* Note that Covered agents not listed on PDL may be considered non-preferred Proprietary & Confidential 2014, Magellan Health Services, Inc. All Rights Reserved.

TennCare Preferred Drug List (PDL) Effective November 1, 2014

PA Prior Authorization required, subject to specific PA criteria, QL Quantity Limit (PA and NP agents require a PA before dispensing) Approval of NP agents requires trial and failure, contraindication or intolerance of 2 preferred agents, unless otherwise indicated.

Please note: With the exception of the Branded Drugs Classified as Generics list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205). Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via a FDA MedWatch form OR contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents.

Preferred Drugs Non-Preferred Drugs

I. Analgesics

Agents for Opiate Detoxification naltrexone PA ReVia PA Buprenorphine and Buprenorphine/Naloxone Suboxone film PA, QL buprenorphine PA, QL Zubsolv PA, QL buprenorphine/naloxone

tablets PA, QL COX-II Inhibitors Class PA N/A Celebrex PA, QL

Transmucosal Fentanyl Products fentanyl lozenge PA, QL Abstral PA, QL Fentora PA, QL Actiq PA, QL Subsys PA, QL Narcotics Agonist/Antagonists nalbuphine PA, QL butorphanol NS PA, QL pentazocine/naloxone PA, QL pentazocine/APAP PA, QL

Narcotics, Long Acting Narcotics fentanyl patch PA, QL Kadian PA (100 mg), QL Avinza PA, QL morphine sulfate SR 24hr PA, QL morphine sulfate SA PA(100 mg), QL Butrans PA, QL MS Contin PA, QL ConZipTM PA, QL Nucynta ER PA,QL Dolophine PA, QL Opana ER PA, QL Duragesic PA, QL OxyContin PA, QL ExalgoTM PA, QL oxymorphone ER PA, QL hydromorphone ER PA, QL tramadol ER PA, QL methadone PA, QL tramadol ER 24 hr PA, QL Methadose PA, QL Ultram ER PA, QL morphine sulfate ER capsules PA, QL Zohydro ER PA, QL

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Preferred Drugs Non-Preferred Drugs

I. Analgesics

Short-Acting Narcotics codeine/APAP QL morphine IR QL (excluding suppositories) butalbital/APAP/caff/codeine QL Norco QL Endocet QL oxycodone QL butalbital/ASA/caff/codeine QL Nucynta QL hydrocodone/APAP QL (excluding generic for Xodol) oxycodone/APAP QL Capital with Codeine QL Opana QL hydrocodone/ibuprofen 5/200 mg QL tramadol QL codeine QL Oxecta QL hydromorphone QL (excluding suppositories) Endodan QL oxymorphone QL Ibudone QL Demerol QL oxycodone/ASA QL dihydrocodeine/APAP/codeine QL oxycodone/IBU QL dihydrocodeine/ASA/codeine QL Panlor SS QL Dilaudid QL Percocet QL Fioricet with Codeine QL Percodan QL Fiorinal with Codeine QL Roxicet QL Hycet QL Roxicodone QL hydrocodone/APAP 5/300 Synalgos-DC QL hydrocodone/APAP 10/300 tramadol/APAP QL hydrocodone/ibuprofen (excluding

5/200 mg) QL Tylenol with Codeine QL

hydromorphone suppositories Tylox QL Levorphanol QL Ultracet QL Lorcet QL Ultram QL Lortab QL Vicodin QL Maxidone QL Vicodin HP QL Magnacet QL Vicoprofen QL meperidine QL XartemisTM XR QL Meperitab QL Xodol QL morphine suppositories QL Zamicet QL NSAID/Anti-Ulcer Agents N/A Arthrotec PA Duexis PA diclofenac/misoprostol PA Vimovo PA

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Preferred Drugs Non-Preferred Drugs

I. Analgesics

Salicylates and Non-Narcotic Combination Agents Be-Flex Plus QL Ed-Flex QL Acuflex QL Flextra DS QL choline mag trisalicylate QL RhinoflexTM QL Alpain QL Flextra-650 QL diflunisal QL salsalate QL Anabar QL Lagesic QL Dologesic QL Tetra-Mag QL Cafgesic QL Levacet QL Cafgesic Forte QL MST 600 QL Durabac QL Rhinoflex 650TM QL Durabac Forte QL Zgesic QL Flextra QL Zorprin QL Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) diclofenac potassium ketorolac QL Anaprox meloxicam suspension diclofenac sodium meloxicam tablets Anaprox DS Mobic diclofenac sodium ER nabumetone CambiaTM Motrin flurbiprofen naproxen Cataflam Nalfon ibuprofen piroxicam Clinoril Naprelan indomethacin sulindac Daypro naproxen sodium ER ketoprofen diclofenac sodium 1.5% Naprosyn EC-Naprosyn Pennsaid PA etodolac Ponstel etodolac ER oxaprozin Feldene Sprix PA fenoprofen tolmetin Flector PA, QL Voltaren indomethacin ER Voltaren Gel PA ketoprofen ER Voltaren-XR meclofenamate Zipsor mefenamic acid Zorvolex PA

Preferred Drugs Non-Preferred Drugs

II. ANTI-INFECTIVES

Antibiotics: Cephalosporins First Generation cefadroxil capsules cephalexin capsules cefadroxil tablets Keflex cefadroxil suspension cephalexin suspension cephalexin tablets

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Preferred Drugs Non-Preferred Drugs

II. ANTI-INFECTIVES

Antibiotics: Cephalosporins Second Generation cefaclor capsules cefuroxime tabs PA cefaclor suspension Ceftin suspension PA cefprozil cefaclor ER Ceftin tabs Antibiotics: Cephalosporins Third Generation cefdinir Suprax Cedax ceftibuten Cefditoren Spectracef cefpodoxime

Antibiotics: Ketolides N/A Ketek PA Antibiotics: Macrolides azithromycin QL erythromycin/sulfisoxazole Biaxin erythromycin brand products azithromycin suspension PA Biaxin XL QL Zithromax QL clarithromycin clarithromycin ER/XL QL Zmax QL erythromycin generic products Dificid PA, QL

Antibiotics: Methenamine and Combo all generic combinations of methenamine, phenylsalicylate, hyoscyamine, atropine, etc. methenamine mandelate all brand combinations of methenamine, phenylsalicylate, hyoscyamine, atropine, etc. Hiprex methenamine hippurate Uroqid Acid #2 Antibiotics: Miscellaneous Agents for UTI N/A Monurol QL, PA

Antibiotics: Non-Absorbable Rifamycin N/A Xifaxan PA Antibiotics: Oral Aminoglycosides neomycin Neo-Fradin N/A Antibiotics: Oral Anti-Tuberculosis ethambutol pyrazinamide cycloserine Rifadin isoniazid rifabutin PA Isonarif PA Rifamate PA Mycobutin PA rifampin Myambutol Rifater PA Paser Seromycin Pulvules Priftin Trecator

Antibiotics: Oral Glycopeptides N/A vancomycin caps PA Antibiotics: Oral Lincosamines clindamycin caps Cleocin Cleocin Pediatric granules PA clindamycin pediatric solution PA

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Preferred Drugs Non-Preferred Drugs

II. ANTI-INFECTIVES

Antibiotics: Oral Nitrofurans nitrofurantoin capsules nitrofurantoin suspension PA Furadantin PA Macrodantin Macrobid Antibiotics: Oxazolidinones N/A Zyvox PA, QL

Antibiotics: Penicillins amoxicillin dicloxacillin all brand penicillins amoxicillin ER amoxicillin/clavulanate penicillin amoxicillin/clavulanic acid XR Antibiotics: Quinolones ciprofloxacin levofloxacin tabs Avelox PA Levaquin tabs Avelox ABC Pack PA Levaquin solution PA Cipro tablets levofloxacin solution PA Cipro suspension PA moxifloxacin PA ciprofloxacin suspension PA Noroxin PA ciprofloxacin ER QL ofloxacin Factive PA

Antibiotics: Tetracyclines doxycycline monohydrate 50 and 100 mg caps Adoxa minocycline ER PA, QL doxycycline hyclate 50 and 100mg demeclocycline PA minocycline tablets minocycline capsules minocycline capsules Morgidox tetracycline doxycycline hyclate DR particles OcudoxTM Kit doxycycline hyclate 20mg PA, QL Oracea doxycycline monohydrate 75 mg

and 150 mg caps Periostat PA, QL doxycycline monohydrate tabs Solodyn PA, QL Doryx Vibramycin Dynacin Antibiotics: Sulfonamides, Folate Antagonist sulfadiazine PA trimethoprim (TMP) TMP/sulfamethoxazole Bactrim Primsol Bactrim DS Septra DS

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Preferred Drugs Non-Preferred Drugs

II. ANTI-INFECTIVES

Antifungals: Oral clotrimazole troches nystatin Ancobon PA ketoconazole PA fluconazole suspension PA terbinafine PA, QL Diflucan suspension PA Lamisil PA, QL fluconazole tablets QL Diflucan tablets QL Noxafil PA griseofulvin suspension flucytosine PA Onmel PA, QL Gris-Peg Grifulvin V Sporanox PA, QL griseofulvin microsize Terbinex PA, QL griseofulvin ultramicrosize Vfend PA itraconazole PA, QL voriconazole PA Antifungals: Vaginal miconazole-3 kit terconazole AVCTM cream miconazole-3 vaginal supp nystatin Gynazole-1 Terazol

Anti-Infectives: Amebicides paromomycin N/A Anti-Infectives: Antimalarials atovaquone/proguanil mefloquine Aralen Malarone chloroquine primaquine Coartem Qualaquin dapsone quinine sulfate Daraprim Anti-Infectives: Anthelmintics Albenza Stromectol N/A Biltricide

Anti-Infectives: Miscellaneous Antiprotozoal Agents metronidazole tabs Alinia PA Flagyl ER atovaquone PA Mepron PA Flagyl metronidazole caps Anti-Infectives: Oral Nitroimidazoles metronidazole tabs Flagyl Tindamax Flagyl ER Tinidazole metronidazole caps Anti-Infectives: Vaginal Antibiotics Cleocin suppositories metronidazole 0.75% gel Cleocin cream MetroGel Vaginal

clindamycin phos 2% cream Vandazole Clindesse vaginal cream

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Preferred Drugs Non-Preferred Drugs

II. ANTI-INFECTIVES

Antivirals: Cytomegalovirus Agents Valcyte N/A Antivirals: Hepatitis B Baraclude Epivir-HBV QL adefovir PA lamivudine-HBV QL entecavir Tyzeka PA Hepsera PA

Antivirals: Hepatitis C Non-Pegylated Interferons Intron-A Alferon N Infergen PA Antivirals: Hepatitis C Pegylated Interferons Pegasys ProClick PA, QL Pegasys Conv. Pack PA, QL PEG-Intron QL PEG-Intron Redipen QL Pegasys syringes PA, QL Pegasys vials PA, QL

Antivirals: Hepatitis C Antivirals IncivekTM PA, QL VictrelisTM PA, QL OlysioTM PA, QL Sovaldi PA, QL Antivirals: Hepatitis C Ribavirins Ribasphere 200 mg tablets ribavirin tablets Copegus ribavirin capsules ModeribaTM dose pack Ribapak Rebetol capsules Ribasphere 200mg capsules Rebetol solution PA Ribasphere 400 & 600 mg tablets

Antivirals: Herpes acyclovir valacyclovir QL Famvir QL Valtrex QL famciclovir QL Sitavig buccal tabs QL Zovirax Antivirals: HIV CCR5 Antagonists Selzentry PA, QL N/A Antivirals: HIV Fusion Inhibitors Fuzeon PA, QL N/A

Antivirals: HIV Integrase Inhibitors Isentress PA, QL Tivicay PA, QL N/A Antivirals: HIV NNRTIs Edurant nevirapine QL nevirapine ER QL Viramune QL Intelence PA, QL Sustiva QL Rescriptor QL Viramune XR QL

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Preferred Drugs Non-Preferred Drugs

II. ANTI-INFECTIVES

Antivirals: HIV NRTIs abacavir QL stavudine QL Retrovir QL Videx capsules QL didanosine capsules QL Videx solution QL Zerit QL Emtriva QL Viread QL Epivir QL Ziagen QL lamivudine QL zidovudine QL Antivirals: HIV NRTI Combos abacavir/lamivudine/ zidovudine PA, QL lamivudine/zidovudine QL N/A Atripla QL Stribild Combivir QL Triumeq QL Complera Trizivir PA, QL Epzicom QL Truvada QL

Antivirals: HIV Protease Inhibitors Aptivus PA, QL Prezista QL Crixivan QL Invirase QL Prezista QL Kaletra QL Reyataz QL Lexiva QL Viracept QL Norvir QL Antivirals: Influenza N/A Relenza PA, QL Tamiflu PA, QL

Preferred Drugs Non-Preferred Drugs

III. CARDIOVASCULAR

Alpha/Beta Blockers labetalol carvedilol QL Coreg QL Trandate Coreg CR QL Alpha-Blockers doxazosin prazosin Cardura Minipress terazosin

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Preferred Drugs Non-Preferred Drugs

III. CARDIOVASCULAR

ACE Inhibitors benazepril lisinopril Accupril perindopril QL captopril ramipril QL Aceon QL Prinivil enalapril Altace QL Quinapril Epaned PA trandolapril QL fosinopril Univasc QL Lotensin Vasotec Mavik QL Zestril moexipril QL ACEI + Calcium Channel Blocker Combo N/A benazepril/amlodipine QL, PA Tarka QL, PA Lotrel QL, PA trandolapril/verapamil QL, PA

ACEI + Diuretic Combination benazepril/HCTZ enalapril/HCTZ Accuretic quinapril/HCTZ captopril/HCTZ lisinopril/HCTZ fosinopril/ HCTZ Uniretic Lotensin HCT Vaseretic moexipril/HCTZ Zestoretic Prinzide Angiotensin II Receptor Blockers losartan QL Atacand QL eprosartan QL Avapro QL irbesartan QL Benicar QL Micardis QL Cozaar QL telmisartan QL candesartan QL Teveten QL Diovan QL valsartan QL EdarbiTM QL

Angiotensin II Receptor Blockers + Calcium Channel Blocker Class PA, QL Exforge PA, QL Azor PA, QL TribenzorTM PA, QL Exforge HCT PA, QL telmisartan/amlodipine PA, QL Twynsta PA, QL Angiotensin II Receptor Blockers + Diuretic losartan/HCTZ QL Atacand HCT Hyzaar Avalide irbesartan/HCTZ Benicar HCT QL Micardis HCT QL candesartan/HCTZ QL telmisartan/ HCTZ QL Diovan HCT QL Teveten HCT Edarbyclor QL valsartan/ HCTZ QL

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Preferred Drugs Non-Preferred Drugs

III. CARDIOVASCULAR

Anti-Anginal Agents: Miscellaneous N/A Ranexa PA Anti-Anginal Agents: Nitrates Isochron nitroglycerin (excluding spray) amyl nitrite Monoket isosorbide dinitrate

(excluding 10 mg tabs and SL tabs) Nitrolingual Dilatrate-SR Nitro-Bid isosorbide mononitrate Nitrostat Imdur Nitro-Dur Minitran Isordil nitroglycerin spray Isosorbide dinitrate 10 mg tabs NitroMistTM isosorbide dinitrate, sublingual Anti-Arrhythmics, Oral amiodarone quinidine sulfate Betapace Pacerone disopyramide sotalol Betapace AF propafenone ER flecainide sotalol AF Cordarone Rythmol mexiletine Tikosyn QL Multaq PA Rythmol SR propafenone Norpace Sorine quinidine gluconate Norpace CR Tambocor

Anti-Hypertensives, Miscellaneous Catapres-TTS QL methyldopa/HCTZ Catapres NexiclonTM XR clonidine clonidine weekly TD patch QL reserpine guanfacine Clorpres Tenex hydralazine guanabenz Vecamyl PA, QL methyldopa minoxidil PA

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Preferred Drugs Non-Preferred Drugs

III. CARDIOVASCULAR

Beta Blockers atenolol propranolol (excluding solution) acebutolol Lopressor metoprolol tartrate sotalol Betapace metoprolol succinate PA, QL nadolol betaxolol pindolol bisoprolol fumarate PA propranolol solution PA Bystolic propranolol ER Cartrol Sectral Corgard Sorine Inderal LA Tenormin InnoPran XL QL timolol maleate Kerlone Toprol XL PA, QL Levatol QL Zebeta Beta Blockers + Diuretic atenolol/chlorthalidone propranolol HCT Corzide nadolol/bendroflumethiazide bisoprolol HCT Dutoprol PA, QL Tenoretic metoprolol HCT Lopressor HCT Ziac

Calcium Channel Blockers (DHP) amlodipine QL Adalat CC QL Norvasc QL felodipine ER Cardene SR QL Nymalize PA nicardipine isradipine QL Procardia nifedipine ER/SA/XL QL nifedipine IR Procardia XL QL nimodipine PA Sular QL nisoldipine QL Calcium Channel Blockers (Non-DHP) diltiazem ER/SR/XR Calan diltiazem ER (generic for

Cardizem LA) QL diltiazem IR Calan SR Tiazac verapamil Cardizem verapamil ER PM verapamil ER QL Cardizem CD Verelan Cardizem LA QL Verelan PM Dilacor XR Cardiac Glycosides digoxin Lanoxin

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Preferred Drugs Non-Preferred Drugs

III. CARDIOVASCULAR

Direct Renin Inhibitors Class PA N/A AmturnideTM PA, QL Tekturna HCT PA, QL Tekamlo PA, QL Tekturna PA, QL Diuretics: Carbonic Anhydrase Inhibitors acetazolamide methazolamide Diamox Sequels

Diuretics: Combination Diuretics amiloride/HCTZ triamterene/HCTZ Aldactazide Maxzide spironolactone/HCTZ Dyazide Diuretics: Loop bumetanide furosemide Demadex Edecrin torsemide Lasix

Diuretics: Potassium Sparing amiloride spironolactone Aldactone Inspra PA eplerenone PA Diuretics: Thiazide and Related Diuretics chlorothiazide indapamide Diuril Microzide chlorthalidone metolazone hydrochlorothiazide 12.5mg tab PA Thalitone hydrochlorothiazide

(excluding 12.5mg tab) methyclothiazide Zaroxolyn Hemostatics, Oral aminocaproic acid tranexamic acid PA, QL Amicar Lysteda PA, QL

Intermittent Claudication cilostazol pentoxifylline PA Pletal Trental PA Lipotropics: Bile Acid Sequestrants cholestyramine WelChol tablets Colestid Questran Light cholestyramine light colestipol WelChol packets PA Prevalite Questran

Lipotropics: Cholesterol Absorption Inhibitors N/A Zetia PA, QL

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Preferred Drugs Non-Preferred Drugs

III. CARDIOVASCULAR

Lipotropics: Fibric Acid Derivatives fenofibrate (excluding generic for Antara) PA gemfibrozil Antara PA Lipofen PA fenofibrate (generic for TriCor) PA fenofibric acid PA Lofibra PA Fenoglide PA Lopid fenofibrate (generic for Antara) PA TriCor PA fenofibrate capsules (generic for Lipofen) PA Triglide PA Fibricor PA TriLipix PA

Lipotropics: Miscellaneous Kynamro PA, QL Juxtapid PA, QL Lipotropics: Niacin Derivatives Class PA Niaspan PA Niacor PA niacin ER PA

Lipotropics: Omega-3 Fatty Acids Class PA N/A Lovaza PA Vascepa PA omega-3 acid ethyl esters PA Lipotropics: Standard Potency Statins QL lovastatin QL simvastatin (5 mg, 10 mg, 20 mg,

40 mg) QL Altoprev QL Livalo QL pravastatin QL fluvastatin QL Mevacor QL Lescol QL Pravachol QL Lescol XL QL Zocor (5 mg, 10 mg, 20 mg, 40 mg) QL

Lipotropics: High Potency Statins QL atorvastatin QL simvastatin 80 mg PA, QL Lipitor QL Zocor 80 mg PA, QL Crestor QL Lipotropics: Combination Antihyperlipidemics QL N/A Advicor PA QL Simcor QL Liptruzet PA Vytorin PA, QL

Lipotropics: Statin + CCB Combination N/A amlodipine/atorvastatin PA, QL Caduet PA, QL Injectable Anticoagulants fondaparinux Lovenox Arixtra enoxaparin Fragmin heparin

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Preferred Drugs Non-Preferred Drugs

III. CARDIOVASCULAR

Oral Anticoagulants Coumadin warfarin Eliquis PA Xarelto PA, QL Jantoven Pradaxa PA Oral Thrombopoietin Agonists N/A Promacta PA, QL

Peripheral Vasodilators ergoloid mesylates Pheochromocytoma Agents N/A Demser PA

Platelet Inhibitors Aggrenox dipyridamole Agrylin Persantine anagrelide ticlopidine Brilinta PA, QL Plavix cilostazol clopidogrel 300 mg Pletal clopidogrel 75 mg Effient PA

Pulmonary Arterial Hypertension Agents Class PA, QL Adcirca PA, QL Tracleer PA, QL Adempas PA, QL Letairis PA, QL Tyvaso PA, QL Opsumit PA, QL Orenitram PA, QL Ventavis PA, QL Revatio PA, QL sildenafil PA, QL Revatio suspension PA, QL Vasopressors midodrine N/A

Vasodilator/Nitrate Combinations N/A BiDil PA

Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Agents for Neuropathic Pain gabapentin capsules QL Cymbalta PA, QL lidocaine patch PA duloxetine QL Lidoderm PA gabapentin solution PA, QL Lyrica PA gabapentin tablets QL Neurontin QL Gralise PA, QL Neurontin solution PA, QL Horizant PA, QL

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Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Alzheimers: Cholinesterase Inhibitors donepezil QL (excluding 23 mg) Exelon Patch QL Aricept ODT PA, QL galantamine solution donepezil ODT PA, QL galantamine tablets Aricept QL galantamine ER QL Aricept 23 mg tablet PA, QL Razadyne donepezil 23 mg PA, QL Razadyne ER QL Exelon rivastigmine Alzheimers: NMDA Receptor Antagonists N/A Namenda PA, QL Namenda XR PA, QL Antiparkinsons Agents: Anticholinergics benztropine trihexyphenidyl N/A

Antiparkinsons Agents: Decarboxylase Inhibitors carbidopa Lodosyn Antiparkinsons Agents: Dopamine Precursors/Decarboxylase Inhibitors carbidopa/levodopa carbidopa/levodopa ER/SR Parcopa Sinemet CR Sinemet

Antiparkinsons Agents: COMT Inhibitors and Combos carbidopa/levodopa/entacapone Stalevo Comtan entacapone Tasmar Antidepressants: SSRIs QL citalopram QL Brisdelle PA Paxil QL escitalopram QL Celexa QL Paxil CR QL fluoxetine QL (excluding 20 mg and 60 mg tabs) fluoxetine 20 mg and 60 mg tabs QL Pexeva QL fluvoxamine QL fluoxetine (PMDD) QL Prozac QL paroxetine QL fluoxetine weekly PA, QL Prozac Weekly PA, QL sertraline QL fluvoxamine ER QL Sarafem QL Lexapro QL Viibryd QL Luvox CR QL Zoloft QL paroxetine CR QL

Antidepressants: SSRI/SRMs N/A Brintellix PA, QL

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Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Antidepressants: SNRIs Class PA, QL venlafaxine PA, QL Cymbalta PA, QL Fetzima PA, QL venlafaxine ER caps QL desvenlafaxine PA, QL Khedezla PA, QL desvenlafaxine ER PA, QL Pristiq PA, QL desvenlafaxine fumarate ER PA, QL Savella PA, QL duloxetine QL venlafaxine ER tabs PA, QL Effexor XR PA, QL Antidepressants: New Generation budeprion SR mirtazapine Aplenzin Remeron SolTab PA budeprion XL QL mirtazapine rapdis PA OleptroTM QL trazodone 300 mg bupropion IR/SR trazodone (excluding 300 mg) Forfivo XL Wellbutrin bupropion XL QL nefazodone Wellbutrin SR maprotiline Remeron Wellbutrin XL QL

Antidepressants: Tricyclics amitriptyline amoxapine protriptyline desipramine Anafranil PA Surmontil doxepin clomipramine PA Tofranil imipramine HCl imipramine pamoate Tofranil-PM nortriptyline Norpramin Vivactil Pamelor Antidepressants: MAOIs Class PA, QL phenelzine PA, QL Emsam PA, QL Parnate PA, QL Marplan PA, QL tranylcypromine PA, QL Nardil PA, QL

Antipsychotics: Typical chlorpromazine perphenazine Haldol fluphenazine thioridazine Loxitane haloperidol thiothixene Moban loxapine trifluoperazine Navane Orap

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Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Antipsychotics: Atypical Class PA Abilify PA, QL quetiapine PA, QL Abilify MaintenaTM PA, QL Risperdal PA, QL Abilify Discmelt PA, QL risperidone PA, QL Clozaril PA Risperdal Consta PA, QL clozapine PA risperidone ODT PA, QL clozapine ODT PA Risperdal M-tab PA, QL Fanapt PA, QL Saphris PA, QL FazaClo ODT PA, QL Zyprexa PA, QL Latuda PA, QL Seroquel XR PA, QL Geodon PA, QL Seroquel PA, QL olanzapine PA, QL ziprasidone PA, QL Invega PA Versacloz suspension PA olanzapine ODT PA, QL Invega SustennaTM PA, QL Zyprexa Zydis PA, QL Atypical Antipsychotic and SSRI Combinations Class PA N/A fluoxetine/olanzapine PA, QL Symbyax PA, QL

Anti-Migraine: Combination Agents butalbital/APAP/caff/codeine QL Cafergot butalbital/ASA/caff QL isomethept/caffeine/APAP QL butalbital/ASA/caff/codeine QL Margesic QL Fioricet with codeine QL Migergot butalbital/APAP/caff QL Fiorinal with codeine QL Anti-Migraine: 5-HT1 Receptor Agonists QL Imitrex Nasal QL rizatriptan QL Alsuma QL naratriptan QL Relpax QL rizatriptan ODT QL Amerge QL sumatriptan kits QL sumatriptan vials QL Axert PA, QL sumatriptan nasal QL sumatriptan tabs QL Frova QL Sumavel DoseProTM QL Imitrex Injectable QL Treximet QL Imitrex Kit QL Zomig QL Imitrex tablets QL Zomig Spray QL Maxalt QL Zomig ZMT QL Maxalt MLT QL

Anti-Migraine: Ergotamine Derivatives N/A Migranal PA, QL

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Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Antihyperkinesis: Stimulants Adderall XR QL Methylin tabs Adderall QL Methylin solution & chewables amphetamine salt IR combo QL methylphenidate amphetamine salt ER combo QL methylphenidate ER QL (generic for Ritalin LA) dextroamphetamine QL methylphenidate ER QL (excluding generic for Ritalin LA) Concerta QL methylphenidate CR QL dextroamphetamine solution QL methylphenidate SA OSM QL Daytrana QL methylphenidate solution Focalin ProCentra QL Desoxyn QL methylphenidate SR 24hr QL Focalin XR QL Quillivant XR QL dexmethylphenidate Ritalin LA QL Metadate ER QL Ritalin dexmethylphenidate XR QL Ritalin SR methamphetamine QL Vyvanse QL Dexedrine Spansule QL Zenzedi Methylin ER QL

Antihyperkinesis: Non-Stimulants Strattera QL clonidine ER PA, QL KapvayTM PA, QL Intuniv PA, QL Agents for Narcolepsy Provigil PA, QL modafinil PA, QL Xyrem PA, QL Nuvigil PA, QL

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Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Anticonvulsants carbamazepine lamotrigine tabs Aptiom PA Lamictal (tabs & chewable tabs) carbamazepine ER (excluding generic Carbatrol) lamotrigine chewable tabs Banzel PA Lamictal ODT PA Carbatrol levetiracetam carbamazepine ER (generic for

Carbatrol only) Lamictal XR Diastat PA, QL levetiracetam ER Celontin lamotrigine ER Dilantin Kapseal 30 mg oxcarbazepine clonazepam (tabs & ODT) PA, QL Lyrica PA Dilantin Infatabs phenobarbital PA Depakene Mysoline divalproex Phenytek Depakote Neurontin QL divalproex DR sprinkles phenytoin Depakote ER Neurontin solutionPA, QL divalproex extended release primidone Depakote Sprinkles OnfiPA Equetro topiramate diazepam rectal gel PA, QL Oxtellar XR ethosuximide Tegretol-XR 100mg Dilantin-125 Peganone gabapentin capsules QL valproic acid Dilantin Kapseal 100 mg Potiga PA Vimpat PA Epitol Sabril PA zonisamide felbamate PA Stavzor Felbatol PA Tegretol FycompaTM PA, QL Tegretol-XR (200 & 400mg) gabapentin solution PA, QL tiagabine gabapentin tablets QL Topamax Gabitril Trileptal Keppra Trokendi XR PA Keppra XR Zarontin Klonopin PA, QL Zonegran Agents for RLS (Restless Leg Syndrome) pramipexole QL ropinirole Horizant PA, QL Neupro PA Mirapex QL Requip

Amyotrophic Lateral Sclerosis (ALS) Rilutek riluzole

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Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Anti-Anxiety Agents alprazolam PA, QL diazepam PA, QL alprazolam ER PA, QL oxazepam PA, QL buspirone (excluding 30 mg) lorazepam PA, QL alprazolam ODT PA, QL Niravam PA, QL chlordiazepoxide PA, QL Ativan PA, QL Tranxene-T PA, QL clorazepate PA, QL Buspar Valium PA, QL buspirone 30 mg Xanax PA, QL Meprobamate Xanax ER PA, QL

Cholinergic Muscle Stimulants Mestinon syrup pyridostigmine 60 mg tab Mytelase Prostigmin Mestinon 180mg ER tab Mestinon 60 mg tab Non-Ergot Dopamine Receptor Agonists pramipexole QL ropinirole bromocriptine Parlodel Cyloset Requip Mirapex QL Requip XL Mirapex ER QL ropinirole ER Neupro PA

MAOI-Bs selegiline N/A Azilect Zelapar PA Eldepryl Miscellaneous CNS Agents N/A Nuedexta PA, QL

Mood Stabilizers carbamazepine lithium citrate Depakote Lamictal XR lamotrigine tabs oxcarbazepine Depakene lamotrigine ER lamotrigine chewable tabs valproic acid Keppra Stavzor levetiracetam Lamictal tabs Tegretol lithium carbonate Lamictal chewable tabs Trileptal lithium carbonate SA Lamictal ODT PA Lithobid

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Preferred Drugs Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Sedative Hypnotic Agents QL zaleplon QL Ambien QL Rozerem QL zolpidem QL Ambien CR QL Silenor PA, QL eszopiclone QL Sonata QL EdluarTM PA, QL temazepam PA, QL estazolam PA, QL triazolam PA, QL flurazepam PA, QL zolpidem ER QL Halcion PA, QL Zolpimist PA, QL Intermezzo QL Lunesta QL Restoril PA, QL Skeletal Muscle Relaxants baclofen methocarbamol Amrix QL orphenadrine chlorzoxazone orphenadrine/ASA/caffeine carisoprodol PA, QL Parafon Forte cyclobenzaprine tizanidine tablets carisoprodol/ASA PA, QL Robaxin dantrolene carisoprodol/ASA/codeine PA Skelaxin cyclobenzaprine 7.5mg Soma PA, QL Flexeril tizanidine capsules Lorzone Zanaflex metaxalone

Preferred Drugs Non-Preferred Drugs

V. DERMATOLOGICS

Topical Antipruritics/Antihistamines N/A Prudoxin PA, QL Zonalon PA, QL Topical Antivirals

acyclovir 5% ointment QL Xerese PA Zovirax ointment QL Denavir cream QL Zovirax cream QL Topical Agents for Burns silver sulfadiazine SSD mefanide Sulfamylon Thermazene Silvadene

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Preferred Drugs Non-Preferred Drugs

V. DERMATOLOGICS

Antiseborrheic Agents Mexar wash Carmol 10% Scalp lotion selenium sulfide/pyrithione zinc in urea

selenium sulfide 2.5% lotion Ovace SelenosTM sulfacetamide sodium 10% wash OvacePlus Selsun Rosula NS Pads sodium sulfacetamide 10%

shampoo Seb-PrevTM sulfacetamide sodium/urea pads selenium sulfide shampoo TL TrisebTM Topical Antibiotic Agents for Skin and Soft Tissue Infections gentamicin mupirocin ointment Altabax Centany Bactroban cream mupirocin cream Bactroban ointment

Topical Antibiotic Agents for Acne (Covered for recipients < 21 years old only) Azelex 20% cream clindamycin phosphate (excluding foam and lotion) benzoyl peroxide (cleanser, gel, microspheres, towlettes, and all strengths not listed as preferred) benzoyl peroxide (2.5%, 5%,

10% excluding cleanser, gel, microspheres, and towlettes) erythromycin (excluding swab) benzoyl peroxide kits and other dermatological kits PA sodium sulfacetamide (excluding suspension) clindamycin phosphate foam and lotion clindamycin/benzoyl peroxide gel erythromycin swab erythromycin/benzoyl peroxide sulfacetamide suspension sodium sulfacetamide/sulfur All branded single agent and combination products of: benzoyl peroxide, clindamycin, erythromycin, and sodium sulfacetamide

Topical Agents for Rosacea (Covered for recipients < 21 years old only) Finacea 15% gel metronidazole gel 1% QL Finacea Plus gel PA MetroLotion QL metronidazole 0.75% cream QL Metrocream QL Mirvaso metronidazole 0.75% gel QL MetroGel 1% QL Noritate 1% cream metronidazole 0.75% lotion QL MetroGel 1% Kit RosadanTM Kit

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Preferred Drugs Non-Preferred Drugs

V. DERMATOLOGICS

Topical Antifungal Agents ciclopirox econazole Bensal HP Luzu PA ciclopirox solution 8% PA ketoconazole (shampoo and cream) Ciclodan Kit PA Loprox clotrimazole nystatin ciclopirox nail kit PA Lotrisone clotrimazole/betamethasone Mentax CNL 8 Nail Kit PA Naftin Ertaczo Nizoral Exelderm Nystatin/triamcinolone Extina Oxistat Jublia PA Pediaderm AF Ketocon Kit PA Pedipirox-4 Nail PA ketoconazole foam Penlac PA Ketodan Kit PA Vusion PA Lamisil

Topical Antipsoriatics Class PA calcipotriene cream PA Vectical PA calcipotriene ointment PA Dovonex Scalp Solution PA calcipotriene scalp solution PA calcitriol ointment PA Sorilux PA Tazorac PA calcipotriene/betamethasone PA Taclonex PA Dovonex PA Genital Wart Agents imiquimod podofilox Aldara Veregen Condylox Immunomodulators imiquimod Aldara

Emollients ammonium lactate lactic acid Lac-Hydrin LacLotion lactic acid with vitamin E Retinoids, Oral N/A acitretin PA, QL Myorisan PA Absorica PA Sotret PA Amnesteem PA Soriatane QL Claravis PA Zenatane PA

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Preferred Drugs Non-Preferred Drugs

V. DERMATOLOGICS

Retinoids, Topical Class PA Tazorac PA tretinoin PA adapalene PA Retin-A PA Atralin PA Retin-A Micro PA Differin PA tretinoin microsphere gel PA Epiduo PA VeltinTM PA FabiorTM Ziana PA Pediculocides/Scabicides QL NatrobaTM QL Sklice QL Elimite QL Ovide QL permethrin QL Eurax QL spinosad QL lindane PA, QL UlesfiaTM QL malathion QL

Keratolytic Agents all generic urea products all generic salicylic acid products All brand urea products All brand salicylic acid products Enzyme Preps and Wound Healing Regranex PA Santyl N/A

Topical Anesthetics lidocaine QL lidocaine viscous All brand lidocaine products Lidoderm PA lidocaine HC lidocaine/prilocaine QL EMLA QL Pliaglis Topical Antineoplastics Carac Panretin diclofenac 3% gel Valchlor PA Fluoroplex Solaraze Efudex Zyclara fluorouracil Targretin Picato

Topical Steroids: Least Potent hydrocortisone 1% cream and ointment Alcortin A hydrocortisone 2.5% cream, lotion and ointment Aqua Glycolic HC Kit hydrocortisone acetate-aloe vera 2% gel Pediaderm HC 2% Kit Texacort 2.5% solution U-cort 1% cream

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Preferred Drugs Non-Preferred Drugs

V. DERMATOLOGICS

Topical Steroids: Mild aclomethasone 0.05% cream and ointment Derma-Smoothe/FS Oil betamethasone valerate 0.1% lotion Desonate 0.05% gel desonide 0.05% cream desonide 0.05% ointment fluocinolone acetonide 0.01% cream, oil and solution Synalar 0.01% solution Verdeso 0.05% foam

Topical Steroids: Lower Mid-Strength betamethasone dipropionate 0.05% lotion Capex shampoo betamethasone valerate 0.1% cream clocortolone 0.1% cream and pump Derma-Top 0.1% ointment Cloderm 0.1% cream fluticasone proprionate 0.05% cream Cutivate 0.05% cream and lotion hydrocortisone butyrate 0.1% solution Derma-Top 0.1% cream desonide 0.05% lotion Desowen 0.05% lotion Diprolene 0.05% lotion fluocinolone acetonide 0.01% shampoo fluocinolone acetonide 0.025% cream fluticasone proprionate 0.05% lotion hydrocortisone butyrate 0.1% cream and ointment hydrocortisone valerate 0.2% cream Pandel 0.1% cream prednicarbate 0.1% cream and ointment

Topical Steroids: Mid-Strength hydrocortisone valerate 0.2% ointment Elocon 0.1% cream and lotion mometasone furoate 0.1% cream and solution (lotion) fluocinolone acetonide 0.025% ointment triamcinolone acetonide 0.1% cream Kenalog aerosol spray Pediaderm TA Kit

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Preferred Drugs Non-Preferred Drugs

V. DERMATOLOGICS

Topical Steroids: Upper Mid-Strength fluocinonide 0.05% emulsified base cream amcinonide 0.1% cream and lotion fluticasone proprionate 0.005% ointment betamethasone dipropionate 0.05% cream triamcinolone acetonide 0.025% cream, lotion and ointment betamethasone valerate 0.1% ointment triamcinolone acetonide 0.1% lotion and ointment betamethasone valerate 0.12% foam triamcinolone acetonide 0.5% cream and ointment desoximetasone 0.05% cream Diprolene AF 0.05% cream Luxiq 0.12% foam Topicort 0.05% cream Trianex 0.05% ointment

Topical Steroids: Potent betamethasone dipropionate, augmented 0.05% cream amcinonide 0.1% ointment fluocinonide 0.05% cream, gel, ointment and solution Apexicon E 0.05% cream mometasone furoate 0.1% ointment betamethasone dipropionate, augmented 0.05% lotion betamethasone dipropionate 0.05% ointment desoximetasone 0.05% gel and ointment desoximetasone 0.25% cream and ointment diflorasone diactetate 0.05% cream and ointment Elocon 0.1% ointment Halog 0.1% ointment and cream Topicort 0.05% gel and ointment Topicort 0.25% cream and ointment

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Preferred Drugs Non-Preferred Drugs

V. DERMATOLOGICS

Topical Steroids: Super Potent clobetasol propionate 0.05% cream, gel, ointment, and solution betamethasone dipropionate, augmented 0.05% gel, and ointment clobetasol propionate emollient base 0.05% cream clobetasol propionate 0.05% foam, lotion and shampoo halobetasol propionate 0.05% cream and ointment clobetasol propionate emollient base 0.05% foam Clobex 0.05% lotion and shampoo Clobex 0.05% spray ClodanTM ClodanTM Kit PA Cordran tape Diprolene 0.05% ointment fluocinonide 0.1% cream Olux 0.05% aerosol Olux-E 0.05% aerosol Temovate 0.05% cream and ointment Temovate E 0.05% cream Ultravate 0.05% cream and ointment Vanos 0.1% cream

Preferred Drugs Non-Preferred Drugs

VI. DIABETIC SUPPLIES

Diabetic Supplies: Blood Glucose Meters Abbott Diabetes Care Products (Covered Meters Include: Freestyle InsuLinx Meter, FreeStyle Lite Meter, FreeStyle Freedom Lite Meter, Precision Xtra Meter) AgaMatrix Products PA LifeScan Products PA Bayer Healthcare Products PA Roche Diagnostics Products PA Home Diagnostics Products PA

Diabetic Supplies: Blood Glucose Test Strips Abbott Test Strips QL (Covered Strips Include: Precision Xtra Test Strips, FreeStyle Test Strips, FreeStyle Lite Test Strips, Freestyle InsuLinx Test Strips) AgaMatrix Products PA, QL LifeScan Products PA, QL Bayer Healthcare Products PA, QL Roche Diagnostics Products PA, QL Home Diagnostics Products PA, QL

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Preferred Drugs Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Agents for Gout allopurinol probenecid Uloric PA Zyloprim Colcrys PA probenecid/colchicine Anabolic Steroids Class PA N/A Anadrol-50 PA Oxandrin PA oxandrolone PA

Androgens Androgel packets PA Testim PA Androderm PA Testred PA Androgel pump PA Android PA testosterone (generic Androgel,

Fortesta, Testim) PA Danazol Axiron PA testosterone cypionate PA, QL Depo-testosterone PA, QL

(200 mg/mL 1 mL vial) Androxy PA testosterone enanthate PA, QL

Delatestryl PA, QL Striant PA Depo-testosterone PA, QL (excluding 200 mg/mL 1 mL vial) VogelxoTM PA Fortesta PA Methitest PA

Antidiuretic/Vasopressor Agents desmopressin tabs DDAVP Stimate PA desmopressin nasal spray Bone: Bisphosphonates Actonel solution PA Actonel QL Fosamax QL alendronate QL Atelvia QL Fosamax Plus D QL Binosto QL ibandronate QL Boniva QL risedronate QL Didronel Skelid QL etidronate Bone: Calcitonin Class PA, QL calcitonin nasal spray PA, QL Fortical PA, QL Miacalcin nasal spray PA, QL Miacalcin injection PA, QL

Bone: SERMs raloxifene QL Evista QL Bone: Parathyroid Hormone N/A Forteo PA

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Preferred Drugs Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Contraceptives, Non-Oral Depo SubQ Provera QL Nuvaring PA Depo-Provera QL Xulane TM PA medroxyprogesterone acetate inj. QL Ortho Evra PA Contraceptives, Oral Altavera Leena Ortho Tri-Cyclen Lo Balziva Seasonale Amethia Lo Lessina Ortho-Cept Generess FE Seasonique Apri Levonorgestrel/ethinyl Ortho-Cyclen Jolessa Tilia FE Aranelle estradiol Ortho-Novum Kariva Tri-Legest FE Aviane Levora Ovcon-50 Lybrel Zenchent Beyaz Lo/Ovral Philith Ogestrel Brevicon Loestrin Plan B Quasense Camila Loestrin 24 FE Plan B One-Step Cesia Loestrin FE Portia Cryselle Lo Loestrin FE Previfem Cyclessa Low-Ogestrel Reclipsen DeblitaneTM Lutera Safyral Desogen Microgestin Solia Drosperinone/ ethinyl estradiol Microgestin FE Sprintec Elinest Mircette Sronyx Ella Modicon Tri-Linyah Enpresse Mononessa Tri-Norinyl Errin Necon Tri-Previfem Estrostep FE Natazia Tri-Sprintec Femcon FE Next Choice Trinessa Gildagia Nikki Trivora Gildess Nor-QD Velivet Heather Nora-BE Vesturna Jolivette Nordette Wymza Fe Junel Norinyl Yasmin Junel FE Nortrel YAZ

Kelnor 1/35 Ortho Micronor Zovia Kurvelo Ortho Tri-Cyclen

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Preferred Drugs Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Diabetes: Alpha-Glucosidase Inhibitors acarbose Glyset Precose Diabetes: Amylin Analogs N/A Symlin PA

Diabetes: Biguanides QL metformin QL Fortamet QL Glumetza QL metformin ER QL Glucophage QL metformin ER osmotic QL Glucophage XR QL Riomet PA, QL Diabetes: DPP-4 Inhibitors and Combinations Class PA, QL Januvia PA, QL KombiglyzeTM XR PA, QL Janumet XR PA, QL Nesina PA, QL Janumet PA, QL Onglyza PA, QL JentaduetoTM PA, QL Oseni PA, QL Juvisync PA, QL Kazano PA, QL TradjentaTM PA, QL

Diabetes: GLP-2 Analogs N/A Gattex PA Diabetes: Incretin Mimetics Class PA, QL Bydureon vials PA, QL Victoza PA, QL Bydureon Pen PA, QL Byetta PA, QL

Diabetes: Insulins Humalog vials Humulin 70/30 Pen PA Apidra Humalog 75/25 vials Lantus vials Apidra Solostar PA Humalog 50/50 vials Levemir vials Lantus OptiClick PA Humalog Kwikpen PA Novolin N Lantus Solostar PA Humalog Mix 50/50 Kwikpen PA Novolin R Levemir FlexPen PA Humalog Mix 75/25 Kwikpen PA Novolin 70/30 Humulin N Novolog vials Humulin N Pen PA Novolog Flex Pen PA Humulin R Novolog Mix 70/30 vials Humulin R U-500 Novolog Mix 70/30 Flex Pen PA Humulin 70/30 vials

Diabetes: Meglitinides and CombinationQL nateglinide QL Prandin QL repaglinide QL PrandimetTM QL Starlix QL

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Preferred Drugs Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Diabetes: Sulfonylureas and Combination glimepiride QL glyburide micronized Amaryl QL Glucovance glipizide glyburide/metformin chlorpropamide Glynase PresTab glipizide ER/XL Diabeta Metaglip glipizide/metformin Glucotrol tolazamide glyburide Glucotrol XL tolbutamide Diabetes: SGLT2 Inhibitors and Combinations Class PA N/A FarxigaTM PA, QL InvokanaTM PA, QL InvokametTM PA, QL Jardiance PA, QL

Diabetes: Thiazolidinediones Class PA, QL pioglitazone PA, QL Actos PA, QL Avandia PA, QL Diabetes: Thiazolidinedione Combinations Class PA, QL pioglitazone-metformin PA, QL ACTOplus Met PA, QL Avandaryl PA, QL ACTOplus Met XR PA, QL DuetAct PA, QL Avandamet PA, QL pioglitazone-glimepiride PA, QL

Disease Modifying Anti-Rheumatic Drugs hydroxychloroquine Ridaura Arava Depen leflunomide sulfasalazine QL Azulfidine QL Plaquenil methotrexate sulfasalazine EC QL Azulfidine EN QL Rheumatrex Note: Injectable agents for the treatment of RA are located under Immunomodulators Cuprimine Trexall

Anti-Rheumatic: Kinase Inhibitors N/A XelJanz PA, QL Glucocorticoids, Oral budesonide capsules PA prednisone Celestone Orapred cortisone Cortef Orapred ODT PA dexamethasone Dexpak Pediapred hydrocortisone Entocort EC PA Rayos methylprednisolone Medrol Uceris PA, QL prednisolone Millipred Veripred

Growth Hormone Agents Class PA Genotropin PA Humatrope PA Saizen PA Norditropin PA Nutropin PA Serostim PA Nutropin AQ PA Tev-Tropin PA Omnitrope PA Zorbtive PA

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Preferred Drugs Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Hematopoietic Agents Class PA Aranesp PA Procrit PA N/A Epogen PA Hormones: Adrenocorticotropic N/A H.P. Acthar PA, QL

Hormones: Anti-Thyroid methimazole propylthiouracil Tapazole Hormones: LHRH leuprolide PA Synarel N/A

Hormones: Oral Estrogens Cenestin estropipate EnJuvia Femtrace estradiol Premarin Estrace Menest Hormones: Oral Estrogen/Progestins Activella PremPhase QL Angeliq JinteliTM FemHRT Low Dose PremPro QL estradiol/norethindrone MimveyTM PreFest FemHRT 1/5

Hormones: Oral Progestins medroxyprogesterone progesterone Aygestin Prometrium megestrol QL Megace QL Provera Megace ES PA, QL norethindrone acetate PA Hormones: Thyroid Cytomel liothyronine Armour Thyroid Levothroid Synthroid Thyroid levothyroxine Unithroid Thyrolar Levoxyl Tirosint

Hormones: Transdermal Estrogens Alora QL Divigel Estrasorb Climara QL Elestrin Evamist Vivelle-Dot QL Estraderm QL Menostar QL estradiol TDS QL Minivelle QL

Hormones: Transdermal Estrogen/Progestins QL Combipatch QL Climara Pro QL

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Preferred Drugs Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Hormones: Vaginal Estrogens Estring Vagifem Estrace Premarin Vaginal Cream QL Femring Insulin-Like Growth Factor-1 Class PA Increlex PA N/A

Mineralocorticoids, Oral fludrocortisone N/A Progesterone Receptor Antagonists N/A Korlym PA

Somatostatic Agents octreotide PA Sandostatin PA Somatuline Depot Signifor PA, QL Somavert

Preferred Drugs Non-Preferred Drugs

VIII. GASTROINTESTINAL

5-ASA Derivatives, Oral QL AprisoTM QL Pentasa QL Asacol HD QL Dipentum QL Asacol QL sulfasalazine EC QL Azulfidine QL Giazo QL balsalazide QL sulfasalazine QL Azulfidine EN QL Delzicol QL Sulfazine EC QL Colazal QL Lialda QL Sulfazine QL 5-ASA Derivatives, Rectal Canasa mesalamine enema mesalamine kit Rowasa Rowasa kit

5HT-3 Receptor Antagonists (IBS) Class PA N/A Lotronex PA, QL Antidiarrheals diphenoxylate with atropine Lonox Lomotil opium tincture Lofene loperamide Motofen paregoric FulyzaqPA

Anti-Emetics: A-9-THC Derivatives Class PA N/A Cesamet PA Marinol PA dronabinol PA

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Preferred Drugs Non-Preferred Drugs

VIII. GASTROINTESTINAL

Anti-Emetics: Anticholinergics meclizine trimethobenzamide Antivert Tigan prochlorperazine Transderm Scp PA, QL Compro promethazine PA Phenergan PA Anti-Emetics: 5-HT3 Antagonists Class PA ondansetron tabs and ODT PA, QL Anzemet PA, QL Zofran ODT PA, QL granisetron PA, QL Zofran Solution PA Kytril PA, QL Zofran PA, QL ondansetron oral soln PA Zuplenz PA, QL Sancuso PA, QL Anti-Emetics: NK-1 Antagonists Class PA N/A Emend PA, QL

Anti-Emetics: Miscellaneous N/A Diclegis PA, QL Antispasmodics/Anticholinergics dicyclomine Symax Fastabs Anaspaz methscopolamine glycopyrrolate Symax-SL Bentyl Pamine HyoMax Cantil Pamine Forte hyoscyamine chlordiazepoxide/clidinium Robinul Hyosyne Cuvposa PA Robinul Forte NuLev Levsin Sal-Tropine propantheline Librax

Miscellaneous Agents for IBS N/A Amitiza PA, QL Linzess PA, QL Combination Products for H. pylori Class PA N/A Helidac PA Prevpac PA, QL lansoprazole/amoxicillin/

clarithromycin PA, QL Pylera PA, QL

Omeclamox PA Gallstone Solubilizing Agents ursodiol QL Actigall QL Urso QL ChenodalTM Urso Forte QL

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Preferred Drugs Non-Preferred Drugs

VIII. GASTROINTESTINAL

H2 Receptor Antagonists cimetidine ranitidine syrup Axid ranitidine capsules famotidine nizatidine Zantac ranitidine tablets Pepcid Laxatives Constulose PEG 3350 powder CoLyte PEG 3350 with flavor packs Enulose PEG 3350 electrolyte solution GoLYTELY PEG 3350 solution generlac HalfLytely Prepopik lactulose Kristalose Suclear MoviPrep Suprep NuLYTELY Trilyte OsmoPrep Visicol

Motility Agents metoclopramide Metozolv ODT PA Reglan Mucosal Protectants misoprostol sucralfate tablets Carafate sucralfate suspension PA Cytotec Pancreatic Enzymes Creon (all strengths) ZenPep Pancreaze Ultresa PertzyeTM Viokace pancrelipase (all strengths)

Proton Pump Inhibitors pantoprazole QL Aciphex QL Prevacid QL Protonix suspension Aciphex sprinkles PA Prevacid SoluTabTM PA, QL omeprazole OL Dexilant QL Prilosec QL esomeprazole QL Protonix QL lansoprazole QL rabeprazole QL lansoprazole ODT PA, QL Zegerid QL Nexium QL Saliva Stimulating Agents pilocarpine PA, QL cevimeline PA, QL Salagen PA, QL Evoxac PA, QL

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Preferred Drugs Non-Preferred Drugs

IX. IMMUNOLOGIC AGENTS

Immunomodulators Class PA, QL Cimzia PA, QL Humira PA, QL Actemra PA, QL Simponi PA, QL Enbrel PA, QL Kineret PA, QL Stelara PA, QL Orencia PA, QL Immunosuppressants azathioprine Gengraf Astagraf XL PA Neoral PA cyclosporine mycophenolate mofetil Azasan PA Prograf PA cyclosporine microemulsion tacrolimus Cellcept PA Rapamune PA Hecoria PA Sandimmune PA Imuran PA sirolimus PA Myfortic PA Zortress PA mycophenolic acid PA

Multiple Sclerosis Agents QL Avonex QL Copaxone20 mg/mL QL Copaxone 40 mg/mL PA, QL Extavia QL Avonex Administration Pack QL Rebif QL Betaseron QL Multiple Sclerosis Agents: Potassium Channel Blockers Ampyra QL N/A

Multiple Sclerosis Agents: Oral Disease Modifying Agents N/A Aubagio PA Gilenya PA, QL Tecfidera PA, QL Topical Immunomodulators Class PA Elidel PA Protopic PA

Preferred Drugs Non-Preferred Drugs

X. MISCELLANEOUS

Gauchers Disease Agents Zavesca CerdelgaTM QL Hereditary Tyrosinemia Agents Orfadin N/A

Oral Iron Chelators Class PA N/A Exjade PA Ferriprox PA

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Preferred Drugs Non-Preferred Drugs

XI. ONCOLOGY AGENTS Afinitor Inlyta Stivarga Afinitor Disperz PA Alkeran Iressa Tabloid Arimidex anastrozole Jakafi Tafinlar Aromasin bicalutamide leucovorin tamoxifen capicitabine Bosulif Leukeran Tarceva Casodex Caprelsa leuprolide PA Targretin Femara Cometriq letrozole Tasigna Hydrea cyclophosphamide lomustine temozolamide Purinethol Droxia Lysodren Thalomid Purixan PA Eligard PA Matulane tretinoin Temodar Emcyt Mekinist Tykerb Erivedge mercaptopurine VotrientTM etoposide Mesna Xalkori exemestane methotrexate Xeloda Fareston Myleran Xtandi flutamide Nexavar Zelboraf Gilotrif Nilandron Zolinza Gleevec OfortaTM Zydelig Hexalen Pomalyst Zykadia Hycamtin Revlimid Zytiga hydroxyurea Sprycel Imbruvica Sutent Effective March 1, 2014, the initial fill of oncology products will be limited to a 14 days supply. If the initial 14 days supply is tolerated, the member is eligible to receive the remainder of the first months supply without additional copay by the pharmacy submitting a Submission Clarification Code (NCPDP D.0 field 42-DK) of 2. After the initial month, members may continue to receive up to a 31 days supply of oncology products per fill.

Preferred Drugs Non-Preferred Drugs

XII. OPHTHALMICS

Ophthalmic Antibiotic/Steroid Combinations neomycin/BAC/poly B/HC TobraDex suspension Blephamide tobramycin/dexamethasone susp neomycin/poly B/dexameth Maxitrol TobraDex ointment sulfacetamide/prednisolone neomycin/poly B/HC TobraDex ST suspension Pred-G Poly-Pred Zylet PA

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XII. OPHTHALMICS

Ophthalmic Antibiotics AK-Poly-BACTM ofloxacin AzaSite Ocuflox bacitracin/poly B polymyxin B/TMP bacitracin Polysporin ciprofloxacin Romycin Besivance Polytrim erythromycin sulfacetamide sodium drops Bleph-10 sulfacetamide ointment Gentak tobramycin Ciloxan Tobrex solution gentamicin Tobrasol Garamycin Zymaxid Moxeza Tobrex ointment gatifloxacin 0.5% solution neomycin/bac/poly B Vigamox levofloxacin 0.5% solution neomycin/poly B/gramicidin Neosporin Ophthalmic Antifungals N/A Natacyn PA Ophthalmic Antivirals trifluridine Viroptic ZirganTM PA > 5yr old

Ophthalmic Antihistamines QL BepreveTM QL Pataday QL azelastine QL LastacaftTM QL ketotifen QL Elestat QL Optivar QL Emadine QL Patanol QL epinastine QL Zaditor QL Ophthalmic Alpha-2 Agonists apraclonidine Alphagan P brimonidine tartrate 0.15% Iopidine

brimonidine tartrate 0.2% Ophthalmic Beta Blockers carteolol timolol maleate Betagan OptiPranolol levobunolol betaxolol timolol gel solution Betimol Timoptic Betoptic-S Timpoptic Occudose Istalol Timoptic-XE metipranolol

Ophthalmic Carbonic Anhydrase Inhibitors QL Azopt QL dorzolamide/timolol QL Cosopt QL Trusopt QL dorzolamide QL Cosopt PF QL Ophthalmic Decongestants naphazoline phenylephrine Neo-Synephrine

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XII. OPHTHALMICS

Ophthalmic Mast Cell Stabilizers Alocril cromolyn sodium Alamast Alomide Mydriatics and Mydriatic Combos atropine AK-PentolateTM Isopto Homatropine Atropine CareTM Cyclogyl Isopto Hyoscine cyclopentolate CyclomydrilTM Mydriacyl tropicamide Isopto Atropine

Ophthalmic NSAIDs Class PA diclofenac PA Acular PA Ilevro PA flurbiprofen PA Acular LS PA Nevanac PA ketorolac PA AcuvailTM PA Ocufen PA BromdayTM PA Voltaren PA bromfenac PA Ophthalmic Prostaglandin Agonists QL latanoprost QL Lumigan QL Rescula QL Xalatan QL Travatan Z QL Zioptan QL Travoprost QL

Ophthalmic Steroids Alrex prednisolone acetate dexamethasone Lotemax Ointment fluorometholone Pred Mild Durezol Maxidex FML ointment Flarex prednisolone sodium phosphate Lotemax Susp FML Forte Pred Forte FML Liquifilm Vexol Lotemax Gel Glaucoma Direct Acting Miotics pilocarpine Isopto Carbachol Pilopine HS Isopto Carpine

Glaucoma Combinations Combigan PA Simbrinza PA Ophthalmic Immunomodulators Class PA, QL Restasis PA, QL N/A

Ophthalmic Vasoconstrictors AK-Dilate 2.5%, 10% NeofrinTM 2.5%, 10% Albalon naphazoline phenylephrine 2.5%, 10% Mydfrin

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Preferred Drugs Non-Preferred Drugs

XII. OPHTHALMICS

Ophthalmic Lubricants and Artificial Tears N/A Lacrisert PA Miscellaneous Ophthalmics N/A Cystaran PA

Preferred Drugs Non-Preferred Drugs

XIII. OTICS

Otic Quinolones CiproDex QL ofloxacin otic QL Cipro HC QL ciprofloxacin otic Otic Steroid/Antibiotic Combinations Cortomycin Otic Cortisporin Otic Coly-Mycin S HC/neomycin/polymyxinB Cortisporin-TC Otic

Miscellaneous Otics acetic acid acetic acid/antipyrine/benzo/ polycosonal RE Benzotic acetic acid/aluminum Acetasol HC RE Chlorphenylcaine acetic acid/HC Aurax Treagan benzocaine/antipyrine DermOtic TriOxin chloroxylenol/pramoxine fluocinolone acetonide VoSol Neotic VoSol HC Otic Edge Zinotic Pramotic Zinotic ES PR Otic

Preferred Drugs Non-Preferred Drugs

XIV. RENAL AND GENITOURINARY

Alpha Blockers for BPH doxazosin tamsulosin QL alfuzosin QL Minipress prazosin terazosin Cardura Rapaflo Cardura XL QL Uroxatral QL Flomax QL Androgen Hormone Inhibitors finasteride QL Avodart QL Proscar QL

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XIV. RENAL AND GENITOURINARY

Combination Agents for BPH N/A JalynPA, QL Phosphorus Depleters calcium acetate Phoslyra Fosrenol Renvela powder for suspension PA EliphosTM Renvela tablets PhosLo sevelamer Renagel Velphoro PA

Urinary Tract Antispasmodics oxybutynin Toviaz QL Detrol QL oxybutynin ER QL tolterodine QL VESIcare QL Ditropan XL QL Oxytrol QL Detrol LA QL Sanctura XR QL Enablex QL tolterodine ER QL flavoxate QL trospium QL GelniqueTM QL trospium XR QL Myrbetriq Urinary Alkalizing Agents citric acid/sodium citrate Cytra-3 Citrolith Polycitra-K Cytra-K solution potassium citrate Cytra-K crystals Urocit-K Cytra-2 potassium citrate/citric acid Ora-Cit Tricitrates Urinary Acidifying Agents acetic acid K-Phos MF Renacidin PA K-Phos Original K-Phos Neutral K-Phos #2 Phospha Neutral

Urinary Analgesics phenazopyridine Phenazo Pyridium Urinary Interstitial Cystitis Agents Elmiron RIMSO-50 N/A

Vaginal Antiseptics Fem pHTM N/A

Preferred Drugs Non-Preferred Drugs

XV. RESPIRATORY

Anaphylaxis Therapy Agents Epipen QL Epipen, Jr. QL Adrenaclick QL epinephrine injectable QL Auvi-QTM PA, QL

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XV. RESPIRATORY

Anticholinergics, Inhaled QL albuterol/ipratropium QL Combivent Respimat QL DuoNeb QL Atrovent HFA QL ipratropium solutionQL Tudorza QL Combivent MDI QL Spiriva QL Anticholinergics, Nasal QL

ipratropium 0.3%, 0.6% QL Atrovent 0.3%, 0.6% QL Antihistamines, First Generation (Covered for recipients < 21 years old only) brompheniramine maleate Dytuss syrup all formulations of brompheniramine tannate Bromspiro hydroxyzine all formulations of chlorpheniramine tannate carbinoxamine maleate LoHist-12 all formulations of diphenhydramine tannate chlorpheniramine maleate promethazine Aldex AN Palgic clemastine dexchlorpheniramine Vazol cyproheptadine hydrochloride Doxytex Vistaril diphenhydramine HCl J-Tan PD

Antihistamines, Non-Sedating (Covered for recipients < 21 years old only) cetirizine chewable PA, QL Allegra QL Clarinex-D 24 Hr QL cetirizine tabs QL Allegra-D 12 Hr QL desloratadine QL cetirizine syrup Allegra-D 24 Hr QL desloratadine ODT PA, QL cetirizine/PSE QL Allegra ODT PA, QL fexofenadine QL loratadine QL Claritin QL fexofenadine/PSE QL loratadine RDT PA, QL Claritin chewable PA, QL levocetirizine QL loratadine/PSE QL Claritin-D 12 Hr QL Semprex-D QL Claritin-D 24 Hr QL Xyzal QL Claritin RediTabs PA, QL Zyrtec QL Clarinex QL Zyrtec chewable PA, QL Clarinex RediTabs PA, QL Zyrtec ODT PA, QL Clarinex-D 12 Hr QL Zyrtec-D QL Antihistamines, Nasal QL Patanase QL Astepro PA, QL Dymista PA, QL azelastine PA, QL

Beta Agonists: Combination Products Class PA, QL Advair Diskus PA, QL Dulera PA, QL Anoro Ellipta PA, QL Advair HFA PA, QL Symbicort PA, QL Breo Ellipta PA, QL

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XV. RESPIRATORY

Beta Agonists: Long Acting MDI Class PA, QL Serevent Diskus PA, QL Foradil PA, QL Arcapta QL Striverdi Respimat QL Beta Agonists: Nebulizer albuterol inhalation solution QL AccuNeb QL Perforomist PA, QL Brovana PA, QL Xopenex PA, QL levalbuterol PA, QL

Beta Agonists: Short Acting MDI QL Proventil HFA QL Maxair Autohaler QL Ventolin HFA QL ProAir HFA QL Xopenex HFA PA, QL Beta Agonist: Oral albuterol syrup terbutaline albuterol tabs VoSpire ER albuterol ER metaproterenol

Cystic Fibrosis Agents QL Bethkis PA,QL TOBI inhalation solution PA, QL Cayston PA, QL Tobi Podhaler PA, QL Pulmozyme PA, QL Kalydeco PA, QL tobramycin solution 300mg/5mL PA, QL

Expectorants SSKI N/A Leukotriene Receptor Antagonists QL montelukast tabs and chewables PA, QL Accolate QL zafirlukast QL montelukast granules PA, QL Zyflo QL Singulair tabs and

chewables PA, QL Zyflo CR QL Singulair granules PA, QL Mast Cell Stabilizers cromolyn QL N/A

Mucolytics acetylcysteine N/A Non-Narcotic Antitussives Class PA benzonatate PA Tessalon PA Zonatuss PA Tessalon Perles PA

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XV. RESPIRATORY

Steroids, Orally Inhaled QL Asmanex QL QVAR QL Aerospan QL Pulmicort Respules PA, QL Flovent HFA QL Alvesco QL Flovent Diskus QL Pulmicort Flexhaler QL budesonide respules PA, QL Steroids, Intranasal QL fluticasone propionate QL Beconase AQ QL Omnaris QL Nasonex QL budesonide nasal spray QL Rhinocort Aqua QL Qnasl QL Flonase QL triamcinolone acetonide QL flunisolide QL Veramyst QL Nasacort AQ QL Zetonna QL Xanthine Derivatives aminophylline Dyphylline GG Difil-G COPD Elixophyllin Dilex-G

DG 200 Jay-Phyl Lufyllin-GG Difil-G Forte Lufyllin Theochron Dy-G Theo-24 Dylix theophylline ER Phosphodiesterase 4 Inhibitor N/A Daliresp PA Vasoconstrictors, Intranasal Adrenalin Tyzine N/A

Preferred Drugs Non-Preferred Drugs

XVI. SMOKING CESSATION AGENTS

Smoking Cessation Agents QL bupropion SR QL nicotine polacrilex lozenge QL Commit QL Nicotrol inhaler QL Chantix QL nicotine transdermal patch QL Nicoderm CQ QL Nicotrol nasal spray QL nicotine polacrilex gum QL Nicorette gum QL Zyban QL

Preferred Drugs Non-Preferred Drugs

XVII. VITAMINS AND ELECTROLYTES

Cystine Depleting Agent Cystagon Procysbi PA

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XVII. VITAMINS AND ELECTROLYTES

Fluoride Products

Denta 5000 Phos-flur Fluor-a-day Chewable Luride Dentagel Renaf Gel-Kam Prevident Epiflur SF Fluor-a-day drops SF 5000 Plus Fluoritab sodium fluoride Ludent Folic Acid Preparations folic acid Deplin PA l-methylfolate PA FalessaTM PA Q-Tabs PA

Kidney Stone Agents Lithostat Thiola N/A Multivitamins with Fluoride (Covered for recipients < 21 years old only) All generic prescription products (various manufacturers) All brand prescription products (various manufacturers)

Multivitamins with Iron (Covered for recipients < 21 years old only) All generic OTC and prescription products All brand OTC and prescription products Potassium Depletors Kalexate sodium polystyrene sulfonate Kayexalate SPS Kionex

Potassium Supplements Effer-K K-Effervescent Epiklor Micro K Kaon-CL K-Vescent K-tabs potassium chloride caps Klor-Con potassium bicarbonate Klor-Con powder Klor-Con/EF potassium chloride tabs and solution Klor-Con M potassium chloride, microencapsulated Prenatal Vitamins All generic OTC and prescription products (various manufacturers) All brand OTC and prescription products (various manufacturers)

Renal Vitamins All OTC and generic prescription products (various manufacturers) All brand prescription products (various manufacturers) Vitamin D / Vitamin D-Analogs calcitriol Vitamin D doxercalciferol PA paricalcitol PA ergocalciferol Drisdol Rocaltrol Hectorol PA Zemplar PA

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XVII. VITAMINS AND ELECTROLYTES

Vitamin K Products Mephyton N/A Zinc Supplements zinc sulfate Zincate Galzin PA