State of West Virginia PEIA PPB Plans A, B, C and D

Transcription

1 State of West Virginia PEIA PPB Plans A, B, C and D October 2017 The State of West Virginia PEIA PPB Plans A, B, C and D is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an allinclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. 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. Your prescription benefit plan design may alter coverage of certain products or vary copay 1 amounts based on the condition being treated. For specific information regarding your prescription benefit coverage and copay 1 information, please visit or contact a CVS Caremark Customer Care representative. CVS Caremark 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 to the market. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. 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. The member's prescription benefit plan design may alter coverage of certain products or vary copay 1 amounts based on the condition being treated This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market. 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. Log in to to check coverage and copay 1 information for a specific medicine. ANALGESICS NSAIDs diclofenac sodium meloxicam naproxen NSAIDs, diclofenac sodiummisoprostol NSAIDs, TOPICAL diclofenac sodium solution VOLTAREN GEL COX-2 celecoxib GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC PA, ST OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal PA, fentanyl transmucosal lozenge PA, hydrocodoneacetaminophen hydromorphone PA, hydromorphone ext-rel PA, methadone PA, morphine PA, morphine ext-rel PA, morphine suppository PA, oxycodone PA, oxycodoneacetaminophen tramadol PA, tramadol ext-rel PA, BUTRANS PA, FENTORA PA, HYSINGLA ER PA, NUCYNTA PA, NUCYNTA ER PA, OXYCONTIN PA, SUBSYS PA, ANTI-INFECTIVES ANTIBACTERIALS CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX ERYTHROMYCINS / MACROLIDES azithromycin clarithromycin clarithromycin ext-rel erythromycins DIFICID FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel levofloxacin moxifloxacin PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK TETRACYCLINES doxycycline hyclate minocycline tetracycline ANTIFUNGALS fluconazole

2 itraconazole terbinafine tablet ANTIRETROVIRAL ANTIRETROVIRAL abacavir-lamivudine ATRIPLA COMPLERA DESCOVY PA EVOTAZ GENVOYA PA ODEFSEY PA PREZCOBIX STRIBILD TRIUMEQ TRUVADA INTEGRASE ISENTRESS TIVICAY NUCLEOSIDE REVERSE TRANSCRIPTASE abacavir tablet lamivudine PROTEASE NORVIR PREZISTA REYATAZ ANTIVIRALS CYTOMEGALOVIRUS valganciclovir HEPATITIS B VEMLIDY HEPATITIS C ribavirin PA, SP EPCLUSA (genotypes 2, 3) PA, SP HARVONI (genotypes 1, 4, 5, 6) PA, SP HERPES acyclovir valacyclovir INFLUENZA RELENZA TAMIFLU MISCELLANEOUS clindamycin ivermectin metronidazole nitrofurantoin sulfamethoxazoletrimethoprim EMVERM PA SIVEXTRO XIFAXAN 550 MG ANTINEOPLASTIC HORMONAL ANTINEOPLASTIC ANTIANDROGENS bicalutamide ZYTIGA PA KINASE imatinib mesylate PA, SP BOSULIF PA, SP CABOMETYX PA, SP SPRYCEL PA, SP MISCELLANEOUS VISTOGARD CARDIOVASCULAR ACE fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC fosinoprilhydrochlorothiazide lisinoprilhydrochlorothiazide quinaprilhydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC candesartan / candesartanhydrochlorothiazide eprosartan irbesartan / irbesartanhydrochlorothiazide losartan / losartanhydrochlorothiazide telmisartan / telmisartanhydrochlorothiazide valsartan / valsartanhydrochlorothiazide BENICAR / BENICAR HCT ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER amlodipine-telmisartan amlodipine-valsartan AZOR ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC amlodipine-valsartanhydrochlorothiazide TRIBENZOR ANTIARRHYTHMICS sotalol MULTAQ ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION ezetimibe FIBRATES fenofibrate fenofibric acid HMG-CoA REDUCTASE / atorvastatin fluvastatin lovastatin pravastatin rosuvastatin simvastatin VYTORIN MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN JUXTAPID PA, SP NIACINS niacin ext-rel OMEGA-3 FATTY ACIDS omega-3 acid ethyl esters VASCEPA PCSK9 REPATHA PA, SP BETA-BLOCKERS atenolol carvedilol metoprolol succinate ext-rel metoprolol tartrate nadolol pindolol propranolol propranolol ext-rel BYSTOLIC COREG CR CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel 2 nifedipine ext-rel verapamil ext-rel CALCIUM CHANNEL BLOCKER / ANTILIPEMIC amlodipine-atorvastatin DIGITALIS GLYCOSIDES digoxin DIRECT RENIN / DIURETIC TEKTURNA PA, ST / TEKTURNA HCT PA, ST DIURETICS amiloride furosemide hydrochlorothiazide metolazone spironolactonehydrochlorothiazide torsemide triamterenehydrochlorothiazide HEART FAILURE BIDIL CORLANOR PA ENTRESTO PA NITRATES nitroglycerin lingual spray nitroglycerin sublingual NITROLINGUAL PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS PA, SP TRACLEER PA, SP PHOSPHODIESTERASE sildenafil PA, SP PROSTAGLANDIN VASODILATORS ORENITRAM PA, SP SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS PA, SP MISCELLANEOUS RANEXA CENTRAL NERVOUS SYSTEM ANTICONVULSANTS carbamazepine carbamazepine ext-rel diazepam rectal gel divalproex sodium divalproex sodium ext-rel ethosuximide gabapentin lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone tiagabine topiramate valproic acid zonisamide FYCOMPA OXTELLAR XR TROKENDI XR VIMPAT ANTIDEMENTIA donepezil galantamine galantamine ext-rel memantine rivastigmine rivastigmine transdermal NAMENDA XR NAMZARIC ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline FLUOXETINE 60 MG TRINTELLIX PA, ST VIIBRYD PA, ST SEROTONIN NOREPINEPHRINE REUPTAKE (SNRIs) 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 ropinirole ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO ANTIPSYCHOTICS ATYPICALS aripiprazole clozapine olanzapine quetiapine

3 risperidone ziprasidone ABILIFY MAINTENA ARISTADA LATUDA SEROQUEL XR ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphetamine mixed salts PA, amphetaminedextroamphetamine mixed salts ext-rel PA, guanfacine ext-rel methylphenidate PA, methylphenidate ext-rel PA, APTENSIO XR PA, QUILLIVANT XR PA, STRATTERA PA, VYVANSE PA, FIBROMYALGIA LYRICA PA, ST SAVELLA HUNTINGTON'S DISEASE tetrabenazine PA, SP HYPNOTICS NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel zolpidem sublingual BELSOMRA PA, ST, TRICYCLICS MIGRAINE ERGOTAMINE DERIVATIVES ergotamine-caffeine SELECTIVE SEROTONIN AGONISTS naratriptan rizatriptan sumatriptan zolmitriptan ONZETRA XSAIL PA, ST, RELPAX PA, ST, ZEMBRACE SYMTOUCH PA, ST, SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET PA, ST, MULTIPLE SCLEROSIS glatiramer PA, SP AUBAGIO PA, SP BETASERON PA, SP COPAXONE 40 MG PA, SP GILENYA PA, SP REBIF PA, SP TECFIDERA PA, SP MUSCULOSKELETAL THERAPY cyclobenzaprine NARCOLEPSY armodafinil PA, POSTHERPETIC NEURALGIA (PHN) GRALISE PA, ST HORIZANT PA, ST PSYCHOTHERAPEUTIC - MISCELLANEOUS OPIOID ANTAGONISTS naloxone injection NARCAN NASAL SPRAY PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet PA, SUBOXONE FILM PA, PSEUDOBULBAR AFFECT NUEDEXTA VASOMOTOR SYMPTOM BRISDELLE ENDOCRINE AND METABOLIC ACROMEGALY SOMATULINE DEPOT PA SOMAVERT PA ANDROGENS testosterone gel 2% PA ANDRODERM PA ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN BIGUANIDES metformin metformin ext-rel (generic of GLUCOPHAGE XR) BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE JANUMET JANUMET XR JENTADUETO JENTADUETO XR INCRETIN MIMETIC TRULICITY VICTOZA INCRETIN MIMETIC AGENT / INSULIN SOLIQUA INSULINS BASAGLAR HUMULIN R U-500 LEVEMIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R 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) FARXIGA JARDIANCE SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE XIGDUO XR SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD ULTRAFINE INSULIN SYRINGES AND NEEDLES ONETOUCH ULTRA STRIPS AND KITS 3 ONETOUCH VERIO STRIPS AND KITS 3 CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate risedronate ATELVIA CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO PA, SP CARNITINE DEFICIENCY levocarnitine CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone ethinyl estradiolnorethindrone acetate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE SAFYRAL TRIPHASIC ethinyl estradiolnorgestimate FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiollevonorgestrel TRANSDERMAL ethinyl estradiolnorelgestromin VAGINAL NUVARING ESTROGENS ORAL estradiol estropipate PREMARIN TRANSDERMAL estradiol DIVIGEL EVAMIST MINIVELLE VAGINAL ESTRACE CREAM PREMARIN CREAM VAGIFEM ESTROGEN / PROGESTINS ORAL estradiol-norethindrone PREMPHASE PREMPRO TRANSDERMAL CLIMARA PRO COMBIPATCH ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR DUAVEE GLUCOCORTICOIDS dexamethasone methylprednisolone prednisone GLUCOSE ELEVATING GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES HUMATROPE PA, SP NORDITROPIN PA, SP PHOSPHATE BINDER calcium acetate PHOSLYRA RENVELA VELPHORO POTASSIUM-REMOVING VELTASSA PROGESTINS ORAL medroxyprogesterone progesterone, micronized MEGACE ES SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene OSPHENA THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine trimethobenzamide DICLEGIS

4 SANCUSO VARUBI H2 RECEPTOR ANTAGONISTS ranitidine INFLAMMATORY BOWEL DISEASE ORAL balsalazide budesonide capsule sulfasalazine sulfasalazine delayed-rel APRISO LIALDA PENTASA UCERIS RECTAL hydrocortisone enema mesalamine rectal suspension CANASA CORTIFOAM IRRITABLE BOWEL SYNDROME AMITIZA LINZESS LOTRONEX VIBERZI LAXATIVES lactulose peg 3350-electrolytes SUPREP OPIOID-INDUCED CONSTIPATION MOVANTIK PANCREATIC ENZYMES CREON VIOKACE ZENPEP PROTON PUMP esomeprazole lansoprazole omeprazole pantoprazole DEXILANT PA, ST STEROIDS, RECTAL PROCTOFOAM-HC ULCER THERAPY PYLERA GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin dutasteride dutasteride-tamsulosin finasteride tamsulosin terazosin CARDURA XL PA, ST RAPAFLO PA, ST URINARY ANTISPASMODICS darifenacin ext-rel oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel MYRBETRIQ PA, ST TOVIAZ PA, ST VESICARE PA, ST HEMATOLOGIC ANTICOAGULANTS warfarin ELIQUIS XARELTO HEMATOPOIETIC GROWTH FACTORS PROCRIT PA, SP ZARXIO PA, SP PLATELET AGGREGATION clopidogrel dipyridamole ext-rel-aspirin BRILINTA EFFIENT IMMUNOLOGIC BIOLOGIC DISEASE- MODIFYING ENBREL PA, SP HUMIRA PA, SP DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO PA, SP NUTRITIONAL / SUPPLEMENTS ELECTROLYTES potassium chloride liquid VITAMINS AND MINERALS PRENATAL VITAMINS prenatal vitamins CITRANATAL RESPIRATORY ANAPHYLAXIS TREATMENT epinephrine auto-injector EPIPEN EPIPEN JR ANTICHOLINERGICS ipratropium inhalation solution SPIRIVA ANTICHOLINERGIC / BETA AGONIST SHORT ACTING ipratropium-albuterol inhalation solution COMBIVENT RESPIMAT LONG ACTING ANORO ELLIPTA BEVESPI AEROSPHERE BETA AGONISTS, INHALANTS SHORT ACTING albuterol inhalation solution levalbuterol tartrate PROAIR HFA PROAIR RESPICLICK LONG ACTING Hand-held Active Inhalation SEREVENT STRIVERDI RESPIMAT Nebulized Passive Inhalation PERFOROMIST LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast NASAL ANTIHISTAMINES azelastine olopatadine NASAL STEROIDS / flunisolide fluticasone mometasone nasal spray triamcinolone nasal spray DYMISTA PA, ST, PHOSPHODIESTERASE-4 DALIRESP PULMONARY FIBROSIS ESBRIET PA OFEV PA STEROID / BETA AGONIST ADVAIR BREO ELLIPTA DULERA STEROID INHALANTS budesonide inhalation suspension ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR TOPICAL DERMATOLOGY ACNE adapalene PA benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin PA ACANYA PA, ST ATRALIN PA BENZACLIN DIFFERIN PA EPIDUO RETIN-A MICRO PA ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod PICATO ZYCLARA ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin JUBLIA PA LUZU NAFTIN ANTIPSORIATICS acitretin calcipotriene methoxsalen ATOPIC DERMATITIS Injectable DUPIXENT SP Topical tacrolimus PA, ST ELIDEL PA, ST CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency hydrocortisone butyrate mometasone triamcinolone CLODERM LOCOID LOTION High Potency desoximetasone fluocinonide Very High Potency clobetasol cream, foam, gel, lotion, ointment, shampoo ROSACEA metronidazole FINACEA ORACEA SOOLANTRA MOUTH / THROAT / DENTAL PROTECTANTS MUGARD PA, SP OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium olopatadine PATADAY PAZEO ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin ofloxacin sulfacetamide tobramycin BESIVANCE MOXEZA VIGAMOX ANTI-INFECTIVE / ANTI-INFLAMMATORY neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- dexamethasone tobramycindexamethasone TOBRADEX OINTMENT TOBRADEX ST ZYLET ANTI-INFLAMMATORIES Nonsteroidal bromfenac diclofenac ketorolac PROLENSA Steroidal dexamethasone prednisolone acetate 1% ALREX DUREZOL

5 LOTEMAX BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE dorzolamide AZOPT CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol COSOPT PF CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC SIMBRINZA DRY EYE DISEASE RESTASIS PA PROSTAGLANDINS latanoprost TRAVATAN Z PA, ST ZIOPTAN PA, ST SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX QUICK REFERENCE DRUG LIST A abacavir tablet abacavir-lamivudine ABILIFY MAINTENA ACANYA PA, ST acitretin acyclovir adapalene PA ADEMPAS PA, SP ADVAIR albuterol inhalation solution alendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine amiloride AMITIZA amlodipine amlodipine-atorvastatin amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartanhydrochlorothiazide amoxicillin amoxicillin-clavulanate amphetaminedextroamphetamine mixed salts PA, amphetaminedextroamphetamine mixed salts ext-rel PA, ANDRODERM PA ANORO ELLIPTA APRISO APTENSIO XR PA, aripiprazole ARISTADA armodafinil PA, ASMANEX ATELVIA atenolol atorvastatin ATRALIN PA ATRIPLA AUBAGIO PA, SP azelastine azelastine nasal spray AZILECT azithromycin AZOPT AZOR B balsalazide BASAGLAR BD ULTRAFINE INSULIN SYRINGES AND NEEDLES BELSOMRA PA, ST, BENICAR BENICAR HCT BENZACLIN benzoyl peroxide BESIVANCE BETASERON PA, SP BETIMOL BETOPTIC S BEVESPI AEROSPHERE BEYAZ bicalutamide BIDIL BOSULIF PA, SP BREO ELLIPTA BRILINTA brimonidine BRISDELLE bromfenac budesonide capsule budesonide inhalation suspension buprenorphine-naloxone sublingual tablet PA, bupropion bupropion ext-rel BUTRANS PA, BYSTOLIC C CABOMETYX PA, SP calcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartanhydrochlorothiazide carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone CARDURA XL PA, ST carvedilol cefdinir cefprozil cefuroxime axetil celecoxib cephalexin cholestyramine ciclopirox 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 CLODERM clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine tablet COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA COPAXONE 40 MG PA, SP COREG CR CORLANOR PA CORTIFOAM COSOPT PF CREON cromolyn sodium cyclobenzaprine D DALIRESP darifenacin ext-rel DESCOVY PA desonide desoximetasone dexamethasone DEXILANT PA, ST diazepam rectal gel DICLEGIS diclofenac diclofenac sodium diclofenac sodium solution diclofenac sodiummisoprostol dicloxacillin DIFFERIN PA DIFICID digoxin diltiazem ext-rel 2 dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DUAVEE DULERA duloxetine DUPIXENT SP DUREZOL dutasteride dutasteride-tamsulosin DYMISTA PA, ST, E econazole EFFIENT ELIDEL PA, ST ELIQUIS EMVERM PA ENBREL PA, SP entacapone ENTRESTO PA EPCLUSA PA, SP EPIDUO epinephrine auto-injector EPIPEN EPIPEN JR eprosartan ergotamine-caffeine erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins ESBRIET PA escitalopram esomeprazole ESTRACE CREAM estradiol estradiol-norethindrone estropipate eszopiclone ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiolnorelgestromin ethinyl estradiolnorethindrone acetate ethinyl estradiol-norgestimate ethosuximide EVAMIST EVOTAZ ezetimibe F FARXIGA fenofibrate fenofibric acid fentanyl transdermal PA, fentanyl transmucosal lozenge PA, FENTORA PA, FINACEA finasteride FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil cream 5% fluorouracil solution fluoxetine FLUOXETINE 60 MG fluticasone fluvastatin FORTEO PA, SP fosinopril fosinopril-hydrochlorothiazide furosemide FYCOMPA G gabapentin galantamine galantamine ext-rel gentamicin GENVOYA PA GILENYA PA, SP glatiramer PA, SP glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT

6 GLUCAGON EMERGENCY KIT GRALISE PA, ST granisetron guanfacine ext-rel H HARVONI PA, SP HORIZANT PA, ST HUMATROPE PA, SP HUMIRA PA, SP HUMULIN R U-500 hydrochlorothiazide hydrocodoneacetaminophen hydrocortisone hydrocortisone butyrate hydrocortisone enema hydromorphone PA, hydromorphone ext-rel PA, HYSINGLA ER PA, I ibandronate imatinib mesylate PA, SP imiquimod ipratropium inhalation solution ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorothiazide ISENTRESS itraconazole ivermectin J JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JUBLIA PA JUXTAPID PA, SP K ketoconazole ketorolac L lactulose lamivudine lamotrigine lamotrigine ext-rel lansoprazole latanoprost LATUDA LETAIRIS PA, SP levalbuterol tartrate LEVEMIR levetiracetam levetiracetam ext-rel levocarnitine levofloxacin levothyroxine LIALDA LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LOTION losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX lovastatin LUZU LYRICA PA, ST M meclizine medroxyprogesterone MEGACE ES meloxicam memantine mesalamine rectal suspension metformin metformin ext-rel (generic of GLUCOPHAGE XR) methadone PA, methoxsalen methylphenidate PA, methylphenidate ext-rel PA, methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole MINASTRIN 24 FE MINIVELLE minocycline MIRAPEX ER mirtazapine mometasone mometasone nasal spray montelukast morphine PA, morphine ext-rel PA, morphine suppository PA, MOVANTIK MOXEZA moxifloxacin MUGARD PA, SP MULTAQ MYRBETRIQ PA, ST N nadolol NAFTIN naloxone injection NAMENDA XR NAMZARIC naproxen naratriptan NARCAN NASAL SPRAY NATAZIA nateglinide neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- dexamethasone NEUPRO niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin lingual spray nitroglycerin sublingual NITROLINGUAL NORDITROPIN PA, SP NORVIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA PA, NUCYNTA ER PA, NUEDEXTA NUVARING nystatin O ODEFSEY PA OFEV PA ofloxacin olanzapine olopatadine olopatadine nasal spray omega-3 acid ethyl esters omeprazole ondansetron ONETOUCH ULTRA STRIPS AND KITS 3 ONETOUCH VERIO STRIPS AND KITS 3 ONZETRA XSAIL PA, ST, ORACEA ORENITRAM PA, SP OSPHENA oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone PA, oxycodoneacetaminophen OXYCONTIN PA, P pantoprazole paroxetine paroxetine ext-rel PATADAY PAZEO peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin potassium chloride liquid pramipexole pravastatin prednisolone acetate 1% prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins PREZCOBIX PREZISTA primidone PROAIR HFA PROAIR RESPICLICK probenecid prochlorperazine PROCRIT PA, SP PROCTOFOAM-HC progesterone, micronized PROLENSA promethazine propranolol propranolol ext-rel PULMICORT FLEXHALER PYLERA Q quetiapine QUILLIVANT XR PA, quinapril quinapril-hydrochlorothiazide QVAR R raloxifene ramipril RANEXA ranitidine RAPAFLO PA, ST RASUVO PA, SP REBIF PA, SP RELENZA RELPAX PA, ST, RENVELA repaglinide REPATHA PA, SP RESTASIS PA RETIN-A MICRO PA REYATAZ ribavirin PA, SP risedronate risperidone rivastigmine rivastigmine transdermal rizatriptan ropinirole ropinirole ext-rel rosuvastatin S SAFYRAL SANCUSO SAVELLA selegiline SEREVENT SEROQUEL XR sertraline sildenafil PA, SP SIMBRINZA simvastatin SIVEXTRO SOLIQUA SOMATULINE DEPOT PA SOMAVERT PA SOOLANTRA sotalol SPIRIVA spironolactonehydrochlorothiazide SPRYCEL PA, SP STRATTERA PA, STRIBILD STRIVERDI RESPIMAT SUBOXONE FILM PA, SUBSYS PA, sulfacetamide sulfamethoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan SUPRAX SUPREP SYMLINPEN SYNTHROID T tacrolimus PA, ST TAMIFLU tamsulosin TECFIDERA PA, SP TEKTURNA PA, ST TEKTURNA HCT PA, ST telmisartan telmisartanhydrochlorothiazide terazosin terbinafine tablet testosterone gel 2% PA tetrabenazine PA, SP tetracycline tiagabine timolol maleate solution TIVICAY TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin-dexamethasone tolterodine tolterodine ext-rel topiramate torsemide TOVIAZ PA, ST TRACLEER PA, SP TRADJENTA tramadol PA, tramadol ext-rel PA, TRAVATAN Z PA, ST trazodone TRESIBA

7 tretinoin PA TREXIMET PA, ST, triamcinolone triamcinolone nasal spray triamterenehydrochlorothiazide TRIBENZOR trimethobenzamide TRINTELLIX PA, ST TRIUMEQ TROKENDI XR trospium trospium ext-rel TRULICITY TRUVADA DRUG NAME(S) ABILIFY ABSTRAL U UCERIS ULORIC PA, ST V VAGIFEM valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothiazide VARUBI VASCEPA VELPHORO VELTASSA VEMLIDY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR fentanyl transmucosal lozenge PA,, FENTORA PA,, SUBSYS PA, ACCU-CHEK STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, ACTOS ADDERALL XR ADRENACLICK AEROSPAN ALCORTIN A ALOQUIN ALORA ALTOPREV ALVESCO AMRIX ANDROGEL ANGELIQ ANTARA APEXICON E APIDRA ARMOUR THYROID ARTHROTEC ASACOL HD pioglitazone amphetamine-dextroamphetamine mixed salts ext-rel PA,, methylphenidate ext-rel PA,, APTENSIO XR PA,, QUILLIVANT XR PA,, VYVANSE PA, epinephrine auto-injector, EPIPEN, EPIPEN JR ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR desonide desonide estradiol, DIVIGEL, EVAMIST, MINIVELLE atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR cyclobenzaprine estradiol-norethindrone, PREMPHASE, PREMPRO fenofibrate, fenofibric acid desoximetasone, fluocinonide NOVOLOG levothyroxine, SYNTHROID celecoxib or diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT PA, ST balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA venlafaxine venlafaxine ext-rel capsule verapamil ext-rel VESICARE PA, ST VIBERZI VICTOZA VIGAMOX VIIBRYD PA, ST VIMPAT VIOKACE VISTOGARD VOLTAREN GEL VYTORIN VYVANSE PA, W PREFERRED OPTIONS LIST DRUG NAME(S) warfarin WELCHOL X XARELTO XIFAXAN 550 MG XIGDUO XR Z ATACAND, ATACAND HCT ATROVENT HFA AVONEX AXERT AZELEX PA, ST BECONASE AQ BENSAL HP BENZAC AC, BENZAC W BENZIQ BETAPACE, BETAPACE AF zafirlukast ZARXIO PA, SP ZEMBRACE SYMTOUCH PA, ST, ZENPEP ZIOPTAN PA, ST ziprasidone zolmitriptan zolpidem zolpidem ext-rel zolpidem sublingual zonisamide ZYCLARA ZYLET ZYTIGA PA candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT ipratropium inhalation solution, SPIRIVA glatiramer PA, SP, AUBAGIO PA, SP, BETASERON PA, SP, COPAXONE 40 MG PA, SP, GILENYA PA, SP, REBIF PA, SP, TECFIDERA PA, SP naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL PA, ST,, RELPAX PA, ST,, ZEMBRACE SYMTOUCH PA, ST,, adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA PA, ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, flunisolide, fluticasone, mometasone nasal spray, triamcinolone nasal spray, DYMISTA PA, ST, desonide, hydrocortisone adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA PA, ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA PA, ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, sotalol BREEZE 2 STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, butalbital-acetaminophencaffeine capsule ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL PA, ST,, RELPAX PA, ST,, ZEMBRACE SYMTOUCH PA, ST,,

8 DRUG NAME(S) BYDUREON BYETTA CAFERGOT CARAC CARDIZEM CARDIZEM CD CARDIZEM LA (and its generics) CARNITOR CARNITOR SF CLINDAGEL PA, ST clobetasol spray CLOBEX SPRAY COLAZAL CONTOUR NEXT STRIPS AND KITS 4 TRULICITY, VICTOZA TRULICITY, VICTOZA ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL PA, ST,, RELPAX PA, ST,, ZEMBRACE SYMTOUCH PA, ST,, fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA diltiazem ext-rel (except generic CARDIZEM LA) diltiazem ext-rel (except generic CARDIZEM LA) diltiazem ext-rel (except generic CARDIZEM LA) levocarnitine levocarnitine erythromycin solution clobetasol foam clobetasol foam balsalazide ONETOUCH ULTRA STRIPS AND KITS 3, CONTOUR STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, CRESTOR CYMBALTA DAKLINZA DELZICOL DETROL LA DEXPAK DIOVAN, DIOVAN HCT DUTOPROL DYRENIUM EDARBI, EDARBYCLOR EDLUAR PA, ST, E.E.S. GRANULES ENABLEX atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN duloxetine, venlafaxine, venlafaxine ext-rel capsule, EPCLUSA (genotypes 2, 3) PA, SP, balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ PA, ST, TOVIAZ PA, ST, VESICARE PA, ST dexamethasone, methylprednisolone, prednisone candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT metoprolol succinate ext-rel WITH hydrochlorothiazide amiloride candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA PA, ST,, erythromycins darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ PA, ST, TOVIAZ PA, ST, VESICARE PA, ST DRUG NAME(S) ERYPED ESTRING EVZIO EXFORGE EXFORGE HCT EXTAVIA FANAPT FEMRING FETZIMA PA, ST FIORICET CAPSULE FIRST TESTOSTERONE PA fluorouracil cream 0.5% FML FORTAMET FORTESTA FOSAMAX PLUS D PA, ST FOSRENOL erythromycins ESTRACE CREAM, PREMARIN CREAM, VAGIFEM naloxone injection, NARCAN NASAL SPRAY amlodipine-telmisartan, amlodipine-valsartan, AZOR amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR glatiramer PA, SP, AUBAGIO PA, SP, BETASERON PA, SP, COPAXONE 40 MG PA, SP, GILENYA PA, SP, REBIF PA, SP, TECFIDERA PA, SP aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR ESTRACE CREAM, PREMARIN CREAM, VAGIFEM duloxetine, venlafaxine, venlafaxine ext-rel capsule, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL PA, ST,, RELPAX PA, ST,, ZEMBRACE SYMTOUCH PA, ST,, fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA dexamethasone, prednisolone acetate 1%, DUREZOL, LOTEMAX metformin, metformin ext-rel (generic of GLUCOPHAGE XR) alendronate, ibandronate, risedronate, ATELVIA calcium acetate, PHOSLYRA, RENVELA, VELPHORO FREESTYLE STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, FROVA GELNIQUE GENOTROPIN GLEEVEC GLUMETZA HUMALOG naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL PA, ST,, RELPAX PA, ST,, ZEMBRACE SYMTOUCH PA, ST,, darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, MYRBETRIQ PA, ST, TOVIAZ PA, ST, VESICARE PA, ST HUMATROPE PA, SP, NORDITROPIN PA, SP imatinib mesylate PA, SP, BOSULIF PA, SP, SPRYCEL PA, SP metformin, metformin ext-rel (generic of GLUCOPHAGE XR) NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN INCRUSE ELLIPTA INDOCIN INTERMEZZO NOVOLIN SPIRIVA celecoxib, diclofenac sodium, meloxicam, naproxen eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA PA, ST,,

9 DRUG NAME(S) INTUNIV INVOKAMET INVOKANA ISTALOL JALYN KAZANO KLOR-CON/25 KOMBIGLYZE XR LANOXIN TABLET (125 MCG and 250 MCG only) LANTUS LASTACAFT LESCOL XL LIPITOR LIVALO LUMIGAN LUNESTA MACRODANTIN Matzim LA MENEST MENOSTAR MIACALCIN INJECTION MIACALCIN NASAL SPRAY MICARDIS, MICARDIS HCT MILLIPRED MINOCIN NAPRELAN NATESTO NESINA NEUPOGEN NEXIUM NILANDRON amphetamine-dextroamphetamine mixed salts ext-rel PA,, guanfacine ext-rel, methylphenidate ext-rel PA,, APTENSIO XR PA,, QUILLIVANT XR PA,, STRATTERA PA,, VYVANSE PA, XIGDUO XR FARXIGA, JARDIANCE timolol maleate solution, BETIMOL dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, CARDURA XL PA, ST or RAPAFLO PA, ST JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR potassium chloride liquid JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR digoxin BASAGLAR, LEVEMIR, TRESIBA azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN latanoprost, TRAVATAN Z PA, ST, ZIOPTAN PA, ST eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA PA, ST,, nitrofurantoin diltiazem ext-rel (except generic CARDIZEM LA) estradiol, estropipate, PREMARIN estradiol alendronate, calcitonin-salmon, ibandronate, risedronate, ATELVIA, FORTEO PA, SP calcitonin-salmon candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT dexamethasone, methylprednisolone, prednisone minocycline celecoxib, diclofenac sodium, meloxicam, naproxen JANUVIA, TRADJENTA ZARXIO PA, ST esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT PA, ST bicalutamide, ZYTIGA PA DRUG NAME(S) NITROMIST NORITATE NORVASC NOVACORT NUTROPIN AQ OLUX-E OLYSIO OMNARIS OMNITROPE ONGLYZA OPSUMIT OSENI OXYTROL PANCREAZE PENNSAID PERTZYE PEXEVA PA, ST PLAVIX PLEGRIDY PRADAXA PRALUENT nitroglycerin lingual spray, nitroglycerin sublingual, NITROLINGUAL metronidazole, FINACEA, SOOLANTRA amlodipine desonide HUMATROPE PA, SP, NORDITROPIN PA, SP clobetasol foam flunisolide, fluticasone, mometasone nasal spray, triamcinolone nasal spray, DYMISTA PA, ST, HUMATROPE PA, SP, NORDITROPIN PA, SP JANUVIA, TRADJENTA LETAIRIS PA, SP, TRACLEER PA, SP JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ PA, ST, TOVIAZ PA, SP, VESICARE PA, ST CREON, VIOKACE, ZENPEP diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL CREON, VIOKACE, ZENPEP citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, FLUOXETINE 60 MG, TRINTELLIX PA, ST, VIIBRYD PA, ST clopidogrel, BRILINTA, EFFIENT glatiramer PA, SP, AUBAGIO PA, SP, BETASERON PA, SP, COPAXONE 40 MG PA, SP, GILENYA PA, SP, REBIF PA, SP, TECFIDERA PA, SP warfarin, ELIQUIS, XARELTO REPATHA PA, SP PRECISION XTRA ONETOUCH ULTRA STRIPS AND KITS 3, STRIPS AND KITS 4 PRED FORTE PRED MILD PREFERAOB PREFEST PRENATAL PLUS PREVACID PROTONIX PROTOPIC PA, ST PROVENTIL HFA QNASL RAYOS dexamethasone, prednisolone acetate 1%, DUREZOL, LOTEMAX dexamethasone, prednisolone acetate 1%, DUREZOL, LOTEMAX generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT PA, ST esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT PA, ST tacrolimus PA, ST, ELIDEL PA, ST levalbuterol tartrate, PROAIR HFA, PROAIR RESPICLICK flunisolide, fluticasone, mometasone nasal spray, triamcinolone nasal spray, DYMISTA PA, ST, dexamethasone, methylprednisolone, prednisone

10 DRUG NAME(S) RELION INSULIN RELISTOR RHINOCORT AQUA RIMSO-50 RIOMET ROZEREM SAIZEN STRIANT PA NOVOLIN INSULIN MOVANTIK flunisolide, fluticasone, mometasone nasal spray, triamcinolone nasal spray, DYMISTA PA, ST, Consult doctor metformin, metformin ext-rel (generic of GLUCOPHAGE XR) eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA PA, ST,, HUMATROPE PA, SP, NORDITROPIN PA, SP SURE-TEST STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, SYMBICORT TANZEUM TASIGNA TECHNIVIE TESTIM testosterone gel 1% 5 TOUJEO TRICOR TRIGLIDE PA, ST TRILIPIX ADVAIR, BREO ELLIPTA, DULERA TRULICITY, VICTOZA imatinib mesylate PA, SP, BOSULIF PA, SP, SPRYCEL PA, SP BASAGLAR, LEVEMIR, TRESIBA fenofibrate, fenofibric acid fenofibrate, fenofibric acid fenofibrate, fenofibric acid TRUETRACK ONETOUCH ULTRA STRIPS AND KITS 3, STRIPS AND KITS 4 TUDORZA UROXATRAL VALCYTE VALTREX SPIRIVA alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, CARDURA XL PA, ST, RAPAFLO PA, ST valganciclovir acyclovir, valacyclovir DRUG NAME(S) VANOXIDE-HC 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 XTANDI ZEGERID ZEPATIER ZETONNA ZONEGRAN ZUBSOLV ZYFLO, ZYFLO CR adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA PA, ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, duloxetine, venlafaxine, venlafaxine ext-rel capsule, duloxetine, venlafaxine, venlafaxine ext-rel capsule, levalbuterol tartrate, PROAIR HFA, PROAIR RESPICLICK generic prenatal vitamins, CITRANATAL tetrabenazine PA, SP levalbuterol tartrate, PROAIR RESPICLICK, PROVENTIL HFA bicalutamide, ZYTIGA PA esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT PA, flunisolide, fluticasone, mometasone nasal spray, triamcinolone nasal spray, DYMISTA PA, ST, carbamazepine, carbamazepine 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, TROKENDI XR, VIMPAT buprenorphine-naloxone sublingual tablet PA,, SUBOXONE FILM PA, montelukast, zafirlukast

11 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 may 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. Log in to to check coverage and copay 1 information for a specific medicine. * 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. PA Prior Authorization required Quantity Limits apply SP Specialty drug ST Step Therapy applies 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 Listing does not include generic CARDIZEM LA. 3 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: ONETOUCH brand test strips are the only preferred options. 5 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