name.

1 Search Tip: This is a large document, but you can search quickly and easily by clicking on the binocular icon on your toolbar. It will then display a search box for you to type in the name of the drug you want to locate. If you do not know the correct spelling, you can start your search by entering just the first few letters of the IndexSpecial CodeTierCategoryDrug NameLast Updated 2/1/2019 Sendero Exchange FormularyDERMATOLOGICALS2-8-MOP CAPANTIVIRALS2-abacavir soln (ZIAGEN equiv)ANTIVIRALS2-abacavir tab (ZIAGEN equiv)ANTIVIRALSSP-abacavir/lamivudine tab (EPZICOM equiv)ANTIVIRALS2-abacavir/lamivudine/zi dovudine tab (TRIZIVIR equiv)ANTIPSYCHOTICS / ANTIMANIC AGENTS3PA-QLABILIFY DISCMELT (QL= 2 tabs/day)ANTIPSYCHOTICS / ANTIMANIC AGENTSNC-ABILIFY MYCITE TABANTIPSYCHOTICS / ANTIMANIC AGENTS3 PAABILIFY SOLNANTIPSYCHOTICS / ANTIMANIC AGENTS3-ABILIFY TABANTINEOPLASTICS AND ADJUNCTIVE THERAPIESSPLMSP-PA-SFabiraterone tab 250mg (ZYTIGA equiv)

2 DERMATOLOGICALSNC-ABSORICA CAPANALGESICS - OPIOID3PA-QLABSTRAL SL TAB (QL= 120 tabs/30 days)NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS INFI nfertilityLDLimited DistributionLMSPL umicera Mandatory Specialty Pharmacy ProgramMMedical BenefitMSPM andatory Specialty Pharmacy ProgramOTCOver-the-CounterPAPrior AuthorizationQLQuantity LimitRSRestricted to SpecialistSFLimited to two 15 day fills per month for first 3 monthsSMKGS moking CessationSPAvailable through Specialty Pharmacy ProgramSTStep TherapyVACV accine ProgramCoverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims transaction processing.** Products listed may not be all inclusive and are subject to 1 of 489 Alphabetical IndexSpecial CodeTierCategoryDrug NameLast Updated 2/1/2019 Sendero Exchange Formulary Cont.

3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - calcium DR tab (CAMPRAL equiv)ANTIDIABETICS1-acarbose tab (PRECOSE equiv)ANTIASTHMATIC AND BRONCHODILATOR AGENTS3-ACCOLATE TABMEDICAL DEVICES AND SUPPLIES$0 OTCACCU-CHECK GUIDE CARE METERMEDICAL DEVICES AND SUPPLIES$0 OTCACCU-CHEK AVIVA PLUS METERDIAGNOSTIC PRODUCTS2 OTCACCU-CHEK AVIVA PLUS TEST STRIPDIAGNOSTIC PRODUCTS2 OTCACCU-CHEK GUIDE TEST STRIPMEDICAL DEVICES AND SUPPLIES$0 OTCACCU-CHEK NANO METERDIAGNOSTIC PRODUCTS2 OTCACCU-CHEK SMARTVIEW TEST STRIPDIAGNOSTIC PRODUCTS2 OTCACCU-CHEK TEST STRIPANTIASTHMATIC AND BRONCHODILATOR AGENTS3-ACCUNEB NEB SOLNANTIHYPERTENSIVES3-ACCUPRIL TABANTIHYPERTENSIVES3-ACCURETIC TABBETA BLOCKERS1-acebutolol cap (SECTRAL equiv)ANTIHYPERTENSIVES3-ACEON TABNC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS INFI nfertilityLDLimited DistributionLMSPL umicera Mandatory Specialty Pharmacy ProgramMMedical BenefitMSPM andatory Specialty Pharmacy ProgramOTCOver-the-CounterPAPrior AuthorizationQLQuantity LimitRSRestricted to SpecialistSFLimited to two 15 day fills per month for first 3 monthsSMKGS moking CessationSPAvailable through Specialty Pharmacy ProgramSTStep TherapyVACV accine ProgramCoverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims transaction processing.

4 ** Products listed may not be all inclusive and are subject to 2 of 489 Alphabetical IndexSpecial CodeTierCategoryDrug NameLast Updated 2/1/2019 Sendero Exchange Formulary Cont. ANALGESICS - OPIOID2-acetaminophen/caffeine/dihydroco deine tab (PANLOR SS equiv)ANALGESICS - OPIOID1-acetaminophen/codeine solnANALGESICS - OPIOID1-acetaminophen/codeine tab (TYLENOL/CODEINE equiv)MIGRAINE PRODUCTSNC-ACETAMINOPHEN/ISOMETHEPTENE/D ICHLORAL CAPMIGRAINE PRODUCTSNC-acetaminophen/isometheptene/d ichloral cap (MIDRIN equiv)OTIC AGENTS3-ACETASOL HC OTIC SOLNDIURETICS2-acetazolamide ER cap (DIAMOX SEQUEL equiv)DIURETICS2-acetazolamide tabOTIC AGENTS1-acetic acid otic soln (VOSOL equiv)OTIC AGENTS1-ACETIC ACID/ALUMINUM ACETATE OTIC SOLNOTIC AGENTS1-acetic acid/hydrocortisone otic soln (VOSOL HC equiv)COUGH / COLD / ALLERGY1-acetylcysteine soln (MUCOMYST equiv)

5 VAGINAL PRODUCTS2-ACIDIC VAGINAL JELLYULCER DRUGSNC-ACIPHEX SPRINKLE CAPULCER DRUGSNC-ACIPHEX TABDERMATOLOGICALS2-acitretin cap (SORIATANE equiv)DERMATOLOGICALS3-ACLOVATE CREAMDERMATOLOGICALS3-ACLOVATE OINTNC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS INFI nfertilityLDLimited DistributionLMSPL umicera Mandatory Specialty Pharmacy ProgramMMedical BenefitMSPM andatory Specialty Pharmacy ProgramOTCOver-the-CounterPAPrior AuthorizationQLQuantity LimitRSRestricted to SpecialistSFLimited to two 15 day fills per month for first 3 monthsSMKGS moking CessationSPAvailable through Specialty Pharmacy ProgramSTStep TherapyVACV accine ProgramCoverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims transaction processing.

6 ** Products listed may not be all inclusive and are subject to 3 of 489 Alphabetical IndexSpecial CodeTierCategoryDrug NameLast Updated 2/1/2019 Sendero Exchange Formulary Cont. ANALGESICS - ANTI-INFLAMMATORYSPLMSP-PA-QLACTEMRA ACTPEN INJ (QL= 2 inj/28 days)ANALGESICS - ANTI-INFLAMMATORYMMACTEMRA IV INJANALGESICS - ANTI-INFLAMMATORYSPLMSP-PA-QLACTEMRA SC INJ (QL= 2 inj/28 days)TETRACYCLINESNC-ACTICLATE TAB 75MG, 150 MGGASTROINTESTINAL AGENTS - CAPANTINEOPLASTICS AND ADJUNCTIVE THERAPIESSPLD-PAACTIMMUNE INJ (Only available through Walgreens 888-347-3416)ANALGESICS - OPIOID3PA-QLACTIQ LOZENGE (QL= 120 units/30 days)ESTROGENS3-ACTIVELLA TABENDOCRINE AND METABOLIC AGENTS - TABANTIDIABETICSNC-ACTOPLUS MET TABANTIDIABETICS3-ACTOPLUS MET XR TABANTIDIABETICS3-ACTOS TABOPHTHALMIC AGENTS3-ACULAR (LS) OPHTH SOLNOPHTHALMIC AGENTS3-ACUVAIL OPHTH SOLNANTIVIRALS1-acyclovir cap (ZOVIRAX equiv)DERMATOLOGICALS2-acyclovir oint (ZOVIRAX OINT equiv)

7 ANTIVIRALS1-acyclovir susp (ZOVIRAX equiv)NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS INFI nfertilityLDLimited DistributionLMSPL umicera Mandatory Specialty Pharmacy ProgramMMedical BenefitMSPM andatory Specialty Pharmacy ProgramOTCOver-the-CounterPAPrior AuthorizationQLQuantity LimitRSRestricted to SpecialistSFLimited to two 15 day fills per month for first 3 monthsSMKGS moking CessationSPAvailable through Specialty Pharmacy ProgramSTStep TherapyVACV accine ProgramCoverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims transaction processing.** Products listed may not be all inclusive and are subject to 4 of 489 Alphabetical IndexSpecial CodeTierCategoryDrug NameLast Updated 2/1/2019 Sendero Exchange Formulary Cont.

8 ANTIVIRALS1-acyclovir tab (ZOVIRAX equiv)DERMATOLOGICALSNC-ACZONE GELDERMATOLOGICALSNC-ACZONE GEL MISCMMADAGEN INJCALCIUM CHANNEL BLOCKERS3-ADALAT CC TABDERMATOLOGICALS2 PAadapalene cream (DIFFERIN equiv) (Acne Only members age 35 or older require Prior Authorization)DERMATOLOGICALS2 PAadapalene gel (DIFFERIN equiv) (Acne Only members age 35 or older require Prior Authorization)DERMATOLOGICALS2 PAADAPALENE LOTION (Acne Only members age 35 or older require Prior Authorization)DERMATOLOGICALS2 PAadapalene/benzoyl peroxide gel (EPIDUO equiv) (Acne Only members age 35 or older require Prior Authorization)ANTIPSYCHOTICS / ANTIMANIC AGENTSNC-ADASUVE INHALERDERMATOLOGICALSNC-ADAZIN CREAMCARDIOVASCULAR AGENTS - TABADHD / ANTI-NARCOLEPSY / ANTI-OBESITY / ANOREXIANTS3-ADDERALL TABNC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS INFI nfertilityLDLimited DistributionLMSPL umicera Mandatory Specialty Pharmacy ProgramMMedical BenefitMSPM andatory Specialty Pharmacy ProgramOTCOver-the-CounterPAPrior AuthorizationQLQuantity LimitRSRestricted to SpecialistSFLimited to two 15 day fills per month for first 3 monthsSMKGS moking CessationSPAvailable through Specialty Pharmacy ProgramSTStep TherapyVACV accine ProgramCoverage of medications, including those not otherwise identified by qualifiers such as QL.

9 May be subject to safety screenings and other clinical edits in the course of claims transaction processing.** Products listed may not be all inclusive and are subject to 5 of 489 Alphabetical IndexSpecial CodeTierCategoryDrug NameLast Updated 2/1/2019 Sendero Exchange Formulary Cont. ADHD / ANTI-NARCOLEPSY / ANTI-OBESITY / ANOREXIANTS2-ADDERALL XR CAPPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - TABANTIVIRALSSPLMSP adefovir dipivoxil tab (HEPSERA equiv)CARDIOVASCULAR AGENTS - TAB (QL= 3 tabs/day; Only available through Accredo 888-773-7376)ANTIDIABETICSNC-ADLYXIN INJTETRACYCLINESNC-ADOXA PAKTETRACYCLINES3-ADOXA TABVASOPRESSORSNC-ADRENACLICK INJ, EPINEPHRINE INJANTIASTHMATIC AND BRONCHODILATOR AGENTS2-ADVAIR DISKUS INHALERANTIASTHMATIC AND BRONCHODILATOR AGENTS2-ADVAIR HFA INHALERANTIHYPERLIPIDEMICSNC-ADVICOR TABNC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS INFI nfertilityLDLimited DistributionLMSPL umicera Mandatory Specialty Pharmacy ProgramMMedical BenefitMSPM andatory Specialty Pharmacy ProgramOTCOver-the-CounterPAPrior AuthorizationQLQuantity LimitRSRestricted to SpecialistSFLimited to two 15 day fills per month for first 3 monthsSMKGS moking CessationSPAvailable through Specialty Pharmacy ProgramSTStep TherapyVACV accine ProgramCoverage of medications.

10 Including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims transaction processing.** Products listed may not be all inclusive and are subject to 6 of 489 Alphabetical IndexSpecial CodeTierCategoryDrug NameLast Updated 2/1/2019 Sendero Exchange Formulary Cont. ADHD / ANTI-NARCOLEPSY / ANTI-OBESITY / ANOREXIANTSNC-ADZENYS XR TABANTI-INFECTIVE AGENTS - TABMEDICAL DEVICES AND SUPPLIES2 OTCAEROCHAMBERMEDICAL DEVICES AND SUPPLIES2-AEROCHAMBER SUPPLIESANTIASTHMATIC AND BRONCHODILATOR AGENTSNC-AEROSPAN HFA INHALERANTINEOPLASTICS AND ADJUNCTIVE THERAPIESSPLMSP-PA-QL-SFAFINITOR DISPERZ (QL= 1 tab/day)ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESSPLMSP-PA-QL-SFAFINITOR TAB (QL= 1 tab/day)VACCINES$0 VACAFLURIA INJVACCINES$0 VACAFLURIA INJ, FLUZONE INJHEMATOLOGICAL AGENTS - KITHEMATOLOGICAL AGENTS - CAPNC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS INFI nfertilityLDLimited DistributionLMSPL umicera Mandatory Specialty Pharmacy ProgramMMedical BenefitMSPM andatory Specialty Pharmacy ProgramOTCOver-the-CounterPAPrior AuthorizationQLQuantity LimitRSRestricted to SpecialistSFLimited to two 15 day fills per month for first 3 monthsSMKGS moking CessationSPAvailable through Specialty Pharmacy ProgramSTStep TherapyVACV accine ProgramCoverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims transaction processing.