USAble Administrators Standard with Step Drug List

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1 October 2018 USAble Administrators Standard with Step 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 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. 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. ANALGESICS NSAIDs diclofenac sodium meloxicam naproxen NSAIDs, diclofenac sodium-misoprostol 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 BELBUCA QL BUTRANS QL FENTORA PA 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 clarithromycin clarithromycin ext-rel erythromycins DIFICID ST, QL FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel

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

3 ANTIPARKINSONIAN amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone entacapone pramipexole pramipexole ext-rel rasagiline ropinirole ropinirole ext-rel selegiline NEUPRO ANTIPSYCHOTICS ATYPICALS aripiprazole clozapine olanzapine quetiapine quetiapine ext-rel risperidone ziprasidone ABILIFY MAINTENA ARISTADA LATUDA ST VRAYLAR ST ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphetamine mixed salts QL amphetaminedextroamphetamine mixed salts ext-rel QL atomoxetine QL guanfacine ext-rel QL methylphenidate QL methylphenidate ext-rel QL VYVANSE QL FIBROMYALGIA LYRICA ST, QL SAVELLA HUNTINGTON'S DISEASE tetrabenazine SGM AUSTEDO SGM HYPNOTICS NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel zolpidem sublingual BELSOMRA ST TRICYCLICS SILENOR ST MIGRAINE ERGOTAMINE DERIVATIVES ergotamine-caffeine SELECTIVE SEROTONIN AGONISTS eletriptan QL naratriptan QL rizatriptan QL sumatriptan QL zolmitriptan QL ONZETRA XSAIL ST ZEMBRACE SYMTOUCH ST ZOMIG NASAL SPRAY QL MULTIPLE SCLEROSIS glatiramer SGM AUBAGIO SGM BETASERON SGM COPAXONE 40 MG SGM GILENYA SGM REBIF SGM TECFIDERA SGM TYSABRI MUSCULOSKELETAL THERAPY cyclobenzaprine NARCOLEPSY armodafinil PA POSTHERPETIC NEURALGIA (PHN) GRALISE ST PSYCHOTHERAPEUTIC - MISCELLANEOUS OPIOID ANTAGONISTS naloxone injection NARCAN NASAL SPRAY PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet QL SUBOXONE FILM QL ZUBSOLV QL PSEUDOBULBAR AFFECT NUEDEXTA PA VASOMOTOR SYMPTOM paroxetine mesylate ENDOCRINE AND METABOLIC ACROMEGALY SOMATULINE DEPOT SGM SOMAVERT SGM ANDROGENS testosterone gel PA testosterone solution PA ANDRODERM PA ANDROGEL 1.62% PA ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE JANUMET JANUMET XR JENTADUETO JENTADUETO XR INCRETIN MIMETIC OZEMPIC TRULICITY VICTOZA INCRETIN MIMETIC AGENT / INSULIN SOLIQUA INSULINS BASAGLAR FIASP HUMULIN R U-500 LEVEMIR NOVOLIN 70/30 OTC NOVOLIN N OTC NOVOLIN R OTC NOVOLOG NOVOLOG MIX 70/30 TRESIBA INSULIN SENSITIZERS pioglitazone INSULIN SENSITIZER / BIGUANIDE pioglitazone-metformin INSULIN SENSITIZER / SULFONYLUREA pioglitazone-glimepiride MEGLITINIDES nateglinide repaglinide SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA INVOKANA SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE INVOKAMET INVOKAMET XR XIGDUO XR SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR QTERN SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD ULTRAFINE INSULIN SYRINGES AND NEEDLES OTC DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM ONETOUCH ULTRA STRIPS AND KITS 4 OTC ONETOUCH VERIO STRIPS AND KITS 4 OTC CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate risedronate CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO SGM TYMLOS SGM MISCELLANEOUS PROLIA CARNITINE DEFICIENCY levocarnitine CONTRACEPTIVES MONOPHASIC ethinyl estradiol-drospirenone ethinyl estradioldrospirenone-levomefolate ethinyl estradiolnorethindrone acetate ethinyl estradiolnorethindrone acetate-iron SAFYRAL BIPHASIC LO LOESTRIN FE TRIPHASIC ethinyl estradiol-norgestimate FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiol-levonorgestrel PROGESTIN INTRAUTERINE DEVICES KYLEENA MIRENA SKYLA TRANSDERMAL ethinyl estradiol-norelgestromin VAGINAL NUVARING ESTROGENS ORAL estradiol estropipate PREMARIN TRANSDERMAL estradiol DIVIGEL EVAMIST MINIVELLE VAGINAL estradiol ESTRACE CREAM ESTRING PREMARIN CREAM ESTROGEN / PROGESTINS ORAL estradiol-norethindrone PREMPHASE PREMPRO TRANSDERMAL CLIMARA PRO COMBIPATCH ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR DUAVEE FERTILITY REGULATORS GNRH / LHRH ANTAGONISTS CETROTIDE OVULATION STIMULANTS, GONADOTROPINS GONAL-F PA OVIDREL GAUCHER DISEASE CERDELGA SGM CEREZYME GLUCOCORTICOIDS dexamethasone

4 methylprednisolone INFLAMMATORY BOWEL tolterodine RESPIRATORY triamcinolone nasal spray QL prednisolone solution DISEASE tolterodine ext-rel DYMISTA ST, QL prednisone trospium ANAPHYLAXIS ORAL trospium ext-rel TREATMENT PHOSPHODIESTERASE-4 GLUCOSE ELEVATING balsalazide MYRBETRIQ ST epinephrine auto-injector INHIBITORS budesonide capsule TOVIAZ ST EPIPEN DALIRESP sulfasalazine GLUCAGEN HYPOKIT VESICARE ST EPIPEN JR sulfasalazine delayed-rel GLUCAGON EMERGENCY PULMONARY FIBROSIS APRISO KIT HEMATOLOGIC ANTICHOLINERGICS LIALDA ipratropium inhalation ESBRIET SGM HEREDITARY TYROSINEMIA PENTASA ANTICOAGULANTS solution QL OFEV SGM TYPE 1 UCERIS warfarin INCRUSE ELLIPTA QL ORFADIN SGM ELIQUIS SPIRIVA QL STEROID / BETA AGONIST RECTAL XARELTO HUMAN GROWTH hydrocortisone enema ANTICHOLINERGIC / BETA ADVAIR QL HORMONES mesalamine rectal HEMATOPOIETIC GROWTH AGONIST BREO ELLIPTA QL HUMATROPE SGM suspension FACTORS SHORT ACTING SYMBICORT QL NORDITROPIN SGM CANASA ARANESP SGM CORTIFOAM ipratropium-albuterol PROCRIT SGM STEROID INHALANTS PHOSPHATE BINDER inhalation solution QL ZARXIO SGM budesonide inhalation IRRITABLE BOWEL COMBIVENT RESPIMAT QL suspension QL SYNDROME calcium acetate HEMOPHILIA LONG ACTING ASMANEX QL lanthanum carbonate alosetron KOGENATE FS ANORO ELLIPTA QL FLOVENT DISKUS QL sevelamer carbonate AMITIZA KOVALTRY BEVESPI AEROSPHERE QL FLOVENT HFA QL PHOSLYRA LINZESS NOVOEIGHT STIOLTO RESPIMAT QL PULMICORT VELPHORO ST VIBERZI NUWIQ FLEXHALER QL LAXATIVES ANTICHOLINERGIC / BETA QVAR QL POTASSIUM-REMOVING PLATELET AGGREGATION AGONIST / STEROID QVAR REDIHALER QL lactulose INHIBITORS INHALANT VELTASSA peg 3350-electrolytes clopidogrel SUPREP TRELEGY ELLIPTA QL TOPICAL dipyridamole ext-rel-aspirin PROGESTINS prasugrel BETA AGONISTS, DERMATOLOGY OPIOID-INDUCED ORAL BRILINTA INHALANTS ACNE CONSTIPATION medroxyprogesterone adapalene PA MOVANTIK SHORT ACTING megestrol acetate IMMUNOLOGIC benzoyl peroxide albuterol inhalation solution QL progesterone, micronized PANCREATIC ENZYMES levalbuterol tartrate CFC-free clindamycin solution clindamycin-benzoyl peroxide CREON ALLERGENIC EXTRACTS VAGINAL aerosol QL erythromycin solution VIOKACE GRASTEK PA PROAIR HFA QL CRINONE PA erythromycin-benzoyl peroxide ZENPEP ORALAIR PA PROAIR RESPICLICK QL ENDOMETRIN PA tretinoin PA RAGWITEK PA PROTON PUMP LONG ACTING ACANYA ST SELECTIVE ESTROGEN INHIBITORS AUTOIMMUNE 5 Hand-held Active Inhalation ATRALIN PA RECEPTOR MODULATORS esomeprazole COSENTYX SGM DIFFERIN PA raloxifene SEREVENT QL lansoprazole ENBREL SGM EPIDUO OSPHENA STRIVERDI RESPIMAT QL omeprazole HUMIRA SGM RETIN-A MICRO PA Nebulized Passive Inhalation TAZORAC PA THYROID SUPPLEMENTS pantoprazole KEVZARA SGM levothyroxine DEXILANT ST OTEZLA SGM PERFOROMIST QL ACTINIC KERATOSIS SYNTHROID STEROIDS, RECTAL STELARA CYSTIC FIBROSIS fluorouracil cream 5% PROCTOFOAM-HC SUBCUTANEOUS fluorouracil solution GASTROINTESTINAL (Plaque Psoriasis and Psoriatic Arthritis tobramycin inhalation solution SGM imiquimod GENITOURINARY only) SGM ANTIEMETICS BETHKIS SGM PICATO BENIGN PROSTATIC DISEASE-MODIFYING TOLAK dronabinol PA, QL HYPERPLASIA ANTIRHEUMATIC DRUGS LEUKOTRIENE ZYCLARA granisetron QL alfuzosin ext-rel (DMARDs) MODULATORS meclizine ANTIFUNGALS metoclopramide doxazosin RASUVO SGM montelukast dutasteride ST zafirlukast ciclopirox PA ondansetron QL NUTRITIONAL / clotrimazole prochlorperazine dutasteride-tamsulosin zileuton ext-rel finasteride SUPPLEMENTS econazole promethazine tamsulosin NASAL ANTIHISTAMINES ketoconazole trimethobenzamide ELECTROLYTES terazosin azelastine spray QL nystatin SANCUSO PA, QL RAPAFLO ST potassium chloride liquid olopatadine spray QL JUBLIA PA VARUBI QL LUZU VITAMINS AND MINERALS URINARY NASAL STEROIDS / NAFTIN H2 RECEPTOR ANTAGONISTS ANTISPASMODICS PRENATAL VITAMINS flunisolide QL ANTIPSORIATICS ranitidine darifenacin ext-rel prenatal vitamins oxybutynin CITRANATAL fluticasone QL acitretin PA oxybutynin ext-rel mometasone nasal calcipotriene QL spray ST, QL methoxsalen

5 ATOPIC DERMATITIS Injectable DUPIXENT SGM Topical tacrolimus ELIDEL 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 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 SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX QUICK REFERENCE DRUG LIST A abacavir tablet QL abacavir-lamivudine QL ABILIFY MAINTENA ACANYA ST acitretin PA ACUVAIL acyclovir adapalene PA ADEMPAS SGM ADVAIR QL albuterol inhalation solution QL alendronate alfuzosin ext-rel allopurinol alosetron ALPHAGAN P amantadine amiloride AMITIZA amlodipine amlodipine-atorvastatin amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartanhydrochlorothiazide amoxicillin amoxicillin-clavulanate amphetaminedextroamphetamine mixed salts QL amphetaminedextroamphetamine mixed salts ext-rel QL ANDRODERM PA ANDROGEL 1.62% PA ANORO ELLIPTA QL APRISO ARANESP SGM aripiprazole ARISTADA armodafinil PA ASMANEX QL atenolol atomoxetine QL atorvastatin ATRALIN PA ATRIPLA QL AUBAGIO SGM AUSTEDO SGM azelastine azelastine spray QL azithromycin AZOPT B balsalazide BASAGLAR BD ULTRAFINE INSULIN SYRINGES AND NEEDLES OTC BELBUCA QL BELSOMRA ST benzoyl peroxide BESIVANCE BETASERON SGM BETHKIS SGM BETIMOL BETOPTIC S BEVESPI AEROSPHERE QL bicalutamide BIDIL BIKTARVY QL BOSULIF SGM BREO ELLIPTA QL BRILINTA brimonidine bromfenac budesonide capsule budesonide inhalation suspension QL buprenorphine-naloxone sublingual tablet QL bupropion bupropion ext-rel BUTRANS QL BYSTOLIC C CABOMETYX SGM calcipotriene QL calcitonin-salmon calcium acetate CANASA candesartan candesartanhydrochlorothiazide carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone carvedilol cefdinir cefprozil cefuroxime axetil celecoxib cephalexin CERDELGA SGM CEREZYME CETROTIDE cholestyramine ciclopirox PA CILOXAN OINTMENT CIPRODEX ciprofloxacin ciprofloxacin ext-rel citalopram CITRANATAL clarithromycin clarithromycin ext-rel CLIMARA PRO clindamycin clindamycin solution clindamycin-benzoyl peroxide clobetasol cream, foam, gel, lotion, ointment, shampoo QL clocortolone QL clopidogrel clotrimazole clozapine codeine-acetaminophen QL colchicine tablet COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT QL COMPLERA QL COPAXONE 40 MG SGM COREG CR CORLANOR CORTIFOAM COSENTYX SGM CREON CRINONE PA cromolyn sodium cyclobenzaprine D DALIRESP darifenacin ext-rel DESCOVY QL desonide QL desoximetasone QL desvenlafaxine ext-rel dexamethasone DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM DEXILANT ST diazepam rectal gel diclofenac diclofenac sodium diclofenac sodium gel 1% PA diclofenac sodium solution diclofenac sodium-misoprostol dicloxacillin DIFFERIN PA DIFICID ST, QL digoxin diltiazem ext-rel 3 dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGEL

6 donepezil lozenge PA INVOKAMET M NUCYNTA QL dorzolamide FENTORA PA INVOKAMET XR NUCYNTA ER QL MAXIDEX dorzolamide-timolol FIASP INVOKANA NUEDEXTA PA meclizine doxazosin FINACEA PA ipratropium inhalation NUVARING medroxyprogesterone doxycycline hyclate finasteride solution QL NUWIQ megestrol acetate dronabinol PA, QL FLAREX ipratropium-albuterol nystatin meloxicam DUAVEE FLOVENT DISKUS QL inhalation solution QL memantine duloxetine FLOVENT HFA QL irbesartan O mesalamine rectal DUPIXENT SGM fluconazole irbesartanhydrochlorothiazide suspension ODEFSEY QL DUREZOL flunisolide QL metformin ODOMZO SGM dutasteride ST fluocinonide QL IRESSA SGM dutasteride-tamsulosin fluorouracil cream 5% ISENTRESS QL DYMISTA ST, QL fluorouracil solution itraconazole PA fluoxetine ivermectin E fluticasone QL econazole fluvastatin J eletriptan QL FML FORTE JANUMET ELIDEL PA FML S.O.P. JANUMET XR ELIGARD SGM ELIQUIS EMVERM FORTEO SGM fosinopril fosinopril-hydrochlorothiazide JANUVIA JENTADUETO JENTADUETO XR metformin ext-rel methadone QL methoxsalen methylphenidate QL methylphenidate ext-rel QL methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole olopatadine olopatadine spray QL omega-3 acid ethyl ENBREL SGM furosemide JUBLIA PA MINIVELLE esters PA ENDOMETRIN PA FYCOMPA minocycline omeprazole entacapone K ENTRESTO G MIRENA ondansetron QL ketoconazole mirtazapine ONETOUCH ULTRA EPCLUSA SGM gabapentin ketorolac QL mometasone QL STRIPS AND KITS 4 OTC EPIDUO galantamine KEVZARA SGM mometasone nasal ONETOUCH VERIO epinephrine auto-injector galantamine ext-rel KISQALI SGM spray ST, QL STRIPS AND KITS 4 OTC EPIPEN gentamicin KISQALI FEMARA montelukast ONZETRA XSAIL ST EPIPEN JR GENVOYA QL CO-PACK SGM morphine QL OPSUMIT SGM eprosartan GILENYA SGM KOGENATE FS morphine ext-rel QL ORACEA PA ergotamine-caffeine glatiramer SGM KOVALTRY morphine suppository QL ORALAIR PA erythromycin glimepiride KYLEENA MOVANTIK ORENITRAM SGM erythromycin solution glipizide MOXEZA ORFADIN SGM erythromycin-benzoyl peroxide glipizide ext-rel L moxifloxacin oseltamivir QL erythromycins glipizide-metformin lactulose MULTAQ OSPHENA ESBRIET SGM GLUCAGEN HYPOKIT lamivudine QL MYRBETRIQ ST OTEZLA SGM escitalopram GLUCAGON EMERGENCY lamotrigine OVIDREL esomeprazole KIT lamotrigine ext-rel N oxcarbazepine ESTRACE CREAM GONAL-F PA lansoprazole nadolol estradiol GRALISE ST lanthanum carbonate NAFTIN estradiol-norethindrone granisetron QL LASTACAFT naloxone injection ESTRING GRASTEK PA latanoprost NAMZARIC estropipate guanfacine ext-rel QL LATUDA ST naproxen eszopiclone LETAIRIS SGM ethinyl estradiol-drospirenone H naratriptan QL levalbuterol tartrate CFC-free NARCAN NASAL SPRAY ethinyl estradiol- HARVONI SGM aerosol QL NATAZIA drospirenone-levomefolate HUMATROPE SGM LEVEMIR nateglinide ethinyl estradiol-levonorgestrel HUMIRA SGM levetiracetam neomycin-polymyxin B- ethinyl estradiol-norelgestromin HUMULIN R U-500 levetiracetam ext-rel bacitracin-hydrocortisone ethinyl estradiolnorethindrone acetate hydrocodone- levofloxacin hydrochlorothiazide levocarnitine neomycin-polymyxin B- dexamethasone OFEV SGM ofloxacin olanzapine olmesartan olmesartan-amlodipinehydrochlorothiazide olmesartanhydrochlorothiazide OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone QL oxycodoneacetaminophen QL OXYCONTIN QL OZEMPIC P pantoprazole paroxetine HCl paroxetine HCl ext-rel ethinyl estradiol- acetaminophen QL levothyroxine NEUPRO paroxetine mesylate norethindrone acetate-iron hydrocortisone LIALDA NEVANAC PAZEO ethinyl estradiol-norgestimate hydrocortisone butyrate QL linezolid niacin ext-rel peg 3350-electrolytes ethosuximide hydrocortisone enema LINZESS nifedipine ext-rel penicillin VK EVAMIST hydromorphone QL lisinopril nitrofurantoin PENTASA EVOTAZ QL hydromorphone ext-rel QL lisinopril-hydrochlorothiazide nitroglycerin lingual spray PERFOROMIST QL ezetimibe HYSINGLA ER QL LO LOESTRIN FE nitroglycerin sublingual phenobarbital ezetimibe-simvastatin losartan NORDITROPIN SGM phenytoin I losartan-hydrochlorothiazide F NORVIR QL phenytoin sodium extended ibandronate lovastatin NOVOEIGHT PHOSLYRA FARXIGA IBRANCE SGM LUMIGAN ST NOVOLIN 70/30 OTC PICATO fenofibrate ILEVRO LUPRON DEPOT NOVOLIN N OTC pindolol fenofibric acid imatinib mesylate SGM LUZU NOVOLIN R OTC pioglitazone fentanyl transdermal QL imiquimod LYRICA ST, QL NOVOLOG pioglitazone-glimepiride fentanyl transmucosal INCRUSE ELLIPTA QL NOVOLOG MIX 70/30 pioglitazone-metformin

7 potassium chloride liquid ranitidine SUBCUTANEOUS SGM tolterodine ext-rel venlafaxine ext-rel capsule pramipexole RAPAFLO ST STIOLTO RESPIMAT QL topiramate verapamil ext-rel pramipexole ext-rel rasagiline STRIBILD QL torsemide VESICARE ST prasugrel RASUVO SGM STRIVERDI RESPIMAT QL TOVIAZ ST VIBERZI pravastatin REBIF SGM SUBOXONE FILM QL TRACLEER SGM VICTOZA PRED MILD RELENZA QL SUBSYS PA TRADJENTA VIIBRYD ST prednisolone acetate 1% repaglinide sulfacetamide tramadol QL VIMPAT prednisolone solution REPATHA SGM sulfamethoxazole- tramadol ext-rel QL VIOKACE prednisone RESTASIS trimethoprim TRAVATAN Z ST VOSEVI 2 SGM PREMARIN RETIN-A MICRO PA sulfasalazine trazodone VRAYLAR ST PREMARIN CREAM REYATAZ QL sulfasalazine delayed-rel TRELEGY ELLIPTA QL VYVANSE QL PREMPHASE ribavirin SGM sumatriptan QL TRESIBA PREMPRO risedronate SUPRAX tretinoin PA W prenatal vitamins risperidone SUPREP triamcinolone warfarin PREZCOBIX QL rivastigmine SYMBICORT QL triamcinolone nasal WELCHOL PREZISTA QL rivastigmine transdermal SYMLINPEN spray QL primidone rizatriptan QL SYNTHROID triamterene- X PROAIR HFA QL ropinirole hydrochlorothiazide XARELTO PROAIR RESPICLICK QL ropinirole ext-rel T trimethobenzamide XIFAXAN 550 MG probenecid rosuvastatin tacrolimus PA TRINTELLIX ST XIGDUO XR prochlorperazine RYDAPT SGM tamsulosin TRIUMEQ QL XIIDRA PROCRIT SGM TAZORAC PA trospium XTANDI SGM PROCTOFOAM-HC S TECFIDERA SGM trospium ext-rel progesterone, micronized SAFYRAL TEKTURNA ST TRULICITY Z PROLIA SANCUSO PA, QL TEKTURNA HCT ST TRUVADA QL zafirlukast promethazine SAVELLA telmisartan TYMLOS SGM ZARXIO SGM propranolol selegiline telmisartan- TYSABRI ZEMBRACE propranolol ext-rel SEREVENT QL hydrochlorothiazide SYMTOUCH ST PULMICORT sertraline terazosin U ZENPEP FLEXHALER QL sevelamer carbonate terbinafine tablet UCERIS zileuton ext-rel sildenafil SGM testosterone gel PA ULORIC ST ziprasidone Q SILENOR ST testosterone solution PA UPTRAVI SGM zolmitriptan QL QTERN SIMBRINZA tetrabenazine SGM zolpidem quetiapine simvastatin tetracycline V zolpidem ext-rel quetiapine ext-rel SKYLA tiagabine valacyclovir zolpidem sublingual quinapril SOLIQUA timolol maleate solution valganciclovir ZOMIG NASAL SPRAY QL quinapril-hydrochlorothiazide SOMATULINE DEPOT SGM TIVICAY QL valproic acid zonisamide QVAR QL SOMAVERT SGM TOBRADEX OINTMENT valsartan ZUBSOLV QL QVAR REDIHALER QL SOOLANTRA PA TOBRADEX ST valsartan-hydrochlorothiazide ZYCLARA sotalol tobramycin VARUBI QL ZYLET R SPIRIVA QL tobramycin inhalation VASCEPA PA ZYTIGA SGM RAGWITEK PA spironolactone- solution SGM VELPHORO ST raloxifene hydrochlorothiazide tobramycin-dexamethasone VELTASSA ramipril SPRYCEL SGM TOLAK VEMLIDY RANEXA STELARA tolterodine venlafaxine PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY ACCU-CHEK STRIPS AND KITS 6 ACTEMRA ACTOS ADDERALL XR AEROSPAN ALCORTIN A ALEVICYN GEL, ALEVICYN KIT, ALEVICYN SG, Alevicyn solution aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA ST, VRAYLAR ST ENBREL SGM, HUMIRA SGM, KEVZARA SGM pioglitazone amphetamine-dextroamphetamine mixed salts ext-rel QL, methylphenidate ext-rel QL, VYVANSE QL ASMANEX QL, FLOVENT DISKUS QL, FLOVENT HFA QL, PULMICORT FLEXHALER QL, QVAR QL, QVAR REDIHALER QL desonide QL, hydrocortisone desonide QL, hydrocortisone ALLISON MEDICAL INSULIN SYRINGES 7 ALOQUIN ALORA ALTOPREV ALVESCO AMRIX ANDROGEL 1% ANGELIQ ANTARA BD ULTRAFINE INSULIN SYRINGES OTC desonide QL, hydrocortisone estradiol, DIVIGEL, EVAMIST, MINIVELLE atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin 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

8 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* APEXICON E desoximetasone QL, fluocinonide QL CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA) APIDRA FIASP, NOVOLOG CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA) ARMOUR THYROID levothyroxine, SYNTHROID CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA) ARTHROTEC ASACOL HD ASCENSIA STRIPS AND KITS 6 ATACAND, ATACAND HCT ATROVENT HFA AXERT AZELEX BECONASE AQ BENICAR, BENICAR HCT BENSAL HP BENZAC AC celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT ST balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ipratropium inhalation solution QL, INCRUSE ELLIPTA QL, SPIRIVA QL 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, ACANYA ST, 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, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide desonide QL, hydrocortisone adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA ST, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA 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 levocarnitine levocarnitine COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM erythromycin solution clobetasol foam QL clobetasol foam QL balsalazide 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, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST BENZIQ BETAPACE, BETAPACE AF BREEZE 2 STRIPS AND KITS 6 butalbital-acetaminophencaffeine capsule BYDUREON BYETTA CAFERGOT CARAC adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA ST, ATRALIN PA, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA sotalol 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 fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA DORYX DORYX MPC DULERA DUTOPROL DYRENIUM EDARBI, EDARBYCLOR EDLUAR E.E.S. GRANULES EFFEXOR XR ELELYSO doxycycline hyclate doxycycline hyclate ADVAIR QL, BREO ELLIPTA QL, SYMBICORT QL metoprolol succinate ext-rel WITH hydrochlorothiazide amiloride candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST erythromycins desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule CERDELGA SGM, CEREZYME

9 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ENABLEX ENTYVIO ERYPED EVZIO EXFORGE EXFORGE HCT EXTAVIA FANAPT FEMRING FETZIMA FIORICET CAPSULE fluorouracil cream 0.5% FOLLISTIM AQ FORTAMET FORTESTA FOSAMAX PLUS D FOSRENOL FREESTYLE STRIPS AND KITS 6 FROVA GENOTROPIN GLEEVEC GLUMETZA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST HUMIRA SGM erythromycins naloxone injection, NARCAN NASAL SPRAY amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE 40 MG 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 eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL HUMATROPE SGM, NORDITROPIN SGM imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM metformin, metformin ext-rel HELIXATE FS 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 NOVOLIN 70/30 OTC NOVOLIN N OTC NOVOLIN R OTC celecoxib, diclofenac sodium, meloxicam, naproxen atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR INTERMEZZO INTUNIV ISTALOL JALYN JARDIANCE 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 MICARDIS, MICARDIS HCT MILLIPRED MINOCIN NAPRELAN NATESTO NESINA NEUPOGEN 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 timolol maleate solution, BETIMOL dutasteride-tamsulosin; dutasteride ST or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ST FARXIGA, INVOKANA JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR ENBREL SGM, HUMIRA SGM, KEVZARA SGM JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR digoxin BASAGLAR, LEVEMIR, TRESIBA fentanyl transmucosal lozenge PA, FENTORA PA, SUBSYS PA atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin fentanyl transdermal QL, hydromorphone ext-rel QL, methadone QL, morphine ext-rel 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 SGM estradiol, estropipate, PREMARIN estradiol alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO SGM, PROLIA, TYMLOS SGM calcitonin-salmon candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide dexamethasone, methylprednisolone, prednisolone solution, prednisone minocycline celecoxib, diclofenac sodium, meloxicam, naproxen testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA JANUVIA, TRADJENTA ZARXIO SGM

10 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* NEXIUM NILANDRON NITROMIST NORITATE esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST bicalutamide, XTANDI SGM, ZYTIGA SGM nitroglycerin lingual spray, nitroglycerin sublingual metronidazole, FINACEA PA, SOOLANTRA PA PREFERAOB PREFEST PRENATAL PLUS PREVACID generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST NORVASC NOVACORT NOVO NORDISK NEEDLES 7 NUTROPIN AQ NUVIGIL OLEPTRO OLUX-E OLYSIO amlodipine desonide QL, hydrocortisone BD ULTRAFINE NEEDLES OTC HUMATROPE SGM, NORDITROPIN SGM armodafinil trazodone clobetasol foam QL EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM PRIMLEV PROTONIX PROTOPIC PROVENTIL HFA QNASL hydrocodone-acetaminophen QL, hydromorphone QL, morphine QL, oxycodone-acetaminophen QL, NUCYNTA QL esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST tacrolimus PA, ELIDEL PA 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 OMNARIS OMNITROPE ONGLYZA ORENCIA CLICKJECT ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS OSENI flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA ST, QL HUMATROPE SGM, NORDITROPIN SGM JANUVIA, TRADJENTA COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR RAYOS RELION INSULIN RELISTOR RIMSO-50 RIOMET ROZEREM SAIZEN SEROQUEL XR SIMPONI SPRIX 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 HUMATROPE SGM, NORDITROPIN SGM 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 diclofenac sodium, meloxicam, naproxen OWEN MUMFORD NEEDLES 7 OXYTROL PANCREAZE PENNSAID PERRIGO NEEDLES 7 PERTZYE PEXEVA PLAVIX PRADAXA PRALUENT PRECISION XTRA STRIPS AND KITS 6 PRED FORTE 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 dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD STRIANT SUMAVEL DOSEPRO SURE-TEST STRIPS AND KITS 6 SYNERDERM SYNJARDY SYNJARDY XR TALTZ TANZEUM TASIGNA TECHNIVIE TESTIM testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL desonide QL, hydrocortisone INVOKAMET, INVOKAMET XR, XIGDUO XR INVOKAMET, INVOKAMET XR, XIGDUO XR COSENTYX SGM, ENBREL SGM, HUMIRA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) SGM OZEMPIC, TRULICITY, VICTOZA 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

11 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* testosterone gel 1% 8 testosterone gel PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM TOBI TOBI PODHALER TOUJEO 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 UROXATRAL VALCYTE VALTREX tobramycin inhalation solution SGM, BETHKIS SGM tobramycin inhalation solution SGM, BETHKIS SGM BASAGLAR, LEVEMIR, TRESIBA fenofibrate, fenofibric acid fenofibrate, fenofibric acid fenofibrate, fenofibric acid BD ULTRAFINE INSULIN SYRINGES OTC INCRUSE ELLIPTA QL, SPIRIVA QL BD ULTRAFINE INSULIN SYRINGES OTC BD ULTRAFINE NEEDLES OTC alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ST valganciclovir acyclovir, valacyclovir VIEKIRA XR VITAFOL-ONE VOGELXO XELJANZ XELJANZ XR XENAZINE XOPENEX HFA ZEGERID ZEPATIER ZETIA ZETONNA ZOLPIMIST 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 ENBREL SGM, HUMIRA SGM, KEVZARA SGM ENBREL SGM, HUMIRA SGM, KEVZARA SGM tetrabenazine SGM, AUSTEDO SGM levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST 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 eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST Vanoxide-HC venlafaxine ext-rel tablet (except 225 mg) VENLAFAXINE EXT-REL TABLET (except 225 MG) adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA ST, 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 ZONEGRAN ZYFLO, ZYFLO CR 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 montelukast, zafirlukast, zileuton ext-rel VENTOLIN HFA levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL

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 Over the Counter PA Prior Authorization QL Quantity Limit SGM Specialty Guideline Management ST 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 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. 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 ONETOUCH 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

13 NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE NOTICE: Our Company complies with applicable federal and state civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, disability, or sex. We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, written information in various formats (large print, audio, accessible electronic formats, other formats), and language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator 601 Gaines Street, Little Rock, AR Phone: ; TDD: You can file a grievance in person, by mail, or by . If you need help filing a grievance our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC Phone: ; TDD: Complaint forms are available at ATTENTION: Language assistance services, free of charge, are available to you. Call ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로전화해주십시오. NOTICE /17 AR v1