Erythromycin/Sulfisoxazole (generic) INTRODUCTION Penicillins ...... Anthem Blue Cross uses a formulary Amoxicillin (generic) (preferred list of drugs) to help your doctor Amoxicillin/Clavulanate (generic/Augmentin make prescribing decisions. This list of drugs chew/XR) is updated quarterly, by a committee Ampicillin (generic) consisting of doctors and pharmacists, so that Dicloxacillin (generic) the list includes drugs that are safe and Penicillin (generic) effective in the treatment of diseases. If you Quinolones ...... have any questions about the accessibility of Ciprofloxacin/XR (generic) your medication, please call the phone number Levofloxacin (Levaquin) listed on the back of your Anthem Blue Cross Sulfonamides ...... member identification card. Erythromycin/Sulfisoxazole (generic) In most cases, if your physician has Sulfamethoxazole/Trimethoprim (generic) determined that it is medically necessary for Sulfisoxazole (generic) you to receive a brand name drug or a drug Tetracyclines ...... that is not on our list, your physician may Doxycycline hyclate (generic) indicate “Dispense as Written” or “Do Not Minocycline (generic) Substitute” on your prescription to ensure Tetracycline (generic) access to the medication through our network ANTIFUNGAL AGENTS (ORAL) ______of community pharmacies, excluding drugs Clotrimazole (generic) that require Prior Authorization of Benefits. Fluconazole (generic) Griseofulvin (generic) Please ask your doctor or pharmacist to refer Itraconazole (generic) to the Anthem Blue Cross Outpatient Ketoconazole (generic) APPROVED Prescription Drug List for a complete listing of Nystatin (generic) products. Terbinafine (generic) ANTI-MALARIALS ______FORMULARY Chloroquine (generic) USE OF GENERICS Mefloquine (generic) Primaquine (Primaquine) Generic drugs are safe and effective Pyrimethamine (Daraprim) DRUG LIST equivalents to brand name medications. In Pyrimethamine/Sulfadoxine (Fansidar) many cases, if a generic equivalent is Quinine (generic) (CONDENSED VERSION) available for a brand name product, the brand ANTI-TUBERCULOSIS AGENTS ______name product will be considered non-preferred Cycloserine (generic) and the generic equivalent will be on the list. Ethambutol (generic) Revised 7/2010 The FDA has endorsed the use of generic Ethionamide (Trecator-SC) equivalents and has found their use to be safe Isoniazid (generic) and effective. Pyrazinamide (generic) Rifabutin (Mycobutin) For medications classified by the FDA as Rifampin (generic) having a narrow therapeutic index (NTI), Anthem Blue Cross discourages the use of OTHER ANTI-INFECTIVES ______these generic substitutions. Clindamycin (generic) Iodoquinol (Yodoxin) Metronidazole (generic) LEGEND Trimethoprim (generic) PRIOR AUTHORIZATION In each class, drugs are alphabetically listed by active ingredient. Anthem Blue Cross may require prior authorization of benefit (PAB) for certain drugs ANTI-NEOPLASTIC AGENTS If only the word 'generic' appears to provide a safe and affordable pharmacy All FDA-approved, self-administered injectable within the parenthesis, only the benefit. Drugs which require PAB are often and oral anti-neoplastic agents are eligible for generic is on Formulary. Example: medications that are appropriate for only very coverage under the prescription drug benefit. Cefaclor (generic) means that the specific medical conditions. If your physician May be subject to PAB. generic, Cefaclor is covered and the believes that a medication requiring PAB is brand is not covered. medically appropriate, he or she should contact WellPoint Pharmacy Management in If the word 'generic' does not appear order to initiate the Prior Authorization Process ANTI-VIRAL AGENTS within the parenthesis, the active on your behalf. The list of drugs is subject to Acyclovir (generic) ingredient is only available as a brand change so please call Customer Service at 1- Amantadine (generic) and is on Formulary. The drug name in 800-700-2541 or check our website at Entecavir (Baraclude) parenthesis is the brand name. www.anthem.com/ca.com to obtain a complete list of PAB drugs. Famciclovir (generic) Example: Levofloxacin (Levaquin) Ganciclovir (generic) means that the brand, Levaquin is Interferon Alfa-2A (Roferon-A)* covered and there is no generic Interferon Alfa-2B (Intron A)* available. Levaquin is the brand name. ANTI-INFECTIVE AGENTS Interferon Alfa-2B/Ribavirin (Rebetron)* Interferon Alfacon-1 (Infergen)* If the word 'generic' and the brand ANTIBIOTICS ______Lamivudine (Epivir HBV) name both appear within the Cephalosporins ...... Peginterferon Alfa-2B (Peg-Intron)* parenthesis, both the generic and the Cefaclor (generic) Peginterferon Alfa-2A (Pegasys)* brand name drugs are on Formulary. Cefdinir (generic) Ribavirin (generic) Example: Warfarin (Coumadin / Cefadroxil (generic) Tenofovir (Viread) generic) means that both the brand Cefditoren (generic) Valacyclovir (generic/Valtrex) and generic are available. Therefore, Cefprozil (generic) Valganciclovir (Valcyte) the brand Coumadin and the generic Cefuroxime (generic)

Warfarin are covered. Cefpodoxamine (generic) Cephalexin (generic) * Members should refer to their Cephradine (generic) AUTONOMIC & CENTRAL NERVOUS SYSTEM Member Handbook for benefit details Macrolides ...... AGENTS regarding applicable copayments or Azithromycin (generic) ANALGESICS, NARCOTIC ______coinsurance. Clarithromycin XL (generic) Acetaminophen/Codeine (generic) Erythromycin (generic) Aspirin/Codeine (generic) Codeine /Sulfate (generic) CEREBRAL STIMULANTS ______Filgrastim (Neupogen)* Fentanyl (generic) Amphet Asp/Amphet/D-Amphet Oprelvekin (Neumega)* Fentanyl Citrate (generic) (Adderall XR/generic) Pegfilgrastim (Neulasta)* Hydrocodone/Acetaminophen (generic) Armodanafil (Nuvigil) Sargramostim (Leukine)* Hydromorphone (generic) Atomoxetine (Strattera) Meperidine (generic) Dexmethylphenidate (generic) Methadone (generic) Dextroamphetamine (generic) Morphine (generic) Lisdexamphetamine (Vyvanse) CARDIOVASCULAR AGENTS Morphine Sulfate (generic /Avinza/MS Contin) Methylphenidate ER ANGIOTENSIN CONVERTING ENZYME Oxycodone/Acetaminophen (generic) (Concerta/Methylin ER) INHIBITORS AND RECEPTOR BLOCKERS ______Oxycodone/Aspirin (generic) Methylphenidate (generic) Amlodipine/Valsartan (Exforge) Oxycododone (Oxycontin/generic) MULTIPLE SCLEROSIS AGENTS ______Amlodipine/Valsartan/HCTZ (Exforge HCT) Propoxyphene (generic) Glatiramer Acetate (Copaxone)* Benazepril/HCTZ (generic) Propoxyphene Compound (generic) Interferon Beta-1A (Avonex)* Benazepril/Amlodipine (generic) Propoxyphene/Acetaminophen (generic) Interferon Beta-1A (Rebif)* Captopril/HCTZ (generic) ANALGESICS, NON-NARCOTIC ______Interferon Beta-1B (Betaseron)* Enalapril/HCTZ (generic) APAP/Isometheptene/Dichlphen (generic) OPIOID DEPENDANCE ______Fosinopril/HCTZ (generic) Acetaminophen/Caffeine/Butalbital (generic) Buprenorphine/Naloxone (Suboxone) Lisinopril/HCTZ (generic) Aspirin/Caffeine/Butalbital (generic) Buprenorphine (generic) Losartan/HCTZ (generic/Cozaar/Hyzaar) Ergotamine (Ergomar) PSYCHOTHERAPEUTIC AGENTS ______Moexipril/HCTZ (generic) Ergotamine/Caffeine (generic) Perindopril (generic) Lidocaine (Lidoderm) Antidepressants ...... Quinapril/HCTZ (generic) Methysergide (Sansert) Amitriptyline (generic) Ramipril (generic) Rizatriptan (Maxalt/MLT) Bupropion/-XL (generic) Trandolapril (generic) Sumatriptan (generic) Citalopram (generic) Valsartan/HCTZ (Diovan/Diovan HCT) Tramadol/-ER (generic) Desipramine (generic) ANTI-ADRENERGIC BLOCKERS ______Zolmitriptan (Zomig/ZMT) Desvenlafaxine (Pristiq) Alfuzosin(Uroxatral) Doxepin (generic) ANALGESICS, NONSTEROIDAL Doxazosin (generic) Duloxetine (Cymbalta) ANTI-INFLAMMATORY ______Dutasteride (Avodart) Escitalopram (Lexapro) Diclofenac (generic/Voltaren Gel) Prazosin (generic) Fluoxetine (generic) Etodolac (generic) Terazosin (generic) Fluoxetine/Olanzapine (Symbyax) Flurbiprofen (generic) Tamsulosin (generic/Flomax) Fluvoxamine (generic) Ibuprofen (generic) ANTIARRHYTHMICS ______Indomethacin (generic) Imipramine (generic) Mirtazapine (generic) Amiodarone (Cordarone/Pacerone/generic) Ketoprofen (generic) Digoxin (Lanoxicap/Lanoxin/generic) Ketorolac (generic) Nortriptyline (generic) Disopyramide (generic) Nabumetone (generic) Paroxetine (generic/CR) Phenelzine (Nardil) Flecainide (generic) Naproxen (generic) Mexiletine (generic) Naproxen/Sumatriptan (Treximet) Sertraline (generic) Moricizine (Ethmozine) Oxaprozin (generic) Tranylcypromine (Parnate) Procainamide (generic) Piroxicam (generic) Trazodone (generic) Propafenone (generic) Sulindac (generic) Venlafaxine/ER (Effexor XR/generic) Antimanic Agents ...... Quinidine Gluconate (generic) ANALGESICS, SALICYLATES ______Sotalol (generic) Lithium Carbonate (Eskalith-CR/ Aspirin (generic) ANTICOAGULANTS/ANTITHROMBOTICS ______Chol Sal/Magnesium Salicylate (generic) Lithobid/generic) Anagrelide (generic) Diflunisal (generic) Lithium Citrate (Lithonate/generic) Cilostazol (generic) Salsalate (generic) Antipsychotic Agents ...... Clopidogrel (Plavix) Aripiprazole (Abilify) ANTICONVULSANTS ______Dalteparin (Fragmin)* (generic) Carbamazepine (Tegretol/XR/ Dipyridamole (generic) Clomipramine (generic) Carbatrol/generic) Enoxaparin (Lovenox)* Clozapine (Fazaclo ODT/generic) Clonazepam (generic) Fondararinux (Arixtra)* Fluphenazine (generic) Diazepam (Diastat) Pentoxifylline (generic) (generic) Divalproex Sodium (generic/Depakote/ER) Prasugrel (Effient) Loxapine (generic) Ethosuximide (generic) Ticlopidine (generic) Mesoridazine (Serentil) Felbamate (Felbatol) Tinzaparin (Innohep)* Olanzapine (Zyprexa/Zydis) Gabapentin (Neurontin solution/generic) Warfarin (Coumadin/generic) Tiagabine (Gabitril) Perphenazine (generic) Pimozide (Orap) ANTILIPEMICS ______Levetiracetam (generics/Keppra/XR) Atorvastatin (Lipitor) Lamotrigine (generic/Lamictal) Prochlorperazine (generic) Cholestyramine (generic) Phenobarbital (generic) Quetiapine (Seroquel) Colesevelam (Welchol) (Dilantin/Phenytek/generic) (generic/RisperdalConsta) Thioridazine (generic) Colestipol (generic) Primidone (generic) Fenofibrate (generic) Oxcarbazepine (generic) Thiothixene (generic) Fenofibric acid (generic/Trilipix) Topiramate (generic/Topamax) Trifluoperazine (generic) Gemfibrozil (generic) Valproic Acid (Depakene/generic) Ziprasidone (Geodon) SEDATIVES, HYPNOTICS AND ANTI-ANXIETY ____ Lovastatin (generic) Zonisamide (generic) (Nicotinex/SloNiacin/Niaspan/generic) Alprazolam (generic) ANTIPARKINSON AGENTS ______Niacin/Lovastatin (Advicor) Buspirone (generic) Akineton (Biperiden) Omega-3 acid ethly (Lovaza) Chloral Hydrate (generic) Amantadine (generic) Pravastatin (generic) Chlordiazepoxide (generic) Benztropine (generic) Rosuvastatin (Crestor) Clorazepate (generic) Bromocriptine (generic) Simvastatin (generic) Diazepam (generic) Carbidopa/Levodopa (generic) BETA-ADRENERGIC BLOCKERS ______Entacapone (Comtan) Flurazepam (generic) Atenolol/Chlorthalidone (generic) Levodopa (Laradopa) Lorazepam (generic) Bisoprolol/HCTZ (generic) Procyclidine (Kemadrin) Meprobamate (generic) Oxazepam (generic) Carvedilol (Coreg-CR/generic) Pramipexole (generic/Mirapex 0.75mg) Labetalol (generic) Rasagiline mesylate (Azilect) Temazepam (generic) Metoprolol/XL/HCTZ (generic) Ropinirole (generic) Triazolam (generic) Zolpidem (generic) Pindolol (generic) Selegiline (generic) Propranolol/XL/HCTZ (generic) Trihexyphenidyl (generic) Sotalol (generic) ALZHEIMER’S AGENTS ______Timolol (generic) Donezepil (Aricept) BLOOD MODIFIERS CALCIUM CHANNEL BLOCKERS ______Memantine (Namenda) Amlodipine (generic) Rivastigmine (Exelon) Erythropoietin (Procrit)* Darbepoetin (Aranesp)* Bepridil (Vascor) Diltiazem (generic) Sodium Sulfacetamide (generic) Tolbutamide (generic) Felodipine (generic) FUNGICIDES ______ANTIDIABETIC SUPPLIES ______Nicardipine (generic) Cicloplrox (Loprox) Select blood testing supplies, such as Nifedipine (generic) Nystatin/Triamcinolone (generic) glucometers, lancets, and test strips, may be Nisoldipine (Sular) Econazole (generic) covered. Accu-Chek and One Touch are the Verapamil (generic) Ketoconazole (generic) only test strips included on formulary. Lifescan CENTRALLY ACTING ANTIHYPERTENSIVES ______TOPICAL ANTI-INFLAMMATORY AGENTS ______(One Touch, One Touch Ultra); Roche Clonidine (generic) Diagnostics (Accu-Chek, Aviva). Quantity Methyldopa (generic) Low Potency ...... limits apply. Urine test strips are also a Desonide (generic) covered benefit. DIURETICS ______Fluocinolone (generic) Acetazolamide (generic) Hydrocortisone (generic) GLUCOSE ELEVATING AGENTS ______Amiloride (generic) Diazoxide (Proglycem) Chlorthalidone (generic) Medium Potency ...... Glucagon (Glucagon) Desoximetasone (generic) Ethacrynic Acid (generic) ANTITHYROID______Furosemide (generic) Fluocinolone (Dermasmoothe F/S/generic) Fluticasone (generic) Methimazole (generic) HCTZ/Triamterene (generic) Propylthiouracil (generic) Hydrochlorothiazide (generic) Mometasone (generic) Indapamide (generic) Prednicarbate (generic) THYROID ______Methazolamide (generic) Triamcinolone (generic) Levothyroxine (Levothroid/Levoxyl/Unithroid/ Metolazone (generic) High Potency ...... Synthroid/generic) /HCTZ (generic) Betamethasone Dipropionate (generic) Liothyronine (Cytomel/generic) Torsemide (generic) Fluocinonide (generic) Liotrix (Thyrolar) Thyroid (Armour Thyroid) Triamterene (generic) Ultra-High Potency ...... VASODILATORS ______Augmented Betamethasone (generic) OTHER ENDOCRINE AGENTS ______Hydralazine (generic) Clobetasol (generic) Leuprolide (Eligard/Lupron/generic)* Isosorbide Dinitrate/Hydralazine (Bidil) Diflorasone (generic) Isosorbide Dinitrate (Dilatrate SR/generic) VAGINAL/RECTAL PREPARATIONS ______Isosorbide Mononitrate (generic) Clindamycin (generic) GASTROINTESTINAL AGENTS Minoxidil (generic) (Ortho-Dienestrol) Nitroglycerin (Nitrostat/Nitrobid/Nitrolingual (Estring/Vagifem) ANTIEMETIC/ANTIVERTIGO ______Spray/generic) , Conjugated (Premarin) Dronabinol (generic) Nitroglycerin (Nitrek/Nitro-Dur/generic) Hydrocortisone (Cortifoam) Granisetron (generic) Ranolazine (Ranexa) Hydrocortisone/Pramoxine (generic/Analpram Meclizine (generic) VASOPRESSORS ______HC lotion/Pramosone cream, lotion, oint) (generic) Epinephrine (Epipen/Jr/Twinject) Mesalamine (Rowasa) Ondansetron (generic) Prochlorperazine (generic) MISCELLANEOUS ______Metronidazole (generic) Nystatin (generic) Promethazine (generic) Aliskiren/HCTZ (Tekturna/HCT) Scopolamine (Transderm-Scop) Amlodipine/Benazepril (Lotrel) Progesterone (Crinone Vaginal Gel) Thiethylperazine (Torecan) Amlodipine/Valsartan (Exforge/Exforge HCT) Sulfanilamide (generic) Sulfathiaz/Sulfacet/Sulfabenz (generic) Trimethobenzamide (generic) MISCELLANEOUS DERMATOLOGICALS ______ANTISPASMODIC/GI MOTILITY ______Calcipotriene (Dovonex) Belladonna/Phenobarbital (generic) CONTRACEPTIVES Crotamiton (Eurax) Clidinium/Chlordiazepoxide (generic) Eth Estradiol/Desogestrel (Apri/generic) Fluorouracil (Fluoroplex/generic) Dicyclomine (generic) Eth Estradiol/Drospirenone (Yaz) Imiquimod (Aldara) Hyoscyamine (generic) Eth Estradiol/Ethynodioldiacetate (Zovia) Lindane (generic) Propantheline (generic) Eth Estradiol/Levonorgestrel Masoprocol (Actinex) ANTIULCER ______(Enpresse/Jolessa/Portia/Trivora/generic) Methoxsalen (Oxsoralen) Cimetidine (generic) Eth Estradiol/Norelgestromin (Ortho-Evra) Permethrin (Elimite) Esomeprazole (Nexium) Eth Estradiol/Norethindrone (Loestrin FE 24) Pimecrolimus (Elidel) Glycopyrolate (generic) Eth Estradiol/Norethindrone (Balziva) Podofilox (Condylox) Lansoprazole (generic) Eth Estradiol/Norethindrone (Necon/generic) Selenium Sulfide (Exsel) Lansoprazole/Amox/Clarith (Prevpac) Eth Estradiol/Norgestimate (Trinessa/ Silver Sulfadiazine (generic) Misoprostol (generic) TriSprintec/generic) Tacrolimus (Protopic) Nizatidine (generic) Eth Estradiol/Norgestimate (Ortho Tri-Cyclen Omeprazole (generic)

LO) Pantoprazole (generic) Eth Estradiol/Norgestrel (Low-Ogestrel/ Ranitidine (generic) Ogestrel) ENDOCRINE AGENTS Sucralfate (generic) Norethindrone (Nora-BE) ANTIDIABETIC AGENTS-INJECTABLE ______OTHER GI PRODUCTS ______EMERGENCY CONTRACEPTIVES ______All forms of insulin are covered. Balsalazide (generic) Levonorgestrel (generic 0.75mg/Plan B 1.5mg) Exenatide (Byetta)* Budesonide (Entocort EC) Pramlintide (Symlin)* Hydrocortizone (Cortifoam) ANTIDIABETIC AGENTS-ORAL ______Lactulose (generic) Acarbose (generic) Mesalamine (Asacol/Pentasa/Lialda/Canasa) DERMATOLOGICALS Acetohexamide (generic) Olsalazine (Dipentum) Pancreatic Lipase (Creon/Pancrease/Ultrase/ ACNE ______Chlorpropamide (generic) Viokase) Adapalene (Differin) Glimepiride (generic) Sulfasalazine (generic) Azelaic Acid (Finacea) Glimepiride/Rosiglitazone (Avandaryl) Ursodiol (generic) Clindamycin (Cleocin T) Glipizide (generic) Clindamycin/benzoyl peroxide (generic,/Duac Glipizide/Metformin (generic) CS) Glyburide/Metformin (generic) Glyburide/Micronized (generic) Erythromycin (generic/Akne-Mycin) GLUCOCORTICOIDS Isotretinoin (generic) Metformin (generic) Minocycline (generic) Miglitol (Glyset) Dexamethasone (generic) Sodium Sulfacetamide (generic) Nateglinide (generic/Starlix) Fludrocortisone (Florinef) Tazarotene (Tazorac) Pioglitazone (Actos) Methylprednisolone (generic) Tretinoin (generic/Retin-A Micro/Retin-A Micro Pioglitazone/glimepiride (Duetact) Prednisolone (generic) Pump) Pioglitazone/Metformin (ActoPlus Met/XR) Prednisone (generic) Repaglinide (Prandin) ANTIBIOTICS/ANTIVIRALS ______Rosiglitazone (Avandia) Acyclovir (generic) Rosiglitazone/Metformin (Avandamet) Bacitracin/Polymyxin B (Bacitracin) Saxagliptin (Onglyza) GOUT THERAPY Metronidazole (generic/Metrogel) Sitagliptin (Januvia) Mupirocin (Bactroban/generic) Allopurinol (generic) Sitagliptin/Metformin (Janumet) Retapamulin (Altabax) Colchicine (generic) Tolazamide (generic) Colchicine/Probenecid (generic) Ofloxacin (Ocuflox/generic) Levalbuterol (generic/Xopenex Inhalation Soln) Indomethacin (generic) Polymyxin B/Trimethoprim (generic) Metaproterenol (generic) Probenecid (generic) Sulfacetamide (generic) Albuterol (Proair HFA/Proventil HFA) Tobramycin (generic) Salmeterol (Serevent Diskus) Moxifloxacin (Vigamox) Terbutaline (Brethaire) ANTI-INFLAMMATORY AGENTS ______Xanthine Derivatives ...... HIV AGENTS Cyclosporine (Restasis) Aminophylline (Truphylline/generic) All oral and self injectable FDA-approved HIV Dexamethasone (generic) Theophylline (Theo-Dur/Theo-24/ agents are eligible for coverage under the Diclofenac (generic) Uniphyl/generic) prescription drug benefit. May be subject to Fluorometholone (generic) OTHER AGENTS______PAB. Flurbiprofen (Ocufen) Albuterol/Ipratropium (Combivent) Ketorolac (generic) Albuterol/Ipratropium (generic)

Ketotifen Fumarate (generic) Cromolyn (generic) Loteprednol (Lotemax) Ipratropium (Atrovent HFA) HORMONES Naphazoline (generic) Montelukast (Singulair) Prednisolone (generic) ______Nedocromil (Tilade) (Arimidex) ANTI-INFECTIVE & ANTI-INFLAMMATORY Potassium Iodide (SSKI) (Evista) COMBINATIONS ______Sodium Chloride (Broncho-Saline/generic) (generic) Loteprednol/Tobramycin (Zylet) Tiotropium (Spiriva) Tobramycin (Tobi) ESTROGENS ______Na Sulfacetm/Fluorometholone (FML-S) Na Sulfacetm/Prednisolone (generic) Estradiol (generic) ANTIHISTAMINES/DECONGESTANTS ______Neomy/Bacitracin/Polymyxin/Hydrocort Estradiol Patch/Spray (generic /Alora/Climara Carbinoxamine/Pseudoephedrine/DM (generic) Pro/Esclim/Estraderm/Evamist/Vivelle/Dot) (generic) Neomy/Polymyx B/Prednisolone (Poly-Pred) Estrogens, Conjugated (Premarin/Low Dose) Fexofenadine (generic) Neomycin/Dexamethasone (Neo-Dex) Estrogens, Esterified (Estratab/Menest) Fexofenadine/PSE 12hr (generic) Neomycin/Polymyx B/Dexamethasone (generic) Hydroxyzine (generic) (generic) Synthetic (Cenestin) Promethazine (generic) Tobramycin/Dexamethasone (generic) Pseudoephed/Brompheniramine (generic) COMBINATIONS ______ANTIVIRAL AGENTS ______Estradiol/Norethindrone Acetate EXPECTORANT AND COUGH PRODUCTS ______Trifluridine (Viroptic) (generic/Activella 0.1-0.5/CombiPatch) Benzonatate (generic) Vidarabine (Vira-A) Estrogen, Con/Medroxyprogesterone Chlorpheniramine/Hydrocodone (Prempro/Premphase) BETA-BLOCKERS ______(TussiCaps/Tussionex) Estrogen, / (generic) Betaxolol (Betoptic/S/generic) Guaifenesin/Codeine (generic) Ethinyl Estradiol/Norethindrone Acetate Carteolol (generic) Guaifenesin/Codeine/Pseudoephedrine (Femhrt) Levobunolol (generic) (generic) Guaifenesin/Pseudoephedrine (generic) GROWTH HORMONE ______Metipranolol (generic) Timolol (Betimol/generic) Guaifenesin/Hydrocodone (generic) Somatropin (Humatrope/Nutropin/Nutropin Hydrocodone/Homatropine (generic) AQ)* MIOTICS ______Phenylephrine/Hydrocodone (generic) PROGESTINS ______Brinzolamide (Azopt) Dorzolamide (generic) Promethazine/Dextromethorphan (generic) Desogestrel (Cyclessa) Dorzolamide/Timolol (generic) Promethazine/Codeine (generic) Medroxyprogesterone (Cycrin/generic) Pilocarpine (generic) Promethazine/Phenylephrine (generic) Megestrol (generic) Promethazine/Phenylephrine/Codeine Micronized Progesterone (Prometrium) MYDRIATICS ______(generic) Atropine (generic) Norethindrone (generic) NASAL MEDICATIONS ______Progesterone (Crinone Vaginal Gel) Cyclopentolate (Cyclogyl) Azelastine (Astelin/Astepro) MISCELLANEOUS HORMONE PRODUCTS ______Homatropine (Isopto Homatropine) Phenylephrine (Neo-Synephrine) Fluticasone (generic/Veramyst)) (generic/Casodex) Tropicamide (Mydriacyl) Mometasone (Nasonex) Cabergoline (Dostinex) (Danocrine) SYMPATHOMIMETICS ______Desmopressin (Stimate) Dipivefrin (generic) Finasteride (generic) SKELETAL AGENTS Flutamide (Eulexin) ANTIRHEUMATICS ______Octreotide (Sandostatin) OTICS (Oxandrin) Auranofin (Ridaura) (Androderm/Androgel/Testim) ANTI-INFECTIVE AGENTS ______Azathioprine (generic) (generic) Hydroxychloroquine (generic) Acetic Acid/Benzethonium (generic) Methotrexate (generic) Ofloxacin (Floxin Otic/generic) BONE ENHANCING AGENTS ______IMMUNOSUPRESSIVE AGENTS ANTI-INFECTIVE & ANTI-INFLAMMATORY Alendronate (Fosamax/-D/generic) Calcitonin-Salmon (generic) All FDA-approved, self-administered injectable COMBINATIONS ______Etidronate (generic) and oral immunosuppressive agents are Ciprofloxacin/Dexamethasone (Ciprodex) Risedronate (Actonel/-with Calcium) eligible for coverage under the prescription Neomycin/Polymxin/HC (generic) drug benefit.

RESPIRATORY RELAXANTS OPHTHALMICS ANTI-ASTHMATIC AGENTS ______Baclofen (generic) Carisoprodol (generic) ALPHA-AGONIST ______Asthma Devices ...... Cyclobenzaprine (generic) Brimonidine Tartrate (generic) Asthma Spacer (Aerochamber/InspirEase/ Diazepam (generic) PROSTAGLANDIN AGONIST ______Optichamber) Metaxalone (Skelaxin) Bimatoprost (Lumigan) Peak Flow Meter (Personal Best/Pocketpeak) Methocarbamol (generic) Latanoprost (Xalatan) Corticosteroids ...... Tizanidine (generic) ANTI-ALLERGY AGENTS Beclomethasone (QVAR) Azelastine (generic) Budesonide (Pulmicort) Cromolyn (generic) Budesonide/Formoterol (Symbicort) Olopatadine (Pataday/Patanol) Flunisolide (Aerobid/-M/Aerospan HFA) URINARY AGENTS ANTI-INFECTIVE AGENTS ______Fluticasone (Flovent) ANTI-INFECTIVES ______Fluticasone/Salmeterol (Advair/Advair HFA) Azithromycin(AzaSite) Nitrofurantoin (generic) Mometasone (Asmanex) Chloramphenicol (generic) Sulfadiazine (generic) Ciprofloxacin (generic) Sympathomimetics ...... Sulfisoxazole (generic) Erythromycin (generic) Albuterol (generic) Trimethoprim/Sulfamethoxazole (generic) Gentamicin (generic) Formoterol (Foradil/Perforomist) CHOLINERGIC AGENTS ______Neomycin/Bacitracin/Polymyxin (generic) Isoproterenol (generic) Bethanechol (generic) Flavoxate (generic)

OTHER URINARY AGENTS ______Fesoterodine (Toviaz) Phenazopyridine (generic) Oxybutynin (generic/-XL/Oxytrol) Solifenacin (Vesicare)

Tolterodine (Detrol/-LA)

VITAMINS & ELECTROLYTES

Calcitriol (Rocaltrol) Anthem Blue Cross is the trade name of Blue Dihydrotachysterol (DHT) Cross of California. Independent Licensee of the Doxecalciferol (Hectorol) Blue Cross Association. ® ANTHEM is a Ergocalciferol (Vitamin D/generic) registered trademark. ® The Blue Cross name Ferrous Sulfate/Folate/Vit B comp/C (generic) and symbol are registered marks of the Blue

Folic Acid (generic) Cross Association. Multivitamins/Fluoride (generic) Multivits/Fe/Hematin (B-Complex Plus Express Scripts, Inc. is a separate company that Vitamin/generic) provides pharmacy services and pharmacy Vit A, C & D/Fluoride/Iron (generic) benefit management services on behalf of health Potassium Supplements (generic) plan members. WellPoint NextRx, NextRx and Prenatal Vitamins (Prenate Elite/generic) PrecisionRx are registered trademarks of WellPoint, Inc. and are used under license by Express Scripts, Inc..

MISCELLANEOUS AGENTS FABC-CA_07/10 (v1) Alprostadil (Caverject/Edex)* Bosentan (Tracleer) Etanercept (Enbrel)* Calcium acetate (generic) Cevimeline (Evoxac) Everolimus (Zortress) Lanthanum Carbonate (Fosrenol) Leucovorin (generic) Methylergonovine (Methergine) Miglustat (Zavesca) Milnacipran (Savella) Mycophenolate (generic/Cellcept) Neostigmine (generic) Pyridostigmine (generic) Sodium Polystyrene Sulfonatem (generic) Sevelamer (Renagel) (Renvela tabs)

Tacrolimus (generic) Thalidomide (Thalomid)

*Members should refer to their Member Handbook for benefit details regarding applicable copayments or coinsurance.