Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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 [sp] ACETIC ACID/OXYQUINOLINE acyclovir acyclovir [inj] adefovir dipivoxil ALBENZA ALINIA amantadine hcl AMBISOME [INJ] amikacin [inj] amoxicillin amoxicillin-clavulanate er amphotericin [inj] ampicillin [inj] ampicillin/sulbactam [inj] APTIVUS [SP] atovaquone-proguanil hcl ATRIPLA [INJ] AUGMENTIN 125-31.25 MG/5ML AVELOX AVELOX ABC PACK AVELOX IV [INJ] AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] azithromycin [inj] azithromycin [sp] aztreonam [inj] bacitracin [inj] BETHKIS BICILLIN C-R [INJ] BICILLIN L-A [INJ] CANCIDAS [INJ] CAPASTAT SULFATE [INJ] CAYSTON [SP] cefaclor cefazolin [inj] cefazolin/dextrose [inj] cefdinir cefepime [inj] cefepime/dextrose [inj] cefotaxime [inj] cefotetan [inj] cefoxitin [inj]

cefoxitin/dextrose [inj] cefpodoxime proxetil cefprozil CEFTAZIDIME ceftazidime [inj] ceftibuten ceftriaxone [inj] ceftriaxone/dextrose [inj] cefuroxime axetil cefuroxime sodium cefuroxime sodium [inj] CEFUROXIME SODIUM 75 G [INJ] cephalexin chloramphenicol [inj] chloroquine phosphate cidofovir [inj] CIPRO SUSPENSION ciprofloxacin ciprofloxacin er ciprofloxacin/dextrose [inj] clarithromycin clarithromycin er clindamycin hcl clindamycin palmitate hcl clindamycin phosphate [inj] clindamycin phosphate/dextrose [inj] clotrimazole COARTEM colistimethate [inj] COMPLERA [SP] CRIXIVAN [SP] CUBICIN [INJ] DALVANCE [INJ] DAPSONE DARAPRIM demeclocycline hcl dicloxacillin sodium didanosine DORIBAX doxycycline hyclate doxycycline hyclate [inj] doxycycline monohydrate EDURANT EMTRIVA

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

entecavir EPIVIR HBV SOLUTION EPIVIR SOLUTION ERYTHROCIN LACTOBIONATE [INJ] erythromycin erythromycin del-rel erythromycin ethylsuccinate erythromycin stearate erythromycin w/sulfisoxazole ethambutol hcl famciclovir fluconazole, in dextrose, saline flucytosine FORTAZ IN ISO-OSMOTIC DEXTROSE [INJ] foscarnet sodium FUZEON [INJ] ganciclovir gentamicin sulfate [inj] gentamicin sulfate in ns GENTAMICIN SULFATE IN NS 100 MG/0.1l [INJ] griseofulvin griseofulvin ultramicrosize hydroxychloroquine sulfate imipenem-cilastatin [inj] INCIVEK INTELENCE INVANZ [INJ] INVIRASE ISENTRESS isoniazid isoniazid [inj] itraconazole KALETRA kanamycin sulfate [inj] ketoconazole LAMISIL lamivudine lamivudine-zidovudine levofloxacin hemihydrate levofloxacin hemihydrate [inj] levofloxacin-d5w [inj] LEXIVA mefloquine hcl meropenem [inj] methenamine hippurate

methenamine mandelate methylene blue [inj] metronidazole metronidazole [inj] MINOCIN minocycline hcl, er MYCAMINE [INJ] MYCOBUTIN nafcillin dextrose [inj] nafcillin sodium [inj] NEBUPENT [INJ] neomycin sulfate nevirapine nitrofurantoin nitrofurantoin macrocrystal NORVIR NOXAFIL nystatin tablet ocudox ofloxacin tablets OLYSIO ORACEA ORABACTIV [INJ] oxacillin sodium [inj] 1g/50ml oxacillin sodium [inj] paromomycin sulfate 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] PREZISTA PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate RELENZA RESCRIPTOR RETROVIR [INJ] REYATAZ ribavirin RIFADIN RIFADIN[INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

rimantadine hcl SELZENTRY SIRTURO SIVEXTRO [INJ] SOLODYN 55, 65, 80, 105, 115MG ER SOVALDI SPORANOX stavudine STREPTOMYCIN SULFATE [INJ] STRIBILD STROMECTOL sulfadiazine sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim [inj] SUSTIVA SYNERCID [INJ] TEFLARO [INJ] terbinafine TETRACYCLINE TIMENTIN [INJ] tinidazole TIVICAY TOBI PODHALER tobramycin sulfate [inj] trimethoprim TRIUMEQ TRUVADA TYGACIL [INJ] TYZEKA valacyclovir VALCYTE vancomycin hcl [inj] VIBATIV [INJ] VICTRELIS VIDEX VIRACEPT VIRAMUNE VIREAD voriconazole voriconazole [inj] XIFAXAN ZIAGEN zidovudine ZOSYN [INJ] ZYVOX

ZYVOX [INJ]

Antineoplatic & Immunosuppresants ABRAXANE [INJ] [SP] ADCETRIS [INJ] [SP] AFINITOR [SP] AFINITOR DISPERZ [SP] ALIMTA [INJ] ALKERAN amifostine [inj] anastrozole ARRANON [INJ] [SP] ARZERRA [INJ] [SP] AVASTIN [INJ] [SP] azacitidine [inj] [sp] AZASAN azathioprine [sp] azathioprine sodium [inj] [sp] BEXXAR [INJ] bicalutamide BICNU [INJ] bleomycin [inj] BOSULIF [SP] BUSULFEX [INJ] calcium folinate [inj] CAPRELSA [SP] carboplatin [inj] CEENU CELLCEPT [INJ] [SP] CELLCEPT SUSPENSION [SP] cisplatin [inj] cladribine [inj] CLOLAR [INJ] cyclophosphamide [inj] CYCLOPHOSPHAMIDE CAPSULES cyclophosphamide tablets cyclosporine [inj] [sp] cyclosporine [sp] cyclosporine modified [sp] CYRAMZA cytarabine [inj] dacarbazine [inj] dactinomycin [inj] daunorubicin [inj]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

DAUNOXOME [INJ] decitabine [inj] [sp] DEPOCYT [INJ] dexrazoxane [inj] DOCEFREZ [INJ] docetaxel [inj] doxorubicin hcl [inj] doxorubicin hcl liposomal [inj] DROXIA ELIGARD ELITEK [INJ] ELSPAR EMCYT epirubicin hcl [inj] ERIVEDGE ETOPOPHOS [INJ] etoposide etoposide [inj] exemestane FARESTON FASLODEX floxuridine [inj] fludarabine phosphate [inj] fluorouracil [inj] flutamide FOLOTYN [INJ] FUSILEV [INJ] GAZYVA [INJ] gemcitabine hcl [inj] GILOTRIF GLEEVEC HALAVEN [INJ] HERCEPTIN [INJ] HEXALEN HYCAMTIN CAPSULES [SP] hydroxyurea ICLUSIG idarubicin hcl [inj] ifosfamide [inj] ifosfamide-mesna IMBRUVICA INLYTA IODOPEN [INJ] irinotecan hcl [inj] ISTODAX [INJ]

IXEMPRA JAKAFI JEVTANA [INJ] KADCYLA [INJ] KEPIVANCE [INJ] KYPROLIS [INJ] letrozole leucovorin calcium leucovorin calcium [inj] LEUKERAN leuprolide acetate LOMUSTINE LUPRON DEPOT LUPRON DEPOT 11.25MG LUPRON DEPOT-PED LYSODREN MARQIBO MATULANE megestrol acetate MEKINIST melphalan hcl [inj] mercaptopurine mesna [inj] MESNEX methotrexate methotrexate [inj] mitomycin [inj] mitoxantrone [inj] MUSTARGEN [INJ] mycophenolate mofetil mycophenolate acid delayed-release MYLERAN NEXAVAR NILANDRON NULOJIX [INJ] octreotide acetate[inj] ONCASPAR ONTAK [INJ] oxaliplatin paclitaxel [inj] PERJETA [INJ] PHOTOFRIN [INJ] POMALYST PROGRAF PROVENGE [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

PURIXAN REVLIMID RITUXAN [INJ] SANDIMMUNE SOLUTION SANDOSTATIN [INJ] SIGNIFOR [INJ] SIMULECT [INJ] SOMATULINE DEPOT [INJ] SPRYCEL STIVARGA SUTENT SYNRIBO [INJ] SYLVANT [INJ] TABLOID tacrolimus TAFINLAR tamoxifen citrate TARCEVA [delete space] TARGRETIN TASIGNA TEMODAR [INJ] temozolomide TENIPOSIDE [INJ] THALOMID thiotepa [inj] topotecan hcl [inj] TORISEL [INJ] TREANDA [INJ] TRELSTAR, DEPOT [INJ], LA tretinoin caps TREXALL TRISENOX [INJ] TYKERB VANTAS VECTIBIX [INJ] VELCADE [INJ] vinblastine sulfate VORAXAZE [INJ] VOTRIENT VUMON [INJ] XALKORI XGEVA [INJ] XOFIGO [INJ] XTANDI

YERVOY [INJ] ZALTRAP [INJ] ZANOSAR [INJ] ZELBORAF ZEVALIN ZOLADEX ZOLINZA ZORTRESS ZYDELIG ZYKADIA ZYTIGA

Autonomic, Neurology and Psych ABILIFY ABILIFY DISCMELT ABILIFY MAINTENA ER acetaminophen w/codeine acetaminophen-diphenhydra-alfentanil [inj] alprazolam alprazolam er alprazolam orally disintegrating tablet amitriptyline hcl amitriptyline/chlordiazepoxide amoxapine amphetamine salt combo, er AMPYRA [SP] AMYTAL [INJ] anectine [inj] APOKYN [INJ] [SP] AZILECT baclofen BANZEL benztropine [inj] benztropine mesylate BRISDELLE buprenorphine [inj] buprenorphine hydrochloride buprenorphine-naloxone bupropion ext-release (12 hour) bupropion hcl bupropion hcl xl er bupropion sr er buspirone hcl butalbital compound

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

butalbital compound w/codeine butalbital-aspirin-caffeine butalbital/apap/caffeine butalbital/caff/apap/codeine butorphanol [inj] butorphanol nasal BUTRANS calcium-folic acid plus d carbamazepine carbamazepine ext-release carbidopa-levodopa er carbidopa-levodopa-entacapone carbidopa/levodopa carbidopa/levodopa orally disintegrating tablets CELEBREX CELONTIN chlordiazepoxide hcl chlorpromazine [inj] chlorpromazine hcl chlorzoxazone choline mag trisalicylate citalopram hbr clomipramine hcl clonazepam clonazepam orally disintegrating tablets clonidine [inj] clonidine hcl er clorazepate dipotassium clozapine clozapine odt codeine sulfate COPAXONE [INJ] [SP] cyclobenzaprine hcl dantrolene sodium DAYTRANA desipramine hcl dexmethylphenidate hcl dextroamphetamine sulfate dextroamphetamine sulfate er diazepam diazepam rectal gel diclofenac potassium diclofenac sodium diclofenac sodium-misoprostol delayed release diflunisal

dihydroergotamine mesylate DILANTIN DILAUDID-HP 250 MG [INJ] diltiazem [inj] diphenhydramine hcl divalproex sodium divalproex sodium er donepezil hcl doxepin hcl DOXYLAMINE SUCCINATE duloxetine EDROPHONIUM CHLORIDE entacapone ERGOLOID MESYLATES ergotamine-caffeine escitalopram oxalate estrazolam ethosuximide etodolac etodolac er EUFLEXXA EXELON felbamate fenoprofen calcium fentanyl [inj] fentanyl citrate, [inj], lozenge flumazenil [inj] fluoxetine dr fluoxetine hcl fluphenazine decanoate [inj] fluphenazine hcl flurazepam hcl flurbiprofen fluvoxamine maleate er 24 hr FOCALIN XR 5, 10, 20, 25, 35MG fosphenytoin sodium FYCOMPA gabapentin GABITRIL 12MG, 16MG GABLOFEN [INJ] galantamine GILENYA GRALISE guanidine hcl haloperidol

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

haloperidol [inj] haloperidol decanoate [inj] haloperidol lactate [inj] HYCAMTIN CAPSULES [SP] hydrocodone bit-ibuprofen hydrocodone w/acetaminophen hydromorphone hcl, rectal, [inj] ibuprofen imipramine hcl imipramine pamoate indomethacin indomethacin [inj] indomethacin er INFUMORPH INTUNIV ISOMETHEPTENE MUCATE ketoprofen er ketorolac tromethamine ketorolac tromethamine [inj] LAMICTAL ODT LAMICTAL XR lamotrigine lamotrigine er LATUDA levetiracetam, [inj], er levorphanol tartrate LIORESAL [INJ] lithium carbonate tab, er, caps lorazepam lorazepam [inj] loxapine succinate LYRICA maprotiline hcl meclofenamate sodium mefenamic acid meloxicam meperidine hcl [inj] MESTINON MESTINON ER methamphetamine hcl methocarbamol methadone hcl methadone hcl [inj] methylphenidate er methylphenidate hcl

midazolam MIRAPEX ER mirtazapine mirtazapine disintegrating tablets modafinil morphine sulfate, [inj], cr, er morphine sulfate tablet nalbuphine hcl [inj] naloxone hcl [inj] naltrexone hydrochloride nabumetone NAPROSYN naproxen naproxen sodium NAMENDA NAMENDA XR naratriptan hcl NEMBUTAL SODIUM [INJ] NEOPROFEN [INJ] neostigmine methylsulfate [inj] nortriptyline hcl NUCYNTA NUCYNTA ER NUEDEXTA OFIRMEV [INJ] olanzapine olanzapine [inj] olanzapine odt olanzapine-fluoxetine hcl ONFI OPANA ER oxaprozin oxycodone hcl oxycodone hcl-ibuprofen oxycodone w/acetaminophen oxycodone w/aspirin OXYCONTIN ER oxymorphone hcl oxymorphone hcl er orphenadrine citrate [inj] orphenadrine citrate er orphenadrine compound ORTHOVISC [INJ] oxazepam oxcarbazepine

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

paroxetine hcl paroxetine hcl er PEGANONE perphenazine perphenazine/amitriptyline phenelzine sulfate phenobarbital phenobarbital sodium [inj] phenytoin phenytoin sodium phenytoin sodium [inj] piroxicam POTIGA pramipexole di-hcl PRIALT [INJ] primidone PRISTIQ ER pyridostigmine bromide QUADRAMET [INJ] quetiapine fumarate QUILLIVANT XR RELPAX RISPERDAL RISPERDAL CONSTA [INJ] RISPERDAL M-TAB DISINTEGRATING rivastigmine rizatriptan rizatriptan disintegrating tablets ROBAXIN [INJ] ropinirole hcl ropinirole hcl er ROZEREM SABRIL SALICYLAMIDE salsalate seconal sodium selegiline hcl SEROQUEL XR SUBOXONE sulindac sumatriptan succinate sumatriptan succinate spray non-aerosol sumatriptan succinate [inj] SUMAVEL DOSEPRO [INJ] SYNVISC [INJ]

SYNVISC-ONE [INJ] TALWIN [INJ] TECFIDERA DELAYED RELEASE TEGRETOL XR temazepam thioridazine hcl thiothixene tiagabine hcl tizanidine hcl tolmetin sodium topiramate tramadol hcl TRAMADOL HCL ER tramadol hcl-acetaminophen tranylcypromine sulfate trazodone hcl TREXIMET triazolam trifluoperazine hcl trihexyphenidyl hcl trimipramine maleate TYSABRI [INJ] ULTIVA [INJ] VALPROATE SODIUM valproate sodium [inj] valproic acid venlafaxine hcl venlafaxine hcl er VIIBRYD VIMOVO VIMPAT [INJ] VIVITROL [INJ] VOLTAREN VYVANSE XENAZINE XYREM zaleplon ziprasidone hcl zolmitriptan zolmitriptan odt zolpidem tartrate zolpidem tartrate er ZOMIG zonisamide ZORVOLEX

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

Cardiovascular, Hypertension & Lipids acebutolol hcl ACTIVASE [INJ] adenosine [inj] ADVATE [INJ] [SP] ADVATE H [INJ] [SP] ADVATE L [INJ] [SP] ADVATE N [INJ] [SP] ADVATE SH [INJ] [SP] ADVATE UH [INJ] [SP] AGGRASTAT [INJ] AGGRENOX ER ALPHANATE [INJ] [SP] ALPHANINE SD [INJ] [SP] ALPROLIX amiloride hcl amiloride hcl w/hctz amiodarone hcl amiodarone hcl [inj] amlodipine besylate amlodipine-atorvastatin AMTURNIDE ANGIOMAX [INJ] [SP] ARGATROBAN [INJ] atenolol atenolol w/chlorthalidone atorvastatin calcium ATRYN AZOR BEBULIN [INJ] [SP] BEBULIN VH IMMUNO [INJ] [SP] benazepril hcl benazepril hcl-hctz BENEFIX [INJ] [SP] BENICAR BENICAR HCT betaxolol hcl bisoprolol fumarate bisoprolol fumarate/hctz BRILINTA bumetanide bumetanide [inj] BYSTOLIC candesartan cilexetil

candesartan-hydrochlorothiazid captopril captopril/hydrochlorothiazide CATHFLO ACTIVASE [INJ] CEPROTIN [INJ] [SP] chlorothiazide chlorothiazide chlorothiazide sodium [inj] chlorthalidone cholestyramine cholestyramine light cilostazol CLEVIPREX [INJ] clonidine hcl clopidogrel colestipol hcl COREG CR ER CORIFACT [INJ] [SP] COUMADIN [INJ] CRESTOR DEMSER DIBENZYLINE digoxin DILATRATE-SR EXT-REL diltiazem [inj] diltiazem 24hr cd diltiazem er diltiazem er 24 hour diltiazem hcl dipyridamole [inj] dobutamine [inj] dobutamine/dextrose [inj] dopamine hcl [inj] dopamine hcl in 5% dextrose doxazosin mesylate EDECRIN[INJ] EFFIENT ELIQUIS ELOCTATE [INJ] enalapril maleate enalapril maleate/hctz enalaprilat [inj] enoxaparin sodium eplerenone epoprostenol [inj] EXFORGE

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

EXFORGE HCT FEIBA NF [INJ] felodipine er fenofibrate fenofibrate caps fenofibric acid fenofibric acid delayed release flecainide acetate fluvastatin sodium fondaparinux sodium fosinopril sodium fosinopril-hydrochlorothiazide FRAGMIN furosemide furosemide [inj] gemfibrozil guanfacine hcl HELIXATE FS [INJ] HEMOFIL [INJ] heparin lock flush [inj] heparin sodium in 0.45% nacl [inj] heparin sodium in 5% dextrose [inj] HUMATE-P [INJ] [SP] hydralazine hcl hydrochlorothiazide ibutilide fumarate [inj] indapamide INTEGRILIN [INJ] irbesartan irbesartan-hydrochlorothiazide isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate er isradipine JUXTAPID KOATE-DVI [INJ] labetalol hcl labetalol hcl [inj] LANOXIN PEDIATRIC lidocaine hcl in 7.5% dextrose [inj] LIPOFEN LIPTRUZET lisinopril lisinopril-hctz losartan potassium

losartan-hydrochlorothiazide lovastatin LOVAZA mannitol MEPHYTON methyclothiazide methyldopa methyldopa/hydrochlorothiazide methyldopate hcl [inj] metolazone metoprolol succinate er metoprolol tartrate metoprolol tartrate [inj] metoprolol-hydrochlorothiazide mexiletine hcl milrinone in 5% dextrose milrinone lactate [inj] minoxidil moexipril hcl moexipril-hydrochlorothiazide MONOCLATE-P [INJ] MONONINE [INJ] MONOVISC nadolol nadolol-bendroflumethiazide NATRECOR [INJ] NEXTERONE niacin er nicardipine hcl nicardipine hcl [inj] nifedipine er nimodipine nitroglycerin nitroglycerin tablets nitroglycerin [inj] nitroglycerin er nitroglycerin in d5w [inj] nitroglycerin spray NITROLINGUAL NITROSTAT norepinephrine bitartrate [inj] NOVOSEVEN [INJ] NPLATE [INJ] papaverine hcl [inj] papaverine hcl er

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

pentoxifylline er perindopril erbumine PHENTOLAMINE MESYLATE [INJ] phenylephrine hcl [inj] PHYTONADIONE pindolol PRADAXA pravastatin sodium prazosin hcl procainamide hcl [inj] PROFILNINE SD [INJ] PROMACTA propafenone hcl propafenone hcl er propranolol hcl propranolol hcl er propranolol hcl-hctz protamine sulfate [inj] quinapril quinapril-hydrochlorothiazide quinidine gluconate [inj] quinidine gluconate er quinidine sulfate quinidine sulfate er ramipril RANEXA RECOMBINATE [INJ] REFLUDAN [INJ] REMODULIN [INJ] REOPRO [INJ] RESECTISOL reserpine RETAVASE RIASTAP SIMCOR ER simvastatin sotalol SOTALOL HCL [INJ] spironolactone spironolactone w/hctz TARKA TEKAMLO TEKTURNA TEKTURNA HCT terazosin hcl

THROMBATE III [INJ] TIKOSYN timolol maleate torsemide torsemide [inj] trandolapril TRANEXAMIC ACID tranexamic acid [inj] TRETTEN TRIBENZOR valsartan valsartan-hydrochlorothiazide VASCEPA verapamil er verapamil er pm verapamil hcl [inj] VYTORIN warfarin sodium WELCHOL WILATE XARELTO XYNTHA XYNTHA SOLOFUSE ZETIA ZONTIVITY

Dermatological & Topical Therapy acitretin acyclovir ointment ACZONE adapalene alclometasone dipropionate alphaquin hp aluminum chloride 20% topical amcinonide ammonium lactate 12% topical ANTHRALIN ATRALIN avo cream bacitracin eye ointment bacitracin/polymyxin eye ointment benprox BENZACLIN BENZOCAINE

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

benzoyl peroxide betamethasone dipropionate augmented betamethasone valerate bupivacaine hcl bupivacaine/epinephrine [inj] calcipotriene calcitriol CARAC CARBOCAINE 2% [INJ] CHLORHEXIDINE GLUCONATE chloroprocaine [inj] ciclopirox clindamycin phosphate topical clindamycin-benzoyl peroxide clobetasol e clobetasol propionate clotrimazole clotrimazole/betamethasone cocaine hcl topical soln CONDYLOX GEL DENAVIR desonide desoximetasone DEXPANTHENOL diclofenac sodium gel DIFFERIN 0.1% LOTION diflorasone diacetate diflorason diacetate/emollient econazole nitrate eletone ELIDEL emulsion sb EPIDUO erythromycin solution erythromycin-benzoyl peroxide ETHYL ALCOHOL ethyl chloride EURAX FINACEA FINACEA PLUS fluocinolone acetonide cream fluocinolone acetonide ointment fluocinonide fluorouracil fluticasone propionate

gentamicin sulfate cream gentamicin sulfate ointment halobetasol propionate hpr foam hpr plus hydrocortisone hydrocortisone butyrate hydrocortisone butyrate/emoll hydrocortisone acetate/lidocaine hydrocortisone acetate/pramoxine hydrocortisone valerate hydroquinone cream hydroquinone ER imiquimod isotretinoin ketoconazole cream lactic acid lidocaine, hcl, jelly, ointment lidocaine hcl w/epinephrine [inj] lidocaine-prilocaine lindane lustra-ultra mafenide acetate malathion mb hydrogel MEPIVACAINE HCL metronidazole cream MIRVASO mometasone furoate mupirocin NAROPIN [INJ] NESACAINE nuquin hp nystatin ointment nystatin w/triamcinoloneOXSORALEN 1% LOTION permethrin podofilox pr cream PRAMOSONE 1% PRAMOSONE 2.5% LOTION, OINTMENT PRAMOSONE E prednicarbate PROTOPIC pruclair prumyx

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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 REGRANEX salicylic acid SANTYL selenium sulfide sensorcaine [inj] silver sulfadiazine sodium sulfacetamide/sulfur sonafine spinosad STELARA [INJ] [SP] sulfacetamide sodium topical sulfacetamide sodium-sulfur SULFAMYLON TACLONEX SUSPENSION TAZORAC tl-cermide TRETIN-X tretinoin cream tretinoin microsphere triamcinolone acetonide 0.1% cream urea VELTIN ZIANA ZOVIRAX CREAM ZYCLARA

Ear, Nose & Throat acetic acid ear solution acetic acid/aluminum ear solution acetic acid/hydrocortisone ear solution antipyrine w/benzocaine ear solution antipyrine w/benzocaine/poly ear solution ASTEPRO ATROVENT SPRAY azelastine hcl nasal spray chloroxylenol/benzocaine/hc acet ear susp CIPRODEX ciprofloxacin hcl FIRST-BXN FIRST-MOUTHWASH BLM hydrocortisone/pramoxine ear solution hydrocortisone/pramoxine/chloroxylenol ipratropium bromide spray

MYALEPT neomycin/polymyxin/hc ofloxacin otic drops oxymetazoline hcl 12 hour sodium fluoride sodium fluoride cream

Endocrine/Diabetes 1ST CHOICE LANCETS A-HYDROCORT [INJ] acarbose ACCU-CHEK FASTCLIX, MULTICLIX, SOFTCLIX LANCETS [OTC] ACCU-CHEK SOFTCLIX LANCETS DEVICE [OTC] ACTHAR H.P. [INJ] [SP] ACTHREL [INJ] ACTOPLUS MET XR ALDURAZYME [INJ] [SP] ANDRODERM ANDROGEL ARISTOSPAN [INJ] ARMOUR THYROID AXIRON BETAMETHASONE BETAMETHASONE ACETATE betamethasone acetate/betamethasone sodium phosphate [inj] BETAMETHASONE SODIUM PHOSPHATE BRAVELLE [INJ] BYDUREON [INJ] BYDUREON PEN BYETTA [INJ] cabergoline calcitonin salmon nasal calcitriol [inj] CEREZYME [INJ] [SP] CETROTIDE [INJ] [SP] chorionic gonadotropin [inj] [sp] clomiphene citrate cortisone acetate cosyntropin [INJ] danazol DEPO-MEDROL 20 MG/ML [INJ] desmopressin acetate

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

desmopressin acetate [inj] DEXCOM G4 SENSOR dexamethasone dexamethasone sodium phosphate ELAPRASE [INJ] ELELYSO [INJ] FABRAZYME [INJ] FEMCAP fludrocortisone acetate FLUOXYMESTERONE FOLLISTIM AQ [INJ] FORA LANCING DEVICE FREESTYLE FREEDOM KIT [OTC] FREESTYLE FREEDOM LITE METER [OTC] FREESTYLE INSULINX GLUCOSE SYSTEM [OTC] FREESTYLE INSULINX TEST STRIPS [OTC] FREESTYLE LITE METER [OTC] FREESTYLE LITE TEST STRIPS [OTC] FREESTYLE TEST STRIPS [OTC] GANIRELIX ACETATE [INJ] glimepiride glipizide glipizide er GLUCAGEN [INJ] GLUCAGON glyburide glyburide micronized glyburide-metformin hcl HECTOROL HECTOROL [INJ] HUMALOG [INJ] HUMULIN [INJ] [OTC] HUMULIN R 500 UNITS [INJ] hyoscyamine/phenyltoloxamine INVOKANA INVOKAMET JANUMET JANUMET XR JANUVIA JENTADUETO JUVISYNC KENALOG [INJ] KOMBIGLYZE XR KUVAN LANTUS [INJ]

LANTUS SOLOSTAR [INJ] LEVEMIR [INJ] LEVOTHROID levothyroxine sodium levothyroxine sodium [inj] liothyronine [inj] liothyronine tablet LUMIZYME [INJ] MEDROL MENOPUR [INJ] metformin hcl metformin hcl er methimazole METHITEST methylprednisolone methylprednisolone acetate [inj] methylprednisolone sod succ [inj] MIACALCIN [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 SMART ONE TOUCH ULTRA SYSTEM ONE TOUCH ULTRA TEST STRIPS ONE TOUCH ULTRAMINI ONE TOUCH VERIO ONE TOUCH VERIO IQ ONE TOUCH VERIO SYNC ONGLYZA OPTIUM OPTIUM EZ ORTHO-DIAPHRAGM oxandrolone pamidronate disodium [inj] PARADIGM INFUSION PARADIGM INSULIN PUMP PARADIGM SILHOUETTE

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

paricalcitol pioglitazone hcl pioglitazone-glimepiride pioglitazone-metformin POLYFIN QR PRANDIMET PRECISION PCX, PCX PLUS, POINT OF CARE,Q-I-D PRECISION XTRA B-KETONE STRIPS [OTC] PRECISION XTRA MONITOR [OTC] PRECISION XTRA TEST STRIPS [OTC] prednisolone prednisolone sodium phosphate [inj] prednisone PRODIGY INSULIN SYRINGE PRODIGY PEN NEEDLE PROGLYCEM propylthiouracil QUICK RELEASE SOFT TEFLON repaglinide RIOMET SAMSCA SENSIPAR SILHOUETTE SILHOUETTE [INJ] SOF-SET SOF-SET MICRO SOFT TOUCH SOLOSITE SOLU-CORTEF [INJ] SOLU-MEDROL [INJ] SOMAVERT [INJ] STIMATE SPRAY SURE-T PARADIGM SYMLINPEN 60 [INJ] SYNAREL testosterone cypionate [inj] testosterone enanthate [inj] THYROID tolazamide tolbutamide TRADJENTA vasopressin [inj] veripred 20 VGO 20 VGO 30

VGO 40 VICTOZA [INJ] VIMIZIM [INJ] [SP] VPRIV [INJ] ZAVESCA ZEMPLAR [INJ] ZOLEDRONIC ACID [INJ] ZOMETA [INJ]

Gastroenterology ALOXI [INJ] AMITIZA ANALPRAM ADVANCED CREAM KIT ANALPRAM 2.5% LOTION ANALPRAM-HC 1% CREAM SINGLES ASACOL HD balsalazide disodium budesonide ec CANASA carafate CHENODAL [SP] cimetidine CITRA PH CORTIFOAM CREON cromolyn sodium oral solution CYSTADANE [SP] DELZICOL DEL-REL dicyclomine hcl dimenhydrinate [inj] diphenoxylate w/atropine dronabinol droperidol [inj] EMEND [INJ] ENTYVIO ENTYVIO [INJ] famotidine famotidine [inj] glycopyrrolate glycopyrrolate [inj] granisetron hcl granisetron hcl [inj] HALFLYTELY-BISACODYL hydrocortisone

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

hydrocortisone acetate hyoscyamine sulfate, odt, er KINEVAC [INJ] KRISTALOSE lactulose lansoprazol-amoxicil-clarithromycin lansoprazole delayed release LEVSIN LIALDA LINZESS loperamide hcl LOTRONEX meclizine hcl mesalamine metoclopramide hcl metoclopramide hcl [inj] misoprostol MOVIPREP NEXIUM NEXIUM [INJ] nizatidine omeprazole delayed release OMEPRAZOLE-SODIUM BICARBONATE ondansetron hcl ondansetron hcl [inj] ondansetron hcl in dextrose [inj] ondansetron in sodium chloride[inj] ondansetron odt opium pancrelipase pantoprazole sodium paregoric peg 3350-electrolyte PENTASA phenobarb/hyoscyamine/atropine/scoplamine polyethylene glycol prochlorperazine edisylate [inj] prochlorperazine maleate PROCTOFOAM-HC ranitidine ranitidine hcl [inj] RECTIV RELISTOR [INJ] REMICADE [INJ] SANCUSO

SCOPOLAMINE HYDROBROMIDE sodium bicarbonate sodium chloride/sodium bicarb SUCLEAR SUCRAID sucralfate sulfasalazine sulfasalazine dr SUPREP TRANSDERM-SCOP trimethobenzamide hcl trimethobenzamide hcl [inj] UCERIS ursodiol VIOKACE ZANTAC RX ZENPEP DEL-REL

Immunology, Vaccines & Biotechnology

ACTHIB [INJ] ACTIMMUNE [INJ] [SP] ADACEL [INJ] AFLURIA [INJ] ALFERON N [INJ] APLISOL [INJ] ARANESP [INJ] [SP] ARCALYST [INJ] [SP] ATGAM [INJ] AVONEX [INJ] [SP] BIOTHRAX [INJ] BOOSTRIX [INJ] BOTOX [INJ] [SP] candin CERVARIX [INJ] COMVAX [INJ] CROFAB [INJ] CYTOGAM [INJ] [SP] EGRIFTA [INJ] [SP] ENGERIX-B [INJ] FLUARIX [INJ] FLULAVAL [INJ] FLULAVAL QUAD [INJ] FLUVIRIN [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

FLUZONE [INJ] fomepizole GAMASTAN S-D [INJ] GAMMAGARD LIQUID [INJ] GAMMAGARD S-D [INJ] GAMUNEX [INJ] GAMUNEX-C [INJ] GARDASIL [INJ] GENOTROPIN [INJ] [SP] GRASTEK HAVRIX HEPAGAM B [INJ] HIZENTRA [INJ] HUMATROPE [INJ] [SP] 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] [SP] INTRON A [INJ] [SP] IPOL [INJ] IXIARO LEUKINE [INJ] M-M-R II VACCINE W/DILUENT [INJ] MENACTRA [INJ] MENOMUNE-A-C-Y-W-135 [INJ] MOZOBIL [INJ] MYOBLOC [INJ] OMNITROPE [INJ] [SP] NEULASTA [INJ] NEUMEGA [INJ] NEUPOGEN [INJ] NORDITROPIN [INJ] [SP] PEDIARIX [INJ] PEDVAXHIB [INJ] PEGASYS [INJ] [SP] PEGASYS PROCLICK [INJ] [SP] PNEUMOVAX 23 [INJ] PREVNAR 13 PRIVIGEN [INJ] PROCRIT [INJ]

PROLEUKIN [INJ] PROQUAD [INJ] RABAVERT RAGWITEK REBIF [INJ] [SP] REBIF REBIDOSE [INJ] [SP] RECOMBIVAX HB ROTATEQ SEROSTIM [INJ] [SP] SYLATRON [INJ] [SP] TETANUS DIPHTHERIA TOXOIDS [INJ] tetanus toxoid THERACYS [INJ] THYMOGLOBULIN [INJ] TICE BCG [INJ] TUBERSOL [INJ] TWINRIX [INJ] TYPHIM VI [INJ] VAQTA VARIVAX VACCINE [INJ] VARIZIG [INJ] VIVOTIF BERNA DEL-REL YF-VAX [INJ]

Musculoskeletal & Rheumatology ACTEMRA [INJ] [SP] alendronate sodium allopurinol ATELVIA BENLYSTA [INJ] [SP] colchicine COLCRYS CUPRIMINE dihydrocodeine/aspirin/caffeine ENBREL [INJ] [SP] FORTEO [INJ] [SP] HUMIRA [INJ] [SP] IBANDRONATE IBANDRONATE [INJ] KRYSTEXXA [INJ] [SP] leflunomide ORENCIA [INJ] [SP] naproxen delayed release probenecid

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

RIDAURA risedronate SAVELLA ULORIC

Obstetrics & Gynecology altavera alyacen amethia amethia lo amethyst apri aranelle aubra [inj] aviane azurette balziva BEYAZ 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 DUAVEE elinest emoquette ENDOMETRIN ENJUVIA enpresse enskyce ERGONOVINE MALEATE errin

estarylla ESTRACE CREAM ESTRACE TABLET estradiol estradiol patch estradiol valerate [inj] estradiol-norethindrone acetate ESTRING estrogen & methyltestosterone estropipate EVAMIST falmina gianvi gildagia gildess gildess fe heather HEMABATE [INJ] IMPLANON introvale isoxsuprine hcl jencycla jolessa jolivette junel junel fe kariva kelnor 1-35 kurvelo leena lessina levonorgestrel levora LO LOESTRIN FE LO MINASTRIN FE LOESTRIN 24 FE loryna low-ogestrel lutera lyza MAKENA [INJ] marlissa medroxyprogesterone acetate [inj] methylergonovine maleate METHYLERGONOVINE MALEATE [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

Metronidazole gel MICONAZOLE 1 microgestin microgestin fe MINIVELLE MIRENA mono-linyah mononessa myzilra NATAZIA necon NEXPLANON nora-be norethindrone acetate norethindrone-ethin estradiol nortrel NUVARING ocella ogestrel orsythia oxytocin [inj] philith pirmella portia PREMARIN PREMARIN [INJ] PREMPHASE PREMPRO progesterone quasense reclipsen SAFYRAL sprintec sronyx syeda terconazole tilia fe tri-estarylla tri-legest fe tri-linyah trinessa trivora VAGIFEM velivet vestura

viorele VIVELLE PATCH wera wymzya fe zarah zenchent zenchent fe zeosa zovia

Ophthalmology acetazolamide, er, [inj] ALPHAGAN P 0.1% ALREX apraclonidine eye solution atropine sulfate eye solution atropine sulfate eye ointment AZASITE azelastine hcl eye solution balanced salt eye irrigation BEPREVE BESIVANCE betaxolol eye solution BETOPTIC S brimonidine eye solution bromfenac eye solution carbachol [INJ] carteolol hcl ciprofloxacin eye solution COMBIGAN cromolyn sodium eye solution cyclopentolate eye solution CYSTARAN [SP] dexamethasone sodium phosphate diclofenac sodium gel dorzolamide hcl dorzolamide-timolol DUREZOL epinastine hcl erythromycin ointment EYLEA [INJ] FLUORESCEIN SODIUM fluorometholone flurbiprofen sodium

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

FML S.O.P. gatifloxacin gentasol homatropine hydrobromide ILEVRO ISOPTO CARBACHOL JETREA [INJ] ketorolac eye solution latanoprost drops levobunolol hcl drops levofloxacin hemihydrate rops LOTEMAX LUCENTIS [INJ] LUMIGAN methazolamide metipranolol drops MOXEZA naphazoline hcl NATACYN neomycin-polymyxin-dexamethasone neomycin/bacitracin/poly/hc neomycin/polymyxin/gramicidin NEVANAC ofloxacin PATADAY PATANOL phenylephrine hcl PHOSPHOLINE IODIDE DROPS physostigmine salicylate [inj] pilocarpine hcl drops PILOPINE HS polymyxin/trimethoprim eye solution PRED MILD prednisolone acetate prednisolone sodium phosphate drops PROLENSA proparacaine hcl proparacaine-fluorescein RESTASIS sodium chloride drops sulfacetamide sodium ointment sulfacetamide sodium drops sulfacetamide w/prednisolone tetracaine drops timolol maleate drops

TOBRADEX TOBRADEX ST tobramycin sulfate drops tobramycin-dexamethasone TRAVATAN Z travoprost TRIFLURIDINE tropicamide VIGAMOX VISUDYNE [INJ] ZYLET

Respiratory, Allergy, Cough & Cold acetylcysteine ADCIRCA [SP] ADVAIR DISKUS ADVAIR HFA albuterol sulfate aminophylline [inj] ANORO ELLIPTA arbinoxa ARCAPTA NEOHALER ASMANEX benzonatate BREO ELLIPTA brompheniramine w/pseudoephed budesonide caffeine/sodium benzoate [inj] carbinoxamine cetirizine syrup chlorphen-pse-dm tannate CINRYZE [INJ] [SP] clemastine fumarate COMBIVENT RESPIMAT cromolyn sodium nebulization solution cyproheptadine hcl D-CHLORPHENIRA/PSE/CHLOPHEDIAN 12.5CPD-

1DCPM-30PSE DALIRESP desloratadine, odt dexchlorpheniramine maleate er DEXTROMETHORPHAN HBR difil-g dihydrocodeine-bpm-pe

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

diphenhydramine [inj] DM/PHENYLEPH/CHLORPHENIRAMINE 10PEH-

4CPM-20DM DULERA DYMISTA ephedrine sulfate epinephrine [inj] EPIPEN EPIPEN JR. epoprostenol diluent [inj] [sp] FIRAZYR FLOVENT DISKUS FLOVENT HFA flunisolide fluticasone propionate FORADIL guaifenesin with codeine hydrocodone-chlorpheniramine er HYDROCODONE/HOMATROPINE hydroxyzine hcl hydroxyzine pamoate ipratropium bromide ipratropium-albuterol nebulization KALBITOR [INJ] LETAIRIS levalbuterol hcl levocetirizine dihydrochloride metaproterenol sulfate montelukast sodium NASONEX OPSUMIT PERFOROMIST [INJ] phenylephrine/chlorpheniramine 10peh-4cpm phenylephrine/chlorpheniramine phenylephrine/dihydrocodeine/chlorphenir PROAIR HFA promethazine hcl, sup, tablets, [inj] promethazine vc w/codeine promethazine w/dm promethegan PSEUDOEPH/CHLOPHEDIANOL/GG 12.5CPD-

100GFN-30PSE pseudoephedrine hcl 12 hour ER pseudoephedrine hcl-d 12 hour pseudoephedrine sulfate ER

PULMICORT PULMICORT FLEXHALER PULMOZYME QNASL QVAR REVATIO [INJ] SEREVENT DISKUS sildenafil citrate sodium chloride nebulizer SPIRIVA SYMBICORT terbutaline sulfate terbutaline sulfate [inj] theophylline anhydrous elixir theophylline anhydrous drops er 12 hr TRACLEER triamcinolone acetonide spray TUDORZA PRESSAIR TUSSICAPS TYVASO VENTAVIS VENTOLIN HFA VERAMYST XOLAIR [INJ] zafirlukast

Urologicals alfuzosin hcl er alprostadil [inj] AMINOACETIC ACID aminoacetic acid [inj] AMMONIUM CHLORIDE [INJ] bethanechol chloride CAVERJECT [INJ] CIALIS CYSTAGON [SP] ELMIRON finasteride flavoxate hcl GELNIQUE glycine hyophen k-phos neutral K-PHOS ORIGINAL

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

MUSE MYRBETRIQ ER 24 HR oxybutynin chloride oxybutynin chloride er OXYTROL PATCH phenazopyridine hcl phenazopyridine plus phosphasal potassium citrate er RAPAFLO RENACIDIN tamsulosin er 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 human [inj] ALZ-NAC amino acid [inj] [ AMINOSYN [INJ] AQUASOL A [INJ] [SP] ascorbic acid [inj] b-complex BAL IN OIL [INJ] bal-care dha calcium acetate calcium chloride [inj] calcium gluconate [inj] cavan-alpha kit cavan-ec sod dha CENOLATE [INJ] centratex choice-ob + dha

choice-tabs chromium chloride [inj] CLINIMIX [INJ] complete natal dha CONCEPTION XR MOTILITY copper chloride [inj] corvita CUPRIC SULFATE [INJ] cyanocobalamin [inj] DAILYVITE dexferrum DIALYVITE 800 DULEEK-MET NEW eliphos 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 folbic rf folcaps folcaps omega-3 folic acid folic acid [inj] folic acid-cyancobal-pyridoxine folivane-f folivane-ob folivane-plus folivane-prx dha nf folplex 2.2 foltanx FREAMINE HBC

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

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 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-NAC L-METHYLFOLATE CALCIUM m.v.i. adult [inj] M.V.I. PEDIATRIC [INJ] M.V.I.-12 [INJ] macnatal cn dha magnesium chloride [inj] magnesium sulfate [inj] MAGNESIUM SULFATE IN DEXTROSE [INJ] manganese [inj] manganese sulfate [inj] metafolbic metafolbic plus multigen multigen folic multigen plus MULTITRACE-4 [INJ] MULTITRACE-5 [INJ] multivitamin w/fluoride & iron multivitamin with fluoride mynatal

mynatal caps mynatal advance mynatal plus mynatal-z mynate 90 plus er mynephrocaps NASCOBAL 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] nutri-tab ob nutrilyte [inj] nutrilyte ii [inj] obstetrix dha PEDITRACE [INJ] PLASMA-LYTE 148 [INJ] pnv ob+dha pnv-dha pnv-first pnv-omega pnv-select pnv-total polysaccharide iron forte poly-iron 150 forte pot chloride/dextrose/ns [inj] potassium acetate [inj] potassium bicarbonate potassium chl-normal saline [inj] potassium chloride potassium chloride/dextrose [inj] pr natal 400 pr natal 400 ec pr natal 430 pr natal 430 ec prefol-dha premasol [inj] prena1

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

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 relnate dha RENA-VITE RX renal caps renalpren reno caps ringers [inj] se-tan dha pernatal se-tan plus se-natal 19 selenium [inj] setonet setonet-ec sodium acetate [inj] sodium chloride 3% sodium chloride0.45% sodium lactate [inj] strovite STUART ONE taron forte taron prenatal taron-bc taron-c dha taron-duo ec therapeutic hematinic therapeutic vitamin w-minerals thiamine hcl

tl g-fol os tl gard rx tl icon tl-care dha tl-fol 500 er tl-hem 150 er 24 hr tl-select TPN ELECTROLYTES [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 triveen-prx rnf triveen-ten triveen-u trust natal dha ultimate ob dha ultimatecare one ultimatecare one nf v-c forte v-natal 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

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

vinate-m virt-bal dha virt-bal dha plus virt-pn virt-pn dha virt-pn plus virt-select virt-vite virt-vite forte vitafol-ob vitafol-pn vitamin a vitaspire 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 vynatal-fa zatean-ch zatean-pn zatean-pn dha zatean-pn plus zinc chloride zinc sulfate

Miscellaneous & Diagnostic Agents acamprosate calcium acetic acid irrigation ADAGEN [INJ] [SP] AMMONUL [INJ] anagrelide hydrochloride ARALAST NP [INJ] [SP] atropen [inj] benzphetamine hcl BREVITAL [INJ] BROMHEXINE HYDROCHLORIDE BUPHENYL TABLETS bupivacaine/dextrose [inj]

caffeine citrated caffeine citrated [inj] CARBAGLU [SP] cevimeline hcl CHANTIX CHEMET citric acid CLINIMIX E [INJ] deferoxamine [inj] DELFLEX W/DEXTROSE dextrose in lactated ringers dextrose in water dextrose with sodium chloride diethylpropion hcl diethylpropion hcl disulfiram EOVIST [INJ] ETHAMOLIN etidronate disodium etomidate [inj] EXJADE EXTRANEAL ICODEXTRIN DIALYSIS FERRIPROX FOSRENOL HEXTEND LACTATED ELECTROLYTE INCRELEX [INJ] ISOVUE [INJ] ISOVUE-M [INJ] ketamine hcl [inj] levocarnitine levocarnitine [inj] LEXISCAN MAGNEVIST [INJ] md-gastroview midodrine hcl neomycin-polymyxin b [inj] OMNIPAQUE ORFADIN PANHEMATIN [INJ] phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl pilocarpine hcl PROHANCE [INJ] PROLASTIN [INJ]

Preferred Drug List

Key: [INJ], [inj] – Injectable Drug Updated January 2015 [OTC] – Over the Counter Drug This list is subject to change at any time and [sp] – Specialty Drug 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

PROLASTIN C [INJ] propofol PROSTAMEN PROTOPAM CHLORIDE [INJ] RAVICTI RENVELA riluzole ringers irrigation SEROTONIN HCL sodium chloride sodium chloride [inj] sodium chloride irrigation SODIUM PHOSPHATE sodium polystyrene sulfonate sodium thiosulfate [inj] SOLIRIS [INJ] SOTRADECOL [INJ] THALLOUS CHLORIDE TL-201 THYROGEN [INJ] TRYPSIN UVA URSI LEAF FLUID EXTRACT VISIPAQUE [INJ] water [inj] water intravenous solution water solution irrigation XIAFLEX [INJ] ZEMAIRA [INJ]