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Generic Premium

With Generic Premium, you have coverage for low-cost generic drugs, plus some of the most common brand drugs. That means you can get the medicine you need, while saving money. Member education

What is Generic Premium? How does Generic Premium work? Generic Premium can help you lower your prescription costs Talk to your doctor before you switch or stop taking any by covering most generic drugs. Some brand drugs are drugs. If you and your doctor agree that a covered drug is a covered by Generic Premium too. They include drugs that good option, you’ll need a new prescription. You can choose treat common conditions like high blood pressure, diabetes, to fi ll the prescription through home delivery or at a local high cholesterol, ulcers and more. So you can choose from a pharmacy. wide range of quality drugs. * Required by the U.S. Food and Drug Administration (FDA). Generics can help you save Generic Premium encourages you to use generic drugs. Why? Generics and their brand versions have the same active ingredient, strength and dose. Generics must meet the same high standards for purity, quality, safety and strength.* Plus, generics normally cost 30 to 60% less than the brand versions. With generics, you get the same quality for less money.

Drug coverage at a glance The Generic Premium drug list includes products used for the health needs and conditions below, plus many more. See the next pages for a list of covered drugs.

• Attention defi cit hyperactivity • High cholesterol disorder (ADHD) • Infections • Arthritis • Osteoporosis • Asthma • Overactive bladder • Birth control • Pain • Depression • Prenatal vitamins • Diabetes drugs and supplies • Seizures • Enlarged prostate • Sleep aids • • Ulcers • High blood pressure

2 | Generic Premium Generic drugs are listed in all ST = Step therapy is needed. lowercase letters. You may need to try another drug before we’ll provide coverage for Brand drugs are listed with a first the medicine. capital letter. DO = Dose optimization is needed. TIER 1 amlodipine besylate (Norvasc)* Tier 1 drugs have the lowest This usually means that you take DO QL copay. Many Tier 1 drugs are the drug once a day instead of contraceptives – all prescription generics. amlodipine besylate/atorvastatin twice a day. strength, self administered generic (Caduet)* contraceptives Tier 2 drugs have a medium copay * Generic versions of these drugs amlodipine besylate/benazepril cough and cold preparations – and offer a good value. are covered. The brand name in (Lotrel)* all prescription strength, self parenthesis is only for reference. administered, generic cough and (Asendin)* Tier 3 drugs have the highest cold preparations amoxicillin trihydrate (Amoxil, copay. Many of these drugs treat ^ These drugs often require your pancreatic enzymes – all prescription Trimox, various)* complex, ongoing conditions and doctor to carefully monitor your may require special handling. strength, self administered, generic amoxicillin trihydrate/potassium dose to make sure the drug pancreatic enzymes clavulanate, ER (Augmentin, XR)* works best for you. In general, PA = Prior authorization is needed. PKU – all prescription strength, self you shouldn’t switch between amphetamine salt combo In this case, you must receive administered, generic PKU formulas (Adderall)* the brand and generic versions approval before the drug vitamins – all prescription strength, of these drugs. Your plan covers ampicillin trihydrate (Principen)* is covered. self administered, generic vitamins both the brand and generic anagrelide hcl (Agrylin)* versions. QL = Quantity limits are needed. antipyrine/benzocaine/glycerin Some drugs have limits on the (Auralgan)* † Once a generic is available, amount you receive for each acarbose (Precose)* aspirin/codeine phosphate the brand version will not prescription or each month. be covered. acebutolol hcl (Sectral)* atovaquone/proguanil acetaminophen/caffeine/butalbital (Malarone)* Key (Fioricet)* QL atenolol (Tenormin)* acetaminophen/codeine (Tylenol w/ atenolol/chlorthalidone Codeine)* QL (Tenoretic)* bromfenac (Xibrom)* carvedilol (Coreg)* acetaminophen/ atorvastatin (Lipitor)* DO, QL EC (Entocort EC)* cefaclor (Ceclor, Ceclor CD)* (Dologesic, various)* sulfate (Isopto Atropine)* bromocriptine mesylate (Parlodel)* cefadroxil hydrate (Duricef)* acetazolamide (Diamox)* azathioprine (Imuran)* bumetanide (Bumex)* cefdinir (Omnicef)* acetic acid (VoSol)* azelastine (Optivar)* QL buprenorphine (Subutex)* QL cefpodoxime proxetil (Vantin)* acetic acid/aluminum azelastine (Astelin Nasal)* QL (Domeboro)* bupropion hcll (Wellbutrin, cefprozil (Cefzil)* azithromycin (Zithromax)* QL acetic acid/ Wellbutrin SR)* cefuroxime axetil (Ceftin)* bacitracin/polymyxin b sulfate (VoSol HC)* bupropion HCl (Wellbutrin XL)* DO, QL cephalexin monohydrate (Keflex)* (Polysporin Ointment)* (XL only) acetylcysteine (Mucomyst)* chloral hydrate (Somnote)* baclofen (Lioresal)* buspirone HCl (Buspar)* acyclovir (Zovirax)* chlordiazepoxide hcl (Librium)* balsalazide disodium butalbital/acetaminophen/caffeine adapalene (Differin)* chlorhexidine gluconate (Peridex)* belladonna alkaloids/phenobarbital (Esgic-Plus)* chloroquine phosphate (Aralen)* albuterol sulfate (Proventil)* (Donnatal)* butalbital/aspirin/caffeine (Fiorinal)* chlorothiazide (Diuril)* albuterol/ipratropium nebulizer soln benazepril hcl (Lotensin)* butorphanol (Stadol)* (Duoneb)* hcl (Thorazine)* benazepril/hydrochlorothiazide cabergoline (Dostinex)* dipropionate (Lotensin HCT)* chlorpropamide (Diabinese)* (Aclovate)* calcipotriene (Dovonex Oint.)* benzonatate (Tessalon Perles)* chlorthalidone (Hygroton)* alendronate (Fosamax)* QL captopril (Capoten)* benzoyl peroxide (Benzagel, chlorzoxazone (Parafon Forte DSC)* alfuzosin (Uroxatral)* captopril/hydrochlorothiazide Benzac AC, various)* (Capozide)* cholestyramine/aspartame allopurinol (Zyloprim)* benztropine mesylate (Cogentin)* carbamazepine (Carbatrol, Tegretol, (Questran Light)* alprazolam, ER (Xanax, Xanax XR)* dipropionate Epitol)^ cholestyramine/sucrose (Questran)* amantadine hcl (Symmetrel)* (Diprosone, Diprolene, Diprosone)* carbamazepine, ER (Tegretol XR)* salicylate/magnesium (Cyclocort)* betamethasone valerate (Betatrex)* carteolol (Ocupress)* salicylate (Tricosal)* amiloride (Midamor)* betametheasone dipropionate/ carbidopa/levodopa (Sinemet, ciclopirox (Loprox Shampoo)* propylene glycol (Diprolene AF)* amiloride/hydrrocholorthiazide Sinemet CR)* ciclopirox (Penlac)* (Moduretic)* betaxolol hcl (Betoptic)* carbidopa/levodopa/entacapone cilostazol (Pletal)* aminophylline chloride (Urecholine)* (Stalevo)* cimetidine – prescription only amiodarone hcl (Cordarone, bisoprol/hydrochlorothiazide (Ziac)* carisoprodol (Soma)* (Tagamet)* Pacerone)^ bisoprolol fumarate (Zebeta)* carisoprodol/aspirin (Soma ciprofloxacin hcl (Cipro)* QL hcl (Elavil)* brimonidine tartrate (Alphagan)* Compound)* ciprofloxacin hcl drops (Ciloxan)*

Generic Premium | 3 citalopram hydrobromide (Topicort)* erythromycin base (Ilotycin)* fluoxetine hcl 10, 20, 40mg only (Celexa)* DO, QL (Decadron)* erythromycin base/benzoyl peroxide (Prozac)* DO, QL citric acid/potassium citrate dexamethasone sodium phosphate (Benzamycin)* fluphenazine hcl (Prolixin)* (Polycitra - K)* (Decadron)* erythromycin base/ (A/T/S)* flurazepam hcl (Dalmane)* citric acid/sodium citrate (Bicitra)* dextroamphetamine sulfate, ER erythromycin base/ethanol (Erycette)* flurbiprofen (Ansaid)* clarithromycin, ER (Biaxin, Biaxin XL)* (Dexedrine, Dextrostat)* erythromycin ethylsuccinate (E.E.S.)* flurbiprofen sodium (Ocufen)* clidinium/chlordiazepoxide (Librax)* diazepam (Valium)* erythromycin fluticasone nasal spray (Flonase)* QL clindamycin hcl (Cleocin HCl)* diazepam rectal (Diastat)^ ethylsuccinate/sulfisoxazole fluticasone propionate (Cutivate)* clindamycin phosphate (Cleocin T)* diclofenac potassium (Cataflam)* (Pediazole)* fluvastatin (lescol)* DO clindamycin/benzoyl peroxide diclofenac sodium (Voltaren, Voltaren escitalopram (Lexapro)* DO, QL fluvoxamine maleate (Luvox)* DO (Benzaclin)* Ophth.)* estazolam (ProSom)* folic acid (Folvite)* propionate (Clobex Lotion, dicloxacillin sodium (Dynapen)* estradiol (Estrace)* Shampoo)* fosinopril sodium (Monopril)* dicyclomine hcl (Bentyl)* estradiol (Climara)* (Cormax)* fosinopril/hydrochlorothiazide diflorasone diacetate (Psorcon)* estradiol/norethindrone (Activella)* (Monopril HCT)* clobetasol propionate (Temovate)* diflunisal (Dolobid)* estrogen, esterified/ furosemide (Lasix)* clobetasol propionate/emollient digoxin (Lanoxin)* methyltestosterone (Syntest D.S.)* (Temovate-E)* gabapentin (Neurontin)* dihydroergotamine mesylate estrogen, esterified/ galantamine (Razadyne, ER)* hcl (Anafranil)* (D.H.E.45, Migranal)* methyltestosterone (Syntest H.S.)* gemfibrozil (Lopid)* clonazepam (Klonopin)* diltiazem hcl (Cardizem, estropipate (Ogen)* gentamicin sulfate (Garamycin)* clonidine hcl (Catapres)* Cardizem LA, Tiazac, Cardizem SR, ethambutol hcl (Myambutol)* gianvi (Yaz)* clonidine patch (Catapres-TTS)* Cardizem CD)* DO ethosuximide (Zarontin)^ glimepiride (Amaryl)* clopidogrel (Plavix)* QL – prescription etidronate (Didronel)* strength (Benadryl)* glipizide, ER (Glucotrol, Glucotrol XL)* clorazepate dipotassium etodolac (Lodine)* (Tranxene T-Tab)* diphenoxylate hcl/atropine sulfate glipizide/metformin hcl (Metaglip)* famciclovir (Famvir)* clotrimazole (Mycelex)* (Lomotil)* glyburide (DiaBeta, Micronase)* felbamate (Felbatol)^ clotrimazole/betamethasone dipyridamole (Persantine)* glyburide, micronized/metformin hcl (Lotrisone)* disopyramide phosphate (Norpace, felodipine (Plendil)* DO, QL (Glucovance)* (Clozaril)^ Norpace CR)* fenofibrate, micronized (Lofibra)* glycopyrrolate codeine phosphate/carisoprodol/ disulfiram (Antabuse)* fenoprofen (Nalfon)* griseofulvin, microsize (Griseofulvin)* asprin (Carisoprodol Compound- divalproex sodium (Depakote)^ fentanyl (Duragesic)* QL guaifenesin/codeine phosphate Codeine)* donepizil 5, 10mg only (Aricept)* fentanyl citrate (Actiq)* PA, QL (Robitussin AC)* codeine sulfate dorzolamide (Trusopt)* ferrous fumarate/folic acid guaifenesin/ hcl codeine/butalbital/aspirin/caffeine dorzolamide/timolol (Cosopt)* (Nephro-Fer RX)* (Entex LA)* (Fiorinal w/Codeine)* doxazosin mesylate (Cardura)* ferrous fumerate/docusate sodium/ guanfacine hcl (Tenex)* colestipol hcl (Colestid)* folic acid hcl (Sinequan)* halobetasol propionate (Ultravate)* cetate fexofenadine hcl (Allegra)* QL doxycycline hyclate (Doryx, haloperidol (Haldol)* cromolyn sodium (Intal)* finasteride (Proscar)* Vibramycin, Vibra-Tabs)* hbr (Isopto cromolyn sodium (Opticrom)* QL doxycycline monohydrate flavoxate hcl (Urispas)* Homatropine)* cyanocobalamin/folic acid/pyridoxine (Adoxa, Monodox)* flecainide acetate (Tambocor)* hyaluronate sodium , ER (Amrix ER, dronabinol (Marinol)* fluconazole (Diflucan)* hydralazine hcl (Apresoline)* Fexmid, Flexeril)* drospirenone/ethinyl estradiol flucytosine (Ancobon)* hydrochlorothiazide (HydroDIURIL)* HCl (Cyclogyl 1%, 2%)* (Yasmin)* fludrocortisone acetate (Florinef)* hydrocodone/acetaminophen econazole nitrate (Spectazole)* flunisolide (Nasalide)* (Vicodin, Lortab, Vicodin ES, various)* dantrolene sodium (Dantrium)* enalapril maleate (Vasotec)* fluocinolone acetonide (Derma- QL demeclocycline hcl (Declomycin)* enalapril/hydrochlorothiazide Smoothe-FS, Dermotic Oil, Synalar)* hydrocodone/chlorpheniramine hcl (Norpramin)* (Vaseretic)* fluocinonide (Lidex)* (Tussionex)* desmopressin acetate (DDAVP)* epinastine (Elestat)* fluocinonide/emollient (Lidex-E)* hydrocodone/homatropine (Hycodan)* /ethinyl estradiol eprosartan mesylate (Teveten)* fluorometholone (FML, Flarex)* ergotamine/caffeine (Cafergot)* hydrocodone/ibuprofen (DesOwen)* fluorouracil (Efudex)* (Vicoprofen)* QL

4 | Generic Premium hydrocortisone (Hytone, Locoid)* lancets methocarbamol (Robaxin)* neomycin sulfate/polymyxin b/ dexamethasone (Maxitrol)* hydrocortisone acetate (Anucort-HC, lansoprazole (Prevacid)* QL methscopolamine bromide (Pamine)* Anusol-HC, various)* latanoprost (Xalatan)* methylergonovine (Methergine)* neomycin sulfate/polymyxin b/ hydrocortisone (Cortisporin)* hydrocortisone acetate/pramoxine leflunomide (Arava)* methyldopa (Aldomet)* hcl (Analpram-HC)* nicardipine, ER (Cardene, SR)* DO levalbuterol (Xopenex)* methyldopa/hydrochlorothiazide hydrocortisone acetate/pramoxine (Aldoril)* nifedipine (Adalat, Procardia, Adalat hcl (Pramosone)* levetiracetam, ER (Keppra, XR)^ CC, Procardia XL)* DO QL levobunolol hcl (Betagan)* methylphenidate hcl (Metadate ER, hydrocortisone valerate (Westcort)* Methylin ER, Methylin, Ritalin, Ritalin nimodipine (Nimotop)* DO hydrocortisone/pramoxine/ levocetirizine (Xyzal)* QL LA, various)* nisoldipine (Sular)* DO, QL chloroxylenol (Cortane-B)* levofloxacin (Levaquin)* QL (Medrol)* nitrofurantoin macrocrystal hydromorphone hcl (Dilaudid)* levofloxacin ophthalmic (Quixin)* metipranolol (OptiPranolol)* (Macrodantin, Macrobid)* hydroxychloroquine sulfate levonorgestrel (Plan B)* metoclopramide hcl (Reglan)* nitroglycerin (Nitrostat)* (Plaquenil)* levonorgestrel/ethinyl estradiol metolazone (Zaroxolyn)* nizatidine – prescription only (Axid)* hydroxyzine hcl (Atarax)* levothyroxine sodium (Synthroid, metoprolol succinate (Toprol XL)* norethindrone (Ortho Micronor)* hydroxyzine pamoate (Vistaril)* various)^ metoprolol tartrate (Lopressor)* norethindrone acetate (Aygestin)* sulfate (Cystospaz, lidocaine hcl (Xylocaine, various)* metronidazole (Flagyl)* norethindrone acetate/ethinyl Levsin, Nulev, Levsinex, Levbid)* liothyronine (Cytomel)* estradiol/ferrouse fumarate metronidazole (Metrogel Vaginal)* ibandronate (Boniva)* QL lisinopril (Prinivil, Zestril*) norgestimate/ethinyl estradiol mexiletine hcl (Mexitil)* ibuprofen (Motrin)* lisinopril/hydrochlorothiazide norgestrel/ethinyl estradiol midodrine hcl (ProAmatine)* ibuprofen/oxycodone hcl (Prinzide, Zestoretic)* hcl (Pamelor)* minocycline hcl (Dynacin, Minocin)* (Combunox)* QL lithium carbonate (Eskalith)^ nystatin (Mycostatin)* minoxidil (Loniten)* hcl (Tofranil)* lithium citrate nystatin/ (Mycolog II)* imiquimod (Aldara)* QL lorazepam (Ativan)* (Remeron, Remeron Sol Tab)* ofloxacin (Floxin)* QL indapamide (Lozol)* losartan (Cozaar)* DO, QL misoprostol (Cytotec)* ofloxacin (Ocuflox)* indomethacin (Indocin)* losartan/hctz (Hyzaar)* DO, QL modafinil (Provigil)* DO, QL, PA (Zyprexa, Zydis)* insulin syringes lovastatin (Mevacor)* DO, QL moexipril hcl (Univasc)* omeprazole – prescription only succinate (Loxitane)* (Prilosec)* QL moexipril/hydrochlorothiazide (Atrovent, Nasal)* QL (Ludiomil)* (Uniretic)* /aspirin/caffeine (Norgesic)* irbesartan (Avapro)* DO, QL mebendazole (Vermox)* furoate (Elocon)* oxandrolone irbesartan/hctz (Avalide)* DO, QL mefenamic acid (Ponstel)* morphine sulfate (Kadian, MS Contin, oxaprozin (Daypro)* iron, carbonyl/vitamin C/vitamin medroxyprogesterone acetate Oramorph SR, RMS-Suppository)* QL B12/folic acid (Provera)* multivitamin combination/ferrous oxazepam (Serax)* isometheptene/acetaminophen/ mefloquine hcl (Lariam)* fumarate/polysaccharide iron oxcarbazepine tab (Trileptal tab)* complex/folic acid dichloralphenazone (Midrin)* meloxicam (Mobic)* QL chloride (Ditropan, mupirocin (Bactroban)* Ditropan XL)* isoniazid meperidine hcl (Demerol, Meperitab)* nabumetone (Relafen)* oxycodone hcl (Roxicodone, isosorbide dinitrate (Isordil)* meperidine hcl/prometh hcl OxyFAST)* isosorbide mononitrate (ISMO, (Meprozine)* nadolol (Corgard)* oxycodone hcl/acetaminophen Imdur)* meprobamate (Miltown)* naltrexone hcl (ReVia)* (Percocet, Tylox)* QL isotretinoin (Accutane)* mesalamine (Rowasa)* naproxen (Naprosyn)* oxycodone/aspirin (Percodan)* isradipine (DynaCirc)* DO metaproterenol sulfate (Alupent)* naproxen sodium (Anaprox, Naprelan)* oxymorphone, ER (Opana, ER)* QL itraconazole (Sporanox)* PA metaxolone (Skelaxin)* naratriptan (Amerge)* QL pantoprazole (Protonix)* QL (Nizoral, Extina)* metformin, ER (Fortamet, Glucophage, paromomycin sulfate (Humatin)* ketoprofen (Orudis)* Glucophage XR)* nateglinide (Starlix)* hcl (Paxil, Paxil CR)* DO, ketorolac tromethamine methadone hcl (Dolophine HCl, nefazodone (Serzone)* QL (Toradol)* QL Methadone Intensol, Methadose)* neomycin sulfate peg 3350/sodium sulfate/sodium methamphetamine (Desoxyn)* ketorolac soln (Acular, LS)* neomycin sulfate/gramicidin/ bicarbonate/sodium chloride/ methazolamide (Neptazane)* polymyxin b (Neosporin)* labetalol hcl (Normodyne)* penicillin v potassium (Pen-Vee K)* methenamine mandelate neomycin sulfate/polymyxin b/ lactulose (Cephulac, Chronulac)* pentoxifylline (Trental)* (Mandelamine)* hydrocortisone (Cortisporin)* lamotrigine (Lamictal)^ perindopril (Aceon)* methimazole (Tapazole)*

Generic Premium | 5 permethrin (Elimite)* quinapril hcl (Accupril)* terbinafine hcll (Lamisil)* ursodiol (Actigall)* perphenazine (Trilafon)* quinapril/hydrochlorothiazide terbutaline sulfate (Brethine)* valacyclovir (Valtrex)* phenazopyridine hcl (Pyridium)* (Accuretic)* terconazole (Terazol)* valproate sodium (Depakene)^ phenelzine (Nardil)* gluconate (Quinaglute)* tetracycline hcl (Achromycin V)* vancomycin (Vancocin capsule)* phenobarbital quinidine sulfate (Quinidex)* theophylline anhydrous (Theo-24)^ venlafaxine hcl, ER (Effexor, XR)* phenylephrine hcl (Neo-Synephrine)* ramipril (Altace)* hcl (Mellaril)* verapamil hcl, ER (Calan, Verelan, Verelan PM, Calan SR, Isoptin S.R.)* phenytoin (Dilantin)^ ranitidine hcl – prescription only thiothixene (Navane)* (Zantac)* voriconazole (Vfend)* hcl (Isopto Carpine)* thyroid (Armour Thyroid)^ rifampin (Rifadin)* warfarin sodium (Coumadin)^ pindolol (Visken)* thyroid, pork (Nature-Throid)* rimantadine hcl (Flumadine)* zafirlukast (Accolate)* piroxicam (Feldene)* ticlopidine hcl (Ticlid)* risperidone (Risperdal)* zaleplon (Sonata)* polymyxin b sulfate/trimethoprim timolol maleate (Timoptic, QL rivastigmine (Exelon)* (Polytrim)* Timoptic-XE)* ziprasidone (Geodon)* ropinirole, ER (Requip, XL)* potassium bicarbonate/potassium tinidazole (Tindamax)* zolpidem, ER (Ambien, CR)* QL citrate (K-Lyte)* salicylic acid tizanidine hcl (Zanaflex)* zonisamide (Zonegran)* potassium chloride (GoLYTELY)* salsalate (Disalcid)* tobramycin/dexamethasone susp potassium chloride (K-Dur, Klor-Con, selegiline hcl (Eldepryl)* (TobraDex)* Slow-K, various)* selenium sulfide (Selsun Rx)* tobramycin sulfate drops TIER 2 potassium chloride/potassium sertraline hcl (Zoloft)* DO, QL (Tobrex)* bicarbonate (K-Lyte/Cl)* Pancreatic Enzymes – all prescription silver sulfadiazine (Silvadene)* tolazamide (Tolinase)* strength, self administered, brand potassium citrate (Urocit K)* simvastatin (Zocor)* DO, QL, tolbutamide (Orinase)* pancreatic enzymes pramipexole (Mirapex)* PA – 80 mg only topiramate (Topamax)^ PKU – all prescription strength, self pravastatin sodium (Pravachol)* DO, administered, brand PKU formulas sodium citrate/potassium citrate torsemide (Demadex) QL Abilify prazosin hcl (Minipress)* sodium citrate (Polycitra)* , ER 100, 200, 300mg (Ultram, ER, Ryzolt ER)* QL Abilify Discmelt (Dermatop)* sodium fluoride (Luride)* tramadol hcl/acetaminophen Accu-Chek Test Strips QL (Prelone)* sodium polystyrene sulfonate (Kayexalate)* (Ultracet)* QL Actoplus Met QL prednisolone acetate (Pred Forte)* sotalol hcl (Betapace, Betapace AF)* trandolapril (Mavik)* Actos† QL prednisolone sodium phosphate trandolapril/verapamil (Tarka)* Advair Diskus QL (Pediapred)* spironolact/hydrochlorothiazide (Aldactazide)* trazodone hcl (Desyrel)* Advair HFA QL prednisolone sodium phosphate (Inflamase Forte)* spironolactone (Aldactone)* Armour Thyroid (Deltasone)* stannous fluoride (Kenalog)* Byetta ST, QL primidone (Mysoline)* sucralfate (Carafate)* triamcinolone acetonide nasal Carbatrol (Nasacort AQ)* QL probenecid (Probenecid)* sulfacetamide sodiujm/sulfur/urea Celebrex ST, QL sulfacetamide sodium (Bleph-10)* triamterene/hydrochlorothiazide Clozaril procainamide hcl (Pronestyl)* (Dyazide, Maxzide)* sulfacetamide sodium (Ovace)* Cordarone prochlorperazine maleate triazolam (Halcion)* sulfacetamide sodium/ Coumadin (Compazine, Compro)* trifluoperazine hcl (Stelazine)* prednisolone Creon (Prometrium)* trifluridine (Viroptic)* sodium phosphate (Vasocidin)* Depakene containing products hcl (Artane)* (Phenergan, various)* sulfacetamide sodium/sulfur Depakote ER (Sulfacet-R)* trimethobenzamide hcl (Tigan)* propafenone hcl (Rythmol)* Diastat sulfadiazine trimethoprim (Proloprim)* proparacaine hcl (Ophthetic)* Dilantin sulfamethoxazole/trimethoprim (Surmontil)* propranolol hcl (Inderal, Inderal LA, Dilantin-125 (Bactrim, Bactrim DS)* tropicamide (Mydriacyl)* Innopran XL)* † sulfasalazine (Azulfidine)* Diovan DO, QL propranolol/hydrochlorothiazide trospium (Sanctura)* Diovan HCT† DO, QL (Inderide)* sulindac (Clinoril)* trypsin/balsam peru/castor oil Droxia propylthiouracil (Propylthiouracil)* sumatriptan (Imitrex)* QL (Granulex)* Duetact QL pyrazinamide tamsulosin (Flomax)* urea (Aluvea 39% cream, Carmol 40)* Elixophyllin pyridostigmine bromide (Mestinon)* temazepam (Restoril)* urine test strips (Urine Acetone, Urine terazosin hcl (Hytrin)* Glucose, Urine Gluc-Acet Comb, Urine Epipen (Seroquel)* Multiple)*

6 | Generic Premium Epipen Jr Qvar QL Emtriva ondansetron (Zofran/ODT)* QL Eskalith CR Relenza QL Enbrel PA, QL Pegasys PA, QL Felbatol Relion Novolin 70-30 Innolet enoxaparin (Lovenox)* Prezista Flovent Diskus QL Relion Novolin N Innolet Epivir HBV Procrit PA Flovent HFA QL Serevent QL Epzicom Rapamune Flumadine Seroquel XR Erivedge PA Rebif PA Gabitril† Singulair† QL etoposide (VePesid)* Rescriptor Glucagen Symbicort QL exemestane (Aromasin)* Revlimid PA, QL Glucagon Synthroid Fareston Reyataz Glyset Tamiflu QL flutamide (Eulexin)* Ribavirin (generics) heparin (>5,000U/ml) Tegretol fondaparinux (Arixtra)* Saizen PA QL Humalog Mix Tegretol XR Fuzeon Sandimmune Humalog Theo-24 ganciclovir (Cytovene)* Selzentry Humulin 70/30 Topamax Gengraf Serostim PA QL Humulin N Twinject Gleevec PA Sprycel PA Humulin R Ultrase, MT granisetron hcl (Kytril)* QL stavudine (Zerit)* Janumet QL Uniphyl Hexalen Sustiva Januvia QL Vesicare hydroxyurea (Hydrea)* Sutent PA Keppra, XR Viokase Inlyta PA tacrolimus (Prograf)* Kombiglyze XR QL Vyvanse Intron-A PA tamoxifen citrate (Nolvadex)* Lamictal, ODT Zarontin Invirase Tarceva PA Lanoxin Zenpep Iressa Targretin PA Lantus Kaletra Tasigna PA Lantus Solostar lamivudine (Epivir)* Temodar† PA Levemir TIER 3 lamivudine/zidovudine (Combivir)* Thalomid PA Lithobid Actimmune letrozole (Femara)* tretinoin (Vesanoid)* Lumigan Alferon N leucovorin calcium Trexall Megace ES Alkeran Leukeran Trizivir Nexium QL Aminocaproic Acid (Amicar)* leuprolide acetate (Lupron)* PA Truvada Novolin 70/30 anastrozole (Arimidex)* Lexiva Tykerb PA Novolin N Atripla Lysodren Valcyte Novolin R Avonex PA Matulane Videx Novolog Mix Azasan (Megace)* Viracept Novolog azathioprine (Imuran)* mercaptopurine (Purinethol)* Viramune XR One Touch Test Strips QL Betaseron PA Mesnex Virazole Onglyza DO, QL bicalutamide (Casodex)* methotrexate sodium (Rheumatrex)* Viread Oxycontin QL Ceenu mycophenolate (Cellcept)^ Xeloda PA Pancrecarb Cellcept Myleran Ziagen Pancrelipase Copaxone PA Neoral zidovudine (Retrovir)* Phenytek Crixivan Neumega PA Zolinza PA Prandin cyclophosphamide (Cytoxan, Neupogen PA Premarin Neosar)* nevirapine (Viramune)* Premarin Vaginal Cream cyclosporine (Sandimmune)^ Nexavar PA Premphase cyclosporine, modified (Neoral, Nilandron Gengraf)^ Prempro Norvir didanosine (Videx EC)* Proair HFA QL Nutropin AQ PA, QL Eligard PA Pulmicort Flexhaler QL Nutropin PA, QL Emcyt PA

Generic Premium | 7 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. 15823ANMENABS Rev. 6/12