MedPerform High Preferred Drug List (PDL)

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1 What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote clinically appropriate utilization of medications in a cost-effective manner. Who decides what medications make up the PDL? The list is developed and maintained by a committee comprised of physicians and pharmacists (the Pharmacy and Therapeutics Committee). Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. Are the medications listed on the PDL the only drugs my physician can prescribe for me? No. The PDL is a select list of commonly prescribed drugs and does not represent all preferred formulary medications available under your plan. The PDL does not limit your prescription coverage, but is provided to encourage the use of preferred generic and brand name drugs within major therapeutic drug classes (e.g., Cardiovascular, Diabetes, etc.). For complete formulary information, visit your Plan website or refer to the phone number listed on your benefit card. How do I get the greatest benefit from my PDL? Print out the Preferred Drug List and take it with you when visiting your physician. Ask your physician to prescribe generic medications whenever possible. All FDA approved generic drugs are considered preferred medications and should reduce your copays. When there is more than one brand name drug available for your medical condition, ask your physician to prescribe a preferred drug listed on your PDL. This should also reduce your copays. Please note: The MedImpact PDL is subject to change due to updates and availability of generic alternatives. Please refer to the MedImpact web site at for the most up-to-date PDL. The PDL is not a complete list of formulary drugs; therefore, you should refer to your plan for a complete drug list and details of any additional coverage or quantity limit restrictions that may apply to certain medications. DRUG CATEGORY EXCLUDED DRUGS (SELECTED) PREFERRED ALTERNATIVES ALLERGY ANTIHISTAMINES Bepreve, Emadine, Lastacaft, Pazeo Pataday, olopatadine NASAL CORTICOSTEROIDS Beconase AQ, Omnaris, Ticanase, Zetonna nasal budesonide, flunisolide, fluticasone, mometasone, triamcinolone, Qnasl NASAL CORTICOSTEROID AND ANTIHISTAMINE COMBINATIONS BEHAVIORAL HEALTH Ticalast azelastine, fluticasone ADHD Adzenys ER, Adzenys XR-ODT, Mydayis Adderall XR, dextroamphetamine/amphetamine Aptensio XR, Cotempla XR-ODT methylphenidate ANTIDEPRESSANTS Forfivo XL bupropion ER DERMATOLOGY Irenka Khedezla Pexeva duloxetine desvenlafaxine succinate ER, desvenlafaxine ER (Ranbaxy) paroxetine ACNE (TOPICAL) Veltin clindamycin/tretinoin, Ziana DIABETES BIGUANIDES Glumetza metformin DPP-4 INHIBITORS Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Qtern GLP-1 AGONISTS Adlyxin, Bydureon, Byetta Trulicity, Victoza SGLT-2 INHIBITORS Farxiga, Ozempic, Qtern, Segluromet, Steglujan, Xigduo XR Januvia, Janumet, Janumet XR, Jentadueto, Jentadueto XR, Tradjenta Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR Page 1 Copyright 2018 All rights reserved.

2 DRUG CATEGORY EXCLUDED DRUGS (SELECTED) PREFERRED ALTERNATIVES INSULINS, RAPID-ACTING Admelog, Apidra, Novolog Humalog INSULINS, SHORT-ACTING Novolin Humulin INSULINS, LONG-ACTING Basaglar, Levemir, Tresiba Lantus, Toujeo DIABETIC SUPPLIES ENDOCRINE All non-abbott manufacturers of diabetic test strips and meters ANDROGENS Fortesta, Natesto, Testim, Vogelxo Androgel ESTROGENS Estrogel Divigel Abbott (Precision, Freestyle) OSTEOPOROSIS Binosto alendronate, ibandronate THYROID Tirosint levothyroxine WEIGHT REDUCTION Qsymia phentermine & topiramate GASTROINTESTINAL CONSTIPATION Symproic, Trulance Linzess, Movantik INFLAMMATORY BOWEL DISEASE Delzicol, Dipentum Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine PANCREATIC ENZYMES Pancreaze, Pertzye Creon, lipase/protease/amylase, Zenpep GENITOURINARY DRUGS TO TREAT IMPOTENCY Levitra, Staxyn, Stendra Viagra NEUROLOGY & PAIN MANAGEMENT HYPNOTICS Edluar, Intermezzo, Rozerem, Zolpimist eszopiclone, zaleplon, zolpidem MIGRAINE Onzetra, Treximet, Zembrace Symtouch sumatriptan NEURALGIA Gralise, Horizant, Lyrica CR gabapentin NSAIDS Capxib celecoxib & capsaicin/menthol Duexis Indocin suppository Naprelan Sprix Tivorbex Vimovo Vivlodex Pennsaid, Zipsor, Zorvolex famotidine & ibuprofen indomethacin oral capsules naproxen ibuprofen, naproxen indomethacin naproxen & esomeprazole meloxicam diclofenac OPIOIDS Kadian morphine sulfate ER, oxycodone ER, Nucynta, Nucynta ER Abstral, Fentora, Lazanda, Onsolis, Subsys fentanyl citrate lozenge OPIOID DEPENDENCY Belbuca Butrans OPIOID REVERSAL AGENT Evzio Narcan OPHTHALMOLOGY GLAUCOMA Zioptan latanoprost, Lumigan, travoprost, Travatan Z RESPIRATORY ANAPHYLAXIS TREATMENT Auvi-Q EpiPen, Adrenaclick BETA-AGONISTS, SHORT-ACTING Proventil HFA, levalbuterol HFA ProAir HFA, Ventolin HFA (SABA) INHALED CORTICOSTEROIDS (ICS) Aerospan, Alvesco, Armonair RespiClick Arnuity Ellipta, Flovent Diskus/HFA, Qvar INHALED CORTICOSTEROID/LONG- ACTING BETA AGONIST (ICS/LABA) COMBINATIONS INHALED LONG-ACTING MUSCARINIC ANTAGONISTS (LAMA) INHALED LONG-ACTING MUSCARINIC ANTAGONISTS AND LONG-ACTING BETA AGONIST (LAMA/LABA) COMBINATIONS Airduo RespiClick, fluticasone/salmeterol (authorized generic) Seebri Neohaler, Tudorza Pressair Bevespi Aerosphere, Utibron Neohaler Advair Diskus/HFA, Breo Ellipta, Dulera, Symbicort Spiriva Handihaler, Spiriva Respimat Stiolto Respimat ANTI-LEUKOTRIENES Zyflo, Zyflo CR montelukast, zafirlukast Page 2 Copyright 2018 All rights reserved.

3 DRUG CATEGORY EXCLUDED DRUGS (SELECTED) PREFERRED ALTERNATIVES SPECIALTY DRUGS AUTOIMMUNE Cimzia, Kevzara, Simponi 50mg, Taltz Cosentyx, Enbrel, Humira, Otezla, Simponi 100mg*, Stelara (*for ulcerative colitis only) GROWTH HORMONES Genotropin, Humatrope, Nutropin, Nutropin AQ, Saizen, Zomacton Omnitrope, Norditropin HEPATITIS C Daklinza, Olysio, Technivie, Viekira Pak, Viekira Harvoni, Epclusa, Vosevi, Mavyret XR, Zepatier MULTIPLE SCLEROSIS Extavia Aubagio, Avonex, Gilenya, Glatopa, Plegridy, Rebif, Tecfidera DRUG CATEGORY OTHER EXCLUDED DRUGS PREFERED ALTERNATIVES SPECIALTY DRUGS ANTI-FUNGAL Alcortin A ANTIBIOTIC Arestin Minocycline DUCHENE MUSCULAR DYSTROPHY Emflaza Prednisone DUCHENE MUSCULAR Dystrophy Exondys 51 Prednisone TARDIVE DYSKINESIA Gocovri Amantadine capsules TARDIVE DYSKINESIA Ingrezza Consult management guidelines ANTI-FUNGAL Jublia Ciclopirox plus Terbinafine or Itraconazole PARKINSON S PSYCHOSIS Nuplazid Quetiapine, Clozapine ANTI-CHOLESTEROL Praluent Atorvastatin, rosuvastatin, simvastatin ANTI-CHOLESTEROL Repatha Atorvastatin, rosuvastatin, simvastatin INHALED STEROIDS Sinuva Fluticasone spray/nasonex Spray SPINAL MUSCULAR ATROPHY Spinraza Consult management guidelines ALLERGY ANTIHISTAMINES Pataday (QL) NASAL CORTICOSTEROIDS Alaway 0.025% (OTC) azelastine nasal spray (QL) azelastine ophthalmic drops carbinoxamine (AGE) cetirizine (OTC) cetirizine/pseudoephedrine (OTC) chlorpheniramine desloratadine (QL) desloratadine ODT (QL, ST) hydroxyzine levocetirizine soln (QL, ST) levocetirizine tabs loratadine (OTC) loratadine/pseudoephedrine (OTC) olopatadine nasal spray (QL, ST) budesonide (QL, ST) flunisolide (QL) fluticasone (QL) triamcinolone (QL) Nasonex (QL) Qnasl (QL, ST) Clarinex D (QL, ST) Clarinex syrup (QL, ST) Karbinal ER (AGE, QL, ST) Dymista (QL, ST) Page 3 Copyright 2018 All rights reserved.

4 BEHAVIORAL HEALTH ANTIDEPRESSANTS Fetzima (QL, ST) Trintellix (QL, ST) Viibryd (QL, ST) ANTIPSYCHOTICS CARDIOVASCULAR ACE INHIBITORS, ARBS, ARNI, AND COMBINATIONS BETA BLOCKERS AND COMBINATIONS amitriptyline bupropion SR/XL citalopram desvenlafaxine ER (Ranbaxy brand) (QL, ST) desvenlafaxine succinate (QL) duloxetine (QL) escitalopram fluoxetine fluoxetine ER fluoxetine/olanzapine (QL) fluvoxamine ER (QL, ST) mirtazapine/soltab nortriptyline paroxetine CR paroxetine IR phenelzine sertraline trazodone venlafaxine IR/XR aripiprazole (QL) aripiprazole ODT/oral solution (QL, ST) clozapine (QL) clozapine ODT (QL, ST) olanzapine (QL) quetiapine IR/XR (QL) risperidone (QL) ziprasidone (QL) benazepril benazepril/hctz candesartan candesartan/hctz enalapril enalapril/hctz eprosartan irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan/hctz olmesartan olmesartan/hctz olmesartan/amlodipine olmesartan/amlodipine/hctz quinapril quinapril/hctz ramipril telmisartan telmisartan/amlodipine telmisartan/hctz valsartan valsartan/hctz atenolol atenolol/chlorthalidone carvedilol metoprolol tartrate metoprolol tartrate/hctz metoprolol succinate propranolol Abilify Discmelt (QL, ST) Abilify oral solution (QL, ST) Latuda (QL, ST) Rexulti (QL, ST) Saphris (QL, ST) Seroquel XR (QL) Vraylar (QL, ST) Entresto (QL) Edarbi (ST) Edarbyclor (ST) Bystolic Byvalson Coreg CR Corlanor (PA, QL) Aplenzin (QL, ST) Desvenlafaxine fumarate ER (QL, ST) Emsam (QL) Oleptro ER (QL, ST) Sarafem Fanapt (QL, ST) Fazaclo (QL, ST) Invega (QL, ST) Versacloz (QL, ST) Amturnide (PA) Epaned (QL, ST) Qbrelis (QL, ST) Tekamlo (PA) Tekturna (PA) Tekturna HCT (PA) Inderal XL (ST) Innopran XL (ST) Levatol Page 4 Copyright 2018 All rights reserved.

5 propranolol/hctz propranolol LA CALCIUM CHANNEL BLOCKERS LIPID-LOWERING ANTICOAGULANTS DIABETES ORAL INSULINS AND INJECTABLE amlodipine amlodipine/benazepril amlodipine/olmesartan amlodipine/valsartan amlodipine/valsartan/hctz diltiazem diltiazem CD diltiazem ER felodipine nifedipine/sa nisoldipine verapamil verapamil LA amlodipine/atorvastatin (QL) atorvastatin (QL) cholestyramine colestipol ezetimibe (QL) fenofibrate/micronized/ nanocrystallized fenofibric acid/choline (ST) fenofibrate (ST) fluvastatin (QL, ST) gemfibrozil lovastatin (QL) niacin ER (Rx only) ST omega-3 ethyl esters (QL) pravastatin (QL) rosuvastatin (QL) simvastatin (ST on 80mg) simvastatin/ezetimibe (QL) simvastatin 80mg/ezetimibe (QL, ST) glimepiride glipizide glipizide/metformin glyburide glyburide/metformin metformin metformin ER miglitol nateglinide pioglitazone pioglitazone/glimepiride (ST) pioglitazone/metformin (ST) repaglinide repaglinide/metformin HCl Livalo (QL) Vascepa (QL) Welchol Xarelto (QL) Eliquis (QL) Glyxambi (QL, ST) Invokamet (QL, ST) Invokamet XR (QL, ST) Invokana (QL, ST) Janumet (QL) Janumet XR (QL) Januvia (QL) Jardiance (QL, ST) Jentadueto (QL) Synjardy (QL, ST) Synjardy XR (QL, ST) Tradjenta (QL) Humulin N (QL) Humulin R (QL) Humulin R-500 (QL) Humulin 70/30 (QL) Humalog (QL) Humalog Mix 50/50 (QL) Humalog Mix 75/25 (QL) Lantus (QL) Cardene SR Covera-HS Dynacirc CR Altoprev (QL, ST) Flolipid (PA) Lescol XL (QL, ST) Savaysa (QL,ST) Pradaxa (QL,ST) Bevyxxa (QL) Avandamet (ST) Avandaryl (ST) Avandia (ST) Cycloset (ST) Fortamet (ST) Afrezza (PA, QL) Fiasp (QL, ST) Page 5 Copyright 2018 All rights reserved.

6 Soliqua (QL, ST) Trulicity (QL, ST) Toujeo (QL) Victoza (QL, ST) Xultophy (QL, ST) DIABETIC SUPPLIES Preferred Abbott diabetic supplies (Precision and FreeStyle brand) (QL) ENDOCRINE CONTRACEPTIVES HORMONE REPLACEMENT OSTEOPOROSIS GASTROINTESTINAL ANTI-ULCER Apri Aviane Fayosim Gianvi, Loryna, or Vestura (ST) Kariva Levora-28 Low-Ogestrel medroxyprogesterone acetate (QL) Mibelas 24 FE Microgestin Fe, Larin Fe, Gildess Fe, Tarina Fe Norethin-eth estra ferrous fum Nortrel Ocella, Syeda, or Zarah (ST) Plan B One Step Rivelsa Sprintec Tilia Fe, Tri-Legest Fe Trinessa Tri-Sprintec Trivora-28 Xulane patch (QL) Zeosa, Zenchent Fe, Wymzya Fe estradiol estradiol patch (QL) estradiol/norethindrone acet estropipate me-testosterone me-testosterone/estrogen, esterified medroxyprogesterone norethindrone ac-eth estradiol progesterone, micronized testosterone 1% gel (PA) testosterone cypionate (PA) testosterone enanthate (PA) alendronate (QL on solution) calcitonin, salmon, synthetic ibandronate 150mg raloxifene (QL) cimetidine esomeprazole magnesium (QL) esomeprazole strontium (QL, ST) famotidine lansoprazole lansoprazole/amoxicil/clarithro (QL) metoclopramide omeprazole capsules (RX) omeprazole magnesium tablets (OTC) omeprazole/sod bicarbonate (QL, ST) Lo Loestrin Fe (ST) Nuvaring (QL) Ortho Tri-Cyclen Lo (ST) Seasonale (QL, ST) Yasmin (ST) Yaz (ST) Androgel 1% (PA) Androgel 1.62% (PA) Combipatch (QL) Crinone Duavee Menest Premarin Premphase Prempro Forteo (PA, QL) Tymlos (PA) Linzess (QL) Movantik (QL) Beyaz (ST) Lo-Seasonique (QL, ST) Natazia (ST) Safyral (ST) Seasonique (QL, ST) Androderm (PA) Cenestin Climara Pro (QL) Enjuvia Estring (QL) Femtrace Prefest Striant (PA) Actonel (QL, ST) Atelvia (QL, ST) Fortical Aciphex Sprinkle (QL) Amitiza (QL, ST) Cholbam (PA) Dexilant (QL, ST) Helidac Protonix granule packet (ST) Relistor (QL, PA) Page 6 Copyright 2018 All rights reserved.

7 pantoprazole rabeprazole (QL) ranitidine sucralfate IRRITABLE BOWEL GENITOURINARY BENIGN PROSTATIC HYPERPLASIA (BPH) alfuzosin doxazosin dutasteride (ST) dutasteride/tamsulosin hcl (ST) finasteride tamsulosin terazosin Linzess (QL) Movantik (QL) Symproic (QL,ST) Trulance (QL, ST) Cialis 2.5mg, 5mg (PA, QL) Cialis 10mg, 20mg (ST, QL) Rapaflo (ST) OVERACTIVE BLADDER OPHTHALMOLOGY GLAUCOMA PAIN MANAGEMENT MIGRAINE NSAIDS OPIOID DEPENDENCY RESPIRATORY ASTHMA/COPD darifenacin (ST) oxybutynin oxybutynin ER tolterodine tartrate (ST) trospium chloride (ST) trospium chloride ER (ST) betaxolol bimatoprost 0.03% (QL) brimonidine tartrate dorzolamide latanoprost levobunolol timolol timolol/dorzolamide travoprost (QL) butalbital/apap butalbital/apap/caffeine butalbital/aspirin/caffeine dihydroergotamine (QL) ergotamine/caffeine (QL) isomethept/dichlphn/acetaminop naratriptan (QL) rizatriptan benzoate (QL) sumatriptan succinate (QL) zolmitriptan/odt (QL, ST) celecoxib diclofenac sodium ibuprofen indomethacin meloxicam nabumetone naproxen buprenorphine/naloxone SL tabs (CU, QL) buprenorphine (PA, CU, QL) albuterol/ipratropium budesonide respules (QL) cromolyn ipratropium levalbuterol hcl soln montelukast theophylline Myrbetriq (ST) Toviaz (ST) Vesicare (ST) Azopt Combigan Lumigan 0.01% (QL) Simbrinza Travatan Z (QL) Cafergot (QL) Migergot (QL) Voltaren gel Suboxone Film(CU, QL) Zubsolv (CU, QL) Advair Diskus (QL) Advair HFA (QL) Arnuity Ellipta (QL) Atrovent HFA (QL) Breo Ellipta (QL) Combivent Respimat Daliresp (QL, ST) Gelnique (ST) Oxytrol (ST) Betimol Betoptic S Cosopt PF (QL, ST) Timoptic Ocudose (QL, ST) Alsuma (QL) Axert (QL, ST) Bupap (QL, ST) Cambia (QL) Ergomar (QL) Frova (QL, ST) Relpax (QL, ST) Sumavel DosePro (QL, ST) Bunavail (CU, QL) Anoro Ellipta (QL, ST) Arcapta (QL, ST) Asmanex HFA (QL, ST) Asmanex Twisthaler (QL, ST) Brovana (QL) Foradil (QL, ST) Incruse Ellipta (QL, ST) Page 7 Copyright 2018 All rights reserved.

8 Dulera (QL) Flovent Diskus (QL) Nucala (PA) Pulmicort Flexhaler (QL, ST) Flovent HFA (QL) Perforomist (QL) ProAir HFA ProAir RespiClick QVAR (QL) Serevent Diskus (QL) Spiriva (QL) Spiriva Respimat (QL) Stiolto Respimat (QL) Striverdi Respimat (QL) Symbicort (QL) Trelegy Ellipta (QL) Ventolin HFA SPECIALTY ANEMIA Procrit (PA) Aranesp (PA) Epogen (PA) Mircera (PA) AUTOIMMUNE GROWTH HORMONES HEPATITIS C MULTIPLE SCLEROSIS Glatopa (PA) Cosentyx (PA) Enbrel (PA) Humira (PA) Otezla (PA, ST) Stelara (PA) Norditropin FlexPro/Nordiflex (PA) Omnitrope (PA) Epclusa (PA) Harvoni (PA) Mavyret (PA) Vosevi (PA) Aubagio (PA) Avonex (PA) Copaxone (PA) Gilenya (PA) Plegridy (PA) Rebif (PA) Rebif Rebidose (PA) Tecfidera (PA) Actemra IV/SC (PA) Inflectra (PA) Kineret (PA) Orencia (PA) Rayos (ST) Remicade (PA) Renflexis (PA) Siliq (PA) Simponi 100mg (PA) Tremfya (PA) Xeljanz (PA) Xeljanz XR (PA) Serostim (PA) Zorbtive (PA) Ampyra (PA) Betaseron (PA) A recommended prescribing guideline may apply (denoted throughout the document using the following symbols): AGE Age Edit Coverage may depend on patient age. CU Concurrent Use Edit Coverage or lack thereof may depend upon concurrent use of another drug PA Prior Authorization Requires specific physician request process. QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period. ST Step Therapy Coverage depends on previous use of another drug Page 8 Copyright 2018 All rights reserved.

MedPerform Medium Preferred Drug List (PDL)

MedPerform Medium Preferred Drug List (PDL) What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote