MetroPlus Health Plan (04/01/2020) INTRODUCTION....................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 4 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 SPECIALTY PLAN DESIGN .................................................................................................................................................................................... 5 PLAN DESIGN.......................................................................................................................................................................................................... 5 LEGEND ................................................................................................................................................................................................................... 5 NOTICE ..................................................................................................................................................................................................................... 6 ANALGESICS........................................................................................................................................................................................................... 7

ANALGESICS, OTHER .................................................................................................................................................................................. 7 NSAIDs ........................................................................................................................................................................................................... 7 NSAIDs, TOPICAL ......................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 NON-OPIOID ANALGESICS .......................................................................................................................................................................... 8

ANTI-INFECTIVES ................................................................................................................................................................................................... 8 ANTIBACTERIALS ......................................................................................................................................................................................... 8 ANTIFUNGALS .............................................................................................................................................................................................. 9 ANTIMALARIALS ........................................................................................................................................................................................... 9 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................ 9 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 11 ANTIVIRALS................................................................................................................................................................................................. 11 MISCELLANEOUS ....................................................................................................................................................................................... 11

ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 12 ALKYLATING AGENTS ............................................................................................................................................................................... 12 ANTIMETABOLITES .................................................................................................................................................................................... 12 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12 IMMUNOMODULATORS ............................................................................................................................................................................. 12 KINASE INHIBITORS ................................................................................................................................................................................... 12 MISCELLANEOUS ....................................................................................................................................................................................... 13

CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS......................................................................................................................................................................................... 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 14 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 14 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 14 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANTIARRHYTHMICS ................................................................................................................................................................................... 14 ANTILIPEMICS............................................................................................................................................................................................. 15 BETA-BLOCKERS ....................................................................................................................................................................................... 15 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 15 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 16 DIURETICS .................................................................................................................................................................................................. 16 HEART FAILURE ......................................................................................................................................................................................... 16 NITRATES .................................................................................................................................................................................................... 17

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PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 17 MISCELLANEOUS ....................................................................................................................................................................................... 17

CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 17 ANTIANXIETY .............................................................................................................................................................................................. 17 ANTICONVULSANTS .................................................................................................................................................................................. 17 ANTIDEMENTIA ........................................................................................................................................................................................... 18 ANTIDEPRESSANTS .................................................................................................................................................................................. 18 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 19 ANTIPSYCHOTICS ...................................................................................................................................................................................... 19 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 20 FIBROMYALGIA........................................................................................................................................................................................... 20 HYPNOTICS................................................................................................................................................................................................. 20 MIGRAINE .................................................................................................................................................................................................... 20 MOOD STABILIZERS .................................................................................................................................................................................. 21 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 21 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 21 MYASTHENIA GRAVIS ............................................................................................................................................................................... 21 NARCOLEPSY ............................................................................................................................................................................................. 21 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 21

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 22 ANDROGENS .............................................................................................................................................................................................. 22 ANTIDIABETICS .......................................................................................................................................................................................... 22 CALCIUM REGULATORS ........................................................................................................................................................................... 23 CONTRACEPTIVES .................................................................................................................................................................................... 23 ENDOMETRIOSIS ....................................................................................................................................................................................... 24 ESTROGENS ............................................................................................................................................................................................... 25 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 25 FERTILITY REGULATORS .......................................................................................................................................................................... 25 GLUCOCORTICOIDS .................................................................................................................................................................................. 25 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 25 HUMAN GROWTH HORMONES ................................................................................................................................................................. 25 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 25 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 26 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 26 POTASSIUM-REMOVING AGENTS............................................................................................................................................................ 26 PROGESTINS .............................................................................................................................................................................................. 26 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 26 THYROID AGENTS ..................................................................................................................................................................................... 26 UREA CYCLE DISORDERS ........................................................................................................................................................................ 26 VASOPRESSIN RECEPTOR ANTAGONISTS ............................................................................................................................................ 26 VASOPRESSINS ......................................................................................................................................................................................... 26 MISCELLANEOUS ....................................................................................................................................................................................... 26

GASTROINTESTINAL ........................................................................................................................................................................................... 26 ANTACIDS ................................................................................................................................................................................................... 26 ANTIDIARRHEALS ...................................................................................................................................................................................... 27 ANTIEMETICS ............................................................................................................................................................................................. 27 ANTISPASMODICS ..................................................................................................................................................................................... 27 CHOLELITHOLYTICS .................................................................................................................................................................................. 27 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 27 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 27 LAXATIVES/STOOL SOFTENERS.............................................................................................................................................................. 28 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 28 PANCREATIC ENZYMES ............................................................................................................................................................................ 28 PROSTAGLANDINS .................................................................................................................................................................................... 28 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 28 SALIVA STIMULANTS ................................................................................................................................................................................. 28 STEROIDS, RECTAL ................................................................................................................................................................................... 28 MISCELLANEOUS ....................................................................................................................................................................................... 28

GENITOURINARY .................................................................................................................................................................................................. 28 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 29 URINARY ANTISPASMODICS .................................................................................................................................................................... 29 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 29 MISCELLANEOUS ....................................................................................................................................................................................... 29

HEMATOLOGIC ..................................................................................................................................................................................................... 29

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ANTICOAGULANTS .................................................................................................................................................................................... 29 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 30 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 30 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 30 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 30 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 30 MISCELLANEOUS ....................................................................................................................................................................................... 30

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 30 AUTOIMMUNE AGENTS ............................................................................................................................................................................. 30 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 30 HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 30 IMMUNOMODULATORS ............................................................................................................................................................................. 30 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 31

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 31 ELECTROLYTES ......................................................................................................................................................................................... 31 VITAMINS AND MINERALS ........................................................................................................................................................................ 31

RESPIRATORY ...................................................................................................................................................................................................... 32 ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 32 ANTICHOLINERGICS .................................................................................................................................................................................. 32 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 32 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 32 ANTIHISTAMINES, NONSEDATING ........................................................................................................................................................... 32 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 32 ANTIHISTAMINE/DECONGESTANT COMBINATIONS .............................................................................................................................. 33 ANTITUSSIVES............................................................................................................................................................................................ 33 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 33 BETA AGONISTS ........................................................................................................................................................................................ 33 CYSTIC FIBROSIS ...................................................................................................................................................................................... 33 DECONGESTANTS ..................................................................................................................................................................................... 34 DECONGESTANT/EXPECTORANT COMBINATIONS .............................................................................................................................. 34 EXPECTORANTS ........................................................................................................................................................................................ 34 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 34 MAST CELL STABILIZERS ......................................................................................................................................................................... 34 MEDICAL SUPPLIES ................................................................................................................................................................................... 34 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 34 NASAL STEROIDS ...................................................................................................................................................................................... 34 RESPIRATORY SYNCYTIAL VIRUS........................................................................................................................................................... 34 SEVERE ASTHMA AGENTS ....................................................................................................................................................................... 34 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 34 STEROID INHALANTS ................................................................................................................................................................................ 34 XANTHINES ................................................................................................................................................................................................. 35 MISCELLANEOUS ....................................................................................................................................................................................... 35

TOPICAL ................................................................................................................................................................................................................ 35 DERMATOLOGY.......................................................................................................................................................................................... 35 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 37 OPHTHALMIC .............................................................................................................................................................................................. 37 OTIC ............................................................................................................................................................................................................. 39 VAGINAL ...................................................................................................................................................................................................... 39

WEBSITES ............................................................................................................................................................................................................. 40 INDEX ..................................................................................................................................................................................................................... 42

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INTRODUCTION

We are pleased to provide the 2020 MetroPlus Health Plan Formulary as a useful reference and informational tool. This document can assist medical providers in selecting clinically appropriate and cost-effective products for their patients. The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The document is reflective of current medical practice as of the date of review. The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This document is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the document is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the Websites section of this publication.

PREFACE The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable oral dosage forms and strengths of the drug cited are included in the document. Drugs represented in this document may have varying cost to the plan member based on the plan's benefit structure. Generic medications typically are available at the lower cost, brand-name medications on the document will generally cost more than generics. Generics should be considered the first line of prescribing subject to applicable rules.

DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the document. Any exceptions are noted. Listed products on the document generally include all strengths and dosage forms of the cited brand-name product. pregabalin Lyrica Oral capsules, oral solution and all strengths of Lyrica would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. esomeprazole magnesium delayed-rel suspension 2.5 mg, 5 mg, 10

mg Nexium suspension

The oral suspension dosage form of Nexium is on the document. From this entry, the oral capsule cannot be assumed to be on the list unless there is a separate entry. If the OTC and Prescription versions of the product are covered, then both are listed. OTC famotidine Pepcid AC famotidine Pepcid Extended-release and delayed-release products require their own entry. metformin Glucophage

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The immediate-release product listing of Glucophage alone would not include the extended-release product Glucophage XR. metformin ext-rel Glucophage XR A separate entry for Glucophage XR confirms that the extended-release product is on the document. Dosage forms on the document will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the document.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product to the market. However, the document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

• Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

• Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.

• Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence).

SPECIALTY PLAN DESIGN Specialty Guideline Management (SGM) SGM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to help ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SGM program are identified in the document as “SGM” for your reference. Prescribers may call 1-866-814-5506 to enroll patients in Specialty plan design.

PLAN DESIGN The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria.

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LEGEND

AL Age Limit OTC Over the counter PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit SGM Specialty Guideline Management ST Step Therapy boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the

listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for

clarification

NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2020. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. MetroPlus Health Plan does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by MetroPlus Health Plan. Please be advised that this document is updated periodically and changes may appear prior to their effective date to allow for client notification.

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ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org ANALGESICS, OTHER Treatment recommendations for osteoarthritis are available at: https://www.rheumatology.org OTC, QL acetaminophen TYLENOL NSAIDs OTC ibuprofen ADVIL OTC naproxen sodium ALEVE diclofenac sodium delayed-rel diclofenac sodium ext-rel diflunisal etodolac etodolac ext-rel flurbiprofen ibuprofen QL ketorolac meloxicam MOBIC nabumetone naproxen NAPROSYN naproxen sodium oxaprozin DAYPRO sulindac NSAIDs, TOPICAL QL diclofenac sodium gel VOLTAREN GEL COX-2 INHIBITORS PA celecoxib CELEBREX GOUT allopurinol ZYLOPRIM QL colchicine tabs COLCRYS probenecid OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MMEs) per day based on a 30-day supply. Members may be subject to additional quantity limit restrictions, including a first-fill limit of 7 days (for members who are opioid-naïve) and 90 days of treatment per 365 days. QL codeine/acetaminophen TYLENOL w/CODEINE PA, QL fentanyl transdermal DURAGESIC QL hydrocodone/acetaminophen NORCO PA, QL hydromorphone ext-rel QL hydromorphone tabs DILAUDID PA, QL methadone tabs 5 mg, 10 mg DOLOPHINE

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QL morphine PA, QL morphine ext-rel MS CONTIN QL oxycodone QL oxycodone ROXICODONE QL oxycodone/acetaminophen PERCOCET QL oxycodone/acetaminophen solution QL oxycodone/aspirin PERCODAN QL tramadol ULTRAM PA, QL tramadol ext-rel tabs QL tramadol/acetaminophen ULTRACET NON-OPIOID ANALGESICS QL butalbital/acetaminophen/caffeine ESGIC QL butalbital/aspirin/caffeine FIORINAL ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS Aminoglycosides neomycin Cephalosporins Cephalosporin Combinations PA ceftolozane/tazobactam ZERBAXA First Generation cefadroxil cephalexin KEFLEX

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Second Generation cefprozil cefuroxime axetil Third Generation cefdinir Erythromycins/Macrolides azithromycin ZITHROMAX clarithromycin clarithromycin ext-rel erythromycin base erythromycin delayed-rel erythromycin ethylsuccinate E.E.S. erythromycin stearate Fluoroquinolones ciprofloxacin tabs CIPRO levofloxacin LEVAQUIN Penicillins amoxicillin amoxicillin/clavulanate AUGMENTIN ampicillin dicloxacillin penicillin G BICILLIN L-A penicillin VK Sulfonamides sulfadiazine sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS Tetracyclines doxycycline monohydrate caps 50 mg, 100 mg doxycycline monohydrate suspension VIBRAMYCIN doxycycline monohydrate tabs 50 mg, 75 mg, 100 mg minocycline MINOCIN tetracycline ANTIFUNGALS clotrimazole troches fluconazole DIFLUCAN griseofulvin microsize suspension griseofulvin ultramicrosize PA, QL itraconazole caps SPORANOX nystatin QL terbinafine tabs PA voriconazole VFEND ANTIMALARIALS QL atovaquone/proguanil MALARONE QL chloroquine QL mefloquine ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants QL cobicistat TYBOST

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Antiretroviral Combinations QL abacavir/dolutegravir/lamivudine TRIUMEQ QL abacavir/lamivudine EPZICOM QL abacavir/lamivudine/zidovudine TRIZIVIR QL atazanavir/cobicistat EVOTAZ QL bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY QL darunavir/cobicistat PREZCOBIX QL darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA QL dolutegravir/lamivudine DOVATO QL dolutegravir/rilpivirine JULUCA QL efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI LO QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD QL emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA QL emtricitabine/tenofovir alafenamide DESCOVY QL, * emtricitabine/tenofovir disoproxil fumarate TRUVADA QL lamivudine/tenofovir disoproxil fumarate CIMDUO QL lamivudine/zidovudine COMBIVIR * Documentation may be required for select instances in which product labeling dictates monitoring Chemokine Receptor Antagonists QL maraviroc SELZENTRY Integrase Inhibitors QL dolutegravir TIVICAY QL raltegravir ISENTRESS Non-nucleoside Reverse Transcriptase Inhibitors QL delavirdine RESCRIPTOR QL efavirenz SUSTIVA QL etravirine INTELENCE QL nevirapine VIRAMUNE QL nevirapine ext-rel VIRAMUNE XR QL rilpivirine EDURANT Nucleoside Reverse Transcriptase Inhibitors QL abacavir ZIAGEN QL didanosine delayed-rel VIDEX EC QL didanosine solution VIDEX QL emtricitabine EMTRIVA QL lamivudine EPIVIR QL stavudine QL zidovudine RETROVIR Nucleotide Reverse Transcriptase Inhibitors QL tenofovir disoproxil fumarate VIREAD Protease Inhibitors QL atazanavir REYATAZ QL darunavir PREZISTA QL fosamprenavir LEXIVA QL indinavir CRIXIVAN QL lopinavir/ritonavir KALETRA QL nelfinavir VIRACEPT

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QL ritonavir NORVIR QL saquinavir mesylate INVIRASE QL tipranavir APTIVUS ANTITUBERCULAR AGENTS ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN ANTIVIRALS Cytomegalovirus Agents valganciclovir VALCYTE Hepatitis Agents Hepatitis B adefovir dipivoxil HEPSERA entecavir solution BARACLUDE entecavir tabs BARACLUDE lamivudine tabs EPIVIR-HBV Hepatitis C #, SGM glecaprevir/pibrentasvir MAVYRET SGM ribavirin caps, tabs 200mg SGM sofosbuvir/velpatasvir # MAVYRET for genotypes 1, 2, 3, 4, 5, 6 Herpes Agents acyclovir caps, suspension, tabs ZOVIRAX famciclovir valacyclovir VALTREX Influenza Agents QL oseltamivir TAMIFLU MISCELLANEOUS OTC pyrantel - Reese's Pinworm Medicine ST atovaquone MEPRON clindamycin CLEOCIN dapsone ivermectin STROMECTOL PA linezolid ZYVOX PA linezolid injection ZYVOX QL mebendazole EMVERM metronidazole FLAGYL nitrofurantoin ext-rel MACROBID nitrofurantoin macrocrystals MACRODANTIN nitrofurantoin suspension PA pyrimethamine DARAPRIM rifabutin MYCOBUTIN trimethoprim QL vancomycin VANCOCIN

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ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org ALKYLATING AGENTS busulfan MYLERAN chlorambucil LEUKERAN cyclophosphamide caps lomustine GLEOSTINE melphalan ALKERAN SGM temozolomide TEMODAR ANTIMETABOLITES SGM capecitabine XELODA mercaptopurine methotrexate TREXALL HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide CASODEX SGM enzalutamide XTANDI flutamide Antiestrogens fulvestrant FASLODEX tamoxifen toremifene FARESTON Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Luteinizing Hormone-Releasing Hormone (LHRH) Agonists SGM goserelin acetate ZOLADEX SGM leuprolide acetate SGM leuprolide acetate LUPRON DEPOT SGM triptorelin pamoate TRELSTAR Gonadotropin Releasing Hormone (GnRH) Antagonists SGM degarelix acetate FIRMAGON Progestins megestrol acetate MEGACE IMMUNOMODULATORS SGM lenalidomide REVLIMID KINASE INHIBITORS SGM afatinib GILOTRIF SGM axitinib INLYTA SGM bosutinib BOSULIF SGM, QL cabozantinib CABOMETYX SGM cabozantinib COMETRIQ SGM ceritinib ZYKADIA SGM dabrafenib TAFINLAR

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SGM dasatinib SPRYCEL SGM erlotinib TARCEVA SGM everolimus AFINITOR SGM ibrutinib IMBRUVICA SGM idelalisib ZYDELIG SGM imatinib mesylate GLEEVEC SGM lapatinib TYKERB SGM lenvatinib LENVIMA SGM midostaurin RYDAPT SGM nilotinib TASIGNA SGM palbociclib IBRANCE SGM pazopanib VOTRIENT SGM ponatinib ICLUSIG SGM regorafenib STIVARGA SGM ruxolitinib JAKAFI SGM sorafenib NEXAVAR SGM sunitinib SUTENT SGM trametinib MEKINIST SGM vandetanib CAPRELSA SGM vemurafenib ZELBORAF MISCELLANEOUS SGM bexarotene caps TARGRETIN etoposide hydroxyurea HYDREA leucovorin mitotane LYSODREN SGM niraparib ZEJULA SGM olaparib LYNPARZA SGM panobinostat FARYDAK procarbazine MATULANE SGM romidepsin ISTODAX SGM rucaparib RUBRACA tretinoin caps uridine triacetate VISTOGARD SGM venetoclax VENCLEXTA SGM vismodegib ERIVEDGE SGM vorinostat ZOLINZA CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org benazepril LOTENSIN captopril

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enalapril VASOTEC fosinopril lisinopril ZESTRIL quinapril ACCUPRIL ramipril ALTACE trandolapril ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril LOTREL ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide LOTENSIN HCT captopril/hydrochlorothiazide enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide ZESTORETIC quinapril/hydrochlorothiazide ACCURETIC ADRENOLYTICS, CENTRAL clonidine CATAPRES clonidine transdermal CATAPRES-TTS guanfacine ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone INSPRA spironolactone ALDACTONE ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 doxazosin CARDURA prazosin MINIPRESS terazosin ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org irbesartan AVAPRO irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR losartan/hydrochlorothiazide HYZAAR valsartan DIOVAN valsartan/hydrochlorothiazide DIOVAN HCT ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org amiodarone disopyramide NORPACE disopyramide ext-rel NORPACE CR SGM dofetilide TIKOSYN flecainide propafenone propafenone ext-rel RYTHMOL SR

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sotalol BETAPACE sotalol BETAPACE AF ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile Acid Resins cholestyramine QUESTRAN/QUESTRAN LIGHT colestipol COLESTID Cholesterol Absorption Inhibitors ezetimibe ZETIA Fibrates fenofibrate fenofibrate TRICOR gemfibrozil LOPID HMG-CoA Reductase Inhibitors atorvastatin LIPITOR lovastatin pravastatin PRAVACHOL ST rosuvastatin CRESTOR simvastatin ZOCOR Niacins niacin ext-rel NIASPAN Omega-3 Fatty Acids PA icosapent ethyl VASCEPA PCSK9 Inhibitors SGM evolocumab REPATHA BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol TENORMIN bisoprolol carvedilol COREG labetalol metoprolol succinate ext-rel TOPROL-XL metoprolol tartrate 25 mg, 50 mg, 100 mg LOPRESSOR nadolol CORGARD pindolol propranolol propranolol ext-rel INDERAL LA timolol

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BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol/chlorthalidone TENORETIC bisoprolol/hydrochlorothiazide ZIAC metoprolol/hydrochlorothiazide LOPRESSOR HCT CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine NORVASC felodipine ext-rel nifedipine ext-rel ADALAT CC nifedipine ext-rel PROCARDIA XL Nondihydropyridines diltiazem CARDIZEM diltiazem ext-rel diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC diltiazem ext-rel, except 120 mg CARDIZEM LA verapamil ext-rel CALAN SR verapamil ext-rel VERELAN PM DIGITALIS GLYCOSIDES digoxin LANOXIN digoxin pediatric elixir DIURETICS Carbonic Anhydrase Inhibitors acetazolamide acetazolamide ext-rel methazolamide Loop Diuretics bumetanide furosemide LASIX torsemide Potassium-sparing Diuretics amiloride Thiazides and Thiazide-like Diuretics chlorthalidone hydrochlorothiazide indapamide metolazone Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide ALDACTAZIDE triamterene/hydrochlorothiazide DYAZIDE triamterene/hydrochlorothiazide MAXZIDE HEART FAILURE ivabradine CORLANOR sacubitril/valsartan ENTRESTO

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NITRATES Oral isosorbide dinitrate oral ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel nitroglycerin ext-rel Sublingual nitroglycerin sublingual NITROSTAT Transdermal nitroglycerin ointment NITRO-BID nitroglycerin transdermal nitroglycerin transdermal NITRO-DUR PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists SGM ambrisentan LETAIRIS SGM bosentan TRACLEER Phosphodiesterase Inhibitors SGM sildenafil REVATIO Prostaglandin Vasodilators SGM epoprostenol sodium FLOLAN SGM iloprost VENTAVIS SGM treprostinil REMODULIN SGM treprostinil TYVASO MISCELLANEOUS hydralazine methyldopa midodrine CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org ANTIANXIETY Benzodiazepines QL alprazolam XANAX chlordiazepoxide clonazepam tabs KLONOPIN QL diazepam VALIUM QL lorazepam ATIVAN QL oxazepam Miscellaneous buspirone QL* clomipramine ANAFRANIL fluvoxamine QL* Only applies to members of age 65 and older

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ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL carbamazepine ext-rel TEGRETOL-XR diazepam rectal gel DIASTAT divalproex sodium delayed-rel DEPAKOTE divalproex sodium ext-rel DEPAKOTE ER ethosuximide ZARONTIN QL gabapentin NEURONTIN lamotrigine LAMICTAL levetiracetam KEPPRA levetiracetam injection KEPPRA oxcarbazepine TRILEPTAL phenobarbital phenytoin DILANTIN INFATABS phenytoin sodium extended DILANTIN phenytoin sodium extended PHENYTEK primidone MYSOLINE tiagabine GABITRIL topiramate sprinkle caps, tabs TOPAMAX valproic acid SGM vigabatrin SABRIL zonisamide ZONEGRAN ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com donepezil ARICEPT galantamine RAZADYNE galantamine ext-rel RAZADYNE ER PA* memantine NAMENDA PA rivastigmine caps, solution PA rivastigmine transdermal EXELON PATCH PA* Only applies to members < 30 years of age ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs) isocarboxazid MARPLAN phenelzine NARDIL tranylcypromine PARNATE Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram CELEXA escitalopram LEXAPRO fluoxetine PROZAC paroxetine HCl ext-rel PAXIL CR paroxetine HCl tabs PAXIL

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sertraline ZOLOFT Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) PA duloxetine delayed-rel CYMBALTA venlafaxine venlafaxine ext-rel EFFEXOR XR Tricyclic Antidepressants (TCAs) QL* amitriptyline QL* desipramine NORPRAMIN QL* doxepin QL* imipramine HCl QL* nortriptyline PAMELOR QL* Only applies to members of age 65 and older Miscellaneous Agents bupropion bupropion ext-rel WELLBUTRIN SR bupropion ext-rel WELLBUTRIN XL mirtazapine REMERON trazodone ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com amantadine benztropine PA bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel SINEMET CR carbidopa/levodopa orally disintegrating tabs carbidopa/levodopa/entacapone STALEVO entacapone COMTAN pramipexole MIRAPEX ropinirole selegiline trihexyphenidyl ANTIPSYCHOTICS Atypicals aripiprazole ABILIFY aripiprazole ext-rel injection ABILIFY MAINTENA aripiprazole lauroxil ext-rel injection ARISTADA aripiprazole lauroxil ext-rel injection ARISTADA INITIO aripiprazole orally disintegrating tabs PA asenapine SAPHRIS clozapine CLOZARIL clozapine orally disintegrating tabs PA iloperidone FANAPT PA lurasidone LATUDA olanzapine ZYPREXA PA paliperidone ext-rel INVEGA paliperidone palmitate ext-rel injection INVEGA SUSTENNA paliperidone palmitate ext-rel injection INVEGA TRINZA quetiapine SEROQUEL PA quetiapine ext-rel SEROQUEL XR

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risperidone RISPERDAL risperidone long-acting injection RISPERDAL CONSTA ziprasidone GEODON Miscellaneous chlorpromazine fluphenazine fluphenazine decanoate injection fluphenazine injection haloperidol haloperidol decanoate injection HALDOL DECANOATE haloperidol lactate injection HALDOL perphenazine SGM pimavanserin NUPLAZID thiothixene trifluoperazine ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org QL amphetamine/dextroamphetamine mixed salts ADDERALL QL amphetamine/dextroamphetamine mixed salts ext-rel ADDERALL XR ST, QL atomoxetine STRATTERA QL dexmethylphenidate FOCALIN QL dextroamphetamine ext-rel DEXEDRINE SPANSULE QL dextroamphetamine tabs 5 mg, 10 mg QL methylphenidate RITALIN QL methylphenidate ext-rel QL methylphenidate ext-rel CONCERTA ST, QL methylphenidate ext-rel 20 mg, 30 mg, 40 mg RITALIN LA QL methylphenidate ext-rel tabs 20 mg - Metadate ER QL methylphenidate solution, tabs METHYLIN FIBROMYALGIA PA milnacipran SAVELLA PA, QL pregabalin LYRICA HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia are available at: https://aasm.org Benzodiazepines QL temazepam RESTORIL Nonbenzodiazepines OTC doxylamine UNISOM QL zolpidem AMBIEN MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Ergotamine Derivatives ergotamine/caffeine CAFERGOT

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Selective Serotonin Agonists ST, QL naratriptan AMERGE ST, QL rizatriptan MAXALT QL sumatriptan IMITREX QL sumatriptan injection IMITREX QL sumatriptan nasal spray IMITREX ST, QL zolmitriptan ZOMIG MOOD STABILIZERS lithium carbonate lithium carbonate ext-rel tabs 300 mg LITHOBID lithium carbonate ext-rel tabs 450 mg lithium citrate MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com SGM fingolimod GILENYA SGM glatiramer COPAXONE SGM interferon beta-1a REBIF SGM interferon beta-1b EXTAVIA SGM teriflunomide AUBAGIO MUSCULOSKELETAL THERAPY AGENTS baclofen 10 mg, 20 mg QL carisoprodol SOMA chlorzoxazone 500 mg cyclobenzaprine 5 mg, 10 mg dantrolene DANTRIUM methocarbamol ROBAXIN orphenadrine ext-rel orphenadrine/aspirin/caffeine tizanidine tabs ZANAFLEX MYASTHENIA GRAVIS pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN NARCOLEPSY PA armodafinil NUVIGIL PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium disulfiram ANTABUSE naltrexone microspheres VIVITROL Opioid Antagonists naloxone injection QL naloxone nasal spray NARCAN naltrexone Partial Opioid Agonists buprenorphine sublingual Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual

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Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html OTC nicotine polacrilex gum, lozenge NICORETTE OTC nicotine transdermal bupropion ext-rel nicotine inhaler NICOTROL nicotine nasal spray NICOTROL NS varenicline CHANTIX ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com PA testosterone cypionate DEPO-TESTOSTERONE PA testosterone enanthate DELATESTRYL PA testosterone gel FORTESTA PA testosterone gel 25 mg/2.5 g ANDROGEL ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose PRECOSE Biguanides metformin GLUCOPHAGE metformin ext-rel GLUCOPHAGE XR Biguanide/Sulfonylurea Combinations glipizide/metformin METAGLIP Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ST sitagliptin JANUVIA Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST sitagliptin/metformin JANUMET ST sitagliptin/metformin ext-rel JANUMET XR Incretin Mimetic Agents ST dulaglutide TRULICITY ST liraglutide VICTOZA Insulins OTC insulin human HUMULIN R OTC insulin human NOVOLIN R OTC insulin isophane human HUMULIN N OTC insulin isophane human NOVOLIN N OTC insulin isophane human 70%/regular 30% HUMULIN 70/30 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 insulin glargine BASAGLAR

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insulin lispro ADMELOG insulin lispro protamine/insulin lispro HUMALOG MIX Insulin Sensitizers pioglitazone ACTOS Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin ACTOPLUS MET Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride DUETACT Meglitinides nateglinide STARLIX repaglinide Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors PA* empagliflozin JARDIANCE ST ertugliflozin STEGLATRO PA* Covered for cardiovascular indication Sulfonylureas glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL Supplies OTC, QL alcohol swabs OTC blood glucose monitoring kits, test strips FREESTYLE FREEDOM LITE kits and

test strips OTC blood glucose monitoring kits, test strips FREESTYLE INSULINX kits and test

strips OTC blood glucose monitoring kits, test strips FREESTYLE LITE kits and test strips OTC blood glucose monitoring kits, test strips PRECISION XTRA kits and test strips OTC insulin syringes, needles BD ULTRAFINE insulin syringes and

needles OTC lancets OTC, QL multiple urine test products KETO-DIASTIX OTC, QL multiple urine test products MULTISTIX CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates alendronate tabs FOSAMAX Calcitonins calcitonin-salmon MIACALCIN CONTRACEPTIVES EE = ethinyl estradiol Monophasic 20 mcg Estrogen drospirenone/EE 3/20 YAZ

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levonorgestrel/EE 0.1/20 norethindrone acetate/EE 1/20 LOESTRIN 1/20 norethindrone acetate/EE 1/20 and iron LOESTRIN FE 1/20 30 mcg Estrogen desogestrel/EE 0.15/30 - Apri drospirenone/EE 3/30 YASMIN levonorgestrel/EE 0.15/30 norethindrone acetate/EE 1.5/30 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron LOESTRIN FE 1.5/30 norgestrel/EE 0.3/30 35 mcg Estrogen ethynodiol diacetate/EE 1/35 norethindrone/EE 0.4/35 norethindrone/EE 0.5/35 norethindrone/EE 1/35 ORTHO-NOVUM 1/35 norgestimate/EE 0.25/35 50 mcg Estrogen ethynodiol diacetate/EE 1/50 norgestrel/EE 0.5/50 - Ogestrel Biphasic desogestrel/EE MIRCETTE Triphasic desogestrel/EE levonorgestrel/EE norethindrone/EE norethindrone/EE ORTHO-NOVUM 7/7/7 norgestimate/EE norgestimate/EE ORTHO TRI-CYCLEN LO Progestin Only norethindrone ORTHO MICRONOR Emergency Contraception OTC, QL levonorgestrel PLAN B ONE-STEP QL ulipristal ELLA Injectable QL medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA Transdermal norelgestromin/EE Vaginal etonogestrel/EE ring NUVARING Miscellaneous OTC, QL condoms, male OTC nonoxynol-9 GYNOL II OTC nonoxynol-9 SHUR-SEAL QL diaphragm ENDOMETRIOSIS danazol

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nafarelin SYNAREL ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf Oral estradiol ESTRACE Transdermal estradiol CLIMARA Vaginal estradiol vaginal tabs VAGIFEM estrogens, conjugated cream PREMARIN ESTROGEN/PROGESTINS Oral EE/norethindrone acetate FEMHRT EE/norethindrone acetate - Jinteli estradiol/norethindrone acetate ACTIVELLA Transdermal estradiol/norethindrone acetate COMBIPATCH FERTILITY REGULATORS Ovulation Stimulants, Synthetic PA, QL clomiphene GLUCOCORTICOIDS dexamethasone fludrocortisone hydrocortisone CORTEF methylprednisolone MEDROL methylprednisolone 2 mg MEDROL methylprednisolone injection SOLU-MEDROL prednisolone sodium phosphate orally disintegrating tabs ORAPRED ODT prednisolone sodium phosphate solution 5 mg/5 mL, 15 mg/5

mL, 25 mg/5 mL

prednisolone syrup PRELONE prednisone GLUCOSE ELEVATING AGENTS QL glucagon, human recombinant GLUCAGEN HYPOKIT QL glucagon, human recombinant GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines SGM somatropin NORDITROPIN SGM somatropin SEROSTIM SGM somatropin ZORBTIVE HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) ROCALTROL doxercalciferol HECTOROL

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paricalcitol ZEMPLAR PHENYLKETONURIA TREATMENT AGENTS SGM sapropterin KUVAN PHOSPHATE BINDER AGENTS calcium acetate ST sucroferric oxyhydroxide VELPHORO POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate PROGESTINS Injectable SGM hydroxyprogesterone caproate MAKENA Oral medroxyprogesterone acetate PROVERA norethindrone acetate AYGESTIN progesterone, micronized PROMETRIUM SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene EVISTA THYROID AGENTS Antithyroid Agents methimazole TAPAZOLE potassium iodide SSKI propylthiouracil Thyroid Supplements levothyroxine levothyroxine SYNTHROID levothyroxine - Levoxyl liothyronine CYTOMEL UREA CYCLE DISORDERS SGM sodium phenylbutyrate BUPHENYL VASOPRESSIN RECEPTOR ANTAGONISTS SGM tolvaptan SAMSCA VASOPRESSINS PA desmopressin spray PA desmopressin spray, tabs DDAVP MISCELLANEOUS cabergoline SGM cysteamine CYSTAGON GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org ANTACIDS OTC alumina/magnesia MAALOX OTC alumina/magnesia/simethicone MAALOX

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OTC alumina/magnesia/simethicone MYLANTA OTC calcium carbonate OTC sodium bicarbonate tabs ANTIDIARRHEALS OTC bismuth subsalicylate PEPTO-BISMOL OTC loperamide diphenoxylate/atropine LOMOTIL loperamide ANTIEMETICS OTC meclizine PA, QL aprepitant caps EMEND QL dronabinol MARINOL QL granisetron tabs meclizine metoclopramide REGLAN QL ondansetron ZOFRAN prochlorperazine promethazine promethazine suppository trimethobenzamide TIGAN ANTISPASMODICS chlordiazepoxide/clidinium dicyclomine BENTYL glycopyrrolate tabs 1 mg, 2 mg hyoscyamine sulfate LEVSIN hyoscyamine sulfate ext-rel LEVBID hyoscyamine sulfate ext-rel caps hyoscyamine sulfate orally disintegrating tabs CHOLELITHOLYTICS ursodiol ACTIGALL ursodiol URSO H2 RECEPTOR ANTAGONISTS OTC cimetidine TAGAMET HB OTC famotidine PEPCID AC OTC ranitidine ZANTAC cimetidine famotidine PEPCID nizatidine ranitidine ZANTAC INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide budesonide delayed-rel caps ENTOCORT EC mesalamine ext-rel caps APRISO sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS Rectal Agents hydrocortisone enema mesalamine rectal suspension ROWASA mesalamine suppository CANASA

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LAXATIVES/STOOL SOFTENERS OTC bisacodyl DULCOLAX OTC docusate calcium OTC docusate sodium COLACE OTC polyethylene glycol 3350 MIRALAX OTC senna OTC sennosides SENOKOT OTC sennosides/docusate sodium SENNA PLUS lactulose solution peg 3350/electrolytes COLYTE peg 3350/electrolytes GOLYTELY peg 3350/electrolytes NULYTELY OPIOID-INDUCED CONSTIPATION naloxegol MOVANTIK PANCREATIC ENZYMES PA pancrelipase VIOKACE PA pancrelipase delayed-rel CREON PA pancrelipase delayed-rel ZENPEP PROSTAGLANDINS misoprostol CYTOTEC PROTON PUMP INHIBITORS OTC, QL esomeprazole magnesium delayed-rel NEXIUM 24HR OTC, QL lansoprazole delayed-rel PREVACID 24HR OTC, QL omeprazole delayed-rel tabs OTC, QL omeprazole magnesium delayed-rel PRILOSEC OTC OTC, QL omeprazole magnesium delayed-rel caps OTC, QL omeprazole/sodium bicarbonate ZEGERID OTC AL*, QL esomeprazole magnesium delayed-rel suspension 2.5 mg, 5 mg,

10 mg NEXIUM

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GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines alfuzosin ext-rel UROXATRAL doxazosin CARDURA finasteride PROSCAR tamsulosin FLOMAX terazosin URINARY ANTISPASMODICS OTC, * oxybutynin transdermal OXYTROL FOR WOMEN oxybutynin oxybutynin ext-rel DITROPAN XL trospium * Gender restriction - Coverage for females VAGINAL ANTI-INFECTIVES OTC clotrimazole OTC miconazole clindamycin cream CLEOCIN clotrimazole metronidazole miconazole terconazole MISCELLANEOUS bethanechol URECHOLINE pentosan polysulfate sodium ELMIRON phenazopyridine PYRIDIUM potassium citrate ext-rel UROCIT-K HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable enoxaparin LOVENOX Oral apixaban ELIQUIS rivaroxaban XARELTO * warfarin COUMADIN * Both Coumadin and warfarin are covered. Synthetic Heparinoid-like Agents fondaparinux ARIXTRA

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HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines SGM darbepoetin alfa ARANESP SGM filgrastim-sndz ZARXIO SGM pegfilgrastim-cbqv UDENYCA PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SGM eculizumab SOLIRIS PLATELET AGGREGATION INHIBITORS OTC aspirin clopidogrel PLAVIX dipyridamole prasugrel EFFIENT ticagrelor BRILINTA PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN THROMBOCYTOPENIA AGENTS SGM eltrombopag tabs PROMACTA MISCELLANEOUS cilostazol IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org AUTOIMMUNE AGENTS SGM adalimumab HUMIRA SGM brodalumab SILIQ SGM etanercept ENBREL SGM sarilumab KEVZARA SGM, QL secukinumab COSENTYX SGM tofacitinib XELJANZ SGM tofacitinib ext-rel XELJANZ XR DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate SGM methotrexate injection RASUVO HEREDITARY ANGIOEDEMA AGENTS SGM C1 esterase inhibitor CINRYZE SGM C1 esterase inhibitor, recombinant RUCONEST

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IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: https://www.aasld.org Interferons SGM interferon alfa-2b INTRON A SGM peginterferon alfa-2a PEGASYS Miscellaneous SGM canakinumab ILARIS IMMUNOSUPPRESSANTS Antimetabolites azathioprine AZASAN azathioprine IMURAN mycophenolate mofetil CELLCEPT Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified NEORAL tacrolimus PROGRAF Rapamycin Derivatives sirolimus RAPAMUNE NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium bicarbonate effervescent tabs 25 mEq potassium chloride ext-rel potassium chloride ext-rel K-TAB potassium chloride liquid Miscellaneous potassium phosphate K-PHOS VITAMINS AND MINERALS Folic Acid/Combinations OTC folic acid folic acid folic acid/vitamin B6/vitamin B12 Prenatal Vitamins prenatal vitamins/carbonyl iron/docusate/folic acid - Prenatal

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prenatal vitamins/carbonyl iron/ferrous fumarate/folic acid + DHA CITRANATAL MEDLEY prenatal vitamins/carbonyl iron/folic acid - Prenatabs Rx prenatal vitamins/DHA/docusate/folic acid CITRANATAL 90 DHA prenatal vitamins/DHA/docusate/folic acid CITRANATAL DHA prenatal vitamins/DHA/docusate/folic acid CITRANATAL HARMONY prenatal vitamins/docusate/folic acid CITRANATAL RX prenatal vitamins/docusate/folic acid + DHA CITRANATAL ASSURE prenatal vitamins/ferrous fumarate/docusate/folic acid -

Prenatal 19

prenatal vitamins/folic acid + pyridoxine CITRANATAL B-CALM

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Miscellaneous OTC biotin OTC calcium OTC calcium/vitamin D OTC cholecalciferol (D3) VITAMIN D OTC electrolyte solution, oral PEDIALYTE OTC ferrous fumarate OTC ferrous gluconate FERGON OTC ferrous sulfate FEOSOL OTC omega-3 fatty acids FISH OIL OTC omega-3 fatty acids/vitamin E FISH OIL OTC pyridoxine 25 mg, 50 mg VITAMIN B6 cyanocobalamin injection ergocalciferol (D2) fluoride drops, tabs multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs phytonadione MEPHYTON vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin B complex/vitamin C/folic acid NEPHROCAPS RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS QL epinephrine EPIPEN QL epinephrine EPIPEN JR. QL epinephrine auto-injector ANTICHOLINERGICS QL ipratropium inhalation solution QL tiotropium SPIRIVA RESPIMAT QL umeclidinium INCRUSE ELLIPTA ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting QL ipratropium/albuterol inhalation solution ANTIHISTAMINES, LOW SEDATING OTC cetirizine ZYRTEC cetirizine ANTIHISTAMINES, NONSEDATING OTC fexofenadine ALLEGRA OTC loratadine CLARITIN ANTIHISTAMINES, SEDATING OTC chlorpheniramine OTC chlorpheniramine ext-rel OTC clemastine

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OTC diphenhydramine BENADRYL clemastine cyproheptadine diphenhydramine hydroxyzine HCl hydroxyzine pamoate VISTARIL ANTIHISTAMINE/DECONGESTANT COMBINATIONS OTC cetirizine/pseudoephedrine ext-rel ZYRTEC-D 12 Hour OTC fexofenadine/pseudoephedrine ext-rel ALLEGRA-D OTC loratadine/pseudoephedrine ext-rel CLARITIN-D OTC triprolidine/pseudoephedrine liquid, syrup promethazine/phenylephrine ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf benzonatate TESSALON ANTITUSSIVE COMBINATIONS Opioid codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine Non-opioid OTC dextromethorphan/guaifenesin ext-rel MUCINEX DM OTC dextromethorphan/guaifenesin liquid, solution, syrup OTC dextromethorphan/guaifenesin/pseudoephedrine liquid 10

mg/100 mg/30 mg/5 mL

dextromethorphan/brompheniramine/pseudoephedrine dextromethorphan/promethazine BETA AGONISTS Inhalants Short Acting QL albuterol inhalation solution QL albuterol sulfate, CFC-free aerosol Long Acting Hand-held Active Inhalation QL olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Oral Agents albuterol albuterol ext-rel terbutaline CYSTIC FIBROSIS SGM dornase alfa PULMOZYME SGM elexacaftor/tezacaftor/ivacaftor + ivacaftor TRIKAFTA SGM ivacaftor KALYDECO SGM lumacaftor/ivacaftor ORKAMBI SGM tobramycin inhalation solution KITABIS PAK

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SGM tobramycin inhalation solution TOBI DECONGESTANTS OTC pseudoephedrine SUDAFED OTC, QL pseudoephedrine ext-rel SUDAFED DECONGESTANT/EXPECTORANT COMBINATIONS OTC pseudoephedrine/guaifenesin ext-rel MUCINEX D OTC pseudoephedrine/guaifenesin syrup 30 mg/100 mg/5 mL EXPECTORANTS OTC guaifenesin ext-rel MUCINEX OTC guaifenesin liquid DIABETIC TUSSIN OTC guaifenesin liquid, syrup, tabs LEUKOTRIENE MODULATORS montelukast SINGULAIR MAST CELL STABILIZERS OTC cromolyn nasal spray NASALCROM QL cromolyn inhalation solution MEDICAL SUPPLIES OTC, QL mask OTC, QL nebulizer OTC sodium chloride inhalation solution OTC, QL spacer AEROCHAMBER OTC, QL vaporizer sodium chloride inhalation solution NASAL ANTIHISTAMINES QL azelastine spray NASAL STEROIDS OTC, QL budesonide spray - Rhinocort Allergy OTC, QL fluticasone spray FLONASE ALLERGY RELIEF OTC, QL triamcinolone acetonide spray NASACORT ALLERGY 24HR QL flunisolide spray RESPIRATORY SYNCYTIAL VIRUS SGM palivizumab SYNAGIS SEVERE ASTHMA AGENTS SGM omalizumab XOLAIR STEROID/BETA AGONIST COMBINATIONS QL budesonide/formoterol SYMBICORT AL*, QL fluticasone/salmeterol 100/50 ADVAIR DISKUS ST, QL mometasone/formoterol DULERA AL* Covered for ages 4-11 years only STEROID INHALANTS QL beclomethasone, CFC-free aerosol QVAR QL budesonide inhalation suspension PULMICORT RESPULES QL fluticasone FLOVENT DISKUS QL fluticasone, CFC-free aerosol FLOVENT HFA QL mometasone ASMANEX

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QL mometasone, CFC-free aerosol ASMANEX HFA XANTHINES theophylline ext-rel caps THEO-24 theophylline ext-rel tabs theophylline liquid theophylline liquid ELIXOPHYLLIN MISCELLANEOUS OTC sodium chloride nasal spray OCEAN ipratropium nasal spray TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral PA isotretinoin PA isotretinoin - Amnesteem PA isotretinoin - Claravis PA isotretinoin - Myorisan PA isotretinoin - Zenatane Topical OTC benzoyl peroxide OTC benzoyl peroxide gel 2.5% benzoyl peroxide, except foam clindamycin gel, lotion, solution CLEOCIN T erythromycin gel 2% erythromycin solution sulfacetamide lotion 10% KLARON PA tretinoin RETIN-A Actinic Keratosis fluorouracil cream 4% TOLAK fluorouracil cream 5% EFUDEX Antibiotics OTC bacitracin OTC bacitracin/polymyxin B POLYSPORIN OTC neomycin/bacitracin/polymyxin B NEOSPORIN gentamicin mupirocin ointment silver sulfadiazine SILVADENE Antifungals OTC miconazole MICATIN OTC tolnaftate TINACTIN ciclopirox LOPROX clotrimazole ketoconazole cream 2% nystatin

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Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Topical ST, QL calcipotriene ointment, solution 0.005% DOVONEX Antiseborrheics OTC selenium sulfide shampoo 1% SELSUN BLUE ketoconazole shampoo 2% NIZORAL SHAMPOO selenium sulfide lotion 2.5% Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines ST, QL crisaborole EUCRISA ST* tacrolimus PROTOPIC ST* tacrolimus 0.1%: In addition to clinical criteria, the member must be at least 16 years of age. Corticosteroids Low Potency OTC hydrocortisone cream, gel, lotion, ointment, solution 1% CORTIZONE-10 OTC hydrocortisone ointment 0.5% OTC hydrocortisone/aloe vera cream 0.5%, 1% alclometasone cream, ointment 0.05% fluocinolone acetonide solution 0.01% QL hydrocortisone cream, lotion, ointment 2.5% Medium Potency QL betamethasone valerate cream, lotion, ointment 0.1% fluocinolone acetonide cream, ointment 0.025% QL fluticasone propionate cream 0.05%, ointment 0.005% CUTIVATE hydrocortisone butyrate solution 0.1% LOCOID QL mometasone cream, lotion, ointment 0.1% ELOCON QL triamcinolone acetonide cream, lotion, ointment 0.025% QL triamcinolone acetonide cream, lotion, ointment 0.1% High Potency QL betamethasone dipropionate augmented cream 0.05% DIPROLENE AF QL betamethasone dipropionate cream, lotion, ointment 0.05% desoximetasone cream 0.25% TOPICORT QL fluocinonide cream, gel, ointment 0.05% fluocinonide solution 0.05% QL triamcinolone acetonide cream, ointment 0.5% Very High Potency QL betamethasone dipropionate augmented ointment 0.05% DIPROLENE clobetasol propionate solution 0.05% QL halobetasol propionate cream, ointment 0.05% ULTRAVATE Emollients OTC ammonium lactate 12% LAC-HYDRIN ammonium lactate 12% LAC-HYDRIN Local Analgesics OTC, QL capsaicin cream 0.025%, 0.1%

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OTC, QL capsaicin cream 0.033%, 0.035%, 0.075% OTC, QL capsaicin liquid 0.15% CAPZASIN OTC, QL capsaicin lotion 0.035% CASTIVA OTC, QL capsaicin/menthol gel 0.025/10% CAPZASIN GEL RELIEF OTC, QL lidocaine patch 4% PA lidocaine patch LIDODERM Local Anesthetics QL lidocaine/prilocaine cream lidocaine/prilocaine kit Rosacea metronidazole cream 0.75% METROCREAM metronidazole gel 0.75% ST metronidazole gel 1% METROGEL metronidazole lotion 0.75% METROLOTION Scabicides and Pediculicides OTC permethrin ST malathion OVIDE permethrin ST spinosad NATROBA Miscellaneous Skin and Mucous Membrane OTC calamine lotion OTC docosanol ABREVA OTC lidocaine/benzalkonium chloride BACTINE OTC, QL mosquito repellent OTC povidone/iodine BETADINE imiquimod ALDARA podofilox solution CONDYLOX MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Steroids - Mouth/Throat triamcinolone paste Miscellaneous chlorhexidine PERIDEX AL sodium fluoride PREVIDENT AL Covered to maximum patient age of 21 OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics OTC ketotifen ZADITOR cromolyn sodium Antifungals natamycin NATACYN Anti-infectives bacitracin

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ciprofloxacin solution CILOXAN erythromycin gentamicin levofloxacin moxifloxacin VIGAMOX neomycin/polymyxin B/gramicidin ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim POLYTRIM sulfacetamide solution 10% BLEPH-10 tobramycin solution TOBREX Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone ointment neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone suspension sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone suspension 0.3%/0.1% TOBRADEX Anti-inflammatories Nonsteroidal diclofenac sodium ketorolac 0.4% ACULAR LS ketorolac 0.5% ACULAR Steroidal dexamethasone sodium phosphate fluorometholone 0.1% suspension FML LIQUIFILM prednisolone acetate 1% PRED FORTE prednisolone phosphate 1% Antivirals trifluridine Beta-blockers Nonselective levobunolol timolol hemihydrate BETIMOL timolol maleate TIMOPTIC timolol maleate gel TIMOPTIC-XE Selective betaxolol 0.5% Carbonic Anhydrase Inhibitors Topical dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate COSOPT Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine SIMBRINZA Prostaglandins latanoprost XALATAN

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Sympathomimetics brimonidine 0.15% ALPHAGAN P brimonidine 0.2% Miscellaneous OTC artificial tears ointment, solution ARTIFICIAL TEARS OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives acetic acid ofloxacin otic Anti-infective/Anti-inflammatory Combinations ciprofloxacin/dexamethasone CIPRODEX neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC VAGINAL OTC acetic acid solution

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WEBSITES Agency for Healthcare Research and Quality https://www.ahrq.gov Alzheimer's Association https://www.alz.org American Academy of Allergy, Asthma and Immunology https://www.aaaai.org American Academy of Child & Adolescent Psychiatry https://www.aacap.org American Academy of Dermatology https://www.aad.org American Academy of Neurology https://www.aan.com American Academy of Ophthalmology https://www.aao.org American Academy of Pediatrics https://www.aap.org American Association for the Study of Liver Disease https://www.aasld.org American Association of Clinical Endocrinologists https://www.aace.com American Association of Diabetes Educators https://www.diabeteseducator.org American Cancer Society https://www.cancer.org American College of Allergy, Asthma and Immunology https://www.acaai.org American College of Cardiology https://www.acc.org American College of Chest Physicians https://www.chestnet.org American College of Gastroenterology https://gi.org American College of Physicians https://www.acponline.org American College of Rheumatology https://www.rheumatology.org

American Congress of Obstetricians and Gynecologists https://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association https://www.gastro.org American Headache Society Committee for Headache Education https://americanheadachesociety.org American Heart Association https://professional.heart.org