The following is an abbreviated version of the drug list (formulary) that is at the fundamental basis of your prescrip�on drug benefit. The list is not all-inclusive and does not guarantee coverage. This list is subject to change.

APEX 8.2019 (continued)

ACEBUTOLOL HCLACYCLOVIRALA-CORTALBUTEROL SULFATEALENDRONATE SODIUMALLOPURINOLALPRAZOLAMALPRAZOLAM ERALPRAZOLAM XRAMANTADINE HCLAMILORIDE HCL W/HCTZAMIODARONE HCLAMITRIPTYLINE HCLAMLODIPINE BESYLATEAMMONIUM LACTATEAMOXICILLINAMOXICILLIN-CLAVULANATE POTASSAQUA CARE SODIUM CHLORIDEATENOLOLATORVASTATIN CALCIUMBACLOFENBENAZEPRIL HCLBENAZEPRIL HCL-HCTZBENZONATATEBENZTROPINE MESYLATEBISOPROLOL FUMARATE/HCTZBP FOAMING WASHBUPROPION SRBUSPIRONE HCLCARBAMAZEPINECARBIDOPA/LEVODOPACARBIDOPA-LEVODOPA ERCARVEDILOLCEPHALEXINCETIRIZINE HCLCHLORDIAZEPOXIDE HCLCHLORHEXIDINE GLUCONATECHOLESTYRAMINECHOLESTYRAMINE LIGHTCILOSTAZOLCIPROFLOXACIN HCLCITALOPRAM HBRCLINDAMYCIN HCLCLONAZEPAMCLONIDINE HCLCONSTULOSECORVITE

CYCLOBENZAPRINE HCLDECADRONDELTASONEDEXAMETHASONEDIAZEPAMDICLOFENAC SODIUMDICYCLOMINE HCLDILANTINDILTIAZEM HCLDIPHENHYDRAMINE HCLDIPYRIDAMOLEDIVALPROEX SODIUMDONEPEZIL HCLDOXYCYCLINE HYCLATEDOXYCYCLINE MONOHYDRATEENALAPRIL MALEATE/HCTZENDOCETENULOSEESCITALOPRAM OXALATEESTRADIOLETHOSUXIMIDEEUTHYROXFAMOTIDINEFINASTERIDEFLECAINIDE ACETATEFLUCONAZOLEFLUORIDEFLUORITABFLUOXETINE HCLFLUPHENAZINE HCLFLURBIPROFENFOLIC ACIDFOSINOPRIL SODIUMFUROSEMIDEGABAPENTINGAVILYTEGEMFIBROZILGENERLACGLIMEPIRIDEGLIPIZIDEGLIPIZIDE ERGLIPIZIDE XLGLYBURIDEGLYBURIDE MICRONIZEDGLYBURIDE-METFORMIN HCLGLYCOLAXGUANFACINE HCLHALOPERIDOL

HYDRALAZINE HCLHYDROCHLOROTHIAZIDEHYDROCORTISONEHYDROMETHYDROXYZINE HCLHYDROXYZINE PAMOATEIBUIBUPROFENINDOMETHACINIPRATROPIUM BROMIDEIPRATROPIUM-ALBUTEROLISONIAZIDISOSORBIDE MONONITRATEJANTOVENKALEXATEKETOCONAZOLEKIONEXLACTULOSELAMOTRIGINELEVETIRACETAMLEVOCETIRIZINE DIHYDROCHLORIDELEVO-TLEVOTHYROXINE SODIUMLEVOXYLLIDOCAINELIDOCAINE HCLLISINOPRILLISINOPRIL-HCTZLITHIUM CARBONATELORAZEPAMLOSARTAN POTASSIUMLOSARTAN-HYDROCHLOROTHIAZIDELOVASTATINLUDENT FLUORIDELYSIPLEX PLUSMECLIZINE HCLMEDROXYPROGESTERONE ACETATEMEGESTROL ACETATEMELOXICAMMETFORMIN HCLMETFORMIN HCL ERMETHADONE HCLMETHADOSEMETHIMAZOLEMETHOCARBAMOLMETHYLDOPAMETHYLPHENIDATE HCLMETOCLOPRAMIDE HCL

METOPROLOL SUCCINATEMETOPROLOL TARTRATEMETRONIDAZOLEMINOCYCLINE HCLMINOXIDILMIRTAZAPINEMOBICMONDOXYNE NLMONTELUKAST SODIUMMULTIVIT W/FLUORIDE & IRONMULTIVITAMIN W/FLUORIDE & IRONMULTIVITAMIN WITH FLUORIDEMVC-FLUORIDEMYNEPHROCAPSMYNEPHRONNAPROXENNEVIRAPINENIACIN-AZE AC-TURMER-FA-B6-ZNNORTRIPTYLINE HCLOLANZAPINEOMEPRAZOLEONDANSETRON HCLOXCARBAZEPINEPACERONEPAMELORPANTOPRAZOLE SODIUMPAROXETINE HCLPEG 3350-ELECTROLYTEPENICILLIN V POTASSIUMPERIOGARDPHENTERMINE HCLPHENYTOINPHENYTOIN SODIUMPOLYETHYLENE GLYCOLPRAMIPEXOLE DI-HCLPREDNISONEPREVALITEPRIMIDONEPROCHLORPERAZINE MALEATEPROMETHAZINE HCLPROMETHAZINE VC W/CODEINEPROMETHAZINE W/CODEINEPROMETHAZINE W/DMPROMETHAZINE-PHENYLEPH-CODEINEPROPAFENONE HCLPROPRANOLOL HCLQUINAPRILRAMIPRIL

APEX 6 TierFormulary

PG 1

The informa�on contained herein is company confiden�al and proprietary. It should not be used for any purpose not expressly approved in wri�ng by Apex.

PRODUCT NAME

Tier 1 ($1.00)

APEX 8.2019 (continued)

PG 2

The informa�on contained herein is company confiden�al and proprietary. It should not be used for any purpose not expressly approved in wri�ng by Apex.

RANITIDINE HCLRENAL CAPSRENO CAPSREPAGLINIDEROSUVASTATIN CALCIUMSALSALATESELENIUM SULFIDESERTRALINE HCLSILVER SULFADIAZINESIMVASTATINSMZ-TMP DSSODIUM CHLORIDESODIUM FLUORIDE

SODIUM POLYSTYRENE SULFONATESORINESOTALOLSOTALOL AFSPIRONOLACTONESUBVENITESUCRALFATESULFAMETHOXAZOLE/TRIMETHOPRIMSULFASALAZINE DRSULFATRIMSULINDACTAMOXIFEN CITRATETEMAZEPAMTERAZOSIN HCL

TERBINAFINETHIOTHIXENETIZANIDINE HCLTOPIRAMATETOPROL XLTORSEMIDETRAMADOL HCLTRAMADOL HCL-ACETAMINOPHENTRAZODONE HCLTRIAMCINOLONE ACETONIDETRIAMTERENE W/HCTZTRIHEXYPHENIDYL HCLTRILYTE WITH FLAVOR PACKETSTRIPHROCAPS

TRIPLE-VITAMIN W-FLUORIDETRI-VITAMIN WITH FLUORIDEUNITHROIDVALPROIC ACIDVENLAFAXINE HCLVENLAFAXINE HCL ERVERAPAMIL HCLVIRT-CAPSVITACELVITAMINS A.C.D & FLUORIDEWARFARIN SODIUMZALEPLONZOLPIDEM TARTRATEZONISAMIDE

Tier 1 ($1.00)

Tier 2(Generics)

ACARBOSEACETAMINOPHEN W/CODEINEACETAZOLAMIDEACYCLOVIRAFEDITAB CRALENDRONATE SODIUMALFUZOSIN HCL ERALLOPURINOLALPRAZOLAM ERALPRAZOLAM XRALTAVERAAMITRIPTYLINE HCLAMLODIPINE BESYLATE-BENAZEPRILAMOXICILLINAMOXICILLIN-CLAVULANATE POTASSANASTROZOLEAPRIATORVASTATIN CALCIUMAUBRAAUBRA EQAVIANEAV-PHOS 250 NEUTRALAV-VITE FB FORTEBACLOFENBENZONATATEBISOPROLOL FUMARATEBROMFED-DMBROMIPHENIRAMIN-PSEUDOEPHED-DMBROMPHENIRAMINE W/PSEUDOEPHEDBUMETANIDEBUPROBANBUPROPION HCL ERBUPROPION SR

CALCITRIOLCARBAMAZEPINECARBIDOPA/LEVODOPACARBIDOPA-LEVODOPA ERCARISOPRODOLCARTIA XTCEFDINIRCEFPROZILCHATEALCHATEAL EQCHLORDIAZEPOXIDE HCLCIMETIDINECIPROFLOXACIN HCLCITALOPRAM HBRCLINDACIN ETZCLINDACIN PCLINDAMYCIN HCLCLINDAMYCIN PALMITATE HCLCLINDAMYCIN PEDIATRICCLINDAMYCIN PHOSPHATECLONIDINE HCLCLOTRIMAZOLECLOZAPINECYPROHEPTADINE HCLCYREDCYRED EQDELYLADESOGESTREL-ETHINYL ESTRADIOLDICLOFENAC SODIUMDICLOXACILLIN SODIUMDILTIAZEM 24HR ER (CD)DILTIAZEM 24HR ER (XR)DILTIAZEM ERDILTIAZEM HCLDILT-XR

DIPHENOXYLATE W/ATROPINEDIVALPROEX SODIUMDOXAZOSIN MESYLATEDOXEPIN HCLDOXYCYCLINE MONOHYDRATEEMOQUETTEENALAPRIL MALEATEENDOCETENSKYCEEPITOLERYTHROMYCINESCITALOPRAM OXALATEESTARYLLAETHYNODIOL-ETHINYL ESTRADIOLETODOLACEUTHYROXFALMINAFELODIPINE ERFEMYNORFENOFIBRATEFLECAINIDE ACETATEFLUCONAZOLEFLUDROCORTISONE ACETATEFLUPHENAZINE HCLFLUTICASONE PROPIONATEFOLBICGABAPENTINGLIPIZIDE ERGLIPIZIDE XLGLIPIZIDE-METFORMINGRISEOFULVINHALOPERIDOLHYDROCODONE BIT-IBUPROFENHYDROCODONE-CHLORPHENIRAMINEHYDROCORTISONE

HYDROMORPHONE HCLHYDROXYUREAHYDROXYZINE HCLHYOSCYAMINE SULFATEIBUPROFENIMIPRAMINE HCLINDAPAMIDEINDOMETHACINIPRATROPIUM BROMIDEIRBESARTANISIBLOOMISONIAZIDISOSORBIDE DINITRATEISOSORBIDE MONONITRATEJULEBERKELNOR 1-50KLOR-CONKLOR-CON MKURVELOLABETALOL HCLLAMOTRIGINELANSOPRAZOLELARISSIALESSINALEVETIRACETAMLEVOCETIRIZINE DIHYDROCHLORIDELEVOFLOXACIN HEMIHYDRATELEVONORGESTREL-ETH ESTRADIOLLEVORALEVO-TLEVOTHYROXINE SODIUMLEVOXYLLILLOWLIOTHYRONINE SODIUM

PRODUCT NAME

PRODUCT NAME

APEX 8.2019 (continued)

PG 3

The informa�on contained herein is company confiden�al and proprietary. It should not be used for any purpose not expressly approved in wri�ng by Apex.

LISINOPRILLOMOTILLOPERAMIDE HCLLOSARTAN POTASSIUMLOSARTAN-HYDROCHLOROTHIAZIDELOVASTATINLOXAPINE SUCCINATELUTERAMARLISSAMEGESTROL ACETATEMEPERIDINE HCLMETHIMAZOLEMETHYLDOPAMETHYLPHENIDATE HCLMETOPROLOL SUCCINATEMETRONIDAZOLEMILIMINITRANMINOCYCLINE HCLMISOPROSTOLMOEXIPRIL HCLMOMETASONE FUROATEMONDOXYNE NLMONO-LINYAHMONONESSAMONTELUKAST SODIUMMYCOPHENOLATE MOFETILNABUMETONE

NAPROXENNIFEDICAL XLNIFEDIPINENIFEDIPINE ERNITROGLYCERINNITRO-TIMENIVA-FOLNIZATIDINENORGESTIMATE-ETHINYL ESTRADIOLNYSTATINOKEBOOLANZAPINEOMEPRAZOLEORSYTHIAOSCIMINOSCIMIN SLOXCARBAZEPINEOXYBUTYNIN CHLORIDEOXYCODONE HCLOXYCODONE W/ACETAMINOPHENOXYCODONE W/ASPIRINPAROXETINE HCLPENTOXIFYLLINEPERINDOPRIL ERBUMINEPHOSPHA 250 NEUTRALPHOSPHOROUSPHOSPHO-TRIN 250 NEUTRALPINDOLOLPIOGLITAZONE HCL

PORTIAPOTASSIUM CHLORIDEPRAVASTATIN SODIUMPRAZOSIN HCLPREDNISOLONE SODIUM PHOSPHATEPREVIFEMPROBENECIDPROCHLORPERAZINE MALEATEPROPAFENONE HCLPROPRANOLOL HCLPYRIDOSTIGMINE BROMIDEQUETIAPINE FUMARATEQUINAPRIL-HYDROCHLOROTHIAZIDERANITIDINE HCLRECLIPSENRISPERIDONEROCALTROLROPINIROLE HCLROWEEPRAROWEEPRA XRSERTRALINE HCLSIMVASTATINSORINESOTALOLSOTALOL AFSPIRONOLACTONESPRINTECSRONYXSULFASALAZINE

SULFAZINESULINDACSYMAX-SLTAMOXIFEN CITRATETAZTIA XTTHEOCHRONTHEOPHYLLINE ANHYDROUSTHIOTHIXENETIZANIDINE HCLTOPIRAMATETORSEMIDETRANDOLAPRILTRIAMCINOLONE ACETONIDETRIDERMTRIMETHOPRIMUNITHROIDVALACYCLOVIRVENLAFAXINE HCLVERAPAMIL ERVIENVAVIRT-PHOS 250 NEUTRALVIRT-VITE FORTEVITAMIN D2VYLIBRAZIDOVUDINEZONISAMIDEZOVIA

Tier 2(Generics)

Tier 3(Preferred Brands)

A.I.R.S. NEBULIZERACACIAACCU-CHEK SPIRITACDACD-AACETAMINOPHENACETIC ACIDACETIC ACID/ALUMINUMACETONEACETYL SALICYLIC ACIDACETYLCYSTEINEACIDOPHILUS LACTOBACILLUSACTIVATED CHARCOALACUICYNADDAMEL NADYNOVATEAFSTYLAALBUTEROL SULFATEALENDRONATE SODIUM

ALPHA PINENEALPRAZOLAM INTENSOLALPROLIXAMINOBENZOIC ACIDAMINOBUTYRIC ACIDAMINOCAPROIC ACIDAMINOPHYLLINEAMINOSALICYLIC ACIDAMINOSYNAMITRIPTYLINE HCLAMITRIPTYLINE/CHLORDIAZEPOXIDEAMITRIPTYLINE-PERPHENAZINEAMOXAPINEAMOXICILLINAMOXICILLIN-CLAVULANATE POTASSAMPICILLIN TRIHYDRATEANASPAZANECTINEAPRISOARALAST NP

ARGININEARMOUR THYROIDBARIUM SULFATEBENZOCAINEBENZOIC ACIDBENZOINBENZOQUINONEBENZOYL PEROXIDEBENZPHETAMINE HCLBENZYL ALCOHOLBENZYL BENZOATEBETA-CAROTENEBETAINEBETAINE HYDROCHLORIDEBETAMETHASONE DIPROPIONATEBUTALBITAL-ASP-CAFFEINECALCIUM-FOLIC ACID PLUS DCALDOLORCAPTOPRIL/HYDROCHLOROTHIAZIDECARAFATE

CARAMELCARBAMAZEPINECARBAMIDE PEROXIDECARBIDOPA-LEVODOPA-ENTACAPONECARBOCAINECARBOGELCARBOHOLCARISOPRODOLCEFACLORCEFAZOLIN SODIUMCEFEPIME HCLCEFOTAXIME SODIUMCEFTRIAXONECIMETIDINECIPROFLOXACINCIPROFLOXACIN HCLCITRATE PHOSPHATE DEXTROSECLARITHROMYCINCLENPIQCLEOCIN PHOSPHATE

PRODUCT NAME

PRODUCT NAME

APEX 8.2019 (continued)

PG 4

The informa�on contained herein is company confiden�al and proprietary. It should not be used for any purpose not expressly approved in wri�ng by Apex.

CORTISONE ACETATECOUMARINCYCLOSPORINECYSTEINEDEXAMETHASONEDIAZEPAMDIGOXINDILANTINDILTIAZEM 24HR ER (XR)DILT-XREPINEPHRINEERY-TABERYTHROMYCINFAMOTIDINEFLUNISOLIDEFUROSEMIDEGLUCOSAMINEGRISEOFULVINGUAIFENESINHYDROCORTISONEK-TABLABETALOL HCLLACTASELACTOSELANOLINLANOLIN ALCOHOLLEUCOVORIN CALCIUMLIDOCAINELITHIUM CARBONATE

MEBENDAZOLEMECLIZINE HCLMETFORMIN HCLMETHADONE HCLMETHADOSEMETHANOLMETHENAMINEMETHOCARBAMOLMETHOTREXATEMETOPROLOL SUCCINATENAPROXENNITROGLYCERINOMEPRAZOLEPANCREATINPREDNISOLONEPREMARINPREMASOLPROVENTPRUCLAIRRETROVIRSULFADIAZINESULFAMERAZINESULFAMETHOXAZOLESULFAMYLONSULFANILAMIDESULFAPYRIDINESULFASALAZINESULFATHIAZOLESULFURSULFURIC ACID

SYRPALTATAURINETERCONAZOLETESTOSTERONETETRACAINETETRACAINE HCLTETRACYCLINE HCLTHEANINETHEOPHYLLINE ANHYDROUSTHIAMINE HCLTHREONINETHYMOLTHYROIDTIMOLOL MALEATETITANIUM DIOXIDETOBRAMYCIN SULFATETOLAZAMIDETOLBUTAMIDETOLMETIN SODIUMTOMMY GELTRACE ELEMENTS-4TRAGACANTHTRANSDERMAL PAIN BASETRANS-PEN TRANSDERMALTRAVASOLTRETINOINTRIACETINTRIAMTERENE W/HCTZTRIANEXTRICHLOROACETIC ACID

TRICITRASOLTRICITRATESTRIETHANOLAMINE LAURYL SULFATETRIMETHOPRIMTRIMO-SANTRINATAL GTTRINATAL RX 1TRINATETRITON X-100TRIVEEN-DUO DHATRI-VITAMIN WITH IRON-FLUORIDETROCHE BASETROLAMINETROMETHAMINETROPHAMINETROPICAL PUNCH FLAVORTRYPSINTRYPTOPHAN (L)TYROSINEUREAVALERIANVALINEVALPROATE SODIUMVANCOMYCIN HCLVARUBIVASCEPAVIMPATZOSYNZOVIA

Tier 3(Preferred Brands)

Tier 4(Non-Preferred Brands)

ACCUPRILACEONACTICOATADALAT CCADDERALLADIPEX-PADZENYS ERAFREZZAAGGRASTATAGGRENOXALBUMINEXALBUTEROL SULFATE HFAALCAINEALDACTAZIDEALDACTONEALEVICYN

ALEVICYN ANTIPRURITIC SGALEVICYN PLUSALFENTAALLEVYN AG ADHESIVEALTACEALTADERM CREAM BASEALTRENOALUVEAAMARYLAMBIENAMIDATEAMINOBENZOATE POTASSIUMANACAINEANALPRAM-HCANAPROX DSANDROGELANGELIQ

ANGIOCATHANTICOAGULANT SODIUM CITRATEAPPTRIMARTHROTECASCORASTAGRAF XLASTRINGYNATACANDATIVANATREVIS HYDROGELATROPINE SULFATEATROPINE SULF-NSAUGMENTINAVANDAMETAVANDIAAVAPROBACLOFEN

BACTRIMBENZAMYCINCAFERGOTCAPHOSOLCARAFATECARBATROLCARBOCAINECARDENECARDIOTEK RXCARDIOVID PLUSCARDURACARNITORCEFTINCELACYN POST PROCEDURECELEBREXCELEXACERACADE

PRODUCT NAME

PRODUCT NAME

APEX 8.2019 (continued)

PG 5

The informa�on contained herein is company confiden�al and proprietary. It should not be used for any purpose not expressly approved in wri�ng by Apex.

Tier 4(Non-Preferred Brands)

CERAMAXCETACAINECHLORPROPAMIDECICLODANCIPROCLAFORANCLAFORAN-DEXTROSECLARINEXCLOBEXCLOROTEKALCOLESTIDCOLYTECONTRAVE ERCOREGCOUMADINCOZAARCROTAMITONCURCUMINDEMADEXDEMEROLDEPAKENEDEPAKOTEDETROLDILANTINDIOVANEFFEXOR XRFELDENEFENOFIBRATEFLORIVAGABITRIL

GLUCOPHAGEGLUCOPHAGE XRGLUCOTROLGLUCOTROL XLGLUCOVANCEIMURANKEFLEXLANOXINLASIXLECITHIN SOYALEUCINELEVICYNLEXAPROLIDOCAINE HCLLIDOCAINE HCL-NSMACROBIDNAPROSYNNARDILNORVASCOVACE PLUSPAMELORPARAFON FORTE DSCPAXILPROCARDIA XLPROGRAFPROZACREGLANREJUVACARE PLUSRELAGARDREQUIP XLRETIN-A

RITALINSINEMET CRSPORANOXTAMIFLUULTANEULTRACETULTRAVATE XULTRAVISTULTRESAUMECTAUROCIT-KVALIUMVANCOMYCIN HCLVASCAZENVASOTECVAYACOGVAYARINVAYAROLVENELEXVERSAPRO LOTION BASEVERSATILEVIBRAMYCINVIRTPREXVISIPAQUEVISTARILVITATRUEVITUZVOGELXOVOLTARENVOLUMENVOSPIRE ER

WELLBUTRINWITEPSOLWP THYROIDXANAXXAQUIL XRXARTEMIS XRXENICALXERAC ACXOPENEXXOPENEX HFAXYLOCAINEYASMINYAZYOSPRALAZANABINZANAFLEXZANTAC RXZARONTINZESTORETICZESTRILZINACEFZITHROMAXZOCORZOLOFTZONATUSSZONEGRANZOVIRAXZUTRIPROZYBANZYLOPRIMZYVOX

Tier 5(Preferred Specialty)

ADVATEALPHANATEALPHANINE SDALPROLIXARALAST NPBEBULINBENEFIXCISPLATINCRIXIVANCYSTAGONCYTARABINE

EMTRIVAEPIVIR HBVFEIBA NFHELIXATE FSHEMOFIL-MHUMATE-PINTELENCEISENTRESSIXINITYKOGENATE FSKOVALTRYLEXIVA

MONOCLATE-PMONONINENEVIRAPINENOVOEIGHTNOVOSEVEN RTOBIZURPACLITAXELPAMIDRONATE DISODIUMPREZISTAPROFILNINE SDPROLASTIN CRESCRIPTOR

RETROVIRRIASTAPSELZENTRYTHROMBATE IIIUVADEXVIDEXWILATEZEMAIRAZOLEDRONIC ACID

PRODUCT NAME

PRODUCT NAME

APEX 8.2019 PG 6

The informa�on contained herein is company confiden�al and proprietary. It should not be used for any purpose not expressly approved in wri�ng by Apex.

Tier 6(Non-Preferred Specialty)

DUOPAELLENCEEPIVIRFIBRYGA

GLASSIAKALETRAKOATEKOATE-DVIMESNEX

PROFILNINEREBETOLRETROVIRRIXUBISSUSTIVA

VIRAMUNEZERITZIAGENZOLEDRONIC ACID

PRODUCT NAME