Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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 phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl VYVANSE

AMINOGLYCOSIDES AMIKACIN [INJ] 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 OTEZLA oxaprozin piroxicam RINVOQ 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

ANALGESICS - OPIOID acetaminophen/codeine alfentanil hcl [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

BELBUCA buprenorphine [INJ] buprenorphine/naloxone butalbital compound/codeine butalbital/caff/apap/codeine butorphanol [INJ] codeine sulfate dihydrocodeine/aspirin/caffeine fentanyl citrate hydrocodone bitartrate er 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 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 albendazole 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 XENLETA XIFAXAN

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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 sulfate albuterol sulfate hfa aminophylline [INJ] ANORO ELLIPTA

ARNUITY ELLIPTA ASMANEX, HFA BREO ELLIPTA COMBIVENT RESPIMAT DALIRESP FLOVENT DISKUS FLOVENT HFA fluticasone-salmeterol INCRUSE ELLIPTA ipratropium bromide ipratropium-albuterol ipratropium/albuterol nebulization levalbuterol hcl metaproterenol sulfate montelukast sodium NUCALA PERFOROMIST [INJ] PROAIR RESPICLICK PULMICORT FLEXHALER QVAR QVAR REDIHALER SEREVENT DISKUS SPIRIVA HANDIHALER 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] heparin sodium syringe PRADAXA

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 rufinamide ROWEEPRA ROWEEPRA XR tiagabine hcl topiramate topiramate er 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 BAQSIMI FARXIGA FIASP FIASP FLEXTOUCH glimepiride glipizide glipizide er glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON glyburide glyburide micronized glyburide/metformin HUMULIN R 500 UNITS [INJ] [OTC] HUMULIN R U-500 KWIKPEN

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

insulin lispro INVOKAMET INVOKAMET XR INVOKANA JANUMET JANUMET XR JANUVIA JENTADUETO JENTADUETO XR LANTUS [INJ] LANTUS SOLOSTAR [INJ] LEVEMIR [INJ] LEVEMIR, FLEXTOUCH metformin hcl metformin hcl er miglitol 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 RYBELSUS 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 deferasirox deferiprone 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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

fluconazole fluconazole in dextrose fluconazole in saline flucytosine griseofulvin griseofulvin ultramicrosize itraconazole ketoconazole micafungin sodium nystatin NYSTATIN 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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

methyldopate hcl [INJ] metoprolol/hydrochlorothiazide metyrosine minoxidil moexipril hcl moexipril/hydrochlorothiazide nadolol-bendroflumethiazide olmesartan medoxomil olmesartan medoxomil/hctz olmesartan/amlodipine/hctz perindopril erbumine 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 hydroxychloroquine sulfate mefloquine hcl primaquine pyrimethamine quinine sulfate

ANTIMYASTHENIC AGENTS guanidine hcl neostigmine methylsulfate [INJ] pyridostigmine bromide

ANTIMYCOBACTERIAL AGENTS ethambutol hcl isoniazid pyrazinamide

rifabutin

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

abiraterone acetate 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 everolimus exemestane floxuridine [INJ] fludarabine phosphate [INJ] flutamide fulvestrant HEXALEN hydroxyprogesterone caproate hydroxyurea ifosfamide-mesna imatinib mesylate

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

INTRON A [INJ] lapatinib ditosylate letrozole leucovorin calcium LEUKERAN levoleucovorin calcium [INJ] LYSODREN MATULANE megestrol acetate melphalan hcl mercaptopurine MESNEX MESNEX 400MG TABLET methotrexate mitomycin MYLERAN nilutamide ONTAK [INJ] SPRYCEL SUTENT tamoxifen citrate TASIGNA temsirolimus 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 ANTIPARKINSON AND RELATED THERAPY

AGENTS NOURIANZ

ANTIPSYCHOTICS/ANTIMANIC AGENTS ABILIFY MAINTENA, ER aripiprazole odt aripiprazole tablets asenapine maleate 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 REXULTI risperidone thioridazine hcl thiothixene trifluoperazine hcl ziprasidone hcl

ANTISEPTICS & DISINFECTANTS chlorhexidine gluconate

ANTIVIRALS abacavir abacavir/lamivudine

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

abacavir/lamivudine/zidovudine acyclovir adefovir dipivoxil atazanavir sulfate capsule cidofovir [INJ] didanosine efavirenz efavirenz/emtricitab/tenofovir efavirenz/lamivudine/tenofovir emtricitabine entecavir famciclovir fosamprenavir calcium lamivudine hbv lamivudine/zidovudine lopinavir/ritonavir oseltamivir phosphate PEGASYS [INJ] PEGASYS PROCLICK [INJ] ribavirin inh rimantadine hcl ritonavir stavudine SUSTIVA tenofovir disoproxil 300mg tablet valacyclovir valganciclovir hcl zidovudine

ASSORTED CLASSES alprostadil [INJ] azathioprine azathioprine sodium [INJ] CELLCEPT 500MG VIAL [INJ] cyclosporine [INJ] DEPEN ETHAMOLIN everolimus mycophenolate acid del rel mycophenolic acid del rel penicillamine 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 NURTEC UBRELVY

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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 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 eluryng ring emoquette enpresse enskyce errin estarylla etonogestrel-ethinyl estradiol ring falmina gianvi gildagia gildess gildess fe heather introvale jencycla jolessa jolivette junel

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 norethin-eth estra ferrous fum norethindrone/eth estradiol/iron norethindrone/ethinyl estradiol nortrel ocella ogestrel orsythia philith pirmella portia quasense reclipsen sprintec sronyx syeda tilia fe tri-estarylla tri-legest fe tri-linyah trinessa

trivora velivet 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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 azelaic benzoyl peroxide betamethasone dipropionate augment betamethasone valerate calcipotriene calcipotriene-betameth diprop calcitriol [INJ] ciclopirox clindamycin phos-tretinoin clindamycin phosphate topical clindamycin/benzoyl peroxide clobetasol e clobetasol propionate clotrimazole clotrimazole/betamethasone cocaine hcl COCAINE HCL COSENTYX dapsone gel desonide desoximetasone diclofenac epolamine diclofenac sodium gel diflorasone diacetate econazole nitrate eletone emulsion sb

EPIDUO EPIDUO FORTE erythromycin solution erythromycin-benzoyl peroxide ETHYL ALCOHOL FLECTOR 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 isotretinoin ivermectin lactic acid LACTIC ACID 88 TO 92 % lidocaine lidocaine hcl lidocaine/prilocaine lindane mafenide acetate malathion mb hydrogel metronidazole mometasone furoate mupirocin nystatin w/triamcinolone ONEXTON OXSORALEN 1% LOTION permethrin podofilox primecrolimus pruclair prumyx

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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

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 Dopamine and Norepinephrine Reuptake

Inhibitors (DNRIs) SUNOSI

ENDOCRINE AND METABOLIC AGENTS - MISC.

alendronate sodium cabergoline calcitonin salmon nasal cinacalcet hcl clomiphene citrate desmopressin acetate [INJ] doxercalciferol etidronate disodium FOLLISTIM AQ GENOTROPIN ibandronate [INJ] levocarnitine

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

nitisinone octreotide acetate OMNITROPE ORILISSA paricalcitol PROLIA risedronate dr risedronate sodium sapropterin dihydrochloride sodium phenylbutyrate tolvaptan TYMLOS vasopressin [INJ] vasopressin-ns zoledronic acid

Estrogen-Progestin-GnRH Antagonist ORIAHNN

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] moxifloxacin hcl ofloxacin

ofloxacin tablets

GASTROINTESTINAL AGENTS - MISC.

balsalazide disodium calcium acetate lanthanum carbonate LINZESS mesalamine metoclopramide hcl 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 silodosin tamsulosin hcl er 24 hr

Glycopeptides vancomycin hcl [INJ] VANCOMYCIN HCL [INJ]

GOUT AGENTS allopurinol allopurinol sodium febuxostat

Preferred Drug List

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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 miglustat multigen multigen folic 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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 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 almotriptan malate dihydroergotamine mesylate eletriptan hbr ergoloid mesylates ergotamine-caffeine frovatriptan succinate naratriptan hcl REYVOW rizatriptan rizatriptan disintegrating tablets sumatriptan succinate sumatriptan-naproxen TOSYMRA 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 klor-con 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]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

potassium bicarbonate POTASSIUM BICARBONATE potassium chl-normal saline [INJ] potassium chloride POTASSIUM CHLORIDE potassium chloride er 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 b-complex bal-care dha 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 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 rena-vite rx renal caps reno caps se-natal 19 strovite taron-bc

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 dantrolene sodium methocarbamol orphenadrine citrate [INJ] orphenadrine compound SYNVISC-ONE tizanidine hcl NASAL AGENTS - SYSTEMIC AND TOPICAL

azelastine hcl azelastine-fluticasone 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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 moxifloxacin hcl 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 travoprost trifluridine tropicamide XIIDRA

Ophthalmic Kinase Inhibitors - Combinations

ROCKLATAN

Orexin Receptor Antagonists BELSOMRA

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 ciprofloxacin hcl CIPROFLOXACIN HCL ciprofloxacin/dexamethasone 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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 AUSTEDO AVONEX [INJ] BAFIERTAM BETASERON bupropion er (12 hour) dalfampridine er dimethyl fumarate disulfiram donepezil hcl galantamine

GILENYA glatiramer acetate memantine memantine dose pack NAMZARIC THERAPY PACK olanzapine/fluoxetine hcl perphenazine/amitriptyline PLEGRIDY rivastigmine SAVELLA tetrabenazine VUMERITY XYREM ZEPOSIA

Pulmonary Hypertension - Prostacyclin Receptor Agonist

UPTRAVI

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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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

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 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

VITAMINS ascorbic acid [INJ] ASCORBIC ACID [INJ] phytonadione PHYTONADIONE pyridoxine hcl PYRIDOXINE HCL thiamine hcl

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [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 22

vitamin a VITAMIN A VITAMINS, HEMATINICS & ELECTROLYTES

elite-ob 400 folivane-f

X-Linked Hypophosphatemia (XLH) Treatment - Agents

CRYSVITA