USAble Administrators Standard with Step Therapy Drug List

Transcription

1 January 2019 USAble Administrators Standard with Step Therapy Drug List The USAble Administrators 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 all-inclusive 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 Administrators. 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 Administrators Customer Care representative toll free at USAble Administrators 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 brandname 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 HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by USAble Administrators. 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. ANTI - INFECTIVES ANTIBACTERIALS CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX ERYTHROMYCINS / MACROLIDES azithromycin 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

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

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

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

5 CORTICOSTEROIDS Low Potency desonide QL hydrocortisone Medium Potency clocortolone QL hydrocortisone butyrate QL mometasone QL triamcinolone High Potency desoximetasone QL fluocinonide QL Very High Potency clobetasol cream, foam, gel, lotion, ointment, shampoo QL ROSACEA metronidazole FINACEA PA ORACEA PA SOOLANTRA PA 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 QUICK REFERENCE DRUG LIST CARBONIC ANHYDRASE INHIBITORS dorzolamide AZOPT 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 A amoxicillin-clavulanate BETASERON SGM cefdinir COREG CR amphetaminedextroamphetamine BETIMOL cefuroxime axetil CORTIFOAM BETHKIS SGM cefprozil CORLANOR abacavir tablet QL abacavir-lamivudine QL mixed salts QL BETOPTIC S celecoxib COSENTYX SGM ABILIFY MAINTENA ABSTRAL PA ACCU-CHEK AVIVA PLUS STRIPS AND KITS 4, OTC ACCU-CHEK COMPACT PLUS STRIPS AND KITS 4, OTC ACCU-CHEK GUIDE STRIPS AND KITS 4, OTC ACCU-CHEK SMARTVIEW STRIPS AND KITS 4, OTC acitretin PA ACUVAIL acyclovir adapalene PA ADEMPAS SGM ADVAIR QL ADYNOVATE albuterol inhalation solution QL alendronate alfuzosin ext-rel azelastine azelastine spray QL CABOMETYX SGM calcipotriene QL shampoo QL clocortolone QL gel 1% PA diclofenac sodium solution azithromycin calcitonin-salmon clopidogrel diclofenac sodium- AZOPT calcium acetate clotrimazole misoprostol B CANASA clozapine dicloxacillin candesartan codeine-acetaminophen QL DIFFERIN PA balsalazide candesartanhydrochlorothiazide colchicine tablet DIFICID ST, QL BASAGLAR COLCRYS digoxin BD ULTRAFINE INSULIN carbamazepine colesevelam diltiazem ext-rel 3 SYRINGES AND carbamazepine ext-rel COMBIGAN dipyridamole ext-rel-aspirin NEEDLES OTC carbidopa-levodopa COMBIPATCH divalproex sodium BELBUCA QL carbidopa-levodopa ext-rel COMBIVENT divalproex sodium ext-rel BELSOMRA ST carbidopa-levodopaentacapone COMPLERA QL RESPIMAT QL DIVIGEL benzoyl peroxide donepezil allopurinol alosetron ALPHAGAN P amantadine amiloride AMITIZA amlodipine amlodipine-atorvastatin amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartanhydrochlorothiazide amoxicillin amphetamine- BEVESPI cephalexin CREON dextroamphetamine AEROSPHERE QL CERDELGA SGM mixed salts ext-rel QL bicalutamide CEREZYME ANDRODERM PA BIDIL CETROTIDE ANDROGEL 1.62% PA ANORO ELLIPTA QL APRISO ARALAST NP ARANESP SGM BIKTARVY QL BOSULIF SGM BREO ELLIPTA QL BRILINTA brimonidine cholestyramine ciclopirox PA CILOXAN OINTMENT CIPRODEX ciprofloxacin D CRINONE PA cromolyn sodium cyclobenzaprine DALIRESP darifenacin ext-rel DESCOVY QL desonide QL desoximetasone QL aripiprazole ARISTADA bromfenac budesonide capsule ciprofloxacin ext-rel citalopram armodafinil PA budesonide inhalation CITRANATAL desvenlafaxine ext-rel ARNUITY ELLIPTA QL suspension QL clarithromycin dexamethasone ASMANEX QL buprenorphine-naloxone clarithromycin ext-rel DEXCOM CONTINUOUS atenolol sublingual tablet QL CLIMARA PRO GLUCOSE MONITORING atomoxetine QL atorvastatin bupropion bupropion ext-rel clindamycin clindamycin solution SYSTEM DEXILANT ST ATRALIN PA BUTRANS QL clindamycin-benzoyl diazepam rectal gel ATRIPLA QL BYSTOLIC peroxide diclofenac AUBAGIO SGM clobetasol cream, foam, gel, diclofenac sodium AUSTEDO SGM C lotion, ointment, diclofenac sodium BESIVANCE carvedilol COPAXONE SGM dorzolamide

6 dorzolamide-timolol fentanyl transdermal QL INCRUSE ELLIPTA QL meloxicam O doxazosin fentanyl transmucosal ipratropium inhalation memantine ODEFSEY QL doxycycline hyclate lozenge PA solution QL mesalamine rectal ODOMZO SGM dronabinol PA, QL FIASP ipratropium-albuterol suspension OFEV SGM DUAVEE FINACEA PA inhalation solution QL metformin ofloxacin duloxetine finasteride irbesartan metformin ext-rel olanzapine DUPIXENT SGM FLAREX irbesartan- methadone QL olmesartan DUREZOL FLOVENT DISKUS QL hydrochlorothiazide methoxsalen dutasteride ST dutasteride-tamsulosin FLOVENT HFA QL fluconazole IRESSA SGM ISENTRESS QL methylphenidate QL methylphenidate ext-rel QL DYMISTA ST, QL flunisolide QL itraconazole PA fluocinonide QL ivermectin E fluorouracil cream 5% econazole fluorouracil solution J eletriptan QL fluoxetine JANUMET metoprolol tartrate ELIDEL PA fluticasone QL JANUMET XR metronidazole ELIGARD SGM fluvastatin JANUVIA MINIVELLE ELIQUIS FML FORTE JARDIANCE minocycline EMBEDA QL FML S.O.P. JIVI MIRENA EMVERM FORTEO SGM JUBLIA PA mirtazapine ENBREL SGM fosinopril mometasone QL ENDOMETRIN PA fosinopril-hydrochlorothiazide K mometasone nasal entacapone furosemide ketoconazole spray ST, QL FYCOMPA ENTRESTO EPCLUSA SGM EPIDUO G ketorolac QL KEVZARA SGM KISQALI SGM methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel montelukast morphine QL morphine ext-rel QL epinephrine auto-injector gabapentin KISQALI FEMARA morphine suppository QL EPIPEN galantamine CO-PACK SGM MOVANTIK EPIPEN JR galantamine ext-rel KOGENATE FS MOXEZA eprosartan GENOTROPIN SGM KOVALTRY moxifloxacin ergotamine-caffeine gentamicin KYLEENA MULTAQ ERLEADA SGM GENVOYA QL MYRBETRIQ ST erythromycin GILENYA SGM L erythromycin solution GLASSIA N lactulose erythromycin-benzoyl glatiramer SGM lamivudine QL nadolol olmesartan-amlodipinehydrochlorothiazide olmesartan- hydrochlorothiazide olopatadine olopatadine spray QL omega-3 acid ethyl esters PA omeprazole ondansetron QL ONZETRA XSAIL ST OPSUMIT SGM ORACEA PA ORALAIR PA ORENITRAM SGM ORFADIN SGM oseltamivir QL OSPHENA OTEZLA SGM OVIDREL oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone QL oxycodoneacetaminophen QL OXYCONTIN QL peroxide glimepiride lamotrigine NAFTIN OZEMPIC erythromycins glipizide lamotrigine ext-rel naloxone injection ESBRIET SGM glipizide ext-rel lansoprazole NAMZARIC P escitalopram esomeprazole ESTRACE CREAM estradiol estradiol-norethindrone ESTRING estropipate eszopiclone glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLYXAMBI GONAL-F PA GRALISE ST granisetron QL lanthanum carbonate LASTACAFT latanoprost LATUDA ST LETAIRIS SGM levalbuterol tartrate CFC-free aerosol QL naproxen naratriptan QL NARCAN NASAL SPRAY NATAZIA nateglinide neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- LEVEMIR ethinyl estradioldrospirenone guanfacine ext-rel QL levetiracetam ext-rel NEUPRO GRASTEK PA levetiracetam dexamethasone ethinyl estradioldrospirenone-levomefolate H levocarnitine NEVANAC levofloxacin niacin ext-rel ethinyl estradiol- HARVONI SGM levothyroxine nifedipine ext-rel levonorgestrel HUMATROPE SGM LIALDA nitrofurantoin ethinyl estradiolnorelgestromin ethinyl estradiolnorethindrone acetate ethinyl estradiolnorethindrone acetate-iron ethinyl estradiol-norgestimate ethosuximide EUCRISA ST EVAMIST EVOTAZ QL ezetimibe ezetimibe-simvastatin HUMIRA SGM HUMULIN R U-500 hydrochlorothiazide hydrocodoneacetaminophen QL hydrocortisone hydrocortisone butyrate QL hydrocortisone enema hydromorphone QL hydromorphone ext-rel QL HYSINGLA ER QL linezolid LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE losartan losartan-hydrochlorothiazide lovastatin LUMIGAN ST LUPRON DEPOT LUZU LYRICA ST, QL nitroglycerin lingual spray nitroglycerin sublingual NORVIR QL NOVOEIGHT NOVOLIN 70/30 OTC NOVOLIN N OTC NOVOLIN R OTC NOVOLOG NOVOLOG MIX 70/30 NUCALA NUCYNTA QL NUCYNTA ER QL NUEDEXTA PA NUVARING 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 PREMARIN CREAM I ibandronate M F IBRANCE SGM MAXIDEX NUWIQ FARXIGA ILEVRO meclizine nystatin PREMPHASE fenofibrate imatinib mesylate SGM medroxyprogesterone PREMPRO fenofibric acid imiquimod megestrol acetate

7 prenatal vitamins REYATAZ QL sulfamethoxazole- TOVIAZ ST VESICARE ST PREZCOBIX QL RHOPRESSA trimethoprim TRACLEER SGM VIBERZI PREZISTA QL ribavirin SGM sulfasalazine tramadol QL VICTOZA primidone risedronate sulfasalazine delayed-rel tramadol ext-rel QL VIIBRYD ST PROAIR HFA QL risperidone sumatriptan QL TRAVATAN Z ST VIMPAT PROAIR RESPICLICK QL rivastigmine SUPRAX trazodone VIOKACE probenecid rivastigmine transdermal SUPREP TRELEGY ELLIPTA QL VOSEVI 2 SGM prochlorperazine rizatriptan QL SYMBICORT QL TRESIBA VRAYLAR ST PROCRIT SGM ropinirole SYMLINPEN tretinoin PA VYVANSE QL PROCTOFOAM-HC ropinirole ext-rel SYNJARDY triamcinolone progesterone, micronized rosuvastatin SYNJARDY XR triamcinolone nasal W PROLIA RYDAPT SGM SYNTHROID spray QL warfarin promethazine triamterenepropranolol S T hydrochlorothiazide X propranolol ext-rel SAFYRAL tacrolimus PA trimethobenzamide XARELTO PULMICORT SANCUSO PA, QL tamsulosin TRINTELLIX ST XELJANZ SGM FLEXHALER QL SAVELLA TAZORAC PA TRIUMEQ QL XELJANZ XR SGM selegiline TECFIDERA SGM trospium XIFAXAN 550 MG Q SEREVENT QL TEKTURNA ST trospium ext-rel XIGDUO XR QTERN sertraline TEKTURNA HCT ST TRULICITY XIIDRA quetiapine sevelamer carbonate telmisartan TRUVADA QL XTANDI SGM quetiapine ext-rel sildenafil SGM telmisartan- TYMLOS SGM quinapril SILENOR ST hydrochlorothiazide TYSABRI Z quinapril-hydrochlorothiazide SIMBRINZA terazosin zafirlukast QVAR QL simvastatin terbinafine tablet U ZARXIO SGM QVAR REDIHALER QL SKYLA testosterone gel PA UCERIS ZEJULA SGM SOLIQUA testosterone solution PA ULORIC ST ZEMBRACE R SOMATULINE DEPOT SGM tetrabenazine SGM UPTRAVI SGM SYMTOUCH ST RAGWITEK PA SOMAVERT SGM tetracycline ZENPEP raloxifene SOOLANTRA PA tiagabine V zileuton ext-rel ramipril sotalol timolol maleate solution valacyclovir ziprasidone RANEXA SPIRIVA QL TIVICAY QL valganciclovir zolmitriptan QL ranitidine spironolactone- TOBRADEX OINTMENT valproic acid zolpidem RAPAFLO ST hydrochlorothiazide TOBRADEX ST valsartan zolpidem ext-rel rasagiline SPRYCEL SGM tobramycin valsartan-hydrochlorothiazide zolpidem sublingual RASUVO SGM STELARA tobramycin inhalation VARUBI QL ZOMIG NASAL SPRAY QL REBIF SGM SUBCUTANEOUS SGM solution SGM VASCEPA PA zonisamide REBINYN STIOLTO RESPIMAT QL tobramycin-dexamethasone VELPHORO ST ZUBSOLV QL RELENZA QL STRIBILD QL TOLAK VELTASSA ZYCLARA repaglinide STRIVERDI RESPIMAT QL tolterodine VEMLIDY ZYLET REPATHA SGM SUBOXONE FILM QL tolterodine ext-rel venlafaxine ZYTIGA SGM RESTASIS SUBSYS PA topiramate venlafaxine ext-rel capsule RETIN-A MICRO PA sulfacetamide torsemide verapamil ext-rel PREFERRED ALTERNATIVES LIST 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 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 ALLISON MEDICAL INSULIN SYRINGES 7 ALORA ALPROLIX ALTOPREV ALVESCO AMRIX ANDROGEL 1% ANGELIQ ANTARA APEXICON E APIDRA ARMOUR THYROID BD ULTRAFINE INSULIN SYRINGES OTC estradiol, DIVIGEL, EVAMIST, MINIVELLE Consult doctor 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

8 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ARTHROTEC ASACOL HD celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT ST balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA BYETTA CAFERGOT 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 ASCENSIA STRIPS AND KITS 6 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 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 CAMBIA CARAC CARDIZEM CARDIZEM CD CARDIZEM LA (and its generics) 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 diclofenac sodium, meloxicam, naproxen fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA diltiazem ext-rel (except generic CARDIZEM LA) diltiazem ext-rel (except generic CARDIZEM LA) diltiazem ext-rel (except generic CARDIZEM LA) 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 butalbital-acetaminophencaffeine capsule BYDUREON diclofenac sodium, naproxen OZEMPIC, TRULICITY, VICTOZA DORYX MPC DULERA DUTOPROL doxycycline hyclate ADVAIR QL, BREO ELLIPTA QL, SYMBICORT QL metoprolol succinate ext-rel WITH hydrochlorothiazide

9 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* DYRENIUM EDARBI, EDARBYCLOR EDLUAR E.E.S. GRANULES EFFEXOR XR amiloride 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 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 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 GLUMETZA HELIXATE FS HORIZANT HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 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 metformin, metformin ext-rel ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ gabapentin, GRALISE ST FIASP, NOVOLOG NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 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

10 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* MENEST MENOSTAR MIACALCIN INJECTION MIACALCIN NASAL SPRAY 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 estradiol, estropipate, PREMARIN estradiol alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO SGM, PROLIA, TYMLOS SGM calcitonin-salmon 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 ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS OSENI OWEN MUMFORD NEEDLES 7 OXYTROL PANCREAZE PENNSAID PERRIGO NEEDLES 7 PERTZYE PEXEVA PLAVIX PRADAXA PRALUENT PRECISION XTRA STRIPS AND KITS 6 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 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 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

11 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* RIMSO-50 Consult doctor ULTIMED INSULIN SYRINGES 7 BD ULTRAFINE INSULIN SYRINGES OTC RIOMET metformin, metformin ext-rel ULTIMED NEEDLES 7 BD ULTRAFINE NEEDLES OTC ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST UROXATRAL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ST SAIZEN GENOTROPIN SGM, HUMATROPE SGM VALCYTE valganciclovir 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 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 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 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 TRUETEST STRIPS AND KITS 6 TRUETRACK STRIPS AND KITS 6 TUDORZA 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 ZOLPIMIST ZONEGRAN ZUPLENZ 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

12 DRUG NAME(S) ZYFLO, ZYFLO CR PREFERRED OPTION(S)* montelukast, zafirlukast, zileuton ext-rel 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