Preferred Drug List (PDL)

Preferred List (PDL) Arizona CRS Effective Date: 7/1/16 2016 United Healthcare Services, Inc. All rights reserved.

Preferred List INTRODUCTION UnitedHealthcare is pleased to provide this Preferred List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare PDL have been reviewed and approved by the Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the prior authorization process. The drugs represented have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare, solely for the convenience of contracted providers. UnitedHealthcare does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. UnitedHealthcare assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. National guidelines can be found on the websites listed in the website section or go to the National Guideline Clearinghouse site at http://www.guideline.gov. PREFACE The UnitedHealthcare PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. The UnitedHealthcare PDL covers selected over-thecounter (OTC) products. You are encouraged to prescribe OTC medications when clinically appropriate. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare medical directors and pharmacists also participate in the P&T Committee. The P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to Doc#: UHC1335a_20110804 i

pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received the PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare internet site. OUTPATIENT PRESCRIPTION DRUG BENEFIT COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Special formula nutrition needs for metabolic patients are also covered. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Benefits and copays are based on the individual member s benefit plan. PRODUCT SELECTION CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations Outcome and pharmacoeconomic studies When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited name product. levetiracetam KEPPRA All strengths of Keppra would be covered by this listing. Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymixin B/ Hydrocortisone CORTISPORIN As listed in the EAR section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the EYE and DERMATOLOGICAL sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not metoprolol 50mg & 100 mg only LOPRESSOR GENERIC SUBSTITUTION The UnitedHealthcare PDL requires substitution on the majority of products when a equivalent is available. Generic substitution is a pharmacy action whereby a equivalent is dispensed rather than the name product. The PDL indicates availability in the column. If a name drug is medically necessary, please submit a prior authorization request. The UnitedHealthcare Maximum Allowable Cost (MAC) list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most s but not ed versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA s review and approval process. An important consideration for substitution is the knowledge that all approvals of drugs by the FDA since 1984, and many approvals prior to 1984, have a showing of bioequivalence between the versions and the reference product. To gain FDA approval: 1. The drug must contain the same active ingredient(s), be the same strength and the same dosage form as the name product. Doc#: UHC1335a_20110804 ii

2. The FDA has given the an A rating compared to the ed product indicating bioequivalence, and has determined the is therapeutically equivalent to the reference. The ratings of drugs are available by referring to the FDA reference, Approved Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent drug product is substituted for the name product. There are now many name products that are repackaged or distributed under a label. The label version should always be considered therapeutically equivalent and substitutable for the source ed product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS s first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare PDL does not cover DESI less than fully effective drg products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare PDL. DESI drugs Antiobesity agents Experimental / research drugs Cosmetic drugs Immunization agents Nutritional / diet supplements Blood and blood plasma products Agents used to promote fertility Doc#: UHC1335a_20110804 iii Agents used for erectile dysfunction Agents used for cosmetic hair growth s from manufacturers that do not participate in the FFS Medicaid Rebate Program Diagnostic products Medical supplies and DME except as listed: syringes, needles, lancets, alcohol swabs, spacers, preferred diabetes test strips, peak flow meters (Astech, Assess, Peak Air s, max two per year), vaporizer (limit of 1 per 3 years), humidifier (limit of 1 per 3 years) Mirena DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare members may receive up to a one month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when eighty-five percent (85%) of the medication has been utilized. If a claim is submitted before 85% of the medication has been used, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. Please call the UnitedHealthcare Pharmacy Department at 800-310-6826 with questions or for help with dosage change authorization. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare PDL requires mandatory substitution on the vast majority of products when a equivalent is available; however, name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare PDL prior authorization (PA) list does not include ed items where a equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. Requests for these exceptions should be made in writing by the physician and faxed to: UnitedHealthcare Pharmacy Services Department Fax 866-940-7328 Phone 800-310-6826 A prior authorization request form is available in the UnitedHealthcare provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical

necessity of the non-pdl request. The UnitedHealthcare Pharmacy Department will respond to all requests in accordance with state requirements. Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare. If a pharmacist receives a prescription for a non-pdl drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Pharmacy Department at 800-310-6826 with questions concerning the prior authorization process. NON-PDL DRUGS 5-DAY OVERRIDES To ensure the use of PDL drugs, all non- PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 5-day supply of the newly prescribed non-pdl drug. The pharmacy should submit a claim for a 5 day supply, with a PA Type of 8 and Prior Authorization number of 00000000120. Please note that non-preferred drugs are available for a 5- day supply, however availability is subject to the benefit design. For assistance, pharmacies may call 800-310- 6826. Pharmacies may dispense a one-time, 15-day supply to members requiring an immediate supply of an ongoing medication. The pharmacist must contact the plan to obtain a manual 15-day override. Before the next dispensing, the pharmacy must contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare at 866-940-7328, Attn: Pharmacy Department. QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The Doc#: UHC1335a_20110804 iv pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician. Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period: opiate analgesics benzodiazepines sedative hypnotic agents barbiturates select muscle relaxants Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits. Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Pharmacy Department at 800-305-0023 with questions. Specialty Pharmaceutical Management Program UnitedHealthcare is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate prior authorization form to the UnitedHealthcare Prior Authorization Department via fax at 866-940-7328. The UnitedHealthcare Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare, will coordinate delivery of the product to the member or provider. s that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior authorization request forms should be faxed to the UnitedHealthcare Pharmacy Department at 866-940-7328. STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA).

STEP Advair First-Line Agent(s) 1) 30 day trial of one inhaled corticosteroid (e.g. Asmanex Twisthaler, Flovent HFA, QVAR) OR 2) 60 day trial of a long acting beta2- agonist (e.g. Arcapta, Striverdi) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). oxymorphone ER 30-day trial of both Fentanyl patch and morphine sulfate ER at least 200mg per day Potiga 30-day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 18 years of age and older. Members less than 18 require prior authorization. Angiotensin II 30 day trial of losartan or losartan/hctz Receptor Blockers (Benicar HCT) Protopic 0.03% Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Aricept 23mg Banzel 90 day trial of Aricept 10mg daily 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Tradjenta, metformin. Jentadueto, Januvia, Janumet, Janumet XR, Onglyza, Kombiglyze) Dulera Elidel 1) 30 day trial of one inhaled corticosteroid (e.g. Asmanex Twisthaler, Flovent HFA, QVAR) Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Protopic 0.1% Ranexa Renvela Symbicort tolterodine Minimum age of 16. Trial of two different topical corticosteroids Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates 8 week trial of calcium acetate 1) 30 day trial of one inhaled corticosteroid (e.g. Asmanex Twisthaler, Flovent HFA, QVAR) OR 2) 60 day trial of a long acting beta2- agonist (e.g. Arcapta, Striverdi) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). 30 day trial of oxybutynin immediate release. fenofibrate Gabitril levocetirizine midodrine Onfi Optivar oxycodone ER Fill of a statin or 90 days of gemfibrozil within the previous 180 days. 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 12 years of age and older. Members less than 12 require prior authorization. 30 day trial of loratadine and cetirizine. Trial of fludrocortisone 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. 14 day trial of ketotifen within previous 90 days required first. 30 day trial of at least 200mg per day of morphine sulfate ER TZD s At least a 90 day trial of 1500mg/day of (ActosPlusMet, metformin ActoPlusMet XR, Duetact) Uloric Vancocin Vimpat 8 week trial of up to 600mg of allopurinol required first. One fill of metronidazole tabs or cap 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 17 years of age and older. Members less than 17 require prior authorization. Xopenex Respules 30 day trial of Albuterol.083% or.5% respules. Doc#: UHC1335a_20110804 v

PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the UnitedHealthcare Director of Pharmacy Services by either mail or fax. Attn: Director of Pharmacy Services UnitedHealthcare Unison Plaza 1001 Brinton Road Pittsburgh, PA 15221 Fax: 866-940-7328 UnitedHealthcare. These trademarked names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare and such third-party pharmaceutical companies. If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification. Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting. EDITOR Your comments and suggestions regarding the UnitedHealthcare PDL are encouraged. Your input is vital to this PDL s continued success. All responses will be reviewed and considered. Please send your comments to: UnitedHealthcare Director of Pharmacy Services Unison Plaza 1001 Brinton Road Pittsburgh, PA 15221 Phone: 800-310-6826 LEGEND # Only the dosage forms/strengths of the name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustainedrelease) PA Prior Authorization required QL Quantity Limits apply ST SP Step Therapy, see pages V-VI for details Specialty Pharmaceuticals, see pages IV-V for details NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Doc#: UHC1335a_20110804 vi

Table of Contents Antineoplastics & Immunosuppressants...4 Antineoplastic Agents...4 Hormonal Antineoplastic Agents....5 Immunomodulators...5 Immunosuppressants...5 Miscellaneous...6 Blood Modifiers - Anticoagulants...7 Anticoagulants...7 Blood Cell Formation...7 Platelet Inhibitors...7 Miscellaneous...7 Cardiovascular Agents...8 Ace Inhibitors...8 Ace Inhibitor/Diuretic Combinations....8 Adrenolytics, Central...8 Alpha Blockers....8 Angiotensin II Receptor Blockers (Antagonists) 8 Angiotensin II Receptor Blocker Combinations. 9 Antiarrhythmics and Cardiac Glycosides...9 Beta Blockers and Beta Blocker/Diuretic Combinations....9 Calcium Channel Blockers....10 Diuretics...10 Lipid Lowering Agents...11 Nitrates...12 Potassium-Removing Agents...12 Miscellaneous...12 Central Nervous System....13 Alzheimer s Disease...13 Analgesics...13 Migraine Acute Therapy...15 Migraine Prophylactic Therapy...15 Multiple Sclerosis....15 Myasthenia Gravis...15 Parkinson s Disease...15 Seizures....16 Miscellaneous...17 Dermatology...17 Acne Vulgaris...17 Bacterial Infections...18 Corticosteroids....19 Fungal Infections...20 Psoriasis...20 Rosacea...21 Scabies and Pediculosis....21 Viral Infections...21 Miscellaneous...21 Ear, Nose & Throat...23 Ear...23 Nose...23 Throat and Mouth...25 Endocrinology....25 Adrenal Corticosteroids...25 Androgens...25 Diabetes Mellitus...26 Growth Stimulating Agents....28 Metabolic Modifiers....28 Osteoporosis...28 Thyroid Disease...28 Miscellaneous...28 Gastrointestinal....29 Diarrhea....29 Emesis....29 Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers...29 Gastrointestinal Spasm...30 Inflammatory Bowel Disease...30 Laxatives...31 Pancreatic Enzymes...31 Probiotic Supplementation....31 Miscellaneous...32 Infectious Diseases...32 Anthelmintics...32 2

Antibacterials...32 Antifungals...34 Antivirals...34 Miscellaneous...36 Metabolics....37 Musculoskeletal...39 Arthritis...39 Gout....40 Skeletal Muscle Relaxants...40 OB-GYN...40 Contraceptives...40 Endometriosis...42 Hormone Therapy/Menopause....42 Vaginal Infections....43 Miscellaneous...43 Ophthalmic...43 Allergy...43 Anti-Inflammatories...43 Glaucoma...44 Infections....45 Miscellaneous...46 Psychiatric....46 Alcohol Deterrents...46 Anxiety....46 Attention Deficit Hyperactivity Disorder (ADHD)....46 Bipolar Disorder....47 Depression...47 Insomnia...48 Narcotic Antagonists...48 Psychoses....48 Smoking Cessation...49 Miscellaneous...49 Respiratory s....49 Antitussives, Decongestants, Expectorants and Combinations....49 Asthma/COPD...55 Miscellaneous...56 Urological...56 Symptomatic Benign Prostatic Hypertrophy..56 Miscellaneous...57 Vitamins and Minerals....57 Potassium...60 Miscellaneous...61 Anaphylaxis...61 Cystic Fibrosis...61 Detoxification Agents....61 Hereditary Angioedema...61 Hyperphosphatemia...61 Idiopathic Pulmonary Fibrosis (IPF)...62 Immune Thrombocytopenic Purpura........ 62 Medical Devices....62 Metabolic Modifiers....62 Vaccine...62 OTC MEDICATIONS...63 Acne....63 Antifungals...63 Atopic Dermatitis...63 Cough/Cold Allergy....63 Diabetes...64 Earwax Removal Products...64 Family Planning...64 First Aid...64 Gastrointestinal...64 Lice Products...65 Motion Sickness....65 Ophthalmics...65 Pain...65 Smoking Cessation Products...65 Vitamins/Minerals...66 Warts...66 Miscellaneous....66 Index of s...67 3

Generic Name Brand Name Antineoplastics & Immunosuppressants Antineoplastic Agents Alkylating Agents altretamine HEXALEN busulfan MYLERAN chlorambucil LEUKERAN cyclophosphamide CYTOXAN estramustine phosphate sodium EMCYT lomustine CEENU melphalan ALKERAN temozolomide TEMODAR PA, SP Antimetabolites capecitabine XELODA PA, SP mercaptopurine PURINETHOL thioguanine TABLOID QL trifluridine/tipiracil LONSURF PA, SP Histone Deacetylase Inhibitors panobinostat FARYDAK PA, SP vorinostat ZOLINZA PA, SP Kinase Inhibitor alectinib ALECENSA PA, SP axitinib INLYTA PA, SP bosutinib BOSULIF PA, SP cabozantinib COMETRIQ PA, SP ceritinib ZYKADIA PA, SP crizotinib XALKORI PA, SP dabrafenib TAFINLAR PA, SP dasatinib SPRYCEL PA, SP erlotinib TARCEVA PA, SP everolimus AFINITOR AFINITOR DISPERZ PA, SP gefitinib IRESSA PA, SP ibrutinib IMBRUVICA PA, SP imatinib mesylate GLEEVEC PA, QL, SP lapatinib ditosylate TYKERB PA, SP lenvatinib LENVIMA PA, SP nilotinib TASIGNA PA, SP palbociclib IBRANCE PA, SP pazopanib VOTRIENT PA, SP ponatinib ICLUSIG PA, SP regorafenib STIVARGA PA, SP 4

Generic Name Brand Name ruxolitinib JAKAFI PA, SP sorafenib NEXAVAR PA, SP sunitinib SUTENT PA, SP trametinib MEKINIST PA, SP vandetanib CAPRELSA PA, SP vemurafenib ZELBORAF PA, SP Hormonal Antineoplastic Agents Androgen Biosynthesis Inhibitors abiraterone ZYTIGA PA, SP Antiandrogens bicalutamide CASODEX flutamide EULEXIN Antiestrogens tamoxifen NOLVADEX toremifene FARESTON Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Gonadotropin Releasing Hormone Analog leuprolide LUPRON PA, SP LUPRON DEPOT leuprolide LUPRON DEPOT 6-MONTH PA, SP LUPRON DEPOT-PED Progestin megestrol acetate MEGACE Immunomodulators Interferons interferon alfa-2a PA, SP interferon alfa-2b INTRON A PA, SP peginterferon alfa-2b SYLATRON PA, SP Miscellaneous lenalidomide REVLIMID PA, SP pomalidomide POMALYST PA, SP thalidomide THALOMID PA, QL, SP Immunosuppressants Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC 5

Generic Name Brand Name Calcineurin Inhibitors cyclosporine GENGRAF NEORAL SOLUTION modified oral soln 100 mg/ml cyclosporine SANDIMMUNE cyclosporine SANDIMMUME SOLUTION oral soln 100 mg/ml cyclosporine, modified NEORAL GENGRAF tacrolimus HECORIA PROGRAF Rapamycin Derivative sirolimus RAPAMUNE tabs sirolimus RAPAMUNE soln Miscellaneous everolimus ZORTRESS Miscellaneous alitretinoin 1% gel PANRETIN PA bexarotene caps TARGRETIN PA, SP bexarotene topical gel TARGRETIN PA, SP cysteamine bitartrate CYSTAGON SP etoposide VEPESID hydroxyurea DROXIA hydroxyurea HYDREA mesna MESNEX tabs mitotane LYSODREN octreotide SANDOSTATIN SP olaparib LYNPARZA PA, SP pasireotide SIGNIFOR PA, SP procarbazine MATULANE SP sonidegib ODOMZO PA, SP tretinoin VESANOID SP, caps vismodegib ERIVEDGE PA, SP 6

Generic Name Brand Name Blood Modifiers - Anticoagulants Anticoagulants apixaban ELIQUIS dabigatran etexilate mesylate PRADAXA capsule, PA edoxaban SAVAYSA enoxaparin LOVENOX PA, QL, PA only applies for quantities greater than 14 days heparin HEPARIN rivaroxaban XARELTO warfarin COUMADIN Blood Cell Formation darbepoetin alfa ARANESP PA, SP epoetin alfa EPOGEN PROCRIT PA, SP filgrastim NEUPOGEN ZARXIO PA, SP pegfilgrastim NEULASTA PA, SP plerixafor MOZOBIL PA, SP sargramostim LEUKINE PA, SP TBO-Filgrastim GRANIX PA, SP Platelet Inhibitors anagrelide AGRYLIN aspirin BAYER OTC ECOTRIN cilostazol PLETAL clopidogrel PLAVIX QL dipyridamole PERSANTINE ticagrelor BRILINTA PA Miscellaneous aminocaproic acid AMICAR tabs & syrup only pentoxifylline extended-release TRENTAL 7

Generic Name Brand Name Cardiovascular Agents Ace Inhibitors benazepril LOTENSIN captopril CAPOTEN captopril CAPTOPRIL POWDER (bulk) powder enalapril VASOTEC enalapril oral soln EPANED Members 8 years of age will require prior authorization. fosinopril MONOPRIL QL lisinopril ZESTRIL QL moexipril UNIVASC perindopril ACEON quinapril ACCUPRIL QL ramipril ALTACE trandolapril MAVIK Ace Inhibitor/Diuretic Combinations benazepril/ LOTENSIN HCT hydrochlorothiazide captopril/ hydrochlorothiazide CAPOZIDE enalapril/ hydrochlorothiazide VASERETIC fosinopril/ hydrochlorothiazide MONOPRIL-HCT QL lisinopril/ hydrochlorothiazide ZESTORETIC QL moexipril/ hydrochlorothiazide UNIRETIC quinapril/ hydrochlorothiazide ACCURETIC QL Adrenolytics, Central clonidine CATAPRES clonidine transdermal CATAPRES-TTS PA guanfacine TENEX Alpha Blockers doxazosin CARDURA prazosin MINIPRESS terazosin HYTRIN Angiotensin II Receptor Blockers (Antagonists) irbesartan AVAPRO losartan COZAAR QL valsartan DIOVAN 8

Generic Name Brand Name Angiotensin II Receptor Blocker Combinations losartan/hctz HYZAAR QL olmesartan/ hydrochlorothiazide BENICAR HCT ST sacubitril/valsartan ENTRESTO PA valsartan/ hydrochlorothiazide DIOVAN HCT Antiarrhythmics and Cardiac Glycosides amiodarone PACERONE amiodarone tabs CORDARONE 200 mg and 400 mg disopyramide NORPACE disopyramide extended-release NORPACE CR dofetilide TIKOSYN dronedarone MULTAQ PA flecainide TAMBOCOR mexiletine MEXITIL propafenone RYTHMOL IR only quinidine gluconate extended-release EXT-REL QUINIDINE GLUCONATE quinidine sulfate QUINIDINE SULFATE quinidine sulfate QUINIDINE SULFATE extended-release EXT-REL Beta Blockers and Beta Blocker/Diuretic Combinations acebutalol SECTRAL atenolol TENORMIN atenolol/chlorthalidone TENORETIC bisoprolol ZEBETA bisoprolol/ hydrochlorothiazide ZIAC carvedilol COREG QL labetalol TRANDATE metoprolol LOPRESSOR metoprolol succinate TOPROL XL nadolol CORGARD pindolol PINDOLOL propranolol HEMANGEOL propranolol INDERAL IR only propranolol/hctz INDERIDE sotalol BETAPACE sotalol (AFIB/AFL) BETAPACE AF timolol maleate tablets 9

Generic Name Brand Name Calcium Channel Blockers Dihydropyridines amlodipine NORVASC QL felodipine extended-release PLENDIL QL isradipine DYNACIRC nicardipine CARDENE nifedipine PROCARDIA nifedipine ADALAT CC extended-release PROCARDIA XL QL nimodipine NIMOTOP QL nimodipine oral soln NYMALIZE nisoldipine SULAR sustained release Nondihydropyridines diltiazem CARDIZEM diltiazem CARDIZEM LA sustained release coated MATXIM LA beads, QL diltiazem CARDIZEM SR sustained release, QL diltiazem extended-release CARDIZEM CD QL diltiazem sustained-release CARDIZEM SR QL diltiazem DILACOR XR extended-release TIAZAC QL verapamil CALAN verapamil VERALAN PM sustained release caps, (100 mg, 200 mg and 300 mg only) verapamil extended-release CALAN SR QL Diuretics amiloride MIDAMOR amiloride/ hydrochlorothiazide MODURETIC bumetanide BUMEX chlorothiazide DIURIL chlorothiazide DIURIL ORAL SUSPENSION QL chlorthalidone CHLORTHALIDONE furosemide LASIX hydrochlorothiazide HYDROCHLOROTHIAZIDE soln, tabs hydrochlorothiazide MICROZIDE 12.5 mg caps 10

Generic Name Brand Name indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone SPIRONOLACTONE powder spironolactone/ hydrochlorothiazide ALDACTAZIDE torsemide DEMADEX triamterene/ DYAZIDE hydrochlorothiazide MAXZIDE Lipid Lowering Agents Bile Acid Resin cholestyramine QUESTRAN Only the bulk products are covered (cans). Individual QUESTRAN-LIGHT packets are not covered. coliestipol COLESTID Fibrates ANTARA fenofibrate LIPOFEN LOFIBRA TRICOR caps, tabs and micronized caps, ST TRIGLIDE gemfibrozil LOPID HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR lovastatin MEVACOR QL pravastatin PRAVACHOL QL simvastatin ZOCOR QL Niacins niacin NIACOR niacin extended-release NIASPAN Miscellaneous alirocumab PRALUENT PA, QL, SP ezetimibe ZETIA PA 11

Generic Name Brand Name Nitrates Oral isosorbide dinitrate ISORDIL DILATRATE-SR isosorbide dinitrate ISOCHRON extended-release ISOSORBIDE DINITRATE ER isosorbide mononitrate ISMO isosorbide mononitrate extended-release IMDUR nitroglycerin extended-release Sublingual isosorbide dinitrate ISORDIL S.L. nitroglycerin NITROLINGUAL nitroglycerin NITROSTAT Transdermal nitroglycerin NITREK NITRO-DUR transdermal, QL nitroglycerin NITRO-BID oint Potassium-Removing Agents sodium polysterene sulfonate KAYEXALATE susp (susp only) Miscellaneous ambrisentan LETAIRIS PA, SP bosentan TRACLEER PA, SP eplerenone INSPRA PA epoprostenol FLOLAN SP, Coverable through Medical Benefit guanabenz WYTENSIN hydralazine APRESOLINE iloprost VENTAVIS SP, Coverable through Medical Benefit methyldopa ALDOMET methyldopa/hctz ALDORIL midodrine PROAMATINE ST minoxidil LONITEN ranolazine RANEXA ST sildenafil REVATIO PA, SP tadalafil (PAH) ADCIRCA PA, SP 12

Generic Name Brand Name treprostinil REMODULIN treprostinil TYVASO Central Nervous System SP, Coverable through Medical Benefit SP, Coverable through Medical Benefit Alzheimer s Disease donepezil ARICEPT 5 mg and 10 mg, QL donepezil ARICEPT 23 mg, ST galantamine RAZADYNE QL memantine NAMENDA QL, Members <18 years of age will require prior authorization. memantine SR NAMENDA XR PA, QL rivastigmine EXELON QL Analgesics Barbiturate Non-Narcotic Analgesics butalbital/acetaminophen PHRENILIN QL butalbital/acetaminophen SEDAPAP QL ESGIC butalbital/acetaminophen/ FIORICET QL caffeine ZEBUTAL butalbital/aspirin/caffeine FIORINAL QL Non-Narcotic Analgesics acetaminophen TYLENOL OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE OTC tramadol ULTRAM QL NSAIDS diclofenac sodium delayed-release VOLTAREN diclofenac sodium SR VOLTAREN XR QL etodolac LODINE IR Only fenoprofen NALFON 400 mg fenoprofen NALFON 600 mg flurbiprofen ANSAID ibuprofen ADVIL tabs, chew tabs ibuprofen MOTRIN and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only 13

Generic Name Brand Name ketoprofen SR ORUDIS cap, 200 mg ketorolac tromethamine TORADOL QL meloxicam MOBIC QL nabumetone RELAFEN naproxen NAPROSYN ENTERIC COATEDnaproxen delayed release NAPROSYN naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Opioids Narcotic Analgesics butalbital/apap/caff/cod FIORICET W/CODEINE QL, 50-325-40-30 mg butalbital/asa/caff/cod FIORINAL W/CODEINE QL butorphanol STADOL nasal spray, QL codeine/acetaminophen TYLENOL W/CODEINE QL codeine sulfate QL fentanyl transdermal DURAGESIC QL LORCET hydrocodone/ acetaminophen LORTAB LORTAB ELIXIR NORCO VICODIN VICODIN ES VICOPROFEN hydrocodone ER ZOHYDRO ER ST hydromorphone DILAUDID QL meperidine DEMEROL QL methadone DOLOPHINE QL morphine MSIR QL morphine RMS QL morphine extended-release MS CONTIN QL oxycodone OXYFAST soln, QL oxycodone ROXICODONE QL oxycodone ER OXYCONTIN PA, QL, 15 mg, 30 mg, 60 mg oxycodone ER OXYCONTIN PA, QL oxycodone/ MAGNACET acetaminophen PERCOCET QL oxycodone/aspirin PERCODAN QL oxymorphone ER OXYMORPHONE ER QL, ST QL 14

Generic Name Brand Name Migraine Acute Therapy Ergotamine Derivatives dihydroergotamine D.H.E. 45 inj, QL dihydroergotamine MIGRANAL ergotamine/caffeine CAFERGOT ergotamine tartrate/ MIGERGOT caffeine SUPPOSITORIES QL Selective Serotonin Agonists naratriptan AMERGE ST rizatriptan MAXALT/MAXALT MLT QL sumatriptan IMITREX QL Migraine Prophylactic Therapy amitriptyline ELAVIL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE divalproex sodium delayed-release DEPAKOTE Minimum age 2 propranolol INDERAL IR only verapamil CALAN Multiple Sclerosis dimethyl fumarate TECFIDERA PA, QL, SP fingolimod GILENYA PA, QL, SP glatiramer acetate COPAXONE PA, QL, SP (40mg) glatiramer acetate COPAXONE GLATOPA PA, QL, SP (20mg) interferon beta-1a AVONEX/AVONEX PEN QL, SP interferon beta-1a REBIF SP interferon beta-1b BETASERON EXTAVIA PA, SP teriflunomide AUBAGIO PA, SP Myasthenia Gravis pyridostigmine MESTINON tabs pyridostigmine MESTINON syrup pyridostigmine extended-release MESTINON TIMESPAN Parkinson s Disease amantadine SYMMETREL except tabs benztropine COGENTIN bromocriptine PARLODEL carbidopa/levodopa SINEMET 15

Generic Name Brand Name carbidopa/levodopa extended-release SINEMET CR entacapone COMTAN pramipexole MIRAPEX pramipexole dihydrochloride SR MIRAPEX ER 24hr tab ropinirole REQUIP ropinirole hydrochloride SR REQUIP XL 24hr tab selegiline ELDEPRYL tabs tolcapone TASMAR trihexyphenidyl ARTANE Seizures carbamazepine TEGRETOL carbamazepine CARBATROL extended-release TEGRETOL-XR carbamazepine SR EPITOL EQUATRO clobazam ONFI ST clobazam suspension ONFI SUSPENSION PA clonazepam KLONOPIN ODT tabs clonazepam KLONOPIN tabs diazepam DIASTAT ACUDIAL rectal gel, QL diazepam DIASTAT PEDIATRIC divalproex sodium cap sprinkle DEPAKOTE SPRINKLE divalproex sodium delayed-release DEPAKOTE Minimum age 2 ethosuximide ZARONTIN exogabine POTIGA Age Limits Apply, ST felbamate FELBATOL felbamate oral susp FELBATOL ORAL SUSP gabapentin NEURONTIN caps and tabs only lacosamide VIMPAT Age Limits Apply, ST lacosamide solution VIMPAT PA lamotrigine LAMICTAL QL lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB lamotrigine dispersible tab LAMICTAL ODT KIT PA lamotrigine ODT LAMICTAL ODT PA lamotrigine SR LAMICTAL XR tab lamotrigine SR ODT LAMICTAL XR ODT KIT PA 16

Generic Name Brand Name lamotrigine starter kit LAMICTAL STARTER KIT lamotrigine titration kit LAMICTAL XR KIT PA levetiracetam KEPPRA QL levetiracetam SR KEPPRA XR methsuximide CELONTIN oxcarbazepine TRILEPTAL QL phenobarbital PHENOBARBITAL phenytoin DILANTIN INFATABS phenytoin sodium DILANTIN extended PHENYTEK pregabalin LYRICA PA pregabalin LYRICA SOLUTION oral solution, PA primidone MYSOLINE rufinamide BANZEL tablets only, QL, ST rufinamide suspension BANZEL SUSPENSION PA tiagabine GABITRIL ge Limits Apply, ST, 2mg & 4mg tiagabine GABITRIL Age Limits Apply, ST, 12mg & 16mg topiramate TOPAMAX QL topiramate sprinkle caps TOPAMAX SPRINKLE QL valproic acid DEPAKENE vigabatrin oral solution SABRIL SOLUTION PA, SP zonisamide ZONEGRAN QL Miscellaneous tetrabenazine XENAZINE PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE Max Age of 25, PA Topical azelaic acid FINACEA gel benzoyl peroxide BENZAC AC benzoyl peroxide BENZEFOAM foam 5.3% & 9.8% benzoyl peroxide BREVOXYL gel 4%, 8% benzoyl peroxide DELOS cleanser 3.5%, OTC benzoyl peroxide NEOBENZ MICR LIQ liquid 7% benzoyl peroxide OC8 gel 7%, OTC benzoyl peroxide PANOXYL CREAM OTC cream 2.5%, OTC benzoyl peroxide TRIAZ CLOTHS cloth 3%, 6%, 9% benzoyl peroxide bar 10% PANOXYL BAR OTC OTC 17

Generic Name benzoyl peroxide creamy wash 8% & benzoyl peroxide bar 5% k benzoyl peroxide gel benzoyl peroxide wash 4% & benzoyl peroxide bar 5% kit Brand Name BPO CREAMY KIT BENZIQ LS BENZIQ BREVOXYL 2.75%, 5.25% BREVOXYL-4 OTC OTC clindamycin CLEOCIN T gel clindamycin CLEOCIN T lotion clindamycin CLEOCIN T soln erythromycin ERYGEL gel 2% erythromycin T-STAT soln erythromycin/benzoyl peroxide salicylic acid BENZAMYCIN CLEAN & CLEAR GEL NEUTROGENA RAPID CLEAR GEL gel 2%, OTC EXUVIANCE salicylic acid KERALYT gel 3, 6% salicylic acid STRI-DEX AVEENO CLEAR PADS OTC pad 0.5%, 1&, 2%, OTC salicylic acid NEUTROGENA OIL FREE ACNE WASH liquid 2%, OTC salicylic acid SALEX lotion 6% sulfacetamide/sulfur SULFACET-R lotion sulfacetamide sodium KLARON LOTION SEBIZON lotion 10% sulfacetamide/sulfur PLEXION ATRALIN tretinoin AVITA RETIN-A Bacterial Infections bacitracin BACITRACIN OTC bacitracin-polymyxinneomycin HC CORTISPORIN OINTMENT oint 1% gentamicin GENTAK mupirocin BACTROBAN ointment, 22 gram tube only 18

Generic Name Brand Name neomycin/polymyxin B/ bacitracin NEOSPORIN OTC silver sulfadiazine SILVADENE Corticosteroids Low Potency alclometasone ACLOVATE 0.05% crm/oint fluocinolone acetonide DERMA-SMOOTHE OIL/FS oil 0.01% fluocinolone acetonide CAPEX SHAMOO shampoo 0.01% fluocinolone acetonide SYNALAR soln/crm 0.01% hydrocortisone CORTAID SOLUTION OTC soln 1%, OTC hydrocortisone CORTIZONE crm, oint, lot OTC hydrocortisone HYTONE crm 0.5%, 1%, & 2.5% hydrocortisone HYTONE lotion 1% & 2.5% hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING crm 0.5% & 1%, OTC Medium Potency betamethasone val. BETA-VAL crm/oint/lotion 0.1% fluocinolone acetonide SYNALAR crm, oint 0.025% flurandrenolide CORDRAN tape fluticasone propionate CUTIVATE crm 0.05%, oint 0.005% fluticasone propionate CUTIVATE LOTION lotion 0.05% hydrocortisone butyrate LOCOID crm/lotion/oint 0.1% hydrocortisone valerate WESTCORT crm/oint 0.2% mometasone furoate ELOCON crm/oint/soln 0.1% prednicarbate DERMATOP crm 0.1% triamcinolone acetonide KENALOG crm/lot/oint 0.025% triamcinolone acetonide KENALOG crm/oint/lotion 0.1% triamcinolone acetonide TRIANEX oint 0.05% High Potency betamethasone augmented dip DIPROLENE lotion 0.05% betamethasone augmented dip DIPROLENE AF crm 0.05% betamethasone dipropionate DIPROSONE crm/lotion/oint 0.05% diflorasone diacetate PSORCON CREAM cream 0.05% diflorasone diacetate PSORCON OINTMENT oint 0.05% fluocinonide LIDEX crm/oint/gel/soln 0.05% fluocinonide emulsified base LIDEX E crm 0.05% triamcinolone acetonide KENALOG crm 0.5% 19

Generic Name Brand Name Very High Potency betamethasone dip augmented DIPROLENE gel 0.05% betamethasone dip augmented DIPROLENE oint 0.05% clobetasol propionate TEMOVATE crm/gel/oint/soln 0.05% Fungal Infections ciclopirox PENLAC SOLUTION 8% clotrimazole LOTRIMIN AF OTC clotrimazole MYCELEX clotrimazole crystals CLOTRIMAZOLE clotrimazole with LOTRISONE betamethasone ketoconazole NIZORAL ketoconazole foam EXTINA 2% ketoconazole gel XOLEGEL 2% ketoconazole gel 2% & hydrocortisone gel 1% kit ketoconazole gel 2% & pyrithione zinc shampoo 1% kit XOLEGEL KIT XOLEGEL DUO KIT ketoconazole shampoo NIZORAL A-D OTC 1% OTC miconazole DESENEX 2% OTC miconazole MICATIN OTC miconazole MONISTAT-DERM miconazole nitrate kit FUNGOID TINCTURE KIT 2% miconazole nitrate lotion ZEASORB-AF 2% OTC miconazole nitrate soln AZOLEN TINCTURE SOLUTION OTC 2% OTC nystatin MYCOSTATIN terbinafine LAMISIL AT OTC terbinafine gel LAMISIL GEL 1% terbinafine HCL LAMISIL SOLUTION soln 1% tolnaftate TINACTIN OTC Psoriasis acitretin SORIATANE oral caps, PA calcipotriene DOVONEX calcitriol VECTICAL methoxsalen OXSORALEN-ULTRA salicylic acid SCALPICIN liquid 3% 20

Generic Name Brand Name Rosacea brimonidine MIRVASO PA METROCREAM metronidazole METROGEL METROLOTION Scabies and Pediculosis crotamiton EURAX ivermectin SKLICE lotion 0.5%, PA malathion OVIDE permethrin ELIMITE 5%, QL permethrin NIX CREME RINSE 1%, OTC pyrethrins/piperonyl but RID SHAMPOO/ BUTOXIDE SHAMPOO 4% OTC spinosad NATROBA susp 0.9%, PA Viral Infections podofilox CONDYLOX SOL sol salicylic acid 17%/collodion DUOFILM OTC Miscellaneous aluminum acetate soln/cream, OTC aluminum chloride DRYSOL OTC soln 12%, OTC aluminum chloride hexahydrate HYPERCARE 20% ammonium lactate LAC-HYDRIN crm 12%, lotion 5% & 12% ammonium lactate LACTINOL lotion 10% becaplermin gel REGRANEX PA calamine lotion/ointment, OTC collagenase oint SANTYL QL fluorouracil CARAC 0.5% cream fluorouracil EFUDEX fluorouracil FLUOROPLEX 1% cream hexachlorophene PHISOHEX hydrocortisone PROCTO-PAK CREAM rectal cream 1% PROCTOSOL HC CREAM 2.5% hydrocortisone PROCTOZONE CREAM-HC 2.5% ANUSOL HC 2.5% hydrocortisone acetate CORTIFOAM AEROSOL rectal foam 90 mg hydrocortisone acetate TUCKS OINTMENT OTC rectal ointment 21

Generic Name Brand Name hydrocortisone acetate w/pramoxine PROCTOFOAM HC FOAM rectal foam 1-1% imiquimod 5% cream ALDARA PA ketoconazole NIZORAL SHAMPOO shampoo 2% lidocaine LIDAMANTEL 3% cream lidocaine LMX-4 4% cream (15 gm tubes), QL lidocaine XYLOCAINE jelly 2% lidocaine XYLOCAINE oint 5% lidocaine patch LIDODERM PATCH 5%, PA lidocaine/prilocaine EMLA 2.5% cream lidocaine-prilocaine EMLA kit 2.5-2.5% nitroglycerin RECTIV 0.4% rectal ointment, PA pimecrolimus ELIDEL cream QL, ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age pimecrolimus ELIDEL cream QL, ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age salicylic acid CALICYLIC cream 10% P & S SHAMPOO salicylic acid SELSUN BLUE shampoo 2%, 3% OTC DHS SAL SHAMPOO OTC salicylic acid SALAC OTC foam 2%, OTC salicylic acid SALACYN 6% cream, lotion salicylic acid SALVAX foam 6% salicylic acid SALEX shampoo 6% selenium sulfide SELSUN shampoo 2.5% ointment 0.03% ST, Step therapy is not required for tacrolimus PROTOPIC 0.03% members ages 2-11; not covered for members less than 2 years of age tacrolimus PROTOPIC 0.1% ointment 0.1%, ST (minimum age 16) urea 40% UREA 40% CREAM AND LOTION cream and lotion 22

Generic Name Brand Name Ear, Nose & Throat Ear acetic acid VOSOL OTIC otic acetic acid/ DOMEBORO OTIC aluminum acetate acetic acid/ hydrocortisone VOSOL HC OTIC antipyrine-benzocaine AURALGAN otic soln 55-14 mg/ml (5.5-1.4%) benzocaine/antipyrine BENZOTIC carbamide peroxide DEBROX 6.5%, OTC ciprofloxacin/ CIPRODEX PA dexamethasone neomycin/polymyxin B/ hydrocortisone CORTISPORIN OTIC otic ofloxacin FLOXIN OTIC Nose Antihistamines - First Generation, Sedating brompheniramine maleate J-TAN PD drops 1 mg/ml brompheniramine maleate RESPA-BR tab SR 12hr 11 mg brompheniramine tannate BROVEX CT chew tab 12 mg chlorpheniramine CHLOR-TRIMETON extended-release ALLERGY chlorpheniramine maleate CHLOR-TRIMETON 12 mg, OTC 2 mg/5 ml, OTC SYRUP chlorpheniramine maleate CHLORPHENIRAMINE drops 2 mg/ml chlorpheniramine maleate CHLORPHENIRAMINE tabs 4 mg chlorpheniramine tannate CHLORPHENIRAMINE susp 2 mg/ml chlorpheniramine tannate CHLORPHENIRAMINE tabs clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE dexchlorpheniramine POLARAMINE syrup 2 mg/5ml maleate diphenhydramine diphenhydramine BENADRYL OTC diphenhydramine BENADRYL tab disp 12.5 mg diphenhydramine TRIAMINIC oral strips hydroxyzine HCL ATARAX hydroxyzine pamoate VISTARIL 23

Generic Name Brand Name Antihistamines - Second Generation, Non-Sedating cetirizine ZYRTEC OTC cetirizine chew tab ZYRTEC CHEWABLE TAB- LET fexofenadine ALLEGRA tabs levocetirizine XYZAL tabs, ST loratadine ALAVERT CLARITIN OTC loratadine CLARITIN CHEW chew tab 5 mg loratadine CLARITIN RDT ODT 5 mg Antihistamines - Others Antihistamine/Decongestant Combinations azelastine ASTELIN spray Antihistamine/Decongestant Combinations - First Generation brompheniramine/ pseudoephedrine LODRANE D cap 4-60 mg chlorpheniramine/ phenylephrine/ TRIOTANN pyrilamine chlorpheniramine/ pseudoephedrine ACTIFED OTC Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride ZYRTEC-D 5 mg-120 mg tablet 12 hours extended-release fexofenadine/ pseudoephedrine ALLEGRA-D SR tabs loratadine/ pseudoephedrine extended-release ALAVERT-D ALAVERT ALRG TAB/SINUS ALLERGY/CONG Nasal Steroids fluticasone FLONASE triamcinolone acetonide NASACORT AQ PA triamcinolone nasal spray NASACORT ALLERGY 24 HOUR OTC OTC Miscellaneous Nasal cromolyn sodium NASALCROM OTC ipratropium bromide ATROVENT NS saline nasal spray 0.65% OCEAN NASAL SPRAY OTC 24

Generic Name Brand Name Miscellaneous Nasal Decongestants oxymetazoline AFRIN OTC phenylephrine NEO-SYNEPHRINE DIMEATAPP DRO OTC DECONGES Throat and Mouth amlexanox APHTHASOL oral paste 5% chlorhexidine PERIOGARD chlorhexidine gluconate PERIDEX lidocaine viscous XYLOCAINE pilocarpine SALAGEN triamcinolone KENALOG IN ORABASE paste Endocrinology Adrenal Corticosteroids cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF hydrocortisone inj SOLU-CORTEF SP, Coverable through Medical Benefit methylprednisolone MEDROL 4mg, 8mg, 16mg, 32mg methylprednisolone MEDROL 2mg methylprednisolone inj SOLU-MEDROL SP, Coverable through Medical Benefit prednisolone prednisolone PRELONE syrup prednisolone sodium ORAPRED phosphate PEDIAPRED prednisone DELTASONE prednisone PREDNISONE conc 5 mg/ml prednisone RAYOS tabs delayed release triamcinolone inj KENALOG-40 SP, Coverable through Medical Benefit Androgens fluoxymesterone ANDROXY PA testosterone ANDRODERM patch 2 mg and 4 mg, PA testosterone ANDROGEL 1.62% gel, PA testosterone cypionate DEPO-TESTOSTERONE testosterone enanthate DELATESTRYL Vials only. Disposable syringes not covered. testosterone gel TESTIM PA 25

Generic Name testosterone gel topical tube, packet, and pump bottle Brand Name TESTOSTERONE 1% TOPI- CAL GEL testotesterone ANDROGEL 1% gel (not pump), PA Diabetes Mellitus Glucose Elevating Agents glucagon, human GLUCAGON QL recombinant Insulins insulin aspart NOVOLOG QL insulin aspart NOVOLOG FLEXPEN PA, QL insulin aspart protamine 70%/insulin aspart 30% insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 QL NOVOLOG MIX 70/30 FL- EXPEN PA PA, QL insulin detemir LEVEMIR PA, QL insulin detemir LEVEMIR FLEXPEN PA, QL insulin glargine LANTUS QL insulin glargine LANTUS SOLOSTAR PA, QL insulin glargine TOUJEO SOLOSTAR 300 units/ml insulin human NOVOLIN R OTC, QL insulin human RELION R OTC, QL insulin isophane HUMULIN N OTC, QL insulin isophane human HUMULIN N PEN PA, QL insulin isophane human NOVOLIN N OTC, QL insulin isophane human RELION N OTC, QL insulin isophane human 70%/regular 30% NOVOLIN 70/30 OTC, QL insulin isophane human 70%/regular 30% RELION 70/30 OTC, QL insulin isophane/regular HUMULIN 70/30 OTC, QL insulin lisopro pro/lispro HUMALOG MIX 50/50 QL insulin lispro prot 50%/lispro 50% KWIKPEN HUMALOG MIX 50/50 PA, QL insulin lisopro prot/lispro HUMALOG MIX 75/25 QL insulin lispro HUMALOG QL insulin lispro HUMALOG KWIKPEN PA, QL insulin lispro prot 75%/lispro 25% KWIKPEN HUMALOG MIX 72/25 PA, QL insulin regular HUMULIN R OTC, QL 26