic Bactroban)

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Infections (Continued) doxycycline 75 mg capsule (generic Monodox) Generic Only Monodox) E.E.S. 400 Brand erythromycin ethylsuccinate (generic E.E.S. 400) Floxin Otic Brand ofloxacin 0.3 % solution (generic Floxin Otic, Ocuflox) Loprox 0.77% Brand ciclopirox 0.77% (generic Loprox) Mepron suspension Brand atovaquone suspension (generic Mepron) Minocin Brand minocycline immediate-release capsules (generic Minocin) Nuvessa Brand metronidazole 0.75% vaginal gel (generic Metrogel-Vaginal) Otovel Brand ofloxacin 0.3% solution (generic Floxin, Ocuflox), Ciprodex Tolsura Brand itraconazole capsule (generic Sporanox) Valcyte Brand valganciclovir (generic Valcyte) Vigamox Brand moxifloxacin ophthalmic solution (generic Vigamox) Zyvox Brand linezolid (generic Zyvox) Inflammatory Bowel Disease Asacol HD Tablet Brand and Authorized Generic balsalazide (generic Colazal), sulfasalazine (generic Azulfidine), Apriso, Lialda Canasa (Brand only) Brand mesalamine suppositories (generic Canasa) Colazal Brand balsalazide (generic Colazal) Delzicol Brand Apriso, Lialda Entocort EC Brand budesonide (generic Entocort EC) Pentasa Brand Apriso, Lialda Inflammatory Conditions Ilumya4 Brand Cimzia, Cosentyx, Humira, Skyrizi, Stelara, Tremfya Plaquenil (Brand Only) Brand hydroxychloroquine (generic Plaquenil) Siliq4 Brand Cimzia, Cosentyx, Humira, Skyrizi, Stelara, Tremfya Taltz4 Brand Cimzia, Cosentyx, Humira, Skyrizi, Stelara, Tremfya Influenza Tamiflu Brand oseltamivir (generic Tamiflu) Iron Overload Exjade (Brand Only) Brand desferasirox (generic Exjade) Irritable Bowel Syndrome Librax Brand chlordiazepoxide/clidinium (generic Librax) Lotronex Brand alosetron (generic Lotronex) Lice/Scabbies Natroba Brand malathion (generic Ovide), permethrin (generic Elimite), spinosad (generic Natroba) Mental Health Abilify MyCite Brand aripiprazole (generic Abilify) Abilify tablets Brand aripiprazole (generic Abilify) Anafranil Brand clomipramine (generic Anafranil) bupropion (generic Wellbutrin), bupropion extended-release (Wellbutrin SR), bupropion extended- Aplenzin Brand release (generic Wellbutrin XL) Celexa Brand citalopram (generic Celexa) Cymbalta Brand duloxetine (generic Cymbalta), venlafaxine ER capsules (generic Effexor ER) Desvenlafaxine Brand desvenlafaxine (generic Pristiq), venlafaxine extended-release capsule (generic Effexor XR) Desvenlafaxine (fumarate) Brand desvenlafaxine (generic Pristiq), venlafaxine extended-release capsule (generic Effexor XR) Effexor XR Brand venlafaxine extended-release capsule (generic Effexor XR) fluoxetine 60 mg tablet Generic Only fluoxetine capsules (generic Prozac) bupropion (generic Wellbutrin), bupropion extended-release (Wellbutrin SR), bupropion extended- Forfivo XL Brand release (generic Wellbutrin XL) Geodon Brand ziprasidone (generic Geodon) Invega Brand paliperidone (generic Invega) Irenka Brand and Authorized Generic duloxetine (generic Cymbalta), venlafaxine extended-release (generic Effexor XR) Khedezla Brand desvenlafaxine (generic Pristiq), venlafaxine extended-release capsule (generic Effexor XR) Lexapro Brand escitalopram (generic Lexapro) Pexeva Brand paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR) Pristiq Brand desvenlafaxine extended-release tablet (generic Pristiq) Prozac Brand fluoxetine capsules (generic Prozac) Risperdal Brand risperidone (generic Risperdal) Sarafem tablets Brand & Generic fluoxetine capsules (generic Prozac)

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Mental Health (Continued) Seroquel Brand quetiapine (generic Seroquel) Seroquel XR Brand quetiapine extended-release (generic Seroquel XR) Venlafaxine ER tablet Brand & Generic venlafaxine extended-release capsule (generic Effexor XR) Versacloz Brand clozapine (generic Clozaril), clozapine orally disinegrating tablet (generic Fazaclo) Wellbutrin SR Brand bupropion extended-release (generic Wellbutrin SR) Wellbutrin XL Brand bupropion extended-release (generic Wellbutrin XL) Zoloft Brand sertraline (generic Zoloft) Zyprexa Brand olanzapine (generic Zyprexa) Zyprexa Zydis Brand olanzapine (generic Zyprexa), olanzapine orally disintegrating tablet (generic Zyprexa Zydis)

Migraines Ajovy Brand Aimovig, Emgality Cambia Brand diclofenac tablets (generic Cataflam, Voltaren) D.H.E. 45 Brand dihydroergotamine (generic D.H.E. 45) Imitrex injection & tablets Brand sumatriptan injection, tablets (generic Imitrex) Maxalt Brand rizatriptan (generic Maxalt), rizatriptan orally disintegrating tablet (generic Maxalt MLT) Maxalt-MLT Brand rizatriptan (generic Maxalt), rizatriptan orally disintegrating tablet (generic Maxalt MLT) dihydroergotamine nasal spray (generic Migranal), naratriptan (generic Amerge), rizatriptan (generic Maxalt/Maxalt MLT), sumatriptan (generic Imitrex), zolmitriptan (generic Zomig/Zomig- Migranal Brand ZMT), eletriptan (generic Relpax) Onzetra Xsail Brand sumatriptan nasal spray (generic Imitrex) Relpax Brand eletriptan (generic Relpax) Treximet Brand & Generic naproxen (generic Naprosyn) plus sumatriptan (generic Imitrex) Zembrace SymTouch Brand sumatriptan injection (generic Imitrex) Multiple Sclerosis Ampyra (Brand only) Brand dalfampridine (generic Ampyra) Copaxone Brand & Generic glatiramer acetate (generic Copaxone)

Extavia Brand glatiramer acetate (generic Copaxone), Aubagio, Avonex, Betaseron, Gilenya, Plegridy, Tecfidera Glatopa (generic Copaxone) Generic Only glatiramer acetate [(generic Copaxone) by Mylan] Muscle Relaxant Amrix Brand & Generic cyclobenzaprine (generic Flexeril) Lorzone Brand and Authorized Generic chlorzoxazone (generic Parafon Forte DSC) cyclobenzaprine (generic Flexeril), chlorzoxazone (generic Parafon Forte DSC), metaxalone Skelaxin Brand (generic Skelaxin), methocarbamol (generic Robaxin) Soma 250 Brand & Generic carisoprodol (generic Soma 350mg) Tizanidine Comfort Pac Brand tizanadine tablet (generic Zanaflex) Muscle Spasms Chlorzoxazone 250 mg tablet Brand chlorzoxazone 500 mg tablet (generic Parafon Forte DSC) Narcolepsy Nuvigil Brand Only armodafinil (generic Nuvigil) Provigil Brand modafinil (generic Provigil) Narcotic Overdose Evzio Brand naloxone (generic Narcan), Narcan Nasal Spray Nasal Polyps Xhance Brand fluticasone (generic Flonase) Nausea Sancuso Brand ondansetron (generic Zofran), granisetron (genric Kytril) Zuplenz Brand ondansetron (generic Zofran) Nausea and vomiting associated with pregnancy Bonjesta Brand OTC doxylamine (Unisom) + pyridoxine (Vitamin B6) Diclegis Brand & Generic OTC doxylamine (Unisom) + pyridoxine (Vitamin B6) Neuropathic Pain Gralise Brand gabapentin (generic Neurontin) Horizant Brand gabapentin (generic Neurontin) gabapentin (generic Neurontin), duloxetine (generic Cymbalta), amitriptyline (generic Elavil), Lyrica CR Brand Lyrica ZTLido Brand lidocaine patch (generic Lidoderm) Neutropenia Fulphila Brand Neulasta Granix Brand Zarxio Neupogen Brand Zarxio

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Neutropenia (Continued) Nivestym Brand Zarxio Udenyca Brand Neulasta Opioid Dependence Bunavail Brand buprenorphine/naloxone (generic Suboxone), Zubsolv Suboxone Film (Brand only) Brand buprenorphine/naloxone (generic Suboxone), Zubsolv Suboxone Tablets (Brand only) Brand buprenorphine/naloxone (generic Suboxone), Zubsolv Opioid Induced Constipation Movantik Brand Symproic Relistor tablet Brand Symproic Oral Steroid Decadron (Brand Only) Brand dexamethasone Decadron elixir (Brand only) Brand dexamethasone elixir (generic Decadron) Rayos Brand prednisone Osteoporosis Binosto Brand alendronate (generic Fosamax) Evista Brand raloxifene tablet (generic Evista)

Atelvia Brand & Generic alendronatey y (g (generic Fosamax), p ), ibandronate y y (generic Boniva), (g risedronate p (generic ), Actonel) , y Overactive Bladder Detrol Brand & Generic OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Detrol LA Brand & Generic OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Enablex Brand & Generic OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Gelnique Brand OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Myrbetriq Brand OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Oxytrol Brand OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Sanctura Brand & Generic OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Sanctura XR Brand & Generic OTC oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Toviaz, Oxytrol Vesicare Brand & Generic OTC Acetaminophen/Caffeine/Dihydrocodeine 325 Pain mg/30mg/16mg tablet (e.g. Dvorah, Panlor) Brand & Generic acetaminophen/codeine (Tylenol with codeine), Trezix Arymo ER Brand morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Butrans Brand tramadol extended-release (generic Ultram ER), Belbuca Celebrex Brand celecoxib (generic Celebrex) ConZip Brand and Authorized Generic tramadol immediate-release (generic Ultram), tramadol extended-release (generic Ultram ER) diclofenac 1% gel (generic Voltaren gel) Generic Only Voltaren gel Duexis Brand ibuprofen (generic Motrin) + OTC famotidine (generic Pepcid AC) Duragesic Brand fentanyl transdermal patch [12, 25, 50, 75, 100 mcg/hr only (generic Duragesic)] Embeda Brand morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Exalgo Brand morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER fentanyl transdermal patch 37.5, 62.5, 87.5 mcg/hr only (Select strengths only) Generic Only fentanyl transdermal patch [12, 25, 50, 75, 100 mcg/hr only (generic Duragesic)] butalbital/acetaminophen/caffeine/codeine phosphate 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine 50 mg/300 mg/40 mg/30 mg Brand & Generic Fioricet with Codeine) Hysingla ER Brand morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Kadian Brand & Generic morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Lidoderm Brand lidocaine transdermal patch (generic Lidoderm) Lodine (Brand only) Brand etodolac (generic Lodine) MorphaBond ER Brand morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Nalocet Brand oxycodone/acetaminophen (generic Percocet) Oxaydo Brand oxycodone immediate-release (generic Roxicodone) OxyContin Brand & Authorized Generic morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Percocet Brand acetaminophen/oxycodone (generic Percocet)

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Pain (Continued) Primlev Brand oxycodone/acetaminophen (generic Percocet) RoxyBond Brand oxycodone immediate-release (generic Roxicodone) Ryzolt [tramadol biphasic 24 hr extended-release tablet] Brand & Generic tramadol (generic Ultram), tramadol extended-release (generic Ultram XR) Tivorbex Brand indomethacin capsule (generic Indocin)

Vivlodex Brand meloxicam (generic Mobic) hydrocodone/acetaminophen 5/325 mg (generic Norco), hydrocodone/acetaminophen 7.5/325 mg Xodol/Vicodin/Vicodin ES/Vicodin HP Brand & Generic generic Norco), hydrocodone/acetaminophen 10/325 mg (generic Norco) diclofenac tablet (generic Cataflam, Voltaren), ibuprofen (generic Motrin), naproxen (generic Zorvolex Brand Anaprox, Anaprox DS, Naprosyn) Pain & Inflammation Fenortho Generic Only ibuprofen (generic Motrin), naproxen (generic Aleve, Naprosyn) Flector Brand and Authorized Generic Voltaren gel Nalfon Brand & Generic ibuprofen (generic Motrin), naproxen (generic Aleve, Naprosyn) Naprelan Brand & Generic naproxen (generic Naprosyn) Pennsaid 1.5% solution Brand & Generic Voltaren gel Pennsaid 2% solution Brand Voltaren Gel

naproxen (generic Naprosyn) plus omeprazole (generic Prilosec), pantoprazole (generic Vimovo Brand Protonix), rabeprazole (generic Aciphex), Dexilant, OTC - Nexium, Prevacid 24, Prilosec, Zegerid Zipsor Brand diclofenac tablets (generic Cataflam, Voltaren) Parkinson's Disease Azilect Brand rasagiline (generic Azilect)

Gocovri Brand amantadine immediate-release (generic Symmetrel) Lodosyn Brand carbidopa (generic Lodosyn) Mirapex ER Brand & Generic pramipexole immediate-release (generic Mirapex) Osmolex ER Brand amantadine immediate-release Parlodel Brand bromocriptine (generic Parlodel) Requip XL Brand & Generic ropinirole immediate-release (generic Requip) carbidopa/levodopa extended-release tablet (generic Sinemet CR), carbidopa/levodopa (generic Rytary Brand Sinemet) Tasmar Brand tolcapone (generic Tasmar)

Xadago Brand selegiline (generic Eldepryl), rasagiline (generic Azilect) betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Psoriasis Clobex Shampoo Brand & Generic Temovate) Pulmonary Arterial Hypertension Revatio Brand sildenafil (generic Revatio) Pulmonary Hypertension Adcirca (Brand only) Brand tadalafil (generic Adcirca) Letairis (Brand Only) Brand ambrisentan (generic Letairis) Reflux Metozolv ODT Brand & Generic metoclopramide (generic Reglan) Rheumatoid Arthritis Otrexup Brand methotrexate tablets, Rasuvo doxycycline delayed-release capsule (Oracea authorized minocycline immediate-release capsules (generic Minocin), doxycycline hyclate (generic Rosacea generic) Authorized Generic Vibramycin), doxycycline monohydrate 50 mg and 100 mg (generic Monodox) Metrogel 1% Brand & Generic metronidazole 0.75% gel (generic Metrogel) Noritate Brand metronidazole 0.75% cream (generic Metrocream) doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50 mg and 100 mg Oracea Brand (generic Monodox) Rosadan Kit - cream Brand metronidazole 0.75% cream (generic Metrocream) Rosadan Kit - gel Brand metronidazole 0.75% gel (generic Metrogel) Scalp Psoriasis Keralyt Scalp Kit Brand salicylic acid shampoo (generic Salex) Seizures Klonopin (Brand Only) Brand clonazepam (generic Klonopin) Oxtellar XR Brand oxcarbazepine (generic Trileptal) topiramate immediate-release (generic Topamax) Qudexy XR Brand and Authorized Generic

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Seizures (Continued) Sabril powder pack Brand vigabatrin powder pack (generic Sabril) Spritam Brand levetiracetam tablets, oral solution (generic Keppra) clobazam (generic Onfi), clonazepam (generic Klonopin), lamotrigine (generic Lamictal), Sympazan Brand topiramate (generic Topamax) Trokendi XR Brand topiramate immediate-release (generic Topamax) Sickle Cell Disease Siklos Brand hydroxyurea (generic Hydrea), Droxia Skin Conditions Bryhali Brand fluocinonide 0.05% gel/solutiongg(gp) (generic Lidex), desoximetasone 0.05% gel (generic Topicort) Clobex Lotion Brand & Generic clobetasol propionate 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Clodan Kit Brand Temovate)

Cloderm cream Brand clocortolone 0.1% cream (generic Cloderm), mometasone furoate cream 0.1% (generic Elocon) hydrocortisone valerate 0.2% cream (generic Westcort cream), prednicarbate 0.1% cream Cordran 0.025% cream Brand (generic Dermatop cream), fluticasone propionate cream 0.05% (generic Cutivate cream) flurandrenolide 0.05% cream (generic Cordran cream), hydrocortisone valerate 0.2% cream Cordran 0.05% cream Brand (generic Westcort cream), prednicarbate 0.1% cream (generic Dermatop cream) flurandrenolide 0.05% lotion (generic Cordran), triamcinolone acetonide 0.1% lotion (generic Cordran 0.05% lotion Brand Kenalog lotion) Dermasorb AF Brand triamcinolone cream/ointment (generic Aristocort) Dermasorb XM 39% Kit Brand urea 40%

diflorasone 0.05% ointment (generic Psorcon) Generic Only clobetasol 0.05% ointment (generic Temovate), halobetasol 0.05% ointment (generic Ultravate) betamethasone dipropionate augmented 0.05% cream (generic Diprolene AF) and fluocinonide Impoyz Brand 0.05% cream (generic Lidex cream) Kenalog Spray Brand triamcinolone spray (generic Kenalog) Keralac Brand urea 40% cream betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% Lexette Brand & Generic gel/solution (generic Temovate) Locoid Lipocream Brand & Generic hydrocortisone butyrate (generic Locoid) hydrocortisone butyrate (generic Locoid), triamcinolone acetonide 0.1% lotion (generic Kenalog Locoid Lotion Brand & Generic lotion) Loprox Shampoo Brand ciclopirox shampoo (generic Loprox Shampoo) Luxiq Brand & Generic betamethasone lotion (generic Valisone) Micort-HC 2.5% cream Brand hydrocortisone 2.5% cream Neo-Synalar cream Brand OTC Triple Antibiotic Ointment plus fluocinolone 0.025% cream (generic Synalar) Neo-Synalar Kit Brand fluocinolone cream (generic Lidex) plus OTC Neosporin betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Olux Brand & Generic Temovate) betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Olux-E Brand & Generic Temovate) Ovace Plus Brand sulfacetamide sodium/sulfur 10-5% Penlac Nail Lacquer Brand ciclopirox 8% solution (generic Penlac Nail Lacquer) Pramosone E Brand hydrocortisone/pramoxine (generic Analpram E) Prescription Emollients Brand & Generic OTC Aquaphor, OTC Eucerin, OTC Lubriderm, OTC White Petroleum ProCort Brand hydrocortisone/pramoxine (generic Analpram E) hydrocortisone 1% cream (generic Proctocort), hydrocortisone 30 mg suppository (generic Proctocort Brand Proctocort) Promiseb Complete Kit Brand Promiseb Protopic Brand tacrolimus ointment (generic Protopic) SelRx Brand selenium sulfide shampoo Sernivo Brand betamethasone lotion (generic Diprosone) Sorilux Brand calcipotriene solution (generic Dovonex)

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 fluocinolone 0.01% solution (generic Synalar solution), fluocinolone 0.025% cream, ointment Skin Conditions (Continued) Synalar cream, ointment, solution Brand (generic Synalar cream, ointment) Synalar Kit Brand fluocinolone 0.025% cream, ointment (generic Synalar cream, ointment) Synalar TS Brand fluocinolone 0.01% solution (generic Synalar solution) Taclonex Ointment Brand betamethasone/calcipotriene ointment (generic Taclonex) Tolak Brand fluorouracil 5% cream (generic Efudex) Topicort spray Brand & Generic desoximetasone 0.05% gel (generic Topicort), fluocinonide 0.05% solution (generic Lidex) Trianex Brand triamcinolone ointment (generic Aristocort) betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% Ultravate 0.05% lotion Brand gel/solution (generic Temovate) Ultravate X Combination Package Brand halobetasol cream (generic Ultravate) Umecta Brand & Generic urea 40% Utopic Brand urea 40% Vanos Brand & Generic fluocinonide 0.05% (generic Lidex) Verdeso Brand desonide lotion (generic Desowen) Zyclara Brand and Authorized Generic imiquimod (generic Aldara) Sleep Ambien Brand zolpidem (generic Ambien) Ambien CR Brand & Generic zolpidem (generic Ambien) Edluar Brand zolpidem (generic Ambien) Intermezzo Brand & Generic zolpidem (generic Ambien) Lunesta Brand eszopiclone (generic Lunesta) Silenor Brand doxepin (generic Sinequan) Stroke & Heart Attack Prevention Durlaza Brand OTC aspirin Plavix Brand clopidogrel (generic Plavix) Yosprala Brand OTC aspirin plus omeprazole (Prilosec), pantoprazole (Protonix) Supportive Care for Cystic Fibrosis Kitabis Pak Brand Bethkis Tobi nebulized solution Brand & Generic Bethkis, Tobi(g Podhaler ) p (g ) p (g Symptoms associated with menopause Brisdelle Brand & Generic CR) Testosterone Replacement Androgel Brand & Generic Androderm, Testim Fortesta Brand & Generic Androderm, Testim Natesto Brand Androderm, Testim Vogelxo (Testosterone topical gel - Upsher Smith) Brand & Generic Androderm, Testim Xyosted Brand testosterone injection, Testim Thyroid Hormone Replacement Tirosint Brand levothyroxine, Synthroid Cytomel (Brand Only) Brand liothyronine (generic Cytomel) Transplant Astagraf XL Brand tacrolimus (generic Prograf) Cellcept Brand mycophenolate (generic Cellcept) Envarsus XR Brand tacrolimus (generic Prograf) Imuran Brand azathioprine (generic Imuran) Myfortic Brand mycophenolate delayed-release (generic Myfortic) Neoral Brand cyclosporine modified (generic Neoral) Prograf Brand tacrolimus (generic Prograf) Rapamune Brand sirolimus (generic Rapamune) Sandimmune Brand cyclosporine (generic Sandimmune) Ulcers due to H. pylori Prevpac Brand & Generic Omeclamox-Pak, Pylera Ulcers, Heartburn & Reflux Aciphex Brand rabeprazole (generic Aciphex) omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Aciphex Sprinkle Brand Dexilant, Nexium Suspension, Prevacid Solu-tab, OTC - Nexium, Prevacid, Prilosec, Zegerid Axid Capsules Brand & Generic OTC Axid AR omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Esomeprazole strontium Brand Dexilant, OTC - Nexium, Prevacid 24, Prilosec, Zegerid

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Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Ulcers, Heartburn & Reflux (Continued) Nexium Capsules Brand & Generic Dexilant, OTC - Nexium, Prevacid, Prilosec, Zegerid omeprazole sodium bicarbonate capsules (generic omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Zegerid capsules) Generic Only Dexilant, OTC - Nexium, Prevacid, Prilosec, Zegerid Pepcid Tablets Brand & Generic OTC Pepcid AC omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Prevacid Capsules Brand & Generic Dexilant, OTC - Nexium, Prevacid, Prilosec, Zegerid omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Prilosec Capsules Brand Dexilant, OTC - Nexium, Prevacid, Prilosec, Zegerid

omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Prilosec Suspension Brand Dexilant, Nexium Suspension, Prevacid Solu-tab, OTC - Nexium, Prevacid, Prilosec, Zegerid Protonix Brand pantoprazolep (g (generic Protonix) ) p p (g ) p (g p ) Protonix Granules for Suspension Brand & Generic Dexilant, Nexium Suspension, Prevacid Solu-tab, OTC - Nexium, Prevacid, Prilosec, Zegerid Zantac Capsules/Tablets Brand & Generic OTC Zantac omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Zegerid capsule Brand Dexilant, OTC - Nexium, Prevacid, Prilosec, Zegerid

omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Zegerid packet Brand Dexilant, Nexium Suspension, Prevacid Solu-tab, OTC - Nexium, Prevacid, Prilosec, Zegerid Vertigo Meclizine Brand & Generic OTC Meclizine acyclovir capsule/tablet (generic Zovirax) famciclovir tablet (generic Famvir), valacyclovir tablet Viral Infections Denavir Brand (generic Valtrex), OTC - Abreva acyclovir capsule/tablet (generic Zovirax) famciclovir tablet (generic Famvir), valacyclovir tablet Sitavig Brand (generic Valtrex), OTC - Abreva Valtrex Brand valacyclovir (generic Valtrex) acyclovir capsule/tablet (generic Zovirax) famciclovir tablet (generic Famvir), valacyclovir tablet (generic Valtrex), OTC Abreva Xerese Brand acyclovir capsule/tablet (generic Zovirax) famciclovir tablet (generic Famvir), valacyclovir tablet Zovirax cream Brand (generic Valtrex), OTC - Abreva acyclovir ointment (generic Zovirax), acyclovir capsule/tablet (generic Zovirax) famciclovir tablet Zovirax Ointment Brand (generic Famvir), valacyclovir tablet (generic Valtrex) Wart Removal UltraSal-ER Brand OTC salicylic acid Virasal Brand & Generic salicylic acid OTC Wilson's Disease Cuprimine Brand & Generic Depen

Page 14 Summary of Excluded Medications Column1 CColumn3 CColumn5 A Colcryst Humatrope Norvir tablets Abilify MyCite ConZip Hydrocodone/Guaifenesin 2.5 mg/200 Novolin 70/30 (includes Relion) Abilify tablets Copaxone Hysingla ER Novolin N (includes Relion) Absorica Cordran 0.025% cream Novolin R (includes Relion) Abstral Cordran 0.05% cream I Novolog Acanya Cordran 0.05% lotion Ilevro Novolog 70/30 Acetaminophen/Caffeine/Dihydrocodeine Coreg CR Ilumya4 Nuvessa Aciphex Cosopt PF Imitrex injection & tablets Nuvigil Aciphex Sprinkle Cotempla XR-ODT Imodium nystatin/triamcinolone (generic Acticlate Crestor Impoyz Mycolog II) cream, ointment Actiq Cuprimine Imuran Actos Cymbalta Inderal LA O Acuvail Cytomel (Brand Only) Intermezzo Olux Adcirca (Brand only) Intuniv Olux-E Adderall D Invega omeprazole sodium bicarbonate Admelog D.H.E. 45 Irenka capsules (generic Zegerid capsules) Adynovate Daytrana Ixinity Omnaris Adzenys Decadron (Brand Only) Omnitrope Afrezza Decadron elixir (Brand only) J Onexton AirDuo Respiclick Delzicol Jalyn Onzetra Xsail Ajovy Denavir Optivar Aktipak Dermasorb AF K Oracea Albuterol HFA [Ventolin HFA authorized Dermasorb XM 39% Kit Kadian Orfadin Allegra Desquam Kapvay Ortho Tri-Cyclen Lo Allzital Desvenlafaxine Karbinal ER Osmolex ER Alogliptin (Nesina authorized generic) Desvenlafaxine (fumarate) Kenalog Spray Otovel Alogliptin/metformin (Kazano authorized Detrol Keralac Otrexup Alogliptin/pioglitazone (Oseni authorized Detrol LA Keralyt Scalp Kit Ovace Plus Altoprev Dexedrine (Brand Only) Khedezla Oxaydo Altreno Dibenzyline Kitabis Pak Oxistat Lotion Ambien Diclegis Klonopin (Brand Only) Oxtellar XR Ambien CR diclofenac 1% gel (generic Voltaren gel) OxyContin amphetamine/dextroamphetamine extended-rDifferin 0.1% cream, gel, lotion L Oxytrol Ampyra (Brand only) Differin 0.3% gel Lac-Hydrin 12% Amrix diflorasone 0.05% ointment (generic Psorcon) Lantus, Lantus SoloStar P Anafranil Diovan Lescol XL Panoxyl Androgel Diovan HCT Letairis (Brand Only) Parlodel Antara 30 mg, 90 mg Doryx Levemir4 Pataday Antara 43 mg, 130 mg doxycycline 75 mg capsule (generic Monodox) Levitra (Brand only) Patanol Anusol HC Supp doxycycline delayed-release capsule (Oracea Lexapro Pazeo Apidra Duac Lexette PCP 100 Kit Aplenzin Duexis Librax Pedia-Profen Aptensio XR Dulera Lidoderm Penlac Nail Lacquer Aricept 23mg Duragesic Lipitor Pennsaid 1.5% solution Arimidex Durlaza Lipofen Pennsaid 2% solution Arymo ER Dutoprol Livalo Pentasa Asacol HD Tablet Dyanavel XR Locoid Lipocream Pepcid Tablets Astagraf XL Dymista Locoid Lotion Percocet Astepro Lodine (Brand only) Pexeva Atelvia E Lodosyn Plaquenil (Brand Only) Ativan E.E.S. 400 Lofibra capsules Plavix Atripla Ecoza Lonhala Magnair Plexion Augmentin Edluar Loprox 0.77% Pramosone E Augmentin ES-600 Effexor XR Loprox Shampoo Prescription Emollients Augmentin XR Effient Lorzone Prestalia Auvi-Q Elestat Lotemax gel Prevacid Capsules Avar Emadine Lotrimin 1% Prevpac Avar LS Embeda Lotronex Prilosec Capsules Avelox tablet Emflaza Lovaza Prilosec Suspension Avita 0.025% Enablex Lovenox (Brand Only) Primlev Avodart Entocort EC Lunesta Pristiq Axid Capsules Envarsus XR Luxiq ProCort Azilect Epiduo Luzu Procrit Azor Epiduo Forte Lyrica CR Proctocort EpiPen/Epipen Jr Prograf B Epogen M Prolensa Balcoltra Epzicom Maxalt Prometrium (Brand Only) Baraclude tablets Ertaczo Maxalt-MLT Promiseb Complete Kit Beconase AQ Esomeprazole strontium Meclizine Protonix Benadryl estradiol transdermal patches (generic for Vivelle- Mepron suspension Protonix Granules for Suspension Benicar Evekeo methylphenidate extended-release tablet Protopic Benicar HCT Evista metoprolol tartrate 37.5, 75 mg Provigil Benzac Evzio Metozolv ODT Prozac Benzaclin jar Exalgo Metrogel 1% Pulmicort inhalation suspension (Brand Benzaclin pump Exelon Patch Micardis Only) Bepreve Exforge Micardis HCT Betapace Exforge HCT4 Micort-HC 2.5% cream Q bexarotene caps (generic for Targretin) Exjade (Brand Only) Migranal Qnasl Beyaz Extavia Minastrin 24 FE Qtern bimatoprost 0.03% (generic Lumigan) Fabior Minivelle (Brand Only) Quartette Binosto Farxiga Minocin Qudexy XR Bonjesta Femara minocycline tablet (generic Dynacin) Quillichew ER Brevoxyl Fenoglide Minolira Quillivant XR Brisdelle Fenortho Mirapex ER BromSite fentanyl transdermal patch 37.5, 62.5, 87.5 mcg/hr Moderiba Tablet, Pak R Bryhali Fentora Morgidox Kit Ranexa (Brand Only) Bunavail Fiasp4 MorphaBond ER Rapamune Butalbital/Acetaminophen 50/300 mg Fibricor Motofen Rayaldee Butrans Fioricet with Codeine 50 mg/300 mg/40 mg/30 mg Motrin Suspension Rayos Flector Movantik Rebinyn C Flomax Mydayis Relistor tablet Caduet Floxin Otic Myfortic Relpax Cambia fluoxetine 60 mg tablet Myrbetriq Renvela tablets Canasa (Brand only) Focalin XR Requip XL capecitabine (generic Xeloda) Forfivo XL N Restasis MultiDose Cardizem Fortamet Naftin 1% and 2% gel Retin-A cream Cardizem CD Fortesta Naftin 1% and 2% cream Retin-A gel Cardizem LA Fosrenol Nalfon Retin-A Micro Celebrex Fulphila Nalocet Revatio Celexa Namenda XR Reyataz capsules Cellcept G Namzaric Rhinocort Aqua Centany AT Gelnique Naprelan Rhopressa Chlorzoxazone 250 mg tablet Generess FE Nasacort AQ Ribasphere Ribapak Cialis (Brand only) Genotropin Nasonex Risperdal Ciclodan Kit Geodon Natesto Ritalin LA Ciclodan/Loprox Cream Kit Glatopa (generic Copaxone) Natroba Rosadan Kit - cream Cinryze Gleevec Neoral Rosadan Kit - gel Clarinex Glumetza Neo-Synalar cream RoxyBond Clarinex-D Glycate Neo-Synalar Kit Ryclora Climara Gocovri Neuac 1.2%-5% Kit Rytary Clindacin Kit/Pac GoNitro Neupogen RyVent Clindagel Gralise Nexium Capsules Ryzolt [tramadol biphasic 24 hr ER tablet] Clobex Lotion Granix Nitrolingual PumpSpray Clobex Shampoo Nivestym S Clodan Kit H Noctiva Sabril powder pack Cloderm cream Hemangeol Norditropin Safyral Colazal Histex Noritate Saizen colchicine capsule (Mitigare generic) Horizant Norvasc (Brand Only) Sanctura Column1 CColumn3 CColumn5

Summary of Excluded Medications (Continued) Column1 CColumn3 CColumn5 S (Continued) V Sanctura XR Vagifem Sancuso Valcyte Sandimmune Valium Sandostatin Valtrex Sarafem tablets Vanos Segluromet Vaseretic Select Diabetic Meters4 Vasotec Select Diabetic Test Strips4 Veltin SelRx Venlafaxine ER tablet Sernivo Verdeso Seroquel Versacloz Seroquel XR Vesicare Seysara Viagra Siklos Vigamox Silenor Vimovo Siliq4 Viramune Simbrinza Viramune XR Singulair Chewable Tablet Virasal Singulair Tablet Viread tablets Sitavig Vivlodex Skelaxin Vogelxo (Testosterone topical gel - Upsher Smith) Solodyn4 Vusion Soltamox Vytorin Soma 250 Vyzulta Sorilux Spritam W Staxyn Wellbutrin SR Steglatro Wellbutrin XL Steglujan Stiolto Respimat X Strattera Xadago Suboxone Film (Brand only) Xalatan (Brand Only) Suboxone Tablets (Brand only) Xanax Subsys Xanax XR Sumadan Xenazine Sumadan Kit Xerese Sumadan XLT Kit Xhance Sumaxin CP Xigduo XR Sumaxin TS Ximino Sympazan Xodol/Vicodin/Vicodin ES/Vicodin HP Symtuza Xopenex Nebs Synalar cream, ointment, solution Xultophy Synalar Kit Xyosted Synalar TS Y T Yonsa Taclonex Ointment Yosprala Taltz4 Tamiflu Z Targadox Zantac Capsules/Tablets Tasmar Zavesca Taytulla Zegerid capsule tazarotene 0.1% cream (generic Tazorac) Zegerid packet Tenoretic Zembrace SymTouch Tenormin Zenzedi Tirosint Zestoretic Tivorbex Zestril Tizanidine Comfort Pac Zetia Tobi nebulized solution Ziana Tobradex ST Zipsor Tolak Zoloft Tolsura Zomacton Topicort spray Zorvolex Toujeo Solostar Zovirax cream Treximet Zovirax Ointment Trianex ZTLido Tribenzor Zuplenz Tricor 48 mg and 145 mg Zyclara trientine (generic Syprine) Zypitamag Triglide (Brand only) Zyprexa Trilipix Zyprexa Zydis Trokendi XR Zyrtec oral solution Tudorza Pressair Zyrtec Tablet Tuzistra XR Zyvox Twynsta

U Udenyca UltraSal-ER Ultravate 0.05% lotion Ultravate X Combination Package Umecta Utibron Neohaler Utopic