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Preferred drug list Effective May 1, 2017

Table of Contents

1.0 Analgesics ………………………………………………………………………………………... 1 2.0 Anesthetics ……………………………………………………………………………………….. 1 3.0 Antibiotics and Antivirals ………………………………………………………………………... 1 4.0 Antineoplastics/Immunosuppressants …………………………………………………………… 2 5.0 Cardiovascular Agents …………………………………………………………………………… 2 6.0 Central Nervous System Agents …………………………………………………………………. 3 7.0 Dermatologicals ………………………………………………………………………………….. 4 8.0 Eyes, Ears, Nose, Mouth and Throat …………………………………………………………….. 4 9.0 Endocrine Agents ………………………………………………………………………………… 5 10.0 Gastrointestinal Agents ………………………………………………………………………….. 5 11.0 Blood Modifiers, Nutritionals and Electrolytes ………………………………………………….. 6 12.0 OB/GYN …………………………………………………………………………………………. 6 13.0 Respiratory Agents ………………………………………………………………………………. 7 14.0 Skeletal Muscle Relaxants ……………………………………………………………………….. 8 15.0 Urologicals ……………………………………………………………………………………….. 8 16.0 Immunologicals, Vaccines and Biotechnology Drugs …………………………………………… 8 17.0 Smoking Cessation ………………………………………………………………………………. 8

www.anthem.com/inmedicaid Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee 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. WEBMAIN-0355-17 May 2017 Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 1 of 8 1.0 ANALGESICS NARCOTIC ANALGESIC rifampin COMBINATIONS Rifater AGENTS FOR MIGRAINE codeine/apap QLL apap/butalbital QLL hydrocodone/apap QLL ANTIVIRALS apap/caffeine/butalb QLL hydrocodone/ibuprofen QLL Abreva (OTC) apap/caffeine/butalbital/ oxycodone/apap QLL acyclovir codeine QLL oxycodone/aspirin QLL amantadine apap/caffeine/isomethep pentazocine/apap Baraclude PA apap/dichloral/caffeine pentazocine/naloxone QLL Descovy PA asa/caffeine/butalbital QLL famciclovir butalbital compound w/codeine QLL NONSTEROIDAL Fuzeon PA asa/butalbital QLL ANTI-INFLAMMATORIES Lamivudine 100mg PA asa/dihydrocodeine/caffeine QLL diclofenac potassium Rebetol solution PA QLL butalbital/asa/caffeine/codeine QLL diclofenac ER Relenza QLL butorphanol NS PA QLL etodolac ER/IR rimantadine divalproex OPT fenoprofen Selzentry ergotamine w/caffeine flurbiprofen Tamiflu QLL sumatriptan QLL ibuprofen valacyclovir PA

indomethacin IR/ER Valcyte CHELATING AGENTS ketoprofen IR/ER Viread PA (WILSON’S DISEASE) ketorolac IR/ER QLL Cuprimine meclofenamate CEPHALOSPORINS Depen meloxicam QLL cefaclor ER QLL Syprine nabumetone cefadroxil QLL

naproxen EC cefdinir QLL DMARDS naproxen sodium DS cefpodoxime QLL Cuprimine oxaprozin cefprozil QLL cyclophosphamide piroxicam cefuroxime QLL Enbrel PA QLL sulindac cephalexin QLL Humira PA QLL tolmetin cephradine hydroxychloroquine ceftriaxone injection leflunomide SALICYLATES methotrexate oral aspirin, aspirin cr 800mg FLUOROQUINOLONES prednisone /magnesium ciprofloxacin QLL PA sulfasalazine QLL salicylate levofloxacin QLL

diflunisal ofloxacin QLL PA GOUT MEDICATIONS salsalate allopurinol ANTIRETROVIRALS – colchicine/probenecid NUCLEOSIDE REVERSE probenecid QLL 2.0 ANESTHETICS TRANSCRIPTASE

TOPICAL LOCAL INHIBITOR (NRTI) HYLAURONICS ANESTHETICS PA ANALOGUES Euflexxa benzocaine (OTC) PA abacavir Gelsyn lidocaine jelly PA adefovir Supartz QLL PA lidocaine 5% patch dipivoxil

lidocaine/hydrocortisone didanosine MISCELLANEOUS lidocaine/prilocaine Emtriva ANALGESICS lamivudine acetaminophen stavudine IR only QLL 3.0 ANTIBIOTICS AND Vitekta tramadol/APAP QLL ANTIVIRALS Ziagen solution AMEBICIDES zidovudine NARCOTIC ANALGESICS metronidazole codeine QLL paromomycin sulfate ANTIRETROVIRAL fentanyl citrate lozenge QLL PA Yodoxin COMBINATIONS fentanyl patch QLL ST abacavir/lamivudine/zidovudine hydromorphone QLL ANTI-TUBERCULOSIS Epzicom meperidine QLL ethambutol Evotaz methadone QLL isoniazid Genvoya morphine sulfate ER tabs/IR QLL Mycobutin Kaletra oxycodone IR QLL Priftin lamivudine/zovudine pyrazinamide

Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 2 of 8 Prezcobix erythromycin base vancomycin capsule PA Stribild erythromycin Triumeq ethylsuccinate ANTIDOTE Truvada erythromycin stearate Evzio QLL doxycycline ANTIRETROVIRALS – monohydrate capsules, 4.0 ANTINEOPLASTICS/ PROTEASE INHIBITORS suspension only IMMUNOSUPPRESSANTS Aptivus minocycline (IR)

Crixivan tetracycline ALKYLATING AGENTS Norvir Alkeran cyclophosphamide Prezista ANTIHELMINTICS Reyataz Albenza Hexalen Viracept Biltricide Leukeran Ivermectin Myleran

PENICILLINS Pin-X (OTC) ANTINEOPLASTIC – amoxicillin QLL Reese Pinworm (OTC) HORMONAL AGENTS – amoxicillin/clavulanate QLL ANTIANDROGEN ampicillin QLL ANTIMALARIALS flutamide dicloxacillin QLL atovaquone/proguanil penicillin VK QLL chloroquine phosphate hydroxychloroquine ANTINEOPLASTIC – ANTIFUNGALS – ORAL mefloquine HORMONAL AGENTS – clotrimazole troche primaquine phosphate ANTIESTROGEN GL fluconazole letrozole tamoxifen flucytosine ANTIPROTAZOALS griseofulvin ultra tab pentamidine griseofulvin susp isoethionate ANTINEOPLASTIC – HORMONAL AGENTS – itraconazole PA ketoconazole ANTIRETROVIRALS AROMATASE INHIBITORS anastrozole GL nystatin INTEGRASE INHIBITORS GL PA exemestane terbinafine tablets Isentress voriconazole Tivicay ANTINEOPLASTIC – Vitekta HORMONAL ANTIFUNGALS – TOPICAL AGENTS – PROGESTINS Various OTC ANTIRETROVIRALS Megestrol butenafine OTC NON- NUCLEOSIDE REVERSE ciclodan 8% soln TRANSCRIPTASE ANTIMETABOLITES ciclopirox 8% crm, soln INHIBITORS (NNRTI) mercaptopurine clotrimazole QLL ANALOGUES methotrexate ketoconazole crm, shampoo Intelence Tabloid clotrimazole/ nevirapine Trexall miconazole nitrate OTC Rescriptor nystatin crm, oint, powder Viramune XR IMMUNO- PA required age 8 and under terbinafine SUPPRESSANTS/ IMMUNO- tolnaftate crm, powder MODULATORS TOPICAL ANTIBIOTICS azathioprine LEPROSTATICS gentamicin Dapsone ointment MISCELLANEOUS silver sulfadiazine ANTINEOPLASTICS MACROLIDES Emcyt PA azithromycin tablet QLL URINARY ANTI-INFECTIVES etoposide clarithromycin methenamine imatinib PA erythromycin nitrofurantoin caps hydroxyurea erythromycin/sulfisoxazole trimethoprim leucovorin Lysodren SULFONAMIDES MISCELLANEOUS ANTI- sulfadiazine INFECTIVES Matulane sulfamethoxazole/trimethoprim DS clindamycin octreotide PA sulfasoxazole tretinoin tinidazole

TETRACYCLINES tobramycin ampules Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 3 of 8 5.0 CARDIOVASCULAR HMG CO A REDUCTASE DIURETICS AGENTS INHIBITORS (STATINS) amiloride, atorvastatin QLL amiloride/hctz ACE INHIBITORS/ACE I lovastatin QLL bumetanide COMBINATIONS pravastatin QLL chlorothiazide benazepril/benazepril hctz QLL simvastatin QLL furosemide captopril/captopril hctz simvastatin 80mg ST hydrochlorothiazide enalapril/enalapril hctz indapamide fosinopril/fosinopril hctz QLL PCSK-9 INHIBITORS methychlothiazide lisinopril/lisinopril hctz QLL Repatha PA QLL metolazone moexipril/moexipril hctz spironolactone; quinapril/quinapril hctz NIACIN spironolactone/hctz ramipril niacinIR/ER (OTC) torsemide trandolapril niacinamide triamterene/hctz

slo-niacin BETAADRENERGIC NITRATES

ANTAGONISTS FIBRATES isosorbide dinitrate acebutolol fenofibrate isosorbide mononitrate atenolol gemfibrozil primidone QLL atenolol/chlorthalidone Nitro-Bid betaxolol BILE ACID SEQUESTRANTS nitroglycerin ER capsules bisoprolol/ bisoprolol/hctz cholestyramine nitroglycerin ointment metoprolol cholestyramine lite nitroglycerin patch metoprolol/hctz colestipol granules nitroglycerin SL nadolol nitroglycerin spray pindolol CALCIUM ANTAGONISTS Nitro-Stat tablets propranolol AND COMBINATIONS propranolol/hctz amlodipine OPT PERIPHERAL sotalol amlodipine/benazepril VASODILATORS timolol diltiazem; AND COMBINATIONS

diltiazem CR OPT hydralazine ALPHA BETA BLOCKERS diltiazem CD OPT hydralazine/hctz carvedilol diltiazem SR OPT minoxidil labetalol felodipine OPT

nicardipine OPT PRESSORS ANGIOTENSION RECEPTOR nifedipine Midodrine BLOCKERS (ARB) AND ARB nifedipine ER OPT COMBINATIONS verapamil candesartan QLL 6.0 CENTRAL NERVOUS verapamil SR OPT candesartan/HCTZ QLL SYSTEM AGENTS irbesartan QLL CARDIAC GLYCOSIDES ANTAGONISTS QLL irbesartan/HCTZ digoxin disulfiram losartan QLL losartan / HCTZ QLL ANTIARRHYTHICS ANTICONVULSANTS QLL valsartan/HCTZ amiodarone HYDANTOINS QLL disopyramide CR phenytoin QLL CENTRALLY ACTING AND flecainide phenytoin extended COMBINATIONS – Mexiletine

ANTIADRENERGICS Pacerone ANTICONVULSANTS – OPT clonidine tablets propafenone SUCCINIMIDES QLL guanabenz ethosuximide OPT guanfacine gluconate methyldopa quinidine sulfate ANTICONVULSANTS – methyldopa hctz Nitro-bid BARBITURATES OPT nitroglycerin ER caps phenobarbital ANTIADRENERGICS – nitroglycerin ointment primidone PERIPHERALLY ACTING nitroglycerin patch doxazosin nitrolycerin SL ANTICONVULSANTS – MISC. OPT QLL prazosin nitrolycerin spray Carbamazepine OPT QLL terazosin Nitro-Stat tablets Carbatrol OPT QLL clonazepam depakene OPT QLL Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 4 of 8 diazepam OPT QLL benzoyl peroxide OTC solution diazepam rectal gel QLL clindamycin 1% solution, pledgets halobetasol crm, oint divalproex OPT QLL clindamycin-benzoyl peroxide 1.2- epitol QLL 5% gel SCABICIDES/PEDICULCIDES lamotrigine disper tab, ER, ODT QLL erythromycin 2% soln, pledgets permethrin levetiracetam QLL metronidazole cream benzyl benzoate QLL oxcarbazepine sodium sulfacetamide/sulfur piperonyl butoxide/pyrethrins (OTC) roweepra QLL tretinoin 0.1% tube Spinosad 0.9% topical susp tiagabine (2mg and 4mg) QLL tretinoin 0.05% emollient cr topiramate QLL KERATOLYTICS zonisamide QLL ISOTRETINOINS podofilox soln valproic acid QLL Claravis PA Myorisan PA MISCELLANEOUS ANTIPARKINSON AGENTS Zenatane PA 8-MOP dramamine aluminum chloride soln amantadine ORAL ANTIPRURITIC amlactin benztropine AGENTS Betamide bromocriptine calamine (OTC) carbidopa/levodopa IR, ER, ODT hydroxyzine OPT fluorouracil QLL lactic acid 50mg tbc spray entacapone ANTI-PSORIASIS/ECZEMA/ urea pramipexole DERMATITIS ropinirole calcipotriene PA 8.0 EYES, EARS, NOSE, selegiline methotrexate MOUTH AND THROAT selenium sulfide tacrolimus oint QLL PA MOUTH AND THROAT/ ALZHEIMERS AGENTS TEETH Donepezil ODT QLL BURN THERAPY doxycycline galatamine QLL nitrofurazone lidocaine viscous Namenda QLL silver sulfadiazine rivastigmine QLL stannous fluoride - acetonide ANTIEMETIC AND TOPICAL ANTIVERTIGOS Low Potency: NASAL STEROIDS dramamine QLL OTC hydrocortisone cream, Flonase Allergy Relief dronabinol PA Nasacort Allergy 24 HR QLL OTC ointment, solution Medium Potency: metoclopramide NASAL MISCELLANEOUS QLL betamethasone dip ondansetron ODT nasal spray QLL prochlorperazine lotion cromolyn nasal solution, spray promenthazine age 2 & up betamethasone val ipratropium bromide nasal spray QLL Transderm–Scop PA cream Trimethobenzamide cream, OPHTHALMICS – ointment ANTIVIRALS ANTIMANIA AGENTS cream, trifluridine lithium ointment, lotion triamcinolone cream, OPHTHALMICS – OPIOID DEPENDANCE ointment ANTI-INFLAMMATORY buprenorphine/naloxone QLL PA High Potency: sl tabs amcinonide ointment diclofenac 0.1% drops naloxone inj QLL betamethasone dip fluorometholone naltrexone tabs cream flurbiprofen sodium Narcan 4mg nasal spray QLL betamethasone val Suboxone film QLL PA sulf/pred sodium oint

MISCELLANEOUS CNS fluocinonide E cream OPHTHALMICS pyridostigmine Very High Potency: – ANTI-ALLERGY/ Clobetasol prop E Cream (OTC) 7.0 DERMATOLOGICALS Alaway Clobetasol prop azelastine QLL PA ANTI-ACNE cream, gel, ointment, cromolyn sodium QLL adapalene PA QLL Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 5 of 8 epinastine QLL /hydrocortisone nateglinide PA ketotifen QLL ofloxacin otic pioglitazone ST QLL PA pramoxinel/chloroxylenol pioglitazone/metformin QLL OPHTHALMICS – /hydrocortisone pioglitazone/glimepiride QLL ANTIBIOTICS repaglinide ST bacitracin 9.0 ENDOCRINE AGENTS Synjardy ST QLL bacitracin/polymyxin B Symlin PA ANDROGENS, ANDROGEN ciprofloxacin Tanzeum ST QLL INHIBITORS/ANABOLIC erythromycin Tradjenta ST QLL STEROIDS ST QLL gentamicin PA QLL Victoza levofloxacin testosterone 1% gel testosterone cyp inj PA neomycin/bacitracin/ INSULIN testosterone enan inj PA polymyxin/HC Apidra neomycin /dexamethasone Basaglar Kwikpen neomycin/polymyxin/bacitracin ANTITHYROID Humulin products propylthiouracil neomycin/polymyxin/gramicidin Novolin products methimazole neomycin/polymyxin/dexamethaso neomycin/polymyxin THYROID /hydrocortisone OSTEOPOROSIS AGENTS levothyroxine QLL ofloxacin alendronate levoxyl QLL polymyxin B/trimethoprim calcitonin-salmon liothyronine sulfacetamide solution Fortical nature-throid Raloxifene sulfacetamide /prednisolone np thyroid tobramycin thyroid tobramycin /dexamethasone ESTROGENS AND ESTROGEN unithroid ANDROGEN COMBINATIONS westhroid estradiol OPHTHALMICS – estradiol patch ANTIGLAUCOMA MISCELLANEOUS acetazolamide estradiol-norethindrone estropipate desmopressin spray, soln, tab apraclonidine Norethindrone fludrocortisone Azopt Premarin cream Dex4 Glucose betaxolol Premphase Insta-Glucose brimonidine Prempro carteolol 10.0 GASTROINTESTINAL dorzolamide Dexamethasone AGENTS dorzolamide/timolol hydrocortisone latanoprost methylprednisolone levobunolol /MOTILITY prednisolone methazolamide /ANTISPASMODICS prednisone metipranolol belladonna/phenobarb triamcinolone pilocarpine hcl chlordiaezepoxide timololPA QLL GROWTH HORMONE /clindium Zomacton PA QLL dicyclomine MISCELLANEOUS glycopyrrolate artificial tears (OTC) HYPERGLYCEMICS sulfate glucagon methscopolamine naphazoline/ metoclopramide HYPOGLYCEMICS propantheline acarbos proparacaine Bydureon ST QLL ANTIDIARRHEAL tetrahydrozoline (OTC) glimepiride (OTC) bismuth subsalicylate glipizide; ER/IR/XL diphenoxylate with atropine OTIC glipizide/metformin QLL acetic acid loperamide glyburide; glyburide acetic acid/aluminum QLL micronized QLL acetate ANTI-INFLAMMATORIES glyburide/metformin QLL antipyrine/benzocaine/glycerin Apriso Januvia ST QLL benzocaine balsalazide Janumet, IR/XR ST QLL cortane-b EC Jardiance ST QLL Floxin 0.3% hydrocortisone enema Jentadueto, XR ST QLL QLL neomycin/polymyxin/ mesalamine metformin ER/IR Pramoxine Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 6 of 8 /hydrocortisone sulfonate 12.0 OB/GYN sulfasalazine EC ANTIFUNGALS – VAGINAL PRENATAL VITAMINS AGES clotrimazole H2 RECEPTOR ANTAGONISTS 12-45, FEMALES ONLY fluconazole 150mg tablet famotidine oral/vial (various) miconazole ranitidine multivitamins w/folic acid nystatin prenatal w/docusate, iron, folic acid terconazole PROTECTANTS prenatal multivitamins with misoprostol minerals/iron ANTI-INFECTIVES – sucralfate /folic acid VAGINAL

Cleocin Ovule PROTON PUMP INHIBITORS VITAMINS clindamycin Nexium OTC QLL /MINERALS fem ph omeprazole OTC QLL /SUPPLEMENTS metronidazole calcitriol

LAXATIVES calcium/magnesium (OTC) MONOPHASICS – bisacodyl (OTC) calcium carbonate (OTC) ORAL CONTRACEPTIVES docusate (OTC) calcium lactate (OTC) (QLL Applies) docusate/casanthranol (OTC) ferrous gluconate (OTC) alyacen 1/35 glycolax ferrous sulfate (OTC) altavera lactulose folic acid apri magnesium hydroxide (OTC) iron/B12/folic acid aviane polyethylene glycol- iron combination capsule balziva electrolyte solution iron/intrinsic factor/B12 briellyn multivitamins (OTC) chateal MISCELLANEOUS multivitamins w/minerals (OTC) cryselle Creon multivitamins w/fluoride cyclafem 1/35 mag hydrox/al hydrox renaphro dasetta 1/35 /simethicone (OTC) sodium flouride drospirenone/ Pancrelipase stannous fluoride ethinyl estradiol sodium bicarbonate triple vitamins w/fluoride elinest ursodiol zinc sulfate (RX only) emoquette PKU enskyce Camino (OTC) 11.0 BLOOD MODIFIERS estarylla Complex MSD (OTC) NUTRITIONALS AND estradiol PAfalmina Glutarade (OTC) ELECTROLYTES gianvi Glytactin (OTC) gildagia PLATELET AGGREGATION Lanaflex (OTC) gildess, fe 1/20, 1.5/30 PA INHIBITORS/ MSUD (OTC) junel, fe 1/20, 1.5/30 PA ANTICOAGULANT Periflex kelnor 1/35 /PVD Phenylade (OTC) kurvelo aspirin PKU (OTC) lessina anagrelide XLEU (OTC) levora cilostazol XLYS (OTC) levonorgestrel/ethinyl clopidogrel QLL XMET (OTC) loryna Coumadin XPHE (OTC) low ogestrel dipyridamole lutera Eliquis MISCELLANEOUS marlissa enoxaparin PA QLL aminocaproic acid microgestin, fe 1/20, 1.5/30 PA Jantoven calcium acetate mono-linyah Pentoxifylline Eliphos PA QLL mononessa PA ticlopidine levocarnitine necon 0.5/35, 1/35, 1/50, warfarin pediatric electrolyte (OTC) norgestimate/ethinyl Xarelto potassium citrate nortrel 0.5/35, 1/35 citric acid ocella POTASSIUM SUPPLEMENTS pot. & sod. citrates ogestrel 0.5/50 potassium chloride w/citric acidsodium citrate & citric orsythia acid philith PA POTASSIUM REMOVING sodium fluoride pirmella PA RESINS Velphoro PA portia sodium polystyrene previfem PA Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 7 of 8 reclipsen quasense /carbetapentane sprintec PA sronyx PROGESTIN ONLY – ORAL /chlorpheniramine syeda CONTRACEPTIVES vestura camila / wera wymzya fe PA errin EXPECTORANT/ zarah heather ANTITUSSIVE zenchent jencycla COMBINATIONS AGE 2 AND fe zeosa zovia,1/35, 1/50 jolivette OVER nora-be benzonatate dextromethorphan BIPHASICS – norethindrone /guaifenesin ORAL CONTRACEPTIVES guaifenesin SR (QLL Applies) OXYTOCICS guaifenesin azurette 28 methylergonovine /dextromethorphan kariva 28 guaifenesin necon 10-11-28 PROGESTINS /pseudoephedrine viorele 28 medroxyprogesterone, oral phenyleph-ephed-cpd with norethindrone carbetapentane TRIPHASICS – progesterone, oral ORAL CONTRACEPTIVES /dextromethorphan (QLL Applies) MISCELLANEOUS pseudoephedrine alyacen 7/7/7 amino-acid cervical /guaifenesin aranelle diaphragm pseudoephed caziant Econtra ez 1.5mg /dexchlorphen/dm cyclafem 7/7/7 Fallback solo 1.5mg tab dasetta 7/7/7 Fem Cap NARCOTIC ANTITUSSIVE/ enpresse levonorgestrel 1.5mg tab QLL EXPECTORANT/ leena levonorgestrel (React) QLL DECONGESTANTS AGE 2 AND levonest My Way 1.5mg QLL OVER myzilra Next Choice One Dose 1.5mg QLL guaifenesin/codeine necon 7/7/7 Nuvaring guaifenesin norgestimate/ethinyl Opcicon One-Step 1.5mg /hydrocodone QLL estradiol hydrocodone with QLL nortrel 7/7/7 ulipristal acetate (Ella) phenyleph/chlorphen/ tilia fe Xulane hydrocodone QLL tri-estarylla phenyleph hcl tri-legest fe /hydrocod bit/cp QLL tri-linyah 13.0 RESPIRATORY AGENTS phenyleph-pyrilamine with tri-nessa – hydrocodone QLL tri-previfem NONSEDATING phenylephrine tri-sprintec fexofenadine QLL /promethazine/codeine QLL trivora fexofenadine /pseudoephredine QLL promethazine/codeine velivet loratadine (OTC) loratadine /pseudoephredine (OTC) BETA AGONIST

OTC CONTRACEPTIVES albuterol ANTIHISTAMINES – OTHER condom male/female (OTC) metaproterenol fumarate condom/spermicide (OTC) Terbutaline diphenhydramine (OTC) diaphragm Ventolin HFA QLL (OTC) vcf contraceptive foam Serevent Diskus ST QLL

ANTIHISTAMINE AND CONTINUOUS CYCLE INHALED DECONGESTANTS AGE 2 AND CONTRACEPTIVES CORTICOSTEROIDS AND OVER Amethyst CORTICOSTERIODS COMBINATIONS /phenyeph EXTENDED CYCLE Aerospan QLL chlorpheniramine CONTRACEPTIVES Arnuity Ellipta QLL /phenyleph amethia PA budesonide respules PA overage 5, QLL chlorphen/phenylprop camrese Breo Ellipta ST QLL /mescopol daysee Dulera ST QLL introvale /pseudoephedrin jolessa PA phenyleph/chlorphen Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 8 of 8 AND SKELETAL MUSCLE RELATED MEDICATIONS RELAXANTS

Atrovent HFA QLL baclofen Anoro Ellipta QLL carisoprodol Combivent Respimat QLL chlorzoxazone ipratropium bromide metaproterenol dantrolene Spiriva QLL methocarbamol QLL

LEUKOTRIENE RECEPTOR tizanidine tablets

ANTAGONISTS /MODIFIERS 15.0 UROLOGICALS QLL doxazosin finasteride PA METHYLXANTHINES dyphylline/guaifenesin meth/salicylate/atropine/ Theo-24 hyos/benzoic methenamine/hyosc/meth syrup elixir theophylline SR blue/sod biphos/phenyl sal IR/ER phenazopyridine MISCELLANEOUS acetylcysteine tamsulosin terazosin Adcirca PA IR/ER Broncho (OTC) epinephrine auto-injectors QLL trospium IR/ER epinephrine 0.1mg/ml syringe epinephrine 1mg/ml vial 16.0 IMMUNOLOGICALS, Pulmozyme PA VACCINES AND sildenafil 20mg PA BIOTECHNOLOGY DRUGS saline INTERFERONS/ 1. sodium chloride spacer IMMUNOMODULATORS Avonex PA PULMONARY ARTERIAL Betaseron PA HYPERTENSION Copaxone 20mg/mL PA PA Letairis Extavia PA Gilenya QLL ST SPACER DEVICES Infergen PA QLL QLL Ace Aerosol Cloud Enhancer imiquimod PA QLL QLL Aerotrach Holding Chamber Rebif PA QLL QLL Aerovent Plus Holding Chamber Tecfidera PA QLL Breatherite Spacer QLL QLL Breathrite Chamber HEMATOPOIETIC GROWTH Compact Space Chamber QLL FACTORS QLL Liteaire Aranesp PA QLL Microchamber Epogen PA QLL Microspacer Procrit PA Optichamber Diamond QLL QLL Pocket Chamber IMMUNE GLOBULINS Primeaire Chamber QLL Gamunex-C PA Prochamber Holding Chamber QLL Octagam PA Riteflo Spacer QLL Vortex Holding Chamber QLL 17.0 SMOKING CESSATION Vortex VHC Frog Child Mask QLL Vortex VHC Ladybug Toddler QLL nicotine patch, lozenge, Watchhaler Spacer QLL gum (OTC) buproban, bupropion OPT

14.0 SKELETAL MUSCLE RELAXANTS