PREFERRED DRUG LIST

Page 1 of 38 Last Updated: February 1, 2018 PREFERRED drug LIST When a generic product is available, for a PREFERRED or non- PREFERRED agent, the pharmacy will receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month s publication. TABLE OF CONTENTS Inhalation Agents Page 1 - 2 Intranasal Agents Page 2 Ophthalmic Agents Page 2 - 3 Otic Agents Page 3 Oral/Injectable/Topical Agents Page 3 - 19 Index (Arranged by Brand Name) Page 20 - 33 INHALATION AGENTS Anticholinergics for the Maintenance Treatment of COPD PREFERRED Non- PREFERRED , Prior Authorization Required Spiriva Handihaler (tiotropium) Atrovent HFA (ipratropium bromide) Incruse Ellipta (umeclidinium bromide) Seebri Neohaler (glycopyrrolate) Spiriva Respimat (tiotropium) Tudorza PressAir (aclidinium) Beta2-Agonists - Long-Acting *Clinical prior authorization may apply PREFERRED Non- PREFERRED , Prior Authorization Required Serevent Diskus (salmeterol) Arcapta (indacaterol) Brovana (arformoterol) Perforomist (formoterol) Striverdi Respimat (olodaterol)

Sumaxin® Wash (sulfacetamide-sulfur) liquid . PREFERRED DRUG LIST Generic drugs and interchangeable biologic products are required when available on the market, for both preferred or non-preferred agents, unless a Brand Medical Necessity prior authorization request is approved.

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