cefprozil Augmentin XR ceftazidime Bactocill IN Dextrose ceftriaxone sodium Bicillin C-R cefuroxime axetil Bicillin L-a October 2015 cefuroxime sodium Moxatag cephalexin Nafcillin Sodium NATIONAL FORMULARY DRUG LIST PREFERRED Nallpen Iso-osmotic IN Dextrose Zerbaxa Nallpen/Dextrose The KPP Drug List is a guide identifying generic, NON PREFERRED Penicillin G Potassium IN Iso-osmotic preferred brand name, and non-preferred brand name medicines within select therapeutic Ancef Dextrose Penicillin G Procaine categories. The Drug List may not include all drugs Avycaz covered by your prescription drug benefit. Generic Cedax Penicillin G Sodium medicines are available within many of the Cefaclor Pfizerpen-G therapeutic categories listed, in addition to Cefaclor ER Timentin categories not listed, and should be considered as Cefazolin Sodium Unasyn the first line of prescribing. Cefazolin Sodium/Dextrose Unasyn Bulk Pack Cefditoren Pivoxil Zosyn For benefit coverage or restrictions please check Cefepime your benefit plan document(s). This listing is revised Cefotetan QUINOLONES GENERIC periodically as new drugs and new prescribing Cefotetan/Dextrose ciprofloxacin information becomes available. It is recommended ciprofloxacin ER that you bring this list of medications when you or a Cefoxitin Sodium ciprofloxacin HCL covered family member sees a physician or other Ceftazidime healthcare provider. Ceftazidime/Dextrose ciprofloxacin I.V.-IN D5W Ceftibuten levofloxacin ANTI-INFECTIVES Ceftin levofloxacin IN D5W ANTIFUNGALS Ceftriaxone IN Iso-osmotic Dextrose moxifloxacin HCL GENERIC Ceftriaxone Sodium ofloxacin fluconazole Ceftriaxone/Dextrose Ciprofloxacin HCL fluconazole IN dextrose Cefuroxime Sodium Ofloxacin fluconazole IN NACL Cefuroxime/Dextrose NON PREFERRED flucytosine Cephalexin Avelox griseofulvin microsize Claforan Avelox Abc Pack griseofulvin ultramicrosize Claforan/D5W Cipro itraconazole Fortaz Cipro I.V.-IN D5W ketoconazole Keflex Cipro XR nystatin Maxipime Factive Levaquin terbinafine HCL Mefoxin Moxifloxacin HCL voriconazole Rocephin Noroxin PREFERRED Spectracef Noxafil Suprax NON PREFERRED Tazicef Abelcet Teflaro TETRACYCLINES Ambisome Zinacef GENERIC Amphotec demeclocycline HCL Amphotericin B PENICILLINS doxycycline doxycycline Ancobon GENERIC hyclate doxycycline Cresemba amoxicillin hyclate DR doxycycline Diflucan amoxicillin/clavulanate potassium monohydrate minocycline Fluconazole IN NACL amoxicillin/clavulanate potassium ER HCL minocycline HCL ER Grifulvin V ampicillin Tetracycline HCL Gris-peg ampicillin sodium NON PREFERRED Lamisil ampicillin-sulbactam Acticlate Onmel dicloxacillin sodium Adoxa Sporanox nafcillin sodium Adoxa PAK 1/100 Sporanox Pulsepak oxacillin sodium Adoxa PAK 1/150 Terbinex penicillin v potassium Adoxa PAK 2/100 Vfend penicillin G potassium Alodox Convenience Kit Vfend IV piperacillin sodium/ tazobactam sodium Doryx CEPHALOSPORINS piperacillin sodium/tazobactam Minocin GENERIC sodium Minocin Kit cefaclor piperacillin/tazobactam Monodox cefadroxil NON PREFERRED Morgidox 1X100MG cefazolin sodium Amoxicillin Morgidox 2X100MG cefdinir Amoxicillin ER Nutridox cefepime Ampicillin Ocudox cefixime Ampicillin Sodium Solodyn cefotaxime sodium Ampicillin-sulbactam Targadox cefoxitin sodium Augmentin Vibramycin cefpodoxime proxetil Augmentin ES-600

Effective October 1, 2015 v.2 ©KPP 2015. All Rights Reserved. May not be copied or distributed without authorization. 1

ANTI-INFLAMMATORY Tivorbex Teveten NSAIDS Vimovo GENERIC Voltaren-XR BETA BLOCKERS celecoxib Zipsor GENERIC diclofenac potassium acebutolol HCL diclofenac sodium DR AUTO-IMMUNE atenolol diclofenac sodium ER betaxolol HCL diclofenac sodium/misoprostol PREFERRED bisoprolol fumarate etodolac Cimzia esmolol HCL etodolac ER Cimzia Starter Kit metoprolol succinate ER flurbiprofen Humira metoprolol tartrate ibuprofen Humira Pediatric Crohns Disease nadolol indomethacin Starter Pack pindolol propranolol indomethacin ER Humira Pen HCL propranolol ketoprofen Humira Pen-crohns Diseasestarter HCL ER sotalol HCL ketorolac tromethamine Humira Pen-psoriasis Starter sotalol HCL (AF) mefenamic acid NON PREFERRED PREFERRED meloxicam Actemra Bystolic nabumetone Enbrel NON PREFERRED naproxen Enbrel Sureclick Betapace naproxen sodium Kineret Betapace AF naproxen sodium CR Orencia Brevibloc naproxen sodium ER Remicade Corgard oxaprozin Simponi Hemangeol piroxicam Simponi Aria Inderal LA sulindac Xeljanz tolmetin sodium Inderal XL Meclofenamate Sodium CARDIOVASCULAR Innopran XL Tolmetin Sodium ACE-INHIBITORS Kerlone PREFERRED GENERIC Levatol Zorvolex benazepril HCL Lopressor NON PREFERRED captopril Propranolol HCL Anaprox enalapril maleate Sectral Anaprox DS enalaprilat Sotalol Hydrochloride Arthrotec 50 fosinopril sodium Sotylize Arthrotec 75 lisinopril Tenormin Caldolor moexipril HCL Timolol Maleate Cataflam perindopril erbumine Toprol XL Celebrex quinapril HCL Zebeta Daypro ramipril Derma Silkrx Anodynexa PAK trandolapril CALCIUM CHANNEL BLOCKERS Derma Silkrx Diclopak NON PREFERRED GENERIC Dermacinrx Inflammatral PAK Accupril amlodipine besylate Duexis Aceon diltiazem CD Dyloject Altace diltiazem HCL EC-naprosyn Epaned diltiazem HCL ER Feldene Lotensin felodipine ER Fenoprofen Calcium Mavik isradipine Ibuprofen Comfort PAC Prinivil nicardipine HCL Indocin Univasc nifedipine Indomethacin Vasotec nifedipine ER Indomethacin Sodium Zestril nimodipine IC 400 nisoldipine IC 800 ANGIOTENSIN RCPTR BLOCKER verapamil HCL Ketoprofen ER GENERIC verapamil HCL ER Ketorocaine-l candesartan cilexetil verapamil HCL SR Ketorocaine-lm irbesartan Verapamil HCL Ketorolac Tromethamine losartan potassium NON PREFERRED Meloxicam telmisartan Adalat CC Meloxicam Comfort PAC valsartan Calan Mobic Eprosartan Mesylate Calan SR Nalfon PREFERRED Cardene I.v. Naprelan Benicar Cardene IV Naprosyn NON PREFERRED Cardene SR Naproxen Atacand Cardizem Naproxen Comfort PAC Avapro Cardizem CD Neoprofen Cozaar Cardizem LA Ponstel Diovan Cleviprex Sprix Edarbi Dilacor XR Micardis

Effective October 1, 2015 2

Diltiazem HCL Azor NON PREFERRED Nisoldipine Benicar HCT Antara Nisoldipine ER Tekamlo Fenoglide Norvasc Tekturna HCT Fibricor Nymalize Tribenzor Lofibra Procardia NON PREFERRED Lopid Procardia XL Accuretic Tricor Sular Atacand HCT Triglide Tiazac Avalide Trilipix Verelan Captopril/Hydrochlorothiazide BILE ACID SEQUESTRANTS Verelan PM Clorpres GENERIC Corzide cholestyramine NITRATES & NITRITES Diovan HCT cholestyramine light GENERIC Dutoprol colestipol HCL isosorbide dinitrate Edarbyclor colestipol HCL for oral suspension isosorbide mononitrate Exforge PREFERRED isosorbide mononitrate ER Exforge HCT Welchol nitroglycerin lingual Hypertensolol NON PREFERRED nitroglycerin transdermal Hyzaar Colestid nitroglycerin ER Lopressor HCT Colestid Flavored nitroglycerin IN dextrose 5% Lotensin HCT Questran nitroglycerin IN 5% dextrose Lotrel Questran Light Isosorbide Dinitrate Lytensopril Kit CHOLEST ABS INHBTR/COMBO Nitroglycerin Lingual Lytensopril-90 PREFERRED PREFERRED Lytensopril-90 Kit Liptruzet Dilatrate SR Methyldopa/Hydrochlorothiazide Vytorin Nitro-bid Micardis HCT Zetia Nitrostat Prestalia NIACIN/COMBINATIONS NON PREFERRED Propranolol/Hydrochlorothiazide GENERIC Imdur Tarka niacin ER Isordil Titradose Tenoretic 100 PREFERRED Isosorbide Dinitrate ER Tenoretic 50 Simcor Nitro-dur Teveten HCT NON PREFERRED Nitroglycerin Twynsta Advicor Nitroglycerin IN Dextrose 5% Uniretic Niacor Nitrolingual Pumpspray Vaseretic Niaspan Nitromist Zestoretic OMEGA-3 FATTY ACIDS Nitronal Ziac GENERIC omega-3-acid ethyl esters ANTI-HTN COMBINATIONS ANTIHYPERLIPIDEMICS PREFERRED GENERIC STATINS Vascepa amlodipine besylate/benazepril GENERIC NON PREFERRED hydrochloride atorvastatin calcium Kynamro amlodipine besylate/benazepril HCL fluvastatin Lovaza amlodipine besylate/valsartan fluvastatin sodium ER amlodipine/valsartan/hctz lovastatin DERMATOLOGICALS atenolol/chlorthalidone pravastatin sodium ACNE benazepril HCL/hydrochlorothiazide simvastatin GENERIC bisoprolol PREFERRED adapalene fumarate/hydrochlorothiazide Crestor benzoyl peroxide candesartan NON PREFERRED benzoyl peroxide SHORT contact cilexetil/hydrochlorothiazide enalapril maleate/hydrochlorothiazide Altoprev clindamycin phosphate fosinopril sodium/hydrochlorothiazide Lescol clindamycin/benzoyl peroxide Lescol XL erythromycin irbesartan/hydrochlorothiazide lisinopril/hydrochlorothiazide Lipitor erythromycin/benzoyl peroxide Livalo metronidazole losartan potassium/hydrochlorothiazide Mevacor sodium sulfacetamide metoprolol/hydrochlorothiazide Pravachol sodium sulfacetamide/sulfur moexipril/hydrochlorothiazide Zocor sodium sulfacetamide/sulfur cleanser nadolol/bendroflumethiazide FIBRATES sodium sulfacetamide/sulfur cleansing quinapril/hydrochlorothiazide GENERIC cloths sodium sulfacetamide/sulfur green telmisartan/amlodipine fenofibrate telmisartan/hydrochloroth fenofibrate micronized sodium sulfacetamide/sulfur w/sunscreen telmisartan/hydrochlorothiazide fenofibric acid DR sodium sulfacetamide/sulfur wash trandolapril/verapamil HCL gemfibrozil Fenofibrate sulfacetamide sodium trandolapril/verapamil HCL ER sulfacetamide sodium/sulfur cleanser valsartan/hydrochlorothiazide Fenofibric Acid tretinoin PREFERRED PREFERRED tretinoin microsphere Amturnide Lipofen tretinoin microsphere P.M.

Effective October 1, 2015 3

Doxycycline Sumadan Wash Desonate PREFERRED Sumadan XLT Desowen Acanya Sumaxin Desowen Cream/Cetaphil Lotion Adapalene Sumaxin CP Kit Desowen Lotion/Cetaphil Cream Epiduo Sumaxin Ts Desowen Ointment/Cetaphil Lotion Epiduo Forte Sumaxin Wash Diprolene Finacea Tretin-x Diprolene AF Mirvaso Triseon Elocon Oracea Vanoxide-HC Epifoam Ziana Veltin First-hydrocortisone NON PREFERRED Zacare 4% Kit Halog Absorica Zacare 8% Kit Halonate Aczone Kenalog Akne-mycin TOPICAL ANTI-INFLAMMATORY Locoid Atralin GENERIC Locoid Lipocream Avar alclometasone dipropionate Luxiq Avar LS augmented betamethasone Nucort Avar LS Cleanser dipropionate Nuzon Avar-e LS betamethasone dipropionate Olux Azelex betamethasone valerate Olux-e Benzac Ac Wash calcipotriene/betamethasone Pandel Benzac W Wash dipropionate Pediaderm HC Benzaclin clobetasol propionate Pediaderm Ta Benzaclin With P.M. clobetasol propionate emollient Scalacort DK desonide Benzamycin Synalar Benzamycinpak desoximetasone Synalar Cream Kit Benzefoam fluocinolone acetonide Synalar Ointment Kit fluocinonide Benzefoamultra Synalar Ts fluocinonide-e Benziq Taclonex fluticasone propionate Benziq LS Temovate halobetasol propionate Clarifoam EF Temovate E hydrocortisone Cleocin-t Texacort hydrocortisone acetate/aloe Clindacin Etz Topicort hydrocortisone butyrate Clindacin PAC Triamcinolone Acetonide hydrocortisone butyrate (lipid) Clindagel Triamsil Combipak hydrocortisone butyrate (lipophilic) Clindap-t Trianex hydrocortisone valerate Clinoin Triderma Forte hydrocortisone IN absorbase Differin Ultravate mometasone furoate Duac Ultravate PAC prednicarbate Erygel Ultravate X triamcinolone acetonide Evoclin Validerm Amcinonide Fabior Vanos Desoximetasone Inova Verdeso Diflorasone Diacetate Inova 4/1 Acne Control Therapy Westcort PREFERRED Inova 8/2 Acne Control Therapy Pramosone Klaron Pramosone E ENDOCRINE Metrocream Tucks Anti-itch CONTRACEPTIVE AGENTS Metrogel GENERIC NON PREFERRED Metrolotion desogestrel/ethinyl estradiol Aclovate Neuac Kit drospirenone/ethinyl estradiol Advanced Allergy Collection Kit Noritate levonorgestrel Ala Scalp Nuox levonorgestrel and ethinyl estradiol Capex Onexton levonorgestrel/ethinyl estradiol Carmol-HC Plexion norethindrone Clobex Plexion Cleanser norethindrone & ethinyl estradiol Clocortolone Pivalate Plexion Cleansing Cloths ferrous fumarate Clocortolone Pivalate P.M. Prascion Ra With Sunscreens norethindrone acetate/ethinyl Clodan Kit Retin-a estradiol Cloderm norethindrone acetate/ethinyl Retin-a Micro Cloderm P.M. estradiol/ferrous fumarate Retin-a Micro P.M. norgestimate/ethinyl estradiol Riax Cordran Cordran Tape Levonorgestrel Rosadan Kit Cortalo PREFERRED Rosanil Cutivate Beyaz Rosula Derma Silkrx Sds PAK Depo-provera Sodium Sulfacetamide/Sulfur LO Loestrin FE Sodium Sulfacetamide/Sulfur Cleanser Derma-smoothe/FS Body Minastrin 24 FE IN Urea Derma-smoothe/FS Scalp Sodium Sulfacetamide/Sulfur IN Urea Dermasorb HC Natazia Soolantra Dermasorb Ta Nuvaring Sulfoam Dermatop Safyral Sumadan Kit

Effective October 1, 2015 4

NON PREFERRED Estrace Novolog Brevicon-28 Estradiol Novolog Flexpen Cyclessa Estrasorb Novolog Mix 70/30 Desogen Estrogel Novolog Mix 70/30 Prefilled Flexpen Ella Estropipate Novolog Penfill Estrostep FE Femhrt Low Dose NON PREFERRED Falessa Femring Afrezza Femcon FE Menest Apidra Generess FE Menostar Apidra Solostar Loestrin FE 1.5/30 Prefest Relion R Loestrin FE 1/20 Premarin Toujeo Solostar Loestrin 1.5/30-21 Vivelle-dot Loestrin 1/20-21 NON-INSULIN HYPOGLYCEMICS Loseasonique TESTOSTERONE AGENTS BIGUANIDES LO Minastrin FE GENERIC GENERIC Mircette danazol metformin HCL Modicon testosterone cypionate metformin HCL ER Necon 1/50-28 testosterone enanthate PREFERRED Necon 10/11-28 Testosterone Riomet Nor-QD Testosterone P.M. NON PREFERRED Norinyl 1+35 PREFERRED Fortamet Norinyl 1+50 Androgel Glucophage Ortho Evra Androgel P.M. Glucophage XR Ortho Micronor Androxy Glumetza Ortho Tri-cyclen Axiron BIGUAN/SULFONYLUREA COMB. Ortho Tri-cyclen LO NON PREFERRED GENERIC Ortho-cept Androderm glipizide/metformin HCL Ortho-cyclen Android glyburide/metformin HCL Ortho-novum 1/35 Aveed NON PREFERRED Ortho-novum 7/7/7 Depo-testosterone Glucovance Ovcon-35 First-testosterone BIGUAN/THIAZOLIDEINEDIONE Plan B First-testosterone Mc Compounding GENERIC Plan B One-step Kit pioglitazone HCL Quartette Fortesta pioglitazone HCL/metformin HCL Seasonique Natesto PREFERRED Tri-norinyl 28 Striant Actoplus Met XR Yasmin 28 Testim NON PREFERRED Yaz Testone Cik Actoplus Met Zovia 1/50e Testopel Actos Testred Avandamet ESTROGENS/COMBINATIONS Vogelxo Avandia GENERIC Vogelxo P.M. DPP-4 INHIBITORS estradiol PREFERRED estradiol valerate INSULIN Januvia estradiol/norethindrone acetate PREFERRED Onglyza estropipate Humalog Tradjenta norethindrone acetate/ethinyl Humalog Kwikpen NON PREFERRED estradiol Humalog Mix 50/50 Nesina PREFERRED Humalog Mix 50/50 Kwikpen BIGUANIDE/DPP-4 COMB. Alora Humalog Mix 75/25 PREFERRED Cenestin Humalog Mix 75/25 Kwikpen Janumet Combipatch Humulin N Janumet XR Duavee Humulin N Kwikpen Jentadueto Enjuvia Humulin N U-100 Pen Kombiglyze XR Estring Humulin R NON PREFERRED Evamist Humulin R U-500 (concentrated) Kazano Minivelle Humulin 70/30 SULFONYLUREAS Premphase Humulin 70/30 Kwikpen GENERIC Prempro Humulin 70/30 Pen glimepiride Vagifem Lantus glipizide NON PREFERRED Lantus Solostar glipizide ER Activella Levemir glyburide Angeliq Levemir Flexpen glyburide micronized Biest/Progesterone Levemir Flextouch tolazamide Climara Novolin N Glyburide Climara Pro Novolin N Relion NON PREFERRED Delestrogen Novolin R Amaryl Depo-estradiol Novolin R Relion Chlorpropamide Divigel Novolin 70/30 Diabeta Elestrin Novolin 70/30 Relion Glucotrol

Effective October 1, 2015 5 Glucotrol XL Famotidine MULTIPLE SCLEROSIS Glynase PREFERRED Tolazamide Carafate PREFERRED Tolbutamide NON PREFERRED Ampyra SULFONYLUREA/TZD COMB. Axid Aubagio GENERIC Cytotec Avonex pioglitazone HCL-glimepiride Deprizine Fusepaq Avonex Pen NON PREFERRED Famotidine Premixed Betaseron Avandaryl Pepcid Copaxone Duetact Zantac Gilenya INCRETINS Plegridy PREFERRED GROWTH HORMONE Plegridy Starter Pack Bydureon Rebif Byetta PREFERRED Rebif Rebidose Victoza Norditropin Cartridge Rebif Rebidose Titration Pack NON PREFERRED Norditropin Flexpro Rebif Titration Pack Tanzeum Norditropin Nordiflex Pen Tecfidera Trulicity Nutropin AQ Nuspin 10 Tecfidera Starter Pack AMYLIN ANALOGS Nutropin AQ Nuspin 20 Tysabri PREFERRED Nutropin AQ Nuspin 5 NON PREFERRED Symlinpen 120 Nutropin AQ Pen Extavia Symlinpen 60 NON PREFERRED Lemtrada DIABETIC OTHER Genotropin PREFERRED Genotropin Miniquick NEUROLOGICALS Farxiga Humatrope ALZHEIMER'S DISEASE Glucagen Hypokit Humatrope Combo Pack GENERIC Glucagon Emergency Kit Omnitrope donepezil HCL Invokamet Saizen galantamine Invokana Saizen Click.easy galantamine hydrobromide Jardiance Serostim memantine HCL Proglycem Tev-tropin memantine HCL titration PAK Xigduo XR Zomacton rivastigmine tartrate NON PREFERRED Zorbtive rivastigmine transdermal system Synjardy Galantamine Hydrobromide HEPATITIS C PREFERRED GASTROINTESTINAL ANTIVIRALS Namenda PROTON PUMP INHIBITORS GENERIC Namenda XR GENERIC ribavirin Namenda XR Titration Pack esomeprazole magnesium PREFERRED NON PREFERRED esomeprazole sodium Harvoni Aricept lansoprazole Moderiba Aricept Odt omeprazole Moderiba 1200 Dose Pack Exelon pantoprazole sodium Moderiba 800 Dose Pack Namenda Titration PAK rabeprazole sodium Ribasphere Namzaric Esomeprazole Sodium Ribasphere Ribapak Razadyne NON PREFERRED Ribatab Razadyne ER Aciphex Sovaldi Aciphex Sprinkle NON PREFERRED ANTICONVULSANTS Dexilant Copegus GENERIC Esomeprazole Strontium Rebetol carbamazepine First-lansoprazole Technivie carbamazepine ER First-omeprazole Viekira PAK clonazepam Nexium clonazepam odt Nexium I.v. INTERFERONS divalproex sodium Omeprazole + Syrspend SF Alka PREFERRED divalproex sodium DR Prevacid Peg-intron divalproex sodium ER Prevacid Solutab Peg-intron Redipen ethosuximide Prilosec Peg-intron Redipen PAK 4 felbamate Protonix Pegasys fosphenytoin sodium Pegasys Proclick gabapentin ULCER DRUGS Pegintron lamotrigine GENERIC NON PREFERRED lamotrigine odt cimetidine Infergen lamotrigine ER cimetidine HCL levetiracetam famotidine PROTEASE INHIBITORS levetiracetam ER misoprostol NON PREFERRED oxcarbazepine nizatidine Olysio phenytoin ranitidine HCL Victrelis phenytoin sodium sucralfate phenytoin sodium extended

Effective October 1, 2015 6 primidone rizatriptan benzoate Metipranolol tiagabine hydrochloride rizatriptan benzoate odt PREFERRED topiramate sumatriptan succinate Combigan valproate sodium sumatriptan succinate refill Lumigan valproic acid zolmitriptan Travatan Z zonisamide zolmitriptan odt Travoprost PREFERRED Dihydroergotamine Mesylate NON PREFERRED Banzel Isometheptene/Caffeine/Acetaminophe Alphagan P Celontin n Azopt Diazepam Sumatriptan Succinate Betagan Fycompa PREFERRED Betimol Lyrica Relpax Betoptic-s Onfi Sumavel Dosepro Cosopt Oxtellar XR Treximet Cosopt PF Peganone Zomig Nasal Spray Iopidine Potiga NON PREFERRED Istalol Tegretol-XR Alsuma Levobunolol HCL NON PREFERRED Amerge Rescula Aptiom Axert Timoptic Carbatrol Cafergot Timoptic Ocudose Cerebyx Cambia Timoptic-xe Depacon D.h.e. 45 Trusopt Depakene Ergomar Xalatan Depakote Frova Zioptan Depakote ER Imitrex Depakote Sprinkles Imitrex Statdose Refill ANTI-INFECTIVES Diastat Acudial Imitrex Statdose System GENERIC Diastat Pediatric Maxalt ciprofloxacin HCL Dilantin Maxalt-MLT erythromycin Dilantin Infatabs Migergot gatifloxacin Dilantin-125 Migral gentamicin sulfate Fanatrex Fusepaq Migranal levofloxacin Felbatol Sumatriptan ofloxacin Gabitril Zecuity tobramycin sulfate Keppra Zomig PREFERRED Keppra XR Zomig ZMT Besivance Klonopin Moxeza Lamictal OPHTHALMICS Vigamox Lamictal Chewable Dispersible ANTI-ALLERGIC AGENTS NON PREFERRED Lamictal Odt GENERIC Azasite Lamictal Starter/Not Taking azelastine HCL Bacitracin Carbamazepine Lamictal cromolyn sodium Ciloxan Starter/Taking Carbamazepine/Not epinastine HCL Garamycin Taking Valproate PREFERRED Mitosol Lamictal Starter/Taking Valproate Bepreve Ocuflox Lamictal XR Pataday Tobrex Levetiracetam Patanol Zymaxid Mysoline Pazeo Neurontin NON PREFERRED ANTI-INFLAMMATORY AGENTS Phenytek Alocril GENERIC Qudexy XR Alomide bromfenac Sabril Elestat cromolyn sodium Stavzor Emadine diclofenac sodium Tegretol Lastacaft flurbiprofen sodium Therapentin-60 Optivar ketorolac tromethamine Therapentin-90 PREFERRED Topamax ANTI-GLAUCOMA AGENTS Ilevro Topamax Sprinkle GENERIC Nevanac Topiramate ER apraclonidine Prolensa Trileptal betaxolol HCL NON PREFERRED Trokendi XR brimonidine tartrate Acular Vimpat carteolol HCL Acular LS Zarontin dorzolamide HCL Acuvail Zonegran dorzolamide HCL/timolol maleate Ocufen latanoprost MIGRAINE/HEADACHE levobunolol HCL CORTICOSTEROIDS/RELATED GENERIC timolol maleate GENERIC almotriptan malate timolol maleate ophthalmic gel dexamethasone sodium phosphate dihydroergotamine mesylate forming fluorometholone naratriptan HCL Bimatoprost Effective October 1, 2015 7 neomycin/polymyxin/bacitracin/hydroco Zoledronic Acid Risperdal M-TAB rtisone Zometa Saphris neomycin/polymyxin/dexamethasone Seroquel prednisolone acetate SERM Versacloz sulfacetamide sodium/prednisolone GENERIC Zyprexa sodium phosphate raloxifene hydrochloride Zyprexa Relprevv tobramycin/dexamethasone NON PREFERRED Zyprexa Zydis PREFERRED Evista Alrex Osphena PSYCHOTHERAPEUTICS, MISC. FML GENERIC Lotemax PSYCHOTHERAPEUTICS amphetamine/dextroamphetamine Ozurdex ANTIPSYCHOTICS/ANTIMANIC clonidine HCL ER Pred Mild GENERIC dexmethylphenidate HCL Retisert aripiprazole dexmethylphenidate HCL ER Tobradex ST chlorpromazine HCL dextroamphetamine sulfate Zylet clozapine dextroamphetamine sulfate ER NON PREFERRED fluphenazine decanoate guanfacine ER Blephamide fluphenazine HCL methamphetamine HCL Blephamide S.o.p. haloperidol methylphenidate hydrochloride Durezol haloperidol decanoate methylphenidate HCL Flarex haloperidol lactate methylphenidate HCL CD FML Forte lithium carbonate methylphenidate HCL ER FML Liquifilm lithium carbonate ER methylphenidate HCL SR Maxidex loxapine modafinil Maxitrol loxapine succinate Methylphenidate HCL ER Neomycin/Polymyxin/Hydrocortisone olanzapine PREFERRED Omnipred olanzapine odt Daytrana Pred Forte perphenazine Nuvigil Pred-G prochlorperazine Quillivant XR Pred-G S.o.p. prochlorperazine edisylate Strattera Prednisolone Sodium Phosphate prochlorperazine maleate Vyvanse Tobradex quetiapine fumarate NON PREFERRED Vexol risperidone Adderall risperidone odt Adderall XR MIOTICS thioridazine HCL Aptensio XR GENERIC thiothixene Concerta pilocarpine HCL trifluoperazine HCL Desoxyn PREFERRED ziprasidone HCL Dexedrine Phospholine Iodide Clozapine Odt Evekeo NON PREFERRED PREFERRED Focalin Isopto Carbachol Abilify Discmelt Focalin XR Isopto Carpine Abilify Maintena Intuniv Latuda Kapvay MISCELLANEOUS Risperdal Consta Kapvay Dose Pack PREFERRED Seroquel XR Metadate CD Restasis NON PREFERRED Methylin NON PREFERRED Abilify Procentra Lacrisert Adasuve Provigil Chlorpromazine HCL Ritalin OSTEOPOROSIS Clozaril Ritalin LA BISPHOSPHONATES Compazine Ritalin SR GENERIC Equetro Zenzedi alendronate sodium Fanapt ibandronate sodium Fanapt Titration Pack SNRI ANTIDEPRESSANTS pamidronate disodium Fazaclo GENERIC risedronate sodium Fluphenazine HCL duloxetine HCL risedronate sodium DR Geodon venlafaxine HCL zoledronic acid Haldol venlafaxine HCL ER PREFERRED Haldol Decanoate 100 Venlafaxine HCL ER Fosamax Plus D Haldol Decanoate 50 PREFERRED NON PREFERRED Invega Pristiq Actonel Invega Sustenna NON PREFERRED Alendronate Sodium Invega Trinza Cymbalta Atelvia Lithium Desvenlafaxine ER Binosto Lithium Carbonate Duloxetine HCL Boniva Lithobid Effexor XR

Effective October 1, 2015 8 Etidronate Disodium Loxitane Fetzima Fosamax Rexulti Fetzima Titration Pack Pamidronate Disodium Risperdal Irenka Reclast

Effective October 1, 2015 9

Khedezla Proair Respiclick Omnaris Serevent Diskus Rhinocort Aqua SSRI ANTIDEPRESSANTS Ventolin HFA Veramyst GENERIC NON PREFERRED Zetonna citalopram hydrobromide Brovana escitalopram oxalate Isuprel STEROID/BETA AGONIST fluoxetine DR Maxair Autohaler PREFERRED fluoxetine HCL Metaproterenol Sulfate Advair Diskus fluvoxamine maleate Proventil HFA Advair HFA fluvoxamine maleate ER Striverdi Respimat Breo Ellipta paroxetine HCL Vospire ER Dulera paroxetine HCL ER Xopenex Symbicort sertraline HCL Xopenex Concentrate NON PREFERRED Xopenex HFA MISCELLANEOUS Celexa PREFERRED Fluoxetine HCL LEUKOTRIENE RCPTR ANTGNST Dymista Lexapro GENERIC Luvox CR montelukast sodium UROLOGICALS Paxil zafirlukast BENIGN PRSTATC HYPRPLSIA Paxil CR NON PREFERRED GENERIC Pexeva Accolate alfuzosin HCL ER Prozac Singulair finasteride Prozac Weekly tamsulosin HCL Zoloft PULMONARY CORTICOSTEROIDS PREFERRED GENERIC Rapaflo RESPIRATORY budesonide NON PREFERRED ANAPHYLAXIS TX AGENTS PREFERRED Avodart PREFERRED Arnuity Ellipta Cardura XL Auvi-q Asmanex HFA Flomax Epipen 2-PAK Asmanex Twisthaler 120 Metered Jalyn Epipen-JR 2-PAK Doses Proscar NON PREFERRED Asmanex Twisthaler 14 Metered Uroxatral Adrenaclick Doses Asmanex Twisthaler 30 Metered Adrenalin Doses ERECTILE DYSFUNCTION Epinephrine PREFERRED Asmanex Twisthaler 60 Metered Doses Cialis ANTICHOLINERGICS Asmanex Twisthaler 7 Metered Doses Viagra GENERIC Flovent Diskus NON PREFERRED ipratropium bromide Flovent HFA Levitra PREFERRED Pulmicort Flexhaler Staxyn Atrovent HFA Qvar Stendra Spiriva Handihaler NON PREFERRED Spiriva Respimat Aerospan URINARY ANTISPASMODICS Tudorza Pressair Alvesco GENERIC NON PREFERRED Pulmicort bethanechol chloride Incruse Ellipta flavoxate HCL NASAL ANTIHISTAMINES oxybutynin chloride ANTICHLNRGC/BETA AGONIST GENERIC oxybutynin chloride ER GENERIC azelastine HCL tolterodine tartrate ipratropium bromide/albuterol sulfate olopatadine HCL tolterodine tartrate ER PREFERRED Anoro NON PREFERRED trospium chloride Ellipta Combivent Astelin trospium chloride ER Respimat NON Astepro PREFERRED PREFERRED Patanase Gelnique Duoneb Myrbetriq NASAL CORTICOSTEROIDS Oxytrol BETA AGONISTS GENERIC Oxytrol For Women GENERIC budesonide Toviaz albuterol sulfate flunisolide Vesicare albuterol sulfate ER fluticasone propionate NON PREFERRED albuterol TAB 4MG triamcinolone acetonide Detrol levalbuterol PREFERRED Detrol LA levalbuterol HCL Nasonex Ditropan XL terbutaline sulfate Qnasl Enablex PREFERRED Qnasl Childrens Sanctura Arcapta Neohaler NON PREFERRED Sanctura XR Foradil Aerolizer Beconase AQ Urecholine Perforomist Flonase Proair HFA Nasacort AQ Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The Effective October 1, 2015 v.2 ©KPP 2015. All Rights Reserved. May not be copied or distributed without authorization. 9 benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of KPP. The presence of a medication on this formulary list does not guarantee coverage. To determine the most up-to-date formulary status of your medication, please visit your member website or call member services at the number listed on your ID card.

Effective October 1, 2015 10