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 Diacetate 0.05% Ointment [High] Fluticasone Propionate 0.005% Ointment [High] Fluocinonide 0.05% Ointment [High] Mometasone Furoate 0.1% Ointment [High] Triamcinolone Acet 0.5% Ointment [High] Amcinonide 0.1% Lotion [High] Betamethasone Diprop 0.05% Aug Lotion [Super Betamethasone Valerate 0.12% Foam [High] High] Desoximetasone 0.25% Cream [High] Fluocinonide 0.05% Cream [High] Betamethasone Diprop 0.05% Gel [High] Betamethasone Valerate 0.1% Ointment [High] Clobetasol Propionate 0.05% Solution [Super High] Fluocinonide 0.05% Gel [High] Fluocinonide 0.05% Solution [High] Clobetasol Propionate 0.05% Foam [Super High] Betamethasone Diprop 0.05% Aug Lotion [Super Clobetasol Propionate 0.05% Lotion [Super High] High] Clobetasol Propionate 0.05% Ointment [Super High] Betamethasone Diprop 0.05% Aug Ointment [Super Clobetasol Propionate 0.05% Spray [Super High] High] Clobetasol Propionate/Emollient 0.05% Foam [Super Clobetasol Propionate 0.05% Solution [Super High] High] Clobetasol 0.05% Emol Cream [Super High] Clobetasol Propionate 0.05% Gel [Super High] Halobetasol Prop 0.05% Ointment [Super High] Fluocinonide 0.1% Cream [Super High] Halobetasol Prop 0.05% Cream [Super High]

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

Clobetasol Propionate 0.05% Shampoo [Super High] Clobetasol Propionate 0.05% Solution [Super High] Fluocinonide 0.05% Solution [High] Desoximetasone 0.05% Gel [High] Fluocinonide 0.05% Gel [High] Betamethasone Diprop 0.05% Gel [High] Depression Clomipramine Capsule Amitriptyline Tablet Desipramine Tablet Doxepin Capsule Imipramine Pamoate Capsule (Tofranil PM) Nortriptyline Capsule Protriptyline Tablet Imipramine HCL Tablet Desvenlafaxine ER Tablet Venlafaxine ER Capsule Venlafaxine ER Tablet Duloxetine 40 mg Capsule Two Duloxetine 20 mg Capsule Fluvoxamine ER Capsule Fluvoxamine Tablet Nefazodone Tablet Sertraline Tablet Paroxetine Tablet Paroxetine CR Tablet Paroxetine Tablet Fluoxetine HCL Capsule DR Weekly 90 mg Fluoxetine Capsule Tranylcypromine Sulfate Tablet Phenelzine Tablet Diabetes Metformin ER Tablet (Fortamet Generic) Metformin ER Tablet (Glucophage XR Generic) Metformin ER Tablet (Glumetza Generic) Metformin IR Tablet Pioglitazone/Glimepiride Combination Tablet Pioglitazone Tablet & Glimepiride Tablet Pioglitazone/Metformin Combination Tablet Pioglitazone Tablet & Metformin Tablet Tolazamide Tablet Glimepiride Tablet Glipizide Tablet Glipizide XL Tablet Chlorpropamide Tablet Glipizide Tablet Glimepiride Tablet Miglitol Tablet Acarbose Tablet Dyslipidemia Amlodipine/Atorvastatin Combo Tablet Amlodipine Tablet & Atorvastatin 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

Fenofibrate 150 mg Capsule (Lipofen) Fenofibrate 54 mg, 160 mg Tablet (Lofibra) Fenofibrate Micronized 43 mg, 130 mg Capsule Fenofibrate, Nanocrystallized 48 mg, 145 mg Tablet (Antara) (Tricor) Fenofibrate 40mg, 120 mg Tablet (Fenoglide) Fenofibrate 50 mg Capsule (Lipofen) Fluvastatin Capsule Pravastatin Tablet Fluvastatin Sodium ER 80mg Tablet Simvastatin Tablet Atrovastatin Tablet Rosuvastatin Omega-3 Acid Ethyl Esters Capsule Pravastatin Tablet Simvastatin Tablet Fenofibrate 54 mg, 160 mg Tablet (Lofibra) Fenofibrate, Nanocrystallized 48 mg, 145 mg Tablet (Tricor) Ear Infections Acetic Acid/Hydrocortisone 2 %-1 % Drops Neomy Sulf/Polymyx B Sulf/HC Drops Gastroesophogeal Reflux Disease Famotidine Oral Suspension Cimetidine Solution Ranitidine Syrup Famotidine Tablet Omeprazole/Sodium Bicarbonate Omeprazole OTC & OTC Antacids (OTC Products Not Covered) Gastrointestinal (GI) Agents Mesalamine Dr Tablet 800 mg (Asacol HD) Balsalazide 750 mg Capsule Mesalamine Kit W/Cleansing Wipes Mesalamine 4 G/60 Ml Enema Budesonide EC 3 Mg Capsule Methylprednisolone Tablet Sulfasalazine 500 Mg Tablet Sulfasalazine 500 Mg DR Tablet Glaucoma Bimatoprost Drops Latanoprost Drops Travoprost Drops Timolol Ophthalmic Gel-Solution Timolol Ophthalmic Drops

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

Glucocorticoids Prednisolone Sodium Phosphate ODT Tablet (Orapred Prednisolone Solution (Prelone) ODT) Prednisolone Sodium Phosphate Solution (Orapred) Prednisone Tablet Hemorrhoids Hydrocortisone Acetate/Lidocaine Kit Hydrocortisone Acetate/Lidocaine Rectal Cream 3- 0.5% Hydrocortisone Acetate/Lidocaine/Aloe Vera Kit Hydrocortisone Acetate/Lidocaine/Aloe Vera Gel (2.8- 9.55%) Hyperparathyrodism Doxercalciferol Capsule Calcitriol Capsule Paricalcitol Capsule Hypertension Amlodipine/Valsartan/HCTZ Combo Tablet Amlodipine Tablet & Valsartan/HCTZ Tablet Amlodipine/Valsartan Combo Tablet & HCTZ Candesartan Tablet Valsartan Tablet Losartan Tablet Candesartan/HCTZ Combo Tablet Valsartan/HCTZ Combo Tablet Telmisartan/HCTZ Combination Tablet Losartan/HCTZ Combo Tablet Captopril Tablet Lisinopril Tablet Benazepril Tablet Ramipril Tablet Diltiazem ER Tablet Diltiazem ER 24 HR Capsule 120, 180, 240, 300, 360 mg Eplerenone Tablet Spironolactone Tablet Nadolol Tablet Atenolol Tablet Carvedilol 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

Nisoldipine ER Tablet Amlodipine Tablet Diltiazem IR Tablet (Cardizem) 30, 60, 90, 230 mg Nifedipine Tablet (Adalat CC) Nifedipine Tablet (Procardia XL) Nifedipine Tablet (Procardia) Verapamil Tablet (Calan SR) Verapamil Tablet (Calan) Verapam Capsuleil (Verelan PM) Verapamil Capsule (Verelan) Telmisartan/Amlodipine Combination Tablet Telmisartan & Amlodipine Tablet Valsartan Tablet & Amlodipine Tablet Metoprolol Tartrate 37.5mg, 75mg Tablet Metoprolol Succinate 24H Tablet Metoprolol Tartrate 50 Mg Tablet Metoprolol Tartrate 100 Mg Tablet Trandolapril/Verapamil HCL Tablet Trandolapril Tablet & Verapamil Tablet Metoprolol Succinate/HCTZ Combo Tablet Bisoprol/HCTZ Combo Tablet (Dutoprolol) Metoprolol Tartrate/HCTZ Combo Tablet (Lopressor HCT) Metoprolol Succinate 24H Tablet & HCTZ Tablet/Capsule Propranolol/HCTZ Combo Tablet Lice Treatments Malathion Lotion Lindane Lotion Spinosad Suspension Permethrin 5% Cream Migraine/Other Headaches Butalbital/APAP/Caffeine 50-300-40 Capsule Butalbital/APAP/Caffeine 50-325-40 Tablet Zolmitriptan Tablet Sumatriptan Tablet Zolmitriptan ODT Rizatriptan Tablet Almotriptan Maleate Tablet Frovatriptan 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

Muscle Relaxants Metaxalone Tablet Methocarbamol Tablet Tizanidine Capsule Chlorzoxazone Tablet Baclofen Tablet Cyclobenzaprine Tablet Tizanidine Tablet Nausea/Anorexia Dronabinol Capsule Ondansetron Tablet Megestrol Tablet Megestrol Solution Granisetron HCL Tablet Ondansetron Tablet Metoclopramide ODT Metoclopramide Tablet Nonsteroidal Anti-inflammatory Drugs Bromfenac Opthalmic Solution Ketorolac Tromethamine Opthalmic Drops (NSAIDs), Ophthalmic Diclofenac Sodium Opthalmic Solution Nonsteroidal Anti-Inflammatory Drugs Diclofenac Sodium 1.5% Topical Solution Meloxicam Tablet (NSAIDs), Topical, Oral Diclofenac Gel 3% Diclofenac Sodium Delayed Release 50 mg , 75mg Etodolac ER Tablet Tablet Fenoprofen Capsule Sulindac Tablet Ketoprofen ER Capsule Nabumetone Tablet Meclofenamate Sodium Capsule Naproxen Tablet (Naprosyn) Mefenamic Acid Capsule Naproxen Tablet DR (EC-Naprosyn) Oxaprozin Tablet Diclofenac Sodium 24 HR Tablet Tolmetin Sodium Tablet Ibuprofen Tablet Indomethacin Capsule Diclofenac Sodium /Misoprostol Combination Tablet Diclofenac Sodium Tablet & Misoprostol Tablet Opioid Analgesics Fentanyl Transdermal Patch 37.5mcg/hr, 62.5 Fentanyl Transdermal Patch 12 mcg/hr, 25mcg/hr, mcg/hr, 87.5mcg/hr 50mcg/hr, 75mcg/hr Oxycodone HCL Oral Solution 25mg/ml Morphine Sulfate Solution Oxycodone Capsule Hydrocodone/APAP 5 mg-300 mg Tablet (Vicodin) Hydrocodone/Acetaminophen 5mg-325mg Tablet (Norco)

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

Hydrocodone/APAP 7.5 mg-300 mg Tablet (Vicodin) Hydrocodone/APAP 7.5 mg-325 mg Tablet (Norco) Hydrocodone/APAP 10 mg-300 mg Tablet (Vicodin) Hydrocodone/APAP 10 mg-325 mg Tablet (Norco) Osteoporosis Etidronate Tablet Alendronate Tablet Risedronate Tablet Alendronate 70 mg Tablet Alendronate Tablet Overactive Bladder (OAB) Agents Tolterodine ER Capsule Oxybutynin IR Tablet Tolterodine Tablet Oxybutynin ER Tablet Trospium ER Capsule Skin Conditions Urea 39 % Cream (G) Urea 40 % Cream Urea 50 % Cream Oxiconazole Nitrate 1% Cream Clotrimazole 1% Cream Naftifine Cream Ciclopirox 0.77% Cream Ketoconazole 2% Cream OTC Terbinafine HCL 1% Cream (OTC Products Not Covered) Ciclopirox 0.77% Gel Ciclopirox 0.77% Cream Econazole Nitrate 0.01% Cream Clotrimazole 1% Cream OTC Terbinafine HCL 1% Cream (OTC Products Not Covered) Ciclopirox 1% Shampoo Ketoconazole 2% Shampoo Sulfacetamide Sodium 10% Shampoo OTC Ketoconazole 1% Shampoo (OTC Products Not Selenium Sulfide 2.25 % Shampoo Covered) Clotrimazole/Betamethasone 2 % - 0.05% Lotion Clotrimazole/Betamethasone 1 % - 0.05% Cream Nystatin/Triamcinolone Cream Nystatin/Triamcinolone Ointment Salicylic Acid/Ceramides Kit Cleanser & Cream Salicylic Acid Gel Mupirocin Calcium Cream Mupirocin Ointment Doxepin 5% Cream OTC Diphenhydramine Cream (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

Ciclopirox 8 % Sol (Ciclodan Generic) Ciclopirox 8 % Sol (Penlac Generic) Metronidazole 1% Gel Metronidazole 0.75% Gel Metronidazole 0.75% Cream Ketoconazole Topical Foam Ketoconazole 2% Shampoo Ketoconazole 2% Cream Testosterone Replacement Fluoxymesterone Tablet Testosterone Enanthate Vial Testosterone Gel /Gel Packet Testosterone Cypionate Vial Testosterone Gel Pump Topical Local Anesthetics Lidocaine Ointment 5% Lidocaine Cream 3% Urinary Analgesics/Antispasmodic Methenamine/Hyoscyamine 81-0.12 mg Combination Methenamine/Hyoscyamine 120-0.12 mg Agents Tablet (Urelle) Combination (Ustell) Tablet Methenamine/Hyoscyamine 81.6-0.12 mg Methenamine/Hyoscyamine 81.6-10.8 mg Combination Tablet (Hyophen Combination Tablet (Utira-C) Methenamine/Hyoscyamine 81.6-.12 mg Combination Tablet (Urogesic-Blue) Methenamine/Hyoscyamine 120-40.8 mg Combination Tablet (Indiomin MB) Urinary Tract Infection Nitrofurantoin Oral Suspension Nitrofurantoin Macrocrystal Capsule Xerostomia Cevimeline Capsule Pilocarpine 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.