Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region

The following is a listing of the drugs on the Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region. This formulary applies only to outpatient drugs provided to members for self-administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the formulary.

Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring.

How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters.

Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-preferred drug.

You can search the list by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category.

All dosage forms and strengths for a particular drug listed may not be formulary. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share.

Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 1 -  Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, Entocort EC®, a drug used for colitis, is restricted to physicians specialized in Gastroenterology.  Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.  Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.  Restricted to Benefit: Some drugs are not covered unless the individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers them.  Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.  Restricted to a specific age: Some medications may be restricted to a certain age or age range.  Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests: o Request to cover a drug that is not on our preferred product list o Request to waive coverage restrictions or limitations  Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s preferred product list, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects.

Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance.  (diamond) = A drug that is designated as a Specialty drug which may process at a Specialty tier of the individual prescription drug benefit, where applicable. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. AG = A drug that is restricted to a specific age range. NC = A drug that is specifically excluded under certain benefit plans.

This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Kaiser Permanente Member Services at 1-888-681-7878.

The medications on this list are subject to change at any time throughout the year

Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 2 -

Drug Name Drug Tier Requirements/Limits ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA Brand BILTRICIDE Brand ivermectin Generic MEBENDAZOLE Brand YODOXIN Brand ANTIBACTERIALS amoxicillin Generic/Brand † amoxicillin & pot clavulanate Generic/Brand † ampicillin Generic/Brand † ampicillin & sulbactam sodium Generic/Brand *† ampicillin sodium Generic * AVELOX Brand * azithromycin Generic/Brand *† aztreonam Generic * BACTOCILL/DEXTROSE Brand * BICILLIN L-A Brand * CAYSTON Brand  cefaclor Generic/Brand † cefadroxil Generic cefazolin sodium Generic/Brand † cefdinir Generic cefepime hcl Generic * cefixime Generic CEFOTETAN Brand * CEFOTETAN/DEXTROSE Brand * cefprozil Generic ceftazidime Generic * ceftriaxone sodium Generic * CEFTRIAXONE SODIUM/DEXTROSE Brand * cefuroxime axetil Generic/Brand † cefuroxime sodium Generic * cephalexin Generic ciprofloxacin Generic/Brand *† ciprofloxacin hcl Generic ciprofloxacin in d5w Generic * ciprofloxacin-ciprofloxacin hcl Generic clarithromycin Generic clindamycin hcl Generic/Brand † dicloxacillin sodium Generic doxycycline (monohydrate) Generic doxycycline hyclate Generic/Brand * E.E.S. 400 Brand ERYTHROCIN LACTOBIONATE Brand * ERYTHROCIN STEARATE Brand erythromycin Generic/Brand †

Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 3 - Drug Name Drug Tier Requirements/Limits erythromycin-sulfisoxazole Generic gentamicin sulfate Generic * INVANZ Brand * levofloxacin Generic * levofloxacin in d5w Generic * linezolid Generic/Brand *  QL minocycline hcl Generic moxifloxacin hcl Generic neomycin sulfate Generic/Brand † PCE Brand penicillin g potassium Generic * PENICILLIN G PROCAINE Brand * PENICILLIN G SODIUM Brand * penicillin v potassium Generic piperacillin sodium-tazobactam sodium Generic * PRIMAXIN IV Brand * PRIMSOL Brand SPECTRACEF Brand STREPTOMYCIN SULFATE Brand * SULFADIAZINE Brand sulfamethoxazole-trimethoprim Generic * sulfasalazine Generic SUPRAX Brand TETRACYCLINE HCL Brand TOBI Podhaler Brand  QL Tobramycin neb Generic  QL tobramycin sulfate Brand * vancomycin hcl Generic *  QL VANCOMYCIN HCL IN DEXTROSE Brand * ZOSYN Brand * ZYVOX Brand *  QL ANTIFUNGALS AMBISOME Brand * AMPHOTERICIN B Brand * ANCOBON Brand CANCIDAS Brand * fluconazole Generic * fluconazole in nacl Generic * griseofulvin microsize Generic/Brand † griseofulvin ultramicrosize Generic itraconazole Generic/Brand † ketoconazole Generic nystatin Generic nystatin (mouth-throat) Generic voriconazole Generic * Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 4 - Drug Name Drug Tier Requirements/Limits ANTIMYCOBACTERIALS atovaquone-proguanil hcl Generic DAPSONE Brand ethambutol hcl Generic isoniazid Generic/Brand † pyrazinamide Generic rifabutin Generic  rifampin Generic * ANTIPROTOZOALS atovaquone Generic  QL atovaquone-proguanil hcl Generic chloroquine phosphate Generic DARAPRIM Brand hydroxychloroquine sulfate Generic mefloquine hcl Generic METRO IV Brand * metronidazole Generic NEBUPENT Brand * paromomycin sulfate Generic PRIMAQUINE PHOSPHATE Brand ANTIVIRALS abacavir-lamivudine-zidovudine Generic  abacavir sulfate Generic/Brand † acyclovir Generic acyclovir sodium Generic * adefovir dipivoxil Generic  QL amantadine hcl Generic/Brand † APTIVUS Brand  ATRIPLA Brand  BARACLUDE SOLN Brand  COMPLERA Brand  CRIXIVAN Brand CYTOVENE Brand * didanosine Generic/Brand † EDURANT Brand  EMTRIVA Brand entecavir Generic EPIVIR HBV Brand EPZICOM Brand  famciclovir Generic FOSCAVIR Brand * ganciclovir Generic * HARVONI Brand  QL INTELENCE Brand  INVIRASE Brand  Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 5 - Drug Name Drug Tier Requirements/Limits ISENTRESS Brand  KALETRA Brand  lamivudine Generic/Brand † lamivudine-zidovudine Generic LEXIVA Brand  nevirapine Generic/Brand † NORVIR Brand  PEG-INTRON Brand *  QL PEGASYS Brand *  QL PREZISTA Brand  RELENZA DISKHALER Brand RESCRIPTOR Brand REYATAZ Brand  ribavirin (hepatitis c) Generic rimantadine hydrochloride Generic SELZENTRY Brand  SOVALDI Brand *  QL stavudine Generic STRIBILD Brand  SUSTIVA Brand SYNAGIS Brand * TAMIFLU Brand TIVICAY Brand  TRUVADA Brand  TYZEKA Brand  QL valacyclovir hcl Generic VALCYTE Brand  QL valganciclovir Generic  QL VICTRELIS Brand  QL VIRACEPT Brand *  VIREAD Brand  zidovudine Generic URINARY ANTI-INFECTIVES methenamine hippurate Generic methenamine mandelate Generic/Brand † methenamine-hyosc-methylene blue-sod phos-phenyl sal Generic nitrofurantoin macrocrystal Generic/Brand † nitrofurantoin monohyd macro Generic trimethoprim Generic UROQID #2 Brand ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS cyproheptadine hcl Generic diphenhydramine hcl Generic * promethazine hcl Generic/Brand *† Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 6 - Drug Name Drug Tier Requirements/Limits ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE Brand * AFINITOR Brand  QL ALKERAN Brand anastrozole Generic AVASTIN Brand * BICNU Brand * bleomycin sulfate Generic * capecitabine Generic carboplatin Generic * CEENU Brand cisplatin Generic * CYCLOPHOSPHAMIDE Generic/Brand *† cytarabine Generic * dacarbazine Generic * dactinomycin Generic * daunorubicin hcl Generic * DOCETAXEL Brand * doxorubicin hcl Generic * ELIGARD Brand * EMCYT Brand  QL ERBITUX Brand * etoposide Generic/Brand *† exemestane Generic fludarabine phosphate Generic * fluorouracil Generic * flutamide Generic GEMZAR Brand * GLEEVEC Brand  QL HERCEPTIN Brand * HEXALEN Brand  hydroxyurea Generic IDAMYCIN PFS Brand * ifosfamide Generic * IFOSFAMIDE/MESNA Brand IMBRUVICA Brand  QL INTRON-A Brand *  QL IRESSA Brand  QL letrozole Generic LEUKERAN Brand leuprolide acetate Generic/Brand *† LUPRON Brand * LUPRON DEPOT-PED Brand * LYSODREN Brand  QL Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 7 - Drug Name Drug Tier Requirements/Limits MATULANE Brand  QL megestrol acetate Generic melphalan hcl Generic * mercaptopurine Generic methotrexate sodium Generic/Brand *† mitomycin Generic * mitoxantrone hcl Generic * MUSTARGEN Brand * MYLERAN Brand NEXAVAR Brand  QL NILANDRON Brand NIPENT Brand * paclitaxel Generic * PURIXAN Brand REVLIMID Brand  QL RHEUMATREX Brand RITUXAN Brand * SPRYCEL Brand  QL SUTENT Brand  QL TABLOID Brand tamoxifen citrate Generic TARCEVA Brand  QL TARGRETIN Brand  QL TASIGNA Brand  QL temozolomide (5mg, 20mg) Generic temozolomide (100mg, 140mg, 180mg, 250mg) Generic  QL THIOTEPA Brand * topotecan hcl Generic * TORISEL Brand * tretinoin (chemotherapy) Generic  QL TYKERB Brand  QL VIDAZA Brand * VINBLASTINE SULFATE Brand * vincristine sulfate Generic * vinorelbine tartrate Generic * VOTRIENT Brand  QL XALKORI Brand  QL XTANDI Brand  QL ZELBORAF Brand  QL ZOLADEX Brand * ZOLINZA Brand  QL ZYDELIG Brand  QL ZYTIGA Brand  QL AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 8 - Drug Name Drug Tier Requirements/Limits atropine sulfate Generic * ATROVENT HFA Brand benztropine mesylate Generic clidinium & chlordiazepoxide Generic dicyclomine hcl Generic/Brand *† DONNATAL EXTENTABS Brand glycopyrrolate Generic * hyoscyamine sulfate Generic ipratropium bromide Generic ipratropium bromide (nasal) Generic PROPANTHELINE BROMIDE Brand SCOPOLAMINE HYDROBROMIDE Brand * SPIRIVA RESPIMAT Brand trihexyphenidyl hcl Generic AUTONOMIC DRUGS, MISCELLANEOUS phenoxybenzamine hcl Generic PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride Generic cevimeline hcl Generic donepezil hydrochloride Generic/Brand † ENLON Brand * neostigmine methylsulfate Generic * pilocarpine hcl (oral) Generic pyridostigmine bromide Generic/Brand † SKELETAL MUSCLE RELAXANTS baclofen Generic carisoprodol Generic carisoprodol w/ aspirin Generic cyclobenzaprine hcl Generic dantrolene sodium Generic * methocarbamol Generic/Brand *† tizanidine hcl Generic SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADRENALIN Brand * ADVAIR DISKUS Brand ALBUTEROL Brand albuterol sulfate Generic/Brand † COMBIVENT Brand DULERA Brand ephedrine sulfate (pressors) Generic * epinephrine hcl Generic/Brand *† ERGOLOID MESYLATES Brand FORADIL AEROLIZER Brand levalbuterol hcl Generic/Brand † METAPROTERENOL SULFATE Brand Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 9 - Drug Name Drug Tier Requirements/Limits midodrine hcl Generic norepinephrine bitartrate Generic * SEREVENT DISKUS Brand terbutaline sulfate Generic * VENTOLIN HFA Brand XOPENEX HFA Brand BLOOD FORMATION, COAGULATION, AND THROMBOSIS ANTITHROMBOTIC AGENTS cilostazol Generic FRAGMIN Brand *  heparin sodium Generic/Brand *† COAGULANTS AND ANTICOAGULANTS ACTIVASE Brand * ADVATE Brand * AGGRENOX Brand ALPHANINE SD Brand * aminocaproic acid Generic/Brand *† anagrelide hcl Generic BENEFIX Brand * BRILINTA Brand clopidogrel bisulfate Generic dipyridamole Generic EFFIENT Brand enoxaparin sodium Generic  fondaparinux sodium Generic *  QL HELIXATE FS Brand * heparin sod (porcine) in d5w Generic * heparin sodium (porcine) Generic * heparin sodium (porcine) lock flush Generic * HESPAN Brand * HUMATE-P Brand * KINLYTIC Brand * KOATE-DVI Brand * pentoxifylline Generic PLASMANATE Brand * PRADAXA Brand PROFILNINE SD Brand *  QL PROTAMINE SULFATE Brand * THROMBIN-JMI DILUENT Brand * TNKASE Brand * tranexamic acid Generic warfarin sodium Generic HEMATOPOIETIC AGENTS anagrelide hcl Generic EPOGEN Brand *  QL Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 10 - Drug Name Drug Tier Requirements/Limits LEUKINE Brand *  QL NEULASTA Brand *  QL NEUPOGEN Brand *  QL PROCRIT Brand *  QL ZARXIO Brand *  QL CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate Generic prazosin hcl Generic terazosin hcl Generic ANTILIPEMIC AGENTS atorvastatin calcium Generic cholestyramine Generic cholestyramine light Generic colestipol hcl Generic/Brand † CRESTOR Brand fenofibrate Generic fenofibrate micronized Generic gemfibrozil Generic lovastatin Generic NIASPAN Brand pravastatin sodium Generic simvastatin Generic BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl Generic atenolol Generic atenolol & chlorthalidone Generic bisoprolol & hydrochlorothiazide Generic bisoprolol fumarate Generic carvedilol Generic COREG CR Brand labetalol hcl Generic * metoprolol succinate Generic metoprolol tartrate Generic * nadolol Generic pindolol Generic propranolol hcl Generic/Brand *† sotalol hcl Generic CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate Generic amlodipine besylate-benazepril hcl Generic CARDENE SR Brand diltiazem hcl Generic * diltiazem hcl coated beads Generic

Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 11 - Drug Name Drug Tier Requirements/Limits diltiazem hcl extended release beads Generic DYNACIRC CR Brand EXFORGE Brand EXFORGE HCT Brand felodipine Generic nifedipine Generic nimodipine Generic TARKA Brand verapamil hcl Generic/Brand *† CARDIAC DRUGS adenosine Generic * amiodarone hcl Generic * digoxin Generic/Brand *† disopyramide phosphate Generic/Brand † dopamine hcl Generic * flecainide acetate Generic lidocaine hcl (cardiac) Generic * lidocaine w/ epinephrine Generic * mexiletine hcl Generic PROCAINAMIDE HCL Brand * propafenone hcl Generic quinidine gluconate Generic quinidine sulfate Generic/Brand † TIKOSYN Brand HYPOTENSIVE AGENTS acetazolamide Generic/Brand † acetazolamide sodium Generic * clonidine hcl Generic guanfacine hcl Generic hydralazine hcl Generic methazolamide Generic methyldopa Generic minoxidil Generic NITROPRESS Brand * PHENTOLAMINE MESYLATE Brand * RESERPINE Brand RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS benazepril & hydrochlorothiazide Generic benazepril hcl Generic captopril Generic CAPTOPRIL/HYDROCHLOROTHIAZIDE Brand enalapril maleate Generic fosinopril sodium Generic fosinopril sodium & hydrochlorothiazide Generic lisinopril Generic Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 12 - Drug Name Drug Tier Requirements/Limits lisinopril & hydrochlorothiazide Generic losartan potassium Generic losartan potassium & hydrochlorothiazide Generic moexipril hcl Generic moexipril-hydrochlorothiazide Generic quinapril hcl Generic quinapril-hydrochlorothiazide Generic ramipril Generic spironolactone Generic spironolactone & hydrochlorothiazide Generic valsartan Generic valsartan-hydrochlorothiazide Generic VASODILATING AGENTS alprostadil Generic * QL, RB epoprostenol sodium Generic * isosorbide dinitrate Generic/Brand † isosorbide mononitrate Generic nitroglycerin Generic/Brand *† sildenafil citrate (pulmonary hypertension) Generic QL, RB OPSUMIT Brand  QL TRACLEER Brand  QL VENTAVIS Brand *  QL CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen w/ codeine Generic BUPRENEX Brand * buprenorphine hcl-naloxone hcl dihydrate Generic/Brand † QL butalbital-acetaminophen Generic butalbital-acetaminophen-caffeine Generic butalbital-acetaminophen-caffeine w/ codeine Generic butalbital-aspirin-caffeine Generic/Brand † butalbital-aspirin-caffeine w/cod Generic butorphanol tartrate Generic * celecoxib Generic choline & mag salicylate Generic CODEINE SULFATE Brand QL diclofenac sodium Generic droperidol Generic * etodolac Generic FENOPROFEN CALCIUM Brand fentanyl Generic QL fentanyl citrate Generic * QL hydrocodone-acetaminophen Generic QL hydromorphone hcl Generic/Brand *† QL ibuprofen Generic Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 13 - Drug Name Drug Tier Requirements/Limits indomethacin Generic/Brand † indomethacin sodium Generic * ketoprofen Generic/Brand † ketorolac tromethamine Generic * MECLOFENAMATE SODIUM Brand meloxicam Generic methadone hcl Generic/Brand † QL morphine sulfate Generic/Brand *† QL nabumetone Generic naproxen Generic naproxen sodium Generic oxaprozin Generic oxycodone hcl Generic/Brand † QL oxycodone w/ acetaminophen Generic/Brand † QL oxycodone-aspirin Generic QL salsalate Generic sufentanil citrate Generic * QL sulindac Generic tramadol hcl Generic QL ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS amphetamine-dextroamphetamine Generic/Brand † QL dexmethylphenidate hcl Generic/Brand † QL dextroamphetamine sulfate Generic QL methylphenidate hcl Generic/Brand † QL modafinil Generic QL phentermine Generic QL, RB ANTICONVULSANTS carbamazepine Generic carbamazepine (extended release) Generic CELONTIN Brand DIASTAT ACUDIAL Brand divalproex sodium Generic ethosuximide Generic felbamate Generic  gabapentin Generic lamotrigine Generic/Brand † levetiracetam Generic magnesium sulfate Generic * oxcarbazepine Generic/Brand † phenytoin Generic/Brand † phenytoin sodium Generic * phenytoin sodium extended Generic/Brand † primidone Generic QSYMIA Brand PA, QL, RB tiagabine hcl Generic/Brand † Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 14 - Drug Name Drug Tier Requirements/Limits topiramate Generic valproate sodium Generic valproic acid Generic zolmitriptan Generic/Brand † zonisamide Generic ANTIMIGRAINE AGENTS CAFERGOT Brand QL dihydroergotamine mesylate Generic/Brand *† QL ERGOMAR Brand QL naratriptan hcl Generic QL rizatriptan benzoate Generic QL sumatriptan succinate Generic/Brand *† QL zolmitriptan Generic/Brand † QL ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam Generic buspirone hcl Generic chlordiazepoxide hcl Generic clonazepam Generic clonazepam ODT Generic clorazepate dipotassium Generic diazepam Generic/Brand *† droperidol Generic * estazolam Generic flurazepam hcl Generic hydroxyzine hcl Generic * hydroxyzine pamoate Generic/Brand † lorazepam Generic/Brand † mephobarbital Generic midazolam hcl Generic * oxazepam Generic phenobarbital Generic/Brand † temazepam Generic triazolam Generic zaleplon Generic zolpidem tartrate Generic CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS acamprosate calcium Generic APOKYN Brand *  QL atracurium besylate Generic * carbidopa-levodopa Generic entacapone Generic galantamine hydrobromide Generic levetiracetam Generic memantine hcl Generic NAMENDA Brand Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 15 - Drug Name Drug Tier Requirements/Limits pramipexole dihydrochloride Generic riluzole Generic ropinirole hydrochloride Generic selegiline hcl Generic trihexyphenidyl hcl Generic vecuronium bromide Generic * ZEMURON Brand * OPIATE ANTAGONISTS naloxone hcl Generic * naltrexone hcl Generic NARCAN Brand PSYCHOTHERAPEUTIC AGENTS ABILIFY Brand amitriptyline hcl Generic AMOXAPINE Brand aripiprazole Generic bupropion hcl Generic bupropion hcl (smoking deterrent) Generic CHLORDIAZEPOXIDE/AMITRIPTYLINE Brand chlorpromazine hcl Generic * citalopram hydrobromide Generic clomipramine hcl Generic clozapine Generic QL desipramine hcl Generic doxepin hcl Generic/Brand † duloxetine hcl Generic escitalopram oxalate Generic fluoxetine hcl Generic fluphenazine decanoate Generic * fluphenazine hcl Generic/Brand † fluvoxamine maleate Generic haloperidol Generic haloperidol decanoate Generic * haloperidol lactate Generic * imipramine hcl Generic imipramine pamoate Generic lithium carbonate Generic/Brand † LITHIUM CITRATE Brand loxapine succinate Generic MAPROTILINE HCL Brand mirtazapine Generic nefazodone hcl Generic/Brand † nortriptyline hcl Generic/Brand † olanzapine Generic olanzapine odt Generic Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 16 - Drug Name Drug Tier Requirements/Limits ORAP Brand paroxetine hcl Generic/Brand † perphenazine Generic phenelzine sulfate Generic prochlorperazine edisylate Generic * prochlorperazine maleate Generic protriptyline hcl Generic quetiapine fumarate Generic risperidone Generic SAVELLA Brand sertraline hcl Generic SURMONTIL Brand thioridazine hcl Generic thiothixene Generic/Brand † tranylcypromine sulfate Generic trazodone hcl Generic trifluoperazine hcl Generic venlafaxine hcl Generic/Brand † ziprasidone hcl Generic RESPIRATORY AGENTS, MISCELLANEOUS albuterol sulfate Generic ANECTINE Brand * benzonatate Generic guaifenesin-codeine Generic hydrocodone polistirex-chlorpheniramine polistirex Generic QL hydrocodone w/ homatropine Generic QL DEVICES DEVICES ASSESS FULL RANGE PEAK FLOW METER Brand NORDIPEN 5 INJECTION DEVICE Brand NORDIPEN DELIVERY SYSTEM Brand DIABETIC SUPPLIES DIABETIC SUPPLIES 1ML TUBERCULIN SYRINGE DETACHABLE NEEDLE Brand SLIP TIP 25GX5/8" 3ML LUER-LOK SYRINGE 22G X 1-1/2" Brand ACCU-CHEK ACTIVE CARE KIT Brand ACCU-CHEK COMPACT BLUE CONTROL SOLUTION Brand (2 LEVELS) ACCU-CHEK COMPACT TEST DRUM Brand ACETEST Brand ACTI-LANCE LITE SAFETY LANCETS 28G Brand ADVOCATE DUO/TALKING Brand ADVOCATE RAPID-SAFE LANCING DEVICE Brand ANTI-STICK INSULIN SYRINGE/U-100/1ML/29G X Brand 1/2" Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 17 - Drug Name Drug Tier Requirements/Limits AUTOJECT 2 Brand AUTOLET II CLINISAFE Brand AUTOPEN Brand BD AUTOSHIELD 29G X 1/2" Brand BD ECLIPSE SYRINGE/1ML/30 GX1/2" Brand BD INSULIN SYRINGE LUER-LOK/U-100/1ML Brand BD INSULIN SYRINGE U-40/1 ML/25G X 5/8" Brand BD NEEDLE/30G X 1/2" Brand BD SAFE CLIP NEEDLE CLIPPER Brand BD SAFETYGLIDE 27G X 5/8" Brand BD SYRINGE LUER-LOK/1ML Brand CARTRIDGE IR 1200 Brand CHEMSTRIP 2 LN STRIPS Brand CHEMSTRIP UGK Brand CHEMSTRIP-MICRAL Brand CLINISTIX Brand CLINITEST Brand DIASCREEN 1G Brand FREESTYLE NAVIGATOR SENSOR KIT Brand INNOVO INSULIN DOSER Brand INSULIN PUMP IR1250 BLUE Brand MEDI-JECTOR ADAPTERS Brand MINILINK REAL-TIME REPLACEMENT KIT Brand PRECISION XTRA Brand SIDEKICK BLOOD GLUCOSE SYSTEM Brand ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS CYTRA-K Brand K-PHOS Brand POTASSIUM CITRATE Brand sodium acetate Generic * sodium bicarbonate Generic * sodium citrate & citric acid Generic/Brand † AMMONIA DETOXICANTS lactulose Generic lactulose (encephalopathy) Generic CALORIC AGENTS dextrose Generic * fat emulsion Generic * PROSOL Brand * DIURETICS amiloride & hydrochlorothiazide Generic amiloride hcl Generic bumetanide Generic chlorothiazide Generic/Brand † Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 18 - Drug Name Drug Tier Requirements/Limits CHLORTHALIDONE Brand DYRENIUM Brand furosemide Generic * hydrochlorothiazide Generic indapamide Generic metolazone Generic SODIUM EDECRIN Brand * torsemide Generic triamterene & hydrochlorothiazide Generic ION-REMOVING AGENTS RENAGEL Brand RENVELA Brand sodium polystyrene sulfonate Generic/Brand † IRRIGATING SOLUTIONS lactated ringer's (irrigation) Generic ringer's irrigation Generic sodium chloride (gu irrigant) Generic water for irrigation, sterile Generic REPLACEMENT PREPARATIONS ADDAMEL N Brand * BACTERIOSTATIC WATER FOR INJECTION/BENZYL Brand * ALCOHOL calcium acetate Generic calcium chloride (dihydrate) Generic * calcium gluconate Generic * chromium chloride Generic * COPPER TRACE METAL Brand * dextrose in lactated ringers Generic * dextrose w/ sodium chloride Generic * ELIPHOS Brand K-PHOS Brand lactated ringer's Generic * MANGANESE SULFATE Brand * MANGANESE TRACE METAL Brand * pot phosphate monobasic w/ sod phosphate dibasic & Generic monobasic potassium acetate Generic * potassium bicarb & chloride Generic potassium chloride Generic/Brand *† potassium chloride in dextrose & sodium chloride Generic * potassium chloride microencapsulated crystals cr Generic ringer's Generic * saline, bacteriostatic Generic * SELENIUM Brand * sodium bicarbonate Generic *

Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 19 - Drug Name Drug Tier Requirements/Limits sodium chloride Generic * sodium phosphate Generic * SSKI Brand water for injection, sterile Generic * zinc sulfate Generic * ZINC TRACE METAL Brand * URICOSURIC AGENTS colchicine Generic colchicine w/ probenecid Generic probenecid Generic ENZYMES ENZYMES ADAGEN Brand * CREON Brand VPRIV Brand *  QL EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES BACITRACIN Brand bacitracin-polymyxin b (ophth) Generic chlorhexidine gluconate (mouth-throat) Generic ciprofloxacin hcl (ophth) Generic/Brand † erythromycin (ophth) Generic gentamicin sulfate (ophth) Generic neomycin-bacitracin zn-polymyxin Generic ofloxacin (ophth) Generic ofloxacin (otic) Generic polymyxin b-trimethoprim Generic sulfacetamide sodium (ophth) Generic tobramycin (ophth) Generic/Brand † trifluridine Generic ANTI-INFLAMMATORY AGENTS bacitracin-poly-neomycin-hc Generic CIPRO HC Brand CIPRODEX Brand COLY-MYCIN S Brand dexamethasone sodium phosphate (ophth) Generic diclofenac sodium (ophth) Generic FLAREX Brand FLUNISOLIDE Brand fluorometholone (ophth) Generic/Brand † flurbiprofen sodium Generic fluticasone propionate (nasal) Generic hydrocortisone w/acetic acid Generic ketorolac tromethamine (ophth) Generic LOTEMAX Brand Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 20 - Drug Name Drug Tier Requirements/Limits NASONEX Brand neomycin-polymy-dexameth Generic neomycin-polymyxin-hc (otic) Generic NEOMYCIN/POLYMYXIN/HYDROCORTISONE Brand PRED-G Brand prednisolone acetate (ophth) Generic/Brand † PREDNISOLONE SODIUM PHOSP HATE Brand RESTASIS Brand sulfacetamide sod-prednisolone Generic/Brand † tobramycin-dexamethasone Generic/Brand † ANTIALLERGIC AGENTS ALOCRIL Brand ALOMIDE Brand azelastine hcl Generic azelastine hcl (ophth) Generic cromolyn sodium (ophth) Generic PATANOL Brand ANTIGLAUCOMA AGENTS AZOPT Brand BETIMOL Brand BETOPTIC-S Brand brimonidine tartrate Generic/Brand † carteolol hcl (ophth) Generic METIPRANOLOL Brand timolol maleate (ophth) Generic EENT DRUGS, MISCELLANEOUS acetic acid (otic) Generic ACETIC ACID/ALUMINUM ACETATE Brand betaxolol hcl (ophth) Generic brimonidine tartrate Generic dorzolamide hcl Generic dorzolamide hcl-timolol maleate Generic EYLEA Brand * fluorescein sodium topical Generic fluorescein w/ proparacaine Generic FLURESS Brand HEALON GV Brand * LACRISERT Brand latanoprost Generic levobunolol hcl Generic/Brand † LUCENTIS Brand ophthalmic irrigation solution - intraocular Generic/Brand † PHOSPHOLINE IODIDE Brand pilocarpine hcl Generic/Brand † timolol maleate (ophth) Generic Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 21 - Drug Name Drug Tier Requirements/Limits LOCAL ANESTHETICS antipyrine-benzocaine Generic COCAINE HCL Brand lidocaine hcl (mouth-throat) Generic proparacaine hcl Generic PROVISC Brand * tetracaine hcl (ophth) Generic TREAGAN OTIC Brand MYDRIATICS atropine sulfate (ophthalmic) Generic/Brand † CYCLOMYDRIL Brand cyclopentolate hcl Generic/Brand † ISOPTO HOMATROPINE Brand ISOPTO HYOSCINE Brand tropicamide Generic VASOCONSTRICTORS ADRENALIN Brand phenylephrine hcl (ophth) Generic GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS balsalazide disodium Generic mesalamine Generic/Brand † ANTIEMETICS ANTIVERT Brand DIMENHYDRINATE Brand * dronabinol Generic EMEND Brand ondansetron Generic ondansetron hcl Generic * prochlorperazine Generic TRANSDERM-SCOP Brand ANTIULCER AGENTS AND ACID SUPPRESSANTS cimetidine hcl Generic famotidine Generic * FAMOTIDINE PREMIXED Brand * misoprostol Generic omeprazole Generic pantoprazole sodium Generic PREVACID SOLUTAB Brand ranitidine hcl Generic * sucralfate Generic/Brand † ZENPEP Brand DIGESTANTS LIPRAM-PN20 Brand PANCREASE MT Brand Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 22 - Drug Name Drug Tier Requirements/Limits PANCRELIPASE Brand GI DRUGS, MISCELLANEOUS diphenoxylate w/ atropine Generic/Brand † LINZESS Brand metoclopramide hcl Generic * OPIUM TINCTURE (PAREGORIC ) Brand peg 3350-kcl-sod bicarb-sod chloride-sod sulfate Generic/Brand † peg 3350-potassium chloride-sod bicarbonate-sod chloride Generic ursodiol Generic GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA Brand HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS BAL IN OIL Brand * CHEMET Brand deferoxamine mesylate Generic * DEPEN Brand  QL EXJADE Brand  QL flumazenil Generic * methylene blue (antidote) Generic * PHYSOSTIGMINE SALICYLATE Brand * sodium thiosulfate Generic * HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS A-HYDROCORT Brand * ARISTOSPAN INTRA-ARTICULA R Brand * ASMANEX 120 METERED DOSES Brand ASMANEX HFA Brand budesonide Generic CORTISONE ACETATE Brand DEPO-MEDROL Brand * dexamethasone Generic/Brand † dexamethasone sodium phosphate Generic * FLOVENT DISKUS Brand FLOVENT HFA Brand fludrocortisone acetate Generic hydrocortisone Generic KENALOG-10 Brand * methylprednisolone Generic/Brand † methylprednisolone sod succ Generic * prednisolone Generic/Brand † prednisolone sodium phosphate Generic prednisone Generic/Brand † PULMICORT Brand Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 23 - Drug Name Drug Tier Requirements/Limits QVAR Brand ANDROGENS ANADROL-50 Brand ANDRODERM Brand ANDROID Brand ANDROXY Brand betamethasone sod phosphate & acetate Generic * danazol Generic testosterone Generic testosterone cypionate Generic * testosterone enanthate Generic * TESTOSTERONE PROPIONATE Brand CONTRACEPTIVES desogestrel & ethinyl estradiol Generic desogestrel-ethinyl estradiol (biphasic) Generic desogestrel-ethinyl estradiol (triphasic) Generic drospirenone-ethinyl estradiol Generic ELLA Brand ethynodiol diacet & ethinyl estradiol Generic/Brand † levonorgestrel & ethinyl estradiol Generic levonorgestrel-ethinyl estradiol (91-day) Generic levonorgestrel-ethinyl estradiol (triphasic) Generic NECON 1/50-28 Brand NECON 10/11-28 Brand norethin acet & ethinyl estradiol-fe Generic norethindrone & ethinyl estradiol Generic norethindrone (contraceptive) Generic norethindrone acet & ethinyl estradiol Generic norethindrone-ethinyl estradiol (triphasic) Generic norgestimate-ethinyl estradiol Generic norgestimate-ethinyl estradiol (triphasic) Generic/Brand † norgestrel & ethinyl estradiol Generic/Brand † NUVARING Brand PLAN B Brand XULANE Brand DIABETIC AGENTS acarbose Generic glimepiride Generic glipizide Generic GLUCAGEN Brand * GLUCAGON EMERGENCY KIT Brand * glyburide Generic/Brand † glyburide-metformin Generic HUMALOG Brand HUMALOG MIX 50/50 Brand Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 24 - Drug Name Drug Tier Requirements/Limits HUMULIN N Brand HUMULIN R Brand LANTUS Brand LEVEMIR Brand LEVEMIR FLEXTOUCH Brand metformin hcl Generic/Brand † NOVOLOG Brand NOVOLOG MIX 70/30 Brand pioglitazone hcl Generic tolazamide Generic/Brand † TOLBUTAMIDE Brand ESTROGENS AND ANTIESTROGENS COMBIPATCH Brand DEPO-ESTRADIOL Brand * esterified estrogens & methyltestosterone Generic ESTRACE Brand estradiol Generic/Brand † estradiol valerate Generic * estropipate Generic/Brand † FEMHRT LOW DOSE Brand PREMARIN Generic/Brand *† PREMPHASE Brand raloxifene hcl Generic VAGIFEM Brand GONADOTROPINS BRAVELLE Brand * RB chorionic gonadotropin Generic * RB clomiphene citrate Generic RB FOLLISTIM AQ Brand * RB GONAL-F Brand * RB MENOPUR Brand * RB OVIDREL Brand * RB SYNAREL Brand RB PARATHYROID FORTEO Brand *  QL FORTICAL Brand * PITUITARY ACTHAR HP Brand *  QL desmopressin acetate Generic/Brand *† desmopressin acetate refrigerated Generic desmopressin acetate spray Generic desmopressin acetate spray refrigerated Generic vasopressin Generic * PROGESTINS DEPO-PROVERA Brand * Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 25 - Drug Name Drug Tier Requirements/Limits medroxyprogesterone acetate Generic medroxyprogesterone acetate (contraceptive) Generic * norethindrone acetate Generic progesterone Generic * RB progesterone micronized Generic RB SOMATOTROPIN AGONISTS AND ANTAGONISTS OMNITROPE Brand *  THYROID AND ANTITHYROID AGENTS ARMOUR THYROID Brand levothyroxine sodium Generic liothyronine sodium Generic methimazole Generic propylthiouracil Generic THYROLAR-1 Brand MISCELLANEOUS THERAPEUTIC AGENTS DIAGNOSTIC AGENT ADENOSCAN Brand * CANDIN Brand * CORTROSYN Brand * indigotindisulfonate sodium Generic * METOPIRONE Brand OMNIPAQUE Brand * PROVOCHOLINE Brand TUBERSOL Brand * MISCELLANEOUS THERAPEUTIC AGENTS acitretin Generic ADCIRCA Brand alendronate sodium Generic/Brand † allopurinol Generic amifostine crystalline Generic * amino acid infusion Generic * AMPHADASE Brand * ARALAST NP Brand * AVONEX Brand *  QL azathioprine Generic/Brand † benztropine mesylate Generic * bicalutamide Generic BORIC ACID Brand BOTOX Brand * BREVITAL SODIUM Brand * bromocriptine mesylate Generic bupivacaine hcl Generic * bupivacaine w/ epinephrine Generic * cabergoline Generic cyclosporine Generic/Brand † Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 26 - Drug Name Drug Tier Requirements/Limits cyclosporine modified (for microemulsion) Generic/Brand † CYSTAGON Brand CYTRA-3 Brand DILTIAZEM HCL Brand disulfiram Generic/Brand † DONNATAL Brand ELMIRON Brand ENBREL Brand *  QL ETIDRONATE DISODIUM Brand EXTAVIA Brand *  QL finasteride Generic FIRAZYR Brand *  QL FORANE Brand FOSAMAX PLUS D Brand GELFILM ENVELOPE Brand GILENYA Brand  QL GLATOPA Generic *  QL HUMIRA Brand *  QL HYPERTET S/D Brand * ketamine hcl Generic * KINERET Brand *  QL leflunomide Generic leucovorin calcium Generic/Brand *† levocarnitine (metabolic modifiers) Generic/Brand *† lidocaine hcl (local anesth.) Generic * lidocaine in d5w Generic * lidocaine w/ epinephrine Generic * mesna Generic/Brand *† methotrexate sodium Generic * mycophenolate mofetil Generic/Brand † mycophenolate sodium Generic/Brand † NESACAINE Brand * octreotide acetate Generic *  QL ORENCIA Brand *  pamidronate disodium Generic * peg 3350-kcl-sod bicarb-sod chloride-sod sulfate Generic propofol Generic * RAPAMUNE Brand  REBIF Brand *  QL REMICADE Brand * RIMSO-50 Brand SANDOSTATIN Brand *  QL SENSIPAR Brand  QL sirolimus Generic/Brand * †  sodium fluoride Generic/Brand † Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 27 - Drug Name Drug Tier Requirements/Limits sodium fluoride (dental) Generic/Brand † sodium polystyrene sulfonate Generic SUPRANE Brand tacrolimus Generic * tamsulosin hcl Generic THALOMID Brand  QL THIOLA Brand ULTANE Brand URSO 250 Brand water for injection, sterile Generic * ZINC SULFATE Brand ZOMETA Brand * OXYTOCICS OXYTOCICS ERGOTRATE MALEATE Brand HEMABATE Brand * methylergonovine maleate Generic * oxytocin Generic * RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS budesonide (inhalation) Generic cromolyn sodium Generic montelukast sodium Generic STRIVERDI RESPIMAT Brand zafirlukast Generic ANTITUSSIVES benzonatate Generic guaifenesin-codeine Generic RESPIRATORY AGENTS, MISCELLANEOUS acetylcysteine Generic HIZENTRA Brand * ipratropium bromide (nasal) Generic LETAIRIS Brand  QL PULMOZYME Brand  QL sodium chloride (inhalant) Generic SERUMS, TOXOIDS, AND VACCINES SERUMS CARIMUNE NANOFILTERED Brand * HYPERRHO S/D Brand * IMOGAM RABIES-HT Brand * NABI-HB Brand * VARIZIG Brand * TOXOIDS DIPHTHERIA/TETANUS TOXOID PEDIATRIC Brand * VACCINES Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 28 - Drug Name Drug Tier Requirements/Limits ADACEL Brand * GAMUNEX-C Brand * GARDASIL Brand * IMOVAX RABIES (H.D.C.V.) Brand * IPOL INACTIVATED IPV Brand * M-M-R II W/DILUENT 10 DOSE Brand * MENACTRA Brand * MENOMUNE-A/C/Y/W-135 Brand * PNEUMOVAX 23/1 DOSE Brand * PREVNAR Brand * PROQUAD Brand * RABAVERT Brand * ROTATEQ Brand * THERACYS Brand * ZOSTAVAX Brand * SEXUAL DYSFUNCTION MISCELLANEOUS THERAPEUTIC AGENTS CAVERJECT Brand * QL, RB CIALIS Brand QL, RB LEVITRA Brand QL, RB OSPHENA Brand QL, RB VIAGRA Brand QL, RB SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir topical Generic AVC Brand BACTROBAN NASAL Brand BENZAMYCINPAK Brand BENZOIC ACID Brand ciclopirox Generic ciclopiroxolamine Generic clindamycin phosphate (topical) Generic clindamycin phosphate vaginal Generic clotrimazole Generic clotrimazole (topical) Generic clotrimazole w/ betamethasone Generic erythromycin (acne aid) Generic EURAX Brand EXELDERM Brand GENTAMICIN SULFATE Brand ketoconazole (topical) Generic lindane Generic metronidazole (topical) Generic/Brand † metronidazole vaginal Generic MICONAZOLE 3 Brand Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 29 - Drug Name Drug Tier Requirements/Limits mupirocin Generic mupirocin calcium (topical) Generic NAFTIN Brand nystatin (topical) Generic selenium sulfide Generic silver sulfadiazine Generic sulfacetamide sodium (acne) Generic terbinafine hcl Generic ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate Generic APEXICON E Brand benzoyl peroxide-erythromycin Generic betamethasone dipropionate (topical) Generic betamethasone dipropionate augmented Generic betamethasone valerate Generic ciclopiroxolamine Generic clobetasol propionate Generic/Brand † clobetasol propionate emollient base Generic CLODERM Brand CORDRAN Brand CORTIFOAM Brand CORTISPORIN Brand desonide Generic desoximetasone Generic/Brand † diflorasone diacetate Generic/Brand † EPIFOAM Brand fluocinolone acetonide Generic fluocinonide Generic fluocinonide emulsified base Generic fluticasone propionate Generic/Brand † halobetasol propionate Generic hydrocortisone (intrarectal) Generic hydrocortisone (rectal) Generic hydrocortisone (topical) Generic hydrocortisone acetate (rectal) Generic hydrocortisone butyrate Generic HYDROCORTISONE MICRONIZED Brand hydrocortisone valerate Generic iodoquinol-hc Generic LOCOID LIPOCREAM Brand mometasone furoate Generic nystatin-triamcinolone Generic PROCTOFOAM HC Brand triamcinolone acetonide (mouth) Generic triamcinolone acetonide (topical) Generic/Brand † Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 30 - Drug Name Drug Tier Requirements/Limits ANTIPRURITICS AND LOCAL ANESTHETICS hydrocortisone acetate w/ pramoxine Generic/Brand † lidocaine-prilocaine Generic phenazopyridine hcl Generic CELL STIMULANTS AND PROLIFERANTS tretinoin (topical) Generic SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS aluminum chloride Generic AMEVIVE Brand * AZELEX Brand calcipotriene Generic COAL TAR Brand DIFFERIN Brand DRITHO-CREME HP Brand ELIDEL Brand ELIMITE Brand ETHYL CHLORIDE/MIST Brand FINACEA Brand fluorouracil (topical) Generic/Brand † GLYCOPYRROLATE Brand imiquimod Generic isotretinoin Generic/Brand † QL ketoconazole (topical) Generic lidocaine Generic lidocaine hcl Generic OXSORALEN Brand OXSORALEN ULTRA Brand papain-urea Generic podofilox Generic/Brand † REGRANEX Brand SANTYL Brand tacrolimus (topical) Generic TARGRETIN Brand  QL TAZORAC Brand trypsin w/ castor oil & peruvian balsam Generic VECTICAL Brand SMOOTH MUSCLE RELAXANTS GENITOURINARY SMOOTH MUSCLE RELAXANTS flavoxate hcl Generic tolterodine tartrate Generic trospium chloride Generic SMOOTH MUSCLE RELAXANTS oxybutynin chloride Generic OXYTROL Brand theophylline Generic/Brand † Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 31 - Drug Name Drug Tier Requirements/Limits VITAMINS VITAMINS AQUASOL A PARENTERAL Brand * calcitriol Generic/Brand † cyanocobalamin Generic * ergocalciferol Generic folic acid Generic * INATAL ULTRA Brand infuvite Generic * iron dextran Generic * MEPHYTON Generic/Brand *† MYNATAL Brand MYNATAL-Z Brand MYNATE 90 PLUS Brand pediatric multivitamins w/fl Generic pediatric vitamins acd w/ fluoride Generic POTABA Brand PRENATAL PLUS IRON Brand PYRIDOXINE HCL Brand * thiamine hcl Generic * VENOFER Brand * VINATE M Brand

Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 32 - INDEX OF DRUGS Kaiser Permanente Colorado Region EPO Comprehensive Formulary Index

ADVOCATE DUO/TALKING 18 1 ADVOCATE RAPID-SAFE LANCING DEVICE 18 AFINITOR 8 1ML TUBERCULIN SYRINGE DETACHABLE NEEDLE SLIP TIP AGGRENOX 11 25GX5/8 18 A-HYDROCORT 24 1ML TUBERCULIN SYRINGE DETACHABLE NEEDLE SLIP TIP ALBENZA 4 25GX5/8" 18 ALBUTEROL 10 albuterol sulfate 10, 18 alclometasone dipropionate 31 3 alendronate sodium 27 3ML LUER-LOK SYRINGE 22G X 1-1/2 18 ALKERAN 8 3ML LUER-LOK SYRINGE 22G X 1-1/2" 18 allopurinol 27 ALOCRIL 22 ALOMIDE 22 A ALPHA-ADRENERGIC BLOCKING AGENTS 12 abacavir sulfate 6 ALPHANINE SD 11 abacavir-lamivudine-zidovudine 6 alprazolam 16 ABILIFY 17 alprostadil 14 ABRAXANE 8 aluminum chloride 32 acamprosate calcium 16 amantadine hcl 6 acarbose 25 AMBISOME 5 ACCU-CHEK ACTIVE CARE KIT 18 AMEVIVE 32 ACCU-CHEK COMPACT BLUE CONTROL SOLUTION (2 amifostine crystalline 27 LEVELS) 18 amiloride & hydrochlorothiazide 19 ACCU-CHEK COMPACT TEST DRUM 18 amiloride hcl 19 acebutolol hcl 12 amino acid infusion 27 acetaminophen w/ codeine 14 aminocaproic acid 11 acetazolamide 13 amiodarone hcl 13 acetazolamide sodium 13 amitriptyline hcl 17 ACETEST 18 amlodipine besylate 12 acetic acid (otic) 22 amlodipine besylate-benazepril hcl 12 ACETIC ACID/ALUMINUM ACETATE 22 AMMONIA DETOXICANTS 19 acetylcysteine 29 AMOXAPINE 17 ACIDIFYING AND ALKALINIZING AGENTS 19 amoxicillin 4 acitretin 27 amoxicillin & pot clavulanate 4 ACTHAR HP 26 AMPHADASE 27 ACTI-LANCE LITE SAFETY LANCETS 28G 18 amphetamine-dextroamphetamine 15 ACTIVASE 11 AMPHOTERICIN B 5 acyclovir 6, 30 ampicillin 4 acyclovir sodium 6 ampicillin & sulbactam sodium 4 acyclovir topical 30 ampicillin sodium 4 ADACEL 30 ANADROL-50 25 ADAGEN 21 anagrelide hcl 11 ADCIRCA 27 ANALGESICS AND ANTIPYRETICS 14 ADDAMEL N 20 anastrozole 8 adefovir dipivoxil 6 ANCOBON 5 ADENOSCAN 27 ANDRODERM 25 adenosine 13 ANDROGENS 25 ADRENALIN 10, 23 ANDROID 25 ADRENALS 24 ANDROXY 25 ADVAIR DISKUS 10 ANECTINE 18 ADVATE 11 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 33 - ANOREXIGENIC AGENTS AND RESPIRATORY AND AUTONOMIC DRUGS, MISCELLANEOUS 10 CEREBRAL STIMULANTS 15 AUTOPEN 19 ANTHELMINTICS 4 AVASTIN 8 ANTIALLERGIC AGENTS 22 AVC 30 ANTIBACTERIALS 4 AVELOX 4 ANTICHOLINERGIC AGENTS 9 AVONEX 27 ANTICONVULSANTS 15 azathioprine 27 ANTIEMETICS 23 azelastine hcl 22 ANTIFUNGALS 5 azelastine hcl (ophth) 22 ANTIGLAUCOMA AGENTS 22 AZELEX 32 ANTIHISTAMINE DRUGS 7 azithromycin 4 ANTI-INFECTIVE AGENTS 4 AZOPT 22 ANTI-INFECTIVES 21 aztreonam 4 ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) 30 ANTI-INFLAMMATORY AGENTS 21, 23, 29 B ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 31 BACITRACIN 21 ANTILIPEMIC AGENTS 12 bacitracin-polymyxin b (ophth) 21 ANTIMIGRAINE AGENTS 16 bacitracin-poly-neomycin-hc 21 ANTIMYCOBACTERIALS 6 baclofen 10 ANTINEOPLASTIC AGENTS 8 BACTERIOSTATIC WATER FOR INJECTION/BENZYL ANTIPROTOZOALS 6 ALCOHOL 20 ANTIPRURITICS AND LOCAL ANESTHETICS 32 BACTOCILL/DEXTROSE 4 antipyrine-benzocaine 23 BACTROBAN NASAL 30 ANTI-STICK INSULIN SYRINGE/U-100/1ML/29G X 1/2 18 BAL IN OIL 24 ANTI-STICK INSULIN SYRINGE/U-100/1ML/29G X 1/2" 18 balsalazide disodium 23 ANTITHROMBOTIC AGENTS 11 BARACLUDE 6 ANTITUSSIVES 29 BD AUTOSHIELD 29G X 1/2 19 ANTIULCER AGENTS AND ACID SUPPRESSANTS 23 BD AUTOSHIELD 29G X 1/2" 19 ANTIVERT 23 BD ECLIPSE SYRINGE/1ML/30 GX1/2 19 ANTIVIRALS 6 BD ECLIPSE SYRINGE/1ML/30 GX1/2" 19 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS 16 BD INSULIN SYRINGE LUER-LOK/U-100/1ML 19 APEXICON E 31 BD INSULIN SYRINGE U-40/1 ML/25G X 5/8 19 APOKYN 16 BD INSULIN SYRINGE U-40/1 ML/25G X 5/8" 19 APTIVUS 6 BD NEEDLE/30G X 1/2 19 AQUASOL A PARENTERAL 33 BD NEEDLE/30G X 1/2" 19 ARALAST NP 27 BD SAFE CLIP NEEDLE CLIPPER 19 aripiprazole 17 BD SAFETYGLIDE 27G X 5/8 19 ARISTOSPAN INTRA-ARTICULA R 24 BD SAFETYGLIDE 27G X 5/8" 19 ARMOUR THYROID 27 BD SYRINGE LUER-LOK/1ML 19 ASMANEX 120 METERED DOSES 24 benazepril & hydrochlorothiazide 13 ASMANEX HFA 24 benazepril hcl 12, 13 ASSESS FULL RANGE PEAK FLOW METER 18 BENEFIX 11 atenolol 12 BENZAMYCINPAK 30 atenolol & chlorthalidone 12 BENZOIC ACID 30 atorvastatin calcium 12 benzonatate 18, 29 atovaquone 6 benzoyl peroxide-erythromycin 31 atovaquone-proguanil hcl 6 benztropine mesylate 10, 27 atracurium besylate 16 BETA-ADRENERGIC BLOCKING AGENTS 12 ATRIPLA 6 betamethasone dipropionate (topical) 31 atropine sulfate 10, 23 betamethasone dipropionate augmented 31 atropine sulfate (ophthalmic) 23 betamethasone sod phosphate & acetate 25 ATROVENT HFA 10 betamethasone valerate 31 AUTOJECT 19 betaxolol hcl (ophth) 22 AUTOJECT 2 19 bethanechol chloride 10 AUTOLET II CLINISAFE 19 BETIMOL 22 AUTONOMIC DRUGS 9 BETOPTIC-S 22 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 34 - bicalutamide 27 CARIMUNE NANOFILTERED 29 BICILLIN 4 carisoprodol 10 BICILLIN L-A 4 carisoprodol w/ aspirin 10 BICNU 8 carteolol hcl (ophth) 22 BILTRICIDE 4 CARTRIDGE IR 1200 19 bisoprolol & hydrochlorothiazide 12 carvedilol 12 bisoprolol fumarate 12 CAVERJECT 30 bleomycin sulfate 8 CAYSTON 4 BLOOD FORMATION, COAGULATION, AND THROMBOSIS CEENU 8 11 cefaclor 4 BORIC ACID 27 cefadroxil 4 BOTOX 27 cefazolin sodium 4 BRAVELLE 26 cefdinir 4 BREVITAL SODIUM 27 cefepime hcl 4 BRILINTA 11 cefixime 4 brimonidine tartrate 22 CEFOTETAN 4 bromocriptine mesylate 27 CEFOTETAN/DEXTROSE 4 budesonide 24, 29 cefprozil 4 budesonide (inhalation) 29 ceftazidime 4 bumetanide 19 ceftriaxone sodium 4 bupivacaine hcl 27 CEFTRIAXONE SODIUM/DEXTROSE 4 bupivacaine w/ epinephrine 27 cefuroxime axetil 4 BUPRENEX 14 cefuroxime sodium 4 buprenorphine hcl-naloxone hcl dihydrate 14 CELEBREX 14 bupropion hcl 17 celecoxib 14 bupropion hcl (smoking deterrent) 17 CELL STIMULANTS AND PROLIFERANTS 32 buspirone hcl 16 CELONTIN 15 butalbital-acetaminophen 14 CENTRAL NERVOUS SYSTEM AGENTS 14 butalbital-acetaminophen-caffeine 14 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS 16 butalbital-acetaminophen-caffeine w/ codeine 14 cephalexin 4 butalbital-aspirin-caffeine 14 cevimeline hcl 10 butalbital-aspirin-caffeine w/cod 14 CHEMET 24 butorphanol tartrate 14 CHEMSTRIP 2 LN STRIPS 19 CHEMSTRIP UGK 19 C CHEMSTRIP-MICRAL 19 chlordiazepoxide hcl 16 cabergoline 27 CHLORDIAZEPOXIDE/AMITRIPTYLINE 17 CAFERGOT 16 chlorhexidine gluconate (mouth-throat) 21 calcipotriene 32 chloroquine phosphate 6 calcitriol 33 chlorothiazide 19 calcium acetate 20 chlorpromazine hcl 17 calcium chloride (dihydrate) 20 CHLORTHALIDONE 20 calcium gluconate 20 cholestyramine 12 CALCIUM-CHANNEL BLOCKING AGENTS 12 cholestyramine light 12 CALORIC AGENTS 19 choline & mag salicylate 14 CANCIDAS 5 chorionic gonadotropin 26 CANDIN 27 chromium chloride 20 capecitabine 8 CIALIS 30 captopril 13 ciclopirox 30 CAPTOPRIL/HYDROCHLOROTHIAZIDE 13 ciclopirox olamine 30 carbamazepine 15 ciclopiroxolamine 30, 31 carbamazepine (extended release) 15 cilostazol 11 carbidopa-levodopa 16 cimetidine hcl 23 carboplatin 8 CIPRO HC 21 CARDENE SR 12 CIPRODEX 21 CARDIAC DRUGS 13 ciprofloxacin 4, 21 CARDIOVASCULAR DRUGS 12 ciprofloxacin hcl 4, 21 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 35 - ciprofloxacin hcl (ophth) 21 cyproheptadine hcl 7 ciprofloxacin in d5w 4 CYSTAGON 28 ciprofloxacin-ciprofloxacin hcl 4 cytarabine 8 cisplatin 8 CYTOVENE 6 citalopram hydrobromide 17 CYTRA-3 28 clarithromycin 4 CYTRA-K 19 clidinium & chlordiazepoxide 10 clindamycin hcl 4 D clindamycin phosphate (topical) 30 clindamycin phosphate vaginal 30 dacarbazine 8 CLINISTIX 19 dactinomycin 8 CLINITEST 19 danazol 25 clobetasol propionate 31 dantrolene sodium 10 clobetasol propionate emollient base 31 DAPSONE 6 CLODERM 31 DARAPRIM 6 clomiphene citrate 26 daunorubicin hcl 8 clomipramine hcl 17 deferoxamine mesylate 24 clonazepam 16 DEPEN 24 clonazepam ODT 16 DEPO-ESTRADIOL 26 clonidine hcl 13 DEPO-MEDROL 24 clopidogrel bisulfate 11 DEPO-PROVERA 26 clorazepate dipotassium 16 desipramine hcl 17 clotrimazole 30 desmopressin acetate 26 clotrimazole (topical) 30 desmopressin acetate refrigerated 26 clotrimazole w/ betamethasone 30 desmopressin acetate spray 26 clozapine 17 desmopressin acetate spray refrigerated 26 COAGULANTS AND ANTICOAGULANTS 11 desogestrel & ethinyl estradiol 25 COAL TAR 32 desogestrel-ethinyl estradiol (biphasic) 25 COCAINE HCL 23 desogestrel-ethinyl estradiol (triphasic) 25 CODEINE SULFATE 14 desonide 31 colchicine 21 desoximetasone 31 colchicine w/ probenecid 21 DEVICES 18 colestipol hcl 12 dexamethasone 21, 22, 24 COLY-MYCIN S 21 dexamethasone sodium phosphate 21, 24 COMBIPATCH 26 dexamethasone sodium phosphate (ophth) 21 COMBIVENT 10 dexmethylphenidate hcl 15 COMPLERA 6 dextroamphetamine sulfate 15 CONTRACEPTIVES 25 dextrose 19, 20 COPPER TRACE METAL 20 dextrose in lactated ringers 20 CORDRAN 31 dextrose w/ sodium chloride 20 COREG CR 12 DIABETIC AGENTS 25 CORTIFOAM 31 DIABETIC SUPPLIES 18 CORTISONE ACETATE 24 DIAGNOSTIC AGENT 27 CORTISPORIN 31 DIASCREEN 1G 19 CORTROSYN 27 DIASTAT ACUDIAL 15 CREON 21 diazepam 16 CRESTOR 12 diclofenac sodium 14, 21 CRIXIVAN 6 diclofenac sodium (ophth) 21 cromolyn sodium 22, 29 dicloxacillin sodium 4 cromolyn sodium (ophth) 22 dicyclomine hcl 10 cyanocobalamin 33 didanosine 6 cyclobenzaprine hcl 10 DIFFERIN 32 CYCLOMYDRIL 23 diflorasone diacetate 31 cyclopentolate hcl 23 DIGESTANTS 23 CYCLOPHOSPHAMIDE 8 digoxin 13 cyclosporine 27, 28 dihydroergotamine mesylate 16 cyclosporine modified (for microemulsion) 28 diltiazem hcl 12, 13 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 36 - DILTIAZEM HCL 28 ephedrine sulfate (pressors) 10 diltiazem hcl coated beads 12 EPIFOAM 31 diltiazem hcl extended release beads 13 epinephrine hcl 10 DIMENHYDRINATE 23 EPIVIR HBV 6 diphenhydramine hcl 7 EPOGEN 11 diphenoxylate w/ atropine 24 epoprostenol sodium 14 DIPHTHERIA/TETANUS TOXOID PEDIATRIC 29 EPZICOM 6 dipyridamole 11 ERBITUX 8 disopyramide phosphate 13 ergocalciferol 33 disulfiram 28 ERGOLOID MESYLATES 10 DIURETICS 19 ERGOMAR 16 divalproex sodium 15 ERGOTRATE MALEATE 29 DOCETAXEL 8 ERYTHROCIN LACTOBIONATE 4 donepezil hydrochloride 10 ERYTHROCIN STEARATE 4 DONNATAL 10, 28 erythromycin 4, 5, 21, 30, 31 DONNATAL EXTENTABS 10 erythromycin (acne aid) 30 dopamine hcl 13 erythromycin (ophth) 21 dorzolamide hcl 22 erythromycin-sulfisoxazole 5 dorzolamide hcl-timolol maleate 22 escitalopram oxalate 17 doxazosin mesylate 12 estazolam 16 doxepin hcl 17 esterified estrogens & methyltestosterone 26 doxorubicin hcl 8 ESTRACE 26 doxycycline (monohydrate) 4 estradiol 25, 26 doxycycline hyclate 4 estradiol valerate 26 DRITHO-CREME HP 32 ESTROGENS AND ANTIESTROGENS 26 dronabinol 23 estropipate 26 droperidol 14, 16 ethambutol hcl 6 drospirenone-ethinyl estradiol 25 ethosuximide 15 DULERA 10 ETHYL CHLORIDE/MIST 32 duloxetine 17 ethynodiol diacet & ethinyl estradiol 25 duloxetine hcl 17 ETIDRONATE DISODIUM 28 DYNACIRC CR 13 etodolac 14 DYRENIUM 20 etoposide 8 EURAX 30 E EXELDERM 30 exemestane 8 E.E.S. 400 4 EXFORGE 13 EDURANT 6 EXFORGE HCT 13 EENT DRUGS, MISCELLANEOUS 22 EXJADE 24 EFFIENT 11 EXTAVIA 28 ELECTROLYTIC, CALORIC, AND WATER BALANCE 19 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS 21 ELIDEL 32 EYLEA 22 ELIGARD 8 ELIMITE 32 F ELIPHOS 20 ELLA 25 famciclovir 6 ELMIRON 28 famotidine 23 EMCYT 8 FAMOTIDINE PREMIXED 23 EMEND 23 fat emulsion 19 EMTRIVA 6 felbamate 15 enalapril maleate 13 felodipine 13 ENBREL 28 FEMHRT LOW DOSE 26 ENLON 10 fenofibrate 12 enoxaparin 11 fenofibrate micronized 12 entacapone 16 FENOPROFEN CALCIUM 14 entecavir 6 fentanyl 14 ENZYMES 21 fentanyl citrate 14 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 37 - FINACEA 32 GEMZAR 8 finasteride 28 GENITOURINARY SMOOTH MUSCLE RELAXANTS 32 FIRAZYR 28 gentamicin sulfate 5, 21 FLAREX 21 GENTAMICIN SULFATE 30 flavoxate hcl 32 gentamicin sulfate (ophth) 21 flecainide acetate 13 GI DRUGS, MISCELLANEOUS 24 FLOVENT DISKUS 24 GILENYA 28 FLOVENT HFA 24 GLATOPA 28 fluconazole 5 GLEEVEC 8 fluconazole in nacl 5 glimepiride 25 fludarabine phosphate 8 glipizide 25 fludrocortisone acetate 24 GLUCAGEN 25 flumazenil 24 GLUCAGON EMERGENCY KIT 25 FLUNISOLIDE 21 glyburide 25 fluocinolone acetonide 31 glyburide-metformin 25 fluocinonide 31 glycopyrrolate 10 fluocinonide emulsified base 31 GLYCOPYRROLATE 32 fluorescein sodium topical 22 GOLD COMPOUNDS 24 fluorescein w/ proparacaine 22 GONADOTROPINS 26 fluorometholone (ophth) 21 GONAL-F 26 fluorouracil 8, 32 griseofulvin microsize 5 fluorouracil (topical) 32 griseofulvin ultramicrosize 5 fluoxetine hcl 17 guaifenesin-codeine 18, 29 fluphenazine decanoate 17 guanfacine hcl 13 fluphenazine hcl 17 flurazepam hcl 16 H flurbiprofen sodium 21 FLURESS 22 halobetasol propionate 31 flutamide 8 haloperidol 17 fluticasone propionate 21, 31 haloperidol decanoate 17 fluticasone propionate (nasal) 21 haloperidol lactate 17 fluvoxamine maleate 17 HARVONI 6 folic acid 33 HEALON GV 22 FOLLISTIM AQ 26 HEAVY METAL ANTAGONISTS 24 fondaparinux sodium 11 HELIXATE FS 11 FORADIL AEROLIZER 10 HEMABATE 29 FORANE 28 HEMATOPOIETIC AGENTS 11 FORTEO 26 heparin sod (porcine) in d5w 11 FORTICAL 26 heparin sodium 11 FOSAMAX PLUS D 28 heparin sodium (porcine) 11 FOSCAVIR 6 heparin sodium (porcine) lock flush 11 fosinopril sodium 13 HERCEPTIN 8 fosinopril sodium & hydrochlorothiazide 13 HESPAN 11 FRAGMIN 11 HEXALEN 8 FREESTYLE NAVIGATOR SENSOR KIT 19 HIZENTRA 29 furosemide 20 HORMONES AND SYNTHETIC SUBSTITUTES 24 HUMALOG 25 G HUMALOG MIX 50/50 25 HUMATE-P 11 gabapentin 15 HUMIRA 28 galantamine hydrobromide 16 HUMULIN N 26 GAMUNEX-C 30 HUMULIN R 26 ganciclovir 6 hydralazine hcl 13 GARDASIL 30 hydrochlorothiazide 12, 13, 14, 19, 20 GASTROINTESTINAL DRUGS 23 hydrocodone polistirex-chlorpheniramine polistirex 18 GELFILM ENVELOPE 28 hydrocodone w/ homatropine 18 gemfibrozil 12 hydrocodone-acetaminophen 14 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 38 - hydrocortisone 21, 24, 31, 32 isosorbide mononitrate 14 hydrocortisone (intrarectal) 31 isotretinoin 32 hydrocortisone (rectal) 31 itraconazole 5 hydrocortisone (topical) 31 ivermectin 4 hydrocortisone acetate (rectal) 31 hydrocortisone acetate w/ pramoxine 32 K hydrocortisone butyrate 31 HYDROCORTISONE MICRONIZED 31 KALETRA 7 hydrocortisone valerate 31 KENALOG-10 24 hydrocortisone w/acetic acid 21 ketamine hcl 28 hydromorphone hcl 14 ketoconazole 5, 30, 32 hydroxychloroquine sulfate 6 ketoconazole (topical) 30, 32 hydroxyurea 8 ketoprofen 15 hydroxyzine hcl 16 ketorolac tromethamine 15, 21 hydroxyzine pamoate 16 ketorolac tromethamine (ophth) 21 hyoscyamine sulfate 10 KINERET 28 HYPERRHO S/D 29 KINLYTIC 11 HYPERTET S/D 28 KOATE-DVI 11 HYPOTENSIVE AGENTS 13 K-PHOS 19, 20

I L ibuprofen 14 labetalol hcl 12 IDAMYCIN PFS 8 LACRISERT 22 ifosfamide 8 lactated ringer's 20 IFOSFAMIDE/MESNA 8 lactated ringer's (irrigation) 20 IMBRUVICA 8 lactulose 19 imipramine hcl 17 lactulose (encephalopathy) 19 imipramine pamoate 17 lamivudine 6, 7 imiquimod 32 lamivudine-zidovudine 6, 7 IMOGAM RABIES-HT 29 lamotrigine 15 IMOVAX RABIES (H.D.C.V.) 30 LANTUS 26 INATAL ULTRA 33 latanoprost 22 indapamide 20 leflunomide 28 indigotindisulfonate sodium 27 LETAIRIS 29 indomethacin 15 letrozole 8 indomethacin sodium 15 leucovorin calcium 28 infuvite 33 LEUKERAN 8 INNOVO INSULIN DOSER 19 LEUKINE 12 INSULIN PUMP IR1250 BLUE 19 leuprolide acetate 8 INTELENCE 6 levalbuterol hcl 10 INTRON-A 8 LEVEMIR 26 INVANZ 5 LEVEMIR FLEXTOUCH 26 INVIRASE 6 levetiracetam 15, 16 iodoquinol-hc 31 LEVITRA 30 ION-REMOVING AGENTS 20 levobunolol hcl 22 IPOL INACTIVATED IPV 30 levocarnitine (metabolic modifiers) 28 ipratropium bromide 10, 29 levofloxacin 5 ipratropium bromide (nasal) 10, 29 levofloxacin in d5w 5 IRESSA 8 levonorgestrel & ethinyl estradiol 25 iron dextran 33 levonorgestrel-ethinyl estradiol (91-day) 25 IRRIGATING SOLUTIONS 20 levonorgestrel-ethinyl estradiol (triphasic) 25 ISENTRESS 7 levothyroxine sodium 27 isoniazid 6 LEXIVA 7 ISOPTO HOMATROPINE 23 lidocaine 13, 23, 28, 32 ISOPTO HYOSCINE 23 lidocaine hcl 13, 23, 28, 32 isosorbide dinitrate 14 lidocaine hcl (cardiac) 13 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 39 - lidocaine hcl (local anesth.) 28 methenamine hippurate 7 lidocaine hcl (mouth-throat) 23 methenamine mandelate 7 lidocaine in d5w 28 methenamine-hyosc-methylene blue-sod phos-phenyl sal 7 lidocaine w/ epinephrine 13, 28 methimazole 27 lidocaine-prilocaine 32 methocarbamol 10 lindane 30 methotrexate sodium 9, 28 linezolid 5 methyldopa 13 LINZESS 24 methylene blue (antidote) 24 liothyronine sodium 27 methylergonovine maleate 29 LIPRAM-PN20 23 methylphenidate hcl 15 lisinopril 13, 14 methylprednisolone 24 lisinopril & hydrochlorothiazide 14 methylprednisolone sod succ 24 lithium carbonate 17 METIPRANOLOL 22 LITHIUM CITRATE 17 metoclopramide hcl 24 LOCAL ANESTHETICS 23 metolazone 20 LOCOID LIPOCREAM 31 METOPIRONE 27 lorazepam 16 metoprolol succinate 12 losartan potassium 14 metoprolol tartrate 12 losartan potassium & hydrochlorothiazide 14 METRO IV 6 LOTEMAX 21 metronidazole 6, 30 lovastatin 12 metronidazole (topical) 30 loxapine succinate 17 metronidazole vaginal 30 LUCENTIS 22 mexiletine hcl 13 LUPRON 8 MICONAZOLE 3 30 LUPRON DEPOT 8 midazolam hcl 16 LUPRON DEPOT-PED 8 midodrine hcl 11 LYSODREN 8 MINILINK REAL-TIME REPLACEMENT KIT 19 minocycline hcl 5 M minoxidil 13 mirtazapine 17 magnesium sulfate 15 MISCELLANEOUS THERAPEUTIC AGENTS 27, 30 MANGANESE SULFATE 20 misoprostol 23 MANGANESE TRACE METAL 20 mitomycin 9 MAPROTILINE HCL 17 mitoxantrone hcl 9 MATULANE 9 M-M-R II W/DILUENT 10 DOSE 30 MEBENDAZOLE 4 modafinil 15 MECLOFENAMATE SODIUM 15 moexipril hcl 14 MEDI-JECTOR ADAPTERS 19 moexipril-hydrochlorothiazide 14 medroxyprogesterone acetate 27 mometasone furoate 31 medroxyprogesterone acetate (contraceptive) 27 montelukast sodium 29 mefloquine hcl 6 morphine sulfate 15 megestrol acetate 9 moxifloxacin hcl 5 meloxicam 15 mupirocin 31 melphalan hcl 9 mupirocin calcium (topical) 31 memantine hcl 16 MUSTARGEN 9 MENACTRA 30 mycophenolate mofetil 28 MENOMUNE-A/C/Y/W-135 30 mycophenolate sodium 28 MENOPUR 26 MYDRIATICS 23 mephobarbital 16 MYLERAN 9 MEPHYTON 33 MYNATAL 33 mercaptopurine 9 MYNATAL-Z 33 mesalamine 23 MYNATE 90 PLUS 33 mesna 28 METAPROTERENOL SULFATE 10 N metformin hcl 26 methadone hcl 15 NABI-HB 29 methazolamide 13 nabumetone 15 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 40 - nadolol 12 O NAFTIN 31 naloxone hcl 14, 17 octreotide acetate 28 naltrexone hcl 17 ofloxacin (ophth) 21 NAMENDA 16 ofloxacin (otic) 21 naproxen 15 olanzapine 17 naproxen sodium 15 olanzapine odt 17 naratriptan hcl 16 omeprazole 2, 23 NARCAN 17 OMNIPAQUE 27 NASONEX 22 OMNITROPE 27 NEBUPENT 6 ondansetron 23 NECON 1/50-28 25 ondansetron hcl 23 NECON 10/11-28 25 ophthalmic irrigation solution - intraocular 22 nefazodone hcl 17 OPIATE ANTAGONISTS 17 neomycin sulfate 5 OPIUM TINCTURE (PAREGORIC ) 24 NEOMYCIN/POLYMYXIN/HYDROCORTISONE 22 OPSUMIT 14 neomycin-bacitracin zn-polymyxin 21 ORAP 18 neomycin-polymy-dexameth 22 ORENCIA 28 neomycin-polymyxin-hc (otic) 22 OSPHENA 30 neostigmine methylsulfate 10 OVIDREL 26 NESACAINE 28 oxaprozin 15 NEULASTA 12 oxazepam 16 NEUPOGEN 12 oxcarbazepine 15 nevirapine 7 OXSORALEN 32 NEXAVAR 9 OXSORALEN ULTRA 32 NIASPAN 12 oxybutynin chloride 32 nifedipine 13 oxycodone hcl 15 NILANDRON 9 oxycodone w/ acetaminophen 15 nimodipine 13 oxycodone-aspirin 15 NIPENT 9 OXYTOCICS 29 nitrofurantoin macrocrystal 7 oxytocin 29 nitrofurantoin monohyd macro 7 OXYTROL 32 nitroglycerin 14 NITROPRESS 13 P NORDIPEN 5 INJECTION DEVICE 18 NORDIPEN DELIVERY SYSTEM 18 paclitaxel 9 norepinephrine bitartrate 11 pamidronate disodium 28 norethin acet & ethinyl estradiol-fe 25 PANCREASE MT 23 norethindrone & ethinyl estradiol 25 PANCRELIPASE 23, 24 norethindrone (contraceptive) 25 pantoprazole sodium 23 norethindrone acet & ethinyl estradiol 25 papain-urea 32 norethindrone acetate 27 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS 10 norethindrone-ethinyl estradiol (triphasic) 25 PARATHYROID 26 norgestimate-ethinyl estradiol 25 paromomycin sulfate 6 norgestimate-ethinyl estradiol (triphasic) 25 paroxetine hcl 18 norgestrel & ethinyl estradiol 25 PATANOL 22 nortriptyline hcl 17 PCE 5 NORVIR 7 pediatric multivitamins w/fl 33 NOVOLOG 26 pediatric vitamins acd w/ fluoride 33 NOVOLOG MIX 70/30 26 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 24, 28 NUVARING 25 peg 3350-potassium chloride-sod bicarbonate-sod chloride nystatin 5, 31 24 nystatin (mouth-throat) 5 PEGASYS 7 nystatin (topical) 31 PEG-INTRON 7 nystatin-triamcinolone 31 penicillin g potassium 5 PENICILLIN G PROCAINE 5 PENICILLIN G SODIUM 5 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 41 - penicillin v potassium 5 PROCAINAMIDE HCL 13 pentoxifylline 11 prochlorperazine 18, 23 perphenazine 18 prochlorperazine edisylate 18 phenazopyridine hcl 32 prochlorperazine maleate 18 phenelzine sulfate 18 PROCRIT 12 phenobarbital 16 PROCTOFOAM HC 31 phenoxybenzamine hcl 10 PROFILNINE SD 11 phentermine 15 progesterone 27 PHENTOLAMINE MESYLATE 13 progesterone micronized 27 phenylephrine hcl (ophth) 23 PROGESTINS 26 phenytoin 15 promethazine hcl 7 phenytoin sodium 15 propafenone hcl 13 phenytoin sodium extended 15 PROPANTHELINE BROMIDE 10 PHOSPHOLINE IODIDE 22 proparacaine hcl 23 PHYSOSTIGMINE SALICYLATE 24 propofol 28 pilocarpine hcl 10, 22 propranolol hcl 12 pilocarpine hcl (oral) 10 propylthiouracil 27 pindolol 12 PROQUAD 30 pioglitazone hcl 26 PROSOL 19 piperacillin sodium-tazobactam sodium 5 PROTAMINE SULFATE 11 PITUITARY 26 protriptyline hcl 18 PLAN B 25 PROVISC 23 PLASMANATE 11 PROVOCHOLINE 27 PNEUMOVAX 23/1 DOSE 30 PSYCHOTHERAPEUTIC AGENTS 17 podofilox 32 PULMICORT 24 polymyxin b-trimethoprim 21 PULMOZYME 29 pot phosphate monobasic w/ sod phosphate dibasic & PURIXAN 9 monobasic 20 pyrazinamide 6 POTABA 33 pyridostigmine bromide 10 potassium acetate 20 PYRIDOXINE HCL 33 potassium bicarb & chloride 20 potassium chloride 20, 24 Q potassium chloride in dextrose & sodium chloride 20 potassium chloride microencapsulated crystals cr 20 QSYMIA 15 POTASSIUM CITRATE 19 quetiapine fumarate 18 PRADAXA 11 quinapril hcl 14 pramipexole dihydrochloride 17 quinapril-hydrochlorothiazide 14 pravastatin sodium 12 quinidine gluconate 13 prazosin hcl 12 quinidine sulfate 13 PRECISION XTRA 19 QVAR 25 PRED-G 22 prednisolone 22, 24 prednisolone acetate (ophth) 22 R PREDNISOLONE SODIUM PHOSP HATE 22 RABAVERT 30 prednisolone sodium phosphate 24 raloxifene hcl 26 prednisone 24 ramipril 14 PREMARIN 26 ranitidine hcl 23 PREMPHASE 26 RAPAMUNE 28 PRENATAL PLUS IRON 33 REBIF 28 PREVACID SOLUTAB 23 REGRANEX 32 PREVNAR 30 RELENZA DISKHALER 7 PREZISTA 7 REMICADE 28 PRIMAQUINE PHOSPHATE 6 RENAGEL 20 PRIMAXIN IV 5 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS primidone 15 13 PRIMSOL 5 RENVELA 20 probenecid 21 REPLACEMENT PREPARATIONS 20 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 42 - RESCRIPTOR 7 SODIUM EDECRIN 20 RESERPINE 13 sodium fluoride 28, 29 RESPIRATORY AGENTS, MISCELLANEOUS 18, 29 sodium fluoride (dental) 29 RESPIRATORY TRACT AGENTS 29 sodium phosphate 21, 24 RESTASIS 22 sodium polystyrene sulfonate 20, 29 REVLIMID 9 sodium thiosulfate 24 REYATAZ 7 SOMATOTROPIN AGONISTS AND ANTAGONISTS 27 RHEUMATREX 9 sotalol hcl 12 ribavirin (hepatitis c) 7 SOVALDI 7 RIDAURA 24 SPECTRACEF 5 rifabutin 6 SPIRIVA RESPIMAT 10 rifampin 6 spironolactone 14 riluzole 17 spironolactone & hydrochlorothiazide 14 rimantadine hydrochloride 7 SPRYCEL 9 RIMSO-50 28 SSKI 21 ringer's 20 stavudine 7 ringer's irrigation 20 STREPTOMYCIN SULFATE 5 risperidone 18 STRIBILD 7 RITUXAN 9 STRIVERDI RESPIMAT 29 rizatriptan benzoate 16 sucralfate 23 ropinirole hydrochloride 17 sufentanil citrate 15 ROTATEQ 30 sulfacetamide sodium (acne) 31 sulfacetamide sodium (ophth) 21 S sulfacetamide sod-prednisolone 22 SULFADIAZINE 5 saline, bacteriostatic 20 sulfamethoxazole-trimethoprim 5 salsalate 15 sulfasalazine 5 SANDOSTATIN 28 sulindac 15 SANTYL 32 sumatriptan succinate 16 SAVELLA 18 SUPRANE 29 SCOPOLAMINE HYDROBROMIDE 10 SUPRAX 5 selegiline hcl 17 SURMONTIL 18 SELENIUM 20 SUSTIVA 7 selenium sulfide 31 SUTENT 9 SELZENTRY 7 SYMPATHOMIMETIC (ADRENERGIC) AGENTS 10 SENSIPAR 28 SYNAGIS 7 SEREVENT DISKUS 11 SYNAREL 26 sertraline hcl 18 SERUMS 29 T SERUMS, TOXOIDS, AND VACCINES 29 SEXUAL DYSFUNCTION 30 TABLOID 9 SIDEKICK BLOOD GLUCOSE SYSTEM 19 tacrolimus 29, 32 sildenafil citrate (pulmonary hypertension) 14 tacrolimus (topical) 32 silver sulfadiazine 31 TAMIFLU 7 simvastatin 12 tamoxifen citrate 9 sirolimus 28 tamsulosin hcl 29 SKELETAL MUSCLE RELAXANTS 10 TARCEVA 9 SKIN AND MUCOUS MEMBRANE AGENTS 30 TARGRETIN 9, 32 SKIN AND MUCOUS MEMBRANE AGENTS, TARKA 13 MISCELLANEOUS 32 TASIGNA 9 SMOOTH MUSCLE RELAXANTS 32 TAZORAC 32 sodium acetate 19 temazepam 16 sodium bicarbonate 19, 20 temozolomide 9 sodium chloride 20, 21, 29 terazosin hcl 12 sodium chloride (gu irrigant) 20 terbinafine hcl 31 sodium chloride (inhalant) 29 terbutaline sulfate 11 sodium citrate & citric acid 19 testosterone 25 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 43 - testosterone cypionate 25 TUBERSOL 27 testosterone enanthate 25 TYKERB 9 TESTOSTERONE PROPIONATE 25 TYZEKA 7 tetracaine hcl (ophth) 23 TETRACYCLINE HCL 5 U THALOMID 29 theophylline 32 ULTANE 29 THERACYS 30 URICOSURIC AGENTS 21 thiamine hcl 33 URINARY ANTI-INFECTIVES 7 THIOLA 29 UROQID #2 7 thioridazine hcl 18 URSO 250 29 THIOTEPA 9 ursodiol 24 thiothixene 18 THROMBIN-JMI DILUENT 11 THYROID AND ANTITHYROID AGENTS 27 V THYROLAR-1 27 VACCINES 29 tiagabine hcl 15 VAGIFEM 26 TIKOSYN 13 valacyclovir hcl 7 timolol maleate (ophth) 22 VALCYTE 7 TIVICAY 7 valganciclovir 7 tizanidine hcl 10 valproate sodium 16 TNKASE 11 valproic acid 16 TOBI Podhaler 5 valsartan 14 tobramycin 5 valsartan-hydrochlorothiazide 14 tobramycin (ophth) 21 vancomycin hcl 5 Tobramycin neb 5 VANCOMYCIN HCL IN DEXTROSE 5 tobramycin sulfate 5 VARIZIG 29 tobramycin-dexamethasone 22 VASOCONSTRICTORS 23 tolazamide 26 VASODILATING AGENTS 14 TOLBUTAMIDE 26 vasopressin 26 tolterodine tartrate 32 VECTICAL 32 topiramate 16 vecuronium bromide 17 topotecan hcl 9 venlafaxine hcl 18 TORISEL 9 VENOFER 33 torsemide 20 VENTAVIS 14 TOXOIDS 29 VENTOLIN HFA 11 TRACLEER 14 verapamil hcl 13 tramadol hcl 15 VIAGRA 30 tranexamic acid 11 VICTRELIS 7 TRANSDERM-SCOP 23 VIDAZA 9 tranylcypromine sulfate 18 VINATE M 33 trazodone hcl 18 VINBLASTINE SULFATE 9 TREAGAN OTIC 23 vincristine sulfate 9 tretinoin (chemotherapy) 9 vinorelbine tartrate 9 tretinoin (topical) 32 VIRACEPT 7 triamcinolone acetonide (mouth) 31 VIREAD 7 triamcinolone acetonide (topical) 31 VITAMINS 33 triamterene & hydrochlorothiazide 20 voriconazole 5 triazolam 16 VOTRIENT 9 trifluoperazine hcl 18 VPRIV 21 trifluridine 21 trihexyphenidyl hcl 10, 17 trimethoprim 5, 7, 21 W tropicamide 23 warfarin sodium 11 trospium chloride 32 water for injection, sterile 21, 29 TRUVADA 7 water for irrigation, sterile 20 trypsin w/ castor oil & peruvian balsam 32 Exclusive Provider Organization (EPO, Self-Funded) Drug Formulary Colorado Region (June 28, 2016) - 44 - X ZENPEP 23 zidovudine 6, 7 XALKORI 9 zinc sulfate 21 XOPENEX HFA 11 ZINC SULFATE 29 XTANDI 9 ZINC TRACE METAL 21 XULANE 25 ziprasidone 18 ziprasidone hcl 18 Y ZOLADEX 9 ZOLINZA 9 YODOXIN 4 zolmitriptan 16 zolpidem tartrate 16 ZOMETA 29 Z zonisamide 16 zafirlukast 29 ZOSTAVAX 30 zaleplon 16 ZOSYN 5 ZARXIO 12 ZYDELIG 9 ZELBORAF 9 ZYTIGA 9 ZEMURON 17 ZYVOX 5

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