Standard Formulary

PHARMACY SERVICES High-Cost Drug Exclusions

The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at the lowest cost, consider talking with your doctor about one of the therapeutically equivalent (similar safety and efficacy) or over-the-counter (OTC) alternatives listed below. We encourage you to talk to your doctor about whether one of these options is right for you. Coverage of alternatives will vary.

These high cost medications may be considered medically necessary when ALL of the alternatives in the table below have been ineffective, not tolerated or all are contraindicated, unless otherwise specified. If your doctor believes that the listed alternatives are not right for you, your doctor may request an exception by contacting Customer Service. Please visit your health plan’s website or contact Customer Service at the number listed on the back of your member ID card for more information about medication coverage.

Questions? Call the Customer Service number on your member ID card.

Regence BlueCross BlueShield of Oregon Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association 100 SW Market Street | Portland, OR 97201 © 2021 Regence BlueCross BlueShield of Oregon

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-344-6347 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-344-6347 (TTY: 711). High-Cost Drug Exclusion List Effective 1/1/2021 Standard Formulary

Drug Alternatives

Absorica Amnesteem, Claravis, isotretinoin, Myorisan, Zenatane

Absorica LD Amnesteem, Claravis, isotretinoin, Myorisan, Zenatane clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Acanya 0.01% and 0.025% gel rabeprazole and at least two of the following lower cost products: esomeprazole capsule, first-lansoprazole kit, first-omeprazole kit, AcipHex Sprinkle lansoprazole, omeprazole, pantoprazole doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Acticlate Vibramycin capsule], minocycline IR capsule acyclovir 5% cream (generic Zovirax) acyclovir 5% ointment At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin Aczone 0.01% and 0.025% gel adapalene 0.1% cream, adapalene 0.1% gel, and at least two of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate adapalene 0.1% pads, solution 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, (generic Differin) tretinoin cream, tretinoin 0.01% and 0.025% gel Aggrenox dipyridamole tablet in combination with over-the-counter aspirin

AirDuo Digihaler fluticasone-salmeterol (generic AirDuo), Advair Diskus, Advair HFA

Aklief cream tretinoin cream, tretinoin 0.01% and 0.025% gel desoximetasone 0.25% cream, fluocinonide 0.05% solution, hydrocortisone Ala-Scalp 2.5% lotion At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen- caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325- Allzital 40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule At least two of the following lower cost triptan medications: eletriptan, almotriptan (generic Axert) naratriptan, rizatriptan, sumatriptan, zolmitriptan

Altoprev atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin betamethasone dipropionate 0.05% cream, desoximetasone 0.25% ointment, fluocinonide 0.05% cream, fluocinonide 0.05% gel, fluocinonide amcinonide cream, lotion, 0.05% ointment, fluticasone propionate 0.005% ointment, triamcinolone ointment 0.5% cream, triamcinolone 0.5% ointment generic naratriptan and at least one of the following lower cost triptan Amerge medications: eletriptan, rizatriptan, sumatriptan, zolmitriptan amlodipine-atorvastatin tablet amlodipine in combination with atorvastatin, amlodipine in combination with (generic Caduet) rosuvastatin or simvastatin amoxicillin-clarithromycin- lansoprazole therapy pack amoxicillin in combination with clarithromycin and over-the-counter (OTC) (generic Prevpac) lansoprazole cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, Amrix metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Standard Formulary

Drug Alternatives At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin Amzeeq 0.01% and 0.025% gel At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate Antara micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule desoximetasone 0.05% cream, fluocinonide 0.05% cream, triamcinolone ApexiCon E 0.5% cream tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/gel/lotion (generic Cleocin-T), tretinoin cream, Arazlo tretinoin 0.01% and 0.025% gel Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, ArmonAir Digihaler Flovent HFA aspirin-dipyridamole ER (extended-release) [generic Aggrenox] dipyridamole tablet in combination with over-the-counter aspirin aspirin-omeprazole ER (extended-release) [generic Yosprala] omeprazole in combination with over-the counter aspirin

Atelvia alendronate, ibandronate, risedronate IR (immediate-release) At least two of the following lower cost triptan medications: eletriptan, Axert naratriptan, rizatriptan, sumatriptan, zolmitriptan At least three of the following lower cost products: azelastine nasal spray, Cromolyn nasal aerosol solution, olopatadine nasal solution, over-the- counter fluticasone/Flonase (or the store brand), over-the-counter Nasacort azelastine-fluticasone nasal Allergy (or the store brand), over-the-counter Pataday, over-the-counter spray (generic Dymista) Rhinocort Allergy (or the store brand) over-the-counter fluticasone/Flonase (or the store brand), ov er-the-counter Nasacort Allergy (or the store brand), over-the-counter Rhinocort Allergy (or Beconase AQ the store brand)

Belsomra eszopiclone, zaleplon, zolpidem benzonatate 100mg and 200mg capsule, guaifenesin-codeine 100- 10mg/5ml solution, promethazine-codeine 6.25-10mg/5ml syrup, benzonatate 150mg capsule promethazine-dm 6.25-15mg/5ml syrup betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% betamethasone valerate 0.12% ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% external foam (generic Luxiq) cream

Bijuva estradiol in combination with progesterone, Fyavolv, Jevantique Lo, Jinteli

Binosto alendronate tablet, alendronate solution betamethasone dipropionate augmented 0.05% lotion, betamethasone Bryhali valerate 0.1% ointment, clobetasol propionate 0.05% lotion At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen- caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325- Bupap 40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule

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Standard Formulary

Drug Alternatives At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen- butalbital-acetaminophen 25- caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325- 325mg tablet 40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen- butalbital-acetaminophen 50- caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325- 300mg capsule (generic Bupap) 40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule amlodipine in combination with atorvastatin, amlodipine in combination with Caduet rosuvastatin or simvastatin At least one of the following lower cost ergot-containing medications: Cafergot generic ergotamine/ caffeine tablet, generic dihydroergotamine injection calcipotriene 0.005% foam (generic Sorilux) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream calcitriol 3mcg/gm ointment (generic Vectical) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam, Cambia packets nabumetone, naproxen, sulindac

Capex fluocinolone 0.01% oil (scalp oil), fluocinolone 0.01% solution

Carac fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution carbinoxamine 4mg tablet and at least three of the following lower cost antihistamine products: carbinoxamine oral solution, cetirizine solution, carbinoxamine 6mg tablet cyproheptadine tablet/syrup, desloratadine tablet, levocetirizine (generic Ryvent) dihydrochloride tablet/solution

Centany mupirocin 2% ointment chlorzoxazone 500mg tablet at least two of the following lower cost chlorzoxazone 250mg, 375mg products: baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone 750mg tablet (generic Lorzone) 800mg tablet, methocarbamol tablet, tizanidine tablet clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Cleocin-T 0.01% and 0.025% gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Clindacin-P 0.01% and 0.025% gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Clindacin ETZ 0.01% and 0.025% gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Clindagel 0.01% and 0.025% gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, clindamycin 1% topical gel adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin (generic Clindagel) 0.01% and 0.025% gel

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Standard Formulary

Drug Alternatives clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, clindamycin foam (generic adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Evoclin) 0.01% and 0.025% gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, clindamycin swab (generic adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Clindacin-P, Clindacin ETZ) 0.01% and 0.025% gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, clindamycin-benzoyl peroxide adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 1.2-2.5% (generic Acanya) 0.01% and 0.025% gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, clindamycin-tretinoin topical gel adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin (generic Veltin, Ziana) 0.01% and 0.025% gel At least two lower cost forms of clobetasol propionate including cream, gel, clobetasol foam (generic Olux) lotion, ointment, and solution clobetasol emulsion foam At least two lower cost forms of clobetasol propionate including cream, gel, (generic Olux-E) lotion, ointment, and solution At least two lower cost forms of clobetasol propionate including cream, gel, clobetasol spray (generic Clobex) lotion, ointment, and solution At least two lower cost forms of clobetasol propionate including cream, gel, Clobex lotion, ointment, and solution clocortolone 0.1% cream (generic fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone Cloderm) 0.1% cream fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone Cloderm cream, pump 0.1% cream

Consensi amlodipine in combination with celecoxib fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone Cordran tape 0.1% ointment desonide 0.05% cream and lotion, fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment, triamcinolone Cordran 0.05% cream, ointment 0.025% lotion and ointment doxycycline IR (immediate-release) [generic Adoxa, Monodox, and CoreMino Vibramycin capsule], minocycline IR capsule

Cuprimine penicillamine 250mg tablet (generic Depen Titratabs) betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, Cutivate triamcinolone 0.1% lotion cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the cyclobenzaprine 7.5mg tablet following lower cost products: baclofen, chlorzoxazone 500mg tablet, (generic Fexmid) metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the cyclobenzaprine ER (extended- following lower cost products: baclofen, chlorzoxazone 500mg tablet, release) capsule [generic Amrix] metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion dapsone 5% and 7.5% gel (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin (generic Aczone) 0.01% and 0.025% gel

Dayvigo eszopiclone, zaleplon, zolpidem

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Standard Formulary

Drug Alternatives At least two lower cost forms of desonide including cream, lotion and Desonate gel ointment desonide 0.05% gel (generic At least two lower cost forms of desonide including cream, lotion and Desonate) ointment betamethasone 0.05% ointment, desoximetasone 0.25% cream and ointment, desoximetasone 0.05% cream, fluocinonide 0.05% gel and desoximetasone spray (generic solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% Topicort spray) ointment

Dexabliss dexamethasone tablet dexamethasone dose pack (generic Dexpak) dexamethasone tablet At least four of the following lower cost antihistamine products: carbinoxamine 4mg tablet, carbinoxamine oral solution, cetirizine solution, dexchlorpheniramine maleate cyproheptadine tablet/syrup, desloratadine tablet, levocetirizine oral solution (generic RyClora) dihydrochloride tablet/solution esomeprazole capsule, lansoprazole, omeprazole, pantoprazole, Dexilant rabeprazole

Dexpak dexamethasone tablet At least one of the following lower cost ergot-containing medications: D.H.E. 45 generic ergotamine/ caffeine tablet, generic dihydroergotamine injection diclofenac topical patch (generic diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution Flector) (generic Pennsaid 1.5%), over-the-counter Voltaren gel adapalene 0.1% gel, adapalene 0.1% cream and at least one of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, Differin 0.1% lotion tretinoin cream, tretinoin 0.01% and 0.025% gel diflorasone cream, ointment desoximetasone 0.05% cream and ointment, fluocinonide 0.05% cream, (generic Psorcon) ointment and solution, triamcinolone 0.5% cream and ointment dihydroergotamine mesylate At least one of the following lower cost ergot-containing medications: nasal spray (generic Migranal) generic ergotamine/ caffeine tablet, generic dihydroergotamine injection At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, doxepin 5% cream (generic pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% Prudoxin, Zonalon) ointment, triamcinolone 0.5% cream Doryx, Doryx MPC (modified doxycycline IR (immediate-release) [generic Adoxa, Monodox, and polymer coat) Vibramycin capsule], minocycline IR capsule doxycycline hyclate DR (delayed- release) tablet [generic Doryx, doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Doryx MPC] Vibramycin capsule], minocycline IR capsule doxycycline 40mg ER (extended- release) capsule (for rosacea) doxycycline IR (immediate-release) [generic Adoxa, Monodox, and [generic Oracea] Vibramycin capsule], minocycline IR capsule doxycycline hyclate 50mg, 75mg, 150mg tablet (generic Acticlate, doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Targadox) Vibramycin capsule], minocycline IR capsule doxycycline monohydrate doxycycline IR (immediate-release) [generic Adoxa, Monodox, and capsule Vibramycin capsule], minocycline IR capsule

Duaklir Pressair Anoro Ellipta, Stiolto Respimat

Duetact pioglitazone in combination with glimepiride

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Standard Formulary

Drug Alternatives

Duexis famotidine in combination with ibuprofen

Duobrii halobetasol propionate 0.05% cream, tazarotene 0.1% cream clopidogrel bisulfate 75mg tablet in combination with over-the-counter Durlaza aspirin 81mg dutasteride in combination with tamsulosin and at least two of the following dutasteride-tamsulosin (generic lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, Jalyn) dutasteride, finasteride, tamsulosin, terazosin

Dutoprol metoprolol in combination with hydrochlorothiazide

Dxevo dexamethasone tablet At least three of the following lower cost products: azelastine nasal spray, Cromolyn nasal aerosol solution, olopatadine nasal solution, over-the- counter fluticasone/Flonase (or the store brand), over-the-counter Nasacort Allergy (or the store brand), over-the-counter Pataday, over-the-counter Dymista Rhinocort Allergy (or the store brand)

Ecoza econazole nitrate 1% cream

Edarbi irbesartan, losartan, olmesartan, telmisartan, valsartan chlorothiazide, indapamide, irbesartan-hydrochlorothiazide (HCTZ), losartan-HCTZ, metolazone, olmesartan-HCTZ, telmisartan-HCTZ, Edarbyclor valsartan-HCTZ

Edluar eszopiclone, zaleplon, zolpidem methylprednisolone, prednisolone syrup, prednisone oral solution, Emflaza prednisone tablet

Enstilar betamethasone 0.05% lotion, calcipotriene 0.005% ointment hydrocortisone 1% cream, hydrocortisone 2.5% lotion, over-the-counter Epifoam pramoxine At least one of the following lower cost ergot-containing medications: Ergomar generic ergotamine/ caffeine tablet, generic dihydroergotamine injection At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Ertaczo counter terbinafine cream esomeprazole capsule and at least two of the following lower cost products: esomeprazole packet (generic f irst-lansoprazole kit, first-omeprazole kit, lansoprazole, omeprazole, Nexium) pantoprazole, rabeprazole clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Evoclin 0.01% and 0.025% gel At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Exelderm 1% cream, solution counter terbinafine cream

Extina ketoconazole 2% cream, ketoconazole 2% shampoo ezetimibe-simvastatin tablet ezetimibe in combination with simvastatin, ezetimibe in combination with (generic Vytorin) atorvastatin or rosuvastatin

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Standard Formulary

Drug Alternatives tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, Fabior tretinoin 0.01% and 0.025% gel At least two of the following lower cost fenofibrate products: choline fenofibrate 40mg tablet, 120mg fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate tablet (generic Fenoglide) micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibrate 50mg capsule fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate (generic Lipofen) micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibrate 160mg tablet (generic fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate Triglide) micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibric acid 35mg, 105mg fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate tablet (generic Fibricor) micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate Fenoglide micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule fenoprofen calcium 600mg tablet and at least three of the following lower fenoprofen capsule (generic cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg Fenortho) capsule, meloxicam, nabumetone, naproxen, sulindac fenoprofen calcium 600mg tablet and at least three of the following lower fenoprofen calcium 400mg cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule (generic Nalfon) capsule, meloxicam, nabumetone, naproxen, sulindac fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg Fenortho capsule, meloxicam, nabumetone, naproxen, sulindac cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, Fexmid metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate Fibricor micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution Flector (generic Pennsaid 1.5%), over-the-counter Voltaren gel

Fluoroplex fluorouracil 2% solution, fluorouracil 5% solution fluorouracil 0.5% cream (generic Carac) fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution flurandrenolide 0.05% ointment fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone (generic Cordran) 0.1% ointment fluticasone propionate 0.05% betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, lotion (generic Cutivate) triamcinolone 0.1% lotion fluvastatin capsule (generic Lescol) atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin fluvastatin ER (extended-release) tablet [generic Lescol XL] atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin metformin, metformin ER (extended-release) [non-osmotic, non-modified Fortamet release]

Fosamax D alendronate in combination with over-the-counter vitamin D

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Standard Formulary

Drug Alternatives At least two of the following lower cost triptan medications: eletriptan, Frova naratriptan, rizatriptan, sumatriptan, zolmitriptan At least two of the following lower cost triptan medications: eletriptan, frovatriptan (generic Frova) naratriptan, rizatriptan, sumatriptan, zolmitriptan metformin, metformin ER (extended-release) [non-osmotic, non-modified Glumetza release]

Glycate glycopyrrolate 1mg tablet, glycopyrrolate 2mg tablet glycopyrrolate 1.5mg tablet (generic Glycate) glycopyrrolate 1mg tablet, glycopyrrolate 2mg tablet

Gocovri amantadine capsule/syrup/ tablet, rasagiline, selegiline amitriptyline tablet, gabapentin capsule/solution/ tablet, pregabalin capsule/ Gralise solution halcinonide 0.1% cream (generic betamethasone AF 0.05% cream, desoximetasone 0.25% cream, Halog) fluocinonide 0.05% cream halobetasol 0.05% foam (generic Lexette) halobetasol cream, halobetasol ointment betamethasone AF 0.05% cream, desoximetasone 0.25% cream, Halog cream fluocinonide 0.05% cream betamethasone dipropionate 0.05% ointment, desoximetasone 0.25% Halog ointment ointment, fluocinonide 0.05% ointment betamethasone AF 0.05% cream, desoximetasone 0.25% cream, Halog solution fluocinonide 0.05% cream, fluocinonide 0.05% solution amoxicillin in combination with clarithromycin and over-the-counter (OTC) Helidac lansoprazole

Hemady dexamethasone tablet

Hidex dexamethasone tablet amitriptyline tablet, gabapentin capsule/ solution/ tablet, pregabalin capsule/ Horizant solution hydrocortisone butyrate 0.1% betamethasone dipropionate 0.05% lotion, fluticasone propionate 0.05% lotion (generic Locoid) cream, triamcinolone 0.1% lotion hydrocortisone butyrate hydrophilic lipo base 0.1% cream betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, (generic Locoid Lipocream) hydrocortisone valerate 0.2% cream imiquimod 3.75% cream (generic Zyclara pump) imiquimod 5% cream generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, Imitrex injection zolmitriptan generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, Imitrex nasal spray zolmitriptan generic sumatriptan and at least one of the following lower cost triptan Imitrex tablet medications: eletriptan, naratriptan, rizatriptan, zolmitriptan betamethasone 0.05% ointment, desoximetasone 0.25% cream, Impoyz fluocinonide 0.05% cream propranolol tablet and solution, propranolol ER (extended-release) capsule Inderal XL [generic Inderal LA], nadolol tablet, timolol tablet ibuprofen suspension 100mg/5ml, indomethacin 25mg capsule, Indocin indomethacin 50mg capsule, over-the-counter Voltaren gel

Page 8 of 17

Standard Formulary

Drug Alternatives indomethacin 25mg capsule, indomethacin 50mg capsule, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 20mg capsule indomethacin 25mg and 50mg capsule, meloxicam, nabumetone, (generic Tivorbex) naproxen, sulindac propranolol tablet and solution, propranolol ER (extended-release) capsule InnoPran XL [generic Inderal LA], nadolol tablet, timolol tablet

Intermezzo eszopiclone, zaleplon, zolpidem

Isordil Titradose 40mg tablet isosorbide dinitrate tablet isosorbide tablet 40mg (generic Isordil Titradose) isosorbide dinitrate tablet

Istalol (once daily) eye drops timolol maleate (twice daily) eye drops [generic Timoptic] dutasteride in combination with tamsulosin and at least two of the following lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, Jalyn dutasteride, finasteride, tamsulosin, terazosin At least four of the following lower cost antihistamine products: carbinoxamine 4mg tablet, carbinoxamine oral solution, cetirizine solution, Karbinal ER (extended-release) cyproheptadine tablet/syrup, desloratadine tablet, levocetirizine suspension dihydrochloride tablet/solution triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone Kenalog 0.025% ointment, triamcinolone 0.1% ointment ketoconazole 2% foam (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo ketodan (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo ketoprofen 50mg capsule and at least three of the following lower cost NSAID products: celecoxib, etodolac, ketoprofen ER (extended-release) 200mg capsule, indomethacin 25mg and 50mg capsule, meloxicam, ketoprofen 25mg capsule nabumetone, naproxen, sulindac At least four of the following lower cost NSAID products: celecoxib, ketorolac nasal spray (generic etodolac, indomethacin 25mg and 50mg capsule, meloxicam, nabumetone, Sprix) naproxen, sulindac lactulose oral crystal packet lactulose solution, polyethylene glycol 3350 oral powder lansoprazole ODT (orally lansoprazole and at least two of the following lower cost products: disintegrating tablet) [generic esomeprazole capsule, first-lansoprazole kit, first-omeprazole kit, Prevacid SoluTab] omeprazole, pantoprazole, rabeprazole

Lescol atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lescol XL atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lexette halobetasol cream, halobetasol ointment diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution Licart (generic Pennsaid 1.5%), over-the-counter Voltaren gel lidocaine-tetracaine cream 7-7% lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the- cream (generic Pliaglis) counter lidocaine gel At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate Lipofen micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Livalo atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Page 9 of 17

Standard Formulary

Drug Alternatives betamethasone 0.05% lotion, fluticasone propionate 0.05% cream, Locoid lotion triamcinolone 0.1% lotion betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, Locoid Lipocream hydrocortisone valerate 0.2% cream chlorzoxazone 500mg tablet at least two of the following lower cost products: baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone Lorzone 800mg tablet, methocarbamol tablet, tizanidine tablet betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% Luxiq cream At least two previous generic antifungals such as clotrimazole 1% cream, luliconazole cream (generic econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Luzu) counter terbinafine cream At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Luzu counter terbinafine cream generic rizatriptan and at least one of the following lower cost triptan Maxalt medications: eletriptan, naratriptan, sumatriptan, zolmitriptan generic rizatriptan orally disintegrating tablet and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan Maxalt ODT (orally disintegrating tablet, sumatriptan, zolmitriptan (also available as an orally disintegrating tablet) tablet) methylprednisolone tablet, prednisolone syrup, prednisone oral solution, Medrol tablet prednisone tablet metaxalone 800mg tablet and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and metaxalone 400mg tablet 10mg tablet, methocarbamol tablet, tizanidine tablet metformin ER (extended-release) modified release [generic metformin, metformin ER (extended-release) [non-osmotic, non-modified Glumetza] release] metformin ER (extended-release) osmotic release [generic metformin, metformin ER (extended-release) [non-osmotic, non-modified Fortamet] release] metoclopramide ODT (orally disintegrating tablet) [generic Metozolv ODT] metoclopramide IR (immediate-release) tablet, metoclopramide solution metoprolol-hydrochlorothiazide ER (extended-release) tablet [generic Dutoprol] metoprolol in combination with hydrochlorothiazide At least two previous generic antifungals such as clotrimazole 1% cream, miconazole-zinc oxide-petroleum ketoconazole 2% cream, nystatin cream, ointment and powder, over-the- ointment (generic Vusion) counter terbinafine cream, over-the-counter miconazole cream At least one of the following lower cost ergot-containing medications: Migergot generic ergotamine/ caffeine tablet, generic dihydroergotamine injection At least one of the following lower cost ergot-containing medications: Migranal generic ergotamine/ caffeine tablet, generic dihydroergotamine injection methylprednisolone tablet, prednisolone syrup, prednisone oral solution, Millipred, Millipred DP prednisone tablet minocycline IR (immediate- doxycycline IR (immediate-release) [generic Adoxa, Monodox, and release) tablet Vibramycin capsule], minocycline IR capsule minocycline ER (extended- doxycycline IR (immediate-release) [generic Adoxa, Monodox, and release) tablet [generic Solodyn] Vibramycin capsule], minocycline IR capsule

Page 10 of 17

Standard Formulary

Drug Alternatives minocycline ER (extended- doxycycline IR (immediate-release) [generic Adoxa, Monodox, and release) capsule [generic Ximino] Vibramycin capsule], minocycline IR capsule doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Minolira Vibramycin capsule], minocycline IR capsule over-the-counter fluticasone/Flonase (or the store brand), over-the-counter mometasone nasal spray Nasacort Allergy (or the store brand), over-the-counter Rhinocort Allergy (or (generic Nasonex) the store brand) doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Mondoxyne NL Vibramycin capsule], minocycline IR capsule mupirocin calcium ointment (generic Bactroban) mupirocin 2% ointment, over-the-counter bacitracin ointment over-the-counter Bismuth, diphenoxylate-atropine, loperamide, opium Mytesi tincture 1%, paregoric tincture 2mg/5ml naftifine gel (generic Naftin) naftifine 1% cream, naftifine 2% cream

Naftin gel naftifine 1% cream, naftifine 2% cream fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg Nalfon capsule, meloxicam, nabumetone, naproxen, sulindac naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam, Naprelan nabumetone, sulindac naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: naproxen ER (extended-release) celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam, [generic Naprelan] nabumetone, sulindac naproxen-esomeprazole (generic Vimovo) esomeprazole in combination with naproxen

Nascobal cyanocobalamin 1000mcg/mL injection over-the-counter fluticasone/Flonase (or the store brand), over-the-counter Nasacort Allergy (or the store brand), over-the-counter Rhinocort Allergy (or Nasonex the store brand) esomeprazole capsule and at least two of the following lower cost products: f irst-lansoprazole kit, first-omeprazole kit, lansoprazole, omeprazole, Nexium packet pantoprazole, rabeprazole

Nexletol atorvastatin, ezetimibe, rosuvastatin, simvastatin

Nexlizet atorvastatin, ezetimibe, rosuvastatin, simvastatin niacin (antihyperlipidemic) [generic Niacor] niacin ER (extended-release) [generic Niaspan], over-the-counter niacin

Niacor niacin ER (extended-release) [generic Niaspan], over-the-counter niacin bethanechol, desmopressin nasal spray, desmopressin tablet, flavoxate, oxybutynin, tolterodine ER (extended-release), tolterodine IR (immediate- Nocdurna release), trospium IR bethanechol, desmopressin nasal spray, desmopressin tablet, flavoxate, oxybutynin, tolterodine ER (extended-release), tolterodine IR (immediate- Noctiva release), trospium IR

Page 11 of 17

Standard Formulary

Drug Alternatives orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, Norgesic Forte tizanidine tablet metronidazole 0.75% cream, metronidazole 0.75% gel, metronidazole 1% Noritate gel, metronidazole 0.75% lotion doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Okebo Vibramycin capsule], minocycline IR capsule At least two lower cost forms of clobetasol propionate including cream, gel, Olux, Olux-E lotion, ointment and solution amoxicillin in combination with clarithromycin and over-the-counter (OTC) Omeclamox-pak lansoprazole esomeprazole, first-lansoprazole kit, first-omeprazole kit, lansoprazole, Omeppi omeprazole, pantoprazole, rabeprazole omeprazole-sodium bicarbonate esomeprazole, first-lansoprazole kit, first-omeprazole kit, lansoprazole, capsule, packet (generic Zegerid) omeprazole, pantoprazole, rabeprazole over-the-counter fluticasone/Flonase (or the store brand), ov er-the-counter Nasacort Allergy (or the store brand), over-the-counter Rhinocort Allergy (or Omnaris the store brand) clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Onexton 0.01% and 0.025% gel At least two of the following lower cost triptan medications: eletriptan, Onzetra Xsail naratriptan, rizatriptan, sumatriptan, zolmitriptan doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Oracea Vibramycin capsule], minocycline IR capsule Orapred ODT (orally methylprednisolone, prednisolone syrup, prednisone oral solution, disintegrating tablet) prednisone tablet

Oravig clotrimazole lozenge, clotrimazole troche, nystatin suspension orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg orphenadrine-aspirin-caffeine and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tablet (generic Norgesic Forte) tizanidine tablet orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, Orphengesic Forte tizanidine tablet At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, oxiconazole cream, Oxistat 1% lotion terbinafine tablet, over-the-counter terbinafine cream oxybutynin IR (immediate-release) tablet, oxybutynin ER (extended- release) tablet, oxybutynin syrup, over-the-counter Oxytrol for Women, Oxytrol patch tolterodine ER, tolterodine IR, trospium IR baclofen tablets and at least two of the following lower cost products: chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, Ozobax oral solution metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet betamethasone valerate 0.1% cream, fluocinolone 0.025% cream, Pandel cream hydrocortisone butyrate 0.1% cream pantoprazole tablet and at least two of the following lower cost products: pantoprazole packet (generic esomeprazole capsule, first-lansoprazole kit, first-omeprazole kit, Protonix packet) lansoprazole, omeprazole, rabeprazole

Page 12 of 17

Standard Formulary

Drug Alternatives penicillamine capsule (generic Cuprimine) penicillamine tablet (generic Depen Titratabs) diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution Pennsaid 2% (generic Pennsaid 1.5%), over-the-counter Voltaren gel pioglitazone-glimepiride tablet (generic Duetact) pioglitazone in combination with glimepiride lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the- Pliaglis counter lidocaine gel prednisolone ODT (orally disintegrating tablet) [generic methylprednisolone tablet, prednisolone syrup, prednisone oral solution, Orapred ODT] prednisone tablet

Prestalia perindopril in combination with amlodipine lansoprazole and at least two of the following lower cost products: esomeprazole capsule, first-lansoprazole kit, first-omeprazole kit, Prevacid SoluTab omeprazole, pantoprazole, rabeprazole amoxicillin in combination with clarithromycin and over-the-counter (OTC) Prevpac lansoprazole f irst-omeprazole kit and at least two of the following lower cost products: esomeprazole capsule, first-lansoprazole kit, lansoprazole, omeprazole, Prilosec packet pantoprazole, rabeprazole albuterol sulfate HFA (generic ProAir HFA and generic Proventil HFA), ProAir Digihaler Ventolin HFA pantoprazole tablet and at least two of the following lower cost products: esomeprazole capsule, first-lansoprazole kit, first-omeprazole kit, Protonix packet lansoprazole, omeprazole, rabeprazole At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% Prudoxin ointment, triamcinolone 0.5% cream desoximetasone 0.05% cream and ointment, fluocinonide 0.05% cream, Psorcon cream ointment and solution, triamcinolone 0.5% cream and ointment metronidazole 250mg tablets in combination with tetracycline capsules and Pylera over-the-counter (OTC) bismuth Qmiiz ODT (orally disintegrating ibuprofen 100mg/5ml suspension, meloxicam tablet, over-the-counter tablet) Voltaren gel over-the-counter fluticasone/Flonase (or the store brand), over-the-counter Nasacort Allergy (or the store brand), over-the-counter Rhinocort Allergy (or Qnasl the store brand) rabeprazole and at least two of the following lower cost products: rabeprazole sprinkle (generic esomeprazole capsule, first-lansoprazole kit, first-omeprazole kit, AcipHex Sprinkle) lansoprazole, omeprazole, pantoprazole ramelteon tablet (generic Rozerem) eszopiclone, zaleplon, zolpidem dexamethasone tablet, methylprednisolone tablet, prednisolone syrup and Rayos solution, prednisone tablet and solution generic nabumetone and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Relafen DS 1000mg tablet meloxicam, naproxen, sulindac generic eletriptan and at least one of the following lower cost triptan Relpax medications: naratriptan, rizatriptan, sumatriptan, zolmitriptan

Renagel 800mg tablet sevelamer carbonate 800mg tablet, sevelamer carbonate packet

Page 13 of 17

Standard Formulary

Drug Alternatives

Retin-A tretinoin cream, tretinoin 0.01% and 0.025% gel risedronate DR (delayed-release) tablet [generic Atelvia] alendronate, ibandronate, risedronate IR (immediate-release)

Rozerem eszopiclone, zaleplon, zolpidem At least four of the following lower cost antihistamine products: carbinoxamine 4mg tablet, carbinoxamine oral solution, cetirizine solution, cyproheptadine tablet/syrup, desloratadine tablet, levocetirizine RyClora dihydrochloride tablet/solution carbinoxamine 4mg tablet and at least three of the following lower cost antihistamine products: carbinoxamine oral solution, cetirizine solution, Ryvent (carbinoxamine 6mg cyproheptadine tablet/syrup, desloratadine tablet, levocetirizine tablet) dihydrochloride tablet/solution At least two lower cost forms of betamethasone including cream, lotion, and Sernivo spray ointment sevelamer hydrochloride 800mg tablet (generic Renagel) sevelamer carbonate 800mg tablet, sevelamer carbonate packet azithromycin, doxycycline IR (immediate-release) [generic Adoxa, Seysara Monodox, and Vibramycin capsule], minocycline IR capsule

Sitavig clotrimazole troches, nystatin suspension doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Solodyn Vibramycin capsule], minocycline IR capsule

Sorilux calcipotriene 0.005% cream/ointment/ solution, tazarotene 0.1% cream At least four of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam, nabumetone, Sprix naproxen, sulindac At least two previous generic antifungals such as clotrimazole 1% cream, sulconazole 1% cream, solution econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- (generic Exelderm) counter terbinafine cream sumatriptan-naproxen (generic Treximet) sumatriptan in combination with naproxen lidocaine-prilocaine cream, lidocaine ointment, lidocaine patch, lidocaine Synera solution

Taclonex calcipotriene-betamethasone dipropionate 0.005-0.064% suspension

Talicia rifabutin in combination with amoxicillin and omeprazole

Taperdex dexamethasone tablet, prednisone tablet therapy pack doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Targadox Vibramycin capsule], minocycline IR capsule tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, Tazorac tretinoin 0.01% and 0.025% gel fluocinolone 0.025% cream, hydrocortisone 1% ointment, triamcinolone Texacort 0.1% ointment timolol maleate (once daily) eye drops [generic Istalol] timolol maleate (twice daily) eye drops [generic Timoptic]

Timoptic Ocudose timolol maleate (twice daily) eye drops [generic Timoptic]

Page 14 of 17

Standard Formulary

Drug Alternatives indomethacin 25mg, indomethacin 50mg capsule, and at least two of the following lower cost NSAID products: celecoxib, etodolac, meloxicam, Tivorbex nabumetone, naproxen, sulindac

Tolsura itraconazole capsule, itraconazole solution

Tolak fluorouracil 2% solution, fluorouracil 5% solution betamethasone 0.05% ointment, desoximetasone 0.25% cream and ointment, desoximetasone 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% Topicort spray ointment generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, Tosymra zolmitriptan

Tovet calcipotriene 0.005% cream/ointment/ solution, tazarotene 0.1% cream

Trexall generic methotrexate tablet, methotrexate injection

Treximet sumatriptan in combination with over-the-counter naproxen triamcinolone 0.05% ointment (generic Trianex) triamcinolone 0.025% ointment, triamcinolone 0.1% ointment triamcinolone topical aerosol triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone spray (generic Kenalog) 0.025% ointment, triamcinolone 0.1% ointment

Trianex ointment triamcinolone 0.025% ointment, triamcinolone 0.1% ointment At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate Triglide micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule hydrocodone-chlorpheniramine suspension, promethazine-codeine 6.25- TussiCaps 10mg/5ml syrup, promethazine-dm 6.25-15mg/5ml syrup

Ultravate 0.05% lotion halobetasol 0.05% cream, halobetasol 0.05% ointment vancomycin oral solution (reconstituted) Firvanq prescription or over-the-counter omega-3 fatty acids, choline fenofibrate, fenofibrate 48mg, 54mg, 145mg, and 160mg tablet, fenofibrate micronized Vascepa 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Vectical calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, Veltin tazarotene 0.1% cream At least two lower cost other forms of desonide including cream, lotion, and Verdeso foam ointment

Vimovo esomeprazole in combination with naproxen generic meloxicam and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Vivlodex nabumetone, naproxen, sulindac At least two previous generic antifungals such as clotrimazole 1% cream, ketoconazole 2% cream, nystatin cream, ointment and powder, over-the- Vusion counter terbinafine cream, over-the-counter miconazole cream

Page 15 of 17

Standard Formulary

Drug Alternatives ezetimibe in combination with simvastatin, ezetimibe in combination with Vytorin atorvastatin or rosuvastatin clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin Winlevi 0.01% and 0.025% gel

Xerese acyclovir ointment in combination with hydrocortisone 1% cream over-the-counter fluticasone/Flonase (or the store brand), over-the-counter Nasacort Allergy (or the store brand), over-the-counter Rhinocort Allergy (or Xhance the store brand) doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Ximino Vibramycin capsule], minocycline IR capsule

Xolegel ketoconazole 2% cream, ketoconazole 2% shampoo

Yosprala omeprazole in combination with over-the counter aspirin esomeprazole, first-lansoprazole kit, first-omeprazole kit, lansoprazole, Zegerid capsule, packet omeprazole, pantoprazole, rabeprazole generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, Zembrace SymTouch zolmitriptan over-the-counter fluticasone/Flonase (or the store brand), over-the-counter Nasacort Allergy (or the store brand), over-the-counter Rhinocort Allergy (or Zetonna the store brand) clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, Ziana tazarotene 0.1% cream zileuton ER (extended-release) montelukast tablet, montelukast chew tablet, montelukast granules packet, [generic Zyflo CR] zafirlukast tablet azelaic acid 15% gel, metronidazole 0.75% cream, metronidazole 0.75% Zilxi gel, metronidazole 1% gel, metronidazole 0.75% lotion, Soolantra diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam, Zipsor nabumetone, naproxen, sulindac zolpidem sublingual tablet (generic Intermezzo) eszopiclone, zaleplon, zolpidem

Zolpimist eszopiclone, zaleplon, zolpidem generic zolmitriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, Zomig nasal spray zolmitriptan tablet generic zolmitriptan orally disintegrating tablets and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan Zomig ZMT (orally disintegrating (also available as an orally disintegrating tablet), sumatriptan, zolmitriptan tablet) tablet generic zolmitriptan tablet and at least one of the following lower cost Zomig tablet triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% Zonalon ointment, triamcinolone 0.5% cream

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Standard Formulary

Drug Alternatives diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam, Zorvolex nabumetone, naproxen, sulindac

Zovirax cream acyclovir 5% ointment

Ztlido lidocaine ointment, lidocaine patch, lidocaine solution

Zuplenz granisetron, ondansetron, ondansetron ODT (orally disintegrating tablet)

Zyclara imiquimod 5% cream montelukast tablet, montelukast chew tablet, montelukast granules packet, Zyflo (immediate-release) zafirlukast tablet montelukast tablet, montelukast chew tablet, montelukast granules packet, Zyflo CR (extended-release) zafirlukast tablet

Zypitamag atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

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