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Drug Exclusions May 1, 2021

Why Doesn’t My Health Plan Cover Some Providers Drugs? To request a formulary exception for a drug noted on the list with a (+), call 877-440-0089. To request a From time to time, our pharmacy committee decides formulary exception for all other listed drugs, call the to no longer cover, or exclude, some drugs because precertification number on the member’s ID card. other safe, effective, less costly alternatives are available. The committee is composed of independent Members doctors and pharmacists who regularly review and To request a formulary exception for all drugs listed, compare prescription drugs to ensure the ones we call the Customer Service number on your ID card. cover include proven medications for treating the Note: Formulary exceptions can only be considered majority of medical conditions. with required documentation from the member’s Newly-launched products and new variations of health care provider. products already on the market are not automatically added to your health plan’s list of covered drugs, also What Happens If I Have A Prescription Filled known as a formulary. A product can be added to the For An Excluded Drug? formulary only if our pharmacy committee decides You will be able to get your drug, but you will pay the that it is clinically appropriate and cost-effective. full cost of it. What Should I Do If My Drug Is Excluded? What Drugs Are Excluded From Coverage? Talk to your doctor to see if a covered alternative drug The drugs on the following pages are excluded from is a good option for treating your condition. Note that coverage as of the date of this list. many excluded brand-name drugs have covered Your pharmacy benefit may not cover certain generic alternatives. categories of drugs, such as those used to treat weight Of course, you and your doctor make the final decision loss or sexual dysfunction. Please check your plan about the medications that are right for you. If your materials for details about coverage for a specific drug doctor believes no alternative drug will work for your category. medical condition, you or your doctor can request a formulary exception to have an excluded drug covered. Just follow these steps:

Check your benefit information to verify coverage or view your personal benefit information on our website. This list may contain trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with your health plan. This list may change or expand from time to time without prior notice. Drug Exclusions List – Effective 5/1/21 1

Excluded Drug List Specialty drugs are noted with a (#). A Android-10 (brand) -- Carteolol Ophthalmic Cosela (#) Abecma (#) Antara (brand) Oint Carticel Cotempla Abilify (brand) Apadaz Benzhydrocodone/ Cataflam Crysvita (#) Abilify Mycite Aplenzin Acetaminophen Celacyn Cuprimine (#) Absorica/LD Apligraf (#) 150 mg Celexa Cutaquig (#) Acanya Aptensio XR (brand) Beovu (#) Cequa Cuvitru (#) Aciphex Arakoda Ceracade Cyclobenzaprine ext rel Acnefree Arazlo Dipropionate- Cerave Cyfolex Acthrel (#) Arestin Cholecal DF Cymbalta (brand) Acticlate (brand & gen.) Arikayce (#) Betapace/AF tablet Chorionic Cystadane (#) Acuicyn Armonair Digihaler Bevacizumab prefilled Gonadotropin (#) Cystadrops (#) Acyclovir 5% cream Armonair Respiclick syr. (#) 250 mg, Cytomel (brand) Artesunate Bevyxxa 375 mg & 750 mg Aczone 5% (brand) D Adagen (#) Arymo ER Biafine Cicatrace Pad Adakveo (#) Asacol HD (brand) Bijuva Ciclopirox-Clobetasol D.H.E. (brand) Adapalene-Benzoyl Asceniv (#) Binosto (brand) Shampoo Daklinza (#) Peroxide- Asmanex Bionect Ciclopirox-Clobetasol- Dandelion Allergenic Ext. Clindamycin Gel Asparlas (#) Bocasal oral rinse Salicylic Acid Shampoo Danyelza (#) Adapalene-Benzoyl Aspergillus Fumigatus Bonjesta Ciclopirox-Salicylic Acid Dapsone-Niacinamide Gel Peroxide- /Omeprazole Bortezemib (#) Shampoo Dapsone-Niacinamide- Niacinamide Gel Atacand/HCT (brand) Botox Cosmetic (#) Ciprofloxacin/Fluocino- Spironolactone Gel Adderall (brand) Ativan (brand) Bravelle (#) lone Otic Daxbia Adhansia XR Atopiclair Breyanzi (#) Cimetidine-Lidocaine- Dayvigo Adlyxin Atralin Breztri Aerosphere Salicylic Acid Cream Defitelio (#) Admelog Atrapro spray/gel/kit Brineura (#) Cinqair (#) Deflux Adzenys XR Aurstat Briviact Clarinex/Clarinex-D Delstrigo Aemcolo Austedo (#) Bromsite Claritin/Claritin-D Denavir Aerospan Auvi-Q Bronchitol Clenpiq Dermatop (brand) Afstyla (#) Avar (brand) Brukinsa (#) Clindagel Desloratadine Airduo Aveed (brand) (#) Bryhali Clindamycin Phos- Desowen Ajovy Avenova Budesonide/Formoterol Niacinamide- Dexchlorpheniramine syr. Aklief Avsola (#) Bunavail (brand) Tretinoin Cream Dexeryl Ala Scalp Azelex (brand) Bupap (brand) Clindamycin Phosphate- Dexilant Alavert Azesco HCL Niacinamide Lotion Dexpak Alcortin A Azor (brand) Butalbital/APAP 50/300 1-4% Dextenza (#) Aldara (brand) Azelaic Acid-Niacinamide Bynfezia Pen (#) Clindamycin Phosphate- Dexycu Alevicyn /Plus Cream Byvalson Niacinamide Gel Diclegis (brand and gen.) Azeschew Clindamycin-Benzoyl Diclofenac caps Allegra/Allegra-D C Peroxide-Niacinamide Diclofenac - Allzital B Aloquin Cabenuva Gel Sodium Hyaluronate- Alora (brand) 5 mg Caduet Clindamycin-Niacinamid- Niacinamide Gel Altoprev (brand) Balcoltra Cafergot tablet Spironolac-Tretinoin Diclofono Altreno Bafiertam (#) Calcipotriene- Gel Differin gel Alvesco Barhemsys Betamethasone Clobetasol Propionate- Diflorasone cream & Alzair Baxdela Calcipotriene-Clobetasol Levocetirizine Dihyd oint. Amcinonide 0.1% cream Beau Rx Propionate Shampoo Dihydroergotamine & ointment Belbuca Caldolor Clobetasol Propionate- spray Ameluz Benicar/HCT (brand) Cambia Niacinamide Dimercaptopropane- Amondys 45 (#) Bensal HP Candida Albicans Extract Cream/Oint/Soln Sulfonate Amphetamine ER Susp Benz Per-Clindamycin- Caplyta Colcrys (brand) Diuril Amrix (brand) Niacinamide- Carac (brand & generic) Conjupri Divigel (brand) Amzeeq Tretinoin Gel Carbinoxamine 6 mg Consensi Doptelet (#) Andexxa (#) Benzaclin (brand) Cardizem CD/LA (brand) Conzip (brand) Doryx/MPC (brand) Androgel 1.62% (brand) Benzamycin (brand) Carnitor/SF Cordran cream/tabs Benzepro (brand) Carospir Cortaid max. strength Doxycycline DR 80mg

Drug Exclusions List – Effective 5/1/21 2

Doxycycline Finasteride-Minoxidil Herzuma (#) Intuniv (brand) Lanoxin 125 & 250 mcg Monohydrate cap 75 Firdapse (#) Horizant (brand) Inveltys tablet mg First Atenolol susp. HPR Plus/MB Hydrogel Iodoquinol- Lansoprazole Drizalma First-Lansoprazole Kit - Lazanda Duaklir (excluded only for Hyaluronate Sodium- Cream Ledipasvir/Sofosbuvir (#) Duexis members 17 years Niacinamide- Ionil liquid Levicyn dermal spray Duobrii and older) Tacrolimus Ipamorelin Acetate (#) Levitra Dutoprol First-Omeprazole Hyaluronate Sodium- Isturisa (#) Levorphanol Duzallo (excluded only for Niacinamide- Ivermectin- Levulan Kerastik Dxevo members 17 years Tretinoin Metronidazole- (brand) Dyanavel XR (brand) and older) Hycofenix (brand) Niacinamide Gel Lexapro (brand) Dyrenium capsule Flolipid Hydrisalic Lexette J Fluconazole-- Hydrocodone 2.5 mg/ Lialda (brand) E Itraconazole- guaifenesin 200 mg Jatenzo Librax (brand) Econazole Nitrate- Terbinafine hydrocortisone 1% in Jelmyto (#) Libtayo (#) Niacinamide Cream Fluocinolone asorbase Jivi (#) Licart Edecrin (brand) Acetonide- Hydroquinone Jornay PM Lidocaine-Tetracaine Edex Niacinamide Cream Emulsion Jublia Cream EES granules Fluorouracil cream 0.5% Hydroquinone- Juluca Lidocaine cream 4.12% Effexor XR (brand) Fluoroplex (brand) Hydrocortisone K Lidoderm (brand) Efudex (brand) Fluticasone/salmeterol Emulsion Lidotrex (lidocaine) Elestrin (brand) inhaler Hydroquinone- Kadian (brand) 2% gel Elepsia XR Folene Hydrocortisone- Kamdoy Lipofen (brand) Eletone Folika-V Tretinoin Emulsion Kanjinti (#) Locoid (brand) Emflaza (#) Folite Hylatopic Plus Kapspargo Lodrane D Endari Folvite-FE Hymovis (#) Katerzia Lokelma Enstilar Forfivo XL (brand) Hyperhep B (#) Kedrab (#) Lonhala Entty Spray Emulsion Fortamet (brand & gen.) Hyperrab (#) Kelarx (silicone) Scar Loprox (brand) Envarsus XR (#) Fosamax + D Hyperrab S/D (#) Care Gel Loteprednol ophth gel Epaned (brand) Fotivda (#) Keramatrix Loyon I Epiceram Fulphila (#) Kerydin Lucemyra Epicoccum Nigrum Fungoid-D IBU 600-EZS Ketoconazole 2% foam Lumoxiti (#) EpiPen/Jr. (brand) Idelvion (#) Ketoconazole- Lunesta (brand) G EryPed 200 & 400 mg Idhifa (#) Hydrocortisone Lupkynis (#) Esomeprazole Gamifant (#) Ilumya (#) Cream Luradrox gel Esperoct (#) Gatifloxacin Iluvien (#) Ketoprofen ER Lutathera (#) esterified estrogen/ imiquimod cream 3.75% HCL Luxturna (#) methyl-testosterone Gelclair Gel Imiquimod- Ketodan Luzu Eucrisa Gemtesa Levocetirizine Dihcl- Ketorolac spray Lyrica/CR Eurax lotion Genadur Niacinamide Gel Keveyis (#) Lyumjev Evekeo/ODT (brand) Genvisc (#) Imiquimod- Khapzory (#) Evenity (#) Giazo (brand) Levocetirizine Dihcl- Kinerase M Evivo Gimoti Tretinoin Gel Klisyri Macrilen (#) Evkeeza (#) Gloperba Imitrex (brand) Klor-Con oral pack for Macrodantin capsules Evomela (#) Glumetza (brand & Imlygic (#) solution Margenza (#) Exondys 51 (#) generic) Imogam (#) Kovaltry (#) Mavenclad (#) Ezallor Glycopyrrolate 1.5mg Impoyz Krintafel Mayzent (#) Gocovri Imvexxy Kristalose pak Mepsevii (#) F GPL Pak Inbrija (#) Krystexxa (#) Metformin ER (only Fasenra (#) Gralise (brand) Inderal LA/XL Kymriah (#) excluded when Fenofibrate 130 mg Grastek Indocin caps./supp./ L prescribed as a Fenoglide (brand) Gvoke PFS susp. generic for brand fenoprofen (generic) Indomethacin Lactinol HX Fortamet or brand H Fenortho (brand) Infugem (#) Lactic Acid-Niacinamide Glumetza) Fetroja Halcinonide cream 0.1% Ingrezza (#) Cream Methionine-Inos- Fexofenadine Halog Innopran XL Lactulose oral packet Choline-Levocarn fexofenadine- Hemady Inrebic (#) 10gm Methylcobala pseudoephedrine Hemlibra (#) Intrarosa Lampit

Drug Exclusions List – Effective 5/1/21 3

Methylphenidate 72 mg Niacinamide- Onfi tab and susp. Prevacid Retisert (#) ER Spironolactone Gel Onpattro (#) Prevymis (#) Retin-A/Micro (brand) Miacalcin injection/ Niacinamide- Ontruzant (#) Prilopentin Revcovi (#) nasal spray Spironolactone- Onzetra Prilosec Revesta Micort Tretinoin Gel Opana ER Primlev Reyvow Microvix LP Niacinamide- Oracea (both brand & Pristiq (brand) Rexaphenac (brand) Midaz/ketamine troche/ Sulfacetamide Sodium generic doxycycline Probuphine Rhofade cream ondansetron Niacinamide-Tacrolimus (Rosacea) delayed Procentra (brand) Rhopressa Midazolam Oint release capsules are Progesterone-Minoxidil Riomet ER Migranal (brand) Niacinamide- excluded) Prolate Rocklatan Millipred/DP Triamcinolone Orafate (#) Prolensa Romidepsin (#) Minastrin 24 FE (brand) Acetonide Cream Oravig Promiseb Roszet Minitran (brand) Niacinamide-Tazarotene Orladeyo (#) Protexa Roxybond Minivelle (brand) Cream Ortikos Prothelial(#) Rozlytrek (#) Minocin (brand) Niacinamide-Tretinoin Osmolex ER Protonix Ruxience (#) Minocycline ER caps Cream/Gel Otiprio Proventil HFA Ruzurgi (#) Minolira ER Niacinamide- Otovel Provigil (brand) Rynoderm Minoxidil-Progesterone- Spironolactone- Ovace Plus/Wash (brand) Prozac (brand) S Tretinoin Tretinoin Gel Oxbryta (#) Pulmicort Respules Mircera (#) Niacor Oxervate (#) (brand) S2 Mitigare (brand) Nilandron (#) Oxlumo (#) Pyridostigmine tablet Salex (brand) Mitomycin (#) Nilutamide (#) Oxtellar XR (brand) 30 mg Salicylic Acid-Sulfaceta- Monodox (brand) Nitro-Dur (brand) Oxycodone/ Pyridoxal-5 Phosphate mide Sodium Monoferric Nitroglycerin lingual acetaminophen Pyrimethamine- Salisol Mondoxyne (brand) (brand) sol.Ozobax Leucovorin Salivamax Morgidox (brand) Nitrolingual Samsca P Q Morphabond ER Nitromist Scarcin Gel Moxatag (brand) Nityr (#) Palforzia (#) Qbrexza pad Scarsilk gel/pad Mugard Nivatopic Plus Palynziq (#) Qmiiz ODT Scenesse (#) Mulpleta (#) Nocdurna (#) Panhematin (#) Qtern Sebuderm Mupirocincream Noctiva (#) Panzyga (#) Quartette (brand) Secuado Mvasi (#) Noritate Parsabiv (#) Qudexy XR (brand) Segluromet Mydayis Nourianz Pennsaid 1.5% & 2% sol. Qelbree selenium sulfide Mylotarg (#) Novacort Pepaxto (#) Quillichew ER (brand) shampoo 2.25% Novolin Relion Pepcid (brand) Quillivant XR (brand) Semglee N Nucala (#) Pexeva (brand) Qutenza (#) Sernivo Nabi-HB (#) Nulibry (#) Phenobarbital/ Quzyttir Seroquel/XR (brand) Nalfon (brand) Belladonna Alkaloids Sevenfact (#) Nuplazid (#) R Nandrolone decanoate Nurtec ODT Seysara Naprosyn susp. 125 mg/ Nutraderm Pifeltro Rabeprazole Siklos (#) 5 mL (brand) Nutraplus Piqray (#) Ragwitek Silenor (brand) Naprosyn tab 500mg Nutraseb Plaquenil (brand) Ranexa Siliq (#) naproxen/ Nuvail Plavix (brand) Rayaldee Sil-K Pad esomeprazole Nuvigil (brand) Plenvu Rayos (brand) Simvastatin Naproxen sodium ER Nuwiq (#) Plexion/Cleanser (brand) Rebinyn (#) Singulair (brand) (generic Naprelan) Nuzyra Pliaglis cream Reblozyl Sitavig Nascobal Nyvepria (#) Ponvory (#) Recarbrio Sitzmarks Nasonex (brand) Polivy (#) Recedo Sodium Hyaluronate- Nayzilam O Portrazza (#) Red Algae Hydroquinone Neocera Ocaliva (#) Praluent Relafen DS Emulsion Neosalus/CP Ocean for Kids Pred-Gati Relexxii Sofosbuvir/Velpatasvir (#) Neutrasal Odactra Prednisone Intensol Relistor injection/ Solaravix Nevestym Ogivri (#) (brand) tablets Solaraze (brand) Nexium Olumiant (#) ER Remedient Solesta (#) Nextstellis omeprazole (OTC only) Pregenna Remodulin (#) Soliqua Niacin (generic) tab 500 omeprazole/sodium Prenara Renflexis (#) Solodyn mg bicarbonate Prenatal 19 Resveratrol Solosec Onexton Pretomanid Retacrit (#) Sovaldi (#)

Drug Exclusions List – Effective 5/1/21 4

Spinraza (#) Tiglutik (#) Valium (brand) Vyxeos (#) Zenzedi (brand) Spravato (#) Timolol gel Valtoco Vyzulta Zepatier (#) Sprix (brand) Tirosint capsule/sol. Valtrex (brand) Zeposia (#) W Staxyn Tivorbex (brand) Vanatol LQ (brand) Zerviate Steglatro Tobi solution (brand) (#) Vanos (brand) Wakix Zetia (brand) Steglujan Tolak (brand) Vanoxide-HC lotion Wellbutrin SR/XL (brand) Ziana (brand) Stendra Tolsura Varizig Winlevi Ziextenzo (#) Strattera (brand) Topicort Spray Varubi Wixela Inhub Zilretta (#) Striant (brand) Tosymra Vaseretic (brand) X Zilxi Sublocade (#) Tramadol HCL ER Vasotec (brand) Zinc Sulfate Sumadan wash (brand) Trazimera (#) Veltassa (#) Xadago Zinplava Sumaxin (brand) Treprostinil (#) Veltin Xanax/XR (brand) Zipsor (brand) Sunosi Treximet (brand) Vemlidy (#) Xaquil XR Zirabev (#) Sutab Trezix (brand) Ventavis (#) Xatmep (#) Zofran/ODT (brand) Symdeko (#) Trianex oint. 0.05% Ventolin HFA Xeloda Zokinvy (#) Symjepi (brand) Verdeso foam 0.05% Xelpros Zolgensma (#) Sympazan Tridesilon (brand) (brand) Xembify (#) Zoloft (brand) Symproic Triglide (brand) Veregen ointment Xenazine (brand) (#) Zolpimist Symtuza Trijardy XR Verquvo Xenleta Zonegran 25 & 100 mg Synderderm Trimo-San gel Vesicare LS Xepi caps Syndros Trinaz Vexasyn gel Xerese Zorvolex (brand) Synera (brand) Triptodur (#) Vibramycin (brand) Xhance Zovirax Syprine (#) Trivisc (#) Viekira Pak/XR (#) Ximino Zuplenz (brand) Trogarzo (#) Viltepso (#) Xofluza Zurampic T Trokendi XR Vimovo Xopenex HFA Zyclara Taclonex Tronvite Viread Xpovio Pak (#) Zyflo CR (brand) Tacrolimus Cream Trop-Phenyl Visco-3 (#) Xtampza ER Zypitamag Takhzyro (#) Trulance Visbiome Xultophy Zyrtec/Zyrtec-D Talicia Truxima (#) Vitafol strips Xuriden (#) Targadox (brand) Turalio (#) Vitafol FE Xvite Targretin (#) Tussicaps (brand) Vitasure Xyosted Tasigna (#) Tuxarin ER Vitrase Xywav (#) Tavalisse (#) Twirla Vivlodex Y Taytulla cap 1 mg/20 mc Tymlos (#) Vizimpro (#) Tegsedi (#) Vocabria Ybuphen U Tenormin Voltaren gel (brand) Yescarta (#) Tepezza (#) Ubrelvy Vonvendi (#) Yonsa (#) Tepotinib HCL (#) Udenyca (#) Vosol HC Yosprala Teriparatide (#) Ukoniq (#) VP-Vite Rx Yupelri Testopel (brand) Ultomiris (#) VSL#3 Yutiq (#) Tetravex gel Ultravate lotion Vtol LQ Z Tetrix Uplizna (#) Vumerity (#) Zalvit Thiola EC (#) Uroxatral tablet Vyepti Zavara Thrombate III (#) Ursodiol Vyleesi Zegalogue Thyquidity (#) Utibron Neohaler Vyndaqel (#) Zegerid (brand & generic) Tiazac (brand) Vyndamax (#) V Zelac Tibsovo (#) Vyondys 53 (#) Zembrace Ticalast Vabomere Vytorin (brand)

Drug Exclusions List – Effective 5/1/21 5

Generics Excluded from Certain Manufacturers These generic drugs are excluded from coverage only when produced by certain manufacturers, but can be available from alternate sources — consult your pharmacist for more information. acetic acid/alum castellani paint levobunolol hcl polymycin b sulfate/ tetracaine hcl acetate cormax scalp /polymyxin/ trimethoprim timolol maleate albuterol sulfate application dexamethasone proparacaine hcl ophthalmic anusol-hc cromolyn sodium neomycin/polymyxin/ salactic film tobramycin/ atropine sulfate cyclopentolate hcl sal-plant dexamethasone /neomycin/ dorzolamide hcl/ opium sulfacetamide sodium tropazone polymyxin timolol m pedi-boro soak pads sulfacetamide sodium/ tropicamide bacitracin/polymyxin b flunisolide pedi-dry ureacin brimonidine tartrate sodium phenylephrine hcl sulfacetamide sodium/ carteolol hcl latanaprost podofilox sulfur

Excluded Compound Bases, Bulk Powders & Compound Kits This list contains many ingredients that are not covered under your prescription benefit coverage when included in certain bases and bulk powders used in compounded drugs, as well as compound kits. Please note that this list is not comprehensive; other compound ingredients are also excluded. 0-9 Base X Chloramphenicol Doxepin HCL Flavor Plus 2-Deoxy-D-Glucose Base-Pcca Mbk (Fatty Doxycycline Hyclate Flavor Sweet-SF 5-Fluorouracil Acid) Chorionic Gonadotropin Drcaps size 1 clear Fluconazole Beclomethasone Chrysaderm Day 5-Methyltetra- E Hydrofolate Dipropiona Cimetidine Fluorouracil Edetate Disodium 5-Methyltetra- Benzocaine Ciprofloxacin HCL Flurbiprofen Dihydrat Hydrofolic A Benzoin compound Citric Acid Anhydrous F-Melt EGCG 7-Keto DHEA tincture Clindamycin HCL/ Freedom Derma-N Benzyl Monohydra Emollient cream/base Freedom Poloxitol A Betahistine HCL/ Clindamycin Phosphate Empty capsule, all sizes G Acacia Dihydrochlori Clobetasol Propionate/ & colors Acetone Betamethasone Sodium Micronized Emu oil Acetyl Hexapeptide-8 Phos Clotrimazole Gentamicin Sulfate Acidophilus Bethanechol Chloride Coal Tar Ethylsuccina Glutamine Lactobacillus BHRT base HCL Estradiol/Micronized/ Glutathione-L Albendazole Biotin Cocoa butter Valerate Glycerin Almond oil, sweet Bitter drug powder Coenzyme Q10 Estriol/Micronized Glycolic Acid Alprostadil Boric Acid Copasil Ethoxy Diglycol Glycopyrrolate HCL Bromfenac Sodium Corn oil Ethyl Alcohol Grape flavor Amphotericin B Budesonide Curcumin Ethyl Oleate Guaifenesin Gum base gelatin Apple flavor Bupropion HCL Cyanocobalamin F Arbem H-Cosmetic Cyclobenzaprine HCL Fagron Capfill Pro/ H Ascorbic Acid C Dispersapro/ Hormone cream base Aspirin Cannabidiol D Supreme cream Botani Auxipro Plasticized Capsublend-P Dehydroepiandroster- Fattibase Hrt base (All) Avicel Ph 105 Capsule Clear Veggie Lo one Fattyblend Hrt Natural/Supreme Microcrysta (All) Dermabase Ferulic Acid cream base Azithromycin Capsule Coni-Snap (All) Dexamethasone/ Carboxymethylcellu- Acetate Anh/Sodium First-Baclofen 5 Hyaluronic Acid Sodium Sa B lose So Phos First-Dukes Hydrocodone Bitartrate Baclofen Carnitine (L) Diazepam First-Lansoprazole Hydrocortisone/ Bacteriostatic Water Celecoxib Dichloralphen-Azone First-Metronida-Zole 50 Acetate/ Micronized Banana creme flavor Cellulose Microcrystallin Diclofenac Sodium First-Mouthwash Blm Hydrogel Base C Polyethyl-Ene Cellulose/Cmc Na HCL First-Omeprazole Hydromorphone HCL Glyco Microcry Dimercapto-1- First-Progester-One Vgs Hydroquinone Base cream with Cetaphil moisturizing Propanesulfo 10/ 20/50 Hydroxyethyl Cellulose Liposome cream Dimercaptosucc-Inic First-Testosterone/Mc 45 Base gelatin Gummy Cetyl Myristoleate Acid First-Vancomycin 25/50 Hydroxyprogester-One Troche Cherry syrup Dimethyl Sulfoxide Flavor blend Capro

Drug Exclusions List – Effective 5/1/21 6

Hydroxypropyl Marshmallow flavor Paraffin Pregnenolone/ Synapsin Cellulose 1/ Mediderm PCCA Anhydrous micronized Syrspend SF/Alka Methylcellu Medi-Rdt base Lipoderm B HCL T Hydroxyurea Medium Chain PCCA cosmetic HRT base Progesterone/Microniz Hypromellose Triglyceride PCCA custom Lipo-Max ed/Ultra Micronized Tamoxifen Citrate Methocel K1 Melatonin PCCA DMAE complex Progesterone wettable Tea tree oil Mercaptopurine PCCA emollient cream HCL Terbinafine HCL I Monohydrat base Propylene Glycol Testosterone/ Ibuprofen Metformin HCL PCCA Emulsifix-205 base Prostaglandin E1 Cypionate Imiquimod Methocel E4m Premium PCCA fixed oil base Purified water Testosterone Isometheptene Mucate Methscopolamine PCCA gelatin base Pyrantel Pamoate micronized/S/Y Itraconazole Bromide PCCA Lecithin Isopropyl Pyridoxal-5-Phosphate Testosterone non- Ivermectin Methylcellulose P Mon micronized Methylcobalamin PCCA Lipoderm base/ Testosterone J Q Methyltestosterone HMW Propionate N/A Metoprolol Tartrate PCCA Loxasperse base Quinacrine HCL Tetracaine/HCL K Metronidazole/ PCCA Natacream Quinine Sulfate Tetracycline HCL Dihydrate Thymol Ketamine HCL Benzoate PCCA plasticized base Thyroid Porcine Ketoconazole Miconazole/Nitrate PCCA Pluronic F127 R Tobramycin/Sulfate Ketoprofen/Micronized/ Midazolam base Ranitidine HCL Tofacitinib Citrate Ultra Micronized Mineral oil light PCCA Polyglycol Troche Resveratrol 98% Ketotifen Hydrogen Mometasone Furoate PCCA Pracasil Tm-Plus Tramadol HCL Fumara Morphine Sulfate base S Transdermal base Kinetin Mucolox PCCA rapid-dissolve Salicylic Acid Tretinoin Mupirocin tablets Salt durable cream L Triamcinolone PCCA Sorbitol lollipop Salt Stable Lo/Ls N Acetonide Lactic Acid base Advanced Nabumetone Troche base Lactose/Anhydrous PCCA Spira-wash base Sermorelin Acetate Naltrexone HCL/ Tutti Frutti flavor Lactose Monohydrate/ PCCA Sweet-SF Sesame oil Anhydrous spray PCCA syrup vehicle Sildenafil Citrate U Natapres Lanolin Anhydrous PCCA T3 Sodium Dilution Silica gel Niacinamide Ubiquinol Lansoprazole PCCA T4 Sodium Simethicone Ursodiol L-Arginine Dilution Simple syrup Nourivan Antiox cream Leucovorin Calcium PCCA vanishing cream/ Sirolimus V base Leuprolide Acetate light/ lotion Sodium Bicarbonate Vancomycin HCL Nystatin/Foreign Levofloxacin PCCA Vanpen base Sodium Chloride/ HCL Hemihydrate O PCCA Xylifos base Bacterios Versabase/foam L-Glutamine PCCA -Plus Ointment base Sodium Hyaluronate Versapro Lidocaine/HCL Penderm emulsifying Sodium Metabisulfite Versatile cream base Liothyronine Sodium Pentravan/Plus Olive oil Solu-K gel Lipmax Peppermint oil W Omeprazole Sorbitol Lipopen/Absorption Phentermine Watermelon flavor Ondansetron HCL Spg Supposi-Base Enhanc Hydrochloride Wax paraffin beads Dihydrate Spironolactone Lipopen Ultra/base Phentolamine Mesylate White Petrolatum Ora-Blend/SF Sterile water for L-Methylfolate Calcium Phytobase Wiley Basic Elements Oral mix flavored susp. injection Lollibase Plo Gel – Mediflo pre- BHRT Oral suspension Stevia extract Lollipop base mix Witepsol H15/Base F Ora-Plus Steviol Glycosides Pluronic F127 Ora-Sweet/SF Succimer DMSA X Loxoral base Polox Sucralfate Oxycodone HCL Xylitol Lozibase S Polyethylene Oxytocin Sulfacetamide Sodium L-Thyroxine Sodium Glycol/blend/ Sulfadiazine Y Lugols P 300/400/1450/3350 Sulfamethoxazole Yellow Petrolatum M Palmitoyl Polypeg suppository Sulfapyridine Pentapeptide-3 base Supposibase F Z Glycinate Papaverine HCL Povidone-Iodine Suspendit N/A Mannitol Praziquantel

Drug Exclusions List – Effective 5/1/21 7

Topical Pain Formulations Excluded Product Categories and Examples Formulary Alternatives Camphomex (-HISTAMINE--LIQUID SPRAY) • OTC Capsaicin patches, cream, gel Lidocaine HCL cream/lotion 3% • Lidoderm or generic Lidocaine 5% patches Lidocin (LIDOCAINE HCL GEL) • Lidocaine 5% ointment Lidorx (LIDOCAINE HCL GEL) • Lidocaine 2% gel Lidovex (lidocaine cream) • Voltaren 1% gel Livixil Pak (lidocaine-prilocaine kit) • Generic Diclofenac 1.5% solution Medi-Derm/L-RX (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SALICYLATE CREAM) Medi-Derm-RX (CAPSAICIN-MENTHOL-METHYL SALICYLATE CREAM) Mentholix (LIDOCAINE-MENTHOL LIQUID SPRAY) Silmanix Pain Relieving (CAPSAICIN-MENTHOL-HISTAMINE CREAM) Tetramex (TETRACAINE-MENTHOL-CAMPHOR LIQUID SPRAY)

Topical Pain Patches Excluded Product Categories and Examples Formulary Alternatives Anodynerx (CAPSAICIN-LIDOCAINE-MENTHOL) • OTC Capsaicin patches Atendia (LIDOCAINE-MENTHOL) • Lidoderm or generic Lidocaine 5% patches Captracin (CAPSAICIN-MENTHOL) Levatio patch (CAPSAICIN-MENTHOL) Lidenza (LIDOCAINE-MENTHOL) Medi-patch (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SALICYLATE) Menthocin/Lidocaine (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SALICYLATE) Qroxin (CAPSAICIN-MENTHOL) Reciphexamin (LIDOCAINE-MENTHOL) Relyyks (LIDOCAINE-MENTHOL) Relyyt (CAPSAICIN-MENTHOL) Renovo (CAPSAICIN-MENTHOL) Sinelee (CAPSAICIN-MENTHOL) Solaice (CAPSAICIN-MENTHOL) Synvexia (LIDOCAINE-MENTHOL) Velma Pain Relief (METHYL SALICYLATE-LIDOCAINE-MENTHOL)

Ear Pain Formulations and Combinations Excluded Product Categories and Examples Formulary Alternatives Antipyrine/Benzocaine Otic (Generic) • Dexamethasone otic Cortane B-Otic (PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLUTION) • Pediotic Otic Care (ANTIPYRINE-BENZOCAINE-POLYCOSANOL OTIC SOLUTION) • Neomycin/polymyxin/hydrocortisone otic Oticin drops (CHLOROXYLENOL-PRAMOXINE) • Acetic acid/hydrocortisone Oto-End 10 solution (CHLOROXYLENOL-PRAMOXINE- • Ciprodex HYDROCORTISONE) • Cipro otic Otozin drops (BENZOCAINE-ANTIPYRINE-ZINC ACETATE) • Cortisporin Pinnacaine 20% Drops (BENZOCAINE)

Drug Exclusions List – Effective 5/1/21 8

Scar Products Excluded Product Categories and Examples Formulary Alternatives Renuu (ALLANTOIN-LIDOCAINE-PETROLATUM) • Lidoderm or generic Lidocaine 5% patches Scar patch (ALLANTOIN-LIDOCAINE-PETROLATUM) • Lidocaine 5% ointment • Lidocaine 2% gel • Miscellaneous emollients (petrolatum, lanolin, glycerin, mineral oil, aloe vera, dimethicone) Convenience Multi-Product Kits Excluded Product Categories and Examples Formulary Alternatives Active-Medicated specimen (URINE SPECIMEN COLLECTION KIT) • OTC Capsaicin patches, cream, gel Active-PAC/Gabapentin (GABAPENTIN CAPS, LENZAGEL • Lidoderm or generic Lidocaine 5% patches [LIDOCAINE-MENTHOL]) • Lidocaine 5% ointment Advanced DNA Medicated CO (DNA COLLECTION PRODUCT KIT) • Lidocaine 2% gel Analpram Advanced (HC-PRAMOXINE CREAM, DIET MANAGE • Lidocaine 2% or 4% solution PROD TAB, CLEAN WIPE KIT) • Voltaren 1% gel Bupivilog kit (TRIAMCINOLONE INJECTION, BUPIVACAINE HCL • Generic Diclofenac 1.5% solution INJECTION KIT) • Generic topical steroids – alclomethasone, DermacinRX Inflammatral Pak (DICLOFENAC DELAYED-RELEASE betamethasone, clobetasol, desonide, fluocinoline, TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) fluocinonide, fluticasone, halobetasol, mometasone, DermacinRX Kit Silapak (TRIAMCINOLONE ACET CREAM, triamcinolone DIMETHICONE CREAM, SILICONE TAPE) • gluconate solution DermacinRX Lexitral (DICLOFENAC SOLUTION, CAPSAICIN CREAM) DermacinRX surgical (CHLORHEXIDINE GLUCONATE 4% SOLUTION) DermacinRX Ticanase Pak (FLUTICASONE NASAL SUSPENSION, SODIUM CHLORIDE SPRAY) Derma SilkRX Anodynexa Pak (DICLOFENAC DELAYED-RELEASE TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) Derma SilkRX Diclopak (DICLOFENAC DELAYED-RELEASE TABLETS, CAPSAICIN CREAM) Derma SilkRX SDS Pak (TRIAMCINOLONE CREAM, DIMETHICONE, SILICONE TAPE) DermaWerx Surgical Plus P (CHLORHEXIDINE SOL 4%- MUPIROCIN, DIMETHICONE, TAPE KIT) DNA collection kit (LIDOCAINE ORAL SOLUTION, GLYCERIN SWAB, BUCCAL SWAB) Genadur kit (DERMATOLOGICAL PRODUCTS MISC TOPICAL/ORAL – KIT) Inflammacin (DICLOFENAC SODIUM, CAPSAICIN CREAM THERA PACK) Morgidox (DOXYCYCLINE HYCLATE CAPSULES WITH CLEANSER KIT) SanadermRX Skin Repair (TRIAMCINOLONE ACET CREAM, DIMETHICONE CREAM, SILICONE TAPE) Silazone PharmaPak (TRIAMCINOLONE ACET CREAM, SILICONE SHEET PACK)

Drug Exclusions List – Effective 5/1/21 9 Rvs 3/13/2017 1 19199-3-2017 Rvs 3/13/2017 2 19199-3-2017