Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 1

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

amphetamine salt combo er armodafinil atomoxetine hcl benzphetamine hcl caffeine citrated caffeine/sodium benzoate [INJ] clonidine hcl er dexmethylphenidate er dexmethylphenidate hcl dexmethylphenidate hcl er dextroamphetamine sulfate dextroamphetamine sulfate er diethylpropion hcl guanfacine er methamphetamine hcl methylphenidate cd methylphenidate er methylphenidate hcl methylphenidate hcl er (cd) methylphenidate la modafinil MYDAYIS phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl VYVANSE

AMINOGLYCOSIDES AMIKACIN [INJ] BETHKIS gentamicin sulfate gentamicin sulfate [INJ] gentamicin sulfate in ns KITABIS PAK neomycin sulfate paromomycin sulfate tobramycin sulfate [INJ] tobramycin sulfate in ns

ANALGESICS - ANTI-INFLAMMATORY celecoxib diclofenac potassium diclofenac sodium diclofenac sodium/misoprostol del rel ENBREL [INJ] etodolac etodolac er fenoprofen calcium flurbiprofen HUMIRA [INJ] ibuprofen ibuprofen lysine indomethacin indomethacin er ketoprofen er ketorolac tromethamine leflunomide meclofenamate sodium mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium XELJANZ XELJANZ XR

ANALGESICS - NonNarcotic acetaminophen-diphenhydramine butalbital compound butalbital/apap/caffeine butalbital/aspirin/caffeine choline mag trisalicylate clonidine [INJ] diflunisal SALICYLAMIDE salsalate

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 2

ANALGESICS - OPIOID acetaminophen/codeine alfentanil hcl [INJ] BELBUCA buprenorphine [INJ] buprenorphine/naloxone butalbital compound/codeine butalbital/caff/apap/codeine butorphanol [INJ] codeine sulfate dihydrocodeine/aspirin/caffeine fentanyl citrate hydrocodone/acetaminophen hydrocodone/ibuprofen hydromorphone hcl levorphanol tartrate meperidine hcl methadone hcl morphine sulfate morphine sulfate cr morphine sulfate er nalbuphine hcl [INJ] oxycodone hcl oxycodone hcl/ibuprofen oxycodone w/aspirin oxycodone/acetaminophen OXYCONTIN oxymorphone hcl oxymorphone hcl er remifentanil hcl ROXYBOND SUBOXONE sufentil 50mcg/ml ampul [INJ] tramadol hcl tramadol hcl er tramadol/acetaminophen XTAMPZA ER ZUBSOLV

ANDROGENS-ANABOLIC danazol oxandrolone testosterone cypionate [INJ]

testosterone enanthate [INJ] testosterone gel

ANORECTAL AGENTS CORTIFOAM hydrocortisone/pramoxine lidocaine-hc pramcort

ANTHELMINTICS ALBENZA ivermectin praziquantel

ANTI-INFECTIVE AGENTS - MISC. atovaquone bacitracin bacitracin [INJ] clindamycin hcl clindamycin palmitate hcl clindamycin phosphate [INJ] CLINDAMYCIN PHOSPHATE [INJ] clindamycin phosphate/dextrose [INJ] colistimethate [INJ] CUBICIN RF dapsone daptomycin imipenem-cilastatin [INJ] linezolid metronidazole pentamidine isethionate polymyxin b sulfate [INJ] sulfamethoxazole/trimethoprim tigecycline tinidazole trimethoprim XIFAXAN

ANTIANGINAL AGENTS DILATRATE-SR isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate er

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 3

minitran nitroglycerin nitroglycerin er nitroglycerin spray nitroglycerin tablets ranolazine er

ANTIANXIETY AGENTS alprazolam alprazolam er alprazolam odt buspirone hcl chlordiazepoxide hcl clorazepate dipotassium diazepam droperidol [INJ] hydroxyzine hcl hydroxyzine pamoate lorazepam oxazepam

ANTIARRHYTHMICS adenosine [INJ] amiodarone hcl dofetilide flecainide acetate ibutilide fumarate [INJ] lidocaine hcl in 7.5% dextrose [INJ] mexiletine hcl procainamide hcl [INJ] propafenone hcl propafenone hcl er quinidine gluconate [INJ] quinidine gluconate er quinidine sulfate QUINIDINE SULFATE

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ADVAIR HFA ALBUTEROL albuterol sulfate albuterol sulfate hfa

aminophylline [INJ] ANORO ELLIPTA ARCAPTA NEOHALER ARNUITY ELLIPTA ASMANEX, HFA BREO ELLIPTA COMBIVENT RESPIMAT DALIRESP FLOVENT DISKUS FLOVENT HFA fluticasone-salmeterol INCRUSE ELLIPTA ipratropium bromide ipratropium/albuterol nebulization ipratropium-albuterol levalbuterol hcl metaproterenol sulfate montelukast sodium PERFOROMIST [INJ] PROAIR HFA PROAIR RESPICLICK PULMICORT FLEXHALER QVAR QVAR REDIHALER SEREVENT DISKUS SPIRIVA RESPIMAT STIOLTO RESPIMAT SYMBICORT terbutaline sulfate theophylline anhydrous drops er 12 hr theophylline anhydrous er TRELEGY ELLIPTA wixela inhub zafirlukast

ANTICOAGULANTS bivalirudin ELIQUIS enoxaparin sodium [INJ] fondaparinux sodium heparin lock flush [INJ] heparin sodium in 0.45% nacl [INJ] heparin sodium in 5% dextrose [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 4

heparin sodium syringe warfarin sodium XARELTO

ANTICONVULSANTS carbamazepine carbamazepine er clobazam clonazepam clonazepam odt diazepam rectal gel divalproex sodium divalproex sodium er ethosuximide felbamate fosphenytoin sodium gabapentin lamotrigine lamotrigine er levetiracetam levetiracetam er oxcarbazepine phenytoin phenytoin sodium pregabalin primidone ROWEEPRA ROWEEPRA XR tiagabine hcl topiramate valproate sodium valproic acid VALPROIC ACID vigabatrin zonisamide

ANTIDEPRESSANTS amitriptyline hcl amoxapine 150mg amoxapine 25mg bupropion hcl bupropion hcl er bupropion hcl xl er

bupropion sr citalopram hbr clomipramine hcl desipramine hcl desvenlafaxine succinate er doxepin hcl duloxetine escitalopram oxalate FETZIMA fluoxetine fluvoxamine maleate er imipramine hcl imipramine pamoate mirtazapine mirtazapine disintegrating nortriptyline hcl paroxetine hcl paroxetine hcl er phenelzine sulfate tranylcypromine sulfate trazodone hcl trimipramine maleate venlafaxine hcl venlafaxine hcl er

ANTIDIABETICS acarbose BYETTA [INJ] FARXIGA glimepiride glipizide glipizide er GLUCAGON glyburide glyburide micronized glyburide/metformin hcl HUMULIN R 500 UNITS [INJ] [OTC] HUMULIN R U-500 KWIKPEN insulin lispro INVOKAMET INVOKAMET XR INVOKANA JANUMET

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 5

JANUMET XR JANUVIA JENTADUETO JENTADUETO XR LANTUS [INJ] LANTUS SOLOSTAR [INJ] LEVEMIR [INJ] LEVEMIR, FLEXTOUCH metformin hcl metformin hcl er nateglinide NOVOLIN 70-30 NOVOLIN N NOVOLIN R NOVOLOG [INJ] NOVOLOG FLEXPEN NOVOLOG MIX 70-30 ONGLYZA OZEMPIC pioglitazone hcl pioglitazone/glimepiride pioglitazone/metformin repaglinide repaglinide/metformin SOLIQUA 100-33 tolazamide tolbutamide TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TRADJENTA TRESIBA TRESIBA FLEXTOUCH TRULICITY VICTOZA [INJ] XIGDUO XR XULTOPHY 100-3.6

ANTIDIARRHEALS diphenoxylate/atropine opium paregoric

ANTIDOTES deferoxamine [INJ] flumazenil [INJ] fomepizole naloxone hcl [INJ] naltrexone hydrochloride NARCAN physostigmine salicylate [INJ] PHYSOSTIGMINE SALICYLATE [INJ] VISTOGARD

ANTIDOTES AND SPECIFIC ANTAGONISTS methylene blue [INJ]

ANTIEMETICS aprepitant dimenhydrinate [INJ] dronabinol fosaprepitant granisetron hcl meclizine hcl ondansetron hcl ondansetron odt palonosetron hcl SANCUSO scopolamine patch trimethobenzamide hcl VARUBI

ANTIFUNGALS amphotericin [INJ] caspofungin acetate CRESEMBA fluconazole fluconazole in dextrose fluconazole in saline flucytosine griseofulvin griseofulvin ultramicrosize itraconazole ketoconazole nystatin NYSTATIN

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 6

posaconazole terbinafine TERBINAFINE voriconazole

ANTIHISTAMINES arbinoxa carbinoxamine cetirizine syrup clemastine fumarate cyproheptadine hcl desloratadine desloratadine disintegrating tablets dexchlorpheniramine maleate er diphenhydramine [INJ] diphenhydramine hcl levocetirizine dihydrochloride promethazine hcl promethegan

ANTIHYPERLIPIDEMICS atorvastatin calcium cholestyramine cholestyramine light colesevelam hcl colestipol hcl ezetimibe ezetimibe/simvastatin fenofibrate FENOFIBRATE fenofibric acid fenofibric acid dr fluvastatin sodium gemfibrozil LIPOFEN LIVALO lovastatin niacin er omega-3-acid ethyl esters pravastatin sodium rosuvastatin simvastatin

VASCEPA

ANTIHYPERTENSIVES aliskiren fumarate amlodipine/olmesartan amlodipine/valsartan amlodipine/valsartan/hctz atenolol/chlorthalidone benazepril hcl benazepril/hctz bisoprolol fumarate/hctz candesartan cilexetil candesartan/hydrochlorothiazide captopril captopril/hydrochlorothiazide clonidine hcl doxazosin mesylate enalapril maleate enalapril maleate/hctz enalaprilat [INJ] eplerenone fosinopril sodium fosinopril/hydrochlorothiazide guanfacine hcl hydralazine hcl irbesartan irbesartan/hydrochlorothiazide lisinopril lisinopril/hctz losartan potassium losartan/hydrochlorothiazide methyldopa methyldopa/hydrochlorothiazide methyldopate hcl [INJ] metoprolol/hydrochlorothiazide minoxidil moexipril hcl moexipril/hydrochlorothiazide nadolol-bendroflumethiazide olmesartan medoxomil olmesartan medoxomil/hctz olmesartan/amlodipine/hctz perindopril erbumine

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 7

phentolamine mesylate [INJ] prazosin hcl propranolol/hctz quinapril quinapril/hydrochlorothiazide ramipril reserpine terazosin hcl trandolapril trandolapril/verapamil er valsartan valsartan/hydrochlorothiazide

ANTIMALARIALS atovaquone/proguanil hcl chloroquine phosphate DARAPRIM hydroxychloroquine sulfate mefloquine hcl primaquine quinine sulfate

ANTIMYASTHENIC AGENTS guanidine hcl neostigmine methylsulfate [INJ] pyridostigmine bromide

ANTIMYCOBACTERIAL AGENTS ethambutol hcl isoniazid pyrazinamide rifabutin

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

abiraterone acetate AFINITOR amifostine [INJ] anastrozole ARRANON [INJ] arsenic trioxide azacitidine [INJ]

bicalutamide bleomycin [INJ] capecitabine carboplatin [INJ] cisplatin [INJ] CISPLATIN POWDER [INJ] cladribine [INJ] cyclophosphamide [INJ] cytarabine [INJ] dacarbazine [INJ] dactinomycin [INJ] daunorubicin [INJ] decitabine [INJ] DEPO-PROVERA 400 MG/ML [INJ] dexrazoxane [INJ] doxorubicin hcl [INJ] doxorubicin hcl liposomal [INJ] ELIGARD EMCYT epirubicin hcl [INJ] erlotinib hcl etoposide exemestane floxuridine [INJ] fludarabine phosphate [INJ] flutamide fulvestrant HEXALEN hydroxyprogesterone caproate hydroxyurea ifosfamide-mesna imatinib mesylate INTRON A [INJ] letrozole leucovorin calcium LEUKERAN levoleucovorin calcium [INJ] LUPRON DEPOT 11.25MG [INJ] LUPRON DEPOT 3.75MG LYSODREN MATULANE megestrol acetate melphalan hcl

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 8

mercaptopurine MESNEX MESNEX 400MG TABLET methotrexate MYLERAN NEXAVAR nilutamide ONTAK [INJ] SPRYCEL SUTENT TABLOID tamoxifen citrate TASIGNA toremifene citrate VORAXAZE [INJ] XALKORI XTANDI

ANTIPARKINSON AGENTS amantadine hcl benztropine [INJ] benztropine mesylate carbidopa/levodopa carbidopa/levodopa er carbidopa/levodopa odt carbidopa/levodopa/entacapone entacapone pramipexole er rasagiline mesylate ropinirole hcl ropinirole hcl er selegiline hcl trihexyphenidyl hcl

ANTIPSYCHOTICS/ANTIMANIC AGENTS ABILIFY MAINTENA, ER aripiprazole odt aripiprazole tablets chlorpromazine [INJ] clozapine clozapine odt fluphenazine decanoate [INJ] fluphenazine hcl

haloperidol haloperidol decanoate [INJ] haloperidol lactate [INJ] lithium carbonate lithium carbonate er loxapine succinate olanzapine olanzapine odt PERSERIS prochlorperazine edisylate [INJ] prochlorperazine maleate quetiapine fumarate quetiapine fumarate er risperidone thioridazine hcl thiothixene trifluoperazine hcl ziprasidone hcl

ANTISEPTICS & DISINFECTANTS chlorhexidine gluconate

ANTIVIRALS abacavir abacavir sulfate/lamivudine abacavir/lamivudine/zidovudine acyclovir adefovir dipivoxil atazanavir sulfate capsule cidofovir [INJ] didanosine efavirenz entecavir famciclovir fosamprenavir calcium lamivudine hbv lamivudine/zidovudine lopinavir-ritonavir oral soln oseltamivir phosphate PEGASYS [INJ] PEGASYS PROCLICK [INJ] ribavirin inh rimantadine hcl

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 9

ritonavir stavudine SUSTIVA tenofovir disoproxil 300mg tablet TRUVADA valacyclovir valganciclovir hcl zidovudine

ASSORTED CLASSES alprostadil [INJ] azathioprine azathioprine sodium [INJ] CELLCEPT 500MG VIAL [INJ] cyclosporine [INJ] DEPEN ETHAMOLIN mycophenolate acid del rel mycophenolic acid del rel penicillamine REVLIMID sirolimus sodium polystyrene sulfonate tacrolimus THALOMID

BETA BLOCKERS acebutolol hcl atenolol betaxolol hcl bisoprolol fumarate BYSTOLIC carvedilol er labetalol hcl metoprolol succinate er metoprolol tartrate nadolol pindolol propranolol hcl propranolol hcl er sotalol timolol maleate

BIOLOGICALS MISC GRASTEK

Calcitonin Gene-Related Peptide (CGRP) Receptor Antag

AIMOVIG EMGALITY

CALCIUM CHANNEL BLOCKERS amlodipine besylate diltiazem [INJ] diltiazem 24hr cd diltiazem er diltiazem er 24 hour diltiazem hcl felodipine er isradipine nicardipine hcl nimodipine verapamil er verapamil er pm verapamil hcl [INJ]

CARDIOTONICS digoxin milrinone in 5% dextrose milrinone lactate [INJ]

CARDIOVASCULAR AGENTS - MISC. ADEMPAS ambrisentan amlodipine-atorvastatin bosentan epoprostenol [INJ] isoxsuprine hcl OPSUMIT papaverine hcl [INJ] papaverine hcl er sildenafil citrate (pah) sildenafil citrate tablet tadalafil

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 10

treprostinil sodium

Cephalosporin Combinations AVYCAZ

CEPHALOSPORINS cefaclor cefazolin [INJ] cefdinir cefepime [INJ] cefotaxime [INJ] cefotetan [INJ] cefoxitin [INJ] cefoxitin/dextrose [INJ] cefpodoxime proxetil cefprozil ceftazidime ceftibuten ceftriaxone [INJ] cefuroxime axetil cefuroxime sodium cephalexin

CONTRACEPTIVES altavera alyacen amethia amethia lo amethyst apri aranelle aubra [INJ] aviane azurette balziva briellyn camrese camrese lo caziant chateal cryselle cyclafem dasetta

daysee drospirenone/eth estra/levomef elinest emoquette enpresse enskyce errin estarylla falmina gianvi gildagia gildess gildess fe heather introvale jencycla jolessa jolivette junel junel fe kariva kelnor 1-35 kurvelo leena lessina levonorgestrel levora LO LOESTRIN FE loryna low-ogestrel lutera lyza marlissa microgestin microgestin fe MINASTRIN 24 FE mono-linyah mononessa myzilra NATAZIA necon nora-be norethindrone/eth estradiol/iron

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 11

norethindrone/ethinyl estradiol norethin-eth estra ferrous fum nortrel NUVARING ocella ogestrel orsythia philith pirmella portia quasense reclipsen sprintec sronyx syeda tilia fe tri-estarylla tri-legest fe tri-linyah trinessa trivora velivet vestura viorele wera wymzya fe zarah zenchent zenchent fe zeosa zovia

CORTICOSTEROIDS a-hydrocort [INJ] BETAMETHASONE BETAMETHASONE ACETATE BETAMETHASONE SODIUM PHOSPHATE budesonide budesonide ec budesonide er cortisone acetate dexamethasone dexamethasone sodium phosphate

fludrocortisone acetate methylprednisolone methylprednisolone acetate [INJ] methylprednisolone sod succ [INJ] prednisolone prednisolone sodium phosphate prednisone triamcinolone veripred 20

COUGH/COLD/ALLERGY acetylcysteine benzonatate brompheniramine/pseudoephedrine chlorphen/pse/dm tannate D-CHLORPHENIRA/PSE/CHLOPHEDIAN 12.5CPD-1DCPM-30PSE dihydrocodeine/bpm/pe DM/PHENYLEPH/CHLORPHENIRAMINE 10PEH-4CPM-20DM hydrocodone/homatropine phenylephrine/chlorpheniramine 10peh-4cpm promethazine vc/codeine promethazine w/codeine promethazine/dextromethorphan pseudoephedrine hcl er

DERMATOLOGICALS acitretin acyclovir adapalene cream, gel adapalene-benzoyl peroxide gel alclometasone dipropionate alphaquin hp amcinonide ammonium lactate avo cream benzoyl peroxide betamethasone dipropionate augment betamethasone valerate calcipotriene calcitriol [INJ] ciclopirox

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 12

clindamycin phosphate topical clindamycin phos-tretinoin clindamycin/benzoyl peroxide clobetasol e clobetasol propionate clotrimazole clotrimazole/betamethasone cocaine hcl COCAINE HCL COSENTYX desonide desoximetasone diclofenac epolamine diclofenac sodium gel diflorasone diacetate econazole nitrate eletone emulsion sb EPIDUO EPIDUO FORTE erythromycin solution erythromycin-benzoyl peroxide ETHYL ALCOHOL fluocinolone acetonide fluocinonide fluorouracil fluticasone propionate halobetasol propionate hpr hpr plus hydrocortisone hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyrate/emoll hydrocortisone valerate hydroquinone cream hydroquinone er cream imiquimod lactic acid LACTIC ACID 88 TO 92 % lidocaine lidocaine hcl lidocaine/prilocaine

lindane mafenide acetate malathion mb hydrogel mometasone furoate mupirocin nystatin w/triamcinolone ONEXTON OXSORALEN 1% LOTION permethrin podofilox primecrolimus pruclair prumyx prutect salicylic acid SALICYLIC ACID selenium sulfide silver sulfadiazine SKYRIZI sodium sulfacetamide/sulfur sonafine STELARA [INJ] sulfacetamide sodium TARGRETIN GEL tazarotene cream TAZORAC GEL tl-cermide tretinoin tretinoin microsphere urea UREAM POWDER, BEADS

DIAGNOSTIC PRODUCTS candin cosyntropin [INJ] md-gastroview TUBERSOL [INJ]

DIAGNOSTICS & MISCELLANEOUS AGENTS neomycin-polymyxin b [INJ] UVA URSI LEAF FLUID EXTRACT

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 13

DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS

folbic foltanx metafolbic metafolbic plus

DIGESTIVE AIDS CREON pancrelipase SUCRAID VIOKACE ZENPEP DEL-REL

DIURETICS acetazolamide acetazolamide er amiloride hcl amiloride hcl w/hctz bumetanide chlorothiazide chlorothiazide sodium [INJ] chlorthalidone ethacrynate sodium furosemide hydrochlorothiazide indapamide mannitol methazolamide methyclothiazide metolazone spironolactone spironolactone/hctz torsemide

ENDOCRINE AND METABOLIC AGENTS - MISC.

alendronate sodium cabergoline calcitonin salmon nasal cinacalcet hcl clomiphene citrate

desmopressin acetate [INJ] doxercalciferol etidronate disodium FOLLISTIM AQ FORTEO [INJ] GENOTROPIN ibandronate [INJ] levocarnitine LUPRON DEPOT-PED [INJ] nitisinone NORDITROPIN octreotide acetate OMNITROPE paricalcitol PROLIA risedronate dr risedronate sodium sodium phenylbutyrate TYMLOS vasopressin [INJ] vasopressin-ns

Estrogen-Selective Estrogen Receptor Modulator Comb

DUAVEE

ESTROGENS estradiol patch estradiol tablet/cream estradiol valerate [INJ] estradiol/norethindrone acetate estrogen/methyltestosterone estropipate PREMARIN PREMPHASE PREMPRO

FLUOROQUINOLONES ciprofloxacin ciprofloxacin er ciprofloxacin suspension ciprofloxacin/dextrose [INJ] levofloxacin/d5w [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 14

moxifloxacin hcl ofloxacin ofloxacin tablets

GASTROINTESTINAL AGENTS - MISC. AMITIZA balsalazide disodium calcium acetate lanthanum carbonate LINZESS mesalamine metoclopramide hcl MOVANTIK sevelamer carbonate sulfasalazine sulfasalazine dr ursodiol VELPHORO

GENERAL ANESTHETICS etomidate [INJ] ketamine hcl [INJ] propofol

GENITOURINARY AGENTS - MISCELLANEOUS

acetic acid irrigation alfuzosin hcl er AMINOACETIC ACID finasteride glycine phenazopyridine hcl potassium citrate er RAPAFLO tamsulosin hcl er 24 hr

Glycopeptides vancomycin hcl [INJ] VANCOMYCIN HCL [INJ]

GOUT AGENTS allopurinol allopurinol sodium febuxostat probenecid

HEMATOLOGICAL AGENTS - MISC. albumin [INJ] anagrelide hydrochloride aspirin / dipyridamole er BRILINTA cilostazol clopidogrel dipyridamole [INJ] eptifibatide hetastarch w/sodium chloride [INJ] icatibant acetate pentoxifylline prasugrel hcl protamine sulfate [INJ]

HEMATOPOIETIC AGENTS centratex DROXIA EPOGEN fabb ferocon ferraplus 90 ferrocite plus ferrogels forte folbee folic acid folplex 2.2 hematinic plus hematinic with folic acid hematogen hematogen fa hematogen forte hemetab hydroxocobalamin iferex 150 forte multigen multigen folic

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multigen plus NEULASTA [INJ] NEUPOGEN [INJ] poly-iron 150 forte polysaccharide iron forte PROCRIT [INJ] se-tan plus taron forte therapeutic hematinic tl gard rx tl icon tl-hem 150 er 24 hr tricon trigels-f forte ZARXIO [INJ]

HEMOSTATICS tranexamic acid

Hepatitis C Agent - Combinations EPCLUSA HARVONI MAVYRET VOSEVI

HYPNOTICS flurazepam hcl midazolam hcl phenobarbital ramelteon temazepam triazolam zaleplon zolpidem tartrate zolpidem tartrate er

LAXATIVES CLENPIQ lactulose peg 3350-electrolyte polyethylene glycol POLYETHYLENE GLYCOL

SUPREP

LOCAL ANESTHETICS-Parenteral bupivacaine hcl bupivacaine/dextrose [INJ] bupivacaine/epinephrine [INJ] chloroprocaine [INJ] lidocaine hcl w/epinephrine [INJ] ropivacaine sensorcaine sensorcaine 5mg/ml vial [INJ]

MACROLIDES azithromycin [INJ] clarithromycin clarithromycin er erythromycin erythromycin del rel erythromycin ethylsuccinate erythromycin stearate erythromycin/sulfisoxazole

MEDICAL DEVICES ACCU-CHEK SOFTCLIX LANCETS DEVICE [OTC] FORA LANCING DEVICE FREESTYLE CONTROL SOLUTION FREESTYLE FREEDOM KIT [OTC] FREESTYLE FREEDOM LITE FREESTYLE FREEDOM LITE METER [OTC] FREESTYLE INSULINX FREESTYLE INSULINX GLUCOSE SYSTEM [OTC] FREESTYLE INSULINX TEST STRIPS [OTC] FREESTYLE LITE METER [OTC] FREESTYLE LITE TEST STRIPS [OTC] FREESTYLE TEST STRIPS [OTC] MINIMED MINIMED RESERVOIR NOVOFINE NOVOFINE AUTOCOVER ONE TOUCH ULTRA 2 ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO ONE TOUCH VERIO FLEX

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 16

ONE TOUCH VERIO IQ ONE TOUCH VERIO SYNC PRECISION XTRA B-KETONE STRIPS [OTC] PRECISION XTRA MONITOR [OTC] PRECISION XTRA TEST STRIPS [OTC] PRODIGY INSULIN SYRINGE PRODIGY PEN NEEDLE SOFT TOUCH

MIGRAINE PRODUCTS dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE eletriptan hbr ergoloid mesylates ergotamine-caffeine naratriptan hcl rizatriptan rizatriptan disintegrating tablets sumatriptan succinate zolmitriptan zolmitriptan odt

MINERALS & ELECTROLYTES calcium chloride [INJ] CALCIUM CHLORIDE [INJ] calcium gluconate [INJ] CALCIUM GLUCONATE 61MG copper chloride [INJ] dextrose in lactated ringers dextrose with sodium chloride magnesium sulfate [INJ] MAGNESIUM SULFATE [INJ] MAGNESIUM SULFATE IN DEXTROSE [INJ] manganese [INJ] manganese sulfate [INJ] MULTITRACE-5 [INJ] nutrilyte [INJ] nutrilyte ii [INJ] pot chloride/dextrose/ns [INJ] potassium acetate [INJ] POTASSIUM ACETATE [INJ] potassium bicarbonate POTASSIUM BICARBONATE

potassium chl-normal saline [INJ] potassium chloride POTASSIUM CHLORIDE potassium chloride/dextrose [INJ] ringers [INJ] ringers irrigation selenium [INJ] sodium acetate [INJ] sodium lactate [INJ] SODIUM PHOSPHATE [INJ] sodium phosphate 3mmol/ml vial [INJ]

Monobactams AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] aztreonam [INJ]

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl sodium fluoride SODIUM FLUORIDE

MULTIVITAMINS advanced am/pm bal-care dha b-complex complete natal dha corvita dailyvite elite ob elite-ob folbee plus folcaps folivane-ob folivane-plus folivane-prx dha nf hemenatal ob hemenatal ob + dha inatal advance inatal ultra LEVOMEFOLATE DHA m.v.i. adult [INJ] M.V.I.-12 [INJ] macnatal cn dha

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 17

multivitamin w/fluoride & iron multivitamin with fluoride mynatal mynatal advance mynatal caps mynatal plus mynatal-z mynate 90 plus er mynephrocaps obstetrix dha pnv ob+dha pnv-dha pnv-omega pnv-select pnv-total pr natal 400 pr natal 400 ec pr natal 430 pr natal 430 ec prena1 prena1 chew prenaissance prenaissance 90 dha prenaissance dha prenaissance harmony dha prenaissance next prenaissance plus prenaplus prenatabs fa prenatabs rx prenatal low iron prenatal plus prenatal-u relnate dha renal caps rena-vite rx reno caps se-natal 19 strovite taron-bc taron-c dha tl g-fol os tl-care dha

tl-fol 500 er tl-select triadvance trinatal gt trinatal rx 1 trinate triphrocaps triveen-duo dha triveen-prx rnf ultimatecare one ultimatecare one nf v-c forte vemavite-prx 2 vena-bal dha venatal-fa vinacal vinate dha vinate ic vinate ii vinate one vinate-m virt-pn virt-pn dha virt-pn plus virt-select vol-care rx vol-nate vol-plus vol-tab rx vp-ch plus vp-ch-pnv vp-heme one vp-zel zatean-ch zatean-pn dha zatean-pn plus

MUSCULOSKELETAL THERAPY AGENTS baclofen chlorzoxazone cyclobenzaprine hcl CYCLOBENZAPRINE HCL cyclobenzaprine hcl er

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 18

dantrolene sodium methocarbamol orphenadrine citrate [INJ] orphenadrine compound SYNVISC-ONE tizanidine hcl

NASAL AGENTS - SYSTEMIC AND TOPICAL azelastine hcl DYMISTA flunisolide nasal spray fluticasone nasal spray ipratropium bromide spray mometasone furoate nasal QNASL triamcinolone acetonide

Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb

ENTRESTO

NEUROMUSCULAR AGENTS anectine [INJ] riluzole

NUTRIENTS dextrose in water intralipid

OPHTHALMIC AGENTS ALPHAGAN P 0.001% apraclonidine ophth solution atropine sulfate azelastine hcl ophth solution bacitracin/polymyxin ophth oint balanced salt ophth irrigation BESIVANCE betaxolol ophth solution BETOPTIC S bimatoprost brimonidine ophth solution bromfenac ophth

carteolol hcl ciprofloxacin ophth solution COMBIGAN cromolyn sodium cyclopentolate ophth solution dexamethasone sod phos ophth dorzolamide hcl dorzolamide/timolol DUREZOL epinastine hcl erythromycin ointment fluorometholone flurbiprofen sodium FML S.O.P. gatifloxacin homatropine hydrobromide HOMATROPINE HYDROBROMIDE ILEVRO ketorolac tromethamine drops latanoprost drops levobunolol hcl drops levofloxacin hemihydrate loteprednol etabonate susp LUMIGAN metipranolol drops MOXEZA neomycin/bacitracin/poly/hc neomycin/polymyxin/gramicidin olopatadine hcl (ophthalmic) PAZEO pilocarpine hcl prednisolone acetate prednisolone sodium phosphate drops proparacaine hcl RESTASIS RESTASIS MULTIDOSE RHOPRESSA sulfacetamide w/prednisolone tetcaine drops TOBRADEX OINTMENT TOBRADEX ST tobramycin sulfate drops tobramycin/dexamethasone

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 19

TRAVATAN Z travoprost trifluridine tropicamide XIIDRA

Ophthalmic Kinase Inhibitors - Combinations

ROCKLATAN

OTIC AGENTS ACETIC ACID acetic acid otic solution acetic acid/aluminum otic sol acetic acid/hydrocortisone otic sol antipyrine/benzocaine otic sol antipyrine/benzocaine/poly otic sol chloroxylenol/benzocaine/hc acetate otic susp CIPRODEX ciprofloxacin hcl CIPROFLOXACIN HCL neomycin/polymyxin/hc otic susp & soln ofloxacin otic drops

OXYTOCICS carboprost methylergonovine maleate oxytocin [INJ]

PASSIVE IMMUNIZING AGENTS GAMUNEX [INJ]

PCSK9 Inhibitors PRALUENT PEN PRALUENT SYRINGE REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE

PENICILLINS amoxicillin amoxicillin/clavulanate er

ampicillin [INJ] ampicillin/sulbactam [INJ] dicloxacillin sodium nafcillin dextrose [INJ] nafcillin sodium [INJ] oxacillin sodium [INJ] penicillin g potassium [INJ] penicillin g procaine penicillin g sodium [INJ] penicillin v potassium piperacillin-tazobactam [INJ]

Phosphodiesterase 4 (PDE4) Inhibitors - Topical

EUCRISA

PROGESTINS medroxyprogesterone acetate [INJ] norethindrone acetate progesterone in oil [INJ] progesterone micronized

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

acamprosate calcium amitriptyline/chlordiazepoxide AVONEX [INJ] BETASERON bupropion er (12 hour) disulfiram donepezil hcl galantamine GILENYA memantine memantine dose pack NAMZARIC THERAPY PACK NUEDEXTA olanzapine/fluoxetine hcl perphenazine/amitriptyline PLEGRIDY rivastigmine SAVELLA

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 20

TECFIDERA tetrabenazine XYREM

RESPIRATORY AGENTS - MISC. FASENRA

Sinus Node Inhibitors CORLANOR

TETRACYCLINES coremino demeclocycline hcl doxycycline hyclate doxycycline monohydrate minocycline hcl minocycline hcl er TETRACYCLINE

THYROID AGENTS levothyroxine sodium LEVOTHYROXINE SODIUM liothyronine sodium methimazole propylthiouracil

TOXOIDS INFANRIX [INJ] PEDIARIX [INJ] TETANUS DIPHTHERIA TOXOIDS - PED [INJ]

ULCER DRUGS cimetidine dicyclomine hcl esomeprazole famotidine glycopyrrolate hyoscyamine sulfate hyoscyamine sulfate disinegrating tablets hyoscyamine sulfate er lansoprazole lansoprazole/amoxicillin/clarithromycin

misoprostol nizatidine omeprazole omeprazole sodium bicarbonate pantoprazole sodium ranitidine hcl sucralfate

URINARY ANTI-INFECTIVES hyophen methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal phosphasal uretron d-s urimar-t urin d.s. urogesic ustell

URINARY ANTISPASMODICS bethanechol chloride darifenacin er flavoxate hcl MYRBETRIQ ER 24 HR oxybutynin chloride oxybutynin chloride er solifenacin succinate tolterodine tartrate trospium chloride er

VACCINES AFLURIA AFLURIA QUAD FLUAD FLUBLOK FLUBLOK QUAD FLUCELVAX QUAD FLULAVAL QUAD FLUMIST FLUZONE HIGH-DOSE FLUZONE QUAD

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated January 1, 2020 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 21

RABAVERT SHINGRIX TWINRIX [INJ] VAQTA VIAL VIVOTIF BERNA DEL REL

VAGINAL PRODUCTS clindamycin phosphate vaginal CRINONE miconazole 1 MICONAZOLE 1 PREMARIN CREAM terconazole yuvafem

VASOPRESSORS dobutamine [INJ] dobutamine/dextrose [INJ] dopamine hcl [INJ] dopamine hcl in 5% dextrose ephedrine sulfate epinephrine ampule/vial epinephrine auto-injector EPINEPHRINE AUTO-INJECTOR [INJ] midodrine hcl norepinephrine bitartrate [INJ] phenylephrine hcl [INJ] phenylephrine hcl-ns PHENYLEPHRINE HCL-NS SYMJEPI

VITAMINS ascorbic acid [INJ] ASCORBIC ACID [INJ] phytonadione PHYTONADIONE pyridoxine hcl PYRIDOXINE HCL thiamine hcl vitamin a VITAMIN A

VITAMINS, HEMATINICS & ELECTROLYTES elite-ob 400 folivane-f

X-Linked Hypophosphatemia (XLH) Treatment - Agents

CRYSVITA