For short-term medications (Up to a 30-day supply) $0 for Tier Zero medications. 10% ($10 min, $25 max) for a generic prescription before refill limit

Transcription

1 EMORY 2018

2 {Begin_Tag} {EPSIIA_Tag}W_ POS Plan Welcome to your new prescription benefit administered by CVS Caremark. Your prescription benefit is designed to bring you quality pharmacy care that will help you save money. Following is a brief summary of your prescription benefits. On the back side, you will find details about Maintenance ChoiceH, which offers two ways for you to save on your long-term medications. CVS Caremark and Emory are confident you will find value with your new prescription benefit program. Tier Zero Select generics used to treat diabetes, CHF, high blood pressure, high cholesterol and brand-name and generic smoking deterrents The Pharmacy at Emory Emory Saint Joseph s Apothecary $0 for Tier Zero medications CVS Caremark Retail Pharmacy Network For short-term medications (Up to a 30-day supply) $0 for Tier Zero medications 100% for long-term Tier Zero medications after refill limit Maintenance ChoiceH CVS Caremark Mail Service Pharmacy or CVS/pharmacy For long-term medications (Up to a 90-day supply) $0 for Tier Zero medications Generic Medications (Tier 1) 1-30 days 10% ($10 min, $25 max) days 10% ($25 min, $62.50 max) 10% ($10 min, $25 max) for a generic prescription before refill limit 100% for a long-term generic prescription after refill limit 10% ($25 min, $62.50 max) for a generic prescription Preferred Brand-Name Medications (Tier 2) 1-30 days 20% ($30 min, $75 max) days 20% ($75 min, $ max) 20% ($30 min, $75 max) for a preferred brand-name prescription before refill limit 100% for a long-term preferred brand-name prescription after refill limit 20% ($75 min, $187.50max) for a preferred brand-name prescription Non-Preferred Brand-Name Medications (Tier 3) Lifestyle Drugs Refill Limit Maximum Out-of-Pocket Web Services Customer Care 1-30 days 30% ($60 min, $120 max) days 30% ($ min, $300 max) 1-30 days 40% ($90 min, $150 max) days 40% ($ min, $375 max) None $2,300 per individual / $4,600 per family 30% ($60 min, $120 max) for a non-preferred brand-name prescription before refill limit 40% ($90 min, $150 max) for a lifestyle drug prescription before refill limit One initial fill plus one refill for long-term medications 100% for a long-term non-preferred brand-name prescription after refill limit 100% for a long-term lifestyle drug prescription after refill limit Not Applicable 30% ($ min, $300 max) for a non-preferred brand-name prescription 40% ($ min, $375 max) for a lifestyle drug prescription Register at to access tools that can help you save money and manage your prescription benefit. To register, have your Prescription Card ready. Visit or call toll-free at None 00001

3 {Begin_Tag} {EPSIIA_Tag}W_ Use Maintenance Choice to Fill Your Long-Term Medications Maintenance ChoiceH offers you choice and savings when it comes to filling long-term prescriptions. Now you have two ways to save: CVS Caremark Mail Service Pharmacy: Enjoy convenient home delivery Receive your medications in private, tamper-resistant and (when needed) temperature-controlled packaging Talk to a pharmacist by phone CVS/pharmacy: Pick up your medication at a time that is convenient for you Enjoy same-day prescription availability Talk with a pharmacist face-to-face Plus, you can easily order refills and manage your prescriptions anytime at To Get Started The following chart provides detailed steps to help you start enjoying all the benefits of Maintenance Choice. IF YOU WOULD LIKE To continue with mail service To pick up at CVS/pharmacy To sign up for mail service for the first time More information THEN You don t have to do anything. We ll continue to send your medications to your location of choice. Please let us know. You can do so quickly and easily. Choose the option that works best for you: Register or log into select a CVS/pharmacy location for pick up Visit your local CVS/pharmacy and talk to the pharmacist Call us toll-free using the number on the back of your Prescription Card, and we ll handle the rest You can do so easily online or by phone. Register or log into select Start a New Prescription, then click on FastStartH Call FastStart toll-free at We ll handle the rest Give us a call. Use the phone number on the back of your Prescription Card to call us toll-free. Before you reach your 30-day fill limit and your out-of-pocket cost increases, we will contact you to help you get started with Maintenance Choice. We ll then help you get a 90-day prescription from your doctor so you can choose to fill it through mail service or at a CVS/pharmacy SUM61_POS_v SML-SUM_61_MOOP-1014

4 January 2018 Drug List for Emory Members The Drug List for Emory Members 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 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. 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. 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. 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 OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel BELBUCA BUTRANS FENTORA HYSINGLA ER NUCYNTA NUCYNTA ER OXYCONTIN SUBSYS 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 itraconazole terbinafine tablet ANTIVIRALS CYTOMEGALOVIRUS valganciclovir HERPES acyclovir valacyclovir INFLUENZA RELENZA TAMIFLU MISCELLANEOUS clindamycin ivermectin metronidazole nitrofurantoin sulfamethoxazoletrimethoprim EMVERM SIVEXTRO XIFAXAN 550 MG ANTINEOPLASTIC HORMONAL ANTINEOPLASTIC ANTIANDROGENS bicalutamide MISCELLANEOUS VISTOGARD CARDIOVASCULAR ACE fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

5 ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC candesartan candesartanhydrochlorothiazide eprosartan irbesartan irbesartanhydrochlorothiazide losartan losartanhydrochlorothiazide olmesartan olmesartanhydrochlorothiazide telmisartan telmisartanhydrochlorothiazide valsartan valsartanhydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC amlodipine-valsartanhydrochlorothiazide olmesartan-amlodipinehydrochlorothiazide ANTIARRHYTHMICS sotalol MULTAQ ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION ezetimibe FIBRATES fenofibrate fenofibric acid HMG-CoA REDUCTASE / atorvastatin ezetimibe-simvastatin fluvastatin lovastatin pravastatin rosuvastatin simvastatin NIACINS niacin ext-rel OMEGA-3 FATTY ACIDS omega-3 acid ethyl esters VASCEPA 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 nifedipine ext-rel verapamil ext-rel CALCIUM CHANNEL BLOCKER / ANTILIPEMIC amlodipine-atorvastatin DIGITALIS GLYCOSIDES digoxin DIRECT RENIN / DIURETIC TEKTURNA TEKTURNA HCT DIURETICS amiloride furosemide hydrochlorothiazide metolazone spironolactonehydrochlorothiazide torsemide triamterenehydrochlorothiazide HEART FAILURE BIDIL CORLANOR ENTRESTO NITRATES nitroglycerin lingual spray nitroglycerin sublingual 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 VIIBRYD SEROTONIN NOREPINEPHRINE REUPTAKE (SNRIs) desvenlafaxine ext-rel duloxetine venlafaxine venlafaxine ext-rel capsule MISCELLANEOUS bupropion bupropion ext-rel mirtazapine trazodone ANTIPARKINSONIAN amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO ANTIPSYCHOTICS ATYPICALS aripiprazole clozapine olanzapine quetiapine risperidone ziprasidone ABILIFY MAINTENA ARISTADA LATUDA VRAYLAR ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel atomoxetine guanfacine ext-rel methylphenidate methylphenidate ext-rel APTENSIO XR QUILLIVANT XR VYVANSE FIBROMYALGIA LYRICA SAVELLA HYPNOTICS NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel zolpidem sublingual BELSOMRA TRICYCLICS SILENOR MIGRAINE ERGOTAMINE DERIVATIVES ergotamine-caffeine SELECTIVE SEROTONIN AGONISTS eletriptan naratriptan rizatriptan sumatriptan zolmitriptan ONZETRA XSAIL ZEMBRACE SYMTOUCH ZOMIG NASAL SPRAY SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET MUSCULOSKELETAL THERAPY cyclobenzaprine NARCOLEPSY armodafinil POSTHERPETIC NEURALGIA (PHN) GRALISE PSYCHOTHERAPEUTIC - MISCELLANEOUS OPIOID ANTAGONISTS naloxone injection NARCAN NASAL SPRAY PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet BUNAVAIL SUBOXONE FILM ZUBSOLV PSEUDOBULBAR AFFECT NUEDEXTA VASOMOTOR SYMPTOM BRISDELLE ENDOCRINE AND METABOLIC ANDROGENS testosterone gel 2% testosterone solution ANDRODERM ANDROGEL 1.62% ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) JANUVIA TRADJENTA Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

6 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE JANUMET JANUMET XR JENTADUETO JENTADUETO XR INCRETIN MIMETIC TRULICITY VICTOZA INCRETIN MIMETIC AGENT / INSULIN SOLIQUA INSULINS BASAGLAR HUMALOG HUMALOG MIX HUMULIN 70/30 HUMULIN N HUMULIN R HUMULIN R U-500 LANTUS LEVEMIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 TOUJEO TRESIBA INSULIN SENSITIZERS pioglitazone INSULIN SENSITIZER / BIGUANIDE pioglitazone-metformin INSULIN SENSITIZER / SULFONYLUREA pioglitazone-glimepiride MEGLITINIDES nateglinide repaglinide SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) FARXIGA INVOKANA JARDIANCE SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE INVOKAMET INVOKAMET XR SYNJARDY SYNJARDY XR XIGDUO XR SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR GLYXAMBI QTERN SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD ULTRAFINE INSULIN SYRINGES AND NEEDLES DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM ONETOUCH ULTRA STRIPS AND KITS ONETOUCH VERIO STRIPS AND KITS ANTIOBESITY INJECTABLE SAXENDA ORAL BELVIQ BELVIQ XR CONTRAVE CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate risedronate CALCITONINS calcitonin-salmon CARNITINE DEFICIENCY levocarnitine CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone ethinyl estradiolnorethindrone acetate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE SAFYRAL TRIPHASIC ethinyl estradiol-norgestimate FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiollevonorgestrel TRANSDERMAL ethinyl estradiolnorelgestromin VAGINAL NUVARING ESTROGENS ORAL estradiol estropipate PREMARIN TRANSDERMAL estradiol DIVIGEL EVAMIST MINIVELLE VAGINAL estradiol ESTRACE CREAM PREMARIN CREAM ESTROGEN / PROGESTINS ORAL estradiol-norethindrone PREMPHASE PREMPRO TRANSDERMAL CLIMARA PRO COMBIPATCH ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR DUAVEE GLUCOCORTICOIDS dexamethasone methylprednisolone prednisolone solution prednisone GLUCOSE ELEVATING GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT PHOSPHATE BINDER calcium acetate PHOSLYRA RENVELA VELPHORO POTASSIUM-REMOVING VELTASSA PROGESTINS ORAL medroxyprogesterone megestrol acetate progesterone, micronized VAGINAL CRINONE ENDOMETRIN SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene OSPHENA THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine trimethobenzamide DICLEGIS 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 STEROIDS, RECTAL PROCTOFOAM-HC ULCER THERAPY PYLERA GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin dutasteride dutasteride-tamsulosin finasteride tamsulosin terazosin RAPAFLO ERECTILE DYSFUNCTION ALPROSTADIL MUSE PHOSPHODIESTERASE CIALIS URINARY ANTISPASMODICS darifenacin ext-rel oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel MYRBETRIQ TOVIAZ VESICARE HEMATOLOGIC ANTICOAGULANTS warfarin ELIQUIS XARELTO PLATELET AGGREGATION clopidogrel dipyridamole ext-rel-aspirin prasugrel BRILINTA IMMUNOLOGIC ALLERGENIC EXTRACTS GRASTEK RAGWITEK Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

7 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 INCRUSE ELLIPTA SPIRIVA ANTICHOLINERGIC / BETA AGONIST SHORT ACTING ipratropium-albuterol inhalation solution COMBIVENT RESPIMAT LONG ACTING ANORO ELLIPTA BEVESPI AEROSPHERE STIOLTO RESPIMAT BETA AGONISTS, INHALANTS SHORT ACTING albuterol inhalation solution levalbuterol tartrate CFC-free aerosol PROAIR HFA PROAIR RESPICLICK LONG ACTING Hand-held Active Inhalation SEREVENT STRIVERDI RESPIMAT Nebulized Passive Inhalation PERFOROMIST DRUG NAME(S) ABILIFY ABSTRAL LEUKOTRIENE MODULATORS montelukast zafirlukast zileuton ext-rel NASAL ANTIHISTAMINES azelastine olopatadine NASAL STEROIDS / flunisolide fluticasone mometasone triamcinolone DYMISTA PHOSPHODIESTERASE-4 DALIRESP STEROID / BETA AGONIST ADVAIR BREO ELLIPTA DULERA SYMBICORT STEROID INHALANTS budesonide inhalation suspension ARNUITY ELLIPTA ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR TOPICAL DERMATOLOGY ACNE adapalene benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin ACANYA ATRALIN BENZACLIN PREFERRED OPTION(S) aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, VRAYLAR DIFFERIN EPIDUO RETIN-A MICRO TAZORAC ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod PICATO ZYCLARA ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin JUBLIA LUZU NAFTIN ANTIPSORIATICS acitretin calcipotriene methoxsalen ENSTILAR TACLONEX SUSPENSION ATOPIC DERMATITIS tacrolimus ELIDEL CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency clocortolone hydrocortisone butyrate mometasone triamcinolone High Potency desoximetasone fluocinonide Very High Potency clobetasol cream, foam, gel, lotion, ointment, shampoo ROSACEA metronidazole FINACEA fentanyl transmucosal lozenge, FENTORA, SUBSYS ACCU-CHEK STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS ACTOS pioglitazone ADDERALL XR amphetamine-dextroamphetamine mixed salts extrel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE PREFERRED OPTIONS LIST DRUG NAME(S) AEROSPAN ALCORTIN A ORACEA SOOLANTRA ALLISON MEDICAL INSULIN SYRINGES ALOQUIN ALORA MOUTH / THROAT / DENTAL PROTECTANTS EPISIL 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 ACUVAIL ILEVRO NEVANAC Steroidal dexamethasone prednisolone acetate 1% DUREZOL PREFERRED OPTION(S) FLAREX FML FORTE FML S.O.P. MAXIDEX PRED MILD BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE dorzolamide AZOPT CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC SIMBRINZA DRY EYE DISEASE RESTASIS XIIDRA PROSTAGLANDINS latanoprost LUMIGAN TRAVATAN Z SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR desonide, hydrocortisone BD ULTRAFINE INSULIN SYRINGES desonide, hydrocortisone estradiol, DIVIGEL, EVAMIST, MINIVELLE Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

8 DRUG NAME(S) PREFERRED OPTION(S) ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin ALVESCO AMRIX ANDROGEL 1% ANGELIQ ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR cyclobenzaprine testosterone gel 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% estradiol-norethindrone, PREMPHASE, PREMPRO ANTARA fenofibrate, fenofibric acid APEXICON E desoximetasone, fluocinonide APIDRA HUMALOG, NOVOLOG ARMOUR THYROID ARTHROTEC ASACOL HD levothyroxine, SYNTHROID celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA ASCENSIA STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ATROVENT HFA AXERT AZELEX BECONASE AQ BENSAL HP BENZAC AC, BENZAC W BENZIQ BETAPACE, BETAPACE AF ipratropium inhalation solution, INCRUSE ELLIPTA, SPIRIVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA desonide, hydrocortisone adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC sotalol BREEZE 2 STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS butalbital-acetaminophencaffeine capsule eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY BYDUREON TRULICITY, VICTOZA BYETTA TRULICITY, VICTOZA DRUG NAME(S) CAFERGOT CARAC PREFERRED OPTION(S) CARDIZEM diltiazem ext-rel CARDIZEM CD diltiazem ext-rel CARDIZEM LA diltiazem ext-rel CARNITOR CARNITOR SF CLINDAGEL clobetasol spray CLOBEX SPRAY COLAZAL CONTOUR NEXT STRIPS AND KITS eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA levocarnitine levocarnitine erythromycin solution clobetasol foam clobetasol foam balsalazide ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS CONTOUR STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin CYMBALTA DELZICOL DETROL LA DEXPAK desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE dexamethasone, methylprednisolone, prednisolone solution, prednisone DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide DORAL eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide DYRENIUM amiloride EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide EDLUAR E.E.S. GRANULES ENABLEX ERYPED ESTRING EVZIO eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR erythromycins darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE erythromycins estradiol, ESTRACE CREAM, PREMARIN CREAM naloxone injection, NARCAN NASAL SPRAY Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

9 DRUG NAME(S) PREFERRED OPTION(S) EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide FANAPT FEMRING FETZIMA FIORICET CAPSULE FIRST TESTOSTERONE fluorouracil cream 0.5% aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, VRAYLAR estradiol, ESTRACE CREAM, PREMARIN CREAM desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY testosterone gel 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA FML LIQUIFILM dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD FORTAMET metformin, metformin ext-rel FORTESTA FOSAMAX PLUS D FOSRENOL testosterone gel 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% alendronate, ibandronate, risedronate calcium acetate, PHOSLYRA, RENVELA, VELPHORO FREESTYLE STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS FROVA GELNIQUE eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE GLUMETZA metformin, metformin ext-rel INDOCIN celecoxib, diclofenac sodium, meloxicam, naproxen INNOPRAN XL atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR INTERMEZZO INTUNIV ISTALOL JALYN eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE timolol maleate solution, BETIMOL dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR LANOXIN TABLET (125 MCG and 250 MCG only) digoxin LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin DRUG NAME(S) PREFERRED OPTION(S) LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin LUNESTA MACRODANTIN MENEST MENOSTAR MIACALCIN INJECTION MIACALCIN NASAL SPRAY MICARDIS, MICARDIS HCT MILLIPRED MINOCIN NAPRELAN NATESTO eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR nitrofurantoin estradiol, estropipate, PREMARIN estradiol alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO 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 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% NESINA JANUVIA, TRADJENTA NEXIUM NILANDRON esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT bicalutamide, ZYTIGA NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual NORITATE NORVASC amlodipine NOVACORT metronidazole, FINACEA, SOOLANTRA desonide, hydrocortisone NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES OLEPTRO OLUX-E OMNARIS trazodone clobetasol foam flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA ONGLYZA JANUVIA, TRADJENTA OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR OWEN MUMFORD NEEDLES BD ULTRAFINE NEEDLES OXYTROL PANCREAZE PENNSAID darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE CREON, VIOKACE, ZENPEP diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL PERRIGO NEEDLES BD ULTRAFINE NEEDLES PERTZYE PEXEVA PLAVIX PRADAXA CREON, VIOKACE, ZENPEP citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, FLUOXETINE 60 MG, TRINTELLIX, VIIBRYD clopidogrel, prasugrel, BRILINTA warfarin, ELIQUIS, XARELTO Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

10 DRUG NAME(S) PRECISION XTRA STRIPS AND KITS PREFERRED OPTION(S) ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS PRED FORTE dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD PREFERAOB PREFEST PRENATAL PLUS PREVACID PROTONIX PROTOPIC PROVENTIL HFA QNASL QSYMIA RAYOS generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT tacrolimus, ELIDEL levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA BELVIQ, BELVIQ XR, CONTRAVE, SAXENDA dexamethasone, methylprednisolone, prednisolone solution, prednisone RELION INSULIN HUMULIN INSULIN, NOVOLIN INSULIN RELISTOR RHINOCORT AQUA RIMSO-50 MOVANTIK flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA Consult doctor RIOMET metformin, metformin ext-rel ROZEREM STRIANT eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR testosterone gel 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% SURE-TEST STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS TANZEUM TRULICITY, VICTOZA TESTIM testosterone gel 1% 2 testosterone gel 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% testosterone gel 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% TRICOR fenofibrate, fenofibric acid TRIGLIDE fenofibrate, fenofibric acid TRILIPIX fenofibrate, fenofibric acid TRIVIDIA INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES DRUG NAME(S) PREFERRED OPTION(S) TRUETEST STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS TRUETRACK STRIPS AND KITS TUDORZA ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS INCRUSE ELLIPTA, SPIRIVA ULTIMED INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES ULTIMED NEEDLES BD ULTRAFINE NEEDLES UROXATRAL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO VALCYTE VALTREX VANOXIDE-HC venlafaxine ext-rel tablet (except 225 mg) VENLAFAXINE EXT-REL TABLET (except 225 MG) VENTOLIN HFA VIAGRA VITAFOL-ONE VOGELXO XOPENEX HFA ZEGERID ZETONNA ZONEGRAN ZYFLO, ZYFLO CR valganciclovir acyclovir, valacyclovir adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK CIALIS generic prenatal vitamins, CITRANATAL testosterone gel 2%, testosterone solution, ANDRODERM, ANDROGEL 1.62% levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA 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, TROKENDI XR, VIMPAT montelukast, zafirlukast, zileuton ext-rel Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

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. 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 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. Select generics used to treat diabetes, heart failure, high blood pressure and high cholesterol, and diabetic supplies are at Tier 0. Select preferred brand-name medications used to treat diabetes, heart failure, high blood pressure, and high cholesterol are at Tier 1. Select non-preferred brand-name medications used to treat diabetes, heart failure, high blood pressure, and high cholesterol are at Tier 2. Select brand-name hypnotics and non-oral medications used to treat erectile dysfunction are at Tier 4. 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 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. 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 Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

12 January 2018 Advanced Control Specialty Formulary for Emory Members The CVS Caremark Advanced Control Specialty Formulary for Emory Members 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 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. 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 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 VISCOSUPPLEMENTS GEL-ONE GELSYN-3 SUPARTZ FX VISCO-3 ANTI-INFECTIVES ANTIRETROVIRAL ANTIRETROVIRAL abacavir-lamivudine lamivudine-zidovudine ATRIPLA COMPLERA DESCOVY EVOTAZ GENVOYA ODEFSEY PREZCOBIX STRIBILD TRIUMEQ TRUVADA FUSION FUZEON INTEGRASE ISENTRESS TIVICAY NON-NUCLEOSIDE REVERSE TRANSCRIPTASE nevirapine nevirapine ext-rel EDURANT INTELENCE SUSTIVA NUCLEOSIDE REVERSE TRANSCRIPTASE abacavir tablet didanosine lamivudine stavudine zidovudine EMTRIVA NUCLEOTIDE REVERSE TRANSCRIPTASE VIREAD PROTEASE lopinavir-ritonavir solution KALETRA TABLET NORVIR PREZISTA REYATAZ ANTIVIRALS HEPATITIS B entecavir tablet lamivudine BARACLUDE SOLUTION VEMLIDY HEPATITIS C ribavirin EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) HARVONI (genotypes 1, 4, 5, 6) VOSEVI 2 Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

13 ANTINEOPLASTIC ALKYLATING temozolomide ANTIMETABOLITES capecitabine HORMONAL ANTINEOPLASTIC ANTIANDROGENS XTANDI ZYTIGA LUTEINIZING HORMONE- RELEASING HORMONE (LHRH) AGONISTS leuprolide acetate ELIGARD LUPRON DEPOT ZOLADEX IMMUNOMODULATORS REVLIMID THALOMID KINASE imatinib mesylate AFINITOR BOSULIF CABOMETYX IBRANCE IRESSA KISQALI KISQALI FEMARA CO-PACK NEXAVAR RYDAPT SPRYCEL SUTENT TARCEVA TYKERB VOTRIENT MISCELLANEOUS bexarotene capsule ZOLINZA CARDIOVASCULAR ANTILIPEMICS MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN JUXTAPID PCSK9 PRALUENT REPATHA PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS OPSUMIT TRACLEER PHOSPHODIESTERASE sildenafil PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI PROSTAGLANDIN VASODILATORS ORENITRAM CENTRAL NERVOUS SYSTEM HUNTINGTON'S DISEASE tetrabenazine MULTIPLE SCLEROSIS glatiramer AUBAGIO BETASERON COPAXONE 40 MG GILENYA REBIF TECFIDERA TYSABRI ENDOCRINE AND METABOLIC ACROMEGALY SOMATULINE DEPOT SOMAVERT CALCIUM REGULATORS PARATHYROID HORMONES FORTEO TYMLOS MISCELLANEOUS PROLIA FERTILITY REGULATORS GNRH / LHRH ANTAGONISTS CETROTIDE OVULATION STIMULANTS, GONADOTROPINS chorionic gonadotropin - Novarel GONAL-F OVIDREL GAUCHER DISEASE CERDELGA CEREZYME HUMAN GROWTH HORMONES HUMATROPE HEMATOLOGIC HEMATOPOIETIC GROWTH FACTORS ARANESP PROCRIT ZARXIO HEMOPHILIA KOGENATE FS KOVALTRY NOVOEIGHT NUWIQ HEREDITARY ANGIOEDEMA RUCONEST IMMUNOLOGIC ALLERGENIC EXTRACTS ORALAIR AUTOIMMUNE See Table 1 for Indication Based Coverage Details ANKYLOSING SPONDYLITIS COSENTYX CROHN'S DISEASE CIMZIA # # After failure of PSORIASIS STELARA SUBCUTANEOUS # TALTZ # # After failure of PSORIATIC ARTHRITIS COSENTYX OTEZLA RHEUMATOID ARTHRITIS KEVZARA ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS ULCERATIVE COLITIS SIMPONI # # After failure of ALL OTHER CONDITIONS DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO IMMUNOSUPPRESSANTS ANTIMETABOLITES mycophenolate mofetil mycophenolate sodium CALCINEURIN cyclosporine cyclosporine, modified tacrolimus RAPAMYCIN DERIVATIVES sirolimus tablet RAPAMUNE SOLUTION RESPIRATORY CYSTIC FIBROSIS tobramycin inhalation solution BETHKIS PULMONARY FIBROSIS ESBRIET OFEV TOPICAL DERMATOLOGY ATOPIC DERMATITIS DUPIXENT MOUTH / THROAT / DENTAL PROTECTANTS MUGARD QUICK REFERENCE DRUG LIST A C D F abacavir tablet abacavir-lamivudine AFINITOR ARANESP ATRIPLA AUBAGIO B BARACLUDE SOLUTION BETASERON BETHKIS bexarotene capsule BOSULIF CABOMETYX capecitabine CERDELGA CEREZYME CETROTIDE chorionic gonadotropin - Novarel CIMZIA COMPLERA COPAXONE 40 MG COSENTYX cyclosporine cyclosporine, modified DESCOVY didanosine DUPIXENT E EDURANT ELIGARD EMTRIVA entecavir tablet EPCLUSA ESBRIET EVOTAZ FORTEO FUZEON G GEL-ONE GELSYN-3 GENVOYA GILENYA glatiramer GONAL-F H HARVONI HUMATROPE I IBRANCE imatinib mesylate INTELENCE IRESSA ISENTRESS J JUXTAPID K KALETRA TABLET KEVZARA KISQALI Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

14 KISQALI FEMARA CO-PACK KOGENATE FS KOVALTRY L lamivudine lamivudine-zidovudine LETAIRIS leuprolide acetate lopinavir-ritonavir solution LUPRON DEPOT M MUGARD mycophenolate mofetil mycophenolate sodium N nevirapine nevirapine ext-rel NEXAVAR NORVIR NOVOEIGHT NUWIQ O ODEFSEY OFEV OPSUMIT ORALAIR ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS ORENITRAM OTEZLA OVIDREL P PRALUENT PREZCOBIX PREZISTA PROCRIT PROLIA R RAPAMUNE SOLUTION RASUVO REBIF REPATHA REVLIMID REYATAZ ribavirin RUCONEST RYDAPT S sildenafil SIMPONI sirolimus tablet SOMATULINE DEPOT SOMAVERT SPRYCEL stavudine STELARA SUBCUTANEOUS STRIBILD SUPARTZ FX SUSTIVA SUTENT T tacrolimus TALTZ TARCEVA TECFIDERA temozolomide tetrabenazine THALOMID TIVICAY tobramycin inhalation solution TRACLEER TRIUMEQ TRUVADA TYKERB TYMLOS TYSABRI U UPTRAVI V VEMLIDY VIREAD VISCO-3 VOSEVI 2 VOTRIENT X XTANDI Z ZARXIO zidovudine ZOLADEX ZOLINZA ZYTIGA PREFERRED OPTIONS FOR EXCLUDED SPECIALTY MEDICATIONS 3 DRUG NAME(S) PREFERRED OPTION(S) DRUG NAME(S) PREFERRED OPTION(S) ADCIRCA sildenafil OMNITROPE HUMATROPE BERINERT RUCONEST ORTHOVISC GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 BRAVELLE GONAL-F OTREXUP RASUVO DAKLINZA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) ELELYSO EUFLEXXA EXTAVIA FOLLISTIM AQ GENOTROPIN GLEEVEC HELIXATE FS HYALGAN CERDELGA, CEREZYME GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA, TYSABRI GONAL-F HUMATROPE imatinib mesylate, BOSULIF, SPRYCEL KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2 MONOVISC NEUPOGEN NORDITROPIN NUTROPIN AQ GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 ZARXIO HUMATROPE HUMATROPE PEGASYS PROGRAF REVATIO SAIZEN SANDOSTATIN LAR SYNVISC, SYNVISC-ONE TASIGNA Consult doctor tacrolimus sildenafil HUMATROPE SOMATULINE DEPOT, SOMAVERT GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 imatinib mesylate, BOSULIF, SPRYCEL TECHNIVIE EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) TOBI TOBI PODHALER tobramycin inhalation solution, BETHKIS tobramycin inhalation solution, BETHKIS VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) VIEKIRA XR EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) XENAZINE tetrabenazine ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) OLYSIO EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

15 TABLE 1 - PREFERRED OPTIONS FOR INDICATION BASED AUTOIMMUNE EXCLUDED MEDICATIONS CONDITION EXCLUDED DRUG NAME(S) PREFERRED OPTION(S) ANKYLOSING SPONDYLITIS CROHN'S DISEASE PSORIASIS PSORIATIC ARTHRITIS RHEUMATOID ARTHRITIS CIMZIA SIMPONI ENTYVIO STELARA COSENTYX OTEZLA CIMZIA ORENCIA CLICKJECT ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS SIMPONI STELARA SUBCUTANEOUS ACTEMRA CIMZIA KINERET ORENCIA INTRAVENOUS SIMPONI XELJANZ XELJANZ XR COSENTYX CIMZIA # STELARA SUBCUTANEOUS # TALTZ # COSENTYX OTEZLA KEVZARA ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS ULCERATIVE COLITIS ENTYVIO SIMPONI # ALL OTHER CONDITIONS ACTEMRA KINERET ORENCIA CLICKJECT ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS # After failure of Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

16 This list does not contain all Specialty Products. If you want to verify if you have a prescription for a Specialty product that must be filled through CVS Specialty Pharmacy, please go to or call CVS Caremark Customer Service at for assistance. 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. 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. 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 An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. Emory or CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with Emory or CVS Caremark. 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 CVS Caremark. All rights reserved ACSF Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.