2021 Express Scripts Medicare Formulary

Express Scripts Medicare (PDP) 2022 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN

Formulary ID Number: 22035, v7

This formulary was updated on 08/24/2021. For more recent information or to price a medication, you can visit us on the Web at express-scripts.com. Or you can contact Express Scripts Medicare ® (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week.

Note to current members: This formulary has changed since last year. Please review this document to understand your plan’s drug coverage.

When this drug list (formulary) refers to “we,” “us” or “our,” it means Medco Containment Life Insurance Company or Medco Containment Insurance Company of New York (for employer plans domiciled in New York). When it refers to “plan” or “our plan,” it means Express Scripts Medicare.

This document includes the list of the covered drugs (formulary) for our plan, which is current as of August 24, 2021. For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover.

You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, premium and/or copayments/coinsurance may change on January 1, 2023. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.800.268.5707 (TTY: 1.800.716.3231).

This document is available in braille. Please contact Customer Service if you need plan information in another format.

CRP2201_009867.1 F0HP2C2A This drug list was updated in August 2021. What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the “formulary.” It contains a list of covered Medicare Part D drugs selected by Express Scripts Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare’s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan’s specific drug coverage, please review your other plan materials, visit us on the Web at express-scripts.com or contact Customer Service. Express Scripts Medicare will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the drug list during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the cases below, you will be affected by coverage changes during the year:  New generic drugs. We may immediately remove a brand-name drug on our formulary if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our formulary, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the formulary?”  Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.  Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand-name drug currently on the formulary or add new restrictions to the brand-name drug or move it to a different cost-sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, if applicable, we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug, at which time the member will receive a one- month supply of the drug.

This drug list was updated in August 2021. i o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2022 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2022 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.

To get current information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back covers.

How do I use the formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular, Hypertension/Lipids.”

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 70. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the “Drug Name” column of the list.

What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

 Prior Authorization: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don’t get approval, the drugs may not be covered. These drugs are noted with “PA” next to them in the formulary.

Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly.

This drug list was updated in August 2021. ii  Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with “QL” next to them in the formulary.

 Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. These drugs are noted with “ST” next to them in the formulary. You may be able to find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 1. Note: This drug list includes all possible restrictions and limits on coverage. The requirements and limits may not apply to your plan’s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at express-scripts.com or contact Customer Service.

You can ask us to make an exception to these restrictions or limits. See the section “How do I request an exception to the formulary?” below for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered.

If you learn that your drug is not covered, you have two options:

 You can ask our Customer Service department for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered.

 You can ask us to make an exception and cover your drug. See below for information about how to request an exception.

You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers or request a formulary exception so that the plan will cover the drug you are taking.

How do I request an exception to the formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

 You can ask us to cover your drug even if it is not on our formulary. If approved, the drug will be covered at a pre-determined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level.

 You can ask us to cover a formulary drug at a lower cost-sharing level. If approved, this would lower the amount you must pay for your drug. In certain Express Scripts Medicare plans, you cannot ask us to change the cost-sharing tier for any drug in the specialty tier, if applicable.

This drug list was updated in August 2021. iii  You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug it will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

You should contact us to ask for an initial coverage decision for a formulary, tier or utilization restriction exception. When you are requesting an exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

Generally, your request for an exception will only be approved if the alternative drugs that are included in the plan formulary, the lower-tiered drugs or the additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. How do I request an appeal? If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. To start an appeal, you, your doctor or your representative must contact us.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision.

For more information about the appeals process, you may contact Customer Service using the information provided on the front and back covers of this document.

Can I get a temporary transition supply while I wait for an exception decision? As a new or continuing member in our plan, you may be taking drugs that are not covered from one year to the next. Or, you may be taking a drug that is covered but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, or while you wait for a coverage decision from us, we may cover a temporary transition supply of your drug in certain cases during the first 90 days that you are enrolled in the plan or at the start of a new coverage year.

For each of your drugs that is not on our formulary, or if your ability to get drugs is limited, we will cover a temporary transition supply when you go to a network pharmacy. This temporary transition supply will be for a one-month supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum of a one-month supply of medication. After your first refill of a one-month supply, we will not pay for these drugs, even if you have been a plan member less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary, or if your ability to get your drug is limited but you are past the first 90 days of membership in our plan, we will cover a minimum of a 31-day emergency transition supply of that drug while you pursue an exception.

This drug list was updated in August 2021. iv Other times when we will cover at least a temporary 30-day transition supply (or less, if you have a prescription written for fewer days) include:  When you enter a long-term care facility  When you leave a long-term care facility  When you are discharged from a hospital  When you leave a skilled nursing facility  When you cancel hospice care  When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized

Express Scripts Medicare will send you a letter within 3 business days of your filling a temporary transition supply notifying you that this was a temporary supply and explaining your options.

Other coverage that your plan may provide Your plan may also cover categories of “excluded” drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. Drugs in the following categories may be covered subject to the rules and limitations of your specific plan:  Prescription drugs when used for anorexia, weight loss or weight gain  Prescription drugs when used to promote fertility  Prescription drugs when used for cosmetic purposes or to promote hair growth  Prescription drugs when used for the symptomatic relief of cough or colds  Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs)  Drugs when used for the treatment of sexual or erectile dysfunction  Over-the-counter (OTC) diabetic supplies  Federal Legend Part B medications – for example, oral chemotherapy agents (e.g., TEMODAR®, XELODA®)  Non-prescription drugs, also known as over-the-counter (OTC) drugs  Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale.

Please contact Customer Service for additional information about your plan’s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses.

Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 70.

The “Drug Name” column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR®) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the “Requirements/Limits” column tells you if there are any special requirements for coverage of that particular drug.

If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary.

This drug list was updated in August 2021. v Your Costs The amount you pay for a covered drug will depend on:  Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit.  The drug tier for your drug. Each covered drug is in one of two drug tiers. Each tier may have a different cost-sharing amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier.

Your other plan materials have more information about your plan’s coverage stages and list the specific cost-sharing amounts for each tier. Drug Tiers Tier Includes Helpful tips Tier 1: This tier includes many Use Tier 1 drugs for the lowest cost-sharing Generic commonly prescribed generic amount. Drugs drugs and may include other low-cost drugs. Tier 2: This tier includes brand-name Tier 2 drugs generally have a higher Brand Drugs drugs as well as some generic cost-sharing amount than Tier 1 drugs. drugs.

If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan’s standard benefit. Members who qualify for Extra Help will receive a notice called “Important Information for Those Who Receive Extra Help Paying for Their Prescription Drugs” (“Low Income Rider” or “LIS Rider”). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan’s specific costs, please review your other plan materials.

If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048. Or visit https://www.medicare.gov.

This drug list was updated in August 2021. vi Below is a list of abbreviations that may appear on the following pages in the “Requirements/Limits” column that tells you if there are any special requirements for coverage of your drug. Note: The following drug list includes all possible restrictions and limitations. Depending on your plan’s specific benefit, you may not experience every restriction or limit indicated in the list. To confirm your plan’s specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

List of abbreviations

LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, contact Customer Service using the information provided on the front and back covers of this formulary.

MO: Mail-Order Drug. This prescription drug is available through Express Scripts® Pharmacy, our home delivery service, as well as through select retail network pharmacies. It may also be available through other network pharmacies. Consider using our home delivery service for your long-term (maintenance) medications, such as high blood pressure medications. Retail network pharmacies may be more appropriate for short-term prescriptions, such as antibiotics.

PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover this drug.

QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

This drug list was updated in August 2021. vii Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ANTI - itraconazole oral 1 MO INFECTIVES solution ketoconazole oral 1 MO ANTIFUNGAL micafungin 1 MO AGENTS NOXAFIL ORAL 2 PA; MO; ABELCET 2 PA; MO SUSPENSION QL (630 per AMBISOME 2 PA; MO 30 days) amphotericin b 1 PA; MO nystatin oral 1 MO caspofungin 1 PA posaconazole oral 1 PA; MO; clotrimazole mucous 1 MO tablet,delayed QL (96 per membrane release (dr/ec) 30 days) CRESEMBA 2 PA terbinafine hcl oral 1 MO ORAL voriconazole 1 PA; MO fluconazole 1 MO ANTIVIRALS fluconazole in nacl 1 PA; MO abacavir 1 MO (iso-osm) abacavir-lamivudine 1 MO intravenous piggyback 200 abacavir- 1 MO mg/100 ml lamivudine- zidovudine fluconazole in nacl 1 PA (iso-osm) acyclovir oral 1 MO intravenous capsule piggyback 400 acyclovir oral 1 MO mg/200 ml suspension 200 mg/5 flucytosine 1 MO ml griseofulvin 1 MO acyclovir oral tablet 1 MO microsize acyclovir sodium 1 PA; MO griseofulvin 1 MO intravenous solution ultramicrosize adefovir 1 MO itraconazole oral 1 MO; QL amantadine hcl 1 MO capsule (120 per 30 APTIVUS 2 MO days) atazanavir 1 MO

Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 1 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits BARACLUDE 2 MO FUZEON 2 MO ORAL SUBCUTANEOU SOLUTION S RECON SOLN BIKTARVY 2 MO GENVOYA 2 MO COMPLERA 2 MO HARVONI ORAL 2 PA; MO; DELSTRIGO 2 MO PELLETS IN QL (28 per PACKET 33.75- 28 days) DESCOVY 2 MO 150 MG DOVATO 2 MO HARVONI ORAL 2 PA; MO; EDURANT 2 MO PELLETS IN QL (56 per efavirenz 1 MO PACKET 45-200 28 days) efavirenz- 1 MO MG emtricitabin-tenofov HARVONI ORAL 2 PA; MO; efavirenz-lamivu- 1 MO TABLET 45-200 QL (56 per tenofov disop MG 28 days) emtricitabine 1 MO HARVONI ORAL 2 PA; MO; TABLET 90-400 QL (28 per emtricitabine- 1 MO MG 28 days) tenofovir (tdf) INTELENCE 2 MO EMTRIVA ORAL 2 MO SOLUTION INVIRASE ORAL 2 MO TABLET entecavir 1 MO ISENTRESS 2 MO EPCLUSA ORAL 2 PA; MO; TABLET 200-50 QL (56 per ISENTRESS HD 2 MO MG 28 days) JULUCA 2 MO EPCLUSA ORAL 2 PA; MO; KALETRA ORAL 2 MO TABLET 400-100 QL (28 per TABLET MG 28 days) lamivudine 1 MO EPIVIR HBV 2 MO lamivudine- 1 MO ORAL zidovudine SOLUTION LEXIVA ORAL 2 MO EVOTAZ 2 MO SUSPENSION famciclovir 1 MO lopinavir-ritonavir 1 MO fosamprenavir 1 MO oral solution

This drug list was updated in August 2021. 2 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits nevirapine oral 1 rimantadine 1 MO suspension ritonavir 1 MO nevirapine oral 1 MO RUKOBIA 2 MO tablet SELZENTRY 2 MO nevirapine oral 1 MO STRIBILD 2 MO tablet extended release 24 hr SYMTUZA 2 MO NORVIR ORAL 2 MO TEMIXYS 2 MO POWDER IN tenofovir disoproxil 1 MO PACKET fumarate NORVIR ORAL 2 MO TIVICAY 2 MO SOLUTION TIVICAY PD 2 MO ODEFSEY 2 MO TRIUMEQ 2 MO oseltamivir 1 MO valacyclovir oral 1 MO; QL PIFELTRO 2 MO tablet 1 gram (120 per 30 PREVYMIS 2 MO; QL days) ORAL (30 per 30 valacyclovir oral 1 MO; QL days) tablet 500 mg (60 per 30 PREZCOBIX 2 MO days) PREZISTA ORAL 2 MO valganciclovir 1 MO SUSPENSION VEMLIDY 2 MO PREZISTA ORAL 2 MO VIRACEPT 2 MO TABLET 150 MG, ORAL TABLET 600 MG, 75 MG, VIREAD ORAL 2 MO 800 MG POWDER RELENZA 2 MO VIREAD ORAL 2 MO DISKHALER TABLET 150 MG, REYATAZ ORAL 2 MO 200 MG, 250 MG POWDER IN VOSEVI 2 PA; MO; PACKET QL (28 per ribavirin oral 1 28 days) capsule zidovudine 1 MO ribavirin oral tablet 1 MO 200 mg

This drug list was updated in August 2021. 3 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits CEPHALOSPO cefoxitin 1 PA; MO RINS intravenous recon soln 1 gram, 2 gram cefaclor oral capsule 1 MO cefoxitin 1 PA cefaclor oral 1 MO intravenous recon suspension for soln 10 gram reconstitution 125 mg/5 ml, 250 mg/5 cefpodoxime 1 MO ml cefprozil 1 MO cefaclor oral 1 ceftazidime injection 1 PA; MO suspension for recon soln 1 gram, 2 reconstitution 375 gram mg/5 ml ceftazidime injection 1 PA cefaclor oral tablet 1 MO recon soln 6 gram extended release 12 ceftriaxone injection 1 MO hr recon soln 1 gram, 2 cefadroxil oral 1 MO gram, 250 mg, 500 capsule mg cefadroxil oral 1 MO ceftriaxone injection 1 suspension for recon soln 10 gram reconstitution 250 cefuroxime axetil 1 MO mg/5 ml, 500 mg/5 oral tablet ml cefuroxime sodium 1 PA; MO cefadroxil oral 1 MO injection recon soln tablet 750 mg cefazolin injection 1 MO cefuroxime sodium 1 PA; MO recon soln 1 gram, intravenous recon 500 mg soln 1.5 gram cefazolin injection 1 cefuroxime sodium 1 PA recon soln 10 gram intravenous recon cefdinir 1 MO soln 7.5 gram cefepime injection 1 MO cephalexin oral 1 MO cefixime 1 MO capsule 250 mg, 500 mg

This drug list was updated in August 2021. 4 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits cephalexin oral 1 MO clarithromycin 1 MO suspension for ery-tab oral 1 MO reconstitution tablet,delayed SUPRAX ORAL 2 release (dr/ec) 250 SUSPENSION mg, 333 mg FOR erythrocin (as 1 MO RECONSTITUTI stearate) oral tablet ON 500 MG/5 ML 250 mg SUPRAX ORAL 2 MO ERYTHROCIN 2 PA; MO TABLET,CHEWA INTRAVENOUS BLE RECON SOLN tazicef injection 1 PA 500 MG recon soln 1 gram, 2 erythromycin 1 gram ethylsuccinate oral tazicef injection 1 PA; MO tablet recon soln 6 gram erythromycin oral 1 MO TEFLARO 2 PA; MO MISCELLANEO ERYTHROMYC US INS / OTHER ANTIINFECTIV MACROLIDES ES azithromycin 1 PA; MO albendazole 1 MO intravenous amikacin injection 1 PA; MO azithromycin oral 1 MO solution 500 mg/2 packet ml azithromycin oral 1 MO ARIKAYCE 2 PA; LA suspension for atovaquone 1 MO reconstitution atovaquone- 1 MO azithromycin oral 1 proguanil tablet 250 mg (6 1 PA; MO pack), 500 mg (3 aztreonam injection

pack) recon soln 1 gram azithromycin oral 1 MO BENZNIDAZOLE 2 MO tablet 250 mg, 500 CAYSTON 2 PA; MO; mg, 600 mg LA; QL (84 per 28 days)

This drug list was updated in August 2021. 5 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits chloroquine 1 MO gentamicin in nacl 1 PA; MO phosphate (iso-osm) clindamycin hcl 1 MO intravenous piggyback 100 clindamycin in 5 % 1 PA; MO mg/100 ml, 60 dextrose mg/50 ml, 80 mg/50 clindamycin 1 MO ml pediatric gentamicin in nacl 1 PA clindamycin 1 PA; MO (iso-osm) phosphate injection intravenous clindamycin 1 PA; MO piggyback 80 phosphate mg/100 ml intravenous solution gentamicin injection 1 PA; MO 600 mg/4 ml solution 40 mg/ml COARTEM 2 MO hydroxychloroquine 1 MO colistin 1 PA; MO imipenem-cilastatin 1 PA; MO (colistimethate na) IMPAVIDO 2 PA; MO dapsone oral 1 MO isoniazid oral 1 MO DAPTOMYCIN 2 MO ivermectin oral 1 MO INTRAVENOUS RECON SOLN linezolid 1 MO 350 MG linezolid in dextrose 1 PA daptomycin 1 MO 5% intravenous recon mefloquine 1 MO soln 500 mg meropenem 1 PA; MO; EMVERM 2 MO intravenous recon QL (30 per ertapenem 1 PA; MO; soln 1 gram 10 days) QL (14 per meropenem 1 PA; MO; 14 days) intravenous recon QL (10 per ethambutol 1 MO soln 500 mg 10 days) metronidazole in 1 PA; MO nacl (iso-os) metronidazole oral 1 MO tablet neomycin 1 MO

This drug list was updated in August 2021. 6 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits nitazoxanide 1 MO vancomycin 1 PA; MO; paromomycin 1 MO intravenous recon QL (20 per soln 1,000 mg, 750 10 days) PASER 2 MO mg pentamidine 1 PA; MO; vancomycin 1 PA; QL (2 inhalation QL (1 per intravenous recon per 10 days) 28 days) soln 10 gram pentamidine 1 MO vancomycin 1 PA; MO; injection intravenous recon QL (10 per praziquantel 1 MO soln 500 mg 10 days) PRIFTIN 2 MO vancomycin oral 1 PA; MO; PRIMAQUINE 2 MO capsule 125 mg QL (40 per pyrazinamide 1 MO 10 days) pyrimethamine 1 PA; MO vancomycin oral 1 PA; MO; capsule 250 mg QL (80 per quinine sulfate 1 MO 10 days) rifabutin 1 MO XIFAXAN ORAL 2 PA; MO; rifampin 1 MO TABLET 200 MG QL (9 per SIRTURO 2 PA; LA 30 days) STREPTOMYCIN 2 PA; MO XIFAXAN ORAL 2 PA; MO; tigecycline 1 PA; MO TABLET 550 MG QL (90 per 30 days) tinidazole 1 MO PENICILLINS tobramycin in 0.225 1 PA; MO; % nacl QL (280 per amoxicillin oral 1 MO 28 days) capsule tobramycin 1 PA; MO; amoxicillin oral 1 MO inhalation QL (224 per suspension for 28 days) reconstitution tobramycin sulfate 1 PA; MO amoxicillin oral 1 MO injection solution tablet TRECATOR 2 MO amoxicillin oral 1 MO tablet,chewable 125 mg, 250 mg

This drug list was updated in August 2021. 7 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits amoxicillin-pot 1 MO oxacillin injection 1 PA clavulanate recon soln 1 gram, ampicillin oral 1 MO 10 gram capsule 500 mg oxacillin injection 1 PA; MO ampicillin sodium 1 PA; MO recon soln 2 gram injection recon soln penicillin g 1 PA; MO 1 gram, 10 gram, potassium injection 125 mg recon soln 20 ampicillin- 1 PA; MO million unit sulbactam injection penicillin g procaine 1 PA; MO recon soln 1.5 gram, intramuscular 3 gram syringe 1.2 million ampicillin- 1 PA unit/2 ml sulbactam injection penicillin g sodium 1 PA; MO recon soln 15 gram penicillin v 1 MO BICILLIN C-R 2 PA; MO potassium BICILLIN L-A 2 PA; MO piperacillin- 1 MO dicloxacillin 1 MO tazobactam intravenous recon nafcillin injection 1 PA; MO soln 2.25 gram, recon soln 1 gram, 2 3.375 gram, 4.5 gram gram nafcillin injection 1 PA piperacillin- 1 recon soln 10 gram tazobactam oxacillin in 1 PA intravenous recon dextrose(iso-osm) soln 40.5 gram intravenous QUINOLONES piggyback 1 gram/50 ml ciprofloxacin hcl 1 MO oxacillin in 1 PA; MO oral dextrose(iso-osm) ciprofloxacin in 5 % 1 PA; MO intravenous dextrose piggyback 2 intravenous gram/50 ml piggyback 200 mg/100 ml

This drug list was updated in August 2021. 8 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits levofloxacin in d5w 1 PA; MO doxycycline 1 MO intravenous monohydrate oral piggyback 500 suspension for mg/100 ml, 750 reconstitution mg/150 ml doxycycline 1 MO levofloxacin 1 PA; MO monohydrate oral intravenous tablet 100 mg, 50 levofloxacin oral 1 MO mg, 75 mg moxifloxacin oral 1 MO minocycline oral 1 MO capsule moxifloxacin- 1 PA; MO sod.chloride(iso) minocycline oral 1 MO tablet ofloxacin oral tablet 1 MO 300 mg, 400 mg mondoxyne nl oral 1 MO capsule 100 mg SULFA'S / RELATED tetracycline 1 MO AGENTS URINARY TRACT sulfadiazine 1 MO AGENTS sulfamethoxazole- 1 MO trimethoprim oral methenamine 1 MO hippurate TETRACYCLIN ES nitrofurantoin 1 MO nitrofurantoin 1 MO doxy-100 1 PA; MO macrocrystal oral doxycycline hyclate 1 MO capsule 100 mg, 50 oral capsule mg doxycycline hyclate 1 MO nitrofurantoin 1 MO oral tablet 20 mg monohyd/m-cryst doxycycline 1 MO trimethoprim 1 MO monohydrate oral capsule 100 mg, 50 mg

This drug list was updated in August 2021. 9 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ANTINEOPL ALUNBRIG 2 PA; QL (30 ASTIC / ORAL TABLET per 30 days) 180 MG, 90 MG IMMUNOSUP ALUNBRIG 2 PA; QL (60 PRESSANT ORAL TABLET per 30 days) DRUGS 30 MG ADJUNCTIVE ALUNBRIG 2 PA; QL (30 AGENTS ORAL per 30 days) TABLETS,DOSE leucovorin calcium 1 MO PACK oral anastrozole 1 MO MESNEX ORAL 2 MO AYVAKIT ORAL 2 PA; LA; XGEVA 2 PA; MO TABLET 100 MG, QL (30 per ANTINEOPLAS 200 MG, 300 MG 30 days) TIC / azathioprine 1 PA; MO IMMUNOSUPP BALVERSA 2 PA; LA RESSANT bexarotene 1 PA; MO DRUGS bicalutamide 1 MO abiraterone oral 1 PA; MO; BOSULIF ORAL 2 PA; MO; tablet 250 mg QL (120 per TABLET 100 MG QL (90 per 30 days) 30 days) abiraterone oral 1 PA; MO; BOSULIF ORAL 2 PA; MO; tablet 500 mg QL (60 per TABLET 400 MG, QL (30 per 30 days) 500 MG 30 days) AFINITOR 2 PA; MO BRAFTOVI 2 PA; MO; DISPERZ ORAL CAPSULE LA; QL AFINITOR ORAL 2 PA; MO; 75 MG (180 per 30 TABLET 10 MG QL (30 per days) 30 days) BRUKINSA 2 PA; LA ALECENSA 2 PA; MO; CABOMETYX 2 PA; MO; QL (240 per LA; QL (30 30 days) per 30 days)

This drug list was updated in August 2021. 10 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits CALQUENCE 2 PA; LA; cyclosporine 1 PA; MO QL (60 per modified oral 30 days) capsule CAPRELSA 2 PA; LA; cyclosporine 1 PA ORAL TABLET QL (60 per modified oral 100 MG 30 days) solution CAPRELSA 2 PA; LA; cyclosporine oral 1 PA; MO ORAL TABLET QL (30 per capsule 300 MG 30 days) DAURISMO 2 PA; MO; COMETRIQ 2 PA; MO; ORAL TABLET QL (30 per ORAL CAPSULE QL (56 per 100 MG 30 days) 100 MG/DAY(80 28 days) DAURISMO 2 PA; MO; MG X1-20 MG ORAL TABLET QL (60 per X1) 25 MG 30 days) COMETRIQ 2 PA; MO; DROXIA 2 MO ORAL CAPSULE QL (112 per EMCYT 2 MO 140 MG/DAY(80 28 days) MG X1-20 MG ERIVEDGE 2 PA; MO; X3) QL (30 per 30 days) COMETRIQ 2 PA; MO; ORAL CAPSULE QL (84 per ERLEADA 2 PA; MO; 60 MG/DAY (20 28 days) QL (120 per MG X 3/DAY) 30 days) COPIKTRA 2 PA; LA; erlotinib oral tablet 1 PA; MO; QL (60 per 100 mg, 150 mg QL (30 per 30 days) 30 days) COTELLIC 2 PA; MO; erlotinib oral tablet 1 PA; MO; LA; QL (63 25 mg QL (60 per per 28 days) 30 days) cyclophosphamide 1 PA; MO everolimus 1 PA; MO; oral capsule (antineoplastic) QL (30 per 30 days) CYCLOPHOSPH 2 PA; MO AMIDE ORAL everolimus 1 PA; MO TABLET (immunosuppressive )

This drug list was updated in August 2021. 11 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits exemestane 1 MO IMBRUVICA 2 PA; QL FARYDAK 2 PA; MO; ORAL CAPSULE (120 per 30 QL (6 per 140 MG days) 21 days) IMBRUVICA 2 PA; QL (30 FIRMAGON KIT 2 PA; MO ORAL CAPSULE per 30 days) W DILUENT 70 MG SYRINGE IMBRUVICA 2 PA; QL (30 flutamide 1 MO ORAL TABLET per 30 days) 280 MG, 420 MG, FOTIVDA 2 PA; LA; 560 MG QL (21 per 28 days) INLYTA ORAL 2 PA; MO; TABLET 1 MG QL (180 per GAVRETO 2 PA; MO; 30 days) LA; QL (120 per 30 INLYTA ORAL 2 PA; MO; days) TABLET 5 MG QL (120 per 30 days) gengraf 1 PA; MO INQOVI 2 PA; MO; GILOTRIF 2 PA; MO; QL (5 per QL (30 per 28 days) 30 days) INREBIC 2 PA; MO; hydroxyurea 1 MO LA; QL IBRANCE 2 PA; MO; (120 per 30 QL (21 per days) 28 days) IRESSA 2 PA; MO; ICLUSIG 2 PA; QL (30 QL (30 per per 30 days) 30 days) IDHIFA 2 PA; MO; JAKAFI 2 PA; MO; LA; QL (30 QL (60 per per 30 days) 30 days) imatinib oral tablet 1 PA; MO; KISQALI 2 PA; MO; 100 mg QL (180 per FEMARA CO- QL (49 per 30 days) PACK ORAL 28 days) imatinib oral tablet 1 PA; MO; TABLET 200 400 mg QL (60 per MG/DAY(200 MG 30 days) X 1)-2.5 MG

This drug list was updated in August 2021. 12 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits KISQALI 2 PA; MO; LORBRENA 2 PA; MO; FEMARA CO- QL (70 per ORAL TABLET QL (30 per PACK ORAL 28 days) 100 MG 30 days) TABLET 400 LORBRENA 2 PA; MO; MG/DAY(200 MG ORAL TABLET QL (90 per X 2)-2.5 MG 25 MG 30 days) KISQALI 2 PA; MO; LUPRON DEPOT 2 PA; MO FEMARA CO- QL (91 per LUPRON DEPOT 2 PA; MO PACK ORAL 28 days) (3 MONTH) TABLET 600 MG/DAY(200 MG LUPRON DEPOT 2 PA; MO X 3)-2.5 MG (4 MONTH) KISQALI ORAL 2 PA; MO; LUPRON DEPOT 2 PA; MO TABLET 200 QL (21 per (6 MONTH) MG/DAY (200 28 days) LYNPARZA 2 PA; MO; MG X 1) ORAL TABLET QL (120 per KISQALI ORAL 2 PA; MO; 30 days) TABLET 400 QL (42 per LYSODREN 2 MG/DAY (200 28 days) MATULANE 2 MG X 2) megestrol oral 1 PA; MO KISQALI ORAL 2 PA; MO; suspension 400 TABLET 600 QL (63 per mg/10 ml (40 MG/DAY (200 28 days) mg/ml), 625 mg/5 MG X 3) ml (125 mg/ml) lapatinib 1 PA; MO; megestrol oral 1 PA; MO QL (180 per tablet 30 days) MEKINIST 2 PA; MO; LENVIMA 2 PA; MO ORAL TABLET QL (90 per letrozole 1 MO 0.5 MG 30 days) LEUKERAN 2 MO MEKINIST 2 PA; MO; leuprolide 1 PA; MO ORAL TABLET 2 QL (30 per subcutaneous kit MG 30 days) LONSURF 2 PA; MO

This drug list was updated in August 2021. 13 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits MEKTOVI 2 PA; MO; ONUREG 2 PA; MO; LA; QL QL (14 per (180 per 30 14 days) days) ORGOVYX 2 PA; LA; mercaptopurine 1 MO QL (30 per methotrexate 1 PA; MO 30 days) sodium PEMAZYRE 2 PA; LA; methotrexate 1 PA; MO QL (14 per sodium (pf) 21 days) injection solution PIQRAY 2 PA; MO MVASI 2 PA; MO POMALYST 2 PA; MO; mycophenolate 1 PA; MO LA mofetil PROGRAF ORAL 2 PA; MO mycophenolate 1 PA; MO GRANULES IN sodium PACKET NERLYNX 2 PA; MO; PURIXAN 2 LA QINLOCK 2 PA; LA; NEXAVAR 2 PA; MO; QL (90 per LA; QL 30 days) (120 per 30 RETEVMO ORAL 2 PA; MO; days) CAPSULE 40 MG LA; QL nilutamide 1 PA; MO (180 per 30 days) NINLARO 2 PA; MO; QL (3 per RETEVMO ORAL 2 PA; MO; 28 days) CAPSULE 80 MG LA; QL (120 per 30 NUBEQA 2 PA; MO; days) LA; QL (120 per 30 REVLIMID 2 PA; MO; days) LA; QL (28 per 28 days) octreotide acetate 1 PA; MO injection solution ROZLYTREK 2 PA; MO; ORAL CAPSULE QL (150 per ODOMZO 2 PA; MO; 100 MG 30 days) LA; QL (30 per 30 days)

This drug list was updated in August 2021. 14 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ROZLYTREK 2 PA; MO; TAFINLAR 2 PA; MO; ORAL CAPSULE QL (90 per QL (120 per 200 MG 30 days) 30 days) RUBRACA 2 PA; MO; TAGRISSO 2 PA; MO; LA; QL LA; QL (30 (120 per 30 per 30 days) days) TALZENNA 2 PA; MO; RUXIENCE 2 PA; MO ORAL CAPSULE QL (90 per RYDAPT 2 PA; MO 0.25 MG 30 days) SANDIMMUNE 2 PA; MO TALZENNA 2 PA; MO; ORAL ORAL CAPSULE QL (30 per SOLUTION 1 MG 30 days) SIGNIFOR 2 PA tamoxifen 1 MO sirolimus 1 PA; MO TARGRETIN 2 PA; MO TOPICAL SOLTAMOX 2 MO TASIGNA ORAL 2 PA; MO; SPRYCEL ORAL 2 PA; MO; CAPSULE 150 QL (112 per TABLET 100 MG, QL (30 per MG, 200 MG 28 days) 140 MG, 50 MG, 30 days) 80 MG TASIGNA ORAL 2 PA; MO; CAPSULE 50 MG QL (120 per SPRYCEL ORAL 2 PA; MO; 30 days) TABLET 20 MG, QL (60 per 70 MG 30 days) TAZVERIK 2 PA; LA STIVARGA 2 PA; MO; TEPMETKO 2 PA; LA QL (84 per THALOMID 2 PA; MO 28 days) TIBSOVO 2 PA SUTENT 2 PA; MO; toremifene 1 MO QL (30 per TRAZIMERA 2 PA; MO 30 days) TRELSTAR 2 PA; MO SYNRIBO 2 PA INTRAMUSCUL TABLOID 2 MO AR SUSPENSION TABRECTA 2 PA; MO FOR tacrolimus oral 1 PA; MO RECONSTITUTI ON

This drug list was updated in August 2021. 15 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits tretinoin 1 MO VITRAKVI ORAL 2 PA; MO; (antineoplastic) CAPSULE 25 MG LA; QL TUKYSA ORAL 2 PA; LA; (180 per 30 TABLET 150 MG QL (120 per days) 30 days) VITRAKVI ORAL 2 PA; MO; TUKYSA ORAL 2 PA; LA; SOLUTION LA; QL TABLET 50 MG QL (300 per (300 per 30 30 days) days) TURALIO 2 PA; LA; VIZIMPRO 2 PA; MO; QL (120 per QL (30 per 30 days) 30 days) UKONIQ 2 PA; LA; VOTRIENT 2 PA; MO; QL (120 per QL (120 per 30 days) 30 days) VENCLEXTA 2 PA; LA; XALKORI 2 PA; MO; ORAL TABLET QL (60 per QL (60 per 10 MG 30 days) 30 days) VENCLEXTA 2 PA; LA; XATMEP 2 PA; MO ORAL TABLET QL (120 per XERMELO 2 PA; LA; 100 MG 30 days) QL (90 per VENCLEXTA 2 PA; LA; 30 days) ORAL TABLET QL (30 per XOSPATA 2 PA; LA 50 MG 30 days) XPOVIO 2 PA; LA VENCLEXTA 2 PA; LA; XTANDI ORAL 2 PA; MO; STARTING QL (42 per CAPSULE QL (120 per PACK 30 days) 30 days) VERZENIO 2 PA; MO; XTANDI ORAL 2 PA; MO; LA; QL (60 TABLET 40 MG QL (120 per per 30 days) 30 days) VITRAKVI ORAL 2 PA; MO; XTANDI ORAL 2 PA; MO; CAPSULE 100 LA; QL (60 TABLET 80 MG QL (60 per MG per 30 days) 30 days) YONSA 2 PA; MO; QL (120 per 30 days)

This drug list was updated in August 2021. 16 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ZEJULA 2 PA; LA; BRIVIACT 2 QL (600 per QL (90 per INTRAVENOUS 30 days) 30 days) BRIVIACT ORAL 2 MO; QL ZELBORAF 2 PA; MO; SOLUTION (600 per 30 QL (240 per days) 30 days) BRIVIACT ORAL 2 MO; QL ZIRABEV 2 PA; MO TABLET (60 per 30 ZOLINZA 2 PA; MO days) ZORTRESS 2 PA; MO carbamazepine oral 1 MO ORAL TABLET 1 capsule, er MG multiphase 12 hr ZYDELIG 2 PA; MO; carbamazepine oral 1 MO QL (60 per suspension 100 mg/5 30 days) ml ZYKADIA ORAL 2 PA; MO; carbamazepine oral 1 MO TABLET QL (90 per tablet 30 days) carbamazepine oral 1 MO AUTONOMIC tablet extended release 12 hr / CNS DRUGS, carbamazepine oral 1 MO NEUROLOGY tablet,chewable / PSYCH CELONTIN 2 MO ANTICONVULS ORAL CAPSULE ANTS 300 MG clobazam oral 1 PA; MO; APTIOM ORAL 2 MO; QL suspension QL (480 per TABLET 200 MG (180 per 30 30 days) days) clobazam oral tablet 1 PA; MO; APTIOM ORAL 2 MO; QL QL (60 per TABLET 400 MG (90 per 30 30 days) days) clonazepam oral 1 MO; QL APTIOM ORAL 2 MO; QL tablet 0.5 mg, 1 mg (90 per 30 TABLET 600 MG, (60 per 30 days) 800 MG days)

This drug list was updated in August 2021. 17 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits clonazepam oral 1 MO; QL FYCOMPA 2 MO; QL tablet 2 mg (300 per 30 ORAL TABLET (30 per 30 days) 10 MG, 12 MG, 8 days) clonazepam oral 1 MO; QL MG tablet,disintegrating (90 per 30 FYCOMPA 2 MO; QL 0.125 mg, 0.25 mg, days) ORAL TABLET 2 (60 per 30 0.5 mg, 1 mg MG, 4 MG, 6 MG days) clonazepam oral 1 MO; QL gabapentin oral 1 MO; QL tablet,disintegrating (300 per 30 capsule 100 mg, 400 (270 per 30 2 mg days) mg days) DIACOMIT 2 PA; LA gabapentin oral 1 MO; QL diazepam rectal 1 MO capsule 300 mg (360 per 30 days) DILANTIN 30 2 MO MG gabapentin oral 1 MO; QL solution 250 mg/5 (2160 per divalproex oral 1 ml 30 days) capsule, delayed rel sprinkle gabapentin oral 1 MO; QL tablet 600 mg (180 per 30 divalproex oral 1 MO days) tablet extended release 24 hr gabapentin oral 1 MO; QL tablet 800 mg (120 per 30 divalproex oral 1 MO days) tablet,delayed release (dr/ec) lamotrigine oral 1 MO tablet EPIDIOLEX 2 PA; MO; LA lamotrigine oral 1 MO tablet extended epitol 1 MO release 24hr ethosuximide 1 MO lamotrigine oral 1 MO felbamate 1 MO tablet, chewable FINTEPLA 2 PA; LA; dispersible QL (360 per lamotrigine oral 1 MO 30 days) tablet,disintegrating FYCOMPA 2 MO; QL levetiracetam oral 1 MO ORAL (720 per 30 solution 100 mg/ml SUSPENSION days)

This drug list was updated in August 2021. 18 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits levetiracetam oral 1 MO primidone 1 MO tablet roweepra oral tablet 1 MO levetiracetam oral 1 MO 500 mg tablet extended rufinamide 1 PA; MO release 24 hr SPRITAM 2 MO NAYZILAM 2 PA; MO; SYMPAZAN 2 PA; MO; QL (10 per QL (60 per 30 days) 30 days) oxcarbazepine 1 MO tiagabine 1 MO phenobarbital oral 1 PA; MO topiramate oral 1 PA; MO elixir capsule, sprinkle phenobarbital oral 1 PA topiramate oral 1 PA; MO tablet 100 mg, 15 tablet mg, 30 mg, 60 mg valproic acid 1 MO phenobarbital oral 1 PA; MO tablet 16.2 mg, 32.4 valproic acid (as 1 MO mg, 64.8 mg, 97.2 sodium salt) oral mg solution 250 mg/5 ml phenytoin oral 1 MO suspension 125 mg/5 VALTOCO 2 PA; MO; ml QL (10 per 30 days) phenytoin oral 1 MO tablet,chewable vigabatrin 1 MO; LA phenytoin sodium 1 MO vigadrone 1 LA extended VIMPAT 2 MO; QL pregabalin oral 1 MO; QL INTRAVENOUS (1200 per capsule 100 mg, 150 (90 per 30 30 days) mg, 200 mg, 25 mg, days) VIMPAT ORAL 2 MO; QL 50 mg, 75 mg SOLUTION (1200 per pregabalin oral 1 MO; QL 30 days) capsule 225 mg, 300 (60 per 30 VIMPAT ORAL 2 MO; QL mg days) TABLET 100 MG, (60 per 30 pregabalin oral 1 MO; QL 150 MG, 200 MG days) solution (900 per 30 days)

This drug list was updated in August 2021. 19 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits VIMPAT ORAL 2 MO; QL NEUPRO 2 MO TABLET 50 MG (120 per 30 pramipexole oral 1 MO days) tablet XCOPRI 2 MO; QL rasagiline 1 MO MAINTENANCE (56 per 28 ropinirole oral 1 MO PACK days) tablet XCOPRI ORAL 2 MO; QL selegiline hcl 1 MO TABLET 100 MG (120 per 30 days) MIGRAINE / XCOPRI ORAL 2 MO; QL CLUSTER TABLET 150 MG, (60 per 30 HEADACHE 200 MG days) THERAPY XCOPRI ORAL 2 MO; QL AJOVY 2 PA; MO; TABLET 50 MG (240 per 30 AUTOINJECTOR QL (1.5 per days) 30 days) XCOPRI 2 MO; QL AJOVY SYRINGE 2 PA; MO; TITRATION (56 per 28 QL (1.5 per PACK days) 30 days) zonisamide 1 PA; MO dihydroergotamine 1 QL (8 per ANTIPARKINS nasal 28 days) ONISM ergotamine-caffeine 1 MO AGENTS naratriptan 1 MO; QL benztropine oral 1 PA; MO (18 per 28 days) bromocriptine 1 MO rizatriptan 1 MO; QL carbidopa 1 MO (36 per 28 carbidopa-levodopa 1 MO days) carbidopa-levodopa- 1 MO sumatriptan nasal 1 MO; QL entacapone spray,non-aerosol (18 per 28 entacapone 1 MO 20 mg/actuation days) KYNMOBI 2 PA; MO; sumatriptan nasal 1 MO; QL SUBLINGUAL QL (150 per spray,non-aerosol 5 (36 per 28 FILM 10 MG, 15 30 days) mg/actuation days) MG, 20 MG, 25 MG, 30 MG

This drug list was updated in August 2021. 20 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits sumatriptan 1 MO; QL dimethyl fumarate 1 PA; MO; succinate oral (18 per 28 oral capsule,delayed QL (60 per days) release(dr/ec) 240 30 days) sumatriptan 1 MO; QL (8 mg succinate per 28 days) donepezil 1 MO subcutaneous FIRDAPSE 2 PA; LA cartridge galantamine 1 MO sumatriptan 1 MO; QL (8 GILENYA ORAL 2 PA; MO; succinate per 28 days) CAPSULE 0.5 MG QL (30 per subcutaneous pen 30 days) injector glatiramer 1 PA; QL (30 sumatriptan 1 MO; QL (8 subcutaneous per 30 days) succinate per 28 days) syringe 20 mg/ml subcutaneous solution glatiramer 1 PA; QL (12 subcutaneous per 28 days) MISCELLANEO syringe 40 mg/ml US glatopa 1 PA; MO; NEUROLOGICA subcutaneous QL (30 per L THERAPY syringe 20 mg/ml 30 days) AUBAGIO 2 PA; MO; glatopa 1 PA; MO; QL (30 per subcutaneous QL (12 per 30 days) syringe 40 mg/ml 28 days) dalfampridine 1 PA; MO; memantine oral 1 PA; MO QL (60 per capsule,sprinkle,er 30 days) 24hr dimethyl fumarate 1 PA; MO; memantine oral 1 PA; MO oral capsule,delayed QL (14 per solution release(dr/ec) 120 30 days) memantine oral 1 PA; MO mg tablet dimethyl fumarate 1 PA; MO; NAMZARIC 2 PA; MO oral capsule,delayed QL (120 per release(dr/ec) 120 180 days) NUEDEXTA 2 PA; MO mg (14)- 240 mg rivastigmine 1 MO (46) rivastigmine tartrate 1 MO

This drug list was updated in August 2021. 21 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits tetrabenazine oral 1 PA; MO; acetaminophen- 1 MO; QL tablet 12.5 mg QL (240 per codeine oral tablet (360 per 30 30 days) 300-15 mg, 300-30 days) tetrabenazine oral 1 PA; MO; mg tablet 25 mg QL (120 per acetaminophen- 1 MO; QL 30 days) codeine oral tablet (180 per 30 MUSCLE 300-60 mg days) RELAXANTS / buprenorphine hcl 1 MO ANTISPASMOD sublingual IC THERAPY endocet oral tablet 1 MO; QL 10-325 mg, 5-325 (360 per 30 baclofen oral 1 MO mg, 7.5-325 mg days) cyclobenzaprine 1 PA; MO fentanyl citrate 1 PA; MO; oral tablet 10 mg, 5 buccal lozenge on a QL (120 per mg handle 30 days) dantrolene oral 1 MO fentanyl 1 PA; MO; pyridostigmine 1 MO transdermal patch QL (10 per bromide oral tablet 72 hour 100 mcg/hr, 30 days) 60 mg 12 mcg/hr, 25 pyridostigmine 1 MO mcg/hr, 50 mcg/hr, bromide oral tablet 75 mcg/hr extended release hydrocodone- 1 MO; QL tizanidine oral 1 MO acetaminophen oral (5550 per tablet solution 7.5-325 30 days) NARCOTIC mg/15 ml ANALGESICS hydrocodone- 1 MO; QL acetaminophen oral (390 per 30 acetaminophen-caff- 1 MO; QL tablet 10-300 mg, 5- days) dihydrocod oral (300 per 30 300 mg, 7.5-300 mg capsule days) hydrocodone- 1 MO; QL acetaminophen- 1 MO; QL acetaminophen oral (360 per 30 codeine oral solution (4500 per tablet 10-325 mg, 5- days) 120-12 mg/5 ml 30 days) 325 mg, 7.5-325 mg

This drug list was updated in August 2021. 22 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits hydrocodone- 1 MO; QL morphine oral tablet 1 MO; QL ibuprofen oral tablet (50 per 30 (180 per 30 7.5-200 mg days) days) hydromorphone 1 QL (240 per morphine oral tablet 1 PA; MO; (pf) injection 30 days) extended release QL (120 per solution 10 (mg/ml) 30 days) (5 ml), 10 mg/ml oxycodone oral 1 MO; QL hydromorphone oral 1 MO; QL capsule (360 per 30 liquid (2400 per days) 30 days) oxycodone oral 1 MO; QL hydromorphone oral 1 MO; QL concentrate (180 per 30 tablet (180 per 30 days) days) oxycodone oral 1 MO; QL hydromorphone oral 1 PA; MO; solution (1200 per tablet extended QL (60 per 30 days) release 24 hr 30 days) oxycodone oral 1 MO; QL methadone oral 1 PA; MO; tablet 10 mg, 15 mg, (180 per 30 solution 10 mg/5 ml QL (600 per 20 mg, 30 mg days) 30 days) oxycodone oral 1 MO; QL methadone oral 1 PA; MO; tablet 5 mg (360 per 30 solution 5 mg/5 ml QL (1200 days) per 30 days) oxycodone- 1 MO; QL methadone oral 1 PA; MO; acetaminophen oral (360 per 30 tablet 10 mg QL (120 per tablet 10-325 mg, days) 30 days) 2.5-325 mg, 5-325 methadone oral 1 PA; MO; mg, 7.5-325 mg tablet 5 mg QL (240 per NON- 30 days) NARCOTIC morphine 1 MO; QL ANALGESICS concentrate oral (900 per 30 buprenorphine- 1 MO; QL solution days) naloxone sublingual (60 per 30 morphine oral 1 MO; QL film 12-3 mg days) solution (900 per 30 buprenorphine- 1 MO; QL days) naloxone sublingual (360 per 30 film 2-0.5 mg days)

This drug list was updated in August 2021. 23 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits buprenorphine- 1 MO; QL meloxicam oral 1 MO; QL naloxone sublingual (90 per 30 tablet 7.5 mg (30 per 30 film 4-1 mg, 8-2 mg days) days) buprenorphine- 1 MO; QL nabumetone 1 MO naloxone sublingual (360 per 30 naloxone injection 1 MO tablet 2-0.5 mg days) solution buprenorphine- 1 MO; QL naloxone injection 1 MO naloxone sublingual (90 per 30 syringe tablet 8-2 mg days) naltrexone 1 MO butorphanol nasal 1 MO; QL naproxen oral 1 MO (10 per 28 suspension days) naproxen oral tablet 1 MO celecoxib 1 MO naproxen oral 1 MO diclofenac 1 MO tablet,delayed potassium release (dr/ec) 375 diclofenac sodium 1 MO mg oral naproxen oral 1 diclofenac sodium 1 MO; QL tablet,delayed topical gel 1 % (1000 per release (dr/ec) 500 28 days) mg diflunisal 1 MO naproxen sodium 1 MO etodolac 1 MO oral tablet 275 mg, flurbiprofen oral 1 MO 550 mg tablet 100 mg NARCAN 2 MO ibu oral tablet 600 1 MO oxaprozin 1 MO mg, 800 mg piroxicam 1 MO ibuprofen oral 1 MO sulindac 1 MO suspension tramadol oral tablet 1 MO; QL ibuprofen oral tablet 1 MO 50 mg (240 per 30 400 mg, 600 mg, days) 800 mg tramadol- 1 MO; QL KLOXXADO 2 acetaminophen (240 per 30 meloxicam oral 1 MO days) tablet 15 mg VIVITROL 2 MO

This drug list was updated in August 2021. 24 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits PSYCHOTHER ARISTADA 2 MO; QL APEUTIC INTRAMUSCUL (2.4 per 28 DRUGS AR days) SUSPENSION,EX ABILIFY 2 MO; QL (1 TENDED REL MAINTENA per 28 days) SYRING 662 amitriptyline 1 MO MG/2.4 ML amoxapine 1 MO ARISTADA 2 MO; QL aripiprazole oral 1 MO INTRAMUSCUL (3.2 per 28 solution AR days) SUSPENSION,EX aripiprazole oral 1 MO; QL TENDED REL tablet (30 per 30 SYRING 882 days) MG/3.2 ML aripiprazole oral 1 MO; QL armodafinil 1 PA; MO; tablet,disintegrating (60 per 30 QL (30 per days) 30 days) ARISTADA 2 MO; QL asenapine maleate 1 MO; QL INITIO (4.8 per 365 (60 per 30 days) days) ARISTADA 2 MO; QL atomoxetine oral 1 MO; QL INTRAMUSCUL (3.9 per 56 capsule 10 mg, 18 (60 per 30 AR days) mg, 25 mg, 40 mg days) SUSPENSION,EX TENDED REL atomoxetine oral 1 MO; QL SYRING 1,064 capsule 100 mg, 60 (30 per 30 MG/3.9 ML mg, 80 mg days) ARISTADA 2 MO; QL bupropion hcl oral 1 MO INTRAMUSCUL (1.6 per 28 tablet AR days) bupropion hcl oral 1 MO; QL SUSPENSION,EX tablet extended (90 per 30 TENDED REL release 24 hr 150 mg days) SYRING 441 bupropion hcl oral 1 MO; QL MG/1.6 ML tablet extended (30 per 30 release 24 hr 300 mg days)

This drug list was updated in August 2021. 25 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits bupropion hcl oral 1 MO; QL diazepam oral 1 PA; MO; tablet sustained- (60 per 30 concentrate QL (240 per release 12 hr days) 30 days) buspirone 1 MO diazepam oral 1 PA; MO; CAPLYTA 2 MO; QL solution 5 mg/5 ml QL (1200 (30 per 30 (1 mg/ml) per 30 days) days) diazepam oral tablet 1 PA; MO; chlorpromazine oral 1 MO QL (120 per tablet 30 days) citalopram oral 1 MO doxepin oral capsule 1 MO solution doxepin oral 1 MO citalopram oral 1 MO; QL concentrate tablet (30 per 30 doxepin oral tablet 1 MO; QL days) (30 per 30 clomipramine 1 MO days) clonidine hcl oral 1 MO DRIZALMA 2 MO; QL tablet extended ORAL CAPSULE, (60 per 30 release 12 hr DELAYED REL days) SPRINKLE 20 clorazepate 1 PA; MO; MG, 30 MG, 60 dipotassium oral QL (180 per MG tablet 15 mg 30 days) DRIZALMA 2 MO; QL clorazepate 1 PA; MO; ORAL CAPSULE, (90 per 30 dipotassium oral QL (90 per DELAYED REL days) tablet 3.75 mg 30 days) SPRINKLE 40 clorazepate 1 PA; MO; MG dipotassium oral QL (360 per duloxetine oral 1 MO; QL tablet 7.5 mg 30 days) capsule,delayed (60 per 30 clozapine 1 release(dr/ec) 20 days) desipramine 1 MO mg, 30 mg, 60 mg desvenlafaxine 1 MO; QL EMSAM 2 MO succinate (30 per 30 escitalopram 1 MO days) oxalate oral solution dextroamphetamine 1 MO -amphetamine

This drug list was updated in August 2021. 26 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits escitalopram 1 MO; QL fluvoxamine oral 1 MO; QL oxalate oral tablet (30 per 30 tablet 25 mg (30 per 30 days) days) eszopiclone 1 MO; QL fluvoxamine oral 1 MO; QL (30 per 30 tablet 50 mg (60 per 30 days) days) FANAPT ORAL 2 MO; QL haloperidol 1 MO TABLET (60 per 30 haloperidol 1 MO days) decanoate FANAPT ORAL 2 MO; QL (8 intramuscular TABLETS,DOSE per 28 days) solution 100 mg/ml, PACK 100 mg/ml (1 ml), FETZIMA ORAL 2 MO; QL 50 mg/ml CAPSULE,EXT (28 per 28 haloperidol 1 REL 24HR DOSE days) decanoate PACK intramuscular FETZIMA ORAL 2 MO; QL solution 50 CAPSULE,EXTE (30 per 30 mg/ml(1ml) NDED RELEASE days) haloperidol lactate 1 MO 24 HR injection fluoxetine oral 1 MO; QL haloperidol lactate 1 MO capsule 10 mg, 20 (30 per 30 oral mg days) HETLIOZ 2 PA; MO; fluoxetine oral 1 MO; QL QL (30 per capsule 40 mg (60 per 30 30 days) days) imipramine hcl 1 MO fluoxetine oral 1 MO imipramine pamoate 1 MO solution INVEGA 2 MO; QL fluphenazine 1 MO SUSTENNA (0.75 per 28 decanoate INTRAMUSCUL days) fluphenazine hcl 1 MO AR SYRINGE 117 fluvoxamine oral 1 MO; QL MG/0.75 ML tablet 100 mg (90 per 30 days)

This drug list was updated in August 2021. 27 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits INVEGA 2 MO; QL (1 INVEGA 2 MO; QL SUSTENNA per 28 days) TRINZA (2.63 per 90 INTRAMUSCUL INTRAMUSCUL days) AR SYRINGE 156 AR SYRINGE 819 MG/ML MG/2.625 ML INVEGA 2 MO; QL LATUDA ORAL 2 MO; QL SUSTENNA (1.5 per 28 TABLET 120 MG, (30 per 30 INTRAMUSCUL days) 20 MG, 40 MG, 60 days) AR SYRINGE 234 MG MG/1.5 ML LATUDA ORAL 2 MO; QL INVEGA 2 MO; QL TABLET 80 MG (60 per 30 SUSTENNA (0.25 per 28 days) INTRAMUSCUL days) lithium carbonate 1 MO AR SYRINGE 39 lithium citrate oral 1 MO MG/0.25 ML solution 8 meq/5 ml INVEGA 2 MO; QL lorazepam intensol 1 PA; QL SUSTENNA (0.5 per 28 (150 per 30 INTRAMUSCUL days) days) AR SYRINGE 78 MG/0.5 ML lorazepam oral 1 PA; MO; tablet 0.5 mg, 1 mg QL (90 per INVEGA 2 MO; QL 30 days) TRINZA (0.88 per 90 INTRAMUSCUL days) lorazepam oral 1 PA; MO; AR SYRINGE 273 tablet 2 mg QL (150 per MG/0.875 ML 30 days) INVEGA 2 MO; QL loxapine succinate 1 MO TRINZA (1.32 per 90 MARPLAN 2 MO INTRAMUSCUL days) methylphenidate hcl 1 MO AR SYRINGE 410 oral capsule,er MG/1.315 ML biphasic 50-50 INVEGA 2 MO; QL methylphenidate hcl 1 MO TRINZA (1.75 per 90 oral solution INTRAMUSCUL days) methylphenidate hcl 1 MO AR SYRINGE 546 oral tablet MG/1.75 ML

This drug list was updated in August 2021. 28 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits methylphenidate hcl 1 MO paroxetine hcl oral 1 MO; QL oral tablet extended tablet 10 mg, 20 mg, (30 per 30 release 40 mg days) methylphenidate hcl 1 MO paroxetine hcl oral 1 MO; QL oral tablet,chewable tablet 30 mg (60 per 30 mirtazapine 1 MO days) modafinil oral tablet 1 PA; MO; PAXIL ORAL 2 MO 100 mg QL (30 per SUSPENSION 30 days) perphenazine 1 MO modafinil oral tablet 1 PA; MO; PERSERIS 2 MO; QL (1 200 mg QL (60 per per 30 days) 30 days) phenelzine 1 MO molindone 1 MO pimozide 1 MO nefazodone 1 MO protriptyline 1 MO nortriptyline 1 MO quetiapine oral 1 MO; QL NUPLAZID 2 PA; MO; tablet 100 mg, 200 (90 per 30 ORAL CAPSULE QL (30 per mg, 25 mg, 50 mg days) 30 days) quetiapine oral 1 MO; QL NUPLAZID 2 PA; MO; tablet 300 mg, 400 (60 per 30 ORAL TABLET QL (30 per mg days) 10 MG 30 days) quetiapine oral 1 MO; QL olanzapine 1 MO tablet extended (30 per 30 intramuscular release 24 hr 150 days) olanzapine oral 1 MO; QL mg, 200 mg (30 per 30 quetiapine oral 1 MO; QL days) tablet extended (60 per 30 paliperidone oral 1 MO; QL release 24 hr 300 days) tablet extended (30 per 30 mg, 400 mg, 50 mg release 24hr 1.5 mg, days) ramelteon 1 MO; QL 3 mg, 9 mg (30 per 30 paliperidone oral 1 MO; QL days) tablet extended (60 per 30 REXULTI 2 MO; QL release 24hr 6 mg days) (30 per 30 days)

This drug list was updated in August 2021. 29 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits RISPERDAL 2 MO; QL (2 trimipramine 1 MO CONSTA per 28 days) TRINTELLIX 2 MO; QL risperidone oral 1 MO (30 per 30 solution days) risperidone oral 1 MO; QL venlafaxine oral 1 MO; QL tablet 0.25 mg, 0.5 (60 per 30 capsule,extended (30 per 30 mg, 1 mg, 2 mg, 3 days) release 24hr 150 days) mg mg, 37.5 mg risperidone oral 1 MO; QL venlafaxine oral 1 MO; QL tablet 4 mg (120 per 30 capsule,extended (90 per 30 days) release 24hr 75 mg days) risperidone oral 1 MO; QL venlafaxine oral 1 MO; QL tablet,disintegrating (60 per 30 tablet (90 per 30 0.25 mg, 0.5 mg, 1 days) days) mg, 2 mg, 3 mg VERSACLOZ 2 risperidone oral 1 MO; QL VIIBRYD ORAL 2 MO; QL tablet,disintegrating (120 per 30 TABLET (30 per 30 4 mg days) days) SECUADO 2 MO; QL VIIBRYD ORAL 2 MO; QL (30 per 30 TABLETS,DOSE (30 per 30 days) PACK 10 MG (7)- days) sertraline oral 1 MO 20 MG (23) concentrate VRAYLAR ORAL 2 MO; QL sertraline oral tablet 1 MO; QL CAPSULE (30 per 30 100 mg, 50 mg (60 per 30 days) days) VRAYLAR ORAL 2 MO; QL (7 sertraline oral tablet 1 MO; QL CAPSULE,DOSE per 30 days) 25 mg (30 per 30 PACK days) XYREM 2 PA; LA; thioridazine 1 MO QL (540 per thiothixene 1 MO 30 days) tranylcypromine 1 MO zaleplon oral 1 MO; QL capsule 10 mg (60 per 30 trazodone 1 MO days) trifluoperazine 1 MO

This drug list was updated in August 2021. 30 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits zaleplon oral 1 MO; QL pacerone oral tablet 1 MO capsule 5 mg (30 per 30 100 mg, 200 mg, days) 400 mg ziprasidone hcl 1 MO; QL propafenone 1 MO (60 per 30 quinidine sulfate 1 MO days) oral tablet ziprasidone 1 sorine oral tablet 1 MO mesylate 120 mg, 160 mg, 80 zolpidem oral tablet 1 MO; QL mg (30 per 30 sorine oral tablet 1 days) 240 mg ZYPREXA 2 MO; QL (2 sotalol af 1 RELPREVV per 28 days) sotalol oral 1 MO INTRAMUSCUL AR SUSPENSION ANTIHYPERTE FOR NSIVE RECONSTITUTI THERAPY ON 210 MG acebutolol 1 MO CARDIOVAS aliskiren 1 MO CULAR, amiloride 1 MO HYPERTENSI amiloride- 1 MO ON / LIPIDS hydrochlorothiazide ANTIARRHYTH amlodipine 1 MO MIC AGENTS amlodipine- 1 MO benazepril amiodarone oral 1 tablet 100 mg, 400 amlodipine- 1 MO mg olmesartan amiodarone oral 1 MO amlodipine- 1 MO tablet 200 mg valsartan dofetilide 1 MO amlodipine- 1 MO valsartan-hcthiazid flecainide 1 MO atenolol 1 MO mexiletine 1 MO atenolol- 1 MO chlorthalidone

This drug list was updated in August 2021. 31 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits benazepril 1 MO diltiazem hcl oral 1 MO benazepril- 1 MO tablet hydrochlorothiazide diltiazem hcl oral 1 betaxolol oral 1 MO tablet extended release 24 hr 180 bisoprolol fumarate 1 MO mg, 240 mg, 300 bisoprolol- 1 MO mg, 360 mg hydrochlorothiazide dilt-xr 1 MO bumetanide 1 MO doxazosin oral 1 MO; QL candesartan 1 MO tablet 1 mg, 2 mg, 4 (30 per 30 candesartan- 1 MO mg days) hydrochlorothiazid doxazosin oral 1 MO; QL captopril 1 MO tablet 8 mg (60 per 30 cartia xt 1 MO days) carvedilol 1 MO enalapril maleate 1 MO chlorthalidone oral 1 MO enalapril- 1 MO tablet 25 mg, 50 mg hydrochlorothiazide clonidine 1 MO; QL (4 eplerenone 1 MO per 28 days) felodipine 1 MO clonidine hcl oral 1 MO fosinopril 1 MO tablet fosinopril- 1 MO diltiazem hcl oral 1 MO hydrochlorothiazide capsule,extended furosemide injection 1 MO release 12 hr furosemide oral 1 MO diltiazem hcl oral 1 MO solution 10 mg/ml, capsule,extended 40 mg/5 ml (8 release 24 hr 360 mg/ml) mg, 420 mg furosemide oral 1 MO diltiazem hcl oral 1 tablet capsule,extended hydralazine oral 1 MO release 24hr 120 mg, 180 mg, 240 hydrochlorothiazide 1 MO mg, 300 mg indapamide 1 MO irbesartan 1 MO

This drug list was updated in August 2021. 32 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits irbesartan- 1 MO olmesartan 1 MO hydrochlorothiazide olmesartan- 1 MO isradipine 1 MO amlodipin-hcthiazid labetalol oral 1 MO olmesartan- 1 MO lisinopril 1 MO hydrochlorothiazide lisinopril- 1 MO perindopril 1 MO hydrochlorothiazide erbumine losartan 1 MO pindolol 1 MO losartan- 1 MO prazosin 1 MO hydrochlorothiazide propranolol oral 1 MO matzim la 1 MO quinapril 1 MO methyldopa 1 MO quinapril- 1 MO metolazone 1 MO hydrochlorothiazide metoprolol 1 MO ramipril 1 MO succinate spironolactone 1 MO metoprolol ta- 1 MO spironolacton- 1 MO hydrochlorothiaz hydrochlorothiaz metoprolol tartrate 1 MO taztia xt 1 MO oral telmisartan 1 MO metyrosine 1 PA; MO telmisartan- 1 MO minoxidil oral 1 MO amlodipine moexipril 1 MO telmisartan- 1 MO nadolol 1 MO hydrochlorothiazid nicardipine oral 1 MO terazosin oral 1 MO; QL capsule 1 mg, 2 mg, (30 per 30 nifedipine oral 1 MO 5 mg days) tablet extended release terazosin oral 1 MO; QL capsule 10 mg (60 per 30 nifedipine oral 1 MO days) tablet extended release 24hr tiadylt er 1 MO nimodipine 1 MO timolol maleate oral 1 MO nisoldipine 1 MO torsemide oral 1 MO

This drug list was updated in August 2021. 33 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits trandolapril 1 MO DOPTELET (30 2 PA; MO; treprostinil sodium 1 PA; MO; TAB PACK) LA LA ELIQUIS 2 MO triamterene- 1 MO ELIQUIS DVT-PE 2 MO hydrochlorothiazid TREAT 30D oral capsule 37.5-25 START mg enoxaparin 1 MO; QL triamterene- 1 MO subcutaneous (28 per 28 hydrochlorothiazid syringe 100 mg/ml, days) oral tablet 150 mg/ml UPTRAVI 2 PA; MO; enoxaparin 1 MO; QL LA subcutaneous (22.4 per 28 valsartan 1 MO syringe 120 mg/0.8 days) ml, 80 mg/0.8 ml valsartan- 1 MO hydrochlorothiazide enoxaparin 1 MO; QL subcutaneous (16.8 per 28 verapamil oral 1 MO syringe 30 mg/0.3 days) COAGULATION ml, 60 mg/0.6 ml THERAPY enoxaparin 1 MO; QL aspirin- 1 MO subcutaneous (11.2 per 28 dipyridamole syringe 40 mg/0.4 days) BRILINTA 2 MO ml CABLIVI 2 PA; LA fondaparinux 1 MO INJECTION KIT heparin (porcine) 1 MO cilostazol 1 MO injection solution clopidogrel oral 1 MO; QL jantoven 1 MO tablet 75 mg (30 per 30 MULPLETA 2 PA; MO days) pentoxifylline 1 MO dipyridamole oral 1 MO prasugrel 1 MO DOPTELET (10 2 PA; MO; PROMACTA 2 PA; MO; TAB PACK) LA LA DOPTELET (15 2 PA; MO; warfarin 1 MO TAB PACK) LA XARELTO 2 MO

This drug list was updated in August 2021. 34 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits XARELTO DVT- 2 MO fenofibrate oral 1 MO PE TREAT 30D tablet 160 mg, 54 START mg LIPID/CHOLES fenofibric acid 1 MO TEROL (choline) LOWERING fluvastatin oral 1 MO; QL AGENTS capsule 20 mg (30 per 30 days) atorvastatin 1 MO; QL (30 per 30 fluvastatin oral 1 MO; QL days) capsule 40 mg (60 per 30 days) cholestyramine 1 MO (with sugar) oral gemfibrozil 1 MO powder in packet icosapent ethyl 1 MO cholestyramine light 1 JUXTAPID ORAL 2 PA; MO; oral powder in CAPSULE 10 MG, LA packet 20 MG, 30 MG, 5 colesevelam 1 MO MG colestipol oral 1 MO lovastatin oral 1 MO; QL packet tablet 10 mg (30 per 30 days) colestipol oral tablet 1 MO lovastatin oral 1 MO; QL ezetimibe 1 MO tablet 20 mg, 40 mg (60 per 30 ezetimibe- 1 MO; QL days) simvastatin (30 per 30 niacin oral tablet 1 days) extended release 24 fenofibrate 1 MO hr micronized oral omega-3 acid ethyl 1 MO capsule 134 mg, 200 esters mg, 43 mg, 67 mg pravastatin 1 MO; QL fenofibrate 1 MO (30 per 30 nanocrystallized days) oral tablet 145 mg, 48 mg prevalite oral 1 MO powder in packet

This drug list was updated in August 2021. 35 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits REPATHA 2 PA; QL (3 LANOXIN ORAL 2 MO per 28 days) TABLET 62.5 REPATHA 2 PA; QL MCG (0.0625 MG) PUSHTRONEX (3.5 per 28 ranolazine 1 MO days) VECAMYL 2 REPATHA 2 PA; QL (3 VYNDAMAX 2 PA; MO SURECLICK per 28 days) VYNDAQEL 2 PA; MO rosuvastatin 1 MO; QL (30 per 30 NITRATES days) isosorbide dinitrate 1 MO simvastatin oral 1 MO; QL oral tablet 10 mg, tablet (30 per 30 20 mg, 30 mg, 5 mg days) isosorbide 1 MO VASCEPA ORAL 2 ST; MO mononitrate CAPSULE 0.5 nitro-bid 1 MO GRAM nitroglycerin 1 MO MISCELLANEO sublingual US nitroglycerin 1 MO CARDIOVASCU transdermal patch LAR AGENTS 24 hour CORLANOR 2 QL (450 per nitroglycerin 1 MO ORAL 30 days) translingual SOLUTION DERMATOL CORLANOR 2 MO; QL OGICALS/TO ORAL TABLET (60 per 30 PICAL days) THERAPY digitek 1 MO digox 1 MO ANTIPSORIATI digoxin oral 1 MO C / ANTISEBORRH ENTRESTO 2 MO; QL EIC (60 per 30 days) acitretin 1 MO

This drug list was updated in August 2021. 36 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits calcipotriene scalp 1 MO; QL TALTZ 2 PA; MO; (120 per 30 AUTOINJECTOR QL (1 per days) 28 days) calcipotriene topical 1 MO; QL TALTZ SYRINGE 2 PA; MO; cream (120 per 30 QL (1 per days) 28 days) calcipotriene topical 1 MO; QL MISCELLANEO ointment (120 per 30 US days) DERMATOLOG selenium sulfide 1 MO ICALS topical lotion ammonium lactate 1 MO SKYRIZI 2 PA; QL (2 DUPIXENT 2 PA; MO; SUBCUTANEOU per 28 days) SUBCUTANEOU QL (8 per S PEN INJECTOR S PEN INJECTOR 28 days) SKYRIZI 2 PA; QL (2 300 MG/2 ML SUBCUTANEOU per 28 days) DUPIXENT 2 PA; MO; S SYRINGE 150 SUBCUTANEOU QL (4.56 MG/ML S SYRINGE 200 per 28 days) SKYRIZI 2 PA; MO; MG/1.14 ML SUBCUTANEOU QL (1 per DUPIXENT 2 PA; MO; S SYRINGE KIT 28 days) SUBCUTANEOU QL (8 per STELARA 2 PA; MO; S SYRINGE 300 28 days) INTRAVENOUS QL (104 per MG/2 ML 28 days) fluorouracil topical 1 MO STELARA 2 PA; MO; cream 5 % SUBCUTANEOU QL (0.5 per fluorouracil topical 1 MO S SOLUTION 28 days) solution STELARA 2 PA; MO; imiquimod topical 1 MO SUBCUTANEOU QL (0.5 per cream in packet 5 % S SYRINGE 45 28 days) MG/0.5 ML lidocaine hcl mucous 1 MO membrane solution STELARA 2 PA; MO; 4 % (40 mg/ml) SUBCUTANEOU QL (1 per S SYRINGE 90 28 days) MG/ML

This drug list was updated in August 2021. 37 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits lidocaine topical 1 PA; MO; clindamycin 1 MO; QL adhesive QL (90 per phosphate topical (120 per 30 patch,medicated 5 30 days) gel days) % clindamycin 1 MO; QL lidocaine topical 1 MO; QL phosphate topical (120 per 30 ointment (36 per 30 lotion days) days) clindamycin 1 MO; QL lidocaine viscous 1 MO phosphate topical (120 per 30 lidocaine-prilocaine 1 MO; QL solution days) topical cream (30 per 30 ery pads 1 MO days) erythromycin with 1 MO methoxsalen 1 MO ethanol topical pimecrolimus 1 PA; MO; solution QL (100 per isotretinoin 1 30 days) metronidazole 1 MO podofilox 1 MO topical cream REGRANEX 2 MO metronidazole 1 MO SANTYL 2 MO topical gel silver sulfadiazine 1 MO metronidazole 1 MO topical lotion ssd 1 MO myorisan 1 tacrolimus topical 1 PA; MO; QL (100 per tazarotene topical 1 PA; MO 30 days) cream VALCHLOR 2 PA; MO TAZORAC 2 PA; MO TOPICAL THERAPY FOR CREAM 0.05 % ACNE TAZORAC 2 PA; MO accutane oral 1 TOPICAL GEL capsule 20 mg, 30 tretinoin topical 1 PA; MO mg, 40 mg zenatane 1 amnesteem 1 avita topical cream 1 PA; MO claravis 1

This drug list was updated in August 2021. 38 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits TOPICAL clotrimazole topical 1 MO; QL ANTIBACTERIA solution (30 per 28 LS days) clotrimazole- 1 MO; QL gentamicin topical 1 MO; QL betamethasone (45 per 28 (60 per 30 topical cream days) days) clotrimazole- 1 MO; QL mafenide acetate 1 MO betamethasone (60 per 28 mupirocin 1 MO; QL topical lotion days) (44 per 30 econazole 1 MO; QL days) (85 per 28 sulfacetamide 1 MO days) sodium (acne) ketoconazole topical 1 MO; QL SULFAMYLON 2 MO cream (60 per 28 TOPICAL days) CREAM ketoconazole topical 1 MO; QL TOPICAL shampoo (120 per 28 ANTIFUNGALS days) ciclopirox topical 1 MO; QL nyamyc 1 MO; QL cream (90 per 28 (180 per 30 days) days) ciclopirox topical 1 MO; QL nystatin topical 1 MO; QL gel (45 per 28 cream (30 per 28 days) days) ciclopirox topical 1 MO; QL nystatin topical 1 MO; QL shampoo (120 per 28 ointment (30 per 28 days) days) ciclopirox topical 1 MO nystatin topical 1 QL (180 per solution powder 30 days) ciclopirox topical 1 MO; QL nystatin- 1 MO; QL suspension (60 per 28 triamcinolone (60 per 28 days) days) clotrimazole topical 1 MO; QL nystop 1 MO; QL cream (45 per 28 (180 per 30 days) days)

This drug list was updated in August 2021. 39 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits TOPICAL clobetasol topical 1 MO; QL ANTIVIRALS foam (100 per 28 days) acyclovir topical 1 PA; MO; ointment QL (30 per clobetasol topical 1 MO; QL 30 days) gel (120 per 28 days) DENAVIR 2 MO; QL (5 per 30 days) clobetasol topical 1 MO; QL lotion (118 per 28 TOPICAL days) CORTICOSTER clobetasol topical 1 MO; QL OIDS ointment (120 per 28 ala-cort topical 1 MO days) cream 1 % clobetasol topical 1 MO; QL ala-cort topical 1 shampoo (236 per 28 cream 2.5 % days) alclometasone 1 MO clobetasol-emollient 1 MO; QL betamethasone 1 MO topical cream (120 per 28 dipropionate days) betamethasone 1 MO clodan 1 MO; QL valerate topical (236 per 28 cream days) betamethasone 1 MO desonide 1 MO valerate topical fluocinolone and 1 MO lotion shower cap betamethasone 1 MO fluocinolone topical 1 MO valerate topical cream ointment fluocinolone topical 1 MO betamethasone, 1 MO ointment augmented fluocinolone topical 1 MO clobetasol scalp 1 MO; QL solution (100 per 28 fluocinonide topical 1 MO; QL days) cream 0.05 % (120 per 30 clobetasol topical 1 MO; QL days) cream (120 per 28 days)

This drug list was updated in August 2021. 40 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits fluocinonide topical 1 MO; QL triamcinolone 1 MO gel (120 per 30 acetonide topical days) ointment 0.025 %, fluocinonide topical 1 MO; QL 0.1 %, 0.5 % ointment (120 per 30 triderm topical 1 MO days) cream fluocinonide topical 1 MO; QL TOPICAL solution (120 per 30 SCABICIDES / days) PEDICULICIDE fluocinonide-e 1 MO; QL S (120 per 30 lindane topical 1 MO days) shampoo halobetasol 1 MO malathion 1 MO propionate topical cream permethrin 1 MO halobetasol 1 MO DIAGNOSTIC propionate topical S / ointment MISCELLAN hydrocortisone 1 MO EOUS topical cream 1 % AGENTS hydrocortisone 1 MO topical lotion 2.5 % MISCELLANEO hydrocortisone 1 MO US AGENTS topical ointment 1 acamprosate 1 MO %, 2.5 % anagrelide 1 MO mometasone topical 1 MO CARBAGLU 2 PA; MO; prednicarbate 1 MO LA topical ointment CHEMET 2 PA triamcinolone 1 MO CLINIMIX 2 PA acetonide topical 4.25%/D5W cream SULFIT FREE triamcinolone 1 MO clovique 1 PA; MO acetonide topical lotion d10 %-0.45 % 1 sodium chloride

This drug list was updated in August 2021. 41 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits d2.5 %-0.45 % 1 riluzole 1 PA; MO sodium chloride risedronate oral 1 MO; QL d5 % and 0.9 % 1 MO tablet 30 mg (30 per 30 sodium chloride days) d5 %-0.45 % sodium 1 MO sevelamer carbonate 1 MO; QL chloride oral tablet (270 per 30 deferasirox 1 PA; MO days) deferiprone 1 PA; MO sodium chloride 0.9 1 MO % intravenous dextrose 10 % and 1 piggyback 0.2 % nacl sodium chloride 1 MO dextrose 10 % in 1 irrigation water (d10w) sodium 1 PA; MO dextrose 5 % in 1 MO phenylbutyrate oral water (d5w) powder intravenous piggyback sodium 1 PA phenylbutyrate oral dextrose 5%-0.2 % 1 tablet sod chloride sodium polystyrene 1 MO disulfiram 1 MO sulfonate oral droxidopa 1 PA; MO powder FERRIPROX 2 PA sps (with sorbitol) 1 MO INCRELEX 2 MO; LA oral levocarnitine (with 1 MO trientine 1 PA; MO sugar) XURIDEN 2 PA levocarnitine oral 1 MO SMOKING tablet DETERRENTS LOKELMA 2 MO bupropion hcl 1 MO midodrine 1 MO (smoking deter) nitisinone 1 PA; MO CHANTIX 2 MO pilocarpine hcl oral 1 MO CHANTIX 2 MO PROLASTIN-C 2 PA; LA CONTINUING RAVICTI 2 PA; MO MONTH BOX

This drug list was updated in August 2021. 42 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits CHANTIX 2 MO fluocinolone 1 MO STARTING acetonide oil MONTH BOX hydrocortisone- 1 MO NICOTROL 2 MO acetic acid NICOTROL NS 2 MO ofloxacin otic (ear) 1 MO EAR, NOSE / OTIC STEROID THROAT / ANTIBIOTIC MEDICATIO ciprofloxacin- 1 MO NS dexamethasone neomycin- 1 MO MISCELLANEO polymyxin-hc otic US AGENTS (ear) azelastine nasal 1 MO; QL ENDOCRINE/ (60 per 30 DIABETES days) chlorhexidine 1 MO ADRENAL gluconate mucous HORMONES membrane dexamethasone oral 1 MO ipratropium 1 MO; QL elixir bromide nasal (30 per 30 dexamethasone oral 1 MO days) tablet periogard 1 MO fludrocortisone 1 MO triamcinolone 1 MO hydrocortisone oral 1 MO acetonide dental methylprednisolone 1 PA; MO MISCELLANEO oral tablet US OTIC methylprednisolone 1 MO PREPARATION oral tablets,dose S pack acetic acid otic 1 MO prednisolone oral 1 MO (ear) solution ciprofloxacin hcl 1 MO otic (ear) flac otic oil 1

This drug list was updated in August 2021. 43 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits prednisolone sodium 1 MO BYETTA 2 PA; MO; phosphate oral SUBCUTANEOU QL (1.2 per solution 25 mg/5 ml S PEN INJECTOR 30 days) (5 mg/ml), 5 mg 5 MCG/DOSE (250 base/5 ml (6.7 mg/5 MCG/ML) 1.2 ML ml) diazoxide 1 MO prednisone 1 MO FARXIGA ORAL 2 MO; QL prednisone intensol 1 MO TABLET 10 MG (30 per 30 ANTITHYROID days) AGENTS FARXIGA ORAL 2 MO; QL TABLET 5 MG (60 per 30 methimazole oral 1 MO days) tablet 10 mg, 5 mg glimepiride oral 1 MO; QL propylthiouracil 1 MO tablet 1 mg (240 per 30 DIABETES days) THERAPY glimepiride oral 1 MO; QL acarbose oral tablet 1 MO; QL tablet 2 mg (120 per 30 100 mg (90 per 30 days) days) glimepiride oral 1 MO; QL acarbose oral tablet 1 MO; QL tablet 4 mg (60 per 30 25 mg (360 per 30 days) days) glipizide oral tablet 1 MO; QL acarbose oral tablet 1 MO; QL 10 mg (120 per 30 50 mg (180 per 30 days) days) glipizide oral tablet 1 MO; QL ALCOHOL PADS 2 5 mg (240 per 30 days) BYDUREON 2 PA; MO; BCISE QL (4 per glipizide oral tablet 1 MO; QL 28 days) extended release (60 per 30 24hr 10 mg days) BYETTA 2 PA; MO; SUBCUTANEOU QL (2.4 per glipizide oral tablet 1 MO; QL S PEN INJECTOR 30 days) extended release (240 per 30 10 24hr 2.5 mg days) MCG/DOSE(250 MCG/ML) 2.4 ML

This drug list was updated in August 2021. 44 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits glipizide oral tablet 1 MO; QL HUMULIN 70/30 2 MO extended release (120 per 30 U-100 KWIKPEN 24hr 5 mg days) HUMULIN N 2 MO glipizide-metformin 1 MO; QL NPH INSULIN oral tablet 2.5-250 (240 per 30 KWIKPEN mg days) HUMULIN N 2 MO glipizide-metformin 1 MO; QL NPH U-100 oral tablet 2.5-500 (120 per 30 INSULIN mg, 5-500 mg days) HUMULIN R 2 MO GVOKE 2 MO REGULAR U-100 HYPOPEN 2- INSULN PACK HUMULIN R U- 2 MO GVOKE PFS 1- 2 MO 500 (CONC) PACK SYRINGE INSULIN HUMALOG 2 MO HUMULIN R U- 2 MO JUNIOR 500 (CONC) KWIKPEN U-100 KWIKPEN HUMALOG 2 MO JANUMET 2 MO; QL KWIKPEN (60 per 30 INSULIN days) HUMALOG MIX 2 MO JANUMET XR 2 MO; QL 50-50 INSULN U- ORAL TABLET, (30 per 30 100 ER days) HUMALOG MIX 2 MO MULTIPHASE 24 50-50 KWIKPEN HR 100-1,000 MG HUMALOG MIX 2 MO JANUMET XR 2 MO; QL 75-25 KWIKPEN ORAL TABLET, (60 per 30 ER days) HUMALOG MIX 2 MO MULTIPHASE 24 75-25(U- HR 50-1,000 MG, 100)INSULN 50-500 MG HUMALOG U- 2 MO JANUVIA 2 MO; QL 100 INSULIN (30 per 30 HUMULIN 70/30 2 MO days) U-100 INSULIN

This drug list was updated in August 2021. 45 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits JARDIANCE 2 MO; QL metformin oral 1 MO; QL (30 per 30 tablet 850 mg (90 per 30 days) days) KOMBIGLYZE 2 MO; QL metformin oral 1 MO; QL XR ORAL (60 per 30 tablet extended (120 per 30 TABLET, ER days) release 24 hr 500 mg days) MULTIPHASE 24 metformin oral 1 MO; QL HR 2.5-1,000 MG tablet extended (60 per 30 KOMBIGLYZE 2 MO; QL release 24 hr 750 mg days) XR ORAL (30 per 30 nateglinide oral 1 MO; QL TABLET, ER days) tablet 120 mg (90 per 30 MULTIPHASE 24 days) HR 5-1,000 MG, 5- nateglinide oral 1 MO; QL 500 MG tablet 60 mg (180 per 30 LANTUS 2 MO days) SOLOSTAR U-100 ONGLYZA 2 MO; QL INSULIN (30 per 30 LANTUS U-100 2 MO days) INSULIN pioglitazone 1 MO; QL LYUMJEV 2 MO (30 per 30 KWIKPEN U-100 days) INSULIN repaglinide oral 1 MO; QL LYUMJEV 2 MO tablet 0.5 mg (960 per 30 KWIKPEN U-200 days) INSULIN repaglinide oral 1 MO; QL LYUMJEV U-100 2 MO tablet 1 mg (480 per 30 INSULIN days) metformin oral 1 MO; QL repaglinide oral 1 MO; QL tablet 1,000 mg (75 per 30 tablet 2 mg (240 per 30 days) days) metformin oral 1 MO; QL SYNJARDY 2 MO; QL tablet 500 mg (150 per 30 (60 per 30 days) days)

This drug list was updated in August 2021. 46 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits SYNJARDY XR 2 MO; QL MISCELLANEO ORAL TABLET, (60 per 30 US HORMONES IR - ER, days) BIPHASIC 24HR cabergoline 1 MO 10-1,000 MG, 12.5- calcitonin (salmon) 1 MO 1,000 MG, 5-1,000 nasal MG calcitriol oral 1 MO SYNJARDY XR 2 MO; QL capsule ORAL TABLET, (30 per 30 calcitriol oral 1 IR - ER, days) solution BIPHASIC 24HR CERDELGA 2 PA; MO 25-1,000 MG cinacalcet 1 PA; MO TOUJEO MAX U- 2 MO 300 SOLOSTAR danazol 1 MO TOUJEO 2 MO desmopressin nasal 1 MO SOLOSTAR U-300 spray with pump INSULIN desmopressin oral 1 MO TRULICITY 2 PA; MO; doxercalciferol oral 1 MO QL (2 per KORLYM 2 PA 28 days) miglustat 1 PA; MO; XIGDUO XR 2 MO; QL LA ORAL TABLET, (30 per 30 MYALEPT 2 PA; MO; IR - ER, days) LA BIPHASIC 24HR 10-1,000 MG, 10- NATPARA 2 PA; MO; 500 MG LA XIGDUO XR 2 MO; QL oxandrolone 1 PA; MO ORAL TABLET, (60 per 30 PALYNZIQ 2 PA; MO; IR - ER, days) SUBCUTANEOU LA; QL (15 BIPHASIC 24HR S SYRINGE 10 per 30 days) 2.5-1,000 MG, 5- MG/0.5 ML 1,000 MG, 5-500 PALYNZIQ 2 PA; MO; MG SUBCUTANEOU LA; QL (4 S SYRINGE 2.5 per 30 days) MG/0.5 ML

This drug list was updated in August 2021. 47 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits PALYNZIQ 2 PA; MO; testosterone 1 PA; MO; SUBCUTANEOU LA; QL (60 transdermal gel in QL (300 per S SYRINGE 20 per 30 days) packet 1 % (25 30 days) MG/ML mg/2.5gram), 1 % paricalcitol oral 1 MO (50 mg/5 gram) SAMSCA ORAL 2 PA; MO testosterone 1 PA; MO; TABLET 15 MG transdermal gel in QL (37.5 packet 1.62 % per 30 days) sapropterin 1 PA; MO (20.25 mg/1.25 SOMAVERT 2 PA; MO gram) STRENSIQ 2 PA; LA testosterone 1 PA; MO; SUBCUTANEOU transdermal gel in QL (150 per S SOLUTION 28 packet 1.62 % (40.5 30 days) MG/0.7 ML, 40 mg/2.5 gram) MG/ML, 80 testosterone 1 PA; MO; MG/0.8 ML transdermal solution QL (180 per SYNAREL 2 PA; MO in metered pump 30 days) testosterone 1 PA; MO w/app cypionate tolvaptan oral tablet 1 PA; MO intramuscular oil 30 mg 100 mg/ml, 200 THYROID mg/ml, 200 mg/ml (1 ml) HORMONES testosterone 1 PA; MO euthyrox 1 MO enanthate levo-t 1 testosterone 1 PA; MO; levothyroxine oral 1 transdermal gel in QL (120 per tablet metered-dose pump 30 days) levoxyl oral tablet 1 MO 10 mg/0.5 gram 100 mcg, 112 mcg, /actuation 125 mcg, 137 mcg, testosterone 1 PA; MO; 150 mcg, 175 mcg, transdermal gel in QL (150 per 200 mcg, 25 mcg, 50 metered-dose pump 30 days) mcg, 75 mcg, 88 20.25 mg/1.25 gram mcg (1.62 %) liothyronine oral 1 MO

This drug list was updated in August 2021. 48 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits unithroid 1 MO CHENODAL 2 PA; LA GASTROENT CHOLBAM 2 PA EROLOGY ORAL CAPSULE 250 MG ANTIDIARRHE CHOLBAM 2 PA; QL ALS / ORAL CAPSULE (120 per 30 ANTISPASMOD 50 MG days) ICS compro 1 MO dicyclomine oral 1 MO constulose 1 MO capsule CORTIFOAM 2 MO dicyclomine oral 1 MO CREON 2 MO solution cromolyn oral 1 MO dicyclomine oral 1 MO CYSTADANE 2 tablet DIPENTUM 2 MO diphenoxylate- 1 MO atropine dronabinol 1 PA; MO glycopyrrolate oral 1 MO EMEND ORAL 2 PA tablet 1 mg, 2 mg SUSPENSION FOR loperamide oral 1 MO RECONSTITUTI capsule ON MISCELLANEO enulose 1 MO US GASTROINTES GATTEX 30-VIAL 2 PA; MO TINAL AGENTS gavilyte-c 1 MO gavilyte-g 1 MO alosetron 1 PA; MO gavilyte-n 1 MO aprepitant 1 PA; MO generlac 1 MO balsalazide 1 MO granisetron hcl oral 1 PA; MO budesonide oral 1 MO capsule,delayed,exte hydrocortisone 1 MO nd.release rectal budesonide oral 1 hydrocortisone 1 MO tablet,delayed and topical cream with ext.release perineal applicator 2.5 %

This drug list was updated in August 2021. 49 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits INFLECTRA 2 PA; MO; peg 3350- 1 MO QL (20 per electrolytes oral 28 days) recon soln 236- lactulose oral 1 MO 22.74-6.74 -5.86 solution 10 gram/15 gram ml peg-electrolyte 1 MO meclizine oral tablet 1 MO PENTASA 2 MO 12.5 mg, 25 mg prochlorperazine 1 MO mesalamine oral 1 MO prochlorperazine 1 MO capsule (with del rel maleate oral tablets) procto-med hc 1 MO mesalamine oral 1 procto-pak 1 MO capsule,extended release 24hr proctosol hc topical 1 MO mesalamine oral 1 MO proctozone-hc 1 MO tablet,delayed RECTIV 2 MO release (dr/ec) RELISTOR 2 MO; QL mesalamine rectal 1 MO SUBCUTANEOU (18 per 30 metoclopramide hcl 1 MO S SOLUTION days) oral solution RELISTOR 2 MO; QL metoclopramide hcl 1 MO SUBCUTANEOU (18 per 30 oral tablet S SYRINGE 12 days) MG/0.6 ML MOVANTIK 2 MO; QL (30 per 30 RELISTOR 2 MO; QL days) SUBCUTANEOU (12 per 30 S SYRINGE 8 days) OCALIVA 2 PA; MO; MG/0.4 ML LA; QL (30 per 30 days) REMICADE 2 PA; MO; QL (20 per ondansetron 1 PA; MO 28 days) ondansetron hcl oral 1 PA; MO scopolamine base 1 MO solution SUCRAID 2 PA ondansetron hcl oral 1 PA; MO tablet 4 mg, 8 mg sulfasalazine 1 MO

This drug list was updated in August 2021. 50 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits trilyte with flavor 1 MO nizatidine oral 1 packets capsule TRULANCE 2 MO omeprazole oral 1 MO; QL ursodiol 1 MO capsule,delayed (30 per 30 release(dr/ec) 10 days) VARUBI ORAL 2 PA mg, 20 mg VIOKACE 2 MO omeprazole oral 1 MO ULCER capsule,delayed THERAPY release(dr/ec) 40 cimetidine 1 MO mg cimetidine hcl oral 1 MO pantoprazole oral 1 MO; QL tablet,delayed (30 per 30 esomeprazole 1 MO; QL release (dr/ec) 20 days) magnesium oral (30 per 30 mg capsule,delayed days) release(dr/ec) 20 pantoprazole oral 1 MO mg tablet,delayed release (dr/ec) 40 esomeprazole 1 MO mg magnesium oral capsule,delayed sucralfate 1 MO release(dr/ec) 40 IMMUNOLO mg GY, famotidine oral 1 MO VACCINES / suspension BIOTECHNO famotidine oral 1 MO tablet 20 mg, 40 mg LOGY lansoprazole oral 1 MO; QL BIOTECHNOLO capsule,delayed (30 per 30 GY DRUGS release(dr/ec) 15 days) ACTIMMUNE 2 PA; MO mg ARCALYST 2 PA; MO lansoprazole oral 1 MO capsule,delayed AVONEX 2 PA; MO; release(dr/ec) 30 INTRAMUSCUL QL (1 per mg AR PEN 28 days) INJECTOR KIT misoprostol 1 MO

This drug list was updated in August 2021. 51 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits AVONEX 2 PA; MO; PLEGRIDY 2 PA; MO; INTRAMUSCUL QL (1 per SUBCUTANEOU QL (1 per AR SYRINGE 28 days) S SYRINGE 63 180 days) KIT MCG/0.5 ML- 94 BETASERON 2 PA; MO; MCG/0.5 ML SUBCUTANEOU QL (14 per PROCRIT 2 PA; MO S KIT 28 days) INJECTION INTRON A 2 PA; MO SOLUTION 10,000 INJECTION UNIT/ML, 2,000 UNIT/ML, 20,000 LEUKINE 2 PA; MO UNIT/ML, 3,000 INJECTION UNIT/ML, 4,000 RECON SOLN UNIT/ML, 40,000 NIVESTYM 2 PA; MO UNIT/ML NYVEPRIA 2 PA; MO RETACRIT 2 PA; MO OMNITROPE 2 PA; MO VACCINES / PEGASYS 2 MO; QL (4 MISCELLANEO SUBCUTANEOU per 28 days) US S SOLUTION IMMUNOLOGI PEGASYS 2 MO; QL (2 CALS SUBCUTANEOU per 28 days) S SYRINGE ACTHIB (PF) 2 MO PLEGRIDY 2 PA; MO; ADACEL(TDAP 2 MO SUBCUTANEOU QL (1 per ADOLESN/ADUL S PEN INJECTOR 28 days) T)(PF) 125 MCG/0.5 ML BCG VACCINE, 2 MO PLEGRIDY 2 PA; MO; LIVE (PF) SUBCUTANEOU QL (1 per BEXSERO 2 MO S PEN INJECTOR 180 days) BOOSTRIX TDAP 2 MO 63 MCG/0.5 ML- DAPTACEL 2 MO 94 MCG/0.5 ML (DTAP PLEGRIDY 2 PA; MO; PEDIATRIC) (PF) SUBCUTANEOU QL (1 per ENGERIX-B (PF) 2 PA; MO S SYRINGE 125 28 days) INTRAMUSCUL MCG/0.5 ML AR SYRINGE

This drug list was updated in August 2021. 52 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ENGERIX-B 2 PA; MO PROQUAD (PF) 2 PEDIATRIC (PF) QUADRACEL 2 GARDASIL 9 (PF) 2 MO (PF) HAVRIX (PF) 2 MO RABAVERT (PF) 2 MO INTRAMUSCUL RECOMBIVAX 2 PA; MO AR SYRINGE HB (PF) HIBERIX (PF) 2 MO INTRAMUSCUL IMOVAX RABIES 2 AR SUSPENSION VACCINE (PF) 10 MCG/ML, 40 MCG/ML INFANRIX 2 MO (DTAP) (PF) RECOMBIVAX 2 PA; MO INTRAMUSCUL HB (PF) AR SYRINGE INTRAMUSCUL AR SYRINGE 10 IPOL 2 MCG/ML IXIARO (PF) 2 RECOMBIVAX 2 PA KINRIX (PF) 2 HB (PF) INTRAMUSCUL INTRAMUSCUL AR SUSPENSION AR SYRINGE 5 KINRIX (PF) 2 MO MCG/0.5 ML INTRAMUSCUL ROTARIX 2 AR SYRINGE ROTATEQ 2 MO MENACTRA (PF) 2 MO VACCINE INTRAMUSCUL SHINGRIX (PF) 2 MO AR SOLUTION TDVAX 2 MO MENQUADFI 2 MO (PF) TENIVAC (PF) 2 MO INTRAMUSCUL MENVEO A-C-Y- 2 MO AR SYRINGE W-135-DIP (PF) TETANUS,DIPH 2 MO M-M-R II (PF) 2 MO THERIA TOX PEDIARIX (PF) 2 MO PED(PF) PEDVAX HIB 2 TRUMENBA 2 MO (PF) TWINRIX (PF) 2 MO PRIVIGEN 2 PA; MO

This drug list was updated in August 2021. 53 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits TYPHIM VI 2 BD NANO 2ND 2 MO INTRAMUSCUL GEN PEN AR SOLUTION NEEDLE TYPHIM VI 2 MO BD ULTRA-FINE 2 MO INTRAMUSCUL MICRO PEN AR SYRINGE NEEDLE VAQTA (PF) 2 MO BD ULTRA-FINE 2 MO VARIVAX (PF) 2 MINI PEN NEEDLE VARIZIG 2 MO BD ULTRA-FINE 2 MO YF-VAX (PF) 2 NANO PEN MISCELLAN NEEDLE EOUS BD ULTRA-FINE 2 MO SUPPLIES SHORT PEN NEEDLE MISCELLANEO BD VEO 2 MO US SUPPLIES INSULIN SYR BD 2 MO (HALF UNIT) AUTOSHIELD BD VEO 2 MO DUO PEN INSULIN NEEDLE SYRINGE UF BD INSULIN 2 MO GAUZE PADS 2 2 SYRINGE (HALF X 2 UNIT) INSULIN PEN 2 MO BD INSULIN 2 MO NEEDLE SYRINGE U-500 INSULIN 2 BD INSULIN 2 MO SYRINGE (DISP) ULTRA-FINE U-100 0.3 ML, 1/2 SYRINGE 0.3 ML ML 30 GAUGE X 1/2", INSULIN 2 MO 0.5 ML 31 SYRINGE (DISP) GAUGE X 5/16", 1 U-100 1 ML ML 30 GAUGE X 1/2" NEEDLES, 2 MO INSULIN DISP.,SAFETY

This drug list was updated in August 2021. 54 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits NOVOFINE 32 2 MO alendronate oral 1 MO; QL (4 NOVOTWIST 2 MO tablet 35 mg, 70 mg per 28 days) OMNIPOD DASH 2 MO ibandronate oral 1 MO; QL (1 5 PACK POD per 30 days) OMNIPOD 2 MO PROLIA 2 PA; MO; INSULIN QL (1 per MANAGEMENT 180 days) OMNIPOD 2 MO raloxifene 1 MO INSULIN risedronate oral 1 MO; QL (1 REFILL tablet 150 mg per 30 days) V-GO 20 2 MO risedronate oral 1 MO; QL (4 V-GO 30 2 MO tablet 35 mg, 35 mg per 28 days) (12 pack), 35 mg (4 V-GO 40 2 MO pack) MUSCULOSK risedronate oral 1 MO; QL ELETAL / tablet 5 mg (30 per 30 RHEUMATO days) LOGY risedronate oral 1 MO; QL (4 tablet,delayed per 28 days) GOUT release (dr/ec) THERAPY TERIPARATIDE 2 PA; MO; allopurinol 1 MO QL (2.48 colchicine oral 1 MO per 28 days) tablet OTHER febuxostat 1 MO RHEUMATOLO probenecid 1 MO GICALS probenecid- 1 MO ACTEMRA 2 PA; MO; colchicine ACTPEN QL (3.6 per OSTEOPOROSI 28 days) S THERAPY ACTEMRA 2 PA; MO; SUBCUTANEOU QL (3.6 per alendronate oral 1 MO; QL S 28 days) tablet 10 mg (30 per 30 days)

This drug list was updated in August 2021. 55 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits BENLYSTA 2 PA; MO HUMIRA(CF) 2 PA; MO; SUBCUTANEOU PEDI CROHNS QL (3 per S STARTER 180 days) ENBREL MINI 2 PA; MO; SUBCUTANEOU QL (8 per S SYRINGE KIT 28 days) 80 MG/0.8 ML ENBREL 2 PA; MO; HUMIRA(CF) 2 PA; MO; SUBCUTANEOU QL (16 per PEDI CROHNS QL (2 per S RECON SOLN 28 days) STARTER 180 days) SUBCUTANEOU ENBREL 2 PA; MO; S SYRINGE KIT SUBCUTANEOU QL (8 per 80 MG/0.8 ML-40 S SOLUTION 28 days) MG/0.4 ML ENBREL 2 PA; MO; HUMIRA(CF) 2 PA; MO; SUBCUTANEOU QL (8 per PEN CROHNS- QL (3 per S SYRINGE 28 days) UC-HS 180 days) ENBREL 2 PA; MO; HUMIRA(CF) 2 PA; MO; SURECLICK QL (8 per PEN PEDIATRIC QL (4 per 28 days) UC 28 days) HUMIRA PEN 2 PA; MO; HUMIRA(CF) 2 PA; MO; QL (4 per PEN PSOR-UV- QL (3 per 28 days) ADOL HS 180 days) HUMIRA PEN 2 PA; MO; HUMIRA(CF) 2 PA; MO; CROHNS-UC-HS QL (6 per SUBCUTANEOU QL (4 per START 180 days) S PEN INJECTOR 28 days) HUMIRA PEN 2 PA; MO; KIT 40 MG/0.4 PSOR-UVEITS- QL (4 per ML ADOL HS 180 days) HUMIRA(CF) 2 PA; MO; HUMIRA 2 PA; MO; SUBCUTANEOU QL (2 per SUBCUTANEOU QL (4 per S PEN INJECTOR 28 days) S SYRINGE KIT 28 days) KIT 80 MG/0.8 40 MG/0.8 ML ML

This drug list was updated in August 2021. 56 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits HUMIRA(CF) 2 PA; MO; penicillamine oral 1 PA; MO SUBCUTANEOU QL (2 per tablet S SYRINGE KIT 28 days) RIDAURA 2 MO 10 MG/0.1 ML, 20 RINVOQ 2 PA; MO; MG/0.2 ML QL (30 per HUMIRA(CF) 2 PA; MO; 30 days) SUBCUTANEOU QL (4 per XELJANZ ORAL 2 PA; MO; S SYRINGE KIT 28 days) SOLUTION QL (300 per 40 MG/0.4 ML 30 days) leflunomide 1 MO; QL XELJANZ ORAL 2 PA; MO; (30 per 30 TABLET QL (60 per days) 30 days) ORENCIA 2 PA; MO; XELJANZ XR 2 PA; MO; CLICKJECT QL (4 per QL (30 per 28 days) 30 days) ORENCIA 2 PA; MO; SUBCUTANEOU QL (4 per OBSTETRICS S SYRINGE 125 28 days) / MG/ML GYNECOLOG ORENCIA 2 PA; MO; Y SUBCUTANEOU QL (1.6 per S SYRINGE 50 28 days) ESTROGENS / MG/0.4 ML PROGESTINS ORENCIA 2 PA; MO; amabelz 1 PA; MO SUBCUTANEOU QL (2.8 per camila 1 MO S SYRINGE 87.5 28 days) deblitane 1 MO MG/0.7 ML dotti 1 PA; MO; OTEZLA 2 PA; MO; QL (8 per QL (60 per 28 days) 30 days) errin 1 MO OTEZLA 2 PA; MO; STARTER ORAL QL (55 per estradiol oral 1 PA; MO TABLETS,DOSE 28 days) estradiol 1 PA; MO; PACK 10 MG (4)- transdermal patch QL (8 per 20 MG (4)-30 MG semiweekly 28 days) (47)

This drug list was updated in August 2021. 57 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits estradiol 1 PA; QL (4 norethindrone ac- 1 PA; MO transdermal patch per 28 days) eth estradiol oral weekly tablet 1-5 mg-mcg estradiol vaginal 1 MO progesterone 1 MO estradiol valerate 1 MO micronized intramuscular oil 20 sharobel 1 MO mg/ml, 40 mg/ml yuvafem 1 MO estradiol- 1 PA; MO MISCELLANEO norethindrone acet US OB/GYN fyavolv 1 PA; MO clindamycin 1 MO incassia 1 MO phosphate vaginal jinteli 1 PA; MO eluryng 1 MO lyllana 1 PA; MO; etonogestrel-ethinyl 1 QL (8 per estradiol 28 days) metronidazole 1 MO lyza 1 vaginal medroxyprogesteron 1 MO terconazole 1 MO e tranexamic acid 1 MO MENEST ORAL 2 PA; MO oral TABLET 0.3 MG, 0.625 MG, 1.25 vandazole 1 MO MG xulane 1 MO mimvey 1 PA; MO zafemy 1 MO nora-be 1 MO ORAL norethindrone 1 CONTRACEPTI (contraceptive) VES / RELATED norethindrone 1 MO AGENTS acetate altavera (28) 1 MO norethindrone ac- 1 PA alyacen 1/35 (28) 1 MO eth estradiol oral apri 1 MO tablet 0.5-2.5 mg- mcg aranelle (28) 1 MO aubra eq 1 MO aviane 1 MO

This drug list was updated in August 2021. 58 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits caziant (28) 1 MO kurvelo (28) 1 MO cryselle (28) 1 MO l norgest/e.estradiol- 1 cyclafem 1/35 (28) 1 MO e.estrad oral tablets,dose pack,3 cyclafem 7/7/7 (28) 1 MO month 0.10 mg-20 cyred eq 1 MO mcg (84)/10 mcg desog- 1 (7), 0.15 mg-30 e.estradiol/e.estradi mcg (84)/10 mcg ol (7) desogestrel-ethinyl 1 l norgest/e.estradiol- 1 MO estradiol e.estrad oral drospirenone-ethinyl 1 MO tablets,dose pack,3 estradiol oral tablet month 0.15 mg-20 3-0.02 mg mcg/ 0.15 mg-25 mcg drospirenone-ethinyl 1 estradiol oral tablet larin 1.5/30 (21) 1 MO 3-0.03 mg larin 1/20 (21) 1 MO emoquette 1 MO larin fe 1.5/30 (28) 1 MO enpresse 1 MO larin fe 1/20 (28) 1 MO enskyce 1 MO larissia 1 MO estarylla 1 MO lessina 1 MO ethynodiol diac-eth 1 levonest (28) 1 MO estradiol levonorgestrel- 1 MO falmina (28) 1 MO ethinyl estrad oral fayosim 1 MO tablet 0.1-20 mg- mcg femynor 1 MO levonorgestrel- 1 introvale 1 MO ethinyl estrad oral isibloom 1 MO tablet 0.15-0.03 mg, jasmiel (28) 1 MO 90-20 mcg (28) juleber 1 MO levonorgestrel- 1 MO kariva (28) 1 MO ethinyl estrad oral tablets,dose pack,3 kelnor 1/35 (28) 1 MO month kelnor 1-50 (28) 1 MO

This drug list was updated in August 2021. 59 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits levonorg-eth estrad 1 MO orsythia 1 MO triphasic pimtrea (28) 1 MO levora-28 1 MO pirmella oral tablet 1 MO loryna (28) 1 MO 1-35 mg-mcg low-ogestrel (28) 1 MO portia 28 1 MO lutera (28) 1 MO previfem 1 MO marlissa (28) 1 MO reclipsen (28) 1 MO microgestin 1.5/30 1 MO setlakin 1 MO (21) sprintec (28) 1 MO microgestin 1/20 1 MO sronyx 1 MO (21) syeda 1 MO microgestin fe 1 MO tarina 24 fe 1 MO 1.5/30 (28) tarina fe 1-20 eq 1 MO microgestin fe 1/20 1 MO (28) (28) tilia fe 1 MO mili 1 MO tri-estarylla 1 MO nikki (28) 1 MO tri-legest fe 1 MO norethindrone ac- 1 MO eth estradiol oral tri-lo-estarylla 1 MO tablet 1-20 mg-mcg tri-lo-sprintec 1 MO norgestimate-ethinyl 1 tri-previfem (28) 1 MO estradiol oral tablet tri-sprintec (28) 1 MO 0.18/0.215/0.25 mg- trivora (28) 1 MO 25 mcg, 0.25-35 mg- mcg velivet triphasic 1 MO regimen (28) norgestimate-ethinyl 1 MO estradiol oral tablet vestura (28) 1 0.18/0.215/0.25 mg- vienva 1 MO 35 mcg (28) zarah 1 MO nortrel 0.5/35 (28) 1 MO zovia 1-35 (28) 1 nortrel 1/35 (21) 1 MO nortrel 1/35 (28) 1 MO nortrel 7/7/7 (28) 1 MO

This drug list was updated in August 2021. 60 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits OPHTHALM ofloxacin 1 MO OLOGY ophthalmic (eye) polymyxin b sulf- 1 MO ANTIBIOTICS trimethoprim bacitracin 1 MO tobramycin 1 MO; QL ophthalmic (eye) ophthalmic (eye) (10 per 14 bacitracin- 1 MO days) polymyxin b ANTIVIRALS ophthalmic (eye) trifluridine 1 MO ciprofloxacin hcl 1 MO ZIRGAN 2 MO ophthalmic (eye) erythromycin 1 MO; QL BETA- ophthalmic (eye) (3.5 per 14 BLOCKERS days) betaxolol 1 MO gatifloxacin 1 MO ophthalmic (eye) gentak ophthalmic 1 MO; QL carteolol 1 MO (eye) ointment (3.5 per 30 levobunolol 1 MO days) ophthalmic (eye) gentamicin 1 MO; QL drops 0.5 % ophthalmic (eye) (70 per 30 timolol maleate 1 MO drops days) ophthalmic (eye) levofloxacin 1 MO drops ophthalmic (eye) timolol maleate 1 MO moxifloxacin 1 MO ophthalmic (eye) ophthalmic (eye) gel forming solution drops MISCELLANEO NATACYN 2 US neomycin- 1 MO OPHTHALMOL bacitracin- OGICS polymyxin atropine ophthalmic 1 MO neomycin- 1 MO (eye) drops polymyxin- azelastine 1 MO gramicidin ophthalmic (eye) BLEPHAMIDE 2 MO

This drug list was updated in August 2021. 61 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits BLEPHAMIDE 2 MO ORAL DRUGS S.O.P. FOR cromolyn 1 MO GLAUCOMA ophthalmic (eye) acetazolamide 1 MO CYSTARAN 2 PA methazolamide 1 MO epinastine 1 MO OTHER olopatadine 1 MO GLAUCOMA ophthalmic (eye) DRUGS OXERVATE 2 PA; MO dorzolamide 1 MO pilocarpine hcl 1 MO ophthalmic (eye) dorzolamide-timolol 1 MO drops 1 %, 2 %, 4 % latanoprost 1 MO sulfacetamide 1 MO travoprost 1 MO sodium ophthalmic STEROID- (eye) ANTIBIOTIC sulfacetamide- 1 MO COMBINATION prednisolone S XIIDRA 2 MO; QL neomycin- 1 MO (60 per 30 bacitracin-poly-hc days) neomycin- 1 MO NON- polymyxin b- STEROIDAL dexameth ANTI- neomycin- 1 MO INFLAMMATO polymyxin-hc RY AGENTS ophthalmic (eye) diclofenac sodium 1 MO tobramycin- 1 MO; QL ophthalmic (eye) dexamethasone (10 per 14 flurbiprofen sodium 1 MO days) ketorolac 1 MO STEROIDS ophthalmic (eye) dexamethasone 1 MO sodium phosphate ophthalmic (eye) fluorometholone 1 MO

This drug list was updated in August 2021. 62 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits loteprednol 1 MO epinephrine injection 1 MO; QL (2 etabonate auto-injector 0.15 per 30 days) prednisolone acetate 1 MO mg/0.3 ml, 0.3 mg/0.3 ml prednisolone sodium 1 MO (manufactured by phosphate mylan specialty) ophthalmic (eye) hydroxyzine hcl oral 1 PA; MO SYMPATHOMI tablet METICS levocetirizine oral 1 MO ALPHAGAN P 2 MO solution OPHTHALMIC levocetirizine oral 1 MO; QL (EYE) DROPS 0.1 tablet (30 per 30 % days) apraclonidine 1 MO promethazine oral 1 PA; MO brimonidine 1 SYMJEPI 2 MO; QL (2 ophthalmic (eye) per 30 days) drops 0.15 % PULMONARY brimonidine 1 MO AGENTS ophthalmic (eye) drops 0.2 % acetylcysteine 1 PA; MO RESPIRATOR ADEMPAS 2 PA; MO; Y AND LA ALLERGY ADVAIR DISKUS 2 MO; QL (60 per 30 ANTIHISTAMI days) NE / albuterol sulfate 1 QL (17 per ANTIALLERGE inhalation hfa 30 days) NIC AGENTS aerosol inhaler 90 mcg/actuation cetirizine oral 1 MO solution 1 mg/ml albuterol sulfate 1 QL (13.4 inhalation hfa per 30 days) aerosol inhaler 90 mcg/actuation package size 6.7 gm

This drug list was updated in August 2021. 63 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits albuterol sulfate 1 PA; MO ASMANEX 2 MO; QL (2 inhalation solution TWISTHALER per 30 days) for nebulization 0.63 INHALATION mg/3 ml, 1.25 mg/3 AEROSOL ml, 2.5 mg /3 ml POWDR (0.083 %), 2.5 BREATH mg/0.5 ml ACTIVATED 220 albuterol sulfate 1 MO MCG/ oral syrup ACTUATION (120) albuterol sulfate 1 MO oral tablet ATROVENT HFA 2 MO; QL (25.8 per 30 alyq 1 PA; QL (60 days) per 30 days) bosentan 1 PA; MO; ambrisentan 1 PA; MO; LA LA BREZTRI 2 MO; QL ASMANEX HFA 2 MO; QL AEROSPHERE (10.7 per 30 (13 per 30 days) days) budesonide 1 PA; MO; ASMANEX 2 MO; QL (1 inhalation QL (120 per TWISTHALER per 30 days) suspension for 30 days) INHALATION nebulization 0.25 AEROSOL mg/2 ml, 0.5 mg/2 POWDR ml BREATH ACTIVATED 110 budesonide 1 PA; MO; MCG/ inhalation QL (60 per ACTUATION suspension for 30 days) (30), 220 MCG/ nebulization 1 mg/2 ACTUATION ml (30), 220 MCG/ CINRYZE 2 PA; MO ACTUATION (60) COMBIVENT 2 MO; QL (8 RESPIMAT per 30 days) cromolyn inhalation 1 PA; MO

This drug list was updated in August 2021. 64 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits DALIRESP 2 PA; MO; OFEV 2 PA; MO; QL (30 per QL (60 per 30 days) 30 days) DULERA 2 MO; QL OPSUMIT 2 PA; MO; (13 per 30 LA days) ORKAMBI ORAL 2 PA; MO; ESBRIET ORAL 2 PA; MO; GRANULES IN QL (56 per CAPSULE QL (270 per PACKET 28 days) 30 days) ORKAMBI ORAL 2 PA; MO; ESBRIET ORAL 2 PA; MO; TABLET QL (112 per TABLET 267 MG QL (270 per 28 days) 30 days) ORLADEYO 2 PA; LA ESBRIET ORAL 2 PA; MO; PERFOROMIST 2 PA; MO TABLET 801 MG QL (90 per PULMOZYME 2 PA; MO 30 days) QVAR 2 MO; QL flunisolide 1 MO; QL REDIHALER (10.6 per 30 (50 per 30 INHALATION days) days) HFA AEROSOL fluticasone 1 MO; QL BREATH propionate nasal (16 per 30 ACTIVATED 40 days) MCG/ACTUATIO icatibant 1 PA; MO N ipratropium 1 PA; MO QVAR 2 MO; QL bromide inhalation REDIHALER (21.2 per 30 ipratropium- 1 PA; MO INHALATION days) albuterol HFA AEROSOL BREATH KALYDECO 2 PA; MO; ACTIVATED 80 ORAL QL (56 per MCG/ACTUATIO GRANULES IN 28 days) N PACKET sildenafil 1 PA; MO; KALYDECO 2 PA; MO; (pulmonary arterial QL (90 per ORAL TABLET QL (60 per hypertension) oral 30 days) 30 days) tablet montelukast 1 MO

This drug list was updated in August 2021. 65 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits SPIRIVA 2 MO; QL (4 XOLAIR 2 PA; MO; RESPIMAT per 30 days) SUBCUTANEOU LA; QL (8 SPIRIVA WITH 2 MO; QL S RECON SOLN per 28 days) HANDIHALER (90 per 90 XOLAIR 2 PA; MO; days) SUBCUTANEOU LA; QL (8 STIOLTO 2 MO; QL (4 S SYRINGE 150 per 28 days) RESPIMAT per 30 days) MG/ML STRIVERDI 2 MO; QL (4 XOLAIR 2 PA; MO; RESPIMAT per 30 days) SUBCUTANEOU LA; QL (1 S SYRINGE 75 per 28 days) SYMBICORT 2 MO; QL MG/0.5 ML (10.2 per 30 days) zafirlukast 1 MO SYMDEKO 2 PA; MO; UROLOGICA QL (56 per LS 28 days) ANTICHOLINE tadalafil 1 PA; QL (60 (pulmonary arterial per 30 days) RGICS / hypertension) oral ANTISPASMOD tablet 20 mg ICS terbutaline oral 1 MO MYRBETRIQ 2 MO THEO-24 2 MO ORAL TABLET EXTENDED theophylline oral 1 MO RELEASE 24 HR solution oxybutynin chloride 1 MO theophylline oral 1 MO tablet extended tolterodine 1 MO release 12 hr 300 mg trospium oral tablet 1 MO theophylline oral 1 MO BENIGN tablet extended PROSTATIC release 24 hr HYPERPLASIA( TRIKAFTA 2 PA; MO; BPH) THERAPY ORAL TABLETS, QL (84 per alfuzosin 1 MO SEQUENTIAL 28 days) 100-50-75 MG(D) dutasteride 1 MO /150 MG (N) finasteride oral 1 MO tablet 5 mg

This drug list was updated in August 2021. 66 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits tamsulosin 1 MO magnesium sulfate 1 MISCELLANEO injection syringe US potassium chlorid- 1 UROLOGICALS d5-0.45%nacl potassium chloride 1 bethanechol chloride 1 MO in 0.9%nacl CYSTAGON 2 PA; LA intravenous ELMIRON 2 MO parenteral solution potassium citrate 1 MO 20 meq/l, 40 meq/l VITAMINS, potassium chloride 1 in 5 % dex HEMATINICS intravenous / parenteral solution ELECTROLY 20 meq/l TES potassium chloride 1 in lr-d5 intravenous ELECTROLYTE parenteral solution S 20 meq/l calcium 1 MO; QL potassium chloride 1 acetate(phosphat (360 per 30 in water intravenous bind) days) piggyback 10 klor-con 10 1 MO meq/100 ml, 20 meq/100 ml, 40 klor-con 8 1 MO meq/100 ml klor-con m10 1 MO potassium chloride 1 klor-con m15 1 MO intravenous klor-con m20 1 MO potassium chloride 1 MO klor-con oral packet 1 MO oral capsule, 20 extended release k-tab oral tablet 1 MO potassium chloride 1 MO extended release 8 oral liquid meq potassium chloride 1 magnesium sulfate 1 MO oral packet injection solution

This drug list was updated in August 2021. 67 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits potassium chloride 1 MO AMINOSYN-PF 7 2 PA oral tablet extended % (SULFITE- release 10 meq, 8 FREE) meq CLINIMIX 2 PA potassium chloride 1 5%/D15W oral tablet extended SULFITE FREE release 20 meq CLINIMIX 2 PA potassium chloride 1 MO 4.25%/D10W oral tablet,er SULF FREE particles/crystals 10 CLINIMIX 5%- 2 PA meq D20W(SULFITE- potassium chloride 1 FREE) oral tablet,er HEPATAMINE 2 PA particles/crystals 20 8% meq intralipid 1 PA potassium chloride- 1 intravenous 0.45 % nacl emulsion 20 % potassium chloride- 1 ISOLYTE S PH 7.4 2 d5-0.2%nacl ISOLYTE-P IN 5 2 intravenous % DEXTROSE parenteral solution 20 meq/l PLASMA-LYTE 2 148 potassium chloride- 1 d5-0.9%nacl PLASMA-LYTE A 2 sodium chloride 0.45 1 MO PLENAMINE 2 PA % intravenous premasol 10 % 1 PA parenteral solution travasol 10 % 1 PA sodium chloride 3 % 1 TROPHAMINE 2 PA sodium chloride 5 % 1 MO 10 % MISCELLANEO VITAMINS / US NUTRITION HEMATINICS PRODUCTS fluoride (sodium) 1 AMINOSYN II 15 2 PA oral tablet %

This drug list was updated in August 2021. 68 Drug Name Drug Requiremen Tier ts/Limits prenatal vitamin 1 oral tablet

This drug list was updated in August 2021. 69 Index abacavir...... 1 allopurinol...... 55 ARCALYST...... 51 abacavir-lamivudine...... 1 alosetron...... 49 ARIKAYCE...... 5 abacavir-lamivudine- ALPHAGAN P...... 63 aripiprazole...... 25 zidovudine...... 1 altavera (28)...... 58 ARISTADA...... 25 ABELCET...... 1 ALUNBRIG...... 10 ARISTADA INITIO...... 25 ABILIFY MAINTENA...... 25 alyacen 1/35 (28)...... 58 armodafinil...... 25 abiraterone...... 10 alyq...... 64 asenapine maleate...... 25 acamprosate...... 41 amabelz...... 57 ASMANEX HFA...... 64 acarbose...... 44 amantadine hcl...... 1 ASMANEX accutane...... 38 AMBISOME...... 1 TWISTHALER...... 64 acebutolol...... 31 ambrisentan...... 64 aspirin-dipyridamole...... 34 acetaminophen-caff- amikacin...... 5 atazanavir...... 1 dihydrocod...... 22 amiloride...... 31 atenolol...... 31 acetaminophen-codeine...... 22 amiloride-hydrochlorothiazide 31 atenolol-chlorthalidone...... 31 acetazolamide...... 62 AMINOSYN II 15 %...... 68 atomoxetine...... 25 acetic acid...... 43 AMINOSYN-PF 7 % atorvastatin...... 35 acetylcysteine...... 63 (SULFITE-FREE)...... 68 atovaquone...... 5 acitretin...... 36 amiodarone...... 31 atovaquone-proguanil...... 5 ACTEMRA...... 55 amitriptyline...... 25 atropine...... 61 ACTEMRA ACTPEN...... 55 amlodipine...... 31 ATROVENT HFA...... 64 ACTHIB (PF)...... 52 amlodipine-benazepril...... 31 AUBAGIO...... 21 ACTIMMUNE...... 51 amlodipine-olmesartan...... 31 aubra eq...... 58 acyclovir...... 1, 40 amlodipine-valsartan...... 31 aviane...... 58 acyclovir sodium...... 1 amlodipine-valsartan- avita...... 38 ADACEL(TDAP hcthiazid...... 31 AVONEX...... 51, 52 ADOLESN/ADULT)(PF).... 52 ammonium lactate...... 37 AYVAKIT...... 10 adefovir...... 1 amnesteem...... 38 azathioprine...... 10 ADEMPAS...... 63 amoxapine...... 25 azelastine...... 43, 61 ADVAIR DISKUS...... 63 amoxicillin...... 7 azithromycin...... 5 AFINITOR...... 10 amoxicillin-pot clavulanate...... 8 aztreonam...... 5 AFINITOR DISPERZ...... 10 amphotericin b...... 1 bacitracin...... 61 AJOVY AUTOINJECTOR.. 20 ampicillin...... 8 bacitracin-polymyxin b...... 61 AJOVY SYRINGE...... 20 ampicillin sodium...... 8 baclofen...... 22 ala-cort...... 40 ampicillin-sulbactam...... 8 balsalazide...... 49 albendazole...... 5 anagrelide...... 41 BALVERSA...... 10 albuterol sulfate...... 63, 64 anastrozole...... 10 BARACLUDE...... 2 alclometasone...... 40 apraclonidine...... 63 BCG VACCINE, LIVE (PF).52 ALCOHOL PADS...... 44 aprepitant...... 49 BD AUTOSHIELD DUO ALECENSA...... 10 apri...... 58 PEN NEEDLE...... 54 alendronate...... 55 APTIOM...... 17 BD INSULIN SYRINGE alfuzosin...... 66 APTIVUS...... 1 (HALF UNIT)...... 54 aliskiren...... 31 aranelle (28)...... 58 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 70 BD INSULIN SYRINGE BOSULIF...... 10 carvedilol...... 32 U-500...... 54 BRAFTOVI...... 10 caspofungin...... 1 BD INSULIN SYRINGE BREZTRI AEROSPHERE.. 64 CAYSTON...... 5 ULTRA-FINE...... 54 BRILINTA...... 34 caziant (28)...... 59 BD NANO 2ND GEN PEN brimonidine...... 63 cefaclor...... 4 NEEDLE...... 54 BRIVIACT...... 17 cefadroxil...... 4 BD ULTRA-FINE MICRO bromocriptine...... 20 cefazolin...... 4 PEN NEEDLE...... 54 BRUKINSA...... 10 cefdinir...... 4 BD ULTRA-FINE MINI budesonide...... 49, 64 cefepime...... 4 PEN NEEDLE...... 54 bumetanide...... 32 cefixime...... 4 BD ULTRA-FINE NANO buprenorphine hcl...... 22 cefoxitin...... 4 PEN NEEDLE...... 54 buprenorphine-naloxone....23, 24 cefpodoxime...... 4 BD ULTRA-FINE SHORT bupropion hcl...... 25, 26 cefprozil...... 4 PEN NEEDLE...... 54 bupropion hcl (smoking ceftazidime...... 4 BD VEO INSULIN SYR deter)...... 42 ceftriaxone...... 4 (HALF UNIT)...... 54 buspirone...... 26 cefuroxime axetil...... 4 BD VEO INSULIN butorphanol...... 24 cefuroxime sodium...... 4 SYRINGE UF...... 54 BYDUREON BCISE...... 44 celecoxib...... 24 benazepril...... 32 BYETTA...... 44 CELONTIN...... 17 benazepril- cabergoline...... 47 cephalexin...... 4, 5 hydrochlorothiazide...... 32 CABLIVI...... 34 CERDELGA...... 47 BENLYSTA...... 56 CABOMETYX...... 10 cetirizine...... 63 BENZNIDAZOLE...... 5 calcipotriene...... 37 CHANTIX...... 42 benztropine...... 20 calcitonin (salmon)...... 47 CHANTIX CONTINUING betamethasone dipropionate....40 calcitriol...... 47 MONTH BOX...... 42 betamethasone valerate...... 40 calcium acetate(phosphat CHANTIX STARTING betamethasone, augmented..... 40 bind)...... 67 MONTH BOX...... 43 BETASERON...... 52 CALQUENCE...... 11 CHEMET...... 41 betaxolol...... 32, 61 camila...... 57 CHENODAL...... 49 bethanechol chloride...... 67 candesartan...... 32 chlorhexidine gluconate...... 43 bexarotene...... 10 candesartan- chloroquine phosphate...... 6 BEXSERO...... 52 hydrochlorothiazid...... 32 chlorpromazine...... 26 bicalutamide...... 10 CAPLYTA...... 26 chlorthalidone...... 32 BICILLIN C-R...... 8 CAPRELSA...... 11 CHOLBAM...... 49 BICILLIN L-A...... 8 captopril...... 32 cholestyramine (with sugar)...35 BIKTARVY...... 2 CARBAGLU...... 41 cholestyramine light...... 35 bisoprolol fumarate...... 32 carbamazepine...... 17 ciclopirox...... 39 bisoprolol- carbidopa...... 20 cilostazol...... 34 hydrochlorothiazide...... 32 carbidopa-levodopa...... 20 cimetidine...... 51 BLEPHAMIDE...... 61 carbidopa-levodopa- cimetidine hcl...... 51 BLEPHAMIDE S.O.P...... 62 entacapone...... 20 cinacalcet...... 47 BOOSTRIX TDAP...... 52 carteolol...... 61 CINRYZE...... 64 bosentan...... 64 cartia xt...... 32 ciprofloxacin hcl...... 8, 43, 61 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 71 ciprofloxacin in 5 % dextrose....8 CORTIFOAM...... 49 desonide...... 40 ciprofloxacin-dexamethasone..43 COTELLIC...... 11 desvenlafaxine succinate...... 26 citalopram...... 26 CREON...... 49 dexamethasone...... 43 claravis...... 38 CRESEMBA...... 1 dexamethasone sodium clarithromycin...... 5 cromolyn...... 49, 62, 64 phosphate...... 62 clindamycin hcl...... 6 cryselle (28)...... 59 dextroamphetamine- clindamycin in 5 % dextrose..... 6 cyclafem 1/35 (28)...... 59 amphetamine...... 26 clindamycin pediatric...... 6 cyclafem 7/7/7 (28)...... 59 dextrose 10 % and 0.2 % nacl. 42 clindamycin phosphate.. 6, 38, 58 cyclobenzaprine...... 22 dextrose 10 % in water CLINIMIX 5%/D15W cyclophosphamide...... 11 (d10w)...... 42 SULFITE FREE...... 68 CYCLOPHOSPHAMIDE.... 11 dextrose 5 % in water (d5w)...42 CLINIMIX 4.25%/D10W cyclosporine...... 11 dextrose 5%-0.2 % sod SULF FREE...... 68 cyclosporine modified...... 11 chloride...... 42 CLINIMIX 4.25%/D5W cyred eq...... 59 DIACOMIT...... 18 SULFIT FREE...... 41 CYSTADANE...... 49 diazepam...... 18, 26 CLINIMIX 5%- CYSTAGON...... 67 diazoxide...... 44 D20W(SULFITE-FREE)...... 68 CYSTARAN...... 62 diclofenac potassium...... 24 clobazam...... 17 d10 %-0.45 % sodium chloride 41 diclofenac sodium...... 24, 62 clobetasol...... 40 d2.5 %-0.45 % sodium dicloxacillin...... 8 clobetasol-emollient...... 40 chloride...... 42 dicyclomine...... 49 clodan...... 40 d5 % and 0.9 % sodium diflunisal...... 24 clomipramine...... 26 chloride...... 42 digitek...... 36 clonazepam...... 17, 18 d5 %-0.45 % sodium chloride.. 42 digox...... 36 clonidine...... 32 dalfampridine...... 21 digoxin...... 36 clonidine hcl...... 26, 32 DALIRESP...... 65 dihydroergotamine...... 20 clopidogrel...... 34 danazol...... 47 DILANTIN 30 MG...... 18 clorazepate dipotassium...... 26 dantrolene...... 22 diltiazem hcl...... 32 clotrimazole...... 1, 39 dapsone...... 6 dilt-xr...... 32 clotrimazole-betamethasone....39 DAPTACEL (DTAP dimethyl fumarate...... 21 clovique...... 41 PEDIATRIC) (PF)...... 52 DIPENTUM...... 49 clozapine...... 26 DAPTOMYCIN...... 6 diphenoxylate-atropine...... 49 COARTEM...... 6 daptomycin...... 6 dipyridamole...... 34 colchicine...... 55 DAURISMO...... 11 disulfiram...... 42 colesevelam...... 35 deblitane...... 57 divalproex...... 18 colestipol...... 35 deferasirox...... 42 dofetilide...... 31 colistin (colistimethate na)...... 6 deferiprone...... 42 donepezil...... 21 COMBIVENT RESPIMAT.. 64 DELSTRIGO...... 2 DOPTELET (10 TAB COMETRIQ...... 11 DENAVIR...... 40 PACK)...... 34 COMPLERA...... 2 DESCOVY...... 2 DOPTELET (15 TAB compro...... 49 desipramine...... 26 PACK)...... 34 constulose...... 49 desmopressin...... 47 DOPTELET (30 TAB COPIKTRA...... 11 desog-e.estradiol/e.estradiol....59 PACK)...... 34 CORLANOR...... 36 desogestrel-ethinyl estradiol....59 dorzolamide...... 62 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 72 dorzolamide-timolol...... 62 endocet...... 22 etonogestrel-ethinyl estradiol.. 58 dotti...... 57 ENGERIX-B (PF)...... 52 euthyrox...... 48 DOVATO...... 2 ENGERIX-B PEDIATRIC everolimus (antineoplastic).... 11 doxazosin...... 32 (PF)...... 53 everolimus doxepin...... 26 enoxaparin...... 34 (immunosuppressive)...... 11 doxercalciferol...... 47 enpresse...... 59 EVOTAZ...... 2 doxy-100...... 9 enskyce...... 59 exemestane...... 12 doxycycline hyclate...... 9 entacapone...... 20 ezetimibe...... 35 doxycycline monohydrate...... 9 entecavir...... 2 ezetimibe-simvastatin...... 35 DRIZALMA SPRINKLE.... 26 ENTRESTO...... 36 falmina (28)...... 59 dronabinol...... 49 enulose...... 49 famciclovir...... 2 drospirenone-ethinyl estradiol. 59 EPCLUSA...... 2 famotidine...... 51 DROXIA...... 11 EPIDIOLEX...... 18 FANAPT...... 27 droxidopa...... 42 epinastine...... 62 FARXIGA...... 44 DULERA...... 65 epinephrine...... 63 FARYDAK...... 12 duloxetine...... 26 epitol...... 18 fayosim...... 59 DUPIXENT PEN...... 37 EPIVIR HBV...... 2 febuxostat...... 55 DUPIXENT SYRINGE...... 37 eplerenone...... 32 felbamate...... 18 dutasteride...... 66 ergotamine-caffeine...... 20 felodipine...... 32 econazole...... 39 ERIVEDGE...... 11 femynor...... 59 EDURANT...... 2 ERLEADA...... 11 fenofibrate...... 35 efavirenz...... 2 erlotinib...... 11 fenofibrate micronized...... 35 efavirenz-emtricitabin-tenofov.. 2 errin...... 57 fenofibrate nanocrystallized....35 efavirenz-lamivu-tenofov ertapenem...... 6 fenofibric acid (choline)...... 35 disop...... 2 ery pads...... 38 fentanyl...... 22 ELIQUIS...... 34 ery-tab...... 5 fentanyl citrate...... 22 ELIQUIS DVT-PE TREAT ERYTHROCIN...... 5 FERRIPROX...... 42 30D START...... 34 erythrocin (as stearate)...... 5 FETZIMA...... 27 ELMIRON...... 67 erythromycin...... 5, 61 finasteride...... 66 eluryng...... 58 erythromycin ethylsuccinate..... 5 FINTEPLA...... 18 EMCYT...... 11 erythromycin with ethanol...... 38 FIRDAPSE...... 21 EMEND...... 49 ESBRIET...... 65 FIRMAGON KIT W emoquette...... 59 escitalopram oxalate...... 26, 27 DILUENT SYRINGE...... 12 EMSAM...... 26 esomeprazole magnesium...... 51 flac otic oil...... 43 emtricitabine...... 2 estarylla...... 59 flecainide...... 31 emtricitabine-tenofovir (tdf).... 2 estradiol...... 57, 58 fluconazole...... 1 EMTRIVA...... 2 estradiol valerate...... 58 fluconazole in nacl (iso-osm)....1 EMVERM...... 6 estradiol-norethindrone acet... 58 flucytosine...... 1 enalapril maleate...... 32 eszopiclone...... 27 fludrocortisone...... 43 enalapril-hydrochlorothiazide. 32 ethambutol...... 6 flunisolide...... 65 ENBREL...... 56 ethosuximide...... 18 fluocinolone...... 40 ENBREL MINI...... 56 ethynodiol diac-eth estradiol... 59 fluocinolone acetonide oil...... 43 ENBREL SURECLICK...... 56 etodolac...... 24 fluocinolone and shower cap....40 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 73 fluocinonide...... 40, 41 glatopa...... 21 HUMIRA(CF) PEDI fluocinonide-e...... 41 glimepiride...... 44 CROHNS STARTER...... 56 fluoride (sodium)...... 68 glipizide...... 44, 45 HUMIRA(CF) PEN...... 56 fluorometholone...... 62 glipizide-metformin...... 45 HUMIRA(CF) PEN fluorouracil...... 37 glycopyrrolate...... 49 CROHNS-UC-HS...... 56 fluoxetine...... 27 granisetron hcl...... 49 HUMIRA(CF) PEN fluphenazine decanoate...... 27 griseofulvin microsize...... 1 PEDIATRIC UC...... 56 fluphenazine hcl...... 27 griseofulvin ultramicrosize...... 1 HUMIRA(CF) PEN PSOR- flurbiprofen...... 24 GVOKE HYPOPEN 2- UV-ADOL HS...... 56 flurbiprofen sodium...... 62 PACK...... 45 HUMULIN 70/30 U-100 flutamide...... 12 GVOKE PFS 1-PACK INSULIN...... 45 fluticasone propionate...... 65 SYRINGE...... 45 HUMULIN 70/30 U-100 fluvastatin...... 35 halobetasol propionate...... 41 KWIKPEN...... 45 fluvoxamine...... 27 haloperidol...... 27 HUMULIN N NPH fondaparinux...... 34 haloperidol decanoate...... 27 INSULIN KWIKPEN...... 45 fosamprenavir...... 2 haloperidol lactate...... 27 HUMULIN N NPH U-100 fosinopril...... 32 HARVONI...... 2 INSULIN...... 45 fosinopril-hydrochlorothiazide 32 HAVRIX (PF)...... 53 HUMULIN R REGULAR FOTIVDA...... 12 heparin (porcine)...... 34 U-100 INSULN...... 45 furosemide...... 32 HEPATAMINE 8%...... 68 HUMULIN R U-500 FUZEON...... 2 HETLIOZ...... 27 (CONC) INSULIN...... 45 fyavolv...... 58 HIBERIX (PF)...... 53 HUMULIN R U-500 FYCOMPA...... 18 HUMALOG JUNIOR (CONC) KWIKPEN...... 45 gabapentin...... 18 KWIKPEN U-100...... 45 hydralazine...... 32 galantamine...... 21 HUMALOG KWIKPEN hydrochlorothiazide...... 32 GARDASIL 9 (PF)...... 53 INSULIN...... 45 hydrocodone-acetaminophen...22 gatifloxacin...... 61 HUMALOG MIX 50-50 hydrocodone-ibuprofen...... 23 GATTEX 30-VIAL...... 49 INSULN U-100...... 45 hydrocortisone...... 41, 43, 49 GAUZE PAD...... 54 HUMALOG MIX 50-50 hydrocortisone-acetic acid...... 43 gavilyte-c...... 49 KWIKPEN...... 45 hydromorphone...... 23 gavilyte-g...... 49 HUMALOG MIX 75-25 hydromorphone (pf)...... 23 gavilyte-n...... 49 KWIKPEN...... 45 hydroxychloroquine...... 6 GAVRETO...... 12 HUMALOG MIX 75-25(U- hydroxyurea...... 12 gemfibrozil...... 35 100)INSULN...... 45 hydroxyzine hcl...... 63 generlac...... 49 HUMALOG U-100 ibandronate...... 55 gengraf...... 12 INSULIN...... 45 IBRANCE...... 12 gentak...... 61 HUMIRA...... 56 ibu...... 24 gentamicin...... 6, 39, 61 HUMIRA PEN...... 56 ibuprofen...... 24 gentamicin in nacl (iso-osm).... 6 HUMIRA PEN CROHNS- icatibant...... 65 GENVOYA...... 2 UC-HS START...... 56 ICLUSIG...... 12 GILENYA...... 21 HUMIRA PEN PSOR- icosapent ethyl...... 35 GILOTRIF...... 12 UVEITS-ADOL HS...... 56 IDHIFA...... 12 glatiramer...... 21 HUMIRA(CF)...... 57 imatinib...... 12 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 74 IMBRUVICA...... 12 isradipine...... 33 lamotrigine...... 18 imipenem-cilastatin...... 6 itraconazole...... 1 LANOXIN...... 36 imipramine hcl...... 27 ivermectin...... 6 lansoprazole...... 51 imipramine pamoate...... 27 IXIARO (PF)...... 53 LANTUS SOLOSTAR U- imiquimod...... 37 JAKAFI...... 12 100 INSULIN...... 46 IMOVAX RABIES jantoven...... 34 LANTUS U-100 INSULIN.. 46 VACCINE (PF)...... 53 JANUMET...... 45 lapatinib...... 13 IMPAVIDO...... 6 JANUMET XR...... 45 larin 1.5/30 (21)...... 59 incassia...... 58 JANUVIA...... 45 larin 1/20 (21)...... 59 INCRELEX...... 42 JARDIANCE...... 46 larin fe 1.5/30 (28)...... 59 indapamide...... 32 jasmiel (28)...... 59 larin fe 1/20 (28)...... 59 INFANRIX (DTAP) (PF).... 53 jinteli...... 58 larissia...... 59 INFLECTRA...... 50 juleber...... 59 latanoprost...... 62 INLYTA...... 12 JULUCA...... 2 LATUDA...... 28 INQOVI...... 12 JUXTAPID...... 35 leflunomide...... 57 INREBIC...... 12 KALETRA...... 2 LENVIMA...... 13 INSULIN PEN NEEDLE.... 54 KALYDECO...... 65 lessina...... 59 INSULIN SYRINGE- kariva (28)...... 59 letrozole...... 13 NEEDLE U-100...... 54 kelnor 1/35 (28)...... 59 leucovorin calcium...... 10 INTELENCE...... 2 kelnor 1-50 (28)...... 59 LEUKERAN...... 13 intralipid...... 68 ketoconazole...... 1, 39 LEUKINE...... 52 INTRON A...... 52 ketorolac...... 62 leuprolide...... 13 introvale...... 59 KINRIX (PF)...... 53 levetiracetam...... 18, 19 INVEGA SUSTENNA... 27, 28 KISQALI...... 13 levobunolol...... 61 INVEGA TRINZA...... 28 KISQALI FEMARA CO- levocarnitine...... 42 INVIRASE...... 2 PACK...... 12, 13 levocarnitine (with sugar)...... 42 IPOL...... 53 klor-con 10...... 67 levocetirizine...... 63 ipratropium bromide...... 43, 65 klor-con 8...... 67 levofloxacin...... 9, 61 ipratropium-albuterol...... 65 klor-con m10...... 67 levofloxacin in d5w...... 9 irbesartan...... 32 klor-con m15...... 67 levonest (28)...... 59 irbesartan- klor-con m20...... 67 levonorgestrel-ethinyl estrad... 59 hydrochlorothiazide...... 33 klor-con oral packet 20...... 67 levonorg-eth estrad triphasic...60 IRESSA...... 12 KLOXXADO...... 24 levora-28...... 60 ISENTRESS...... 2 KOMBIGLYZE XR...... 46 levo-t...... 48 ISENTRESS HD...... 2 KORLYM...... 47 levothyroxine...... 48 isibloom...... 59 k-tab...... 67 levoxyl...... 48 ISOLYTE S PH 7.4...... 68 kurvelo (28)...... 59 LEXIVA...... 2 ISOLYTE-P IN 5 % KYNMOBI...... 20 lidocaine...... 38 DEXTROSE...... 68 l norgest/e.estradiol-e.estrad... 59 lidocaine hcl...... 37 isoniazid...... 6 labetalol...... 33 lidocaine viscous...... 38 isosorbide dinitrate...... 36 lactulose...... 50 lidocaine-prilocaine...... 38 isosorbide mononitrate...... 36 lamivudine...... 2 lindane...... 41 isotretinoin...... 38 lamivudine-zidovudine...... 2 linezolid...... 6 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 75 linezolid in dextrose 5%...... 6 MATULANE...... 13 microgestin fe 1.5/30 (28)...... 60 liothyronine...... 48 matzim la...... 33 microgestin fe 1/20 (28)...... 60 lisinopril...... 33 meclizine...... 50 midodrine...... 42 lisinopril-hydrochlorothiazide. 33 medroxyprogesterone...... 58 miglustat...... 47 lithium carbonate...... 28 mefloquine...... 6 mili...... 60 lithium citrate...... 28 megestrol...... 13 mimvey...... 58 LOKELMA...... 42 MEKINIST...... 13 minocycline...... 9 LONSURF...... 13 MEKTOVI...... 14 minoxidil...... 33 loperamide...... 49 meloxicam...... 24 mirtazapine...... 29 lopinavir-ritonavir...... 2 memantine...... 21 misoprostol...... 51 lorazepam...... 28 MENACTRA (PF)...... 53 M-M-R II (PF)...... 53 lorazepam intensol...... 28 MENEST...... 58 modafinil...... 29 LORBRENA...... 13 MENQUADFI (PF)...... 53 moexipril...... 33 loryna (28)...... 60 MENVEO A-C-Y-W-135- molindone...... 29 losartan...... 33 DIP (PF)...... 53 mometasone...... 41 losartan-hydrochlorothiazide.. 33 mercaptopurine...... 14 mondoxyne nl...... 9 loteprednol etabonate...... 63 meropenem...... 6 montelukast...... 65 lovastatin...... 35 mesalamine...... 50 morphine...... 23 low-ogestrel (28)...... 60 MESNEX...... 10 morphine concentrate...... 23 loxapine succinate...... 28 metformin...... 46 MOVANTIK...... 50 LUPRON DEPOT...... 13 methadone...... 23 moxifloxacin...... 9, 61 LUPRON DEPOT (3 methazolamide...... 62 moxifloxacin- MONTH)...... 13 methenamine hippurate...... 9 sod.chloride(iso)...... 9 LUPRON DEPOT (4 methimazole...... 44 MULPLETA...... 34 MONTH)...... 13 methotrexate sodium...... 14 mupirocin...... 39 LUPRON DEPOT (6 methotrexate sodium (pf)...... 14 MVASI...... 14 MONTH)...... 13 methoxsalen...... 38 MYALEPT...... 47 lutera (28)...... 60 methyldopa...... 33 mycophenolate mofetil...... 14 lyllana...... 58 methylphenidate hcl...... 28, 29 mycophenolate sodium...... 14 LYNPARZA...... 13 methylprednisolone...... 43 myorisan...... 38 LYSODREN...... 13 metoclopramide hcl...... 50 MYRBETRIQ...... 66 LYUMJEV KWIKPEN U- metolazone...... 33 nabumetone...... 24 100 INSULIN...... 46 metoprolol succinate...... 33 nadolol...... 33 LYUMJEV KWIKPEN U- metoprolol ta- nafcillin...... 8 200 INSULIN...... 46 hydrochlorothiaz...... 33 naloxone...... 24 LYUMJEV U-100 metoprolol tartrate...... 33 naltrexone...... 24 INSULIN...... 46 metronidazole...... 6, 38, 58 NAMZARIC...... 21 lyza...... 58 metronidazole in nacl (iso-os).. 6 naproxen...... 24 mafenide acetate...... 39 metyrosine...... 33 naproxen sodium...... 24 magnesium sulfate...... 67 mexiletine...... 31 naratriptan...... 20 malathion...... 41 micafungin...... 1 NARCAN...... 24 marlissa (28)...... 60 microgestin 1.5/30 (21)...... 60 NATACYN...... 61 MARPLAN...... 28 microgestin 1/20 (21)...... 60 nateglinide...... 46 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 76 NATPARA...... 47 norethindrone ac-eth estradiol ondansetron hcl...... 50 NAYZILAM...... 19 ...... 58, 60 ONGLYZA...... 46 NEEDLES, INSULIN norgestimate-ethinyl estradiol.60 ONUREG...... 14 DISP.,SAFETY...... 54 nortrel 0.5/35 (28)...... 60 OPSUMIT...... 65 nefazodone...... 29 nortrel 1/35 (21)...... 60 ORENCIA...... 57 neomycin...... 6 nortrel 1/35 (28)...... 60 ORENCIA CLICKJECT...... 57 neomycin-bacitracin-poly-hc...62 nortrel 7/7/7 (28)...... 60 ORGOVYX...... 14 neomycin-bacitracin- nortriptyline...... 29 ORKAMBI...... 65 polymyxin...... 61 NORVIR...... 3 ORLADEYO...... 65 neomycin-polymyxin b- NOVOFINE 32...... 55 orsythia...... 60 dexameth...... 62 NOVOTWIST...... 55 oseltamivir...... 3 neomycin-polymyxin- NOXAFIL...... 1 OTEZLA...... 57 gramicidin...... 61 NUBEQA...... 14 OTEZLA STARTER...... 57 neomycin-polymyxin-hc.... 43, 62 NUEDEXTA...... 21 oxacillin...... 8 NERLYNX...... 14 NUPLAZID...... 29 oxacillin in dextrose(iso-osm).. 8 NEUPRO...... 20 nyamyc...... 39 oxandrolone...... 47 nevirapine...... 3 nystatin...... 1, 39 oxaprozin...... 24 NEXAVAR...... 14 nystatin-triamcinolone...... 39 oxcarbazepine...... 19 niacin...... 35 nystop...... 39 OXERVATE...... 62 nicardipine...... 33 NYVEPRIA...... 52 oxybutynin chloride...... 66 NICOTROL...... 43 OCALIVA...... 50 oxycodone...... 23 NICOTROL NS...... 43 octreotide acetate...... 14 oxycodone-acetaminophen...... 23 nifedipine...... 33 ODEFSEY...... 3 pacerone...... 31 nikki (28)...... 60 ODOMZO...... 14 paliperidone...... 29 nilutamide...... 14 OFEV...... 65 PALYNZIQ...... 47, 48 nimodipine...... 33 ofloxacin...... 9, 43, 61 pantoprazole...... 51 NINLARO...... 14 olanzapine...... 29 paricalcitol...... 48 nisoldipine...... 33 olmesartan...... 33 paromomycin...... 7 nitazoxanide...... 7 olmesartan-amlodipin- paroxetine hcl...... 29 nitisinone...... 42 hcthiazid...... 33 PASER...... 7 nitro-bid...... 36 olmesartan- PAXIL...... 29 nitrofurantoin...... 9 hydrochlorothiazide...... 33 PEDIARIX (PF)...... 53 nitrofurantoin macrocrystal...... 9 olopatadine...... 62 PEDVAX HIB (PF)...... 53 nitrofurantoin monohyd/m- omega-3 acid ethyl esters...... 35 peg 3350-electrolytes...... 50 cryst...... 9 omeprazole...... 51 PEGASYS...... 52 nitroglycerin...... 36 OMNIPOD DASH 5 PACK peg-electrolyte...... 50 NIVESTYM...... 52 POD...... 55 PEMAZYRE...... 14 nizatidine...... 51 OMNIPOD INSULIN penicillamine...... 57 nora-be...... 58 MANAGEMENT...... 55 penicillin g potassium...... 8 norethindrone (contraceptive) 58 OMNIPOD INSULIN penicillin g procaine...... 8 norethindrone acetate...... 58 REFILL...... 55 penicillin g sodium...... 8 OMNITROPE...... 52 penicillin v potassium...... 8 ondansetron...... 50 pentamidine...... 7 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 77 PENTASA...... 50 potassium chloride-d5- promethazine...... 63 pentoxifylline...... 34 0.2%nacl...... 68 propafenone...... 31 PERFOROMIST...... 65 potassium chloride-d5- propranolol...... 33 perindopril erbumine...... 33 0.9%nacl...... 68 propylthiouracil...... 44 periogard...... 43 potassium citrate...... 67 PROQUAD (PF)...... 53 permethrin...... 41 pramipexole...... 20 protriptyline...... 29 perphenazine...... 29 prasugrel...... 34 PULMOZYME...... 65 PERSERIS...... 29 pravastatin...... 35 PURIXAN...... 14 phenelzine...... 29 praziquantel...... 7 pyrazinamide...... 7 phenobarbital...... 19 prazosin...... 33 pyridostigmine bromide...... 22 phenytoin...... 19 prednicarbate...... 41 pyrimethamine...... 7 phenytoin sodium extended..... 19 prednisolone...... 43 QINLOCK...... 14 PIFELTRO...... 3 prednisolone acetate...... 63 QUADRACEL (PF)...... 53 pilocarpine hcl...... 42, 62 prednisolone sodium quetiapine...... 29 pimecrolimus...... 38 phosphate...... 44, 63 quinapril...... 33 pimozide...... 29 prednisone...... 44 quinapril-hydrochlorothiazide. 33 pimtrea (28)...... 60 prednisone intensol...... 44 quinidine sulfate...... 31 pindolol...... 33 pregabalin...... 19 quinine sulfate...... 7 pioglitazone...... 46 premasol 10 %...... 68 QVAR REDIHALER...... 65 piperacillin-tazobactam...... 8 prenatal vitamin oral tablet.....69 RABAVERT (PF)...... 53 PIQRAY...... 14 prevalite...... 35 raloxifene...... 55 pirmella...... 60 previfem...... 60 ramelteon...... 29 piroxicam...... 24 PREVYMIS...... 3 ramipril...... 33 PLASMA-LYTE 148...... 68 PREZCOBIX...... 3 ranolazine...... 36 PLASMA-LYTE A...... 68 PREZISTA...... 3 rasagiline...... 20 PLEGRIDY...... 52 PRIFTIN...... 7 RAVICTI...... 42 PLENAMINE...... 68 PRIMAQUINE...... 7 reclipsen (28)...... 60 podofilox...... 38 primidone...... 19 RECOMBIVAX HB (PF)..... 53 polymyxin b sulf- PRIVIGEN...... 53 RECTIV...... 50 trimethoprim...... 61 probenecid...... 55 REGRANEX...... 38 POMALYST...... 14 probenecid-colchicine...... 55 RELENZA DISKHALER...... 3 portia 28...... 60 prochlorperazine...... 50 RELISTOR...... 50 posaconazole...... 1 prochlorperazine maleate oral.50 REMICADE...... 50 potassium chlorid-d5- PROCRIT...... 52 repaglinide...... 46 0.45%nacl...... 67 procto-med hc...... 50 REPATHA...... 36 potassium chloride...... 67, 68 procto-pak...... 50 REPATHA potassium chloride in proctosol hc...... 50 PUSHTRONEX...... 36 0.9%nacl...... 67 proctozone-hc...... 50 REPATHA SURECLICK.... 36 potassium chloride in 5 % dex. 67 progesterone micronized...... 58 RETACRIT...... 52 potassium chloride in lr-d5...... 67 PROGRAF...... 14 RETEVMO...... 14 potassium chloride in water.....67 PROLASTIN-C...... 42 REVLIMID...... 14 potassium chloride-0.45 % PROLIA...... 55 REXULTI...... 29 nacl...... 68 PROMACTA...... 34 REYATAZ...... 3 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 78 ribavirin...... 3 simvastatin...... 36 SULFAMYLON...... 39 RIDAURA...... 57 sirolimus...... 15 sulfasalazine...... 50 rifabutin...... 7 SIRTURO...... 7 sulindac...... 24 rifampin...... 7 SKYRIZI...... 37 sumatriptan...... 20 riluzole...... 42 sodium chloride...... 42 sumatriptan succinate...... 21 rimantadine...... 3 sodium chloride 0.45 %...... 68 SUPRAX...... 5 RINVOQ...... 57 sodium chloride 0.9 %...... 42 SUTENT...... 15 risedronate...... 42, 55 sodium chloride 3 %...... 68 syeda...... 60 RISPERDAL CONSTA...... 30 sodium chloride 5 %...... 68 SYMBICORT...... 66 risperidone...... 30 sodium phenylbutyrate...... 42 SYMDEKO...... 66 ritonavir...... 3 sodium polystyrene sulfonate.. 42 SYMJEPI...... 63 rivastigmine...... 21 SOLTAMOX...... 15 SYMPAZAN...... 19 rivastigmine tartrate...... 21 SOMAVERT...... 48 SYMTUZA...... 3 rizatriptan...... 20 sorine...... 31 SYNAREL...... 48 ropinirole...... 20 sotalol...... 31 SYNJARDY...... 46 rosuvastatin...... 36 sotalol af...... 31 SYNJARDY XR...... 47 ROTARIX...... 53 SPIRIVA RESPIMAT...... 66 SYNRIBO...... 15 ROTATEQ VACCINE...... 53 SPIRIVA WITH TABLOID...... 15 roweepra...... 19 HANDIHALER...... 66 TABRECTA...... 15 ROZLYTREK...... 14, 15 spironolactone...... 33 tacrolimus...... 15, 38 RUBRACA...... 15 spironolacton- tadalafil (pulmonary arterial rufinamide...... 19 hydrochlorothiaz...... 33 hypertension) oral tablet 20 RUKOBIA...... 3 sprintec (28)...... 60 mg...... 66 RUXIENCE...... 15 SPRITAM...... 19 TAFINLAR...... 15 RYDAPT...... 15 SPRYCEL...... 15 TAGRISSO...... 15 SAMSCA...... 48 sps (with sorbitol)...... 42 TALTZ AUTOINJECTOR.. 37 SANDIMMUNE...... 15 sronyx...... 60 TALTZ SYRINGE...... 37 SANTYL...... 38 ssd...... 38 TALZENNA...... 15 sapropterin...... 48 STELARA...... 37 tamoxifen...... 15 scopolamine base...... 50 STIOLTO RESPIMAT...... 66 tamsulosin...... 67 SECUADO...... 30 STIVARGA...... 15 TARGRETIN...... 15 selegiline hcl...... 20 STRENSIQ...... 48 tarina 24 fe...... 60 selenium sulfide...... 37 STREPTOMYCIN...... 7 tarina fe 1-20 eq (28)...... 60 SELZENTRY...... 3 STRIBILD...... 3 TASIGNA...... 15 sertraline...... 30 STRIVERDI RESPIMAT.... 66 tazarotene...... 38 setlakin...... 60 SUCRAID...... 50 tazicef...... 5 sevelamer carbonate...... 42 sucralfate...... 51 TAZORAC...... 38 sharobel...... 58 sulfacetamide sodium...... 62 taztia xt...... 33 SHINGRIX (PF)...... 53 sulfacetamide sodium (acne).. 39 TAZVERIK...... 15 SIGNIFOR...... 15 sulfacetamide-prednisolone..... 62 TDVAX...... 53 sildenafil (pulmonary arterial sulfadiazine...... 9 TEFLARO...... 5 hypertension)...... 65 sulfamethoxazole- telmisartan...... 33 silver sulfadiazine...... 38 trimethoprim...... 9 telmisartan-amlodipine...... 33 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 79 telmisartan- TOUJEO MAX U-300 TUKYSA...... 16 hydrochlorothiazid...... 33 SOLOSTAR...... 47 TURALIO...... 16 TEMIXYS...... 3 TOUJEO SOLOSTAR U- TWINRIX (PF)...... 53 TENIVAC (PF)...... 53 300 INSULIN...... 47 TYPHIM VI...... 54 tenofovir disoproxil fumarate....3 tramadol...... 24 UKONIQ...... 16 TEPMETKO...... 15 tramadol-acetaminophen...... 24 unithroid...... 49 terazosin...... 33 trandolapril...... 34 UPTRAVI...... 34 terbinafine hcl...... 1 tranexamic acid...... 58 ursodiol...... 51 terbutaline...... 66 tranylcypromine...... 30 valacyclovir...... 3 terconazole...... 58 travasol 10 %...... 68 VALCHLOR...... 38 TERIPARATIDE...... 55 travoprost...... 62 valganciclovir...... 3 testosterone...... 48 TRAZIMERA...... 15 valproic acid...... 19 testosterone cypionate...... 48 trazodone...... 30 valproic acid (as sodium salt).19 testosterone enanthate...... 48 TRECATOR...... 7 valsartan...... 34 TETANUS,DIPHTHERIA TRELSTAR...... 15 valsartan-hydrochlorothiazide.34 TOX PED(PF)...... 53 treprostinil sodium...... 34 VALTOCO...... 19 tetrabenazine...... 22 tretinoin (antineoplastic)...... 16 vancomycin...... 7 tetracycline...... 9 tretinoin topical...... 38 vandazole...... 58 THALOMID...... 15 triamcinolone acetonide.... 41, 43 VAQTA (PF)...... 54 THEO-24...... 66 triamterene- VARIVAX (PF)...... 54 theophylline...... 66 hydrochlorothiazid...... 34 VARIZIG...... 54 thioridazine...... 30 triderm...... 41 VARUBI...... 51 thiothixene...... 30 trientine...... 42 VASCEPA...... 36 tiadylt er...... 33 tri-estarylla...... 60 VECAMYL...... 36 tiagabine...... 19 trifluoperazine...... 30 velivet triphasic regimen (28). 60 TIBSOVO...... 15 trifluridine...... 61 VEMLIDY...... 3 tigecycline...... 7 TRIKAFTA...... 66 VENCLEXTA...... 16 tilia fe...... 60 tri-legest fe...... 60 VENCLEXTA STARTING timolol maleate...... 33, 61 tri-lo-estarylla...... 60 PACK...... 16 tinidazole...... 7 tri-lo-sprintec...... 60 venlafaxine...... 30 TIVICAY...... 3 trilyte with flavor packets...... 51 verapamil...... 34 TIVICAY PD...... 3 trimethoprim...... 9 VERSACLOZ...... 30 tizanidine...... 22 trimipramine...... 30 VERZENIO...... 16 tobramycin...... 7, 61 TRINTELLIX...... 30 vestura (28)...... 60 tobramycin in 0.225 % nacl...... 7 tri-previfem (28)...... 60 V-GO 20...... 55 tobramycin sulfate...... 7 tri-sprintec (28)...... 60 V-GO 30...... 55 tobramycin-dexamethasone.... 62 TRIUMEQ...... 3 V-GO 40...... 55 tolterodine...... 66 trivora (28)...... 60 vienva...... 60 tolvaptan...... 48 TROPHAMINE 10 %...... 68 vigabatrin...... 19 topiramate...... 19 trospium...... 66 vigadrone...... 19 toremifene...... 15 TRULANCE...... 51 VIIBRYD...... 30 torsemide...... 33 TRULICITY...... 47 VIMPAT...... 19, 20 TRUMENBA...... 53 VIOKACE...... 51 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 80 VIRACEPT...... 3 ZEJULA...... 17 VIREAD...... 3 ZELBORAF...... 17 VITRAKVI...... 16 zenatane...... 38 VIVITROL...... 24 zidovudine...... 3 VIZIMPRO...... 16 ziprasidone hcl...... 31 voriconazole...... 1 ziprasidone mesylate...... 31 VOSEVI...... 3 ZIRABEV...... 17 VOTRIENT...... 16 ZIRGAN...... 61 VRAYLAR...... 30 ZOLINZA...... 17 VYNDAMAX...... 36 zolpidem...... 31 VYNDAQEL...... 36 zonisamide...... 20 warfarin...... 34 ZORTRESS...... 17 XALKORI...... 16 zovia 1-35 (28)...... 60 XARELTO...... 34 ZYDELIG...... 17 XARELTO DVT-PE ZYKADIA...... 17 TREAT 30D START...... 35 ZYPREXA RELPREVV...... 31 XATMEP...... 16 XCOPRI...... 20 XCOPRI MAINTENANCE PACK...... 20 XCOPRI TITRATION PACK...... 20 XELJANZ...... 57 XELJANZ XR...... 57 XERMELO...... 16 XGEVA...... 10 XIFAXAN...... 7 XIGDUO XR...... 47 XIIDRA...... 62 XOLAIR...... 66 XOSPATA...... 16 XPOVIO...... 16 XTANDI...... 16 xulane...... 58 XURIDEN...... 42 XYREM...... 30 YF-VAX (PF)...... 54 YONSA...... 16 yuvafem...... 58 zafemy...... 58 zafirlukast...... 66 zaleplon...... 30, 31 zarah...... 60 Note: The drug list includes all possible restrictions and limitations. Depending on your plan's specific benefit, you may not experience every restriction or limit indicated in the list. You can find information on what the symbols and abbreviations on this table mean by going to page vii. To confirm your plan's specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com.

This drug list was updated in August 2021. 81

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This page intentionally left blank You must use network pharmacies to fill your prescriptions to get the most out of your benefit. However, there are emergency circumstances under which you may be reimbursed for a covered prescription that is not filled at a network pharmacy. Limitations, copayments and restrictions may apply.

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This drug list was updated in August 2021.