USAble Mutual Standard with Step Therapy Drug List

Transcription

1 January 2019 USAble Mutual Standard with Step Therapy Drug List The USAble Mutual Standard with Step Therapy Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an allinclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with a prescription benefit program administered by USAble Mutual. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. Please note: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. You may be responsible for the full cost of non-formulary products that are removed from coverage. For specific information regarding your prescription benefit coverage and copay 1 information, please visit or contact a USAble Mutual Customer Care representative toll free at USAble Mutual may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. In most instances, a brand-name drug for which a generic product becomes available will be designated as a nonpreferred option upon release of the generic product onto the market. ANALGESICS NSAIDs diclofenac sodium meloxicam naproxen NSAIDs, diclofenac sodiummisoprostol NSAIDs, TOPICAL diclofenac sodium gel 1% PA diclofenac sodium solution COX-2 INHIBITORS celecoxib GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC ST OPIOID ANALGESICS codeine-acetaminophen QL fentanyl transdermal QL fentanyl transmucosal lozenge PA hydrocodoneacetaminophen QL hydromorphone QL hydromorphone ext-rel QL methadone QL morphine QL morphine ext-rel QL morphine suppository QL oxycodone QL oxycodoneacetaminophen QL tramadol QL tramadol ext-rel QL ABSTRAL PA BELBUCA QL BUTRANS QL EMBEDA QL HYSINGLA ER QL NUCYNTA QL NUCYNTA ER QL OXYCONTIN QL SUBSYS PA ANTI - INFECTIVES ANTIBACTERIALS CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX ERYTHROMYCINS / MACROLIDES azithromycin HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by USAble Mutual. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Please note: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Log in to to check coverage and copay information for a specific medicine. clarithromycin clarithromycin ext-rel erythromycins DIFICID ST, QL FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel levofloxacin moxifloxacin PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK TETRACYCLINES doxycycline hyclate minocycline tetracycline ANTIFUNGALS fluconazole itraconazole PA terbinafine tablet ANTIRETROVIRAL ANTIRETROVIRAL abacavir-lamivudine QL ATRIPLA QL BIKTARVY QL COMPLERA QL DESCOVY QL EVOTAZ QL GENVOYA QL ODEFSEY QL PREZCOBIX QL STRIBILD QL TRIUMEQ QL TRUVADA QL

2 INTEGRASE INHIBITORS IRESSA SGM CHOLESTEROL HEART FAILURE NAMZARIC ISENTRESS QL KISQALI SGM ABSORPTION INHIBITORS BIDIL TIVICAY QL KISQALI FEMARA ANTIDEPRESSANTS ezetimibe CORLANOR CO-PACK SGM ENTRESTO SELECTIVE SEROTONIN NUCLEOSIDE REVERSE RYDAPT SGM FIBRATES REUPTAKE INHIBITORS TRANSCRIPTASE SPRYCEL SGM fenofibrate NITRATES (SSRIs) INHIBITORS fenofibric acid nitroglycerin lingual spray citalopram abacavir tablet QL MISCELLANEOUS nitroglycerin sublingual escitalopram lamivudine QL ODOMZO SGM HMG-CoA REDUCTASE fluoxetine ZEJULA SGM INHIBITORS / PULMONARY ARTERIAL paroxetine HCl PROTEASE INHIBITORS HYPERTENSION paroxetine HCl ext-rel NORVIR QL CARDIOVASCULAR atorvastatin ENDOTHELIN RECEPTOR sertraline PREZISTA QL ACE INHIBITORS ezetimibe-simvastatin ANTAGONISTS TRINTELLIX ST REYATAZ QL VIIBRYD ST ANTIVIRALS CYTOMEGALOVIRUS valganciclovir HEPATITIS B VEMLIDY fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide fluvastatin lovastatin pravastatin rosuvastatin NIACINS niacin ext-rel OMEGA-3 FATTY ACIDS omega-3 acid ethyl esters PA VASCEPA PA LETAIRIS SGM OPSUMIT SGM TRACLEER SGM SEROTONIN NOREPINEPHRINE simvastatin PHOSPHODIESTERASE REUPTAKE INHIBITORS INHIBITORS sildenafil SGM PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI SGM (SNRIs) desvenlafaxine ext-rel duloxetine venlafaxine venlafaxine ext-rel capsule HEPATITIS C ribavirin SGM ANGIOTENSIN II MISCELLANEOUS EPCLUSA PROSTAGLANDIN RECEPTOR ANTAGONISTS / (genotypes 1, 2, 3, 4, 5, 6) SGM PCSK9 INHIBITORS VASODILATORS DIURETIC bupropion HARVONI REPATHA SGM ORENITRAM SGM candesartan / candesartanhydrochlorothiazide BETA-BLOCKERS bupropion ext-rel (genotypes 1, 4, 5, 6) SGM VOSEVI 2 mirtazapine SGM SOLUBLE GUANYLATE eprosartan trazodone atenolol CYCLASE STIMULATORS HERPES irbesartan / irbesartan- carvedilol ADEMPAS SGM ANTIPARKINSONIAN acyclovir hydrochlorothiazide metoprolol succinate ext-rel valacyclovir losartan / losartan- metoprolol tartrate MISCELLANEOUS amantadine hydrochlorothiazide nadolol RANEXA carbidopa-levodopa INFLUENZA olmesartan / olmesartan- pindolol carbidopa-levodopa ext-rel oseltamivir QL hydrochlorothiazide propranolol CENTRAL NERVOUS carbidopa-levodopa- RELENZA QL telmisartan / telmisartan- propranolol ext-rel SYSTEM entacapone MISCELLANEOUS clindamycin ivermectin linezolid metronidazole nitrofurantoin sulfamethoxazoletrimethoprim EMVERM ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER amlodipine-olmesartan amlodipine-telmisartan BYSTOLIC COREG CR CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel 3 nifedipine ext-rel verapamil ext-rel ANTICONVULSANTS carbamazepine carbamazepine ext-rel diazepam rectal gel divalproex sodium divalproex sodium ext-rel ethosuximide gabapentin lamotrigine entacapone pramipexole pramipexole ext-rel rasagiline ropinirole ropinirole ext-rel selegiline NEUPRO ANTIPSYCHOTICS XIFAXAN 550 MG amlodipine-valsartan CALCIUM CHANNEL lamotrigine ext-rel ATYPICALS ANTINEOPLASTIC BLOCKER / ANTILIPEMIC levetiracetam aripiprazole ANGIOTENSIN II levetiracetam ext-rel clozapine RECEPTOR ANTAGONIST / amlodipine-atorvastatin oxcarbazepine olanzapine HORMONAL CALCIUM CHANNEL phenobarbital quetiapine hydrochlorothiazide valsartan / valsartanhydrochlorothiazide ANTINEOPLASTIC BLOCKER / DIURETIC DIGITALIS GLYCOSIDES phenytoin quetiapine ext-rel ANTIANDROGENS digoxin phenytoin sodium extended risperidone amlodipine-valsartanhydrochlorothiazide DIRECT RENIN INHIBITORS / bicalutamide primidone ziprasidone ERLEADA SGM tiagabine ABILIFY MAINTENA olmesartan-amlodipinehydrochlorothiazide TEKTURNA ST / DIURETIC XTANDI SGM topiramate ARISTADA ZYTIGA SGM valproic acid LATUDA ST TEKTURNA HCT ST zonisamide VRAYLAR ST ANTIARRHYTHMICS LUTEINIZING HORMONE- FYCOMPA RELEASING HORMONE sotalol DIURETICS OXTELLAR XR ATTENTION DEFICIT (LHRH) AGONISTS MULTAQ amiloride VIMPAT HYPERACTIVITY DISORDER furosemide ELIGARD SGM amphetaminedextroamphetamine ANTILIPEMICS LUPRON DEPOT hydrochlorothiazide ANTIDEMENTIA BILE ACID RESINS metolazone donepezil mixed salts QL KINASE INHIBITORS cholestyramine spironolactone- galantamine amphetamineimatinib mesylate SGM colesevelam hydrochlorothiazide galantamine ext-rel dextroamphetamine BOSULIF SGM torsemide memantine mixed salts ext-rel QL CABOMETYX SGM triamterene- rivastigmine atomoxetine QL IBRANCE SGM hydrochlorothiazide rivastigmine transdermal guanfacine ext-rel QL

3 methylphenidate QL PARTIAL OPIOID AGONIST / PARATHYROID HORMONES PREMPRO methylphenidate ext-rel QL OPIOID ANTAGONIST INSULIN SENSITIZERS FORTEO SGM VYVANSE QL pioglitazone TRANSDERMAL TYMLOS SGM buprenorphine-naloxone CLIMARA PRO FIBROMYALGIA INSULIN SENSITIZER / sublingual tablet QL MISCELLANEOUS COMBIPATCH LYRICA ST, QL BIGUANIDE SUBOXONE FILM QL PROLIA SAVELLA pioglitazone-metformin ESTROGEN / SELECTIVE ZUBSOLV QL CARNITINE DEFICIENCY ESTROGEN RECEPTOR HUNTINGTON'S DISEASE INSULIN SENSITIZER / PSEUDOBULBAR AFFECT MODULATOR SULFONYLUREA levocarnitine tetrabenazine SGM NUEDEXTA PA DUAVEE AUSTEDO SGM pioglitazone-glimepiride CONTRACEPTIVES VASOMOTOR SYMPTOM MONOPHASIC FERTILITY REGULATORS HYPNOTICS MEGLITINIDES ethinyl estradiolnateglinide GNRH / LHRH NONBENZODIAZEPINES paroxetine mesylate drospirenone ANTAGONISTS eszopiclone repaglinide ethinyl estradiolzolpidem ENDOCRINE AND CETROTIDE SODIUM-GLUCOSE drospirenone-levomefolate zolpidem ext-rel METABOLIC OVULATION STIMULANTS, CO-TRANSPORTER 2 ethinyl estradiolzolpidem sublingual GONADOTROPINS ACROMEGALY (SGLT2) INHIBITORS norethindrone acetate BELSOMRA ST ethinyl estradiol- GONAL-F PA SOMATULINE DEPOT SGM FARXIGA norethindrone acetate-iron OVIDREL TRICYCLICS SOMAVERT SGM JARDIANCE SAFYRAL SILENOR ST GAUCHER DISEASE ANDROGENS SODIUM-GLUCOSE BIPHASIC CERDELGA SGM MIGRAINE testosterone gel PA CO-TRANSPORTER 2 CEREZYME (SGLT2) INHIBITOR / LO LOESTRIN FE ERGOTAMINE testosterone solution PA BIGUANIDE DERIVATIVES ANDRODERM PA TRIPHASIC GLUCOCORTICOIDS ANDROGEL 1.62% PA SYNJARDY ergotamine-caffeine ethinyl estradiol-norgestimate dexamethasone SYNJARDY XR methylprednisolone SELECTIVE SEROTONIN ANTIDIABETICS XIGDUO XR FOUR PHASE prednisolone solution AGONISTS AMYLIN ANALOGS NATAZIA prednisone SODIUM-GLUCOSE eletriptan QL SYMLINPEN CO-TRANSPORTER 2 EXTENDED CYCLE GLUCOSE ELEVATING naratriptan QL BIGUANIDES (SGLT2) INHIBITOR / ethinyl estradiolrizatriptan QL DIPEPTIDYL PEPTIDASE-4 sumatriptan QL metformin levonorgestrel GLUCAGEN HYPOKIT (DPP-4) INHIBITOR zolmitriptan QL metformin ext-rel GLUCAGON EMERGENCY PROGESTIN INTRAUTERINE ONZETRA XSAIL ST KIT BIGUANIDE / GLYXAMBI DEVICES ZEMBRACE SYMTOUCH ST SULFONYLUREA QTERN KYLEENA HEREDITARY TYROSINEMIA ZOMIG NASAL SPRAY QL MIRENA TYPE 1 SULFONYLUREAS MULTIPLE SCLEROSIS glipizide-metformin SKYLA ORFADIN SGM glimepiride DIPEPTIDYL PEPTIDASE-4 glipizide TRANSDERMAL HUMAN GROWTH glatiramer SGM (DPP-4) INHIBITORS glipizide ext-rel ethinyl estradiol- HORMONES AUBAGIO SGM JANUVIA norelgestromin GENOTROPIN SGM BETASERON SGM SUPPLIES HUMATROPE SGM COPAXONE SGM DIPEPTIDYL PEPTIDASE-4 ACCU-CHEK AVIVA PLUS VAGINAL GILENYA SGM (DPP-4) INHIBITOR / STRIPS AND KITS 4, OTC NUVARING PHOSPHATE BINDER REBIF SGM BIGUANIDE ACCU-CHEK COMPACT TECFIDERA SGM JANUMET PLUS STRIPS ESTROGENS calcium acetate TYSABRI JANUMET XR AND KITS 4, OTC ORAL lanthanum carbonate MUSCULOSKELETAL ACCU-CHEK GUIDE estradiol sevelamer carbonate INCRETIN MIMETIC THERAPY STRIPS AND KITS 4, OTC estropipate PHOSLYRA OZEMPIC ACCU-CHEK SMARTVIEW PREMARIN VELPHORO ST cyclobenzaprine TRULICITY STRIPS AND KITS 4, OTC VICTOZA BD ULTRAFINE INSULIN TRANSDERMAL POTASSIUM-REMOVING NARCOLEPSY SYRINGES AND armodafinil PA estradiol INCRETIN MIMETIC AGENT / NEEDLES OTC DIVIGEL VELTASSA POSTHERPETIC INSULIN DEXCOM CONTINUOUS EVAMIST SOLIQUA PROGESTINS NEURALGIA (PHN) GLUCOSE MONITORING MINIVELLE SYSTEM ORAL GRALISE ST INSULINS VAGINAL medroxyprogesterone PSYCHOTHERAPEUTIC - BASAGLAR CALCIUM REGULATORS estradiol megestrol acetate MISCELLANEOUS FIASP BISPHOSPHONATES ESTRACE CREAM progesterone, micronized OPIOID ANTAGONISTS HUMULIN R U-500 alendronate ESTRING LEVEMIR ibandronate PREMARIN CREAM VAGINAL naloxone injection NOVOLIN 70/30 OTC risedronate CRINONE PA NARCAN NASAL SPRAY NOVOLIN N OTC ESTROGEN / PROGESTINS ENDOMETRIN PA NOVOLIN R OTC CALCITONINS ORAL NOVOLOG calcitonin-salmon SELECTIVE ESTROGEN estradiol-norethindrone NOVOLOG MIX 70/30 RECEPTOR MODULATORS PREMPHASE TRESIBA raloxifene

4 OSPHENA STEROIDS, RECTAL KEVZARA SGM clindamycin-benzoyl OTEZLA SGM Nebulized Passive Inhalation PROCTOFOAM-HC peroxide THYROID SUPPLEMENTS STELARA PERFOROMIST QL erythromycin solution levothyroxine GENITOURINARY SUBCUTANEOUS erythromycin-benzoyl SYNTHROID CYSTIC FIBROSIS (Plaque Psoriasis and Psoriatic Arthritis peroxide BENIGN PROSTATIC tobramycin inhalation only) SGM tretinoin PA GASTROINTESTINAL HYPERPLASIA XELJANZ SGM solution SGM ATRALIN PA alfuzosin ext-rel XELJANZ XR SGM BETHKIS SGM ANTIEMETICS DIFFERIN PA doxazosin EPIDUO dronabinol PA, QL dutasteride ST DISEASE-MODIFYING LEUKOTRIENE RETIN-A MICRO PA granisetron QL dutasteride-tamsulosin ANTIRHEUMATIC DRUGS MODULATORS TAZORAC PA meclizine finasteride (DMARDs) montelukast metoclopramide tamsulosin RASUVO SGM zafirlukast ACTINIC KERATOSIS ondansetron QL prochlorperazine terazosin zileuton ext-rel fluorouracil cream 5% NUTRITIONAL / promethazine RAPAFLO ST SUPPLEMENTS NASAL ANTIHISTAMINES fluorouracil solution imiquimod trimethobenzamide URINARY azelastine spray QL ELECTROLYTES PICATO SANCUSO PA, QL ANTISPASMODICS olopatadine spray QL TOLAK VARUBI QL darifenacin ext-rel potassium chloride liquid NASAL STEROIDS / ZYCLARA oxybutynin H2 RECEPTOR VITAMINS AND MINERALS oxybutynin ext-rel ANTIFUNGALS ANTAGONISTS tolterodine PRENATAL VITAMINS flunisolide QL ciclopirox PA ranitidine tolterodine ext-rel prenatal vitamins fluticasone QL clotrimazole trospium CITRANATAL mometasone nasal INFLAMMATORY BOWEL econazole spray ST, QL DISEASE trospium ext-rel ketoconazole MYRBETRIQ ST RESPIRATORY triamcinolone nasal spray QL nystatin ORAL TOVIAZ ST DYMISTA ST, QL ANAPHYLAXIS JUBLIA PA balsalazide VESICARE ST TREATMENT PHOSPHODIESTERASE-4 LUZU budesonide capsule NAFTIN sulfasalazine HEMATOLOGIC epinephrine auto-injector INHIBITORS sulfasalazine delayed-rel EPIPEN DALIRESP ANTIPSORIATICS APRISO ANTICOAGULANTS EPIPEN JR PULMONARY ENZYME acitretin PA LIALDA warfarin ANTICHOLINERGICS DEFICIENCY calcipotriene QL PENTASA ELIQUIS ipratropium inhalation methoxsalen UCERIS XARELTO ARALAST NP solution QL GLASSIA ATOPIC DERMATITIS RECTAL HEMATOPOIETIC GROWTH INCRUSE ELLIPTA QL PULMONARY FIBROSIS Injectable hydrocortisone enema FACTORS SPIRIVA QL DUPIXENT SGM mesalamine rectal ARANESP SGM ANTICHOLINERGIC / BETA suspension PROCRIT SGM ESBRIET SGM AGONIST Topical CANASA ZARXIO SGM OFEV SGM SHORT ACTING tacrolimus PA CORTIFOAM HEMOPHILIA A SEVERE ASTHMA ELIDEL PA ipratropium-albuterol IRRITABLE BOWEL EUCRISA ST ADYNOVATE inhalation solution QL NUCALA SYNDROME JIVI COMBIVENT RESPIMAT QL STEROID / BETA AGONIST CORTICOSTEROIDS alosetron KOGENATE FS LONG ACTING Low Potency AMITIZA KOVALTRY NOVOEIGHT ANORO ELLIPTA QL ADVAIR QL desonide QL LINZESS BEVESPI BREO ELLIPTA QL hydrocortisone VIBERZI NUWIQ AEROSPHERE QL SYMBICORT QL HEMOPHILIA B Medium Potency LAXATIVES STIOLTO RESPIMAT QL STEROID INHALANTS clocortolone QL lactulose REBINYN ANTICHOLINERGIC / BETA budesonide inhalation hydrocortisone butyrate QL peg 3350-electrolytes PLATELET AGGREGATION AGONIST / STEROID suspension QL mometasone QL SUPREP INHIBITORS INHALANT ARNUITY ELLIPTA QL triamcinolone OPIOID-INDUCED clopidogrel TRELEGY ELLIPTA QL ASMANEX QL FLOVENT DISKUS QL High Potency CONSTIPATION dipyridamole ext-rel-aspirin BETA AGONISTS, FLOVENT HFA QL desoximetasone QL MOVANTIK prasugrel BRILINTA INHALANTS PULMICORT fluocinonide QL PANCREATIC ENZYMES SHORT ACTING FLEXHALER QL Very High Potency CREON IMMUNOLOGIC albuterol inhalation QVAR QL QVAR REDIHALER QL clobetasol cream, foam, gel, VIOKACE solution QL lotion, ointment, ZENPEP ALLERGENIC EXTRACTS levalbuterol tartrate CFC-free TOPICAL shampoo QL aerosol QL PROTON PUMP GRASTEK PA PROAIR HFA QL DERMATOLOGY ROSACEA INHIBITORS ORALAIR PA PROAIR RESPICLICK QL RAGWITEK PA ACNE metronidazole esomeprazole Topical FINACEA PA lansoprazole 5 LONG ACTING AUTOIMMUNE ORACEA PA omeprazole Hand-held Active Inhalation adapalene PA COSENTYX SGM SOOLANTRA PA pantoprazole SEREVENT QL benzoyl peroxide DEXILANT ST ENBREL SGM STRIVERDI RESPIMAT QL clindamycin solution HUMIRA SGM

5 OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium olopatadine LASTACAFT PAZEO ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin moxifloxacin ofloxacin sulfacetamide tobramycin BESIVANCE CILOXAN OINTMENT MOXEZA ANTI-INFECTIVE / ANTI-INFLAMMATORY neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- dexamethasone tobramycin-dexamethasone TOBRADEX OINTMENT TOBRADEX ST ZYLET ANTI-INFLAMMATORIES Nonsteroidal bromfenac diclofenac ketorolac QL ACUVAIL ILEVRO NEVANAC Steroidal dexamethasone prednisolone acetate 1% DUREZOL FLAREX FML FORTE FML S.O.P. MAXIDEX PRED MILD BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE INHIBITORS dorzolamide AZOPT QUICK REFERENCE DRUG LIST CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC SIMBRINZA DRY EYE DISEASE RESTASIS XIIDRA PROSTAGLANDINS latanoprost LUMIGAN ST TRAVATAN Z ST RHO KINASE INHIBITORS RHOPRESSA SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX ACCU-CHEK SMARTVIEW STRIPS AND KITS 4, OTC acitretin PA ACUVAIL acyclovir adapalene PA ADEMPAS SGM ARNUITY ELLIPTA QL ASMANEX QL atenolol atomoxetine QL atorvastatin ATRALIN PA ATRIPLA QL C BUTRANS QL BYSTOLIC CABOMETYX SGM calcipotriene QL calcitonin-salmon calcium acetate CANASA clocortolone QL clopidogrel clotrimazole clozapine codeine-acetaminophen QL colchicine tablet COLCRYS dicloxacillin DIFFERIN PA DIFICID ST, QL digoxin diltiazem ext-rel 3 dipyridamole ext-rel-aspirin divalproex sodium A amphetamine- BOSULIF SGM citalopram DEXCOM CONTINUOUS abacavir tablet QL dextroamphetamine BREO ELLIPTA QL CITRANATAL GLUCOSE MONITORING abacavir-lamivudine QL mixed salts ext-rel QL BRILINTA clarithromycin SYSTEM ANDRODERM PA brimonidine clarithromycin ext-rel DEXILANT ST ABILIFY MAINTENA ANDROGEL 1.62% PA bromfenac CLIMARA PRO diazepam rectal gel ABSTRAL PA ANORO ELLIPTA QL budesonide capsule clindamycin diclofenac ACCU-CHEK AVIVA PLUS STRIPS AND KITS 4 APRISO budesonide inhalation clindamycin solution diclofenac sodium, OTC ARALAST NP ACCU-CHEK COMPACT suspension QL clindamycin-benzoyl diclofenac sodium ARANESP SGM buprenorphine-naloxone peroxide gel 1% PA PLUS STRIPS AND KITS 4 aripiprazole sublingual tablet QL clobetasol cream, foam, gel, diclofenac sodium solution, OTC ARISTADA ACCU-CHEK GUIDE bupropion lotion, ointment, diclofenac sodium- STRIPS AND KITS 4 armodafinil PA bupropion ext-rel shampoo QL misoprostol, OTC AUBAGIO SGM colesevelam ADVAIR QL divalproex sodium ext-rel ADYNOVATE AUSTEDO SGM COMBIGAN DIVIGEL azelastine albuterol inhalation candesartan COMBIPATCH donepezil azelastine spray QL solution QL candesartanhydrochlorothiazide RESPIMAT QL dorzolamide-timolol COMBIVENT dorzolamide azithromycin alendronate AZOPT alfuzosin ext-rel carbamazepine COMPLERA QL doxazosin allopurinol carbamazepine ext-rel COPAXONE SGM doxycycline hyclate B alosetron carbidopa-levodopa COREG CR dronabinol PA, QL ALPHAGAN P balsalazide carbidopa-levodopa ext-rel CORLANOR DUAVEE amantadine BASAGLAR carbidopa-levodopa- CORTIFOAM duloxetine amiloride BD ULTRAFINE INSULIN entacapone COSENTYX SGM DUPIXENT SGM AMITIZA SYRINGES AND carvedilol CREON DUREZOL amlodipine NEEDLES OTC cefdinir CRINONE PA amlodipine-atorvastatin BELBUCA QL cefprozil cromolyn sodium amlodipine-olmesartan BELSOMRA ST cefuroxime axetil cyclobenzaprine amlodipine-telmisartan benzoyl peroxide celecoxib amlodipine-valsartan BESIVANCE cephalexin D E amlodipine-valsartanhydrochlorothiazide BETHKIS SGM CEREZYME darifenacin ext-rel eletriptan QL BETASERON SGM CERDELGA SGM DALIRESP econazole amoxicillin BETIMOL CETROTIDE DESCOVY QL ELIDEL PA amoxicillin-clavulanate BETOPTIC S cholestyramine desonide QL ELIGARD SGM amphetaminedextroamphetamine mixed salts QL BEVESPI AEROSPHERE QL bicalutamide ciclopirox PA CILOXAN OINTMENT CIPRODEX desoximetasone QL desvenlafaxine ext-rel dexamethasone dutasteride ST dutasteride-tamsulosin DYMISTA ST, QL ELIQUIS EMBEDA QL EMVERM BIDIL ciprofloxacin ENBREL SGM BIKTARVY QL ciprofloxacin ext-rel ENDOMETRIN PA

6 entacapone furosemide K mometasone QL ORENITRAM SGM ENTRESTO FYCOMPA mometasone nasal ORFADIN SGM ketoconazole EPCLUSA SGM spray ST, QL oseltamivir QL EPIDUO G ketorolac QL montelukast OSPHENA KEVZARA SGM epinephrine auto-injector gabapentin morphine QL OTEZLA SGM KISQALI SGM EPIPEN galantamine morphine ext-rel QL OVIDREL KISQALI FEMARA EPIPEN JR galantamine ext-rel morphine suppository QL oxcarbazepine CO-PACK SGM eprosartan GENOTROPIN SGM KOGENATE FS MOVANTIK OXTELLAR XR ergotamine-caffeine gentamicin KOVALTRY MOXEZA oxybutynin ERLEADA SGM GENVOYA QL KYLEENA moxifloxacin oxybutynin ext-rel erythromycin GILENYA SGM MULTAQ oxycodone QL erythromycin solution GLASSIA L MYRBETRIQ ST oxycodoneerythromycin-benzoyl glatiramer SGM lactulose peroxide glimepiride N lamivudine QL erythromycins glipizide nadolol lamotrigine ESBRIET SGM glipizide ext-rel NAFTIN lamotrigine ext-rel escitalopram glipizide-metformin naloxone injection P lansoprazole esomeprazole GLUCAGEN HYPOKIT NAMZARIC lanthanum carbonate ESTRACE CREAM GLUCAGON EMERGENCY naproxen LASTACAFT estradiol KIT naratriptan QL latanoprost estradiol-norethindrone GLYXAMBI NARCAN NASAL SPRAY LATUDA ST ESTRING GONAL-F PA NATAZIA LETAIRIS SGM estropipate GRALISE ST nateglinide levalbuterol tartrate CFC-free eszopiclone granisetron QL neomycin-polymyxin B- aerosol QL ethinyl estradioldrospirenone guanfacine ext-rel QL GRASTEK PA LEVEMIR bacitracin-hydrocortisone levetiracetam neomycin-polymyxin B- ethinyl estradioldrospirenone-levomefolate H levetiracetam ext-rel dexamethasone levocarnitine NEUPRO ethinyl estradiollevonorgestrel HUMATROPE SGM niacin ext-rel HARVONI SGM levofloxacin NEVANAC levothyroxine ethinyl estradiolnorelgestromin HUMULIN R U-500 nitrofurantoin HUMIRA SGM nifedipine ext-rel LIALDA linezolid ethinyl estradiolnorethindrone acetate hydrocodone- nitroglycerin sublingual hydrochlorothiazide nitroglycerin lingual spray LINZESS lisinopril ethinyl estradiolnorethindrone acetate-iron hydrocortisone NOVOEIGHT acetaminophen QL NORVIR QL lisinopril-hydrochlorothiazide LO LOESTRIN FE ethinyl estradiol-norgestimate hydrocortisone butyrate QL NOVOLIN 70/30 OTC losartan ethosuximide hydrocortisone enema NOVOLIN N OTC losartan-hydrochlorothiazide EUCRISA ST hydromorphone QL NOVOLIN R OTC lovastatin EVAMIST hydromorphone ext-rel QL NOVOLOG LUMIGAN ST EVOTAZ QL HYSINGLA ER QL LUPRON DEPOT ezetimibe NOVOLOG MIX 70/30 LUZU NUCALA ezetimibe-simvastatin I LYRICA ST, QL NUCYNTA QL ibandronate NUCYNTA ER QL F FARXIGA fenofibrate fenofibric acid fentanyl transdermal QL fentanyl transmucosal lozenge PA FIASP FINACEA PA finasteride FLAREX FLOVENT DISKUS QL FLOVENT HFA QL fluconazole flunisolide QL fluocinonide QL fluorouracil cream 5% fluorouracil solution fluoxetine fluticasone QL fluvastatin FML FORTE FML S.O.P. FORTEO SGM fosinopril fosinopril-hydrochlorothiazide IBRANCE SGM ILEVRO imatinib mesylate SGM imiquimod INCRUSE ELLIPTA QL ipratropium inhalation solution QL ipratropium-albuterol inhalation solution QL irbesartan irbesartanhydrochlorothiazide IRESSA SGM ISENTRESS QL itraconazole PA ivermectin J JANUMET JANUMET XR JANUVIA JARDIANCE JIVI JUBLIA PA M MAXIDEX meclizine medroxyprogesterone megestrol acetate meloxicam memantine mesalamine rectal suspension metformin metformin ext-rel methadone QL methoxsalen methylphenidate QL methylphenidate ext-rel QL methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole MINIVELLE minocycline MIRENA mirtazapine NUEDEXTA PA NUVARING NUWIQ nystatin O ODEFSEY QL ODOMZO SGM OFEV SGM ofloxacin olanzapine olmesartan olmesartan-amlodipinehydrochlorothiazide olmesartanhydrochlorothiazide olopatadine olopatadine spray QL omega-3 acid ethyl esters PA omeprazole ondansetron QL ONZETRA XSAIL ST OPSUMIT SGM ORACEA PA ORALAIR PA acetaminophen QL OXYCONTIN QL OZEMPIC pantoprazole paroxetine HCl paroxetine HCl ext-rel paroxetine mesylate PAZEO peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST QL phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin potassium chloride liquid pramipexole pramipexole ext-rel prasugrel pravastatin PRED MILD prednisolone acetate 1% prednisolone solution prednisone PREMARIN Q PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins PREZCOBIX QL PREZISTA QL primidone PROAIR HFA QL PROAIR RESPICLICK QL probenecid prochlorperazine PROCRIT SGM PROCTOFOAM-HC progesterone, micronized PROLIA promethazine propranolol propranolol ext-rel PULMICORT FLEXHALER QL QTERN quetiapine quetiapine ext-rel

7 quinapril SEREVENT QL T tretinoin PA VIMPAT quinapril-hydrochlorothiazide QVAR QL QVAR REDIHALER QL R S RAGWITEK PA raloxifene ramipril RANEXA ranitidine RAPAFLO ST rasagiline RASUVO SGM REBIF SGM REBINYN RELENZA QL repaglinide REPATHA SGM RESTASIS RETIN-A MICRO PA REYATAZ QL RHOPRESSA ribavirin SGM risedronate risperidone rivastigmine rivastigmine transdermal rizatriptan QL ropinirole ropinirole ext-rel rosuvastatin RYDAPT SGM SAFYRAL SANCUSO PA, QL SAVELLA selegiline sertraline sevelamer carbonate sildenafil SGM SILENOR ST SIMBRINZA simvastatin SKYLA SOLIQUA SOMATULINE DEPOT SGM SOMAVERT SGM SOOLANTRA PA sotalol SPIRIVA QL spironolactonehydrochlorothiazide SPRYCEL SGM STELARA SUBCUTANEOUS SGM STIOLTO RESPIMAT QL STRIBILD QL STRIVERDI RESPIMAT QL SUBOXONE FILM QL SUBSYS PA sulfacetamide sulfamethoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan QL SUPRAX SUPREP SYMBICORT QL SYMLINPEN SYNJARDY SYNJARDY XR SYNTHROID tacrolimus PA tamsulosin TAZORAC PA TECFIDERA SGM TEKTURNA ST TEKTURNA HCT ST telmisartan telmisartanhydrochlorothiazide terazosin terbinafine tablet testosterone gel PA testosterone solution PA tetrabenazine SGM tetracycline tiagabine timolol maleate solution TIVICAY QL TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin inhalation solution SGM tobramycin-dexamethasone TOLAK tolterodine tolterodine ext-rel topiramate torsemide TOVIAZ ST TRACLEER SGM tramadol QL tramadol ext-rel QL TRAVATAN Z ST trazodone TRELEGY ELLIPTA QL TRESIBA U V triamcinolone triamcinolone nasal spray QL triamterenehydrochlorothiazide trimethobenzamide TRINTELLIX ST TRIUMEQ QL trospium trospium ext-rel TRULICITY TRUVADA QL TYMLOS SGM TYSABRI UCERIS ULORIC ST UPTRAVI SGM PREFERRED ALTERNATIVES LIST valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothiazide VARUBI QL VASCEPA PA VELPHORO ST VELTASSA VEMLIDY venlafaxine venlafaxine ext-rel capsule verapamil ext-rel VESICARE ST VIBERZI VICTOZA VIIBRYD ST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY ACANYA ACTEMRA ACTICLATE ACTOS ADDERALL XR ALCORTIN A ALEVICYN GEL, ALEVICYN KIT, ALEVICYN SG, Alevicyn solution ALLISON MEDICAL INSULIN SYRINGES 7 ALORA ALPROLIX aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA ST, VRAYLAR ST adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA ENBREL SGM, HUMIRA SGM, KEVZARA SGM, XELJANZ SGM, XELJANZ XR SGM doxycycline hyclate pioglitazone amphetamine-dextroamphetamine mixed salts ext-rel QL, methylphenidate ext-rel QL, VYVANSE QL desonide QL, hydrocortisone desonide QL, hydrocortisone BD ULTRAFINE INSULIN SYRINGES OTC estradiol, DIVIGEL, EVAMIST, MINIVELLE Consult doctor ALTOPREV ALVESCO AMRIX ANDROGEL 1% ANGELIQ ANTARA APEXICON E APIDRA ARMOUR THYROID ARTHROTEC ASACOL HD ASCENSIA STRIPS AND KITS 6 VIOKACE VOSEVI 2 SGM VRAYLAR ST VYVANSE QL W X Z warfarin XARELTO XELJANZ SGM XELJANZ XR SGM XIFAXAN 550 MG XIGDUO XR XIIDRA XTANDI SGM zafirlukast ZARXIO SGM ZEJULA SGM ZEMBRACE SYMTOUCH ST ZENPEP zileuton ext-rel ziprasidone zolmitriptan QL zolpidem zolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY QL zonisamide ZUBSOLV QL ZYCLARA ZYLET ZYTIGA SGM atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin ARNUITY ELLIPTA QL, ASMANEX QL, FLOVENT DISKUS QL, FLOVENT HFA QL, PULMICORT FLEXHALER QL, QVAR QL, QVAR REDIHALER QL cyclobenzaprine testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA estradiol-norethindrone, PREMPHASE, PREMPRO fenofibrate, fenofibric acid desoximetasone QL, fluocinonide QL FIASP, NOVOLOG levothyroxine, SYNTHROID celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT ST balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA

8 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ATACAND, ATACAND HCT ATROVENT HFA AVENOVA AXERT AZELEX BECONASE AQ BENICAR, BENICAR HCT BENSAL HP BENZAC AC BENZACLIN BENZIQ BETAPACE, BETAPACE AF BREEZE 2 STRIPS AND KITS 6 butalbital-acetaminophencaffeine capsule BYDUREON BYETTA CAFERGOT CAMBIA CARAC ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, olmesartan, olmesartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ipratropium inhalation solution QL, INCRUSE ELLIPTA QL, SPIRIVA QL Consult doctor eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA ST, QL candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, olmesartan, olmesartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide desonide QL, hydrocortisone adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA sotalol ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND diclofenac sodium, naproxen OZEMPIC, TRULICITY, VICTOZA OZEMPIC, TRULICITY, VICTOZA eletriptan QL, ergotamine-caffeine, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL diclofenac sodium, meloxicam, naproxen fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA CARDIZEM CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA) diltiazem ext-rel (except generic CARDIZEM LA) CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA) CARNITOR CARNITOR SF CIMZIA CLINDAGEL clobetasol spray CLOBEX SPRAY COLAZAL CONTOUR NEXT STRIPS AND KITS 6 CONTOUR STRIPS AND KITS 6 CRESTOR CYMBALTA DAKLINZA DELZICOL DETROL LA DEXPAK DIOVAN, DIOVAN HCT DORAL DORYX DORYX MPC DULERA DUTOPROL DYRENIUM EDARBI, EDARBYCLOR levocarnitine levocarnitine COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM, XELJANZ SGM, XELJANZ XR SGM erythromycin solution clobetasol foam QL clobetasol foam QL balsalazide ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST dexamethasone, methylprednisolone, prednisolone solution, prednisone candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, olmesartan, olmesartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST doxycycline hyclate doxycycline hyclate ADVAIR QL, BREO ELLIPTA QL, SYMBICORT QL metoprolol succinate ext-rel WITH hydrochlorothiazide amiloride candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, olmesartan, olmesartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

9 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* EDLUAR E.E.S. GRANULES EFFEXOR XR eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST erythromycins desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule ELELYSO CERDELGA SGM, CEREZYME ELOCTATE ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ ENABLEX ENTYVIO ERYPED EVZIO EXFORGE EXFORGE HCT EXTAVIA FANAPT darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST HUMIRA SGM, XELJANZ SGM erythromycins FASENRA NUCALA FEMRING FETZIMA FIORICET CAPSULE fluorouracil cream 0.5% FOLLISTIM AQ FORTAMET FORTESTA FOSAMAX PLUS D FOSRENOL FREESTYLE STRIPS AND KITS 6 FROVA GLEEVEC GLUMETZA naloxone injection, NARCAN NASAL SPRAY amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE SGM, GILENYA SGM, REBIF SGM, TECFIDERA SGM, TYSABRI aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA ST, VRAYLAR ST estradiol, ESTRACE CREAM, ESTRING, PREMARIN CREAM desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule diclofenac sodium, naproxen fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA GONAL-F PA metformin, metformin ext-rel testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA alendronate, ibandronate, risedronate calcium acetate, lanthanum carbonate, sevelamer carbonate, PHOSLYRA, VELPHORO ST ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM metformin, metformin ext-rel HELIXATE FS ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ HORIZANT HUMALOG gabapentin, GRALISE ST FIASP, NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN 70/30 HUMULIN N HUMULIN R INDOCIN INNOPRAN XL INTERMEZZO INTUNIV INVOKAMET INVOKAMET XR INVOKANA ISTALOL JALYN JENTADUETO JENTADUETO XR KAZANO KINERET KOMBIGLYZE XR LANOXIN TABLET (125 MCG and 250 MCG only) LANTUS LAZANDA LESCOL XL levorphanol LIPITOR LIVALO LUNESTA MACRODANTIN Matzim LA MAVYRET MENEST MENOSTAR MIACALCIN INJECTION MIACALCIN NASAL SPRAY NOVOLIN 70/30 OTC NOVOLIN N OTC NOVOLIN R OTC diclofenac sodium, meloxicam, naproxen atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST amphetamine-dextroamphetamine mixed salts ext-rel QL, atomoxetine QL, guanfacine ext-rel QL, methylphenidate ext-rel QL, VYVANSE QL SYNJARDY, SYNJARDY XR, XIGDUO XR SYNJARDY, SYNJARDY XR, XIGDUO XR FARXIGA, JARDIANCE timolol maleate solution, BETIMOL dutasteride-tamsulosin; dutasteride ST or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ST JANUMET, JANUMET XR JANUMET, JANUMET XR JANUMET, JANUMET XR ENBREL SGM, HUMIRA SGM, KEVZARA SGM, XELJANZ SGM, XELJANZ XR SGM JANUMET, JANUMET XR digoxin BASAGLAR, LEVEMIR, TRESIBA fentanyl transmucosal lozenge PA, ABSTRAL PA, SUBSYS PA atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin fentanyl transdermal QL, hydromorphone ext-rel QL, methadone QL, morphine ext-rel QL, EMBEDA QL, HYSINGLA ER QL, NUCYNTA ER QL, OXYCONTIN QL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST nitrofurantoin diltiazem ext-rel (except generic CARDIZEM LA) EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM, VOSEVI 2 SG M estradiol, estropipate, PREMARIN estradiol alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO SGM, PROLIA, TYMLOS SGM calcitonin-salmon

10 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* MICARDIS, MICARDIS HCT MILLIPRED MINOCIN NAPRELAN NATESTO NESINA NEUPOGEN NEXIUM NILANDRON NITROMIST NORDITROPIN NORITATE NORVASC NOVACORT NOVO NORDISK NEEDLES 7 NUTROPIN AQ NUVIGIL OLEPTRO OLUX-E OMNARIS OMNITROPE ONETOUCH ULTRA STRIPS AND KITS 6 ONETOUCH VERIO STRIPS AND KITS 6 ONEXTON ONGLYZA ORENCIA CLICKJECT ORENCIA INTRAVENOUS candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, olmesartan, olmesartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide dexamethasone, methylprednisolone, prednisolone solution, prednisone minocycline diclofenac sodium, meloxicam, naproxen testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA JANUVIA ZARXIO SGM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST bicalutamide, XTANDI SGM, ZYTIGA SGM nitroglycerin lingual spray, nitroglycerin sublingual GENOTROPIN SGM, HUMATROPE SGM metronidazole, FINACEA PA, SOOLANTRA PA amlodipine desonide QL, hydrocortisone BD ULTRAFINE NEEDLES OTC GENOTROPIN SGM, HUMATROPE SGM armodafinil trazodone clobetasol foam QL flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA ST, QL GENOTROPIN SGM, HUMATROPE SGM ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A-MICRO PA, TAZORAC PA JANUVIA COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM, XELJANZ SGM, XELJANZ XR SGM COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM, XELJANZ SGM, XELJANZ XR SGM ORENCIA SUBCUTANEOUS OSENI OWEN MUMFORD NEEDLES 7 OXYTROL PANCREAZE PENNSAID PERRIGO NEEDLES 7 PERTZYE PEXEVA PLAVIX PRADAXA PRALUENT PRECISION XTRA STRIPS AND KITS 6 COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM, XELJANZ SGM, XELJANZ XR SGM JANUMET, JANUMET XR BD ULTRAFINE NEEDLES OTC darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST CREON, VIOKACE, ZENPEP diclofenac sodium, diclofenac sodium gel 1% PA, diclofenac sodium solution, meloxicam, naproxen BD ULTRAFINE NEEDLES OTC CREON, VIOKACE, ZENPEP citalopram, escitalopram, fluoxetine, paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX ST, VIIBRYD ST clopidogrel, prasugrel, BRILINTA warfarin, ELIQUIS, XARELTO REPATHA SGM ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND PRED FORTE dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD PREFERAOB PREFEST PRENATAL PLUS PREVACID PRIMLEV generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST hydrocodone-acetaminophen QL, hydromorphone QL, morphine QL, oxycodoneacetaminophen QL, NUCYNTA QL PROLASTIN-C ARALAST NP, GLASSIA PROTONIX PROTOPIC PROVENTIL HFA QNASL RAYOS RELION INSULIN RELISTOR RIMSO-50 RIOMET ROZEREM SAIZEN esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST tacrolimus PA, ELIDEL PA, EUCRISA ST levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA ST, QL dexamethasone, methylprednisolone, prednisolone solution, prednisone NOVOLIN INSULIN OTC MOVANTIK Consult doctor metformin, metformin ext-rel eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST GENOTROPIN SGM, HUMATROPE SGM

11 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* SEROQUEL XR SIMPONI SORILUX SPRIX STRIANT SURE-TEST STRIPS AND KITS 6 SYNERDERM TALTZ TANZEUM TARGADOX TASIGNA TECHNIVIE TESTIM testosterone gel 1% 8 TIROSINT TOBI TOBI PODHALER TOUJEO TRADJENTA TRICOR TRIGLIDE TRILIPIX TRIVIDIA INSULIN SYRINGES 7 TRUETEST STRIPS AND KITS 6 TRUETRACK STRIPS AND KITS 6 TUDORZA ULTIMED INSULIN SYRINGES 7 ULTIMED NEEDLES 7 aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR ST COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM, XELJANZ SGM, XELJANZ XR SGM calcipotriene QL diclofenac sodium, meloxicam, naproxen testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND desonide QL, hydrocortisone COSENTYX SGM, ENBREL SGM, HUMIRA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM, XELJANZ SGM, XELJANZ XR SGM OZEMPIC, TRULICITY, VICTOZA doxycycline hyclate imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA levothyroxine, SYNTHROID tobramycin inhalation solution SGM, BETHKIS SGM tobramycin inhalation solution SGM, BETHKIS SGM BASAGLAR, LEVEMIR, TRESIBA JANUVIA fenofibrate, fenofibric acid fenofibrate, fenofibric acid fenofibrate, fenofibric acid BD ULTRAFINE INSULIN SYRINGES OTC ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND ACCU-CHEK GUIDE STRIPS AND ACCU-CHEK SMARTVIEW STRIPS AND INCRUSE ELLIPTA QL, SPIRIVA QL BD ULTRAFINE INSULIN SYRINGES OTC BD ULTRAFINE NEEDLES OTC VALCYTE VALTREX VANATOL LQ VANATOL S Vanoxide-HC VELTIN venlafaxine ext-rel tablet (except 225 mg) VENLAFAXINE EXT-REL TABLET (except 225 MG) VENTOLIN HFA VIEKIRA PAK VIEKIRA XR VITAFOL-ONE VOGELXO XENAZINE XOPENEX HFA ZEGERID ZEMAIRA ZEPATIER ZETIA ZETONNA ZIANA ZOLPIMIST ZONEGRAN ZUPLENZ ZYFLO, ZYFLO CR valganciclovir acyclovir, valacyclovir diclofenac sodium, naproxen diclofenac sodium, naproxen adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A-MICRO PA, TAZORAC PA adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A-MICRO PA, TAZORAC PA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM generic prenatal vitamins, CITRANATAL testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA tetrabenazine SGM, AUSTEDO SGM levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST ARALAST NP, GLASSIA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM ezetimibe flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA ST, QL adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A-MICRO PA, TAZORAC PA eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, VIMPAT granisetron QL, ondansetron QL, SANCUSO PA, QL montelukast, zafirlukast, zileuton ext-rel UROXATRAL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ST

12 You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information. FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay 1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Generics are available in this class and should be considered the first line of prescribing. Coverage determined under the Medical Benefit OTC PA QL SGM ST Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3 3 Listing does not include generic CARDIZEM LA. 4 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on how to obtain a blood glucose meter, call: Coverage may be altered or copay 1 amounts may vary based on the condition being treated (e.g. psoriasis). 6 ACCU-CHEK brand test strips are the only preferred options. 7 BD ULTRAFINE syringes and needles are the only preferred options. 8 Listing reflects the authorized generics for TESTIM and VOGELXO. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission All rights reserved