Quick Reference List

October 2017

The University of Maryland Health Partners Quick Reference List is a guide to the medicines that are most appropriate and cost effective for each therapeutic class. This list can help your doctor choose the medicines that are right for you. If a medicine that you use is not on this list, it may still be covered if your doctor asks for you to get it.

Authorizations:

Authorization requests for both FORMULARY and NON-FORMULARY products requiring either a PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy) or medical necessity review - contact CVS Caremark® at: 1-877-418-4133.

Authorization requests for specific MENTAL HEALTH/HIV products - contact MDH - Maryland Department of Health at: 1-800-932-3918 (Anti-Psychotic Peer Review Line for children 0-9 years old: 1-855-283-0876).

BRAND PRODUCTS are listed in CAPITAL LETTERS, branded generics in upper-and lowercase Italics, and generic products in lowercase italic letters.

This list is not an all-inclusive list and does not guarantee coverage. Please visit www.umhealthpartners.com for a complete list.

ANALGESICS morphine QL erythromycin delayed-rel voriconazole PA trandolapril morphine ext-rel QL, † erythromycin ethylsuccinate ANTIRETROVIRAL AGENTS § ACE INHIBITOR / CALCIUM § ANALGESICS, OTHER morphine supp QL erythromycin stearate Drugs used to treat HIV/AIDS acetaminophen OTC, QL oxycodone QL CHANNEL BLOCKER are covered by Medicaid fee-for- oxycodone-acetaminophen § FLUOROQUINOLONES COMBINATIONS § NSAIDs service. 2.5/325 mg, 5/325 mg, ciprofloxacin ext-rel amlodipine-benazepril aspirin delayed-rel OTC 7.5/325 mg, 10/325 mg QL ciprofloxacin tabs ANTIVIRALS § ACE INHIBITOR / ibuprofen OTC oxycodone-aspirin QL levofloxacin § HERPES AGENTS naproxen sodium OTC DIURETIC COMBINATIONS tramadol QL acyclovir caps, susp, tabs diclofenac potassium § PENICILLINS benazepril- tramadol ext-rel tabs QL, † famciclovir diclofenac sodium amoxicillin hydrochlorothiazide tramadol-acetaminophen QL valacyclovir delayed-rel amoxicillin-clavulanate captopril-hydrochlorothiazide PA may apply to higher diclofenac sodium ext-rel † ampicillin enalapril-hydrochlorothiazide strengths § MISCELLANEOUS diflunisal dicloxacillin pyrantel - Reeses Pinworm fosinopril-hydrochlorothiazide etodolac penicillin VK lisinopril-hydrochlorothiazide § NON-OPIOID ANALGESICS Medicine OTC BICILLIN L-A quinapril-hydrochlorothiazide etodolac ext-rel butalbital-acetaminophen- atovaquone flurbiprofen caffeine QL § SULFONAMIDES clindamycin § ADRENOLYTICS, ibuprofen butalbital-aspirin-caffeine QL dapsone CENTRAL ketoprofen sulfamethoxazole- ivermectin ketorolac QL trimethoprim clonidine ANTI-INFECTIVES linezolid PA sulfamethoxazole- clonidine transdermal meloxicam linezolid inj PA nabumetone ANTIBACTERIALS trimethoprim DS guanfacine metronidazole naproxen CEPHALOSPORINS SULFADIAZINE nitrofurantoin ext-rel § ALDOSTERONE naproxen sodium § First Generation § TETRACYCLINES nitrofurantoin macrocrystals RECEPTOR ANTAGONISTS oxaprozin cefadroxil nitrofurantoin susp doxycycline hyclate caps eplerenone sulindac cephalexin rifabutin 50 mg, 100 mg spironolactone trimethoprim § COX-2 INHIBITORS § Second Generation doxycycline hyclate tabs § ALPHA BLOCKERS 20 mg, 100 mg vancomycin ST celecoxib PA cefprozil doxycycline monohydrate EMVERM doxazosin cefuroxime axetil § OPIOID ANALGESICS susp XIFAXAN 550 MG ST prazosin codeine-acetaminophen QL § Third Generation minocycline terazosin CARDIOVASCULAR fentanyl transdermal QL, † tetracycline cefdinir § ANGIOTENSIN II hydrocodone-acetaminophen § ACE INHIBITORS ceftriaxone inj § ANTIFUNGALS RECEPTOR ANTAGONISTS / 5/325 mg, 7.5/325 mg, benazepril DIURETIC COMBINATIONS clotrimazole troches 10/325 mg QL § ERYTHROMYCINS / captopril fluconazole irbesartan hydrocodone-acetaminophen MACROLIDES enalapril griseofulvin microsize susp irbesartan- soln 7.5/325 mg/15 mL QL azithromycin fosinopril griseofulvin ultramicrosize hydrochlorothiazide hydromorphone tabs QL clarithromycin lisinopril itraconazole caps PA, QL losartan methadone tabs 5 mg, clarithromycin ext-rel quinapril nystatin losartan-hydrochlorothiazide 10 mg QL erythromycin base ramipril terbinafine tabs QL valsartan

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

valsartan-hydrochlorothiazide felodipine ext-rel § PHOSPHODIESTERASE ergotamine-caffeine AMYLIN ANALOGS

nifedipine ext-rel INHIBITORS SYMLINPEN PA § ANTIARRHYTHMICS § SELECTIVE SEROTONIN sildenafil PA, SP amiodarone 200 mg § NONDIHYDROPYRIDINES AGONISTS § BIGUANIDES disopyramide diltiazem PROSTACYCLIN RECEPTOR naratriptan ST, QL metformin dofetilide PA, SP diltiazem ext-rel AGONISTS rizatriptan ST, QL metformin ext-rel flecainide verapamil ext-rel UPTRAVI PA, SP sumatriptan QL propafenone sumatriptan inj QL § BIGUANIDE / § DIGITALIS GLYCOSIDES propafenone ext-rel § PROSTAGLANDIN sumatriptan nasal spray QL SULFONYLUREA sotalol digoxin VASODILATORS zolmitriptan ST, QL COMBINATIONS

NORPACE CR digoxin ped elixir epoprostenol sodium PA, SP glipizide-metformin § MULTIPLE SCLEROSIS REMODULIN PA, SP glyburide-metformin ANTILIPEMICS DIURETICS AGENTS TYVASO PA, SP § CARBONIC ANHYDRASE DIPEPTIDYL PEPTIDASE-4 § BILE ACID RESINS VENTAVIS PA, SP glatiramer PA, SP INHIBITORS (DPP-4) INHIBITORS cholestyramine AUBAGIO PA, SP § MISCELLANEOUS colestipol acetazolamide AVONEX PA, SP JANUVIA ST acetazolamide ext-rel hydralazine COPAXONE DIPEPTIDYL PEPTIDASE-4 § CHOLESTEROL methazolamide methyldopa 40 MG/ML PA, SP (DPP-4) INHIBITOR / ABSORPTION INHIBITORS midodrine EXTAVIA PA, SP § LOOP DIURETICS BIGUANIDE COMBINATIONS ezetimibe RANEXA ST GILENYA PA, SP bumetanide REBIF PA, SP JANUMET ST § FIBRATES furosemide CENTRAL NERVOUS TECFIDERA PA, SP JANUMET XR ST 1 fenofibrate torsemide SYSTEM INCRETIN MIMETIC AGENTS gemfibrozil § MUSCULOSKELETAL § ANTICONVULSANTS § POTASSIUM-SPARING THERAPY AGENTS TRULICITY ST § HMG-CoA REDUCTASE DIURETICS phenobarbital baclofen VICTOZA ST

INHIBITORS amiloride primidone carisoprodol QL INSULINS atorvastatin ethosuximide chlorzoxazone § THIAZIDES AND THIAZIDE- lovastatin phenytoin cyclobenzaprine 5 mg, 10 mg HUMULIN 70/30 OTC LIKE DIURETICS pravastatin phenytoin sodium extended dantrolene HUMULIN N OTC simvastatin chlorthalidone methocarbamol HUMULIN R OTC § ANTIDEMENTIA hydrochlorothiazide orphenadrine ext-rel NOVOLIN 70/30 OTC MICROSOMAL donepezil indapamide orphenadrine-aspirin-caffeine NOVOLIN N OTC TRIGLYCERIDE TRANSFER galantamine metolazone tizanidine tabs NOVOLIN R OTC PROTEIN INHIBITORS galantamine ext-rel APIDRA § DIURETIC COMBINATIONS JUXTAPID PA, SP memantine PA* PSYCHOTHERAPEUTIC- BASAGLAR amiloride-hydrochlorothiazide rivastigmine PA MISCELLANEOUS HUMALOG 100 UNITS/ML § NIACINS spironolactone- rivastigmine transdermal PA § ALCOHOL DETERRENTS HUMALOG MIX niacin ext-rel hydrochlorothiazide Most Substance Use Disorders NOVOLOG PA*Only applies to members triamterene- <30 years of age (SUD) Medications are covered NOVOLOG MIX 70/30 PCSK9 INHIBITORS by Medicaid fee-for-service. hydrochlorothiazide TRESIBA REPATHA PA, SP § ANTIPARKINSONIAN § OPIOID ANTAGONISTS HEART FAILURE AGENTS § INSULIN SENSITIZERS § BETA-BLOCKERS Most Substance Use Disorders CORLANOR amantadine (SUD) Medications are covered pioglitazone atenolol ENTRESTO bromocriptine by Medicaid fee-for-service. bisoprolol § INSULIN SENSITIZER / carbidopa-levodopa carvedilol NITRATES § PARTIAL OPIOID BIGUANIDE COMBINATIONS carbidopa-levodopa ext-rel AGONISTS labetalol § ORAL carbidopa-levodopa orally pioglitazone-metformin metoprolol succinate ext-rel Most Substance Use Disorders isosorbide dinitrate disintegrating tabs metoprolol tartrate 25 mg, (SUD) Medications are covered § INSULIN SENSITIZER / ext-rel tabs carbidopa-levodopa- by Medicaid fee-for-service. 50 mg, 100 mg SULFONYLUREA isosorbide dinitrate oral entacapone nadolol COMBINATIONS isosorbide mononitrate entacapone § PARTIAL OPIOID AGONIST / pindolol pioglitazone-glimepiride isosorbide mononitrate OPIOID ANTAGONIST pramipexole propranolol ext-rel COMBINATIONS ropinirole § MEGLITINIDES propranolol ext-rel nitroglycerin ext-rel selegiline Most Substance Use Disorders timolol (SUD) Medications are covered nateglinide § SUBLINGUAL § ATTENTION DEFICIT by Medicaid fee-for-service. repaglinide § BETA-BLOCKER / nitroglycerin sublingual HYPERACTIVITY DISORDER § SMOKING DETERRENTS SODIUM-GLUCOSE DIURETIC COMBINATIONS 2 clonidine ext-rel Most smoking cessation CO-TRANSPORTER 2 atenolol-chlorthalidone § TRANSDERMAL 2 guanfacine ext-rel products are covered by (SGLT2) INHIBITORS bisoprolol- nitroglycerin transdermal Medicaid fee-for-service.

hydrochlorothiazide NITRO-BID FIBROMYALGIA INVOKANA ST metoprolol- ENDOCRINE AND SAVELLA PA SODIUM-GLUCOSE hydrochlorothiazide PULMONARY ARTERIAL METABOLIC HYPERTENSION MIGRAINE CO-TRANSPORTER 2 ANTIDIABETICS (SGLT2) INHIBITOR / CALCIUM CHANNEL ENDOTHELIN RECEPTOR § ERGOTAMINE § ALPHA-GLUCOSIDASE BIGUANIDE COMBINATIONS BLOCKERS ANTAGONISTS DERIVATIVES § DIHYDROPYRIDINES INHIBITORS INVOKAMET ST LETAIRIS PA, SP dihydroergotamine inj acarbose INVOKAMET XR ST amlodipine TRACLEER PA, SP dihydroergotamine spray QL

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

§ SULFONYLUREAS § TRIPHASIC methylprednisolone psyllium OTC HEMATOPOIETIC GROWTH glimepiride desogestrel-EE prednisolone sodium KRISTALOSE FACTORS glipizide levonorgestrel-EE phosphate SUPREP ARANESP PA, SP glipizide ext-rel norethindrone-EE prednisolone syrup NEULASTA PA, SP PANCREATIC ENZYMES glyburide norgestimate-EE prednisone ZARXIO PA, SP CREON glyburide, micronized MEDROL 2 MG § PROGESTIN ONLY VIOKACE § PLATELET AGGREGATION § PROGESTINS SUPPLIES norethindrone ZENPEP INHIBITORS

ALCOHOL SWABS OTC, QL medroxyprogesterone aspirin OTC § PROTON PUMP BD ULTRAFINE INSULIN § EMERGENCY acetate clopidogrel CONTRACEPTION INHIBITORS SYRINGES AND norethindrone acetate dipyridamole NEEDLES OTC levonorgestrel OTC *, QL progesterone, micronized lansoprazole BRILINTA

KETO-DIASTIX OTC, QL levonorgestrel QL delayed-rel OTC, QL EFFIENT § SELECTIVE ESTROGEN omeprazole magnesium LANCETS OTC ELLA QL ZONTIVITY RECEPTOR MODULATORS delayed-rel caps OTC, QL MULTISTIX OTC, QL OTC* Prescription is not required raloxifene omeprazole-sodium ONETOUCH ULTRA regardless of member's IMMUNOLOGIC STRIPS age OSPHENA bicarbonate OTC, QL AGENTS NEXIUM 24HR OTC, QL AND KITS OTC, QL* IMPLANT THYROID AGENTS BIOLOGIC DISEASE- ONETOUCH VERIO STRIPS PRILOSEC OTC OTC, QL § THYROID SUPPLEMENTS omeprazole delayed-rel MODIFYING AGENTS AND KITS OTC, QL* NEXPLANON SP, QL levothyroxine caps QL ENBREL PA, SP § INJECTABLE QL* Applies to test strips only levothyroxine - Levoxyl pantoprazole delayed-rel HUMIRA PA, SP

medroxyprogesterone liothyronine tabs QL CALCIUM REGULATORS IMMUNOMODULATORS acetate 150 mg/mL QL NEXIUM SUSP 2.5 MG, § BISPHOSPHONATES GASTROINTESTINAL 5 MG, 10 MG AL*, QL INTERFERONS PROGESTIN INTRAUTERINE alendronate tabs INTRON A PA, SP DEVICE § ANTACIDS AL* Covered for < 1 year only PEGASYS PA, SP CONTRACEPTIVES MIRENA SP, QL alumina-magnesia OTC EE = ethinyl estradiol SKYLA SP, QL alumina-magnesia- § MISCELLANEOUS IMMUNOSUPPRESSANTS ME = mestranol simethicone OTC loperamide-simethicone OTC § ANTIMETABOLITES TRANSDERMAL calcium carbonate OTC MONOPHASIC simethicone OTC azathioprine norelgestromin-EE

§ 20 mcg Estrogen § ANTIEMETICS sucralfate mycophenolate mofetil CUVPOSA PA* AZASAN drospirenone-EE 3/20 VAGINAL meclizine OTC levonorgestrel-EE 0.1/20 NUVARING aprepitant PA, QL PA*Covered for 3-16 years of § CALCINEURIN INHIBITORS norethindrone acetate-EE dronabinol QL age MISCELLANEOUS cyclosporine 1/20 granisetron tabs QL cyclosporine, modified norethindrone acetate-EE CONDOMS, meclizine GENITOURINARY tacrolimus

1/20 and iron MALE OTC*, QL metoclopramide § BENIGN PROSTATIC GYNOL II OTC ondansetron QL § 30 mcg Estrogen HYPERPLASIA § RAPAMYCIN DERIVATIVES SHUR-SEAL OTC prochlorperazine desogestrel-EE 0.15/30 - alfuzosin ext-rel sirolimus DIAPHRAGM QL promethazine Apri doxazosin Prescription is not required promethazine supp NUTRITIONAL / OTC* finasteride drospirenone-EE 3/30 trimethobenzamide regardless of member's tamsulosin SUPPLEMENTS levonorgestrel-EE 0.15/30 age norethindrone acetate-EE § H2 RECEPTOR terazosin ELECTROLYTES ESTROGENS 1.5/30 ANTAGONISTS § VAGINAL § POTASSIUM norethindrone acetate-EE § ORAL cimetidine OTC ANTI-INFECTIVES potassium bicarbonate effer 1.5/30 and iron estradiol famotidine OTC clotrimazole OTC tabs 25 mEq norgestrel-EE 0.3/30 estropipate ranitidine OTC miconazole OTC potassium chloride ext-rel cimetidine § 35 mcg Estrogen clindamycin crm potassium chloride liquid § TRANSDERMAL famotidine ethynodiol diacetate-EE 1/35 clotrimazole estradiol nizatidine VITAMINS AND MINERALS norethindrone-EE 0.4/35 metronidazole ranitidine § FOLIC ACID / § VAGINAL miconazole norethindrone-EE 0.5/35 COMBINATIONS terconazole norethindrone-EE 1/35 estradiol vaginal tabs § LAXATIVES / STOOL folic acid OTC norgestimate-EE 0.25/35 SOFTENERS ESTROGEN / PROGESTINS HEMATOLOGIC folic acid bisacodyl OTC § 50 mcg Estrogen folic acid-vitamin B6- § ORAL docusate calcium OTC ANTICOAGULANTS ethynodiol diacetate-EE 1/50 - vitamin B12 EE-norethindrone acetate docusate sodium OTC § INJECTABLE Zovia 1/50 estradiol-norethindrone polyethylene glycol enoxaparin § PRENATAL VITAMINS * norethindrone-ME 1/50 acetate 3350 OTC * All generic prenatal vitamins norgestrel-EE 0.5/50 - senna OTC § ORAL both OTC and Rx are covered. Ogestrel TRANSDERMAL sennosides OTC warfarin prenatal vitamins- COMBIPATCH sennosides- XARELTO § BIPHASIC carbonyl iron-docusate- docusate sodium OTC desogestrel-EE § GLUCOCORTICOIDS folic acid - Prenatal AD lactulose prenatal vitamins- dexamethasone peg 3350-electrolytes carbonyl iron-folic acid - fludrocortisone polyethylene glycol 3350 hydrocortisone Prenatabs Rx

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

prenatal vitamins- § ANTIHISTAMINES, § DECONGESTANT / § ANTIBIOTICS § Very High Potency 1 ferrous fumarate-docusate- SEDATING EXPECTORANT bacitracin OTC betamethasone dipropionate folic acid - Prenatal 19 chlorpheniramine OTC COMBINATIONS bacitracin-polymyxin B OTC augmented gel, oint 0.05% CITRANATAL 90 DHA chlorpheniramine ext-rel OTC pseudoephedrine- neomycin-bacitracin- diflorasone diacetate oint CITRANATAL ASSURE clemastine OTC guaifenesin ext-rel OTC polymyxin B OTC 0.05% CITRANATAL B-CALM diphenhydramine OTC pseudoephedrine- gentamicin halobetasol propionate crm, CITRANATAL DHA clemastine guaifenesin syp mupirocin oint 0.05% CITRANATAL HARMONY cyproheptadine 30 mg/100 mg/5 mL OTC silver sulfadiazine CITRANATAL RX diphenhydramine BACTROBAN NASAL § MISCELLANEOUS SKIN § EXPECTORANTS AND MUCOUS MEMBRANE § MISCELLANEOUS § ANTIHISTAMINE / guaifenesin liq, syp, § ANTIFUNGALS lidocaine-benzalkonium calcium OTC DECONGESTANT tabs OTC miconazole OTC chloride OTC calcium-vitamin D OTC COMBINATIONS MUCINEX OTC tolnaftate OTC povidone-iodine OTC cholecalciferol (D3) OTC cetirizine-pseudoephedrine ciclopirox ABREVA OTC § LEUKOTRIENE RECEPTOR electrolyte soln, oral OTC ext-rel OTC clotrimazole CALAMINE LOTION OTC ANTAGONISTS ferrous fumarate OTC fexofenadine- ketoconazole crm 2% imiquimod ferrous gluconate OTC pseudoephedrine montelukast nystatin podofilox soln ferrous sulfate OTC ext-rel OTC SANTYL § MAST CELL STABILIZERS omega-3 fatty acids OTC loratadine-pseudoephedrine CORTICOSTEROIDS OPHTHALMIC omega-3 fatty acids- ext-rel OTC cromolyn sodium nasal § Low Potency vitamin E OTC triprolidine-pseudoephedrine spray OTC hydrocortisone crm, gel, § ANTIALLERGICS cromolyn soln pyridoxine 50 mg OTC liq, syp OTC lotion, oint, soln 1% OTC ketotifen OTC for inhalation QL thiamine 50 mg, 100 mg OTC promethazine-phenylephrine hydrocortisone oint azelastine cyanocobalamin inj § NASAL ANTIHISTAMINES 0.5% OTC cromolyn sodium ergocalciferol (D2) ANTITUSSIVE hydrocortisone-aloe vera crm fluoride drops, tabs COMBINATIONS azelastine spray QL § ANTI-INFECTIVES 0.5%, 1% OTC multivitamins-fluoride drops, § NON-OPIOID § NASAL STEROIDS alclometasone crm, oint bacitracin tabs ciprofloxacin soln dextromethorphan- budesonide spray - 0.05% multivitamins-fluoride-iron guaifenesin ext-rel OTC desonide crm, lotion, oint erythromycin Rhinocort Allergy OTC, QL drops, tabs dextromethorphan- 0.05% gentamicin fluticasone spray OTC, QL vitamin ADC-fluoride drops levofloxacin guaifenesin liq, soln, triamcinolone acetonide fluocinolone acetonide soln vitamin ADC-fluoride-iron syp OTC 0.01% neomycin-polymyxin B- spray OTC, QL drops dextromethorphan- hydrocortisone crm, lotion, gramicidin flunisolide spray QL vitamin B complex-vitamin C- guaifenesin- oint 2.5% ofloxacin fluticasone spray QL folic acid polymyxin B-bacitracin pseudoephedrine liq triamcinolone acetonide MEPHYTON 10 mg/100 mg/ § Medium Potency polymyxin B-trimethoprim spray QL 30 mg/5 mL OTC betamethasone valerate crm, sulfacetamide soln 10% RESPIRATORY dextromethorphan- STEROID / BETA AGONIST lotion, oint 0.1% tobramycin soln brompheniramine- COMBINATIONS desoximetasone crm 0.05% § ANAPHYLAXIS ANTI-INFLAMMATORIES TREATMENT AGENTS pseudoephedrine ADVAIR DISKUS fluocinolone acetonide crm, dextromethorphan- oint 0.025% § Nonsteroidal epinephrine auto-injector QL 100/50 AL*, ST, QL promethazine fluticasone propionate crm diclofenac sodium EPIPEN QL DULERA ST, QL 0.05%, oint 0.005% ketorolac 0.4%, 0.5% SYMBICORT ST, QL EPIPEN JR. QL BETA AGONISTS hydrocortisone butyrate crm, § Steroidal § ANTICHOLINERGICS INHALANTS AL* Covered for ages 4-11 years oint, soln 0.1% only hydrocortisone valerate crm, dexamethasone sodium ipratropium soln QL § Short Acting oint 0.2% phosphate INCRUSE ELLIPTA QL albuterol inhalation soln QL § STEROID INHALANTS mometasone crm, lotion, oint fluorometholone 0.1% susp SPIRIVA RESPIMAT QL VENTOLIN HFA QL budesonide inhalation 0.1% prednisolone acetate 1% susp QL ANTICHOLINERGIC / BETA Long Acting triamcinolone acetonide crm, PREDNISOLONE ASMANEX QL AGONIST COMBINATIONS lotion, oint 0.025% PHOSPHATE 1% Hand-held Active Inhalation ASMANEX HFA QL triamcinolone acetonide crm, § SHORT ACTING STRIVERDI RESPIMAT QL PULMICORT BETA-BLOCKERS lotion, oint 0.1% ipratropium-albuterol soln QL FLEXHALER QL § ORAL AGENTS § Nonselective COMBIVENT RESPIMAT QL QVAR QL § High Potency albuterol levobunolol § ANTIHISTAMINES, LOW albuterol ext-rel § XANTHINES betamethasone dipropionate metipranolol augmented crm, lotion timolol maleate SEDATING terbutaline theophylline ext-rel tabs 0.05% timolol maleate gel cetirizine OTC theophylline liquid § DECONGESTANTS betamethasone dipropionate BETIMOL cetirizine ELIXOPHYLLIN pseudoephedrine OTC crm, lotion, oint 0.05% THEO-24 § Selective § ANTIHISTAMINES, pseudoephedrine desoximetasone crm, oint NONSEDATING ext-rel OTC, QL TOPICAL 0.25%, gel 0.05% betaxolol 0.5% diflorasone diacetate crm fexofenadine OTC CARBONIC ANHYDRASE DERMATOLOGY 0.05% loratadine OTC INHIBITORS § ACTINIC KERATOSIS fluocinonide crm, gel, oint, § Topical fluorouracil soln 0.05% triamcinolone acetonide crm, dorzolamide oint 0.5%

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

§ CARBONIC ANHYDRASE § PROSTAGLANDINS OTIC § ANTI-INFECTIVE / INHIBITOR / BETA- latanoprost § ANTI-INFECTIVES ANTI-INFLAMMATORY BLOCKER COMBINATIONS COMBINATIONS acetic acid § SYMPATHOMIMETICS dorzolamide-timolol maleate acetic acid-aluminum acetate neomycin-polymyxin B- brimonidine 0.15%, 0.2% ofloxacin otic hydrocortisone

CIPRODEX PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)† ACCU-CHEK STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, 3, COREG CR atenolol; bisoprolol; carvedilol; labetalol; ONETOUCH VERIO STRIPS AND KITS OTC, QL, 3 metoprolol succinate ext-rel; metoprolol tartrate 25 mg, 50 mg, 100 mg; nadolol; pindolol; propranolol; ADRENACLICK epinephrine auto-injector QL, EPIPEN QL, propranolol ext-rel; timolol EPIPEN JR QL DEXILANT lansoprazole delayed-rel OTC, QL, AEROSPAN ASMANEX QL, ASMANEX HFA QL, omeprazole magnesium delayed-rel capsule OTC, QL, PULMICORT FLEXHALER QL, QVAR QL omeprazole-sodium bicarbonate OTC, QL, ALCORTIN A desonide, hydrocortisone NEXIUM 24HR OTC, QL, PRILOSEC OTC OTC, QL, omeprazole delayed-rel capsule QL, ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES pantoprazole delayed-rel tablet QL INSULIN SYRINGES 4 DEXPAK dexamethasone, methylprednisolone, prednisone ALOQUIN desonide, hydrocortisone DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide ALORA estradiol DYRENIUM amiloride ALTOPREV atorvastatin, lovastatin, pravastatin, simvastatin EDARBI, EDARBYCLOR irbesartan, irbesartan-hydrochlorothiazide, losartan, ALVESCO ASMANEX QL, ASMANEX HFA QL, losartan-hydrochlorothiazide, valsartan, PULMICORT FLEXHALER QL, QVAR QL valsartan-hydrochlorothiazide AMRIX cyclobenzaprine 5 mg, 10 mg ESTRING estradiol vaginal tabs ANGELIQ EE-norethindrone, estradiol-norethindrone FEMRING estradiol vaginal tabs ANTARA fenofibrate FLOVENT DISKUS, ASMANEX QL, ASMANEX HFA QL, FLOVENT HFA PULMICORT FLEXHALER QL, QVAR QL ARMOUR THYROID levothyroxine, levothyroxine-Levoxyl FORTAMET metformin, metformin ext-rel ASCENSIA STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, 3, ONETOUCH VERIO STRIPS AND KITS OTC, QL, 3 FOSAMAX PLUS D alendronate tablet ATROVENT HFA INCRUSE ELLIPTA QL, SPIRIVA RESPIMAT QL FREESTYLE STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, 3, ONETOUCH VERIO STRIPS AND KITS OTC, QL, 3 AXERT naratriptan ST, QL, rizatriptan ST, QL, sumatriptan QL, sumatriptan nasal spray QL, FROVA naratriptan ST, QL, rizatriptan ST, QL, zolmitriptan ST, QL sumatriptan QL, sumatriptan nasal spray QL, zolmitriptan ST, QL BECONASE AQ budesonide spray - Rhinocort Allergy OTC, QL, fluticasone spray OTC, QL, triamcinolone GLUMETZA metformin, metformin ext-rel acetonide spray OTC, QL, flunisolide spray QL, fluticasone spray QL, triamcinolone acetonide spray QL INNOPRAN XL atenolol; bisoprolol; carvedilol; labetalol; metoprolol succinate ext-rel; metoprolol tartrate 25 mg, BENSAL HP desonide, hydrocortisone 50 mg, 100 mg; nadolol; pindolol; propranolol; propranolol ext-rel; timolol BREEZE 2 STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, 3, ONETOUCH VERIO STRIPS AND KITS OTC, QL, 3 ISTALOL levobunolol, metipranolol, timolol maleate gel, timolol maleate solution, BETIMOL BREO ELLIPTA ADVAIR AL, ST, QL, SYMBICORT ST, QL KAZANO JANUMET ST, JANUMET XR ST BYDUREON TRULICITY ST, VICTOZA ST KOMBIGLYZE XR JANUMET ST, JANUMET XR ST BYETTA TRULICITY ST, VICTOZA ST LANTUS BASAGLAR, TRESIBA BYSTOLIC atenolol; bisoprolol; carvedilol; labetalol; metoprolol succinate ext-rel; metoprolol tartrate 25 mg, LASTACAFT ketotifen OTC, azelastine, cromolyn sodium spray 50 mg, 100 mg; nadolol; pindolol; propranolol; propranolol ext-rel; timolol LIVALO atorvastatin, lovastatin, pravastatin, simvastatin CARDURA XL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin LUMIGAN latanoprost CLIMARA PRO COMBIPATCH MENEST estradiol, estropipate CONTOUR NEXT STRIPS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, 3, MENOSTAR estradiol 3 AND KITS ONETOUCH VERIO STRIPS AND KITS OTC, QL, MILLIPRED dexamethasone, methylprednisolone, prednisone 3 CONTOUR STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, , NESINA JANUVIA ST ONETOUCH VERIO STRIPS AND KITS OTC, QL, 3 NOVACORT desonide, hydrocortisone NOVO NORDISK NEEDLES 4 BD ULTRAFINE NEEDLES

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)† OMNARIS budesonide spray - Rhinocort Allergy OTC, QL, RAYOS dexamethasone, methylprednisolone, prednisone fluticasone spray OTC, QL, triamcinolone acetonide spray OTC, QL, RELION INSULIN HUMULIN INSULIN OTC, NOVOLIN INSULIN OTC flunisolide spray QL, fluticasone spray QL, RELPAX naratriptan ST, QL, rizatriptan ST, QL, triamcinolone acetonide spray QL sumatriptan QL, sumatriptan nasal spray QL, ONGLYZA JANUVIA ST zolmitriptan ST, QL OPSUMIT LETAIRIS PA, SP, TRACLEER PA, SP RIOMET metformin, metformin ext-rel 3 OSENI JANUMET ST, JANUMET XR ST SURE-TEST STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, , ONETOUCH VERIO STRIPS AND KITS OTC, QL, 3 OWEN MUMFORD NEEDLES 4 BD ULTRAFINE NEEDLES TOUJEO BASAGLAR, TRESIBA PANCREAZE CREON, VIOKACE, ZENPEP TRAVATAN Z latanoprost PERRIGO NEEDLES 4 BD ULTRAFINE NEEDLES TRIGLIDE fenofibrate PERTZYE CREON, VIOKACE, ZENPEP TRIVIDIA INSULIN SYRINGES 4 BD ULTRAFINE INSULIN SYRINGES PLEGRIDY glatiramer PA, SP, AUBAGIO PA, SP, 3 AVONEX PA, SP, COPAXONE 40 MG/ML PA, SP, TRUETEST STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, , 3 EXTAVIA PA, SP, GILENYA PA, SP, ONETOUCH VERIO STRIPS AND KITS OTC, QL, REBIF PA, SP, TECFIDERA PA, SP TRUETRACK STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, 3, 3 PRADAXA warfarin, XARELTO ONETOUCH VERIO STRIPS AND KITS OTC, QL, PRALUENT REPATHA PA, SP TUDORZA INCRUSE ELLIPTA QL, SPIRIVA RESPIMAT QL 4 PRECISION XTRA STRIPS ONETOUCH ULTRA STRIPS AND KITS OTC, QL, 3, ULTIMED INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES 3 AND KITS ONETOUCH VERIO STRIPS AND KITS OTC, QL, ULTIMED NEEDLES 4 BD ULTRAFINE NEEDLES PRED MILD dexamethasone sodium phosphate, UROXATRAL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin fluorometholone 0.1% susp, prednisolone acetate 1%, PREDNISOLONE PHOSPHATE 1% VANOXIDE-HC benzoyl peroxide PREFERAOB generic prenatal vitamins, CITRANATAL VITAFOL-ONE generic prenatal vitamins, CITRANATAL PREFEST EE-norethindrone, estradiol-norethindrone XOPENEX HFA VENTOLIN HFA QL PRENATAL PLUS generic prenatal vitamins, CITRANATAL ZETONNA budesonide spray - Rhinocort Allergy OTC, QL, fluticasone spray OTC, QL, PROAIR HFA VENTOLIN HFA QL triamcinolone acetonide spray OTC, QL, PROVENTIL HFA VENTOLIN HFA QL flunisolide spray QL, fluticasone spray QL, triamcinolone acetonide spray QL QNASL budesonide spray - Rhinocort Allergy OTC, QL, fluticasone spray OTC, QL, ZIOPTAN latanoprost triamcinolone acetonide spray OTC, QL, ZYFLO, ZYFLO CR montelukast flunisolide spray QL, fluticasone spray QL, triamcinolone acetonide spray QL UNIVERSITY OF MARYLAND HEALTH PARTNERS OTC REFERENCE LIST

The UM Health Partners OTC Reference List is a guide to the medicines that are most appropriate and cost effective for each therapeutic class. This list can help your doctor choose the medicines that are right for you. If an OTC medicine that you use is not on this list, it may still be covered if your doctor asks for you to get it.

This list is not an all-inclusive list and does not guarantee coverage. Please visit www.umhealthpartners.com for a complete list.

PRODUCT NAME ‡ BRAND NAME EXAMPLES acetaminophen QL TYLENOL acetic acid soln alcohol swabs QL alumina-magnesia MAALOX alumina-magnesia-simethicone MAALOX alumina-magnesia-simethicone MYLANTA ammonium lactate 12% LAC-HYDRIN artificial tears oint, soln ARTIFICIAL TEARS aspirin aspirin delayed-rel

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

PRODUCT NAME ‡ BRAND NAME EXAMPLES bacitracin bacitracin-polymyxin B POLYSPORIN benzoyl peroxide bisacodyl DULCOLAX bismuth subsalicylate PEPTO-BISMOL blood glucose monitoring kits, test strips QL, 3 ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS budesonide spray QL RHINOCORT ALLERGY calamine lotion calcium calcium carbonate calcium-vitamin D cetirizine ZYRTEC cetirizine-pseudoephedrine ext-rel ZYRTEC-D 12 Hour chlorpheniramine chlorpheniramine ext-rel cholecalciferol (D3) VITAMIN D cimetidine TAGAMET HB clemastine clotrimazole condoms, male QL, 5 cromolyn sodium nasal spray NASALCROM dextromethorphan-guaifenesin ext-rel MUCINEX DM dextromethorphan-guaifenesin liq, soln, syp dextromethorphan-guaifenesin-pseudoephedrine liq 10 mg/100 mg/30 mg/5 mL diphenhydramine BENADRYL docosanol ABREVA docusate calcium docusate sodium COLACE electrolyte soln, oral PEDIALYTE esomeprazole magnesium delayed-rel QL NEXIUM 24HR famotidine PEPCID AC ferrous fumarate ferrous gluconate FERGON ferrous sulfate FEOSOL fexofenadine ALLEGRA fexofenadine-pseudoephedrine ext-rel ALLEGRA-D fluticasone spray QL FLONASE ALLERGY RELIEF folic acid guaifenesin ext-rel MUCINEX guaifenesin liq DIABETIC TUSSIN guaifenesin liq, syp, tabs hydrocortisone crm, gel, lotion, oint, soln 1% CORTIZONE-10 hydrocortisone oint 0.5% hydrocortisone-aloe vera crm 0.5%, 1% ibuprofen ADVIL insulin human HUMULIN R insulin human NOVOLIN R

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

PRODUCT NAME ‡ BRAND NAME EXAMPLES insulin isophane human HUMULIN N insulin isophane human NOVOLIN N insulin isophane human 70%/regular 30% HUMULIN 70/30 insulin isophane human 70%/regular 30% NOVOLIN 70/30 insulin syringes, needles ketotifen ZADITOR lancets lansoprazole delayed-rel QL PREVACID 24HR levonorgestrel QL, 5 PLAN B ONE-STEP lidocaine-benzalkonium chloride BACTINE loperamide loperamide-simethicone IMODIUM loratadine CLARITIN loratadine-pseudoephedrine ext-rel CLARITIN-D meclizine miconazole MICATIN multiple urine test products QL KETO-DIASTIX multiple urine test products QL MULTISTIX naproxen sodium ALEVE nebulizer QL neomycin-bacitracin-polymyxin B NEOSPORIN nonoxynol-9 GYNOL II nonoxynol-9 QL SHUR-SEAL omega-3 fatty acids FISH OIL omega-3 fatty acids-vitamin E FISH OIL omeprazole delayed-rel tabs QL omeprazole magnesium delayed-rel QL PRILOSEC OTC omeprazole magnesium delayed-rel caps QL omeprazole-sodium bicarbonate QL ZEGERID OTC oxybutynin transdermal 6 OXYTROL FOR WOMEN peak flow meter QL permethrin polyethylene glycol 3350 MIRALAX povidone-iodine BETADINE pseudoephedrine SUDAFED pseudoephedrine ext-rel QL SUDAFED pseudoephedrine-guaifenesin ext-rel MUCINEX D pseudoephedrine-guaifenesin syp 30 mg/100 mg/5 mL psyllium pyrantel - Reeses Pinworm Medicine pyridoxine 50 mg VITAMIN B6 ranitidine ZANTAC respiratory mask QL selenium sulfide shampoo 1% SELSUN BLUE senna sennosides SENOKOT sennosides-docusate sodium SENNA PLUS

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy

PRODUCT NAME ‡ BRAND NAME EXAMPLES simethicone sodium chloride for inhalation sodium chloride nasal spray OCEAN spacer QL AEROCHAMBER thiamine 50 mg, 100 mg VITAMIN B1 tolnaftate TINACTIN triamcinolone acetonide spray QL NASACORT ALLERGY 24HR triprolidine-pseudoephedrine liq, syp vaporizer QL

FOR YOUR INFORMATION: This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. In most instances, a brand-name drug for which a generic product becomes available will require prior authorization or will no longer be covered upon release of the generic product onto the market. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper-and lowercase Italics, and generic products in lowercase italics. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to www.umhealthpartners.com to check coverage.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

§ Generics are available in this class and should be considered the first line of prescribing. † The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. ‡ Only the generic version(s) are covered when available. 1 Most Mental Health drugs are on MDH Medical Mental Health Formulary and covered by Medicaid fee-for-service. 2 Covered for members ages 6 - 17. This drug is part of the mental health formulary and is billed fee for service. A medical exception may be requested for members not in this age range by calling UM Health Partners. 3 Quantity Limits apply to test strips only 4 BD ULTRAFINE syringes and needles are the only preferred options. 5 Prescription is not required regardless of age. 6 Gender restriction - Coverage only for females.

Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.

©2017. All rights reserved. 106-1044712-1-100117 www.umhealthpartners.com

AL: Age Limit OTC: Over the counter PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval LEGEND QL: Quantity Limit SP: Specialty Drug ST: Step Therapy