PRIMARY/PREFERRED DRUG LIST (FORMULARY)

Transcription

1 PRIMARY/PREFERRED DRUG LIST (FORMULARY) A ACANYA ADEMPAS ADVAIR ALBENZA ALPHAGAN P ALREX AMITZA ANDRODERM ANORO ELLIPTA APRISO APTENSIO XR ARANESP ARCAPTA ARISTADA ASMANEX ATELVIA ATRALIN ATRIPLA AUBAGIO AXIRON AZILECT AZOPT AZOR B BASAGLAR BD INSULIN SYRINGES & NEEDLES BELVIQ BENICAR BENICAR HCT BENZACLIN BESIVANCE BETASERON BETHKIS BETIMOL BETOPTIC S BEVESPI AEROSPHERE BEYAZ BIDIL BOSULIF BREO ELLIPTA BRILINTA BRISDELLE BUTRANS BYSTOLIC C CANASA CARDURA XL CETROTIDE CIALIS CIPRODEX CITRANATAL CLODERM COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA CONTRAVE COPAXONE 40 MG COREG CR CORTIFOAM COSOPT PF CREON CRINONE D DALIRESP DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM DEXILANT DICLEGIS DIFFERIN DIFICID DIVIGEL DUAVEE DULERA DUREZOL E EFFIENT ELIDEL ELIQUIS ENBREL ENDOMETRIN ENTRESTO EPCLUSA EPIDUO EPIPEN EPIPEN JR EPISIL EPZICOM ESBRIET ESTRACE CREAM EVAMIST EVOTAZ F FARXIGA FENTORA FINACEA FLOVENT DISKUS FLOVENT HFA FLUOXETINE 60 MG FOLLISTIM AQ FORTEO FYCOMPA G GEL-ONE GILENYA GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GRALISE GRASTEK H HARVONI HUMATROPE HUMIRA HUMULIN R U-500 VIAL HUMULIN R U-500 KWIK PEN HYALGAN HYSINGLA ER I ISENTRESS J JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JUBLIA K KOGENATE FS KOVALTRY L LATUDA LETAIRIS LEVEMIR LIALDA LINZESS LO LOESTRIN FE LOCOID LOTION LOTEMAX LOTRONEX 3 LUZU LYRICA M MEGACE ES MINASTRIN 24 FE MINIVELLE MIRAPEX ER MOVANTIK MOVIPREP MOXEZA MUGARD MUSE MYRBETRIQ N NAFTIN NAMENDA XR NARCAN NASAL SPRAY NATAZIA NEUPRO NITROLINGUAL NITROSTAT NORDITROPIN NORVIR NOVOEIGHT NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING NUVIGIL NUWIQ O OFEV ONETOUCH ULTRA STRIPS FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This SignatureScripts primary drug list is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. Specific prescription benefit plan design may not cover categories, regardless of their appearance in this document. The plan participant s prescription benefit plan may have a different copay 1 for specific products on this list. Unless otherwise indicated, drug list products will include all dosage forms. 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. Contact SignatureScripts Customer Service to check coverage and co-payments* for a specific medicine.

2 PRIMARY/PREFERRED DRUG LIST (FORMULARY) & KITS 2 ONETOUCH VERIO STRIPS & KITS 2 OPANA ER ORACEA ORALAIR ORENITRAM ORTHO TRI-CYCLEN LO OSPHENA OVIDREL OXTELLAR XR OXYCONTIN P PATADAY PAZEO PENTASA PERFOROMIST PHOSLYRA PICATO PREMARIN PREMARIN CREAM PREMPHASE PREMPRO PREZCOBIX PREZISTA PRISTIQ PROAIR HFA PROAIR RESPICLICK PROCRIT PROCTOFOAM -HC PROLENSA PULMICORT FLEXHALER PYLERA Q QUDEXY XR QUILLIVANT XR QVAR R RAGWITEK RANEXA RAPAFLO RASUVO REBIF RELPAX RENVELA REPATHA RESTASIS RETIN-A MICRO REYATAZ S SAFRYAL SANCUSO SAVELLA SAXENDA SEREVENT SEROQUEL XR SILENOR SIMBRINZA SIVEXTRO SOOLANTRA SPIRIVA SPRYCEL STRATTERA STRIBILD SUBOXONE FILM SUBSYS SUPARTZ FX SUPRAX SUPREP SYMLINPEN SYNTHROID T TAMIFLU TAZORAC TECFIDERA TEKTURNA TEKTURNA HCT TIVICAY TOBRADEX OINTMENT TOBRADEX ST TOVIAZ TRACLEER TRADJENTA TRAVATAN Z TRESIBA TREXIMET TRIBENZOR TRINTELLIX TRIUMUEQ TROKENDI XR TRULICITY TRUVADA U UCERIS ULORIC V VAGIFEM VARUBI VASCEPA VELPHORO VENTOLIN HFA VESICARE VIBERZI VICTOZA VIGAMOX VIIBRYD VIMPAT VIOKACE VISTOGARD VOLTAREN GEL VYTORIN VYVANSE W WELCHOL X XARELTO XIFIXAN 550 MG XIGDUO XR XIIDRA Z ZARXIO ZENPREP ZETIA ZIOPTAN ZOMIG NASAL SPRAY ZYCLARA ZYLET ZYTIGA FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This SignatureScripts primary drug list is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. Specific prescription benefit plan design may not cover categories, regardless of their appearance in this document. The plan participant s prescription benefit plan may have a different copay 1 for specific products on this list. Unless otherwise indicated, drug list products will include all dosage forms. 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. Contact SignatureScripts Customer Service to check coverage and co-payments* for a specific medicine.

3 j January 2017 INFORMATION FOR THE PLAN PARTICIPANT Your Benefit Plan provides you with a prescription benefit program that is administered by SignatureScripts. 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. For specific information regarding your prescription benefit coverage and co-pay* information, contact a SignatureScripts customer service representative, toll-free: A OneTouch blood glucose meter will 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 SignatureScripts Customer Service. The drug list is subject to change. For the most up-to-date list visit SignatureScripts/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. Generics should be considered the first line of prescribing. The drug list is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. The plan participant's specific prescription benefit plan may have different co-pays for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Any brand drug for which a generic product becomes available may be designated as a non-preferred product. The drug list is subject to change. For the most up-to-date list visit For plans with traditional 3-tier co-pays: Tier 1 = All generic medications. Tier 2 = All brand name / formulary medications that appear on this list. Tier 3 = All brand name / non-formulary medications that DO NOT appear on this list. INFORMATION FOR THE HEALTHCARE PROVIDER Your patient is covered under a prescription benefit plan administered by SignatureScripts. As a way to help manage healthcare costs, authorize generic substitution whenever possible. If you believe a brand name product is necessary, consider prescribing a brand listed in this brochure. Healthcare providers may direct questions about the list to a SignatureScripts customer service representative at Thank you for your professional cooperation in providing cost-effective quality healthcare. * Co-payment or co-pay means the amount a plan participant 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. This SignatureScripts primary / preferred drug list contains prescription brand name medicines that are registered or trademarks of pharmaceutical manufacturers that are not affiliated with SignatureScripts. Listed products are for informational purposes only and are not intended to replace clinical judgment of the prescriber. Your privacy is important to us. Our associates are trained regarding the appropriate way to handle your private health information.

4 j ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR AXERT naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY ABSTRAL fentanyl transmucosal lozenge, FENTORA, SUBSYS AZELEX adapalene,benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC ACCU-CHEK STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 ONETOUCH VERIO STRIPS AND KITS 3 BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone, ACTOS pioglitazone BENZAC AC, BENZAC W adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzol peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC ADDERALL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate extrel, QUILLIVANT XR, STRATTERA, VYVANSE ADRENACLICK EPIPEN, EPIPEN JR BREEZE 2 STRIPS AND BENZIQ adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzol peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC ONETOUCH ULTRA STRIPS AND KITS 2 KITS 4 ONETOUCH VERIO STRIPS AND KITS 2 BYDUREON TRULICITY, VICTOZA ADVICOR atorvastatin, fluvastatin, lovastatin, pravastatin, AEROSPAN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, BYETTA TRULICITY, VICTOZA PULMICORT FLEXHALER, QVAR ALCORTIN A Hydrocortisone CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES CARDIZEM diltiazem ext-rel(except generic Cardizem LA) INSULIN SYRINGES 5 ALOQUIN hydrocortisone CARDIZEM CD diltiazem ext-rel(except generic Cardizem LA) ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE CARDIZEM LA diltiazem ext-rel(except generic Cardizem LA) ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastatin, CARDURA XL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, CARNITOR levocamitine PULMICORT FLEXHALER, QVAR AMRIX cyclobenzaprine CARNITOR SF levocamitine ANDROGEL ANDRODERM, AXIRON CLIMARA PRO COMBIPATCH ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO CLINDAGEL erythromycin solution ANTARA fenofibrate,fenofibric acid clobetasol spray clobetsol foam APEXICON E desoximestasone, fluocinonide CLOBEX SPRAY clobetsol foam APIDRA NOVOLOG CONTOUR NEXT STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2 ONETOUCH VERIO STRIPS AND KITS 2 ARMOUR THYROID levothyroxine, SYNTHROID CONTOUR STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2 ONETOUCH VERIO STRIPS AND KITS 2 ARTHROTEC celecoxib, diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, CRESTOR atorvastatin, fluvastatin, lovastatin, pravastatin, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, OR DEXILANT ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayedrel, CYMBALTA duloxetine, venlafaxine, venlafaxine ext-rel, PRISTIQ APRISO, LIALDA, PENTASA, UCERIS ASCENSIA STRIPS & KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2 ONETOUCH VERIO STRIPS AND KITS 2 DAKLINZA EPCLUSA (genotypes 2,3) HARVONI (genotypes 1,4,5,6) ATACAND, ATACAND HCT candesartan,, candesartan-hydrochlorothiazide, eprosartan,irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS ATROVENT HFA SPIRIVA DETROL LA oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE AVONEX glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF,TECFIDERA DEXPAK dexamethasone, methylprednisone, prednisone DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, HELIXATE FS KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ

5 Preferred Alternatives List DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartanhydrochlorothiazide, BENICAR, BENICAR-HCT DORAL eszopiclone, zolpidem, zolpidem ext-rel, SILENOR HUMALOG NOVOLOG DUTOPROL metoprolol succinate ext-rel WITH HUMALOG MIX 50/50 NOVOLOG MIX 70/30 hydrochlorothiazide flunisolide, fluticasone, triamcinolone or NASONEX HUMALOG MIX 75/25 NOVOLOG MIX 70/30 WITH azelastine, or olopatadine EDARBI,EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, HUMULIN NOVOLIN eprosartan, irbesartan, irbesartanhydrochlorthiazide, losartan, losartanhydrochlorthiazide,telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT EDLUAR eszopiclone, zolpidem, zolipidem ext-rel, SILENOR INCRUSE ELLIPTA SPIRIVA ENABLEX oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext- rel, MYRBETRIQ, TOVIAZ, VESICARE INNOPRAN XL atenolol, carvedilol, metoprolol, metoprolol succinate ext-rel, metroprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR ENJUVIA estradiol, estropriate, PREMARIN INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, SILENOR ESTRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM INTUNIV amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts extrel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE EUFLEXXA GEL-ONE, HYALGAN, SUPARTZ FX INVOKAMET XIGDUO XR EVZIO naloxone injection, NARCAN NASAL SPRAY INVOKANA FARXIGA, JARDIANCE EXFORGE amlodipine-telmisartan, amlodipine-valsartan, ISTALOL timolol maleate solution, BETIMOL AZOR EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR JALYN dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR FEMRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM KLOR-CON/25 potassium chloride liquid FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR FIORICET CAPSULE naratriptan, rizatriptan, sumatriptan, zolmitriptan, LANTUS BASAGLAR, LEVIMIR, TRESIBA RELPAX, ZOMIG NASAL SPRAY FIRST TESTOSTERONE ANDRODERM, AXIRON LASTACAFT azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO FORTAMET metformin, metformin ext-rel LESCOL XL atorvastatin, fluvastatin, lovastatin, pravastatin, FORTESTA ANDRODERM, AXIRON LEVITRA CIALIS FOSAMAX PLUS D alendronate, ibandronate,risedronate, ATELVIA LIPITOR atorvastatin, fluvastatin, lovastatin, pravastatin, FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO LIPTRUZET atorvastatin, fluvastatin, lovastatin, pravastatin, FREESTYLE STRIPS AND KITS 4,5 ONETOUCH ULTRA STRIPS AND KITS 3 ONETOUCH VERIO STRIPS AND KITS 3 LIVALO atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, CRESTOR, VYTORIN FROVA naratriptan, rizatriptan, sumatriptan nasal spray, LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY GELNIQUE oxybutynin ext rel, tolterodine, tolterdine ext rel, LUNESTA eszopiclone, zolpidem, zolpidem-ext-rel, SILENOR trospium, trospium ext rel, MYBETRIQ, TOVIAZ, VESICARE GENOTROPIN HUMATROPE, NORDITROPIN Matzim LA diltiazem ext-rel (except generic Cardizem LA) GLEEVAC imatinib mesylate, BOSULIF, SPRYCE MENEST estradiol, estropipate, PREMARIN GLUMETZA metformin, metformin ext-rel MENOSTAR estradiol MICARDIS, MICARDIS HCT candesartan,candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan- PRECISION XTRA STRIPS ONETOUCH ULTRA STRIPS AND KITS 2 AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 2

6 Preferred Alternatives List DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* hydrochlorothiazide, losartan, losartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT MILLIPRED dexamethasone, methylprednisone, prednisone PRED MILD dexamethasone, DUREZOL,LOTEMAX MONOVISC GEL-ONE, HYALGAN, SUPARTZ FX PREFERAOB generic prenatal vitamins, CITRANATAL NAPRELAN celecoxib, diclofenac sodium, meloxicam, PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO naproxen NATESTO ANDRODERM, AXIRON PRENATAL PLUS generic prenatal vitamins, CITRANATAL NESINA JANUVIA, TRADJENTA PREVACID esomeprazole, lansaprazole, omeprazole, pantoprazole, DEXILANT NEUPOGEN ZARXIO PROTONIX esomeprazole, lansaprazole, omeprazole, pantoprazole, DEXILANT NEXIUM esomeprazole, lansoprazole, omeprazole, PROTOPIC tacrolimus, ELIDEL pantoprazole, DEXILANT NILANDRON bicalutamide,zytiga PROVENTIL HFA PROAIR HFA, PROAIR RESPICLICK NITROMIST nitroglycerin sublingual spray, NITROLINGUAL, QNASL flunisolide, fluticasone, mometasone, triamcinolone, NITROSTAT NORITRATE metronidazole, FINACEA, SOOLANTRA QSYMIA BELVIQ, CONTRAVE, SAXENDA NORVASC amlodipine RAYOS dexamethasone, methylprednisolone, prednisone NOVACORT hydrocortisone RELION INSULIN NOVOLIN INSULIN NOVO NORDISK BD ULTRAFINE NEEDLES RELISTOR MOVANTIK NEEDLES 5 NUTROPIN AQ HUMATROPE, NORDITROPIN RHINOCORT AQUA flunisolide, fluticasone, mometasone, triamcinolene, OLEPTRO trazodone RIOMET metformin, metformin ext-rel OLUX-E clobetasol foam ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, SILENOR OLYSIO EPCLUSA (genotypes 2, 3) HARVONI (genotypes 1,4,5,6) OMNARIS flunisolide, fluticasone, mometasone, SAIZEN HUMATROPE, NORDITROPIN triamcinolone, OMNITROPE HUMATROPE, NORDITROPIN STRIANT ANDRODERM, AXIRON ONGLYZA JUNUVIA, TRADJENTA SURE-TEST STRIPS AND ONETOUCH ULTRA STRIPS AND KITS 2 KITS ONETOUCH VERIO STRIPS AND KITS 2 OPSUMIT LETARIS, TRACLEER SYMBICORT ADVAIR, BREO ELLIPTA, DULERA ORTHOVISC GEL-ONE, HYALGAN, SUPARTZ FX SYNVISC, SYNVISC ONE GEL-ONE, HYALGAN, SUPARTZ FX OSENI JANUMET, JANUMET XR, JENTADUETO, TANZEUM TRULICITY, VICTOZA JENTADUETO XR OWEN MUMFORD BD ULTRAFINE NEEDLES TASIGNA imatinib mesylate, BOSULIF, SPRYCEL NEEDLES 5 OXYTROL oxybutynin ext-rel, tolterodine, tolterodine ext-rel, TECHNIVIE EPCLUSA (genotypes 2, 3) HARVONI (genotypes trospium, trospium ext-rel, GELNIQUE, 1,4,5,6) MYRBETRIQ, TOVIAZ, VESICARE PANCREAZE CREON, VIOKACE, ZENPREP PENNSAID diclofenac sodium, diclofenac sodium solution, TESTIM ANDRODERM, AXIRON meloxicam, naproxen, VOLTAREN GEL PERRIGO NEEDLES 5 BD ULTRAFINE NEEDLES TEVETEN, TEVETEN-HCT candesartan, candesartanhydrochlorothiazide,eprosartan,irbesartan,irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide,telmisartan, telmisartan hydrochlorothiazide, valsartan, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT PERTZYE CREON, VIOKACE, ZENPREP TOBI tobramycin inhalation solution, BETHKIS PEXEVA citalopram, escitalopram, fluoxetine, paroxetine, TOBI PODHALER tobramycin inhalation solution, BETHKIS paroxetine ext-rel, sertraline, FLUOXETINE 60 MG, TRINTELLIX, VIIBRYD PLAVIX clopidogrel, BRILINTA, EFFIENT TOUJEO BASAGLAR, LEVIMIR, TRESIBA PLEGRIDY glatiramer, AUBAGIO, BETASERON, COPAXONE 40 TRICOR fenofibrate, fenofibric acid MG, GILENYA, REBIF, TECFIDERA PRADAXA warfarin, ELIQUIS, XARELTO TRIGLIDE fenofibrate, fenofibric acid PRALUENT REPATHA TRILIPIX fenofibrate, fenofibric acid VIAGRA CIALIS TRIVIDIA INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES VIEKIRA PAK EPCLUSA (genotypes 2,3) HARVONI (genotypes 1,4,5,6)

7 Preferred Alternatives List DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* TRUETEST STRIPS AND ONETOUCH ULTRA STRIPS AND KITS 3 VITAFOL-ONE generic prenatal vitamins, CITRANATAL KITS 4 ONETOUCH VERIO STRIPS AND KITS 3 TRUETACK STRIPS ONETOUCH ULTRA STRIPS AND KITS 3 VOGELXO ANDRODERM, AXIRON AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 3 TUDORZA SPIRIVA XENAZINE tetrabenazine ULTIMED INSULIN BD ULTRAFINE INSULIN SYRINGES XOPENEX HFA PROAIR HFA, PROAIR RESPICLICK SYRINGES 5 ULTIMED NEEDLES 5 BD ULTRAFINE NEEDLES XTANDI bicalutamide, ZYTIGA VALCYTE valganciclovir ZEGRID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT VALTREX acyclovir, valacyclovir ZEPATIER EPCLUSA (genotypes 2,3) HARVONI (genotypes 1,4,5,6) VENLAFAXINE EXT-REL duloxetine, valcyclovir, venlafaxine ext rel capsule, ZETONNA flunisolide, flucasone, mometasone, triamcinolone, TABLET (except 225 PRISTIQ mg) VENTOLIN HFA PROAIR HFA, PROAIR RESPICLICK ZUBSOLV buprenorphine-nalomone sublingual tablet, SUBOXONE FILM VERAMYST flunisolide, fluticasone, triamcinolone, NASONEX ZYFLO, ZYFLO CR montelukast, zafirlukast 1 Higher co-payments* may apply depending on the plan participant s specific prescription benefit plan. Call SignatureScripts to find the co-payment under a specific plan. 2 Listing does not include generic Cardizem LA.

8 Preferred Alternatives List DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* 3 A OneTouch blood glucose meter will 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 SignatureScripts Customer Service at OneTouchbrand test strips are the only preferred options. 5 A medical exception process is in place for specific clinical circumstances that may require continued coverage for one of these specific drugs: Freestyle diabetic test strips. If your doctor believes you have a specific clinical need for one of these drugs, he or she should fax a medical exception request to Listing reflects the authorized generics for TESTIM and VOGELXO Note: Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. Contact SignatureScripts Customer Service to check coverage and co-pays for a specific medicine. *The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit or contact a SignatureScripts Customer Service Representative. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber.