Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

Anti-Infectives abacavir abacavir sulfate/lamivudine abacavir/lamivudine/zidovudine acyclovir adefovir dipivoxil ALBENZA ALINIA amantadine hcl AMANTADINE HCL POWDER AMBISOME [INJ] AMIKACIN [INJ] AMIKACIN POWDER [INJ] amoxicillin AMOXICILLIN POWDER amoxicillin/clavulanate er amphotericin [INJ] AMPHOTERICIN POWDER [INJ] ampicillin [INJ] ampicillin/sulbactam [INJ] APTIVUS atovaquone atovaquone/proguanil hcl ATRIPLA AUGMENTIN 125-31.25 MG/5ML AVELOX IV [INJ] AVYCAZ AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] azithromycin [INJ] AZITHROMYCIN POWDER [INJ] aztreonam [INJ] bacitracin [INJ] BACITRACIN POWDER [INJ] BETHKIS BICILLIN C-R [INJ] BICILLIN L-A [INJ] BILTRICIDE CANCIDAS [INJ] CAPASTAT SULFATE [INJ] CAYSTON cefaclor cefazolin [INJ] cefdinir

cefepime [INJ] cefotaxime [INJ] cefotetan [INJ] cefoxitin [INJ] cefoxitin/dextrose [INJ] cefpodoxime proxetil cefprozil ceftazidime CEFTAZIDIME IV PIGGYBACK ceftibuten ceftriaxone [INJ] CEFUROXIME 75G BULK BAG cefuroxime axetil cefuroxime sodium cephalexin CHLORAMPHENICOL [INJ] chloroquine phosphate CHLOROQUINE PHOSPHATE POWDER cidofovir [INJ] ciprofloxacin ciprofloxacin er ciprofloxacin suspension ciprofloxacin/dextrose [INJ] clarithromycin clarithromycin er CLARITHROMYCIN POWDER clindamycin hcl CLINDAMYCIN HCL POWDER clindamycin palmitate hcl clindamycin phosphate [INJ] CLINDAMYCIN PHOSPHATE [INJ] clindamycin phosphate/dextrose [INJ] COARTEM colistimethate [INJ] COLISTIMETHATE POWDER [INJ] COMPLERA CRESEMBA CRIXIVAN CUBICIN RF DAKLINZA DALVANCE [INJ] dapsone DAPSONE POWDER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

daptomycin DARAPRIM demeclocycline hcl DEMECLOCYCLINE HCL POWDER DESCOVY dicloxacillin sodium didanosine DORIBAX doxycycline hyclate DOXYCYCLINE HYCLATE POWDER doxycycline monohydrate EDURANT EMTRIVA EMVERM entecavir EPCLUSA ERYTHROCIN LACTOBIONATE [INJ] erythromycin erythromycin del rel erythromycin ethylsuccinate ERYTHROMYCIN ETHYLSUCCINATE POWDER ERYTHROMYCIN POWDER erythromycin stearate erythromycin/sulfisoxazole ethambutol hcl famciclovir fluconazole fluconazole in dextrose fluconazole in saline FLUCONAZOLE POWDER flucytosine FLUCYTOSINE POWDER FORTAZ IN ISO-OSMOTIC DEXTROSE [INJ] foscarnet sodium FUZEON [INJ] ganciclovir gentamicin sulfate [INJ] gentamicin sulfate in ns GENTAMICIN SULFATE IN NS 100MG/50ML GENVOYA griseofulvin GRISEOFULVIN POWDER griseofulvin ultramicrosize

hydroxychloroquine sulfate HYDROXYCHLOROQUINE SULFATE POWDER imipenem-cilastatin [INJ] IMPAVIDO INTELENCE INVANZ [INJ] INVIRASE ISENTRESS isoniazid ISONIAZID POWDER itraconazole ITRACONAZOLE POWDER ivermectin IVERMECTIN POWDER KALETRA TABLETS kanamycin sulfate [INJ] KANAMYCIN SULFATE POWDER [INJ] ketoconazole KETOCONAZOLE POWDER KITABIS PAK LAMISIL lamivudine lamivudine hbv lamivudine/zidovudine LEVOFLOXACIN HEMIHYDRATE POWDER levofloxacin/d5w [INJ] LEXIVA linezolid lopinavir-ritonavir oral soln mefloquine hcl MEROPENEM - 0.9% NACL [INJ] methenamine hippurate methenamine mandelate METHENAMINE MANDELATE POWDER methylene blue [INJ] metronidazole METRONIDAZOLE POWDER [INJ] MINOCIN 100MG VIAL minocycline hcl minocycline hcl er MINOCYCLINE HCL POWDER moxifloxacin hcl MOXIFLOXACIN HCL IV PIGGYBACK

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

MYCAMINE [INJ] nafcillin dextrose [INJ] nafcillin sodium [INJ] NEBUPENT [INJ] neomycin sulfate NEOMYCIN SULFATE POWDER nevirapine er nitrofurantoin nitrofurantoin macrocrystal NITROFURANTOIN POWDER NORVIR NOXAFIL nystatin NYSTATIN ocudox ODEFSEY ofloxacin tablets ORACEA oseltamivir phosphate capsule oxacillin sodium [INJ] paromomycin sulfate PAROMOMYCIN SULFATE POWDER penicillin g potassium [INJ] penicillin g procaine penicillin g sodium [INJ] PENICILLIN GK-ISO-OSM DEXTROSE penicillin v potassium piperacillin-tazobactam [INJ] polymyxin b sulfate [INJ] POLYMYXIN B SULFATE POWDER [INJ] PREZISTA PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate QUININE SULFATE POWDER RAPIVAB RELENZA RESCRIPTOR RETROVIR VIAL [INJ] REYATAZ ribavirin RIBAVIRIN POWDER

rifabutin rimantadine hcl SELZENTRY SIRTURO SIVEXTRO VIAL [INJ] SOLODYN ER SOVALDI SPORANOX SOLUTION stavudine STREPTOMYCIN SULFATE [INJ] STRIBILD sulfadiazine SULFADIAZINE POWDER sulfamethoxazole/trimethoprim SUSTIVA SYNERCID [INJ] TAMIFLU ORAL SUSPENSION TECHNIVIE TEFLARO [INJ] terbinafine TERBINAFINE TETRACYCLINE TIMENTIN [INJ] tinidazole TINIDAZOLE POWDER TIVICAY TOBI PODHALER tobramycin sulfate [INJ] tobramycin sulfate in ns TOBRAMYCIN SULFATE POWDER [INJ] trimethoprim TRIMETHOPRIM POWDER TRIUMEQ TRUVADA TYGACIL [INJ] TYZEKA valacyclovir VALACYCLOVIR POWDER valganciclovir hcl vancomycin hcl [INJ] VANCOMYCIN HCL [INJ] VEMLIDY VIBATIV [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

VICTRELIS VIDEX VIRACEPT VIREAD voriconazole VORICONAZOLE POWDER XIFAXAN ZEPATIER ZERBAXA ZIAGEN SOLUTION zidovudine ZOSYN IV SOLUTION [INJ]

Antineoplastic & Immunosuppresants ABRAXANE [INJ] ADCETRIS [INJ] AFINITOR AFINITOR DISPERZ ALIMTA [INJ] ALKERAN 2MG amifostine [INJ] anastrozole ANASTROZOLE POWDER ARRANON [INJ] ARZERRA [INJ] AVASTIN [INJ] azacitidine [INJ] AZASAN azathioprine AZATHIOPRINE POWDER azathioprine sodium [INJ] BAVENCIO BENDEKA BEXXAR 14MG/ML [INJ] bicalutamide BICNU [INJ] bleomycin [INJ] BLINCYTO BOSULIF BUSULFEX [INJ] calcium folinate [INJ] CALCIUM FOLINATE POWDER [INJ] capecitabine

CAPRELSA carboplatin [INJ] CEENU CELLCEPT 500MG VIAL [INJ] cisplatin [INJ] CISPLATIN POWDER [INJ] cladribine [INJ] CLOLAR [INJ] COTELLIC cyclophosphamide [INJ] CYCLOPHOSPHAMIDE [INJ] cyclosporine [INJ] CYCLOSPORINE POWDER [INJ] CYRAMZA cytarabine [INJ] dacarbazine [INJ] dactinomycin [INJ] DARZALEX daunorubicin [INJ] DAUNOXOME [INJ] decitabine [INJ] DEPOCYT [INJ] dexrazoxane [INJ] DOCEFREZ [INJ] docetaxel [INJ] doxorubicin hcl [INJ] doxorubicin hcl liposomal [INJ] DROXIA ELIGARD ELITEK [INJ] ELSPAR EMCYT epirubicin hcl [INJ] ERBITUX [INJ] ERIVEDGE ETOPOPHOS [INJ] etoposide ETOPOSIDE POWDER exemestane FARESTON FASLODEX FIRMAGON floxuridine [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

FLOXURIDINE POWDER [INJ] fludarabine phosphate [INJ] flutamide FOLOTYN [INJ] GAZYVA [INJ] gemcitabine hcl [INJ] GILOTRIF GLEOSTINE HALAVEN [INJ] HERCEPTIN [INJ] HEXALEN HYCAMTIN CAPSULES hydroxyurea HYDROXYUREA POWDER IBRANCE ICLUSIG idarubicin hcl [INJ] ifosfamide [INJ] ifosfamide-mesna imatinib mesylate IMBRUVICA INLYTA IODOPEN [INJ] irinotecan hcl [INJ] ISTODAX [INJ] IXEMPRA [INJ] JAKAFI JEVTANA [INJ] KADCYLA [INJ] KEPIVANCE [INJ] KEYTRUDA KYPROLIS [INJ] LARTRUVO LENVIMA letrozole LETROZOLE POWDER leucovorin calcium LEUCOVORIN CALCIUM POWDER LEUKERAN leuprolide acetate [INJ] LEUPROLIDE ACETATE POWDER [INJ] levoleucovorin calcium [INJ] LOMUSTINE

LONSURF LUPRON DEPOT [INJ] LUPRON DEPOT 11.25MG [INJ] LUPRON DEPOT-PED [INJ] LYNPARZA LYSODREN MARQIBO MATULANE megestrol acetate MEGESTROL ACETATE POWDER MEKINIST melphalan hcl [INJ] mercaptopurine MERCAPTOPURINE POWDER mesna [INJ] MESNEX 400MG TABLET methotrexate METHOTREXATE POWDER mitomycin [INJ] MITOMYCIN POWDER [INJ] mitoxantrone [INJ] MUSTARGEN [INJ] mycophenolate acid del rel mycophenolate mofetil mycophenolic acid del rel MYLERAN NEXAVAR nilutamide NINLARO NULOJIX [INJ] octreotide acetate [INJ] ONCASPAR ONIVYDE ONTAK [INJ] OPDIVO oxaliplatin paclitaxel [INJ] PERJETA [INJ] PHOTOFRIN [INJ] POMALYST PROGRAF 5MG/ML AMPUL PROVENGE [INJ] PURIXAN

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

RAPAMUNE SOLUTION RASUVO REVLIMID RITUXAN [INJ] RUBRACA RYDAPT SANDIMMUNE SOLUTION 100MG/ML SOLUTION SANDOSTATIN KIT [INJ] SANDOSTATIN LAR DEPOT SIGNIFOR [INJ] SIMULECT [INJ] sirolimus SIROLIMUS POWDER SOMATULINE DEPOT [INJ] SPRYCEL STIVARGA SUTENT SYLVANT [INJ] SYNRIBO [INJ] TABLOID tacrolimus TACROLIMUS POWDER TAFINLAR TAGRISSO tamoxifen citrate TAMOXIFEN CITRATE POWDER TARCEVA TARGRETIN GEL TASIGNA TECENTRIQ TEMODAR 100MG VIAL [INJ] temozolomide TENIPOSIDE [INJ] THALOMID thiotepa [INJ] THIOTEPA POWDER [INJ] topotecan hcl [INJ] TORISEL [INJ] TREANDA [INJ] TRELSTAR VIAL tretinoin cap TRETINOIN POWDER

TREXALL TRISENOX [INJ] TYKERB UNITUXIN VALCHLOR VALSTAR [INJ] VANTAS VECTIBIX [INJ] VELCADE [INJ] VENCLEXTA VENCLEXTA STARTER PACK vinblastine sulfate VISTOGARD VORAXAZE [INJ] VOTRIENT VUMON [INJ] XALKORI XERMELO XGEVA [INJ] XOFIGO [INJ] YERVOY [INJ] YONDELIS ZALTRAP [INJ] ZANOSAR [INJ] ZEJULA ZELBORAF ZEVALIN ZOLADEX ZOLINZA ZORTRESS ZYDELIG ZYKADIA ZYTIGA

Autonomic, Neurology and Psych ABILIFY MAINTENA, ER acetaminophen/codeine acetaminophen-diphenhydramine alfentanil hcl [INJ] alprazolam alprazolam er alprazolam ODT ALPRAZOLAM POWDER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

amitriptyline hcl AMITRIPTYLINE HCL POWDER amitriptyline/chlordiazepoxide amoxapine 150mg amoxapine 25mg amphetamine salt combo,er AMPYRA AMYTAL [INJ] anectine [INJ] APOKYN [INJ] aripiprazole ODT aripiprazole tablets ARISTADA armodafinil baclofen BACLOFEN POWDER BANZEL benztropine [INJ] benztropine mesylate BRISDELLE buprenorphine [INJ] BUPRENORPHINE POWDER [INJ] buprenorphine/naloxone bupropion er (12 hour) bupropion hcl bupropion hcl er BUPROPION HCL POWDER bupropion hcl xl er bupropion sr buspirone hcl BUSPIRONE HCL POWDER butalbital compound butalbital compound/codeine butalbital/apap/caffeine butalbital/aspirin/caffeine butalbital/caff/apap/codeine butorphanol [INJ] BUTORPHANOL POWDER [INJ] BUTRANS carbamazepine carbamazepine er CARBAMAZEPINE POWDER carbidopa/levodopa

carbidopa/levodopa er carbidopa/levodopa ODT carbidopa/levodopa/entacapone celecoxib CELECOXIB POWDER CELONTIN chlordiazepoxide hcl chlorpromazine [INJ] CHLORPROMAZINE POWDER [INJ] chlorzoxazone choline mag trisalicylate CHOLINE MAG TRISALICYLATE POWDER citalopram hbr clomipramine hcl CLOMIPRAMINE HCL POWDER clonazepam clonazepam ODT CLONAZEPAM POWDER clonidine [INJ] clonidine hcl er clorazepate dipotassium clozapine clozapine ODT codeine sulfate cyclobenzaprine hcl CYCLOBENZAPRINE HCL dantrolene sodium DANTROLENE SODIUM POWDER DAYTRANA desipramine hcl DESIPRAMINE HCL POWDER desvenlafaxine succinate er dexmethylphenidate er dextroamphetamine sulfate dextroamphetamine sulfate er diazepam DIAZEPAM POWDER diazepam rectal gel diclofenac potassium diclofenac sodium DICLOFENAC SODIUM POWDER diclofenac sodium/misoprostol del rel diflunisal

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE DILANTIN 30MG diphenhydramine hcl divalproex sodium divalproex sodium er donepezil hcl doxepin hcl DOXEPIN HCL POWDER DOXYLAMINE SUCCINATE duloxetine EDROPHONIUM CHLORIDE entacapone ergoloid mesylates ERGOLOID MESYLATES POWDER ergotamine-caffeine escitalopram oxalate ethosuximide ETHOSUXIMIDE POWDER etodolac etodolac er ETODOLAC POWDER EVEKEO felbamate fenoprofen calcium fentanyl fentanyl citrate FENTANYL CITRATE POWDER FETZIMA FLECTOR flumazenil [INJ] fluoxetine FLUOXETINE POWDER fluphenazine decanoate [INJ] FLUPHENAZINE DECANOATE 2.5% [INJ] fluphenazine hcl flurazepam hcl flurbiprofen FLURBIPROFEN POWDER fluvoxamine maleate er fosphenytoin sodium FYCOMPA gabapentin

GABAPENTIN POWDER GABITRIL 12MG, 16 MG GABLOFEN [INJ] galantamine GILENYA GLATOPA GRALISE guanfacine er guanidine hcl haloperidol haloperidol decanoate [INJ] HALOPERIDOL DECANOATE POWDER [INJ] haloperidol lactate [INJ] HALOPERIDOL POWDER hydrocodone/acetaminophen hydrocodone/ibuprofen hydromorphone hcl HYDROMORPHONE HCL 1GM POWDER ibuprofen ibuprofen lysine IBUPROFEN POWDER imipramine hcl IMIPRAMINE HCL POWDER imipramine pamoate indomethacin indomethacin er INDOMETHACIN POWDER INFUMORPH ISOMETHEPTENE MUCATE ketoprofen er KETOPROFEN ER POWDER ketorolac tromethamine KETOROLAC TROMETHAMINE POWDER LAMICTAL XR lamotrigine lamotrigine er LAMOTRIGINE POWDER LATUDA LEMTRADA levetiracetam levetiracetam er LEVETIRACETAM POWDER levorphanol tartrate

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

LEVORPHANOL TARTRATE POWDER LIORESAL [INJ] lithium carbonate lithium carbonate er LITHIUM CARBONATE POWDER lorazepam LORAZEPAM POWDER loxapine succinate LOXAPINE SUCCINATE POWDER LYRICA meclofenamate sodium MECLOFENAMATE SODIUM POWDER mefenamic acid MEFENAMIC ACID POWDER meloxicam MELOXICAM POWDER memantine MEPERIDINE HCL POWDER MESTINON SYRUP methadone hcl METHADONE HCL POWDER methamphetamine hcl methocarbamol METHOCARBAMOL POWDER methylphenidate cd methylphenidate er methylphenidate hcl METHYLPHENIDATE HCL POWDER methylphenidate la midazolam hcl MIDAZOLAM HCL POWDER mirtazapine mirtazapine disintegrating MIRTAZAPINE POWDER MITIGARE modafinil MONOVISC [INJ] morphine sulfate morphine sulfate cr morphine sulfate er MORPHINE SULFATE TABLET POWDER MOVANTIK nabumetone

nalbuphine hcl [INJ] NALBUPHINE HCL POWDER [INJ] naloxone hcl [INJ] NALOXONE HCL POWDER [INJ] naltrexone hydrochloride NALTREXONE HYDROCHLORIDE POWDER NAMENDA XR NAMZARIC NAMZARIC THERAPY PACK naproxen NAPROXEN POWDER naproxen sodium NAPROXEN SODIUM POWDER naratriptan hcl NARCAN NEMBUTAL SODIUM [INJ] neostigmine methylsulfate [INJ] NEOSTIGMINE METHYLSULFATE POWDER [INJ] nortriptyline hcl NORTRIPTYLINE HCL POWDER NUCYNTA NUCYNTA ER NUEDEXTA OCREVUS OFIRMEV [INJ] olanzapine olanzapine ODT olanzapine/fluoxetine hcl ONFI OPANA ER orphenadrine citrate [INJ] ORPHENADRINE CITRATE POWDER [INJ] orphenadrine compound ORTHOVISC [INJ] oxaprozin oxazepam oxcarbazepine oxycodone hcl OXYCODONE HCL POWDER oxycodone hcl/ibuprofen oxycodone w/acetaminophen oxycodone w/aspirin OXYCONTIN ER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

oxymorphone hcl oxymorphone hcl er paroxetine hcl paroxetine hcl er PEGANONE pentazocine lactate perphenazine perphenazine/amitriptyline phenelzine sulfate PHENELZINE SULFATE POWDER phenobarbital PHENOBARBITAL POWDER phenobarbital sodium [INJ] PHENOBARBITAL SODIUM POWDER [INJ] phenytoin PHENYTOIN POWDER phenytoin sodium PHENYTOIN SODIUM POWDER piroxicam PIROXICAM POWDER POTIGA pramipexole er PRIALT [INJ] primidone PRIMIDONE POWDER pyridostigmine bromide PYRIDOSTIGMINE BROMIDE POWDER QUADRAMET [INJ] QUDEXY XR quetiapine fumarate quetiapine fumarate er QUILLICHEW ER QUILLIVANT XR rasagiline mesylate RELPAX RISPERDAL CONSTA [INJ] risperidone rivastigmine rizatriptan rizatriptan disintegrating tablets ropinirole hcl ropinirole hcl er ROZEREM

SABRIL SALICYLAMIDE salsalate SALSALATE POWDER seconal sodium selegiline hcl SELEGILINE HCL POWDER SPINRAZA SUBOXONE sufentil 50mcg/ml ampul [INJ] SUFENTIL POWDER [INJ] sulindac SULINDAC POWDER sumatriptan succinate SUMATRIPTAN SUCCINATE POWDER SUMAVEL DOSEPRO [INJ] SYNVISC [INJ] SYNVISC-ONE [INJ] TECFIDERA temazepam thioridazine hcl THIORIDAZINE HCL POWDER thiothixene tiagabine hcl tizanidine hcl TIZANIDINE HCL POWDER tolmetin sodium topiramate TOPIRAMATE POWDER tramadol hcl tramadol hcl er TRAMADOL HCL POWDER tramadol/acetaminophen tranylcypromine sulfate trazodone hcl TRAZODONE HCL POWDER triazolam trifluoperazine hcl trihexyphenidyl hcl trimipramine maleate TYSABRI [INJ] ULTIVA [INJ] valproate sodium

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

VALPROATE SODIUM POWDER valproic acid VALPROIC ACID venlafaxine hcl venlafaxine hcl er VIIBRYD VIMIZIM VIMPAT [INJ] VIVITROL [INJ] VYVANSE XYREM zaleplon ziprasidone hcl zolmitriptan zolmitriptan ODT zolpidem tartrate zolpidem tartrate er ZOMIG SPRAY zonisamide ZORVOLEX ZUBSOLV

Cardiovascular, Hypertension & Lipids acebutolol hcl ACEBUTOLOL HCL POWDER ACTIVASE [INJ] adenosine [INJ] ADENOSINE POWDER [INJ] ADVATE [INJ] ADVATE H [INJ] ADVATE L [INJ] ADVATE N [INJ] ADVATE SH [INJ] ADVATE UH [INJ] ADYNOVATE ALPHANATE [INJ] ALPHANINE SD [INJ] ALPROLIX [INJ] AMICAR amiloride hcl AMILORIDE HCL POWDER amiloride hcl w/hctz amiodarone hcl

AMIODARONE HCL POWDER amlodipine besylate AMLODIPINE BESYLATE POWDER amlodipine/valsartan amlodipine/valsartan/hctz amlodipine-atorvastatin amlodipine-olmesartan ARGATROBAN [INJ] aspirin / dipyridamole er atenolol ATENOLOL POWDER atenolol/chlorthalidone atorvastatin calcium BEBULIN [INJ] BEBULIN VH IMMUNO [INJ] benazepril hcl BENAZEPRIL HCL POWDER benazepril/hctz BENEFIX [INJ] betaxolol hcl bisoprolol fumarate bisoprolol fumarate/hctz bivalirudin BRILINTA bumetanide BYSTOLIC BYVALSON candesartan cilexetil candesartan/hydrochlorothiazide captopril CAPTOPRIL POWDER captopril/hydrochlorothiazide CATHFLO ACTIVASE [INJ] CEPROTIN [INJ] chlorothiazide chlorothiazide sodium [INJ] chlorthalidone cholestyramine cholestyramine light CHOLESTYRAMINE POWDER cilostazol clonidine hcl CLONIDINE HCL POWDER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

clonidine/chlorthalidone clopidogrel COAGADEX colestipol hcl COREG CR CORIFACT [INJ] CORLANOR COUMADIN 5MG VIAL [INJ] DEMSER digoxin DIGOXIN POWDER DILATRATE-SR diltiazem [INJ] diltiazem 24hr cd diltiazem er diltiazem er 24 hour diltiazem hcl DILTIAZEM HCL POWDER DILUENT FOR REMODULIN dipyridamole [INJ] DIPYRIDAMOLE POWDER [INJ] dobutamine [INJ] dobutamine/dextrose [INJ] dofetilide dopamine hcl [INJ] dopamine hcl in 5% dextrose DOPAMINE HCL POWDER [INJ] doxazosin mesylate EDARBI EDARBYCLOR EFFIENT ELIQUIS ELOCTATE [INJ] enalapril maleate ENALAPRIL MALEATE POWDER enalapril maleate/hctz enalaprilat [INJ] enoxaparin sodium [INJ] ENTRESTO eplerenone epoprostenol [INJ] epoprostenol diluent [INJ] eptifibatide

ethacrynate sodium ezetimibe-simvastatin FEIBA NF [INJ] felodipine er fenofibrate fenofibric acid fenofibric acid del rel flecainide acetate FLOLAN fluvastatin sodium fondaparinux sodium fosinopril sodium fosinopril/hydrochlorothiazide FRAGMIN furosemide FUROSEMIDE POWDER gemfibrozil GEMFIBROZIL POWDER guanfacine hcl HELIXATE FS [INJ] HEMOFIL [INJ] heparin lock flush [INJ] heparin sodium in 0.45% nacl [INJ] heparin sodium in 5% dextrose [INJ] heparin sodium syringe HUMATE-P [INJ] hydralazine hcl HYDRALAZINE HCL POWDER hydrochlorothiazide HYDROCHLOROTHIAZIDE POWDER ibutilide fumarate [INJ] indapamide irbesartan irbesartan/hydrochlorothiazide isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate er isradipine IXINITY JUXTAPID KOATE-DVI [INJ] KOGENATE FS labetalol hcl

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

LABETALOL HCL POWDER LANOXIN PEDIATRIC lidocaine hcl in 7.5% dextrose [INJ] LIPOFEN lisinopril LISINOPRIL POWDER lisinopril/hctz LIVALO losartan potassium losartan/hydrochlorothiazide lovastatin mannitol MANNITOL POWDER MEPHYTON methyclothiazide methyldopa methyldopa/hydrochlorothiazide methyldopate hcl [INJ] metolazone metoprolol succinate er metoprolol tartrate METOPROLOL TARTRATE POWDER metoprolol/hydrochlorothiazide mexiletine hcl MEXILETINE HCL POWDER milrinone in 5% dextrose milrinone lactate [INJ] minoxidil MINOXIDIL POWDER moexipril hcl moexipril/hydrochlorothiazide MONOCLATE-P [INJ] MONONINE [INJ] nadolol NADOLOL POWDER nadolol-bendroflumethiazide NATRECOR [INJ] NEXTERONE niacin er nicardipine hcl nimodipine nitroglycerin nitroglycerin er

nitroglycerin in d5w [INJ] nitroglycerin spray nitroglycerin tablets norepinephrine bitartrate [INJ] NOVOSEVEN RT [INJ] NPLATE [INJ] OBIZUR olmesartan medoxomil olmesartan medoxomil/hctz olmesartan-amlodipine-hctz omega-3-acid ethyl esters papaverine hcl [INJ] papaverine hcl er PAPAVERINE HCL POWDER [INJ] pentoxifylline PENTOXIFYLLINE POWDER perindopril erbumine phentolamine mesylate [INJ] PHENTOLAMINE MESYLATE POWDER [INJ] phenylephrine hcl [INJ] PHENYLEPHRINE HCL POWDER [INJ] phenylephrine hcl-ns PHENYLEPHRINE HCL-NS PHYTONADIONE pindolol PRADAXA PRALUENT PEN PRALUENT SYRINGE pravastatin sodium prazosin hcl procainamide hcl [INJ] PROCAINAMIDE HCL POWDER [INJ] PROFILNINE SD [INJ] PROMACTA propafenone hcl propafenone hcl er propranolol hcl propranolol hcl er PROPRANOLOL HCL POWDER propranolol/hctz protamine sulfate [INJ] PROTAMINE SULFATE POWDER [INJ] quinapril

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

quinapril/hydrochlorothiazide quinidine gluconate [INJ] quinidine gluconate er quinidine sulfate QUINIDINE SULFATE ramipril RANEXA RECOMBINATE [INJ] REFLUDAN [INJ] REMODULIN [INJ] REOPRO [INJ] REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE RESECTISOL reserpine RESERPINE POWDER RETAVASE RIASTAP rosuvastatin SIMCOR ER simvastatin SIMVASTATIN POWDER sotalol SOTALOL HCL [INJ] SOTYLIZE spironolactone SPIRONOLACTONE POWDER spironolactone/hctz TEKAMLO TEKTURNA TEKTURNA HCT terazosin hcl THROMBATE III [INJ] timolol maleate TIMOLOL MALEATE POWDER torsemide trandolapril trandolapril/verapamil er tranexamic acid TRANEXAMIC ACID POWDER TRETTEN UPTRAVI

valsartan valsartan/hydrochlorothiazide VASCEPA verapamil er verapamil er pm verapamil hcl [INJ] VERAPAMIL HCL POWDER [INJ] VONVENDI warfarin sodium WARFARIN SODIUM POWDER WELCHOL WILATE [INJ] XARELTO XYNTHA [INJ] ZETIA ZONTIVITY

Dermatological & Topical Therapy ABSORICA acitretin acyclovir 5% oint ACYCLOVIR POWDER adapalene cream, gel alclometasone dipropionate alphaquin hp ALUMINUM CHLORIDE POWDER aluminum chloride topical amcinonide ammonium lactate AMMONIUM LACTATE ANTHRALIN avo cream bacitracin bacitracin/polymyxin ophth oint benprox BENZOCAINE benzoyl peroxide BENZOYL PEROXIDE POWDER betamethasone dipropionate augment BETAMETHASONE DIPROPIONATE AUGMENT POWDER betamethasone valerate BETAMETHASONE VALERATE POWDER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 15

bupivacaine hcl BUPIVACAINE HCL POWDER bupivacaine/epinephrine [INJ] calcipotriene CALCIPOTRIENE POWDER CARAC chlorhexidine gluconate CHLORHEXIDINE GLUCONATE 0.2 SOLUTION chloroprocaine [INJ] ciclopirox clindamycin phos/benzoyl peroxide clindamycin phosphate topical clindamycin phos-tretinoin clindamycin-benzoyl peroxide clobetasol e clobetasol propionate CLOBETASOL PROPIONATE POWDER clotrimazole CLOTRIMAZOLE POWDER clotrimazole/betamethasone cocaine hcl COCAINE HCL CONDYLOX GEL COSENTYX desonide DESONIDE POWDER desoximetasone DESOXIMETASONE POWDER dexpanthenol DEXPANTHENOL diflorason diacetate/emollient diflorasone diacetate DUPIXENT [INJ] econazole nitrate ECONAZOLE NITRATE POWDER eletone ELIDEL emulsion sb ENSTILAR EPIDUO EPIDUO FORTE erythromycin solution erythromycin-benzoyl peroxide

ETHYL ALCOHOL ethyl chloride FINACEA FINACEA PLUS fluocinolone acetonide FLUOCINOLONE ACETONIDE POWDER fluocinonide FLUOCINONIDE POWDER fluorouracil FLUOROURACIL POWDER fluticasone propionate FLUTICASONE PROPIONATE POWDER gentamicin sulfate GENTAMICIN SULFATE POWDER halobetasol propionate hpr hpr plus hydrocortisone hydrocortisone acetate HYDROCORTISONE ACETATE POWDER hydrocortisone butyrate hydrocortisone butyrate/emoll hydrocortisone valerate hydroquinone cream hydroquinone er cream HYDROQUINONE POWDER imiquimod IMIQUIMOD POWDER lactic acid LACTIC ACID 88 TO 92 % lidocaine lidocaine hcl LIDOCAINE HCL POWDER lidocaine hcl w/epinephrine [INJ] LIDOCAINE POWDER lidocaine/prilocaine lidocaine-hc lindane lustra-ultra mafenide acetate MAFENIDE ACETATE POWDER malathion mb hydrogel

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

MEPIVACAINE HCL POWDER MIRVASO mometasone furoate MOMETASONE FUROATE POWDER mupirocin MUPIROCIN POWDER nuquin hp nystatin NYSTATIN nystatin w/triamcinolone ONEXTON OXSORALEN 1% LOTION permethrin PERMETHRIN PICATO podofilox pruclair prumyx prutect REGRANEX ropivacaine ROPIVACAINE POWDER salicylic acid SALICYLIC ACID SANTYL selenium sulfide SELENIUM SULFIDE POWDER sensorcaine 5MG/ML VIAL [INJ] silver sulfadiazine SILVER SULFADIAZINE POWDER sodium sulfacetamide/sulfur sonafine SOOLANTRA spinosad STELARA [INJ] sulfacetamide sodium SULFAMYLON CREAM SULFAMYLON PACKET TACLONEX SUSPENSION tazarotene cream TAZORAC GEL tl-cermide tretinoin

tretinoin microsphere TRIAMCINOLONE ACETONIDE POWDER urea UREAM POWDER, BEADS ZOVIRAX 5% CREAM

Ear, Nose & Throat acetic acid otic solution acetic acid/aluminum otic sol acetic acid/hydrocortisone otic sol antipyrine/benzocaine otic sol antipyrine/benzocaine/poly otic sol azelastine hcl chloroxylenol/benzocaine/hc acetate otic susp CIPRODEX ciprofloxacin hcl CIPROFLOXACIN HCL FIRST-BXN FIRST-MOUTHWASH BLM ipratropium bromide spray MYALEPT neomycin/polymyxin/hc otic susp & soln ofloxacin otic drops OTOVEL oxymetazoline hcl 12 hour OXYMETAZOLINE HCL POWDER sodium chloride sodium fluoride SODIUM FLUORIDE SODIUM FLUORIDE POWDER

Endocrine/Diabetes 1ST CHOICE LANCETS acarbose ACCU-CHEK FASTCLIX, MULTICLIX, SOFTCLIX LANCETS [OTC] ACCU-CHEK SOFTCLIX LANCETS DEVICE [OTC] ACTHREL [INJ] ACTOPLUS MET XR a-hydrocort [INJ] ALDURAZYME [INJ] ARISTOSPAN [INJ] ARMOUR THYROID

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

AXIRON BASAGLAR KWIKPEN U-100 BETAMETHASONE BETAMETHASONE ACETATE BETAMETHASONE SODIUM PHOSPHATE BYDUREON [INJ] BYDUREON PEN BYETTA [INJ] cabergoline calcitonin salmon nasal calcitriol [INJ] CERDELGA CEREZYME [INJ] chorionic gonadotropin [INJ] CHORIONIC GONADOTROPIN POWDER [INJ] clomiphene citrate CLOMIPHENE CITRATE POWDER cortisone acetate CORTISONE ACETATE POWDER cosyntropin [INJ] danazol DANAZOL POWDER desmopressin acetate [INJ] DESMOPRESSIN ACETATE POWDER [INJ] dexamethasone DEXAMETHASONE POWDER dexamethasone sodium phosphate DEXAMETHASONE SODIUM PHOSPHATE POWDER DEXCOM G4 METER DEXCOM G4 SENSOR DEXCOM G4 TRANSMITTER DEXCOM G5 METER DEXCOM G5 TRANSMITTER doxercalciferol ELAPRASE [INJ] ELELYSO [INJ] FABRAZYME [INJ] FEMCAP fludrocortisone acetate FLUDROCORTISONE ACETATE POWDER FLUOXYMESTERONE FOLLISTIM AQ [INJ]

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] glimepiride glipizide glipizide er GLIPIZIDE POWDER GLUCAGEN [INJ] glyburide glyburide micronized GLYBURIDE POWDER glyburide/metformin hcl GLYXAMBI GONAL-F GONAL-F RFF GONAL-F RFF REDI-JECT HUMALOG [INJ] HUMULIN 70/30 KWIKPEN [INJ] [OTC] HUMULIN N KWIKPEN [INJ] [OTC] HUMULIN R 500 UNITS [INJ] [OTC] HUMULIN R U-500 KWIKPEN INVOKAMET INVOKAMET XR INVOKANA JANUMET JANUMET XR JANUVIA JENTADUETO JENTADUETO XR JUVISYNC KALYDECO KOMBIGLYZE XR KUVAN LANTUS [INJ] LANTUS SOLOSTAR [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

LEVEMIR [INJ] LEVEMIR, FLEXTOUCH levothroid levothyroxine sodium LEVOTHYROXINE SODIUM liothyronine sodium LIOTHYRONINE SODIUM POWDER LUMIZYME [INJ] MEDISENSE MEDISENSE GLUCOSE KETONE CONTR MENOPUR [INJ] metformin hcl metformin hcl er METFORMIN HCL POWDER methimazole METHIMAZOLE POWDER METHITEST methylprednisolone methylprednisolone acetate [INJ] METHYLPREDNISOLONE POWDER methylprednisolone sod succ [INJ] METHYLPREDNISOLONE SOD SUCC POWDER [INJ] MIACALCIN VIAL [INJ] MINIMED MINIMED RESERVOIR MYOZYME [INJ] NAGLAZYME [INJ] nateglinide NOVOFINE NOVOFINE AUTOCOVER NOVOLOG [INJ] NOVOLOG FLEXPEN NOVOLOG MIX 70-30 ONE TOUCH ULTRA 2 ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO ONE TOUCH VERIO FLEX ONE TOUCH VERIO IQ ONE TOUCH VERIO SYNC ONGLYZA oxandrolone OXANDROLONE POWDER

pamidronate disodium [INJ] PARADIGM INFUSION PARADIGM INSULIN PUMP PARADIGM SILHOUETTE paricalcitol pioglitazone hcl pioglitazone/glimepiride pioglitazone/metformin POLYFIN QR PRECISION XTRA B-KETONE STRIPS [OTC] PRECISION XTRA MONITOR [OTC] PRECISION XTRA TEST STRIPS [OTC] prednisolone PREDNISOLONE POWDER prednisolone sodium phosphate prednisone PREDNISONE POWDER PRODIGY INSULIN SYRINGE PRODIGY PEN NEEDLE PROGLYCEM propylthiouracil PROPYLTHIOURACIL POWDER QUICK RELEASE SOFT TEFLON repaglinide/metformin REPRONEX SAMSCA SENSIPAR SILHOUETTE SNAP INSULIN PUMP CONTROLLER SOF-SET SOF-SET MICRO SOFT TOUCH SOLOSITE SOLU-CORTEF [INJ] SOMAVERT [INJ] STIMATE SPRAY SURE-T PARADIGM SYMLINPEN 60 [INJ] SYNAREL SYNJARDY SYNJARDY XR testosterone cypionate [INJ] TESTOSTERONE CYPIONATE POWDER [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

testosterone enanthate [INJ] TESTOSTERONE ENANTHATE POWDER [INJ] testosterone gel TESTOSTERONE POWDER THYROID tolazamide tolbutamide TOUJEO SOLOSTAR TRADJENTA TRESIBA FLEXTOUCH U-100 TRESIBA FLEXTOUCH U-200 vasopressin [INJ] vasopressin-ns veripred 20 VGO 20 VGO 30 VGO 40 VICTOZA [INJ] VPRIV [INJ] XIGDUO XR ZAVESCA zoledronic acid [INJ] ZOMETA INFUSION BOTTLE [INJ]

Gastroenterology AKYNZEO ALOXI [INJ] AMITIZA aprepitant capsule, dose pack ASACOL HD balsalazide disodium budesonide budesonide ec CANASA carafate CHENODAL CHOLBAM cimetidine CIMETIDINE POWDER CITRA PH CORTIFOAM CREON CYSTADANE

DELZICOL dicyclomine hcl DICYCLOMINE HCL POWDER dimenhydrinate [INJ] DIMENHYDRINATE POWDER [INJ] diphenoxylate/atropine dronabinol droperidol [INJ] DROPERIDOL POWDER [INJ] EMEND 40MG; 125MG CAPSULE ENTYVIO esomeprazole famotidine FAMOTIDINE POWDER glycopyrrolate GLYCOPYRROLATE POWDER granisetron hcl granisol hydrocortisone HYDROCORTISONE POWDER hydrocortisone/pramoxine hyoscyamine sulfate hyoscyamine sulfate disinegrating tablets hyoscyamine sulfate er HYOSCYAMINE SULFATE POWDER KINEVAC [INJ] lactulose lansoprazole del rel LANSOPRAZOLE POWDER lansoprazole/amoxicillin/clarithromycin LEVSIN 0.5MG/ML AMPUL LIALDA LINZESS loperamide hcl LOPERAMIDE HCL meclizine hcl MECLIZINE HCL POWDER mesalamine MESALAMINE POWDER metoclopramide hcl METOCLOPRAMIDE HCL POWDER misoprostol MISOPROSTOL POWDER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

NEXIUM (RX) SUSP NEXIUM 24HR nizatidine OCALIVA omeprazole del rel OMEPRAZOLE POWDER omeprazole sodium bicarbonate ondansetron hcl ONDANSETRON HCL POWDER ondansetron ODT opium pancrelipase pantoprazole sodium paregoric peg 3350-electrolyte PENTASA polyethylene glycol POLYETHYLENE GLYCOL pramcort PREPOPIK prochlorperazine edisylate [INJ] PROCHLORPERAZINE EDISYLATE POWDER [INJ] prochlorperazine maleate PROCHLORPERAZINE MALEATE POWDER PROCTOFOAM-HC ranitidine hcl RANITIDINE HCL POWDER RECTIV RELISTOR [INJ] REMICADE [INJ] SANCUSO SCOPOLAMINE HYDROBROMIDE sodium bicarbonate [INJ] SODIUM BICARBONATE POWDER [INJ] SUCLEAR SUCRAID sucralfate SUCRALFATE POWDER sulfasalazine sulfasalazine dr SULFASALAZINE POWDER SUPREP trimethobenzamide hcl

TRIMETHOBENZAMIDE HCL POWDER UCERIS EXTENDED RELEASE ursodiol URSODIOL POWDER VARUBI VIBERZI VIOKACE ZENPEP DEL-REL

Immunology, Vaccines & Biotechnology ACTHIB [INJ] ACTIMMUNE [INJ] ADACEL [INJ] AFLURIA AFLURIA QUAD 2016-2017 ALFERON N [INJ] APLISOL [INJ] ARANESP [INJ] ARCALYST [INJ] ATGAM [INJ] AVONEX [INJ] BETASERON BEXSERO BIOTHRAX [INJ] BOOSTRIX [INJ] BOTOX [INJ] candin CERVARIX [INJ] COMVAX [INJ] CROFAB [INJ] CYTOGAM [INJ] EGRIFTA [INJ] ENGERIX-B [INJ] FLUAD 2016-2017 FLUARIX FLUBLOK 2016-2017 FLUCELVAX QUAD 2016-2017 FLULAVAL FLULAVAL QUAD [INJ] FLUMIST FLUVIRIN FLUZONE [INJ] FLUZONE HIGH-DOSE

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

FLUZONE INTRADERM QUAD FLUZONE INTRADERM QUAD 2016-17 FLUZONE QUAD 2016-2017 FLUZONE QUAD PEDI 2016-2017 fomepizole GAMASTAN S-D [INJ] GAMMAGARD LIQUID [INJ] GAMMAGARD S-D [INJ] GAMUNEX [INJ] GAMUNEX-C [INJ] GARDASIL 9 [INJ] GENOTROPIN GRANIX [INJ] GRASTEK HAVRIX [INJ] HEPAGAM B [INJ] HIZENTRA [INJ] HUMATROPE [INJ] HYPERHEP B S-D [INJ] HYPERRAB S-D [INJ] HYPERRHO S-D HYPERTET S-D ILARIS [INJ] IMOGAM RABIES-HT [INJ] IMOVAX RABIES VACCINE [INJ] INFANRIX [INJ] INFERGEN [INJ] INTRON A [INJ] IPOL [INJ] IXIARO [INJ] LEUKINE [INJ] MENACTRA [INJ] MENOMUNE-A-C-Y-W-135 [INJ] M-M-R II VACCINE W/DILUENT [INJ] MOZOBIL [INJ] MYOBLOC [INJ] NEULASTA [INJ] NEUMEGA [INJ] NEUPOGEN [INJ] NORDITROPIN PEDIARIX [INJ] PEDVAXHIB [INJ] PEGASYS [INJ]

PEGASYS PROCLICK [INJ] PENTACEL PLEGRIDY PNEUMOVAX 23 [INJ] PREVNAR 13 PRIVIGEN [INJ] PROCRIT [INJ] PROLEUKIN [INJ] PROQUAD [INJ] QUADRACEL DTAP-IPV RABAVERT RAGWITEK REBIF REBIF REBIDOSE RECOMBIVAX HB [INJ] ROTATEQ SEROSTIM [INJ] STAMARIL SYLATRON SYNAGIS [INJ] TETANUS DIPHTHERIA TOXOIDS [INJ] TETANUS DIPHTHERIA TOXOIDS - PED [INJ] tetanus toxoid THERACYS [INJ] THYMOGLOBULIN [INJ] TICE BCG [INJ] TRUMENBA TUBERSOL [INJ] TWINRIX [INJ] TYPHIM VI [INJ] VAQTA VIAL VARIVAX VACCINE [INJ] VARIZIG [INJ] VAXCHORA VACCINE VIVOTIF BERNA DEL REL YF-VAX [INJ] ZARXIO [INJ]

Miscellaneous & Diagnostic Agents acamprosate calcium ACETIC ACID acetic acid irrigation ADAGEN [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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

AMMONUL [INJ] anagrelide hydrochloride ARALAST NP [INJ] benzphetamine hcl BREVITAL [INJ] BROMHEXINE HYDROCHLORIDE BUPHENYL bupivacaine/dextrose [INJ] caffeine citrated CAFFEINE CITRATED POWDER CARBAGLU cevimeline hcl CHANTIX CHEMET citric acid CITRIC ACID POWDER deferoxamine [INJ] delflex w/dextrose dextrose in lactated ringers dextrose in water dextrose with sodium chloride diethylpropion hcl DIETHYLPROPION HCL POWDER disulfiram DISULFIRAM POWDER EOVIST [INJ] ETHAMOLIN etidronate disodium etomidate [INJ] ETOMIDATE POWDER [INJ] EXJADE EXTRANEAL ICODEXTRIN DIALYSIS FERRIPROX FOSRENOL HEXTEND LACTATED ELECTROLYTE INCRELEX [INJ] JADENU KANUMA ketamine hcl [INJ] KETAMINE HCL POWDER [INJ] levocarnitine LEVOCARNITINE POWDER LEXISCAN

md-gastroview midodrine hcl NATPARA neomycin-polymyxin b [INJ] OMNIPAQUE ORFADIN PANHEMATIN [INJ] phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl PHENTERMINE HCL POWDER pilocarpine hcl PROLASTIN C [INJ] propofol PROTOPAM CHLORIDE [INJ] RAVICTI RENVELA riluzole ringers irrigation SEROTONIN HCL sodium chloride SODIUM PHOSPHATE [INJ] sodium phosphate 3mmol/ml vial [INJ] sodium polystyrene sulfonate sodium thiosulfate [INJ] SODIUM THIOSULFATE [INJ] SOLIRIS [INJ] SOTRADECOL [INJ] STRENSIQ THALLOUS CHLORIDE TL-201 THYROGEN [INJ] TRYPSIN UVA URSI LEAF FLUID EXTRACT VELTASSA water [INJ] WATER [INJ] water intravenous solution water solution; irrigation XIAFLEX [INJ] XURIDEN ZEMAIRA [INJ]

Musculoskeletal & Rheumatology

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 23

ACTEMRA [INJ] alendronate sodium allopurinol ALLOPURINOL POWDER allopurinol sodium BENLYSTA [INJ] COLCHICINE POWDER COLCRYS DEPEN ENBREL [INJ] FORTEO [INJ] HUMIRA [INJ] ibandronate [INJ] ibandronate sodium KRYSTEXXA [INJ] leflunomide OTREXUP probenecid RIDAURA risedronate dr risedronate sodium SAVELLA SIMPONI 100MG/ML ULORIC XELJANZ XELJANZ XR

Obstetrics & Gynecology altavera alyacen amethia amethia lo amethyst apri aranelle aubra [INJ] aviane azurette balziva briellyn CALDOLOR [INJ] camrese camrese lo

caziant CENESTIN chateal clindamycin phosphate vaginal COMBIPATCH CRINONE cryselle cyclafem dasetta daysee DEPO-ESTRADIOL [INJ] DEPO-PROVERA 400 MG/ML [INJ] DIVIGEL drospirenone-eth estra-levomef DUAVEE elinest emoquette ENDOMETRIN ENJUVIA enpresse enskyce ERGONOVINE MALEATE errin estarylla ESTRACE CREAM estradiol estradiol patch estradiol valerate [INJ] ESTRADIOL VALERATE POWDER [INJ] estradiol/norethindrone acetate estrogen/methyltestosterone estropipate falmina gianvi gildagia gildess gildess fe heather HEMABATE [INJ] IMPLANON introvale isoxsuprine hcl ISOXSUPRINE HCL POWDER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 24

jencycla jolessa jolivette junel junel fe kariva kelnor 1-35 kurvelo leena lessina levonorgestrel levora LO LOESTRIN FE loryna low-ogestrel lutera lyza MAKENA [INJ] marlissa medroxyprogesterone acetate [INJ] methylergonovine maleate miconazole 1 MICONAZOLE 1 microgestin microgestin fe MINIVELLE MIRENA mono-linyah mononessa myzilra NATAZIA necon NEXPLANON nora-be norethindrone acetate NORETHINDRONE ACETATE POWDER norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol iron norethin-eth estra ferrous fum nortrel NUVARING ocella ogestrel

orsythia ORTHO-DIAPHRAGM OSPHENA oxytocin [INJ] OXYTOCIN POWDER [INJ] philith pirmella portia PREMARIN PREMARIN CREAM PREMPHASE PREMPRO progesterone in oil [INJ] progesterone micronized PROGESTERONE MICRONIZED POWDER quasense reclipsen SAFYRAL sprintec sronyx syeda TAYTULLA terconazole tilia fe TODAY CONTRACEPTIVE SPONGE tri-estarylla tri-legest fe tri-linyah trinessa trivora velivet vestura viorele wera wymzya fe yuvafem zarah zenchent zenchent fe zeosa zovia

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 25

Ophthalmology acetazolamide acetazolamide er ACETAZOLAMIDE POWDER ALPHAGAN P 0.001% ALREX apraclonidine ophth solution atropine sulfate ATROPINE SULFATE POWDER AZASITE azelastine hcl ophth solution balanced salt ophth irrigation BEPREVE BESIVANCE betaxolol ophth solution bimatoprost brimonidine ophth solution BRIMONIDINE POWDER bromfenac ophth CARBACHOL [INJ] carteolol hcl ciprofloxacin ophth solution COMBIGAN cromolyn sodium cyclopentolate ophth solution CYCLOPENTOLATE POWDER CYSTARAN dorzolamide hcl dorzolamide/timolol epinastine hcl erythromycin ointment EYLEA [INJ] FLUORESCEIN SODIUM fluorometholone FLUOROMETHOLONE POWDER flurbiprofen sodium FML S.O.P. gatifloxacin gentasol homatropine hydrobromide HOMATROPINE HYDROBROMIDE ILEVRO ISOPTO CARBACHOL 0.015

JETREA [INJ] ketorolac tromethamine drops latanoprost drops levobunolol hcl drops levofloxacin hemihydrate LOTEMAX LUCENTIS [INJ] methazolamide METHAZOLAMIDE POWDER metipranolol drops MOXEZA naphazoline hcl NAPHAZOLINE HCL POWDER NATACYN neomycin/bacitracin/poly/hc neomycin/polymyxin/gramicidin NEVANAC ofloxacin olopatindine PATADAY PAZEO PHOSPHOLINE IODIDE DROPS physostigmine salicylate [INJ] PHYSOSTIGMINE SALICYLATE [INJ] pilocarpine hcl PILOCARPINE HCL POWDER PILOPINE HS PRED MILD prednisolone acetate PREDNISOLONE ACETATE POWDER prednisolone sodium phosphate drops PREDNISOLONE SODIUM PHOSPHATE DROPS POWDER PROLENSA proparacaine hcl PROPARACAINE HCL POWDER proparacaine/fluorescein RESTASIS RESTASIS MULTIDOSE sodium chloride drops sulfacetamide sodium sulfacetamide w/prednisolone tetcaine drops

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 26

TOBRADEX OINTMENT TOBRADEX ST tobramycin sulfate drops TOBRAMYCIN SULFATE POWDER tobramycin/dexamethasone TRAVATAN Z travoprost trifluridine TRIFLURIDINE POWDER tropicamide TROPICAMIDE POWDER VIGAMOX VISUDYNE [INJ] XIIDRA ZYLET

Respiratory, Allergy, Cough & Cold acetylcysteine ACETYLCYSTEINE POWDER ADCIRCA ADEMPAS ADVAIR DISKUS ADVAIR HFA ALBUTEROL albuterol sulfate ALBUTEROL SULFATE POWDER aminophylline [INJ] AMINOPHYLLINE POWDER [INJ] ANORO ELLIPTA arbinoxa ARCAPTA NEOHALER ARNUITY ELLIPTA ASMANEX, HFA benzonatate BERINERT BEVESPI AEROSPHERE BREO ELLIPTA brompheniramine/pseudoephedrine budesonide BUDESONIDE POWDER caffeine/sodium benzoate [INJ] carbinoxamine cetirizine syrup

chlorphen/pse/dm tannate CINRYZE [INJ] clemastine fumarate CLEMASTINE FUMARATE POWDER COMBIVENT RESPIMAT cromolyn sodium CROMOLYN SODIUM POWDER cyproheptadine hcl CYPROHEPTADINE HCL POWDER DALIRESP D-CHLORPHENIRA/PSE/CHLOPHEDIAN 12.5CPD-1DCPM-30PSE desloratadine desloratadine disintegrating tablets dexchlorpheniramine maleate er DEXTROMETHORPHAN HBR difil-g dihydrocodeine/aspirin/caffeine dihydrocodeine/bpm/pe diphenhydramine [INJ] DIPHENHYDRAMINE POWDER [INJ] DM/PHENYLEPH/CHLORPHENIRAMINE 10PEH-4CPM-20DM DULERA DYMISTA ephedrine sulfate EPHEDRINE SULFATE POWDER epinephrine ampule/vial EPINEPHRINE AUTO-INJECTOR [INJ] EPINEPHRINE POWDER EPIPEN EPIPEN JR. ESBRIET FIRAZYR [INJ] FLOVENT DISKUS FLOVENT HFA flunisolide FLUNISOLIDE POWDER guaifenesin/codeine hydrocodone/chlorpheniramine er hydrocodone/homatropine hydroxyzine hcl HYDROXYZINE HCL POWDER

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 27

hydroxyzine pamoate HYDROXYZINE PAMOATE POWDER ipratropium bromide IPRATROPIUM BROMIDE POWDER ipratropium/albuterol nebulization KALBITOR [INJ] LETAIRIS levalbuterol hcl LEVALBUTEROL HCL POWDER levocetirizine dihydrochloride LEVOCETIRIZINE DIHYDROCHLORIDE POWDER metaproterenol sulfate METAPROTERENOL SULFATE POWDER mometasone furoate nasal montelukast sodium MONTELUKAST SODIUM POWDER NUCALA OPSUMIT ORKAMBI PERFOROMIST [INJ] phenylephrine/chlorpheniramine 10peh-4cpm PROAIR HFA PROAIR RESPICLICK promethazine hcl PROMETHAZINE HCL POWDER PROMETHAZINE HCL TABLETS POWDER promethazine vc/codeine promethazine/dextromethorphan promethegan pseudoephedrine hcl PSEUDOEPHEDRINE HCL pseudoephedrine hcl er PULMICORT FLEXHALER PULMOZYME QVAR SEREVENT DISKUS sildenafil citrate SILDENAFIL CITRATE POWDER sodium chloride SPIRIVA RESPIMAT STIOLTO RESPIMAT STRIVERDI RESPIMAT SYMBICORT

terbutaline sulfate TERBUTALINE SULFATE POWDER theophylline anhydrous drops er 12 hr theophylline anhydrous er THEOPHYLLINE ANHYDROUS POWDER TRACLEER triamcinolone acetonide TUDORZA PRESSAIR TUSSICAPS TYVASO VENTAVIS VENTOLIN HFA VERAMYST XOLAIR [INJ] zafirlukast

Urologicals alfuzosin hcl er alprostadil [INJ] ALPROSTADIL POWDER [INJ] AMINOACETIC ACID AMMONIUM CHLORIDE [INJ] bethanechol chloride BETHANECHOL CHLORIDE POWDER CAVERJECT [INJ] CIALIS CYSTAGON darifenacin er ELMIRON finasteride FINASTERIDE POWDER flavoxate hcl GELNIQUE glycine GLYCINE POWDER hyophen K-PHOS ORIGINAL MUSE MYRBETRIQ ER 24 HR oxybutynin chloride oxybutynin chloride er OXYBUTYNIN CHLORIDE POWDER phenazopyridine hcl

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 28

PHENAZOPYRIDINE HCL POWDER phenazopyridine plus phosphasal potassium citrate er RAPAFLO RENACIDIN tamsulosin hcl er 24 hr tolterodine tartrate TOVIAZ tricitrates trospium chloride er uretron d-s urimar-t urin d.s. urogesic ustell VESICARE VIAGRA

Vitamins, Hematinics & Electrolytes ADDAMEL N [INJ] advanced am/pm albumin [INJ] amino acid [INJ] AMINOSYN [INJ] AQUASOL A [INJ] ascorbic acid [INJ] ASCORBIC ACID [INJ] BAL IN OIL [INJ] bal-care dha b-complex calcium acetate CALCIUM ACETATE POWDER calcium chloride [INJ] CALCIUM CHLORIDE [INJ] calcium gluconate [INJ] CALCIUM GLUCONATE 61MG CALCIUM GLUCONATE POWDER [INJ] cavan-alpha kit cavan-ec sod dha centratex choice-ob + dha choice-tabs

chromium chloride [INJ] CLINIMIX [INJ] CLINIMIX E complete natal dha copper chloride [INJ] corvita CUPRIC SULFATE [INJ] dailyvite dexferrum dialyvite 800 eliphos elite ob elite-ob elite-ob 400 fabb fe 90 plus fe c FERAHEME ferocon ferotrinsic ferraplus 90 ferrex 150 forte ferrex 150 forte plus ferrex 28 ferrocite plus ferrogels forte folbecal folbee folbee plus folbic folcaps folcaps omega-3 folic acid FOLIC ACID POWDER folic acid/cyancobal/pyridoxine folivane-f folivane-ob folivane-plus folivane-prx dha nf folplex 2.2 foltanx FREAMINE HBC freamine iii

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 29

FREAMINE III GLYCOPHOS [INJ] hematinic plus hematinic with folic acid hematogen hematogen fa hematogen forte hemenatal ob hemenatal ob + dha hemetab HEPATAMINE [INJ] HEPATASOL [INJ] hetastarch w/sodium chloride [INJ] hydroxocobalamin HYDROXOCOBALAMIN POWDER iferex 150 forte inatal advance inatal gt inatal ultra infed [INJ] INFUVITE [INJ] intralipid IONOSOL B WITH DEXTROSE 5% ISOLYTE S [INJ] k-phos neutral l-mefolate-pyridox-mecobalamin l-methyl-b6-b12 l-methylfolate calcium L-METHYLFOLATE CALCIUM POWEDER l-methylfolate-mecobalamin-nac m.v.i. adult [INJ] M.V.I. PEDIATRIC [INJ] M.V.I.-12 [INJ] macnatal cn dha magnesium chloride [INJ] MAGNESIUM CHLORIDE [INJ] magnesium sulfate [INJ] MAGNESIUM SULFATE [INJ] MAGNESIUM SULFATE IN DEXTROSE [INJ] manganese [INJ] manganese sulfate [INJ] MANGANESE SULFATE POWDER [INJ] mefolate-pyridox-mecobalamin

metafolbic metafolbic plus methyl-b6-b12 multigen multigen folic multigen plus multitrace-4 [INJ] MULTITRACE-4 [INJ] MULTITRACE-5 [INJ] multivitamin w/fluoride & iron multivitamin with fluoride mynatal mynatal advance mynatal caps mynatal plus mynatal-z mynate 90 plus er mynephrocaps NASCOBAL [INJ] natal-v rx natalvirt 90 dha natalvirt ca natalvirt flt nephplex rx NEPHRAMINE [INJ] nephro-vite rx NEUT [INJ] NORMOSOL-M AND DEXTROSE [INJ] NORMOSOL-R AND DEXTROSE [INJ] NORMOSOL-R PH 7.4 [INJ] nutrilyte [INJ] nutrilyte ii [INJ] nutri-tab ob obstetrix dha PEDITRACE [INJ] PLASMA-LYTE 148 [INJ] pnv ob+dha pnv-dha pnv-first pnv-omega pnv-select pnv-total poly-iron 150 forte

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 30

polysaccharide iron forte 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] pr natal 400 pr natal 400 ec pr natal 430 pr natal 430 ec prefol-dha premasol [INJ] PREMASOL [INJ] prena1 prena1 chew prena1 plus prenaissance prenaissance 90 dha prenaissance balance prenaissance dha prenaissance harmony dha prenaissance next prenaissance plus prenaplus prenatabs fa prenatabs rx prenatal ad prenatal low iron prenatal plus prenatal-u PROCALAMINE PROSOL pyridoxine hcl PYRIDOXINE HCL relnate dha renal caps renalpren rena-vite rx reno caps

ringers [INJ] selenium [INJ] se-natal 19 se-tan dha prenatal se-tan plus setonet setonet ec sodium acetate [INJ] SODIUM ACETATE POWDER [INJ] sodium chloride [INJ] sodium lactate [INJ] SODIUM LACTATE [INJ] strovite taron forte taron prenatal taron-bc taron-c dha taron-duo ec therapeutic hematinic therapeutic vitamin/minerals thiamine hcl THIAMINE HCL POWDER tl gard rx tl g-fol os tl icon tl-care dha tl-fol 500 er tl-hem 150 er 24 hr tl-select TPN ELECTROLYTES 18-18-5MEQ [INJ] TRACE ELEMENTS [INJ] travasol [INJ] tri rx triadvance tricon trigels-f forte trinatal gt trinatal rx 1 trinatal ultra trinate triphrocaps triveen-duo dha triveen-one

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated August 1, 2017 [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 31

triveen-prx rnf triveen-ten triveen-u TROPHAMINE [INJ] trust natal dha ultimate ob dha ultimatecare one ultimatecare one nf v-c forte vemavite-prx 2 vena-bal dha venatal complete dha venatal-fa VENOFER [INJ] vinacal vinate az vinate c vinate calcium vinate dha vinate gt vinate ic vinate ii vinate one vinate ultra vinate-m virt-bal dha virt-bal dha plus virt-pn virt-pn dha virt-pn plus virt-select virt-vite virt-vite forte vitacirc-b vitafol-ob vitafol-pn vitamin a VITAMIN A v-natal vol-care rx vol-nate vol-plus vol-tab rx

vp-ch plus vp-ch-pnv vp-era ob plus vp-ggr-b6 vp-heme one vp-zel zatean-ch zatean-pn zatean-pn dha zatean-pn plus zinc chloride ZINC CHLORIDE zinc sulfate ZINC SULFATE zingiber