High-Cost Generics and Formulary Alternatives Reference Effective Date: July 1, 2017 Disease / Therapeutic Category High-Cost Non-Formulary Generics Lower Cost Generic Formulary Alternatives Acne Adapalene 0.1% Lotion Adapalene 0.1% Cream Adapalene 0.3% Gel Pump Tretinoin 0.05% Cream Tretinoin Gel Micro 0.04% Pump Tretinoin 0.05% Emollient Cream Tretinoin Gel Micro 0.1% Pump Tretinoin 0.025% Gel Tretinoin Gel Micro 0.04% Tube Tretinoin 0.025% Cream Tretinoin Gel Micro 0.1% Tube Tretinoin 0.01% Gel Tretinoin 0.05% Gel OTC Adapalene 0.1% Gel (OTC Products Not Covered) Clindamycin Phosphate Foam Clindamycin Phosphate Solution Clindamycin Phosphate 1% Gel Clindamycin Phosphate/Benzoyl Peroxide Gel or Gel Clindamycin Solution & OTC Benzoyl Peroxide (OTC Pump Products Not Covered) Clindamycin Phosphate 1% Gel Erythromycin-Benzoyl Gel Erythromycin Topical Solution Erythromycin Topical Soln & OTC Benzoyl Peroxide (OTC Products Not Covered) Sulfacetamide Sodium/Sulfur Medicated Pads Clindamycin Phosphate Solution Sulfacetamide Sodium/Sulfur Suspension Erythromycin Topical Solution Sulfacetamide Sodium/Sulfur Lotion Sulfacetamide Sodium 10% Suspension Sulfacetamide Sodium/Sulfur 10 %-5 % Foam Erythromycin Topical Gel Erythromycin Topical Solution Clindamycin/Tretinoin Gel Clindamycin Phosphate Gel 1% & Tretinoin 0.025% Gel Benzoyl Peroxide 4% Gel Benzoyl Peroxide 5% Gel Benzoyl Peroxide 8% Gel Benzoyl Peroxide 10% Gel Benzoyl Peroxide 6 % Towelette OTC Benzoyl Peroxide Wash (OTC Products Not Covered) Copyright © 2016 MedImpact, Inc. All rights reserved. This document is confidential and proprietary to MedImpact and contains material MedImpact may consider Trade Secrets. This document is intended for specified use by Business Partners of MedImpact under permission by MedImpact and may not otherwise be used, reproduced, transmitted, published, or disclosed to others without prior written authorization. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this document. High-Cost Generics and Formulary Alternatives Reference Effective Date: July 1, 2017 Disease / Therapeutic Category High-Cost Non-Formulary Generics Lower Cost Generic Formulary Alternatives ADHD/Narcolepsy Amphetamine/Dextroamphetamine ER Capsule Mixed Amphetamines IR Tablet Dexmethylphenidate ER Capsule Methylphenidate IR Tablet Dextroamphetamine ER Capsule Dexmethylphenidate IR Tablet Dextroamphetamine Tablet Methamphetamine Tablet Methylphenidate ER Capsule (Metadate CD) Methylphenidate ER Capsule (Ritalin LA) Methylphenidate ER Tablet (Concerta) Methylphenidate HCL Tablet ER (Metadate ER) Allergies Budesonide Nasal Spray OTC Fluticasone Nasal Spray (Flonase)- (OTC Products Olopatadine Nasal Spray Not Covered) Mometasone Nasal Spray OTC Azelastine Nasal Spray (Astelin) - (OTC Products Not Covered) OTC Traimcinolone Nasal Spray (Nasacort) - (OTC Products Not Covered) OTC Budesonide Nasal Spray (Rhinocort Allergy) - (OTC Products Not Covered) Desloratadine ODT OTC Loratadine (OTC Products Not Covered) OTC Cetirizine (OTC Products Not Covered) OTC Fexofenadine (OTC Products Not Covered) Zafirlukast Tablet Monteleukast Tablet Montelukast Chewable Tablet Fexofenadine-PSE Combo Tablet (Allegra D 24 Hour) OTC Fexofenadine & OTC Pseudoephedrine (OTC Products Not Covered) Alzheimer's Disease Donepezil 23 mg Tablet Donepezil 10 mg Tablet Angina Nitroglycerin Translingual Spray Nitroglycerin Sublingual Tablet Antibiotics Amoxicillin/Clavulanate ER Tablet Amoxicillin/Clavulanate IR Tablet Doxycycline Hyclate 75 mg Delayed Release Tablet Doxycycline Monohydrate 75 mg Tablet Doxycycline Monohydrate 75 mg Capsule Copyright © 2016 MedImpact, Inc. All rights reserved. This document is confidential and proprietary to MedImpact and contains material MedImpact may consider Trade Secrets. This document is intended for specified use by Business Partners of MedImpact under permission by MedImpact and may not otherwise be used, reproduced, transmitted, published, or disclosed to others without prior written authorization. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this document. High-Cost Generics and Formulary Alternatives Reference Effective Date: July 1, 2017 Disease / Therapeutic Category High-Cost Non-Formulary Generics Lower Cost Generic Formulary Alternatives Doxycycline Hyclate 100 mg Delayed Release Tablet Doxycycline Monohydrate 100 mg Capsule Doxycycline Hyclate 100mg Tablet Doxycycline Hyclate 150 mg Delayed Release Tablet Doxycycline Monohydrate 150 mg Tablet Doxycycline Monohydrate 150 mg Capsule Doxycycline Monohydrate 40 mg Capsule, Biphasic Doxycycline Monohydrate 50 mg Capsule Release Doxycycine Hyclate 20 mg Tablet (Two Tablets) Doxycycline Monohydrate 50 Mg Tablet Minocycline ER Tablet Minocycline Capsule Minocycline IR Tablet Doxycycline Hyclate 200mg Delayed Tablet Doxycycline Hyclate 100mg Tablet Doxycycline Hyclate 50mg Delayed Tablet Doxycycline Hyclate 50 mg Capsule Clarithromycin 500 mg ER Tablet Clarithromycin IR Tablets (250mg, 500 mg) Antifungals, oral Griseofulvin Ultramicrosize Tablet Terbinafine Tablet Griseofulvin Microsize Tablet Ketoconazole Tablet Voriconazole Tablet Itraconazole Tablet Antiprotozoal Tinidazole Tablet Metronidazole Tablet/Capsule Clindamycin Capsule Chloroquine Tablet Antipsychotics Olanzapine ODT Olanzapine Tablet Olanzapine/Fluoxetine Combination Capsule Olanzapine Tab & Fluoxetine Capsule Risperidone ODT Risperidone Tablet Aripiprazole ODT Aripiprazole Tablet Fluphenazine HCL Tablet Risperidone Tablet Haloperidol Tablet Paliperidone Tab ER Tablet Quetiapine Tablet Risperidone Tablet Olanzapine Tablet Aripiprazole Tablet Anxiety Alprazolam ODT Alprazolam Tablet Copyright © 2016 MedImpact, Inc. All rights reserved. This document is confidential and proprietary to MedImpact and contains material MedImpact may consider Trade Secrets. This document is intended for specified use by Business Partners of MedImpact under permission by MedImpact and may not otherwise be used, reproduced, transmitted, published, or disclosed to others without prior written authorization. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this document. High-Cost Generics and Formulary Alternatives Reference Effective Date: July 1, 2017 Disease / Therapeutic Category High-Cost Non-Formulary Generics Lower Cost Generic Formulary Alternatives Meprobamate Tablet Buspirone Tablet Asthma Levalbuterol Inhalation Solution Albuterol Inhalation Solution Carbonic Anhydrase Inhibitors Methazolamide Tablet Acetazolamide ER 500mg Capsule Acetazolamide IR Tablet Corticosteroids, Topical Low Potency Desonide 0.05% Cream [Low] Alclometasone Diprop 0.05% Cream [Low] Fluocinolone 0.01% Cream [Low] Triamcinolone Acet 0.025% Cream [Low] Desonide 0.05% Lotion [Low] Betamethasone Val 0.025% Lotion [Low] Triamcinolone Acet 0.025% Lotion [Lower-Mid] Fluocinolone Acetonide 0.01% Soln [Low] Mometasone Furoate 0.1% Solution [Medium] Corticosteroids, Topical Medium/Low Clocortolone Pivalate 0.1% Cream [Medium] Mometasone Furoate 0.1% Cream [Medium] to Medium Potency Desoximetasone 0.05% Cream [Medium] Triamcinolone Acetonide 0.1% Cream [Medium] Triamcinolone/Dimethicone 0.1%-5% Kit [Medium] Desonide 0.05% Ointment [Lower-Mid] Fluocinolone Acetonide 0.025% Ointment [Medium] Desoximetasone 0.05% Ointment [Medium] Triamcinolone Acetonide 0.025% Ointment[Lower- Hydrocortisone Butyrate 0.1% Ointment [Lower-Mid] Mid] Hydrocortisone Valerate 0.2% Ointment [Medium] Triamcinolone Acetonide 0.1% Ointment [Medium] Triamcinolone Absorbase 0.05% Ointment [Medium] Fluticasone 0.05% Lotion [Lower-Mid] Fluticasone Prop 0.05% Cream [Lower-Mid] Hydrocortisone Butyrate 0.1% Solution [Lower-Mid] Triamcinolone Acet 0.1% Lotion [Lower-Mid] Mometasone Furoate 0.1% Solution [Medium] Hydrocortisone Butyrate 0.1% Lipo Cream [Lower- Betamethasone Valerate 0.1% Cream [Lower-Mid] Mid] Fluocinolone Acetonide 0.025% Cream [Lower-Mid] Hydrocortisone Butyrate 0.1% Cream [Lower-Mid] Fluticasone Prop 0.05% Cream [Lower-Mid] Hydrocortisone Valerate 0.2% Cream [Lower-Mid] Flurandrenolide 0.05% Cream [Lower-Mid] Triamcinolone Topical Spray [Medium] Mometasone Furoate 0.1% Solution [Medium] Triamcinolone Acetonide 0.1% Cream [Medium] Triamcinolone Acetonide 0.1% Ointment [Medium] Copyright © 2016 MedImpact, Inc. All rights reserved. This document is confidential and proprietary to MedImpact and contains material MedImpact may consider Trade Secrets. This document is intended for specified use by Business Partners of MedImpact under permission by MedImpact and may not otherwise be used, reproduced, transmitted, published, or disclosed to others without prior written authorization. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this document. High-Cost Generics and Formulary Alternatives Reference Effective Date: July 1, 2017 Disease / Therapeutic Category High-Cost Non-Formulary Generics Lower Cost Generic Formulary Alternatives Corticosteroids, Topical Super Amcinonide 0.1% Cream [High] Betamethasone Diprop 0.05% Cream [High] High/High Potency Diflorasone Diacetate 0.05% Cream [High] Betamethasone Dipropionate Augmented 0.05% Cream [High] Desoximetasone 0.25% Cream [High] Fluocinonide 0.05% Cream [High] Fluocinonide 0.05% Emollient Cream [High] Triamcinolone Acetonide 0.05% Cream [High] Amcinonide 0.1% Ointment [High] Betamethasone Dipropionate 0.05% Ointment [High] Desoximetasone 0.25% Ointment [High] Betamethasone Valerate 0.1% Ointment [High] Diflorasone