Caremark TRS Activecare Drug List

July 2016

TRS-ActiveCare Drug List

The TRS-ActiveCare Drug List is a guide within select therapeutic categories for clients, plan participants 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 PARTICIPANT HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by Caremark. Ask your doctor to consider prescribing, administered by Caremark. As a way to help manage health care when medically appropriate, a preferred medicine from this list. costs, authorize generic substitution whenever possible. If you Take this list along when you or a covered family member sees a believe a brand-name product is necessary, consider prescribing a doctor. brand name on this list. Please note: Please note:

• Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food • This drug list represents a summary of prescription coverage. and Drug Administration (FDA) may not be covered upon It is not all-inclusive and does not guarantee coverage. The plan release to the market. participant’s specific prescription benefit plan design may not cover certain products or categories, regardless of their • You may be responsible for the full cost of non-formulary appearance in this document. Products recently approved by products that are removed from coverage. the FDA may not be covered upon release to the market. For specific information regarding your prescription benefit • 1 • The plan participant's prescription benefit plan may have a coverage and copay information, please visit different copay for specific products on the list. www.caremark.com or contact a Caremark Customer Care representative at: 1-800-222-9205. • Unless specifically indicated, drug list products will include all dosage forms. • Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or • Log in to www.caremark.com to check coverage and copay generic equivalent. This may result in your doctor prescribing, information for a specific medicine. 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 non- preferred option upon release of the generic product to the market.

ANALGESICS § OPIOID ANALGESICS VISCOSUPPLEMENTS levofloxacin PREZCOBIX codeine-acetaminophen GEL-ONE moxifloxacin STRIBILD § NSAIDs fentanyl transdermal HYALGAN TRIUMEQ § PENICILLINS diclofenac sodium fentanyl transmucosal SUPARTZ FX TRUVADA amoxicillin meloxicam lozenge INTEGRASE INHIBITORS naproxen hydrocodone-acetaminophen ANTI-INFECTIVES amoxicillin-clavulanate

hydromorphone dicloxacillin ISENTRESS § NSAIDs, COMBINATIONS ANTIBACTERIALS hydromorphone ext-rel penicillin VK TIVICAY diclofenac sodium- § CEPHALOSPORINS methadone misoprostol § TETRACYCLINES § NUCLEOSIDE REVERSE morphine cefdinir doxycycline hyclate TRANSCRIPTASE morphine ext-rel cefprozil § NSAIDs, TOPICAL minocycline INHIBITORS morphine suppository cefuroxime axetil diclofenac sodium solution tetracycline abacavir oxycodone cephalexin VOLTAREN GEL SUPRAX lamivudine oxycodone-acetaminophen § ANTIFUNGALS tramadol § COX-2 INHIBITORS § ERYTHROMYCINS / fluconazole PROTEASE INHIBITORS tramadol ext-rel celecoxib MACROLIDES itraconazole NORVIR ABSTRAL azithromycin terbinafine tablet PREZISTA § GOUT BUTRANS clarithromycin REYATAZ allopurinol FENTORA ANTIRETROVIRAL AGENTS clarithromycin ext-rel colchicine tablet HYSINGLA ER § ANTIRETROVIRAL ANTIVIRALS erythromycins probenecid NUCYNTA COMBINATIONS § CYTOMEGALOVIRUS DIFICID NUCYNTA ER COLCRYS ATRIPLA AGENTS OPANA ER ULORIC § FLUOROQUINOLONES COMPLERA valganciclovir OXYCONTIN ciprofloxacin EPZICOM SUBSYS ciprofloxacin ext-rel EVOTAZ

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.caremark.com or contact a Caremark Customer Care representative at: 1-800-222-9205.

§ HEPATITIS C AGENTS § ANGIOTENSIN II DIRECT RENIN INHIBITORS / TROKENDI XR § ATTENTION DEFICIT ribavirin RECEPTOR ANTAGONIST / DIURETIC COMBINATIONS VIMPAT HYPERACTIVITY DISORDER

HARVONI CALCIUM CHANNEL TEKTURNA / amphetamine- § ANTIDEMENTIA SOVALDI BLOCKER / DIURETIC TEKTURNA HCT dextroamphetamine donepezil COMBINATIONS mixed salts § HERPES AGENTS amlodipine-valsartan- § DIURETICS galantamine amphetamine- galantamine ext-rel acyclovir hydrochlorothiazide furosemide dextroamphetamine valacyclovir TRIBENZOR hydrochlorothiazide memantine mixed salts ext-rel

metolazone rivastigmine guanfacine ext-rel INFLUENZA AGENTS ANTILIPEMICS spironolactone- rivastigmine transdermal methylphenidate

RELENZA § BILE ACID RESINS hydrochlorothiazide NAMENDA XR methylphenidate ext-rel

TAMIFLU cholestyramine torsemide QUILLIVANT XR ANTIDEPRESSANTS WELCHOL triamterene- STRATTERA § MISCELLANEOUS § SELECTIVE SEROTONIN hydrochlorothiazide VYVANSE clindamycin CHOLESTEROL REUPTAKE INHIBITORS ivermectin ABSORPTION INHIBITORS § NITRATES (SSRIs) FIBROMYALGIA metronidazole ZETIA nitroglycerin lingual spray citalopram LYRICA nitrofurantoin NITROLINGUAL escitalopram SAVELLA sulfamethoxazole- § FIBRATES NITROSTAT fluoxetine

trimethoprim fenofibrate paroxetine HYPNOTICS NITRATE / VASODILATOR ALBENZA fenofibric acid paroxetine ext-rel § NONBENZODIAZEPINES SIVEXTRO COMBINATIONS sertraline eszopiclone XIFAXAN 550 MG § HMG-CoA REDUCTASE BIDIL BRINTELLIX zolpidem

INHIBITORS / FLUOXETINE 60 MG PULMONARY ARTERIAL zolpidem ext-rel ANTINEOPLASTIC COMBINATIONS VIIBRYD HYPERTENSION AGENTS atorvastatin TRICYCLICS ENDOTHELIN RECEPTOR § SEROTONIN § KINASE INHIBITORS fluvastatin SILENOR lovastatin ANTAGONISTS NOREPINEPHRINE imatinib mesylate pravastatin LETAIRIS REUPTAKE INHIBITORS MIGRAINE BOSULIF simvastatin OPSUMIT (SNRIs) § SELECTIVE SEROTONIN SPRYCEL

CRESTOR TRACLEER duloxetine AGONISTS

VYTORIN venlafaxine naratriptan CARDIOVASCULAR § PHOSPHODIESTERASE venlafaxine ext-rel rizatriptan § NIACINS INHIBITORS § ACE INHIBITORS KHEDEZLA sumatriptan fosinopril niacin ext-rel sildenafil PRISTIQ zolmitriptan lisinopril § OMEGA-3 FATTY ACIDS SOLUBLE GUANYLATE § MISCELLANEOUS RELPAX quinapril ZOMIG NASAL SPRAY omega-3 acid ethyl esters CYCLASE STIMULATORS AGENTS ramipril ADEMPAS bupropion SELECTIVE SEROTONIN PCSK9 INHIBITORS § ACE INHIBITOR / bupropion ext-rel AGONIST / NONSTEROIDAL MISCELLANEOUS DIURETIC COMBINATIONS REPATHA mirtazapine ANTI-INFLAMMATORY RANEXA fosinopril-hydrochlorothiazide trazodone DRUG (NSAID) § BETA-BLOCKERS lisinopril-hydrochlorothiazide COMBINATIONS atenolol CENTRAL NERVOUS § ANTIPARKINSONIAN quinapril-hydrochlorothiazide TREXIMET

carvedilol SYSTEM AGENTS metoprolol succinate ext-rel § ANGIOTENSIN II § ANTICONVULSANTS amantadine § MULTIPLE SCLEROSIS RECEPTOR ANTAGONISTS / metoprolol tartrate carbidopa-levodopa AGENTS nadolol carbamazepine DIURETIC COMBINATIONS carbidopa-levodopa ext-rel glatiramer propranolol carbamazepine ext-rel candesartan / candesartan- carbidopa-levodopa- AUBAGIO propranolol ext-rel diazepam rectal gel hydrochlorothiazide entacapone BETASERON BYSTOLIC divalproex sodium entacapone eprosartan divalproex sodium ext-rel COPAXONE 40 MG COREG CR pramipexole irbesartan / irbesartan- ethosuximide GILENYA ropinirole hydrochlorothiazide § CALCIUM CHANNEL gabapentin REBIF ropinirole ext-rel losartan / losartan- BLOCKERS lamotrigine TECFIDERA hydrochlorothiazide selegiline amlodipine lamotrigine ext-rel telmisartan / telmisartan- AZILECT § MUSCULOSKELETAL diltiazem ext-rel 2 levetiracetam hydrochlorothiazide MIRAPEX ER THERAPY AGENTS nifedipine ext-rel levetiracetam ext-rel NEUPRO cyclobenzaprine valsartan / valsartan- verapamil ext-rel oxcarbazepine hydrochlorothiazide phenobarbital ANTIPSYCHOTICS NARCOLEPSY BENICAR / BENICAR HCT § CALCIUM CHANNEL phenytoin § ATYPICALS BLOCKER / ANTILIPEMIC NUVIGIL phenytoin sodium extended § ANGIOTENSIN II aripiprazole COMBINATIONS primidone POSTHERPETIC RECEPTOR ANTAGONIST / clozapine amlodipine-atorvastatin tiagabine NEURALGIA CALCIUM CHANNEL olanzapine topiramate BLOCKER COMBINATIONS § DIGITALIS GLYCOSIDES quetiapine GRALISE valproic acid amlodipine-telmisartan risperidone digoxin zonisamide PSYCHOTHERAPEUTIC - amlodipine-valsartan ziprasidone FYCOMPA MISCELLANEOUS AZOR LATUDA OXTELLAR XR § OPIOID ANTAGONISTS SEROQUEL XR QUDEXY XR NARCAN NASAL SPRAY

§ PARTIAL OPIOID AGONIST / § MEGLITINIDES § EXTENDED CYCLE § PHOSPHATE BINDER § LAXATIVES OPIOID ANTAGONIST nateglinide ethinyl estradiol- AGENTS lactulose COMBINATIONS repaglinide levonorgestrel calcium acetate peg 3350-electrolytes buprenorphine-naloxone PHOSLYRA MOVIPREP SODIUM-GLUCOSE § TRANSDERMAL sublingual tablet RENVELA SUPREP CO-TRANSPORTER 2 SUBOXONE FILM ethinyl estradiol- VELPHORO (SGLT2) INHIBITORS norelgestromin OPIOID-INDUCED VASOMOTOR SYMPTOM FARXIGA PROGESTINS CONSTIPATION VAGINAL AGENTS JARDIANCE § ORAL MOVANTIK NUVARING BRISDELLE medroxyprogesterone SODIUM-GLUCOSE PANCREATIC ENZYMES progesterone, micronized CO-TRANSPORTER 2 ESTROGENS ENDOCRINE AND MEGACE ES CREON METABOLIC (SGLT2) INHIBITOR / § ORAL ULTRESA BIGUANIDE COMBINATIONS estradiol VAGINAL VIOKACE § ANDROGENS XIGDUO XR estropipate CRINONE ZENPEP ANDRODERM PREMARIN ENDOMETRIN AXIRON § SULFONYLUREAS § PROTON PUMP

glimepiride § TRANSDERMAL § SELECTIVE ESTROGEN INHIBITORS ANTIDIABETICS glipizide estradiol RECEPTOR MODULATORS esomeprazole AMYLIN ANALOGS glipizide ext-rel DIVIGEL raloxifene lansoprazole

SYMLINPEN EVAMIST OSPHENA omeprazole SUPPLIES MINIVELLE omeprazole-sodium § BIGUANIDES BD INSULIN SYRINGES § THYROID SUPPLEMENTS bicarbonate capsule VAGINAL metformin AND NEEDLES levothyroxine pantoprazole metformin ext-rel DEXCOM CONTINUOUS ESTRACE CREAM SYNTHROID DEXILANT

GLUCOSE MONITORING PREMARIN CREAM § BIGUANIDE / SYSTEM VAGIFEM GASTROINTESTINAL § STEROIDS, RECTAL SULFONYLUREA ONETOUCH ULTRA PROCTOFOAM-HC COMBINATIONS § ANTIEMETICS STRIPS AND KITS 3 ESTROGEN / PROGESTINS glipizide-metformin ONETOUCH VERIO § ORAL dronabinol § ULCER THERAPY COMBINATIONS STRIPS AND KITS 3 granisetron DIPEPTIDYL PEPTIDASE-4 estradiol-norethindrone meclizine PYLERA (DPP-4) INHIBITORS PREMPHASE ANTIOBESITY metoclopramide PREMPRO JANUVIA INJECTABLE ondansetron GENITOURINARY TRADJENTA TRANSDERMAL prochlorperazine SAXENDA § BENIGN PROSTATIC promethazine DIPEPTIDYL PEPTIDASE-4 COMBIPATCH HYPERPLASIA ORAL trimethobenzamide (DPP-4) INHIBITOR alfuzosin ext-rel BELVIQ ESTROGEN / SELECTIVE DICLEGIS COMBINATIONS doxazosin CONTRAVE ESTROGEN RECEPTOR SANCUSO dutasteride JANUMET MODULATOR VARUBI JANUMET XR CALCIUM REGULATORS COMBINATIONS finasteride § H2 RECEPTOR tamsulosin JENTADUETO § BISPHOSPHONATES DUAVEE

ANTAGONISTS terazosin INCRETIN MIMETIC AGENTS alendronate FERTILITY REGULATORS ranitidine RAPAFLO ibandronate TRULICITY GNRH / LHRH risedronate ERECTILE DYSFUNCTION VICTOZA ANTAGONISTS INFLAMMATORY BOWEL ATELVIA DISEASE ALPROSTADIL AGENTS INSULINS CETROTIDE § CALCITONINS § ORAL AGENTS MUSE HUMULIN R U-500 VIAL calcitonin-salmon § OVULATION STIMULANTS, balsalazide LANTUS PHOSPHODIESTERASE GONADOTROPINS budesonide capsule LEVEMIR INHIBITORS PARATHYROID HORMONES FOLLISTIM AQ sulfasalazine NOVOLIN 70/30 CIALIS FORTEO OVIDREL sulfasalazine delayed-rel NOVOLIN N APRISO NOVOLIN R CONTRACEPTIVES § URINARY § GLUCOCORTICOIDS LIALDA NOVOLOG ANTISPASMODICS § MONOPHASIC dexamethasone PENTASA NOVOLOG MIX 70/30 oxybutynin ethinyl estradiol- methylprednisolone UCERIS TOUJEO oxybutynin ext-rel drospirenone prednisone TRESIBA tolterodine ethinyl estradiol- § RECTAL AGENTS GLUCOSE ELEVATING tolterodine ext-rel § INSULIN SENSITIZERS norethindrone acetate hydrocortisone enema AGENTS trospium BEYAZ mesalamine rectal pioglitazone trospium ext-rel LO LOESTRIN FE GLUCAGEN HYPOKIT suspension GELNIQUE § INSULIN SENSITIZER / MINASTRIN 24 FE GLUCAGON EMERGENCY CANASA MYRBETRIQ BIGUANIDE COMBINATIONS SAFYRAL KIT CORTIFOAM VESICARE pioglitazone-metformin HUMAN GROWTH § IRRITABLE BOWEL § TRIPHASIC HORMONES SYNDROME HEMATOLOGIC § INSULIN SENSITIZER / ethinyl estradiol-norgestimate SULFONYLUREA ORTHO TRI-CYCLEN LO HUMATROPE LINZESS § ANTICOAGULANTS COMBINATIONS NORDITROPIN LOTRONEX warfarin FOUR PHASE VIBERZI pioglitazone-glimepiride ELIQUIS NATAZIA PRADAXA

XARELTO BETA AGONISTS, clindamycin-benzoyl § IMMUNOMODULATORS ketorolac

INHALANTS peroxide tacrolimus PROLENSA HEMATOPOIETIC GROWTH § SHORT ACTING erythromycin solution ELIDEL FACTORS erythromycin-benzoyl § Steroidal albuterol inhalation solution ARANESP peroxide § ROSACEA dexamethasone PROAIR HFA PROCRIT tretinoin metronidazole ALREX PROVENTIL HFA ACANYA sulfacetamide-sulfur DUREZOL § PLATELET AGGREGATION VENTOLIN HFA ATRALIN FINACEA LOTEMAX INHIBITORS LONG ACTING BENZACLIN ORACEA clopidogrel BETA-BLOCKERS Hand-held Active Inhalation DIFFERIN SOOLANTRA dipyridamole ext-rel-aspirin EPIDUO § Nonselective ARCAPTA BRILINTA RETIN-A MICRO § MISCELLANEOUS SKIN timolol maleate solution SEREVENT EFFIENT TAZORAC AND MUCOUS MEMBRANE BETIMOL

Nebulized Passive Inhalation DENAVIR IMMUNOLOGIC § ACTINIC KERATOSIS Selective AGENTS PERFOROMIST MOUTH / THROAT / fluorouracil cream 5% BETOPTIC S DENTAL AGENTS § LEUKOTRIENE RECEPTOR fluorouracil solution ALLERGENIC EXTRACTS § CARBONIC ANHYDRASE ANTAGONISTS imiquimod PROTECTANTS GRASTEK INHIBITORS PICATO montelukast EPISIL ORALAIR dorzolamide ZYCLARA MUGARD RAGWITEK zafirlukast AZOPT

§ NASAL ANTIHISTAMINES § ANTIFUNGALS OPHTHALMIC BIOLOGIC DISEASE- § CARBONIC ANHYDRASE ciclopirox § ANTIALLERGICS MODIFYING AGENTS azelastine INHIBITOR / BETA- clotrimazole ENBREL olopatadine azelastine BLOCKER COMBINATIONS econazole HUMIRA cromolyn sodium § NASAL STEROIDS dorzolamide-timolol ketoconazole olopatadine COSOPT PF § DISEASE-MODIFYING nystatin flunisolide PATADAY JUBLIA ANTIRHEUMATIC DRUGS fluticasone PAZEO CARBONIC ANHYDRASE LUZU (DMARDs) triamcinolone INHIBITOR / § ANTI-INFECTIVES RASUVO NASONEX NAFTIN SYMPATHOMIMETIC ciprofloxacin PHOSPHODIESTERASE-4 § ANTIPSORIATICS COMBINATIONS NUTRITIONAL erythromycin INHIBITORS acitretin SIMBRINZA gentamicin § PRENATAL VITAMINS calcipotriene DALIRESP levofloxacin IMMUNOMODULATORS prenatal vitamins methoxsalen ofloxacin RESTASIS STEROID / BETA AGONIST SORILUX CITRANATAL sulfacetamide COMBINATIONS tobramycin § PROSTAGLANDINS RESPIRATORY CORTICOSTEROIDS ADVAIR BESIVANCE § Low Potency latanoprost DULERA MOXEZA ANAPHYLAXIS TREATMENT travoprost desonide AGENTS § STEROID INHALANTS VIGAMOX TRAVATAN Z hydrocortisone AUVI-Q ZIOPTAN budesonide inhalation § ANTI-INFECTIVE / EPIPEN § Medium Potency suspension ANTI-INFLAMMATORY § SYMPATHOMIMETICS EPIPEN JR ASMANEX hydrocortisone butyrate COMBINATIONS brimonidine FLOVENT DISKUS mometasone § ANTICHOLINERGICS neomycin-polymyxin B- ALPHAGAN P FLOVENT HFA triamcinolone bacitracin-hydrocortisone SPIRIVA

PULMICORT FLEXHALER CLODERM neomycin-polymyxin B- SYMPATHOMIMETIC / BETA- ANTICHOLINERGIC / BETA QVAR LOCOID LOTION dexamethasone BLOCKER COMBINATIONS

AGONIST COMBINATIONS tobramycin-dexamethasone COMBIGAN TOPICAL § High Potency § SHORT ACTING TOBRADEX OINTMENT desoximetasone OTIC DERMATOLOGY TOBRADEX ST ipratropium-albuterol fluocinonide ZYLET § ANTI-INFECTIVE / inhalation solution § ACNE ANTI-INFLAMMATORY COMBIVENT RESPIMAT adapalene § Very High Potency ANTI-INFLAMMATORIES COMBINATIONS benzoyl peroxide clobetasol cream, foam, gel, LONG ACTING § Nonsteroidal CIPRODEX

clindamycin solution lotion, ointment, shampoo ANORO ELLIPTA bromfenac diclofenac QUICK REFERENCE DRUG LIST

A ADVAIR amlodipine amphetamine- ARANESP ALBENZA amlodipine-atorvastatin dextroamphetamine ARCAPTA abacavir albuterol inhalation solution amlodipine-telmisartan mixed salts aripiprazole ABSTRAL alendronate amlodipine-valsartan amphetamine- ASMANEX ACANYA alfuzosin ext-rel amlodipine-valsartan- dextroamphetamine ATELVIA acitretin allopurinol hydrochlorothiazide mixed salts ext-rel atenolol acyclovir ALPHAGAN P amoxicillin ANDRODERM atorvastatin adapalene ALREX amoxicillin-clavulanate ANORO ELLIPTA ATRALIN ADEMPAS amantadine APRISO ATRIPLA

AUBAGIO clarithromycin E galantamine LETAIRIS AUVI-Q clarithromycin ext-rel galantamine ext-rel LEVEMIR econazole AXIRON clindamycin GELNIQUE levetiracetam EFFIENT azelastine clindamycin solution GEL-ONE levetiracetam ext-rel ELIDEL AZILECT clindamycin-benzoyl gentamicin levofloxacin ELIQUIS azithromycin peroxide GILENYA levothyroxine ENBREL AZOPT clobetasol cream, foam, gel, glatiramer LIALDA ENDOMETRIN AZOR lotion, ointment, shampoo glimepiride LINZESS entacapone CLODERM glipizide lisinopril EPIDUO B clopidogrel glipizide ext-rel lisinopril-hydrochlorothiazide EPIPEN clotrimazole glipizide-metformin LO LOESTRIN FE balsalazide EPIPEN JR clozapine GLUCAGEN HYPOKIT LOCOID LOTION BD INSULIN SYRINGES EPISIL codeine-acetaminophen GLUCAGON EMERGENCY losartan AND NEEDLES eprosartan colchicine tablet KIT losartan-hydrochlorothiazide BELVIQ EPZICOM BENICAR COLCRYS GRALISE LOTEMAX erythromycin BENICAR HCT COMBIGAN granisetron LOTRONEX erythromycin solution COMBIPATCH GRASTEK lovastatin BENZACLIN erythromycin-benzoyl benzoyl peroxide COMBIVENT RESPIMAT guanfacine ext-rel LUZU peroxide BESIVANCE COMPLERA LYRICA erythromycins BETASERON CONTRAVE H escitalopram BETIMOL COPAXONE 40 MG HARVONI M esomeprazole BETOPTIC S COREG CR HUMATROPE meclizine ESTRACE CREAM BEYAZ CORTIFOAM HUMIRA medroxyprogesterone estradiol BIDIL COSOPT PF HUMULIN R U-500 VIAL MEGACE ES estradiol-norethindrone CREON BOSULIF estropipate HYALGAN meloxicam CRESTOR BRILINTA eszopiclone hydrochlorothiazide memantine brimonidine CRINONE ethinyl estradiol- hydrocodone-acetaminophen mesalamine rectal cromolyn sodium BRINTELLIX drospirenone hydrocortisone suspension BRISDELLE cyclobenzaprine hydrocortisone butyrate metformin ethinyl estradiol- bromfenac hydrocortisone enema metformin ext-rel D levonorgestrel budesonide capsule ethinyl estradiol- hydromorphone methadone budesonide inhalation DALIRESP hydromorphone ext-rel methoxsalen norelgestromin suspension DENAVIR ethinyl estradiol- HYSINGLA ER methylphenidate buprenorphine-naloxone desonide methylphenidate ext-rel norethindrone acetate sublingual tablet desoximetasone I methylprednisolone ethinyl estradiol-norgestimate bupropion dexamethasone metoclopramide ethosuximide ibandronate bupropion ext-rel DEXCOM CONTINUOUS metolazone EVAMIST imatinib mesylate BUTRANS GLUCOSE MONITORING metoprolol succinate ext-rel EVOTAZ imiquimod BYSTOLIC SYSTEM ipratropium-albuterol metoprolol tartrate

DEXILANT F inhalation solution metronidazole C diazepam rectal gel MINASTRIN 24 FE FARXIGA irbesartan DICLEGIS MINIVELLE calcipotriene fenofibrate irbesartan- diclofenac minocycline calcitonin-salmon fenofibric acid hydrochlorothiazide diclofenac sodium MIRAPEX ER calcium acetate fentanyl transdermal ISENTRESS CANASA diclofenac sodium solution fentanyl transmucosal itraconazole mirtazapine diclofenac sodium- mometasone candesartan lozenge ivermectin candesartan- misoprostol montelukast FENTORA hydrochlorothiazide dicloxacillin J morphine FINACEA carbamazepine DIFFERIN morphine ext-rel finasteride JANUMET carbamazepine ext-rel DIFICID morphine suppository FLOVENT DISKUS JANUMET XR digoxin MOVANTIK carbidopa-levodopa JANUVIA 2 FLOVENT HFA carbidopa-levodopa ext-rel diltiazem ext-rel MOVIPREP fluconazole JARDIANCE carbidopa-levodopa- dipyridamole ext-rel-aspirin MOXEZA flunisolide JENTADUETO entacapone divalproex sodium moxifloxacin fluocinonide JUBLIA carvedilol divalproex sodium ext-rel MUGARD fluorouracil cream 5% DIVIGEL K MUSE cefdinir fluorouracil solution cefprozil donepezil ketoconazole MYRBETRIQ fluoxetine dorzolamide cefuroxime axetil FLUOXETINE 60 MG ketorolac dorzolamide-timolol N celecoxib fluticasone KHEDEZLA doxazosin cephalexin fluvastatin nadolol doxycycline hyclate CETROTIDE FOLLISTIM AQ L NAFTIN dronabinol cholestyramine FORTEO lactulose NAMENDA XR DUAVEE CIALIS fosinopril lamivudine naproxen ciclopirox DULERA naratriptan fosinopril-hydrochlorothiazide lamotrigine CIPRODEX duloxetine NARCAN NASAL SPRAY furosemide lamotrigine ext-rel ciprofloxacin DUREZOL NASONEX FYCOMPA lansoprazole ciprofloxacin ext-rel dutasteride NATAZIA LANTUS citalopram G latanoprost nateglinide CITRANATAL gabapentin LATUDA

neomycin-polymyxin B- paroxetine ramipril sumatriptan U bacitracin-hydrocortisone paroxetine ext-rel RANEXA SUPARTZ FX UCERIS neomycin-polymyxin B- PATADAY ranitidine SUPRAX ULORIC dexamethasone PAZEO RAPAFLO SUPREP ULTRESA NEUPRO peg 3350-electrolytes RASUVO SYMLINPEN niacin ext-rel penicillin VK REBIF SYNTHROID V nifedipine ext-rel PENTASA RELENZA VAGIFEM nitrofurantoin PERFOROMIST RELPAX T valacyclovir nitroglycerin lingual spray phenobarbital RENVELA tacrolimus valganciclovir NITROLINGUAL phenytoin repaglinide TAMIFLU valproic acid NITROSTAT phenytoin sodium extended REPATHA tamsulosin valsartan NORDITROPIN PHOSLYRA RESTASIS TAZORAC valsartan-hydrochlorothiazide NORVIR PICATO RETIN-A MICRO TECFIDERA VARUBI NOVOLIN 70/30 pioglitazone REYATAZ TEKTURNA VELPHORO NOVOLIN N pioglitazone-glimepiride ribavirin TEKTURNA HCT venlafaxine NOVOLIN R pioglitazone-metformin risedronate telmisartan venlafaxine ext-rel NOVOLOG PRADAXA risperidone telmisartan- VENTOLIN HFA NOVOLOG MIX 70/30 pramipexole rivastigmine hydrochlorothiazide verapamil ext-rel NUCYNTA pravastatin rivastigmine transdermal terazosin VESICARE NUCYNTA ER prednisone rizatriptan terbinafine tablet VIBERZI NUVARING PREMARIN ropinirole tetracycline VICTOZA NUVIGIL PREMARIN CREAM ropinirole ext-rel tiagabine VIGAMOX nystatin PREMPHASE timolol maleate solution VIIBRYD PREMPRO S TIVICAY VIMPAT O prenatal vitamins SAFYRAL TOBRADEX OINTMENT VIOKACE ofloxacin PREZCOBIX SANCUSO TOBRADEX ST VOLTAREN GEL olanzapine PREZISTA SAVELLA tobramycin VYTORIN olopatadine primidone SAXENDA tobramycin-dexamethasone VYVANSE omega-3 acid ethyl esters PRISTIQ selegiline tolterodine omeprazole PROAIR HFA SEREVENT tolterodine ext-rel W omeprazole-sodium probenecid SEROQUEL XR topiramate warfarin bicarbonate capsule prochlorperazine sertraline torsemide WELCHOL PROCRIT ondansetron sildenafil TOUJEO PROCTOFOAM-HC ONETOUCH ULTRA SILENOR TRACLEER X STRIPS AND KITS 3 progesterone, micronized SIMBRINZA TRADJENTA XARELTO ONETOUCH VERIO PROLENSA simvastatin tramadol XIFAXAN 550 MG STRIPS AND KITS 3 promethazine SIVEXTRO tramadol ext-rel XIGDUO XR OPANA ER propranolol SOOLANTRA TRAVATAN Z

OPSUMIT propranolol ext-rel SORILUX travoprost Z ORACEA PROVENTIL HFA SOVALDI trazodone ORALAIR PULMICORT FLEXHALER SPIRIVA TRESIBA zafirlukast ORTHO TRI-CYCLEN LO PYLERA spironolactone- tretinoin ZENPEP

OSPHENA hydrochlorothiazide TREXIMET ZETIA OVIDREL Q SPRYCEL triamcinolone ZIOPTAN oxcarbazepine QUDEXY XR STRATTERA triamterene- ziprasidone OXTELLAR XR quetiapine STRIBILD hydrochlorothiazide zolmitriptan oxybutynin QUILLIVANT XR SUBOXONE FILM TRIBENZOR zolpidem oxybutynin ext-rel quinapril SUBSYS trimethobenzamide zolpidem ext-rel oxycodone quinapril-hydrochlorothiazide sulfacetamide TRIUMEQ ZOMIG NASAL SPRAY oxycodone-acetaminophen QVAR sulfacetamide-sulfur TROKENDI XR zonisamide OXYCONTIN sulfamethoxazole- trospium ZYCLARA R trimethoprim trospium ext-rel ZYLET

P RAGWITEK sulfasalazine TRULICITY pantoprazole raloxifene sulfasalazine delayed-rel TRUVADA

PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, BENZAC AC, BENZAC W adapalene, benzoyl peroxide, clindamycin solution, risperidone, ziprasidone, LATUDA, SEROQUEL XR clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, 4 3 ACCU-CHEK STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS , ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, 3 ONETOUCH VERIO STRIPS AND KITS RETIN-A MICRO, TAZORAC ACTOS pioglitazone BENZIQ adapalene, benzoyl peroxide, clindamycin solution, ADDERALL XR amphetamine-dextroamphetamine mixed salts, clindamycin-benzoyl peroxide, erythromycin solution, amphetamine-dextroamphetamine mixed salts ext-rel, erythromycin-benzoyl peroxide, tretinoin, ACANYA, guanfacine ext-rel, methylphenidate, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, methylphenidate ext-rel, QUILLIVANT XR, RETIN-A MICRO, TAZORAC STRATTERA, VYVANSE BREEZE 2 STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, 3 ADRENACLICK AUVI-Q, EPIPEN, EPIPEN JR ONETOUCH VERIO STRIPS AND KITS ADVICOR atorvastatin, fluvastatin, lovastatin, pravastatin, BREO ELLIPTA ADVAIR simvastatin, CRESTOR, VYTORIN BYDUREON TRULICITY, VICTOZA AEROSPAN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, BYETTA TRULICITY, VICTOZA PULMICORT FLEXHALER, QVAR CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE PICATO, ZYCLARA ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastatin, CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA) simvastatin, CRESTOR, VYTORIN CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA) ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA) AMITIZA LINZESS CARDURA XL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO AMRIX cyclobenzaprine CLIMARA PRO COMBIPATCH ANDROGEL ANDRODERM, AXIRON CLINDAGEL erythromycin solution ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO clobetasol spray clobetasol foam ANTARA fenofibrate, fenofibric acid CLOBEX SPRAY clobetasol foam APEXICON E desoximetasone, fluocinonide CONTOUR NEXT STRIPS ONETOUCH ULTRA STRIPS AND KITS 3, APIDRA NOVOLOG AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 3 ARMOUR THYROID levothyroxine, SYNTHROID CONTOUR STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, 3 ARTHROTEC celecoxib; diclofenac sodium, meloxicam or ONETOUCH VERIO STRIPS AND KITS naproxen WITH esomeprazole, lansoprazole, CYMBALTA duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, omeprazole, omeprazole-sodium bicarbonate capsule, PRISTIQ pantoprazole or DEXILANT DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS APRISO, LIALDA, PENTASA, UCERIS DETROL LA oxybutynin ext-rel, tolterodine, tolterodine ext-rel, 4 3 ASCENSIA STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS , trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, 3 ONETOUCH VERIO STRIPS AND KITS VESICARE ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT BENICAR HCT ATROVENT HFA SPIRIVA DORAL eszopiclone, zolpidem, zolpidem ext-rel, SILENOR AVONEX glatiramer, AUBAGIO, BETASERON, DUEXIS celecoxib; diclofenac sodium, meloxicam or COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA naproxen WITH esomeprazole, lansoprazole, AXERT naratriptan, rizatriptan, sumatriptan nasal spray, omeprazole, omeprazole-sodium bicarbonate capsule, sumatriptan tablet, zolmitriptan, RELPAX, pantoprazole or DEXILANT ZOMIG NASAL SPRAY DYMISTA flunisolide, fluticasone, triamcinolone or AZELEX adapalene, benzoyl peroxide, clindamycin solution, NASONEX WITH azelastine or olopatadine clindamycin-benzoyl peroxide, erythromycin solution, EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, erythromycin-benzoyl peroxide, tretinoin, ACANYA, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, losartan, losartan-hydrochlorothiazide, telmisartan, RETIN-A MICRO, TAZORAC telmisartan-hydrochlorothiazide, valsartan, BECONASE AQ flunisolide, fluticasone, triamcinolone, NASONEX valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT EDLUAR eszopiclone, zolpidem, zolpidem ext-rel, SILENOR

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ENABLEX oxybutynin ext-rel, tolterodine, tolterodine ext-rel, LEVITRA CIALIS trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE LIPITOR atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, VYTORIN ENJUVIA estradiol, estropipate, PREMARIN LIPTRUZET atorvastatin, fluvastatin, lovastatin, pravastatin, ESTRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM simvastatin, CRESTOR, VYTORIN EUFLEXXA GEL-ONE, HYALGAN, SUPARTZ FX LIVALO atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, VYTORIN EXFORGE amlodipine-telmisartan, amlodipine-valsartan, AZOR LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR LUNESTA eszopiclone, zolpidem, zolpidem ext-rel, SILENOR EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA Matzim LA diltiazem ext-rel (except generic CARDIZEM LA) FEMRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM MENEST estradiol, estropipate, PREMARIN FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, MENOSTAR estradiol PRISTIQ MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, FIRST TESTOSTERONE ANDRODERM, AXIRON eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, telmisartan-hydrochlorothiazide, valsartan, PICATO, ZYCLARA valsartan-hydrochlorothiazide, BENICAR, FORTAMET metformin, metformin ext-rel BENICAR HCT FORTESTA ANDRODERM, AXIRON MONOVISC GEL-ONE, HYALGAN, SUPARTZ FX FOSAMAX PLUS D alendronate, ibandronate, risedronate, ATELVIA NAPRELAN celecoxib, diclofenac sodium, meloxicam, naproxen FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO NATESTO ANDRODERM, AXIRON FREESTYLE STRIPS ONETOUCH ULTRA STRIPS AND KITS 3, NESINA JANUVIA, TRADJENTA 4, 5 3 AND KITS ONETOUCH VERIO STRIPS AND KITS NITROMIST nitroglycerin lingual spray, NITROLINGUAL, FROVA naratriptan, rizatriptan, sumatriptan nasal spray, NITROSTAT sumatriptan tablet, zolmitriptan, RELPAX, NORITATE metronidazole, sulfacetamide-sulfur, FINACEA, ZOMIG NASAL SPRAY SOOLANTRA GENOTROPIN HUMATROPE, NORDITROPIN NORVASC amlodipine GLUMETZA metformin, metformin ext-rel NUTROPIN AQ HUMATROPE, NORDITROPIN HUMALOG NOVOLOG OLEPTRO trazodone HUMALOG MIX 50/50 NOVOLOG MIX 70/30 OLUX-E clobetasol foam HUMALOG MIX 75/25 NOVOLOG MIX 70/30 OMNARIS flunisolide, fluticasone, triamcinolone, NASONEX HUMULIN NOVOLIN OMNITROPE HUMATROPE, NORDITROPIN INCRUSE ELLIPTA SPIRIVA ONGLYZA JANUVIA, TRADJENTA INNOPRAN XL atenolol, carvedilol, metoprolol succinate ext-rel, ORTHOVISC GEL-ONE, HYALGAN, SUPARTZ FX metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR OSENI JANUMET, JANUMET XR, JENTADUETO INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, SILENOR OXYTROL oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, INTUNIV amphetamine-dextroamphetamine mixed salts, VESICARE amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, PANCREAZE CREON, ULTRESA, VIOKACE, ZENPEP methylphenidate ext-rel, QUILLIVANT XR, STRATTERA, VYVANSE PENNSAID diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL INVOKAMET XIGDUO XR PERTZYE CREON, ULTRESA, VIOKACE, ZENPEP INVOKANA FARXIGA, JARDIANCE PEXEVA citalopram, escitalopram, fluoxetine, paroxetine, ISTALOL timolol maleate solution, BETIMOL paroxetine ext-rel, sertraline, BRINTELLIX, FLUOXETINE 60 MG, VIIBRYD JALYN dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO PLAVIX clopidogrel, BRILINTA, EFFIENT KAZANO JANUMET, JANUMET XR, JENTADUETO PLEGRIDY glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO PRALUENT REPATHA LASTACAFT azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO PRECISION XTRA STRIPS ONETOUCH ULTRA STRIPS AND KITS 3, AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 3 LESCOL XL atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, VYTORIN PRED MILD dexamethasone, DUREZOL, LOTEMAX

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* PREFERAOB generic prenatal vitamins, CITRANATAL TOVIAZ oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO VESICARE PRENATAL PLUS generic prenatal vitamins, CITRANATAL TRICOR fenofibrate, fenofibric acid PREVACID esomeprazole, lansoprazole, omeprazole, TRIGLIDE fenofibrate, fenofibric acid omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT TRILIPIX fenofibrate, fenofibric acid PROTONIX esomeprazole, lansoprazole, omeprazole, TRUETEST STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, omeprazole-sodium bicarbonate capsule, pantoprazole, ONETOUCH VERIO STRIPS AND KITS 3 DEXILANT TRUETRACK STRIPS ONETOUCH ULTRA STRIPS AND KITS 3, PROTOPIC tacrolimus, ELIDEL AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 3 QNASL flunisolide, fluticasone, triamcinolone, NASONEX TUDORZA SPIRIVA QSYMIA BELVIQ, CONTRAVE, SAXENDA VALCYTE valganciclovir RAYOS dexamethasone, methylprednisolone, prednisone VALTREX acyclovir, valacyclovir RELION INSULIN NOVOLIN INSULIN VASCEPA omega-3 acid ethyl esters RELISTOR MOVANTIK VERAMYST flunisolide, fluticasone, triamcinolone, NASONEX RHINOCORT AQUA flunisolide, fluticasone, triamcinolone, NASONEX VIAGRA CIALIS RIOMET metformin, metformin ext-rel VIEKIRA PAK HARVONI ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, SILENOR VIMOVO celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, SAIZEN HUMATROPE, NORDITROPIN omeprazole, omeprazole-sodium bicarbonate capsule, STRIANT ANDRODERM, AXIRON pantoprazole or DEXILANT SURE-TEST STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, VITAFOL-ONE generic prenatal vitamins, CITRANATAL 3 ONETOUCH VERIO STRIPS AND KITS VOGELXO ANDRODERM, AXIRON SYMBICORT ADVAIR, DULERA XOPENEX HFA PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA SYNVISC, SYNVISC-ONE GEL-ONE, HYALGAN, SUPARTZ FX ZETONNA flunisolide, fluticasone, triamcinolone, NASONEX TANZEUM TRULICITY, VICTOZA ZUBSOLV buprenorphine-naloxone sublingual tablet, TESTIM ANDRODERM, AXIRON SUBOXONE FILM testosterone gel 1% 6 ANDRODERM, AXIRON ZYFLO, ZYFLO CR montelukast, zafirlukast

TEVETEN, TEVETEN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

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 until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the Caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body). 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 plan participant's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. 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 www.caremark.com to check coverage and copay 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 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. 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: 1-800-588-4456. 4 ONETOUCH brand test strips are the only preferred options. 5 An exception process is in place for specific clinical circumstances that may require continued coverage for FREESTYLE diabetic test strips. If your doctor believes you have a specific clinical need for this product, he or she should fax an exception request to: 1-888-487-9257. Your plan may choose to provide an exception process for additional medications on this list. 6 Listing reflects the authorized generics for TESTIM and VOGELXO.

Plan participant privacy is important to us. Our employees are trained regarding the appropriate way to handle participants' 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.