Prescription Drug Listing - Horizon NJ Health

1 A Formulary is alist of approvedmedications coveredby Horizon NJ Health Y ou can haveprescriptions filledat any note that Horizon NJ Health maximum days supply limit is 30 Drug NJ Health wants to make sure you are getting the Health care you need. Very often, that Health care may include Prescription drugs. Most Prescription and non- Prescription (over-the-counter) drugs are covered at no cost, or low cost to you, as long as your doctor orders them and they are listed on our Formulary. A committee of doctorsand pharmacists reviews the list of drugs on our formulary to make sure that the drugs are safe and effective. If your doctor decides that you must have a drug that is not included in the Prescription Drug List (Formulary) or your drug needs pre-approval, including a brand name medication exception, he or she can call and ask for special permission for you to get the drug.

2 Your doctor can call the Horizon NJ Health Pharmacy Department at a pharmacy near you, visit our Provider Directory at or call Member Services toll free at1-800-682-9090. People with hearing or speech difficulties cancall our TTY/TDD service at and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey, each an independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies. 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey Brand name drugs@Needs pre-approval or other limitations applyYOMeans years old *Limitations apply (quantity, age) Subject to Step Therapy of first-line agentsSome members may have their HIV/AIDS medications covered through the AIDS Drug Distribution Program (ADDP).

3 Vitamin A derivatives are considered noncovered pharmacy benefits for members 35 years of age and older. 1 of 7 December 2017A abacavir@* abacavir/ lamivudine@* ABILIFY MAINTENA* ABREVA* acarbose@* acebutolol* acetasol acetasol hc acetazolamide acetic acid acetylcysteine acid jelly ACTHAR HP @ ACULAR LS* acyclovir capsule, tablet, oral suspension, powder, vial* acyclovir ointment @* ADACEL @* ADCIRCA* ADVICOR* ADVIL COLD AND SINUS AFINITOR@* AFINITOR DISPERSZ@* AGGRENOX* AGRYLIN AIRDUO* (generic only) AKINETON AKNE-MYCIN alavert* ALAWAY* ALBENZA albuterol* alclometasone* alendronate* alfuzosin* ALKERAN allopurinol ALOCRIL Alogliptin@* Alogliptin/ metformin* Alogliptin/ pioglitazone@* alprazolam amantadine AMBISOME@ amidrine amiloride amiloride/ hydrochloro- thiazide aminocaproic acid aminophylline* amiodarone AMITIZA @* amitriptyline amlodipine* amlodipine/ benazepril* ammonium lactate* amoxapine* amoxicillin* amoxacillin/ clavulanate* amphetamine- dextro- amphetamine.

4 ER@* amphotericin ampicillin AMPYRA* ANA-KIT ANADROL-50 antipyrene/ benzocaine acetaminophen/ codeine* apri* apraclonidine APRISO ER* APTIVUS@* aquatab d ARCALYST @* ARICEPT 5mg/10mg* ARIMIDEX @* aripiprazole* aripiprazole ODT* ARIXTRA* AROMASIN @ aspirin/codeine* aspirin ASMANEX TWISTHALER/HFA* ASSESS* atenolol/chlorthalidone atomoxetine* atorvastatin* ATRIPLA@* atropine sulfate ATROVENT HFA* atovaquone/proguanil augmented betamethasone cream* AUGMENTIN XR* aurodex* AVANDARYL@* AVANDIA@* AVANDAMET* AVASTIN @ AVC aviane* AVONEX @* AXID AR (OTC)* aygestin* AZACTAM @ azathioprine azelastine nasal spray* azithromycin* B b-c/folic b-complex bacitracin/neomycin/ polymyxin* bacitracin baclofen BASAGLAR KWIKPEN* belladonna/opium bellamine-s bencort BENLYSTA@ benzonatate( 11YO)* benzoyl peroxide cream, lotion* benztropine* BERINERT @ betamethasone* betamethasone dipropionate ointment* betamethasone valerate* BETASERON @* betaxolol* bethanechol BETOPTIC-S BIDIL* BICILLIN BILTRICIDE bisoprolol/ hydrochloro- thiazide bisoprolol bleomycin bleph-10 BLEPHAMIDE BOOSTRIX @* BOTOX @* brimonidine , * bromanate bromfenex bromocriptine* budesonide nebulizer solution ( 8YO)

5 * bumetanide buprenorphine @* buprenorphine/ naloxone tablets @* bupropion, SR* bupropion XL* buspirone butalbital/acetamin- ophen/caffeine* butalbital/aspirin/ caffeine* butorphanol* BYDUREON@* C cabergoline CAFCIT calcipotriene* calcitriol calcitonin* calcium acetate CALDEROL CAMPRAL* CANASA CAPITROL CARBAGLU carbidopa* carbdopa/ levodopa, CR* carbidopa/levodopa /entacapone* carbamazepine, ER CARBATROL Page 2 of 7 December 2017 CARBILEV carboplatin CARDEC CARDEC DM carisoprodol* CARMOL 40 CARMOL SCALP CARMOL-HC cartia xt CASODEX CATAPRES-TTS* carvedilol* CAYSTON* cefaclor, ER cefadroxil cefdinir* cefpodoxime* cefprozil* ceftriaxone cefuroxime celecoxib* CENESTIN cephalexin CEREZYME @ CETACAINE cetirizine (OTC)* cetirizine/ pseudoephedrine (OTC)* CHEMET chemstrip bg CHILDREN S ADVIL chlorpheniramine chloral hydrate chlordiazepoxide chloroquin chlorothiazide chlorpromazine chlorthalidone chlorzoxazone cholestyramine, light chromagen ciclopirox 8%* ciclopirox cream* cilostazol* CILOXAN ointment* CINRYZE @* CIPRO HC* CIPRODEX* ciprofloxacin ( 1YO)*ciprofloxacin ER ( 18YO)

6 * ciprofloxacin eye drops* ciprofloxacin otic* cisplatin citalopram* citric acid clarithromycin, SR clemastine CLEOCIN VAGINAL clindamycin cream/ solution/capsule* CLINDESSE* clindets clobetasol cream* clobetasol E cream* clomipramine* clonazepam clonidine* clopidogrel* clorazepate clotrimazole* clotrimazole/ betamethasone cream clozapine* clozapine ODT* COARTEM* codeine sulfate colchicine capsule* colestipol colocort COLY-MYCIN colyte colyte flavored COMBIPATCH COMBIVENT* COMETRIQ@* COMPLERA@* COMTAN* constulose COPAXONE 20mg/mL* cormax cortic CORTIFOAM cortisone CORTISPORIN* CORZIDE COTELLIC@* COUMADIN CREON CRIXIVAN@* cromolyn* CUVPOSA* cyanocobalamine cyclobenzaprine cyclopentolate cyclophosphamide cyclosporine cyproheptadine CYSTARAN@* cytarabine CYTOMEL CYTOVENE cytra k cytra-2 cytra-3 D danazol dantrolene DAPSONE DARAPRIM darifenacin ER* daunorubicin DELATESTRYL@

7 Demeclocycline* DENAVIR @ * DEPEN* DEPO-PROVERA* desipramine* desogestrel/ethin estradiol* desonide cream* desmopressin* desoximetasone gel, ointment, cream* dexamethason/ neomycin/polymyxin dexamethasone* dexchloropheniramine DEXFERRUM @ dexmethylphenidate* dextroamphetamine dextroamphetamine /amphetamine dextroamphetamine /amphetamine XR* DHT diazepam DIBENZYLINE diclofenac 1% gel* diclofenac tablet dicloxacillin dicyclomine* didanosine@* DIFFERIN OTC gel* (Not covered if 35 YO) DIFICID* diflunisal digitek digoxin diltia xt diltiazem DIMETAPP DIPENTUM* diphenhydramine diphenoxylate/ atropine dipyridamole disopyramide disulfiram* divalproex sodium DIURIL dorzolamide dorzolamide hydrochloride/ timolol maleate doxazosin* doxepin* doxorubicin dextromethorphan doxycycline* dronabinol @ duloxetine* DURICEF dutasteride* dyphyllin* DYRENIUM E ear-gesic* EASIVENT econazole* ECONOPRED EDURANT@* EFUDEX* EGRIFTA* ELELYSO @ ELIGARD @* ELIQUIS* ELLA* ELMIRON ELOXATIN @ EMEND@* Page 3 of 7 December 2017 EMSAM* EMTRIVA@* enalapril* enalapril/ hydrochloro- thiazide* ENBREL @* endodan ENGERIX-B @* enoxaparin entecavir* ENTEX ENTEX LA entex pse epinephrine* epinephrine jr* epitol EPIVIR HBV* ERBITUX @ ergotamine/ caffeine

8 ERIVEDGE@* erythromycin topical solution ESBRIET@* escitalopram* ESCLIM ESKALITH CR estazolam ESTINYL ESTRACE estradiol* estradiol/ norethindrone* estradiol patch* estradiol valerate injection ESTRING ESTROGEL estrogen/methyl- testosterone estropipate ethambutol ethosuximide ethyl chloride etidronate etoposide EUFLEXXA @* EURAX* EVOXAC EXELON, patch* EYLEA* ezetimibe @ * F famotidine* FAMVIR* FARESTON@* felbamate felodipine ER FEMARA FEMRING fenofibrate* fentanyl patches@* fentanyl citrate, oral transmucosal@* FERAHEME @ FERRLECIT @ ferrous sulfate* fexofenadine 180mg, 30mg/5 ml * fexofenadine/ pseudoephedrine (OTC)* finasteride* FIRAZYR@* FIRMAGON FLAGYL ER* FLAREX flecainide FLOLAN FLOVENT* fluconazole* flucytosine fludrocortisone fluocinolone cream/ointment* fluocinolone otic oil* fluocinonide cream, gel, ointment* fluoritab FLUOROPLEX fluorouracil fluoxetine capsule* fluphenazine* flurazepam flurbiprofen flutamide fluticasone* fluticasone/ salmeterol* fluvoxamine* FML FORTE FML FML-S folic acid FORADIL* FOSAMAX PLUS D* fosinopril.

9 Hydrochloro- thiazide* FOSRENOL FRAGMIN FULVICIN UF FUNGOID FURADANTIN furosemide FUZEON@* G gabapentin* GABITRIL galantamine* GARDASIL@* GASTROCROM* GATTEX@ gavilyte-N* gemfibrozil GEMZAR GENEDEL gentak gentamicin GENVOYA@* GILENYA* GILOTRIF@* GLASSIA GLEOSTINE@* glimepiride@* glipizide@* glipizide er@* GLUCAGON glyburide@* glyburide/metformin* glycopyrrolate griseofulvin guaifenesin guanfacine, ER* GYNAZOLE* H Haloperidol HAVRIX @* HECTOROL HEMANGEOL* hemril hep-lock heparin sodium HEPSERA HERCEPTIN* HIPREX HIZENTRA homatropine* HUMALOG 100U/mL vial* (only 3mL vial for LTC) HUMATROPE @ HUMIRA @* HUMULIN 100U/mL vial*(only 3mL vial for LTC) hydralazine hydralazine/ hydrochlorothiazide hydrochlorothiazide hydrocodone / acetaminophen 325mg* hydrocodone / ibuprofen* hydrocortisone* hydrocortisone/ pramoxine* hydromorphone hydroxychloroquine hydroxyurea hydroxyzine I IBRANCE@* ibuprofen ILARIS @ imatinib* IMBRUVICA@* imipramine* imiquimod cream@* INCRELEX indapamide indomethacin INFED @ INGREZZA@* INLYTA* INNOHEP INSPRA* INSPIREASE* insulin syringes* INTAL INHALER* INTELENCE@* INTRON-A @ INVEGA SUSTENNA* INVIRASE@* iophen nr Page 4 of 7 December 2017iophen c-nr iophen dm-nr IPLEX* ipratropium* ipratropium/ albuterol* IPRIVASK* irbesartan* irbesartan/ hydrochloro- thiazide* IRESSA* irinotecan iron complex* ISENTRESS@* isoniazid isosorbide

10 Dinitrate isosorbide mononitrate isotretinoin itraconazole* J JAKAFI@* JALYN* JARDIANCE@* JUXTAPID@* K KALBITOR @ KALYDECO@* KALETRA@* kariva* KERALAC NAILSTICK* ketoconazole* ketoconazole shampoo* ketoprofen ketorolac* ketorolac eye drops* KORLYM @* KRISTALOSE KYNAMRO@* L labetalol lactic acid* lactulose* LAMISIL AT* lamivudine@* lamivudine- zidovudine@* lamotrigine* LANOXICAPS lansoprazole capsules* larin* latanoprost* leflunomide LENVIMA@* LETAIRIS* leucovorin LEUKERAN leuprolide@* levetiracetam, ER* levobunolol levocarnitine levocetirizine 5mg* levofloxacin* levofloxacin eye drops* levora* levororgestrel / ethinyl estradoil* levothyroxine* LEVOXYL* LEXIVA@* lidocaine cream/ lotion/4% ointment* lidocaine patch@* linezolid liquibid lisinopril* lisinopril/ hydrochloro- thiazide* lithium carbonate lithium citrate LITHOBID loperamide* loratadine (otc)