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Drug Exclusions October 1, 2020

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 10/1/20 1

Excluded Drug List Specialty drugs are noted with a (#). A Aspergillus Fumigatus Bupivacaine HCL Colcrys (brand) E Abilify (brand) Aspirin/Omeprazole Butalbital/APAP 50/300 Conjupri Nitrate- Abilify Mycite Atacand/HCT (brand) Bynfezia Pen Consensi Niacinamide Cream Absorica/LD Ativan (brand) Byvalson Conzip (brand) Edecrin (brand) Atopiclair Cordran Acanya C Edex Aciphex Atralin Cortaid max. strength EES granules Acnefree Atrapro spray/gel/kit Cafergot tablet Cotempla Effexor XR (brand) Acticlate (brand & gen.) Aurstat Calcipotriene- Crysvita (#+) Efudex (brand) Acuicyn Austedo (#) Betamethasone Cuprimine Elestrin (brand) Aczone 5% (brand) Auvi-Q Calcipotriene-Clobetasol Cutaquig (#) Eletone Adagen (#) Avar (brand) Propionate Cuvitru (#+) Emflaza (#) Adakveo (#) Aveed (brand) Caldolor Cyclobenzaprine ext rel Endari Adapalene-Benzoyl Avenova Cambia Cyfolex Enstilar Peroxide- Avsola (#) Candida Albicans Extract Cymbalta (brand) Entty Spray Emulsion Gel Azelex (brand) Caplyta Cytomel (brand) Envarsus XR (#) Adapalene-Benzoyl Azesco Carac (brand & generic) Epaned (brand) Peroxide- Azor (brand) Carbinoxamine 6 mg D Epiceram Niacinamide Gel Azelaic Acid-Niacinamide Cardizem CD/LA (brand) D.H.E. (brand) Epicoccum Nigrum Adderall (brand) Cream Carnitor/SF Daklinza (#) EpiPen/EpiPen Jr. Adhansia XR Azeschew Carospir Dandelion Allergenic Ext. (brand) Carteolol Ophthalmic Adlyxin B -Niacinamide EryPed susp. 200 & 400 Admelog Celacyn Gel mg Adzenys XR Baclofen 5 mg Cequa Dapsone-Niacinamide- Esomeprazole Aemcolo Balcoltra Ceracade Gel Esperoct (#) Aerospan Baxdela Cerave Daxbia esterified Afstyla (#) Beau Rx Cetrotide (#) Dayvigo estrogen/methyl- Airduo Belbuca Cholecal DF Defitelio (#) testosterone Ajovy Benicar/HCT (brand) Chorionic Deflux Eucrisa Aklief Bensal HP Gonadotropin (#) Delstrigo Eurax lotion Alavert Benz Per-Clindamycin- Chlorzoxazone 250 mg Denavir Evekeo/ODT (brand) Alcortin A Niacinamide- Cicatrace Pad Dermatop (brand) Evenity (#) Aldara (brand) Tretinoin Gel Ciclopirox-Clobetasol Desloratadine Evivo Alevicyn Antipruritic/ Benzaclin (brand) Shampoo Desowen Evomela (#+) Plus Benzamycin (brand) Ciclopirox-Clobetasol- Dexchlorpheniramine Evrysdi (#) Allegra/Allegra-D Benzepro (brand) Shampoo syrup Exondys 51 (#) Allzital Benzocaine-Lidocaine- Ciclopirox-Salicylic Acid Dexeryl Ezallor Aloquin Tetracaine Oint Shampoo Dexilant Alora (brand) Benzhydrocodone/ Ciprofloxacin/Fluocinol Dexpak F Altoprev (brand) Acetaminophen one Otic Dextenza (#) Fasenra (#+) Altreno Benzonatate 150 mg Cimetidine-Lidocaine- Dexycu Fenoglide (brand) Alvesco Beovu (#) Salicylic Acid Cream Diclegis (brand and gen.) fenoprofen (generic) Alzair Betamethasone Cinqair (#+) Diclofenac caps Fenortho (brand) Ameluz Dipropionate- Clarinex/Clarinex-D Diclofenac Sodium- Fetroja Amphetamine ER Susp Claritin/Claritin-D Sodium Hyaluronate- Fexofenadine Amrix (brand) Betapace/AF tablet Clenpiq Niacinamide Gel fexofenadine- Amzeeq Bevacizumab prefilled Clindagel Diclofono pseudoephedrine Andexxa syr. (#) Clindamycin Phos- Diflorasone cream and -Minoxidil Androgel 1.62% (brand) Bevyxxa Niacinamide- oint. Firdapse (#) Android-10 (brand) Biafine Tretinoin Cream Dimercaptopropane- First Atenolol Annovera Bijuva Clindamycin Phosphate- Sulfonate suspension Antara (brand) Binosto (brand) Niacinamide Lotion Diuril First-Lansoprazole Apadaz Bionect 1-4% Divigel (brand) (excluded only for Aplenzin Bocasal oral rinse Clindamycin Phosphate- Doptelet (#) members 17 years Apligraf (#) Bonjesta Niacinamide Gel Doryx/MPC (brand) and older) Aptensio XR (brand) Bortezemib (#) Clindamycin-Benzoyl Doxepin cream/tabs First-Omeprazole Arakoda (#) Bravelle (#) Peroxide-Niacinamide Doxycycline DR 80mg (excluded only for Arazlo Breztri Aerosphere Gel Drizalma members 17 years Arestin Brineura (#) Clindamycin-Niacinamid- Duaklir and older) Arikayce (#) Briviact Spironolac-Tretinoin Duexis Flolipid Armonair Digihaler Bromsite Gel Duobrii -Ibuprofen- Armonair Respiclick Brukinsa (#) Clobetasol Propionate- Dutoprol - Arymo ER Bryhali Levocetirizine Dihyd Duzallo Asacol HD (brand) Budesonide/Formoterol Shampoo Dxevo Fluocinolone Asceniv (#) Bunavail (brand) Clobetasol Propionate- Dyanavel XR (brand) Acetonide- Asparlas (#) Bupap (brand) Niacinamide Dyrenium capsule Niacinamide Cream Cream/Oint/Soln

Drug Exclusions List – Effective 10/1/20 2 Fluocinonide 0.1% I L Migranal (brand) Noctiva cream IBU 600-EZS Lactinol HX Millipred/DP Noritate Fluorouracil cream 0.5% Idelvion (#) -Niacinamide Minastrin 24 FE (brand) Nourianz Fluoroplex (brand) Idhifa (#+) Cream Minitran (brand) Novacort Fluticasone/salmeterol Ilumya (#) Lactulose oral packet Minivelle (brand) Novarel (#) inhaler Iluvien (#) 10gm Minocin (brand) Novolin Relion Folene Imiquimod- Lanoxin 125 & 250 mcg Minocycline ER caps Nubeqa (#+) Folika-V Levocetirizine Dihcl- tablet Minolira ER Nucala (#+) Folite Niacinamide Gel Lansoprazole Minoxidil-Progesterone- Nuplazid (#+) Follistim AQ (#) Imiquimod- Lazanda Tretinoin Nurtec ODT Folvite-FE Levocetirizine Dihcl- Ledipasvir/Sofosbuvir Mircera (#) Nutraderm Forfivo XL (brand) Tretinoin Gel Levicyn dermal spray Mitigare (brand) Nutraplus Fortamet (brand & gen.) Imitrex (brand) Levitra Monodox (brand) Nutraseb Fulphila (#+) Imlygic (#) Levorphanol Mondoxyne (brand) Nuvail Fungoid-D Imogam (#) Levulan Kerastik Morgidox (brand) Nuvigil (brand) Morphabond ER Nuwiq (#+) G Impoyz (brand) Imvexxy Lexapro (brand) Moxatag (brand) Nuzyra Gamifant (#) Mugard (#) Inbrija Lexette O Ganirelix AC (#) Inderal LA Lialda (brand) Mulpleta (#) Gatifloxacin Indocin caps./supp./ Librax (brand) Mupirocin cream Ocaliva (#+) dexamethasone susp. Libtayo (#) Mvasi (#+) Ocean for Kids Gelclair Gel Odactra Indomethacin Licart Mydayis Genadur Lidocaine-Tetracaine Mylotarg (#) Ogivri (#) Genvisc (#+) Infugem (#) Olumiant (#) Ingrezza (#) Cream N Giazo (brand) Lidocaine cream 4.12% Olysio (#) Gimoti Innopran XL Nabi-HB (#) omeprazole (OTC only) Inrebic (#+) Lidoderm (brand) Gloperba Lidotrex (lidocaine) Nalfon (brand) omeprazole/sodium Glumetza (brand & Intrarosa Nandrolone decanoate bicarbonate Intuniv (brand) 2% gel generic) Lipofen (brand) naproxen/ Onexton Glycopyrrolate 1.5mg Inveltys esomeprazole Onzetra Iodoquinol- Locoid (brand) Gocovri Lodrane D Naproxen sodium ER Opana ER GPL Pak Hydrocortisone- (generic Naprelan) Oracea (both brand & Cream Lokelma (#) Gralise (brand) Lonhala Nascobal generic doxycycline Grastek Ionil liquid Nasonex (brand) (Rosacea) delayed Ivermectin- Loprox (brand) Gvoke PFS Loyon Nayzilam release capsules are - Neocera excluded) H Niacinamide Gel Lucemyra Lumoxiti (#) Neosalus/CP Oravig Hemady J Lunesta (brand) Neutrasal Ortikos Hemlibra (#) Nevestym Osmolex ER Jatenzo Luradrox gel Herzuma (#) Lutathera (#) Nexium Otiprio Horizant (brand) Jivi (#+) Nexletol Otovel Jornay PM Luxturna (#) HPR Plus Luzu Niacinamide- Ovace Plus/Wash (brand) HPR Plus MB Hydrogel Jublia Spironolactone Gel Ovidrel (#) Juluca Lyrica CR Kit Lyumjev Niacinamide- Oxbryta (#) Hyaluronate Sodium- Jynarque (#) Spironolactone- Oxervate (#) Niacinamide- K M Tretinoin Gel Oxtellar XR (brand) Niacinamide- Ozobax Kadian (brand) Macrilen (#) Hyaluronate Sodium- Macrodantin capsules Sulfacetamide Sodium Niacinamide- Kamdoy Niacinamide-Tacrolimus P Kanjinti (#+) Mavenclad (#) Tretinoin Mayzent (#) Oint Palforzia (#) Hycofenix (brand) Kapspargo Niacinamide- Palynziq (#) Katerzia Menopur (#) Hydrisalic Mepsevii (#) Triamcinolone Panzyga (#) Hydrocodone 2.5mg/ Kedrab (#) Acetonide Cream Parsabiv (#) Kelarx (silicone) Scar Metformin ER (only guaifenesin 200mg excluded when Niacinamide-Tazarotene Pennsaid 1.5% & 2% sol. hydrocortisone 1% in Care Gel Cream Pepcid (brand) Kerydin prescribed as a asorbase generic for brand Niacinamide-Tretinoin Pexeva (brand) Ketoconazole 2% foam Cream/Gel Phenobarbital/Belladonna Ketoconazole- Fortamet or brand Emulsion Glumetza) Niacinamide- Alkaloids Hydroquinone- Hydrocortisone Spironolactone- Phenol Cream Methionine-Inos- Hydrocortisone Choline-Levocarn Tretinoin Gel Pifeltro Emulsion Ketamine HCL Nilandron Piqray (#+) Ketodan Methylcobala Hydroquinone- Methylphenidate 72 mg Nilutamide Plaquenil (brand) Hydrocortisone- Ketorolac spray Nitro-Dur (brand) Plavix (brand) Keveyis (#) ER Tretinoin Emulsion Miacalcin injection/ Nitroglycerin lingual Plenvu Hylatopic Plus Khapzory (#) (brand) Plexion/Cleanser (brand) Kinerase nasal spray Hymovis (#+) Micort Nitrolingual Polivy (#) Hyperhep B (#) Klor-Con oral pack for Nitromist Portrazza (#) solution Microvix LP Hyperrab (#) Midaz/ketamine troche/ Nityr (#) Praluent (#) Hyperrab S/D (#) Kovaltry (#+) Nivatopic Plus Pred-Gati Krintafel ondansetron Midazolam Nivestym (#+) Prednisone Intensol Kymriah (#) Nocdurna (#) (brand)

Drug Exclusions List – Effective 10/1/20 3

Pregenna Reyvow Striant (brand) U X Prenara Rexaphenac (brand) Sublocade Ubrelvy Xadago Prenatal 19 Rhofade cream Sumadan wash (brand) Udenyca (#) Xanax/XR (brand) Pretomanid Rhopressa Sumaxin (brand) Ultomiris (#) Xaquil XR Prevacid Riomet ER Sunosi Ultravate lotion Xatmep (#+) Prevymis (#) Rocklatan Symdeko (#) Uplizna Xcopri Prilopentin Roxybond Symjepi Upneeq Xelpros Prilosec Rozlytrek (#+) Sympazan Uroxatral tablet Xembify (#) Primlev Ruxience (#) Symproic Utibron Neohaler Xenazine (brand) Pristiq (brand) Ruzurgi (#) Symtuza Xenleta Probuphine Rybelsus Synderderm V Xepi Procentra (brand) Rynoderm Syndros Vabomere Xerese Progesterone- Synera (brand) Valium (brand) Xhance Minoxidil S T Valtoco Ximino Prolate S2 Valtrex (brand) Xofluza Prolensa Salex (brand) Taclonex Vanatol LQ (brand) Xopenex HFA Promiseb Salicylic Acid-Sulfaceta- Tacrolimus Cream Vanos (brand) Xpovio Pak Protexa mide Sodium Takhzyro (#+) Vanoxide-HC lotion Xtampza ER Prothelial(#) Salisol Talicia Varizig (#) Xultophy Protonix Salivamax Targadox (brand) Varubi Xuriden (#) Proventil HFA Scarcin Gel Tasigna (#+) Vaseretic (brand) Xvite Provigil (brand) Scarsilk gel/pad Tavalisse (#) Vasotec (brand) Xyosted Prozac (brand) Scenesse (#) Technivie (#) Veltassa (#) Pulmicort Respules Sebuderm Tegsedi (#) Vemlidy (#) Y (brand) Secuado Tepezza (#) Ventavis (#+) Ybuphen Pyridostigmine tablet Segluromet Testopel (brand) Ventolin HFA Yescarta (#) 30mg selenium sulfide Tetravex gel Verdeso foam 0.05% Yonsa (#+) Pyridoxal-5 Phosphate shampoo 2.25% Tetrix (brand) Yosprala Pyrimethamine- Semglee Thiola EC Veregen ointment Yupelri Leucovorin Sernivo Tiazac (brand) Vexasyn gel Yutiq (#) Seroquel/XR (brand) Tibsovo (#+) Q Viagra Seysara Ticalast Vibramycin (brand) Z Qbrexza pad Siklos (#) Tiglutik (#) Viekira Pak/XR (#) Zalvit Qmiiz ODT Silenor (brand) Tirosint capsule/ Vimovo Zavara Qtern Siliq (#+) solution Visco-3 (#) Zegerid (brand & generic) Quartette (brand) Sil-K Pad Tivorbex (brand) Visbiome Zelac Qudexy XR (brand) Simvastatin Tobi solution (brand) Vitafol strips Zembrace Quillichew ER (brand) Singulair (brand) Tolak (brand) Vitafol FE+ Zenzedi (brand) Quillivant XR (brand) Sitavig Tolsura Vitasure Zepatier (#) Qutenza (#) Sitzmarks Topicort Spray Vitrase Zepzelca Quzyttir Slynd Tosymra Vivlodex Zerviate Sodium Hyaluronate- Trazimera (#) R Vizimpro (#+) Zetia (brand) Hydroquinone Trelegy Ellipta Voltaren gel (brand) Ziana (brand) Rabeprazole Emulsion Trezix (brand) Vonvendi (#) Ziextenzo (#) Ragwitek Sofosbuvir/Velpatasvir Trianex oint. 0.05% Vosol HC Zilretta (#) Rayaldee Solaravix (brand) VP-Vite Rx Zilxi Rayos (brand) Solaraze (brand) Tridesilon (brand) VSL#3 Zinbryta (#+) Rebinyn (#) Solesta (#) Triglide (brand) Vtol LQ Zinc Sulfate Reblozyl (#) Soliqua Trijardy XR Vumerity (#) Zinplava Recarbrio Solodyn Trikafta (#) Vyepti Zipsor (brand) Recedo Solosec Trimo-San gel Vyleesi Zirabev (#) Red Algae Sovaldi (#) Trinaz Vyndaqel (#) Zofran/ODT (brand) Relafen DS Spinraza (#+) (excluded Triptodur (#) Vyndamax (#) Zolgensma (#) Relexxii under the pharmacy Trivisc (#) Vyondys 53 Zoloft (brand) Relistor injection/ benefit; covered Trogarzo Vytorin (brand) Zolpimist tablets under the medical Trokendi XR Vyxeos (#) Zonegran 25 & 100 mg Remedient benefit) Tronvite Vyzulta caps Remodulin (#) Spravato Trop-Phenyl Zorvolex (brand) Renflexis (#+) Sprix (brand) Trulance W Zovirax Resveratrol Staxyn Truxima (#) Wakix Zuplenz (brand) Retacrit (#) Steglatro Turalio (#+) Wellbutrin SR/XL (brand) Zurampic Retin-A/Micro (brand) Steglujan Tussicaps (brand) Wixela Inhub Zyclara Revcovi (#) Stendra Tuxarin ER Zyflo CR (brand) Revesta Strattera (brand) Twirla Zypitamag Tymlos (#+) Zyrtec/Zyrtec-D

Drug Exclusions List – Effective 10/1/20 4

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. /alum cormax scalp neomycin/polymyxin/ proparacaine hcl tobramycin/ acetate application dexamethasone salactic film dexamethasone albuterol sulfate cromolyn sodium neomycin/polymyxin/ sal-plant tropazone anusol-hc cyclopentolate hcl gramicidin sulfacetamide sodium tropicamide atropine sulfate dorzolamide hcl/ opium sulfacetamide sodium/ ureacin bacitracin/neomycin/ timolol m pedi-boro soak pads prednisolone polymyxin flunisolide pedi-dry sulfacetamide sodium/ bacitracin/polymyxin b flurbiprofen sodium phenylephrine hcl sulfur tartrate latanaprost podofilox tetracaine hcl carteolol hcl levobunolol hcl polymycin b sulfate/ timolol maleate castellani paint trimethoprim ophthalmic 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 gelatin Gummy Cetaphil moisturizing Dimercapto-1- First-Omeprazole 2-Deoxy-D-Glucose Troche cream Propanesulfo First-Progester-One Vgs 5-Fluorouracil Base X Cetyl Myristoleate Dimercaptosucc-Inic 10/ 20/50 5-Methyltetra- Base-Pcca Mbk (Fatty Cherry syrup Acid First-Testosterone/Mc Hydrofolate Acid) Dimethyl Sulfoxide First-Vancomycin 25/50 5-Methyltetra- Beclomethasone Cholesterol Doxepin HCL Flavor blend Hydrofolic A Dipropiona Chorionic Gonadotropin Doxycycline Hyclate Flavor Plus 7-Keto DHEA Benzocaine Chrysaderm Day Drcaps size 1 clear Flavor Sweet-SF Benzoin compound Cimetidine Fluconazole E A tincture Ciprofloxacin HCL Fluocinonide Acacia Benzyl alcohol Citric Acid Anhydrous Edetate Disodium Fluorouracil Acetone Betahistine HCL/ Clindamycin HCL/ Dihydrat Flurbiprofen Acetyl Hexapeptide-8 Dihydrochlori Monohydra EGCG F-Melt Acidophilus Betamethasone Sodium Clindamycin Phosphate Emollient cream/base Freedom Derma-N Lactobacillus Phos Clobetasol Propionate/ Empty capsule, all sizes Freedom Poloxitol Albendazole Bethanechol Chloride Micronized & colors G Almond oil, sweet BHRT base Emu oil Alprostadil Biotin Coal Tar Erythromycin Gabapentin Amitriptyline HCL Bitter drug powder Cocaine HCL Ethylsuccina Gentamicin Sulfate Boric Acid Cocoa butter Estradiol/Micronized/ Glutamine Apple flavor Bromfenac Sodium Coenzyme Q10 Valerate Glutathione-L Arbem H-Cosmetic Budesonide Copasil Estriol/Micronized Glycerin Ascorbic Acid Bupropion HCL Corn oil Ethoxy Diglycol Glycolic Acid Aspirin Curcumin Ethyl Alcohol Glycopyrrolate C Auxipro Plasticized Cyanocobalamin Ethyl Oleate Grape flavor Cannabidiol Guaifenesin Avicel Ph 105 Cyclobenzaprine HCL F Microcrysta Capsublend-P Gum base gelatin Capsule Clear Veggie Lo D Fagron Capfill Pro/ Azithromycin H (All) Dehydroepiandroster- Dispersapro/ B Capsule Coni-Snap (All) one Supreme cream Hormone cream base Baclofen Carboxymethylcellu- Dermabase Fattibase Botani Bacteriostatic Water lose So Dexamethasone/ Fattyblend Hrt base (All) Banana creme flavor Carnitine (L) Acetate Anh/Sodium Ferulic Acid Hrt Natural/Supreme Base C Polyethyl-Ene Celecoxib Phos First-Baclofen 5 cream base Glyco Cellulose Microcrystallin Diazepam First-Dukes mouthwash Sodium Sa Base cream with Cellulose/Cmc Na Dichloralphen-Azone First-Lansoprazole Hydrocodone Bitartrate Liposome Microcry Diclofenac Sodium First-Metronida-Zole 50 Hydrocortisone/ Diltiazem HCL First-Mouthwash Blm Acetate/ Micronized

Drug Exclusions List – Effective 10/1/20 5

Hydrogel L-Thyroxine Sodium P Polypeg suppository Supposibase F Hydromorphone HCL Lugols Palmitoyl base Suspendit Hydroquinone Povidone-Iodine Synapsin M Pentapeptide-3 Hydroxyethyl Cellulose Papaverine HCL Praziquantel Syrspend SF/Alka Magnesium Glycinate 45 Paraffin Pregnenolone/ Mannitol T Hydroxyprogester-One PCCA Anhydrous micronized Marshmallow flavor Tamoxifen Citrate Capro Lipoderm B Prilocaine HCL Mediderm Hydroxypropyl PCCA cosmetic HRT base Progesterone/Microniz Medi-Rdt base Terbinafine HCL Cellulose 1/ PCCA custom Lipo-Max ed/Ultra Micronized Medium Chain Testosterone/ Methylcellu PCCA DMAE complex Progesterone wettable Triglyceride Cypionate Hydroxyurea PCCA emollient cream Promethazine HCL Melatonin Testosterone Hypromellose base Propylene Glycol Mercaptopurine micronized/S/Y Methocel K1 PCCA Emulsifix-205 base Prostaglandin E1 Monohydrat Testosterone non- PCCA fixed oil base Purified water I Metformin HCL micronized PCCA gelatin base Pyrantel Pamoate Ibuprofen Methocel E4m Premium Testosterone PCCA Lecithin Isopropyl Pyridoxal-5-Phosphate Imiquimod Methscopolamine Propionate P Mon Isometheptene Mucate Bromide Tetracaine/HCL PCCA Lipoderm base/ Itraconazole Methylcellulose Q Tetracycline HCL HMW Ivermectin Methylcobalamin Quinacrine HCL Thymol PCCA Loxasperse base Methyltestosterone Quinine Sulfate Thyroid Porcine J PCCA Natacream Metoprolol Tartrate Dihydrate Tobramycin/Sulfate PCCA plasticized base N/A Metronidazole/ Tofacitinib Citrate PCCA Pluronic F127 R Benzoate Topiramate K base /Nitrate Ranitidine HCL Tramadol HCL Ketamine HCL PCCA Polyglycol Troche Midazolam Resveratrol 98+% Transdermal pain base Ketoconazole PCCA Pracasil Tm-Plus Mineral oil light Tretinoin Ketoprofen/Micronized/ base S Mometasone Furoate Triamcinolone Ultra Micronized PCCA rapid-dissolve Salicylic Acid Morphine Sulfate Acetonide Ketotifen Hydrogen tablets Salt durable cream Mucolox Troche base Fumara PCCA Sorbitol lollipop Salt Stable Lo/Ls Mupirocin Tutti Frutti flavor Kinetin base Advanced PCCA Spira-wash base Sermorelin Acetate L N U Nabumetone PCCA Sweet-SF Sesame oil Ubiquinol Lactic Acid Naltrexone HCL/ PCCA syrup vehicle Sildenafil Citrate Ursodiol Lactose/Anhydrous Anhydrous PCCA T3 Sodium Dilution Silica gel Lactose Monohydrate/ V Natapres PCCA T4 Sodium Simethicone spray Niacinamide Dilution Simple syrup Vancomycin HCL Lanolin Anhydrous Nifedipine PCCA vanishing cream/ Sirolimus Verapamil HCL Lansoprazole Nourivan Antiox cream light/ lotion Sodium Bicarbonate Versabase/foam L-Arginine base PCCA Vanpen base Sodium Chloride/ Versapro Leucovorin Calcium /Foreign PCCA Xylifos base Bacterios Versatile cream base Leuprolide Acetate PCCA -Plus Sodium Hyaluronate W Levofloxacin O Penderm Sodium Metabisulfite Hemihydrate Ointment base Pentravan/Plus Solu-K gel Watermelon flavor L-Glutamine emulsifying Peppermint oil Sorbitol Wax paraffin beads Lidocaine/HCL Olive oil Phentermine Spg Supposi-Base White Petrolatum Liothyronine Sodium Omeprazole Hydrochloride Spironolactone Wiley Basic Elements Lipmax Ondansetron HCL Phentolamine Mesylate Sterile water for BHRT Lipopen/Absorption Dihydrate Phytobase injection Witepsol H15/Base F Enhanc Ora-Blend/SF Plo Gel – Mediflo pre- Stevia extract X Lipopen Ultra/base Oral mix flavored susp. Steviol Glycosides mix Xylitol L-Methylfolate Calcium Oral suspension Pluronic F127 Succimer DMSA Lollibase Ora-Plus Polox Sucralfate Y Lollipop base Ora-Sweet/SF Polyethylene Sulfacetamide Sodium Yellow Petrolatum Lorazepam Oxycodone HCL Glycol/blend/ Sulfadiazine Loxoral base Oxytocin 300/400/1450/3350 Sulfamethoxazole Z Lozibase S Sulfapyridine N/A

Drug Exclusions List – Effective 10/1/20 6

Topical Product Exclusions Topical Pain Formulations Excluded Product Categories and Examples Formulary Alternatives Camphomex (CAMPHOR-HISTAMINE-MENTHOL-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 10/1/20 7

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) • Chlorhexidine 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 10/1/20 8