1

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

ADHDINTUNIV guanfacine hcl (adhd)

ANTI-INFECTIVES, MISCPLAQUENIL hydroxychloroquine sulfateASTHMA / COPDACCOLATE zafirlukastADVAIR DISKUS, ADVAIR HFA, AIRDUO fluticasone-salmeterolAEROSPAN flunisolide hfaALVESCO ciclesonideANORO ELLIPTA umeclidinium-vilanterolARCAPTA NEOHALER indacaterol maleateARNUITY ELLIPTA fluticasone furoate (inhalation)ASMANEX TWISTHALER, ASMANEX HFA mometasone furoate (inhalation)ATROVENT HFA ipratropium bromide hfaBEVESPI AEROSPHERE glycopyrrolate-formoterol fumarateBREO ELLIPTA fluticasone furoate-vilanterol

Your 201990 Day Supply Drug ListBrand and/or generic may be excluded from coverage. Lower-cost options are available and covered. Brand may be excluded from coverage. Lower-cost options are available and covered.

Medications subject to change without notice. This is not a complete list of medications, and not all medications listed may be covered under your plan. Review your benefit plan documents to see what medications are covered under your plan. Where differences are noted between this list and your benefit plan documents, the benefit plan documents will govern. Please refer to myuhc.com® for information on specific drugs included in this program or call the member phone number listed on your health plan ID card.

2

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

BROVANA arformoterol tartrateCOMBIVENT RESPIMAT ipratropium-albuterolDALIRESP roflumilastDULERA mometasone furoate-formoterol fumarate dihydrateELIXOPHYLLIN, THEO-24, THEOCHRON theophyllineFLOVENT DISKUS, ARMONAIR RESPICLICK fluticasone propionate (inhalation)FLOVENT HFA fluticasone propionate hfaINCRUSE ELLIPTA umeclidinium bromideIPRATROPIUM BROMIDE ipratropium bromidePERFOROMIST formoterol fumaratePULMICORT FLEXHALER, PULMICORT budesonide (inhalation)QVAR beclomethasone dipropionateQVAR REDIHALER beclomethasone dipropionate hfaSEEBRI NEOHALER, LONHALA MAGNAIR glycopyrrolate (inhalation)SEREVENT DISKUS salmeterol xinafoateSINGULAIR montelukast sodiumSPIRIVA HANDIHALER, SPIRIVA RESPIMAT tiotropium bromide monohydrateSTRIVERDI RESPIMAT olodaterol hclSYMBICORT budesonide-formoterol fumarate dihydrateTRELEGY ELLIPTA fluticasone-umeclidinium-vilanterolTUDORZA PRESSAIR aclidinium bromideUTIBRON NEOHALER indacaterol maleate-glycopyrrolateZYFLO, ZYFLO CR zileutonBLOOD CLOT PREVENTION / STROKE PREVENTIONAGGRENOX aspirin-dipyridamoleBEVYXXA betrixaban maleateBRILINTA ticagrelorDIPYRIDAMOLE dipyridamoleEFFIENT prasugrel hclELIQUIS apixabanPLAVIX clopidogrel bisulfatePLETAL cilostazol

3

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

PRADAXA dabigatran etexilate mesylateSAVAYSA edoxaban tosylateXARELTO rivaroxabanZONTIVITY vorapaxar sulfateBLOOD DISORDERSTRENTAL TAB 400MG pentoxifyllineBLOOD GLUCOSE MONITORINGGLUCOSE BLOOD TEST STRIP glucose blood test stripCARDIOVASCULARACCUPRIL quinapril hclACCURETIC quinapril-hydrochlorothiazideACEBUTOLOL HCL acebutolol hclACEON perindopril erbumineADALAT CC, PROCARDIA, PROCARDIA XL,

NIFEDIAC CC, AFEDITAB CR, NIFEDICAL XL

nifedipine

ALDACTAZIDE spironolactone & hydrochlorothiazideALTACE ramiprilAMILORIDE HCL amiloride hclAMILORIDE/HYDROCHLOROTHIAZIDE amiloride & hydrochlorothiazideATACAND candesartan cilexetilATACAND HCT candesartan cilexetil-hydrochlorothiazideAVALIDE irbesartan-hydrochlorothiazideAVAPRO irbesartanAZOR amlodipine besylate-olmesartan medoxomilBENICAR olmesartan medoxomilBENICAR HCT olmesartan medoxomil-hydrochlorothiazideBETAPACE AF sotalol hcl (afib/afl)BETAPACE, SORINE sotalol hclBETAXOLOL HCL betaxolol hclBIDIL isosorbide dinitrate-hydralazine hclBUMEX bumetanide

4

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

BYSTOLIC nebivolol hclBYVALSON nebivolol-valsartanCADUET amlodipine besylate-atorvastatin calciumCALAN, CALAN SR, ISOPTIN SR,

VERELAN PM, VERELAN verapamil hcl

CAPTOPRIL captoprilCAPTOPRIL/HYDROCHLOROTHIAZIDE captopril & hydrochlorothiazideCARDIZEM diltiazem hclCARDIZEM LA, CARDIZEM CD,

DILTIAZEM CD, MATZIM LA, CARTIA XT diltiazem hcl coated beads

CARDURA doxazosin mesylateCAROSPIR, ALDACTONE spironolactoneCATAPRES, CATAPRES TTS clonidine hclCHLORTHALIDONE chlorthalidoneCLORPRES clonidine & chlorthalidoneCOREG carvedilolCOREG CR carvedilol phosphateCORGARD nadololCORLANOR ivabradine hclCORZIDE nadolol & bendroflumethiazideCOZAAR losartan potassiumDEMADEX torsemideDIOVAN valsartanDIOVAN HCT valsartan-hydrochlorothiazideDIURIL chlorothiazideDYAZIDE, MAXZIDE triamterene & hydrochlorothiazideDYRENIUM triamtereneEDARBI azilsartan medoxomilEDARBYCLOR azilsartan medoxomil-chlorthalidoneEDECRIN ethacrynic acidENTRESTO sacubitril-valsartanEPANED, VASOTEC enalapril maleateEPROSARTAN MESYLATE eprosartan mesylate

5

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

EXFORGE amlodipine besylate-valsartanEXFORGE HCT amlodipine-valsartan-hydrochlorothiazideFELODIPINE ER felodipineFLECAINIDE ACETATE flecainide acetateFOSINOPRIL SODIUM fosinopril sodiumFOSINOPRIL SODIUM/

HYDROCHLOROTHIAZIDE fosinopril sodium & hydrochlorothiazide

GUANFACINE HCL guanfacine hclHEMANGEOL, INDERAL LA propranolol hclHYDRALAZINE HCL hydralazine hclHYZAAR losartan potassium & hydrochlorothiazideINDAPAMIDE indapamideINNOPRAN XL, INDERAL XL propranolol hcl sustained-release beadsINSPRA eplerenoneISORDIL TITRADOSE, DILATRATE SR isosorbide dinitrateISOSORBIDE MONONITRATE, ISOSORBIDE

MONONITRATE ER isosorbide mononitrate

ISRADIPINE isradipineKAPSPARGO SPRINKLE, TOPROL XL,

FIRST METOPROLOL metoprolol succinate

LABETALOL HCL labetalol hclLANOXIN, DIGITEK, DIGOX digoxinLASIX furosemideLOPRESSOR metoprolol tartrateLOPRESSOR HCT, DUTOPROL metoprolol & hydrochlorothiazideLOTENSIN benazepril hclLOTENSIN HCT benazepril & hydrochlorothiazideLOTREL amlodipine besylate-benazepril hclMAVIK trandolaprilMETHYCLOTHIAZIDE methyclothiazideMETHYLDOPA methyldopaMETHYLDOPA/HYDROCHLOROTHIAZIDE methyldopa & hydrochlorothiazideMETOLAZONE metolazoneMEXILETINE HCL mexiletine hcl

6

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

MICARDIS telmisartanMICARDIS HCT telmisartan-hydrochlorothiazideMICROZIDE, EZIDE hydrochlorothiazideMINIPRESS prazosin hclMINOXIDIL minoxidilMOEXIPRIL HCL moexipril hclMOEXIPRIL/HYDROCHLOROTHIAZIDE moexipril-hydrochlorothiazideMULTAQ dronedarone hclNICARDIPINE HCL nicardipine hclNIMODIPINE nimodipineNITRO-DUR, NITRO-BID, NITRO-TIME,

MINITRAN nitroglycerin

NORPACE CR, NORPACE disopyramide phosphateNORVASC amlodipine besylatePACERONE amiodarone hclPINDOLOL pindololPRESTALIA perindopril arginine-amlodipine besylatePROPRANOLOL/HYDROCHLOROTHIAZIDE propranolol & hydrochlorothiazideQBRELIS, PRINIVIL, ZESTRIL lisinoprilQUINIDINE GLUCONATE quinidine gluconateQUINIDINE SULFATE quinidine sulfateRANEXA ranolazineRYTHMOL SR propafenone hclSULAR nisoldipineTARKA trandolapril-verapamil hclTEKTURNA aliskiren fumarateTEKTURNA HCT aliskiren-hydrochlorothiazideTENORETIC atenolol & chlorthalidoneTENORMIN atenololTERAZOSIN HCL terazosin hclTIAZAC, TAZTIA XT diltiazem hcl extended release beadsTIKOSYN dofetilide

7

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

TIMOLOL MALEATE timolol maleate

TRIBENZOR olmesartan medoxomil-amlodipine-hydrochlorothiazide

TWYNSTA telmisartan-amlodipineVASERETIC enalapril maleate & hydrochlorothiazideZEBETA bisoprolol fumarateZESTORETIC lisinopril & hydrochlorothiazideZIAC bisoprolol & hydrochlorothiazideCHOLESTEROL LOWERING AGENTSALTOPREV, MEVACOR lovastatinCOLESTID colestipol hclCRESTOR rosuvastatin calciumFIBRICOR fenofibric acidFLOLIPID, ZOCOR simvastatinLESCOL XL, LESCOL fluvastatin sodiumLIPITOR atorvastatin calciumLIVALO pitavastatin calciumLOFIBRA fenofibrate micronizedLOPID gemfibrozilLOVAZA, TRIKLO omega-3-acid ethyl estersNIASPAN, NIACOR niacin (antihyperlipidemic)PRAVACHOL pravastatin sodiumQUESTRAN cholestyramineQUESTRAN LIGHT, PREVALITE cholestyramine lightTRICOR, FENOGLIDE, LIPOFEN, TRIGLIDE fenofibrateTRILIPIX choline fenofibrateVASCEPA icosapent ethylVYTORIN ezetimibe-simvastatinWELCHOL colesevelam hclZETIA ezetimibeZYPITAMAG pitavastatin magnesium

8

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

CONTRACEPTIONAMETHYST levonorgestrel-ethinyl estradiol (continuous)BALCOLTRA levonorgestrel-ethinyl estradiol-ferrous bisglycinateCRYSELLE-28, ELINEST, LOW-OGESTREL,

OGESTREL norgestrel & ethinyl estradiol

CYCLESSA, VELIVET, CAZIANT, CESIA desogestrel-ethinyl estradiol (triphasic)DESOGEN, RECLIPSEN, APRI,

EMOQUETTE, ISIBLOOM, JULEBER, CYRED, SOLIA, ENSKYCE

desogestrel & ethinyl estradiol

ENPRESSE-28, MYZILRA, LEVONEST, TRIVORA-28 levonorgestrel-eth estradiol (triphasic)

ESTROSTEP FE, TRI-LEGEST FE, TILIA FE norethindrone acetate-ethinyl estradiol-feFALESSA levonorgestrel-ethinyl estradiol & folic acidFEMCON FE, GENERESS FE, LAYOLIS FE,

ZENCHENT FE, WYMZYA FE, KAITLIB FE

norethindrone & ethinyl estradiol-fe

KELNOR, ZOVIA ethynodiol diacet & eth estradLESSINA, PORTIA-28, AVIANE, ORSYTHIA,

VIENVA, ALTAVERA, FALMINA, AUBRA, CHATEAL, AUBRA EQ, CHATEAL EQ, DELYLA, LUTERA, LEVORA 0.15/30-28, SRONYX, MARLISSA, KURVELO, LARISSIA, LILLOW

levonorgestrel & eth estradiol

LO LOESTRIN FE norethindrone acetate-ethinyl estradiol-fe fum (biphasic)

LOESTRIN 1.5/30-21, LOESTRIN 1/20-21, JUNEL 1/20, JUNEL 1.5/30, LARIN 1.5/30, LARIN 1/20, MICROGESTIN 1/20, MICROGESTIN 1.5/30

norethindrone acet & eth estra

MIRCETTE, KARIVA, KIMIDESS, PIMTREA, AZURETTE, VIORELE, BEKYREE desogestrel-ethinyl estradiol (biphasic)

NATAZIA estradiol valerate-dienogestNECON 1/50-28 norethindrone & mestranolNECON 10/11-28 norethindrone-eth estradiol (biphasic)NUVARING etonogestrel-ethinyl estradiol

9

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

ORTHO MICRONOR, DEBLITANE, SHAROBEL, LYZA, TULANA, NORLYROC ,ERRIN, CAMILA, NORA-BE, JOLIVETTE, HEATHER, INCASSIA, JENCYCLA, NORLYDA

norethindrone

ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO, TRI-LO-SPRINTEC, TRI-SPRINTEC, TRI-PREVIFEM, TRI-ESTARYLLA, TRI-LO-ESTARYLLA, TRI-LINYAH, TRINESSA, TRI-VYLIBRA, TRINESSA LO, TRI-LO-MARZIA, TRI FEMYNOR, TRI-MILI

norgestimate-ethinyl estradiol (triphasic)

ORTHO-CYCLEN, SPRINTEC 28, PREVIFEM, ESTARYLLA, MONO-LINYAH, VYLIBRA, MONONESSA, MILI, FEMYNOR

norgestimate-ethinyl estradiol

ORTHO-NOVUM 7/7/7, TRI-NORINYL 28, NORTREL 7/7/7, ARANELLE, CYCLAFEM 7/7/7, DASETTA 7/7/7, LEENA, NECON 7/7/7, ALYACEN 7/7/7, PIRMELLA 7/7/7

norethindrone-eth estradiol (triphasic)

OVCON-35, ORTHO-NOVUM 1/35, BREVICON-28, NORINYL 1+35, ZENCHENT, NORTREL 0.5/35 (28), NORTREL 1/35, BALZIVA, GILDAGIA, CYCLAFEM 1/35, PHILITH, DASETTA 1/35, WERA, NECON 1/35, NECON 0.5/35-28, ALYACEN 1/35, VYFEMLA, PIRMELLA 1/35, BRIELLYN

norethindrone & eth estradiol

SAFYRAL, BEYAZ, RAJANI, TYDEMY drospirenone-ethinyl estradiol-levomefolate calciumSEASONIQUE, LOSEASONIQUE,

QUARTETTE, CAMRESE, RIVELSA, CAMRESE LO, LEVONORGESTREL/ETHINYL ESTRADIOL, LEVONORGESTREL AND ETHINYL ESTRADIOL, JOLESSA, INTROVALE, SETLAKIN, AMETHIA LO, AMETHIA, QUASENSE, ASHLYNA, DAYSEE, FAYOSIM

levonorgestrel-ethinyl estradiol (91-day)

10

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

TAYTULLA, MINASTRIN 24 FE, LOESTRIN FE 1/20, LOESTRIN FE 1.5/30, JUNEL FE 24, JUNEL FE 1/20, JUNEL FE 1.5/30, LARIN FE 1.5/30, LARIN FE 1/20, LARIN 24 FE, TARINA FE 1/20, MICROGESTIN FE, MICROGESTIN FE 1.5/30, MICROGESTIN 24 FE, GILDESS FE 1/20, GILDESS FE 1.5/30, LOMEDIA 24 FE, BLISOVI 24 FE, BLISOVI FE 1/20, BLISOVI FE 1.5/30, MIBELAS 24 FE, MELODETTA 24 FE

norethin acet & estrad-fe

XULANE norelgestromin-ethinyl estradiolYAZ, YASMIN 28, GIANVI, OCELLA,

LORYNA, SYEDA, ZARAH, VESTURA, NIKKI

drospirenone-ethinyl estradiol

COUGH AND COLDSSKI potassium iodide (expectorant)DEMENTIAARICEPT donepezil hydrochlorideEXELON rivastigmineNAMENDA, NAMENDA XR memantine hclNAMZARIC memantine hcl-donepezil hclRAZADYNE ER, RAZADYNE galantamine hydrobromideRIVASTIGMINE TARTRATE rivastigmine tartrateDEPRESSIONAPLENZIN bupropion hydrobromideCELEXA citalopram hydrobromideCYMBALTA duloxetine hclDESVENLAFAXINE ER desvenlafaxine fumarateEFFEXOR XR, EFFEXOR venlafaxine hclFETZIMA levomilnacipran hclFLUVOXAMINE MALEATE, FLUVOXAMINE

MALEATE ER fluvoxamine maleate

FORFIVO XL, WELLBUTRIN SR, WELLBUTRIN XL bupropion hcl

KHEDEZLA desvenlafaxine

11

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

LEXAPRO escitalopram oxalateMAPROTILINE HCL maprotiline hclNEFAZODONE HCL nefazodone hclPAXIL, PAXIL CR paroxetine hclPEXEVA paroxetine mesylatePRISTIQ desvenlafaxine succinatePROZAC WEEKLY, PROZAC fluoxetine hclREMERON, REMERON SOLTAB mirtazapineTRAZODONE HCL trazodone hclTRINTELLIX vortioxetine hbrVIIBRYD vilazodone hclZOLOFT sertraline hclDIABETESACTOPLUS MET XR, ACTOPLUS MET pioglitazone hcl-metformin hclACTOS pioglitazone hclADLYXIN lixisenatideAMARYL glimepirideAPIDRA, APIDRA SOLOSTAR insulin glulisineBASAGLAR KWIKPEN, TOUJEO SOLOSTAR,

TOUJEO MAX SOLOSTAR, LANTUS SOLOSTAR, LANTUS

insulin glargine

BYETTA, BYDUREON exenatideCHLORPROPAMIDE chlorpropamideCYCLOSET bromocriptine mesylate (diabetes)DUETACT pioglitazone hcl-glimepirideGLIPIZIDE/METFORMIN HCL glipizide-metformin hclGLUCOPHAGE, GLUCOPHAGE XR,

FORTAMET, GLUMETZA, RIOMET metformin hcl

GLUCOTROL XL, GLUCOTROL glipizideGLUCOVANCE glyburide-metforminGLYBURIDE glyburideGLYNASE glyburide micronizedGLYSET miglitol

12

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

GLYXAMBI empagliflozin-linagliptinHUMALOG MIX 75/25, HUMALOG MIX

50/50, HUMALOG MIX 75/25 KWIKPEN, HUMALOG MIX 50/50 KWIKPEN

insulin lispro protamine & lispro

HUMALOG, HUMALOG JUNIOR KWIKPEN, HUMALOG KWIKPEN, ADMELOG, ADMELOG SOLOSTAR

insulin lispro

INVOKAMET, INVOKAMET XR canagliflozin-metformin hclINVOKANA canagliflozinJANUMET XR, JANUMET sitagliptin-metformin hclJANUVIA sitagliptin phosphateJARDIANCE empagliflozinJENTADUETO, JENTADUETO XR linagliptin-metformin hclKAZANO alogliptin-metformin hclKOMBIGLYZE XR saxagliptin-metformin hclLEVEMIR, LEVEMIR FLEXTOUCH insulin detemirNESINA alogliptin benzoateNOVOLIN 70/30, HUMULIN 70/30,

HUMULIN 70/30 KWIKPEN, NOVOLIN 70/30 RELION

insulin nph isophane & reg (human)

NOVOLIN N, HUMULIN N, HUMULIN N KWIKPEN, NOVOLIN N RELION, NOVOLIN N U-100

insulin nph (human) (isophane)

NOVOLIN R, RELION R, HUMULIN R, HUMULIN R U-500 (CONCENTRATED), HUMULIN R U-500 KWIKPEN, NOVOLIN R RELION, AFREZZA

insulin regular (human)

NOVOLOG MIX 70/30, NOVOLOG MIX 70/30 PREFILLED FLEXPEN insulin aspart protamine & aspart (human)

NOVOLOG, FIASP, FIASP FLEXTOUCH, NOVOLOG PENFILL, NOVOLOG FLEXPEN

insulin aspart

ONGLYZA saxagliptin hclOSENI alogliptin-pioglitazoneOZEMPIC semaglutidePRANDIN repaglinide

13

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

PRECOSE acarboseQTERN dapagliflozin-saxagliptinREPAGLINIDE/METFORMIN

HYDROCHLORIDE repaglinide-metformin hcl

SEGLUROMET ertugliflozin-metformin hclSOLIQUA 100/33 insulin glargine-lixisenatideSTARLIX nateglinideSTEGLATRO ertugliflozin l-pyroglutamic acidSTEGLUJAN ertugliflozin-sitagliptinSYMLINPEN pramlintide acetateSYNJARDY, SYNJARDY XR empagliflozin-metformin hclTANZEUM albiglutideTOLAZAMIDE tolazamideTOLBUTAMIDE tolbutamideTRADJENTA linagliptinTRESIBA FLEXTOUCH insulin degludecTRULICITY dulaglutideVICTOZA liraglutideXIGDUO XR dapagliflozin-metformin hclXULTOPHY 100/3.6 insulin degludec-liraglutideDIABETIC SUPPLIESBLOOD GLUCOSE CALIBRATION blood glucose calibrationLANCETS lancetsENDOCRINE AND METABOLICDEMSER metyrosineDIBENZYLINE phenoxybenzamine hclPROGLYCEM diazoxideROCALTROL calcitriolGASTROINTESTINAL, MISCAMITIZA lubiprostoneLEVBID, SYMAX-SR, OSCIMIN SR hyoscyamine sulfateLINZESS linaclotide

14

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

LOTRONEX alosetron hclMOTEGRITY prucalopride succinateMOVANTIK naloxegol oxalateRELISTOR methylnaltrexone bromideSYMPROIC naldemedine tosylateTRULANCE plecanatideVIBERZI eluxadolineZENPEP, CREON, PANCREAZE, VIOKACE,

PERTZYE pancrelipase (lipase-protease-amylase)

GLAUCOMAALPHAGAN P brimonidine tartrateDIAMOX acetazolamideIOPIDINE apraclonidine hclISOPTO CARPINE pilocarpine hclLUMIGAN bimatoprostNEPTAZANE methazolamideRHOPRESSA netarsudil dimesylateROCKLATAN netarsudil dimesylate-latanoprostSIMBRINZA brinzolamide-brimonidine tartrateTRAVATAN Z travoprostVYZULTA latanoprostene bunodXALATAN latanoprostZIOPTAN tafluprostGOUTCOLCRYS, MITIGARE colchicineDUZALLO lesinurad-allopurinolPROBENECID probenecidPROBENECID/COLCHICINE colchicine w/ probenecidULORIC febuxostatZURAMPIC lesinuradZYLOPRIM allopurinol

15

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

HORMONE MODIFYING AGENTSEVISTA raloxifene hclOSPHENA ospemifeneHYPERTHYROIDISMPROPYLTHIOURACIL propylthiouracilTAPAZOLE methimazoleINFLAMMATORY CONDITIONSARAVA leflunomideAZULFIDINE, AZULFIDINE EN sulfasalazineDELZICOL, ROWASA, APRISO, PENTASA,

CANASA, ASACOL HD, LIALDA mesalamine

DIPENTUM olsalazine sodiumGIAZO, COLAZAL balsalazide disodiumRIDAURA auranofinROWASA mesalamine w/ cleanserINSOMNIAPHENOBARBITAL phenobarbitalIV ADMINISTRATION SUPPLIESINSULIN PEN NEEDLE insulin pen needleINSULIN SYRINGES insulin syringesKIDNEY DISEASEAURYXIA ferric citrateFOSRENOL lanthanum carbonatePHOSLYRA, PHOSLO, CALPHRON,

ELIPHOS calcium acetate (phosphate binder)

RENAGEL sevelamer hclRENVELA sevelamer carbonateVELPHORO sucroferric oxyhydroxideMALE AND FEMALE HORMONE REPLACEMENTANDROXY fluoxymesteroneANGELIQ drospirenone-estradiolAYGESTIN norethindrone acetateBIJUVA estradiol-progesterone

16

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

CLIMARA PRO estradiol-levonorgestrelCOMBIPATCH, ACTIVELLA, MIMVEY LO,

MIMVEY, AMABELZ, LOPREEZA estradiol & norethindrone acetate

COVARYX, COVARYX HS, EEMT, EEMT HS esterified estrogens & methyltestosteroneDUAVEE conjugated estrogens-bazedoxifeneESTRING, IMVEXXY, VAGIFEM, ESTRACE,

YUVAFEM estradiol vaginal

ESTROPIPATE estropipateEVAMIST, ESTROGEL, MENOSTAR, ALORA,

DIVIGEL, MINIVELLE, VIVELLE-DOT, ESTRACE, CLIMARA, ESTRADIOL

estradiol

FEMHRT LOW DOSE, JINTELI, JEVANTIQUE LO, FYAVOLV norethindrone acetate-ethinyl estradiol

FEMRING estradiol acetate vaginalMENEST esterified estrogensMETHITEST, TESTRED, ANDROID methyltestosteronePREFEST estradiol-norgestimatePREMARIN estrogens, conjugatedPREMARIN estrogens, conjugated vaginalPREMPRO, PREMPHASE conjugated estrogens-medroxyprogesterone acetatePROMETRIUM progesterone micronizedPROVERA medroxyprogesterone acetateSTRIANT, ANDROGEL, ANDRODERM,

VOGELXO testosterone

MISC THROAT PRODUCTSEVOXAC cevimeline hclSALAGEN pilocarpine hcl (oral)MISC WOMEN’S HEALTHBRISDELLE paroxetine mesylate (vasomotor)INTRAROSA prasterone vaginalNEUROLOGICGRALISE gabapentin (once-daily)HORIZANT gabapentin enacarbilLYRICA CR pregabalin (once-daily)

17

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

SAVELLA milnacipran hclNEUROMUSCULAR DISORDERSMESTINON, MESTINON TIMESPAN pyridostigmine bromideONCOLOGYARIMIDEX anastrozoleAROMASIN exemestaneFARESTON toremifene citrateFEMARA letrozoleSOLTAMOX tamoxifen citrateOPTHALAMIC AGENTSAZOPT brinzolamideBETAGAN levobunolol hclBETIMOL timololBETOPTIC-S betaxolol hcl (ophth)CARTEOLOL HCL carteolol hcl (ophth)COMBIGAN brimonidine tartrate-timolol maleateCOSOPT PF, COSOPT dorzolamide hcl-timolol maleateMETIPRANOLOL metipranololTIMOPTIC OCUDOSE, ISTALOL, TIMOPTIC,

TIMOPTIC-XE timolol maleate (ophth)

TRUSOPT dorzolamide hclOSTEOPOROSISACTONEL, ATELVIA risedronate sodiumBINOSTO, FOSAMAX alendronate sodiumBONIVA ibandronate sodiumETIDRONATE DISODIUM etidronate disodiumFOSAMAX PLUS D alendronate sodium-cholecalciferolOVERACTIVE BLADDER / INCONTINENCEDETROL, DETROL LA tolterodine tartrateENABLEX darifenacin hydrobromideFLAVOXATE HCL flavoxate hclGELNIQUE, DITROPAN XL oxybutynin chloride

18

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

MYRBETRIQ mirabegronOXYTROL FOR WOMEN, OXYTROL oxybutyninTOVIAZ fesoterodine fumarateTROSPIUM CHLORIDE trospium chlorideVESICARE solifenacin succinatePARKINSON'S DISEASEAZILECT rasagiline mesylateBENZTROPINE MESYLATE benztropine mesylateCOMTAN entacaponeINBRIJA levodopa inhal powder capLODOSYN carbidopaMIRAPEX, MIRAPEX ER pramipexole dihydrochlorideNEUPRO rotigotineOSMOLEX ER, GOCOVRI amantadine hclPARLODEL bromocriptine mesylateREQUIP XL, REQUIP ropinirole hydrochlorideRYTARY, SINEMET, SINEMET CR carbidopa-levodopaSTALEVO carbidopa-levodopa-entacaponeTASMAR tolcaponeTRIHEXYPHENIDYL HCL trihexyphenidyl hclXADAGO safinamide mesylateZELAPAR, ELDEPRYL selegiline hclPREMENSTRUAL DYSPHORIC DISORDERSARAFEM fluoxetine hcl (pmdd)PROSTATIC HYPERTROPHYAVODART dutasterideCARDURA XL doxazosin mesylate (bph)FLOMAX tamsulosin hclJALYN dutasteride-tamsulosin hclPROSCAR finasterideRAPAFLO silodosinUROXATRAL alfuzosin hcl

19

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

SEIZURE DISORDERSAPTIOM eslicarbazepine acetateBANZEL rufinamideBRIVIACT brivaracetamCELONTIN methsuximideDEPAKENE valproate sodiumDEPAKENE valproic acidDEPAKOTE ER, DEPAKOTE SPRINKLES,

DEPAKOTE divalproex sodium

DILANTIN phenytoinDILANTIN, PHENYTEK phenytoin sodium extendedFELBATOL felbamateGABITRIL tiagabine hclKLONOPIN clonazepamLAMICTAL CHEWABLE DISPERSIBLE,

LAMICTAL, LAMICTAL XR, LAMICTAL ODT

lamotrigine

LYRICA pregabalinMYSOLINE primidoneNEURONTIN gabapentinOXTELLAR XR, TRILEPTAL oxcarbazepinePEGANONE ethotoinPOTIGA ezogabineSPRITAM, KEPPRA, KEPPRA XR levetiracetamTEGRETOL, TEGRETOL-XR, CARBATROL,

EPITOL carbamazepine

TROKENDI XR, QUDEXY XR, TOPAMAX, TOPAMAX SPRINKLE topiramate

VIMPAT lacosamideZARONTIN ethosuximideZONEGRAN zonisamide

20

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

THYROID REPLACEMENTARMOUR THYROID, NATURE-THROID, WP

THYROID, WESTHROID thyroid

CYTOMEL liothyronine sodiumTIROSINT, SYNTHROID, UNITHROID

DIRECT, LEVO-T, LEVOXYL, UNITHROID levothyroxine sodium

ULCER/ACID REFLUX/GERDACIPHEX rabeprazole sodiumAXID nizatidineCARAFATE sucralfateCIMETIDINE HCL cimetidine hclCYTOTEC misoprostolDEXILANT dexlansoprazoleESOMEPRAZOLE STRONTIUM esomeprazole strontiumNEXIUM, NEXIUM 24HR esomeprazole magnesiumPEPCID AC MAXIMUM STRENGTH, PEPCID famotidinePREVACID 24HR, PREVACID SOLUTAB,

PREVACID lansoprazole

PRILOSEC omeprazolePRILOSEC omeprazole magnesiumPROTONIX pantoprazole sodiumTAGAMET cimetidineZANTAC ranitidine hclZEGERID, OMEPPI omeprazole-sodium bicarbonateVITAMINS, MINERALS, ELECTROLYTESDRISDOL, VITAMIN D ergocalciferolEFFER-K potassium bicarbonate-citric acidEFFERVESCENT POTASSIUM/CHLORIDE potassium bicarb & chlorideFOLIC ACID folic acidK-EFFERVESCENT, K-VESCENT, K-PRIME,

KLOR-CON/EF potassium bicarbonate

KLOR-CON M15, KLOR-CON M10, KLOR-CON M20 potassium chloride microencapsulated crystals er

K-PHOS potassium phosphate monobasic

21

90 Day Supply Drug ListEffective 07-01-19

Brand Drug Name Generic Drug Name

K-PHOS NEUTRAL, PHOSPHO-TRIN, PHOSPHA

pot phosphate monobasic w/ sod phosphate dibasic & monobasi

K-TAB, MICRO-K, KLOR-CON, KLOR-CON 10, KLOR-CON 8, KLOR-CON/25, KLOR-CON SPRINKLE

potassium chloride

NASCOBAL cyanocobalaminPOTASSIUM GLUCONATE ER potassium gluconate