2019 Express Scripts National Preferred Formulary

The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.

2019 Express Scripts PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by National Preferred Formulary all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY BD AUTOSHIELD clonidine enalapril GENOTROPIN [INJ] [INJ] - Injectable Drug DUO NEEDLES clopidogrel ENBREL [INJ] GENVOYA Brand-name drugs are listed BD ULTRAFINE clotrimazole/betamethasone enoxaparin [INJ] GILENYA in CAPITAL letters. INSULIN SYRINGES dipropionate ENSTILAR GILOTRIF Generic drugs are listed BD ULTRAFINE PEN NEEDLES COLCRYS ENTRESTO glimepiride in lower case letters. BELBUCA COMBIGAN EPCLUSA glipizide benazepril COMBIPATCH EPIDIOLEX glipizide ext-release A benzonatate COMBIVENT RESPIMAT EPIDUO FORTE GLUCAGEN [INJ] BEPREVE COPAXONE 40 MG [INJ] epinephrine autoinjector GLUCAGON [INJ] ABILIFY MAINTENA [INJ] BETASERON [INJ] CORLANOR (by Mylan) [INJ] glyburide ABSORICA BETHKIS COSENTYX [INJ] EPIPEN, EPIPEN JR [INJ] GLYXAMBI ACANYA BEVESPI AEROSPHERE CREON ergocalciferol GONAL-F, GONAL-F RFF, acetaminophen/codeine BIKTARVY CRINONE ERIVEDGE GONAL-F RFF ACTEMRA [INJ] bisoprolol/hctz cyanocobalamin [INJ] ERLEADA REDI-JECT [INJ] acyclovir blisovi fe cyclobenzaprine erythromycin eye ointment GRALISE ADEMPAS BOSULIF ESBRIET GRANIX [INJ] ADVAIR DISKUS BREO ELLIPTA D escitalopram GRASTEK ADVAIR HFA BRILINTA esomeprazole magnesium guanfacine ext-release AFSTYLA [INJ] budesonide nebulization DALIRESP delayed-release AIMOVIG [INJ] suspension DARAPRIM estradiol H AKYNZEO bupropion DAYTRANA estradiol patches albuterol nebulization bupropion ext-release DESCOVY estradiol/norethindrone HARVONI solution buspirone desloratadine acetate HELIXATE FS [INJ] alendronate butalbital/acetaminophen/ desvenlafaxine succinate ESTRING HUMALOG [INJ] allopurinol caffeine ext-release eszopiclone HUMIRA [INJ] ALPHAGAN P 0.1% BYDUREON [INJ] dexamethasone EUFLEXXA [INJ] HUMULIN [INJ] alprazolam BYETTA [INJ] DEXCOM RECEIVER, SENSOR, ezetimibe hydralazine ALREX BYSTOLIC TRANSMITTER ezetimibe/simvastatin hydrochlorothiazide amiodarone BYVALSON dexmethylphenidate hydrocodone/acetaminophen AMITIZA ext-release F hydrocodone/ amitriptyline C dextroamphetamine/ chlorpheniramine polistirex amlodipine amphetamine famotidine ext-release amlodipine/benazepril CABOMETYX dextroamphetamine/ FARXIGA hydrocortisone topical amlodipine/valsartan CANASA amphetamine ext-release fenofibrate hydromorphone amoxicillin CARAC diazepam fenofibrate micronized hydroxychloroquine amoxicillin/potassium CARAFATE SUSPENSION diclofenac sodium fenofibric acid hydroxyzine hcl clavulanate carbidopa/levodopa delayed-release delayed-release hydroxyzine pamoate anastrozole carvedilol dicyclomine fentanyl patches HYSINGLA ER ANDRODERM cefdinir digoxin FETZIMA ANORO ELLIPTA cefuroxime axetil diltiazem ext-release FINACEA FOAM I APRISO celecoxib diphenoxylate/atropine finasteride ARCAPTA NEOHALER cephalexin divalproex delayed-release FIRAZYR [INJ] ibandronate ARIKAYCE CERDELGA divalproex ext-release FLECTOR IBRANCE aripiprazole CEREZYME [INJ] DIVIGEL FLOVENT DISKUS ibuprofen ARISTADA [INJ] CETROTIDE [INJ] donepezil FLOVENT HFA ILEVRO ARMONAIR RESPICLICK CHANTIX doxazosin fluconazole INCRUSE ELLIPTA ARNUITY ELLIPTA chlorhexidine gluconate doxycycline hyclate fluocinonide indomethacin ASMANEX HFA chlorthalidone doxycycline monohydrate fluoxetine INLYTA ASMANEX TWISTHALER CIMDUO DUAVEE fluticasone nasal spray INVOKAMET atenolol CIPRODEX DULERA folic acid INVOKAMET XR atenolol/chlorthalidone ciprofloxacin duloxetine delayed-release FORTEO [INJ] INVOKANA atomoxetine citalopram DUPIXENT [INJ] FRAGMIN [INJ] irbesartan atorvastatin clarithromycin DYMISTA FREESTYLE LIBRE READER, IRESSA AVONEX [INJ] CLENPIQ SENSOR isosorbide mononitrate AZASITE clindamycin hcl E furosemide ext-release azelastine nasal spray clindamycin phosphate FYCOMPA azithromycin topical EDARBI J clindamycin phosphate/ EDARBYCLOR G B benzoyl peroxide ELIDEL JANUMET, JANUMET XR clobetasol propionate ELIQUIS gabapentin JANUVIA baclofen clomiphene citrate EMGALITY [INJ] GELNIQUE JARDIANCE BARACLUDE SOLUTION clonazepam EMVERM gemfibrozil JENTADUETO (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 1 PRMT22157-19 (01/01/19) JENTADUETO XR montelukast P rosuvastatin TRESIBA [INJ] JIVI [INJ] morphine sulfate ext-release RUCONEST [INJ] triamcinolone topical junel MOVANTIK pantoprazole delayed-release triamterene/hctz junel fe MOXEZA paroxetine hcl S tri-lo-marzia moxifloxacin eye solution PAZEO trinessa K mupirocin penicillin v potassium SANCUSO TRIPTODUR [INJ] MUSE PENTASA SAVELLA tri-sprintec ketoconazole topical MYDAYIS PERFOROMIST SEGLUROMET TRULANCE ketorolac MYRBETRIQ PHOSLYRA SEREVENT DISKUS TRULICITY [INJ] KITABIS PAK PICATO sertraline TUDORZA PRESSAIR KOGENATE FS [INJ] N pioglitazone sildenafil TYMLOS [INJ] KOVALTRY [INJ] PLEGRIDY [INJ] SIMPONI 100 MG (for KYLEENA nabumetone polymyxin/trimethoprim ulcerative colitis only) [INJ] U NAMZARIC eye solution simvastatin L naproxen, naproxen sodium POMALYST SKYLA UCERIS FOAM NARCAN NASAL SPRAY potassium chloride SOLIQUA [INJ] ULORIC labetalol NASCOBAL ext-release SOLODYN UPTRAVI lamotrigine neomycin/polymyxin/ PRALUENT [INJ] SOMATULINE DEPOT [INJ] lansoprazole delayed-release hydrocortisone ear solution pramipexole SOOLANTRA V LANTUS [INJ] NEXIUM PACKETS pravastatin SPIRIVA RESPIMAT latanoprost eye solution niacin ext-release prednisolone acetate spironolactone valacyclovir LATUDA nifedipine ext-release eye suspension sprintec valsartan LETAIRIS nitrofurantoin macrocrystal prednisolone sodium SPRYCEL valsartan/hctz LEVEMIR [INJ] NITYR phosphate STEGLATRO VARUBI levetiracetam NORDITROPIN [INJ] prednisone STELARA SC [INJ] VASCEPA levocetirizine nortriptyline PREMARIN CREAM STIOLTO RESPIMAT VELPHORO levofloxacin NOVAREL [INJ] PREMARIN TABLETS STRENSIQ [INJ] VELTASSA levothyroxine sodium NOVOEIGHT [INJ] PREMPHASE STRIVERDI RESPIMAT venlafaxine lidocaine patches NOVOFINE AUTOSHIELD PREMPRO SUBOXONE SL FILM venlafaxine ext-release LINZESS NEEDLES PREPOPIK sulfamethoxazole/ VENTOLIN HFA liothyronine NOVOFINE NEEDLES PROAIR HFA trimethoprim verapamil ext-release LIPOFEN NOVOTWIST NEEDLES PROAIR RESPICLICK sumatriptan VESICARE lisinopril NUCALA [INJ] PROCRIT [INJ] SUPREP VIBERZI lisinopril/hctz NUCYNTA, NUCYNTA ER progesterone micronized SUTENT VIIBRYD LIVALO NUEDEXTA PROLASTIN C [INJ] SYMBICORT VIMPAT LO LOESTRIN FE NUVARING PROLENSA SYMFI VIOKACE LOKELMA NUWIQ [INJ] promethazine SYMFI LO VOSEVI lorazepam nystatin promethazine/ SYMLINPEN [INJ] VYVANSE losartan nystatin topical dextromethorphan SYMPROIC losartan/hctz propranolol SYNJARDY, SYNJARDY XR W LOTEMAX O propranolol ext-release lovastatin PULMICORT FLEXHALER T warfarin LUMIGAN ODACTRA PYLERA LYRICA OFEV TACLONEX SUSPENSION X ofloxacin Q tacrolimus topical M olanzapine tadalafil XALKORI olmesartan QBREXZA tamoxifen XARELTO meclizine olmesartan/hctz QNASL tamsulosin ext-release XELJANZ, XELJANZ XR medroxyprogesterone olopatadine eye solution QUDEXY XR TARCEVA XIFAXAN meloxicam omega-3 acid ethyl esters quetiapine TASIGNA XIGDUO XR MESTINON SYRUP omeprazole delayed-release QUILLICHEW ER TAYTULLA XIIDRA metaxalone ondansetron QUILLIVANT XR TAZORAC GEL XOFLUZA metformin ondansetron orally quinapril TAZORAC 0.05% CREAM XOLAIR [INJ] metformin ext-release disintegrating tablets QVAR TECFIDERA XTANDI methimazole ONETOUCH KITS/METERS; QVAR REDIHALER TEKTURNA, TEKTURNA HCT XULTOPHY [INJ] methocarbamol ULTRA 2, ULTRAMINI, terazosin methotrexate VERIO, VERIO FLEX, R terconazole vaginal Y methylphenidate VERIO IQ, VERIO SYNC testosterone cypionate [INJ] methylphenidate ext-release ONETOUCH TEST STRIPS; rabeprazole delayed-release THALOMID YONSA methylprednisolone ULTRA, VERIO RAGWITEK timolol maleate eye solution yuvafem metoclopramide ONEXTON raloxifene tizanidine metoprolol succinate OPSUMIT ramipril TOBI PODHALER Z ext-release ORACEA RANEXA TOBRADEX OINTMENT metoprolol tartrate ORFADIN ranitidine TOBRADEX ST ZARXIO [INJ] metronidazole ORTHOVISC [INJ] RAPAFLO tobramycin eye solution ZENPEP metronidazole topical oseltamivir RASUVO [INJ] tobramycin/dexamethasone ZEPATIER metronidazole vaginal OTEZLA REBIF [INJ] eye suspension zolpidem microgestin fe OTOVEL RECTIV topiramate zolpidem ext-release MINIVELLE OTREXUP [INJ] RELISTOR [INJ] TOUJEO [INJ] ZOMIG NASAL minocycline OVIDREL [INJ] REMICADE [INJ] TOVIAZ ZONTIVITY MIRENA oxcarbazepine RESTASIS TRACLEER ZOVIRAX CREAM mirtazapine oxybutynin ext-release RETACRIT [INJ] TRADJENTA ZTLIDO MIRVASO oxycodone REVLIMID tramadol ZUBSOLV MITIGARE oxycodone/acetaminophen RHOPRESSA TRAVATAN Z ZYLET moderiba OXYCONTIN risperidone trazodone ZYTIGA mometasone OZEMPIC [INJ] rizatriptan TRELEGY ELLIPTA MONOVISC [INJ] ropinirole TREMFYA [INJ] Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans.

Drug Class Excluded Medications Preferred Alternatives

AUTONOMIC & CENTRAL NERVOUS SYSTEM LUCEMYRA clonidine Alpha-2 Adrenergic Agonists (for Opioid Withdrawal)

Anti-Migraine Therapy SUMAVEL DOSEPRO sumatriptan injection

amantadine capsules, amantadine tablets, GOCOVRI ER, OSMOLEX ER Antiparkinsonism Agents amantadine oral solution XADAGO rasagiline, selegiline

AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, Beta Interferons for Multiple Sclerosis EXTAVIA PLEGRIDY, REBIF, REBIF REBIDOSE

Calcitonin Gene-Related Peptide Antagonists AJOVY AIMOVIG, EMGALITY

EMFLAZA prednisone solution, prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51 No alternatives recommended

hydromorphone ER, morphine sulfate ER, oxymorphone ER, Long-Acting Opioid Oral Analgesics EMBEDA, OXYCODONE ER HYSINGLA ER, NUCYNTA ER, OXYCONTIN

Narcotic Analgesics BUTRANS BELBUCA

Narcotic Antagonists EVZIO naloxone syringes, NARCAN NASAL SPRAY

Neuropathic Agents LYRICA CR gabapentin, GRALISE, LYRICA

Transmucosal Fentanyl Analgesics ABSTRAL, FENTORA, LAZANDA fentanyl citrate lozenges

CARDIOVASCULAR PRADAXA, SAVAYSA ELIQUIS, XARELTO Anticoagulants

Beta Blockers KAPSPARGO SPRINKLE metoprolol succinate

HMG & Cholesterol Inhibitor Combinations ALTOPREV, ZYPITAMAG atorvastatin, lovastatin, rosuvastatin, simvastatin, LIVALO

PCSK9 Inhibitors REPATHA PRALUENT

DERMATOLOGICAL MINOCYCLINE ER 55 MG TABLETS, MINOLIRA minocycline ER Oral Agents for Acne

Oral Agents for Rosacea DOXYCYCLINE 40 MG CAPSULES ORACEA

Topical Acne PLIXDA adapalene

clindamycin/benzoyl peroxide, clindamycin/tretinoin, Topical Acne/Antibiotic Combinations AKTIPAK, VELTIN erythromycin/benzoyl peroxide, ACANYA, ONEXTON

diclofenac 3% gel, fluorouracil 2% solution, FLUOROURACIL 0.5% CREAM, Topical Agents for Actinic Keratosis fluorouracil 5% cream, imiquimod 5% cream, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA CARAC, PICATO

Topical Antifungals LULICONAZOLE ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

acyclovir capsules, acyclovir tablets, famciclovir tablets, Topical Antiviral Agents XERESE CREAM valacyclovir tablets, ZOVIRAX CREAM

desonide 0.05% cream/lotion/ointment, Topical Corticosteroids TOPICORT SPRAY, VERDESO FOAM desoximetasone 0.25% cream/ointment

Miscellaneous Topical Dermatological Agents ALCORTIN A hydrocortisone, mupirocin

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© 2018 Express Scripts. All Rights Reserved. 204612 All trademarks are the property of their respective owners. Page 3 DL44109Q-SD-19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

ABBOTT (FREESTYLE, PRECISION), BAYER (BREEZE, CONTOUR), NATIONAL MEDICAL (ADVOCATE), OMNIS DIABETES HEALTH (EMBRACE, VICTORY), ROCHE (ACCU-CHEK), LIFESCAN (ONETOUCH) Blood Glucose Meters & Test Strips TRIVIDIA (TRUETEST, TRUETRACK), UNISTRIP ALL OTHER METERS & STRIPS THAT ARE NOT LIFESCAN BRAND

ALOGLIPTIN, NESINA, ONGLYZA JANUVIA, TRADJENTA Dipeptidyl Peptidase-4 Inhibitors & Combinations ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

Glucagon-Like Peptide-1 Agonists ADLYXIN, TANZEUM, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY

NOVOLIN HUMULIN Insulins ADMELOG, APIDRA, FIASP, NOVOLOG HUMALOG

EAR/NOSE BECONASE AQ, OMNARIS, ZETONNA budesonide, flunisolide, fluticasone, mometasone, QNASL Nasal Steroids

ciprofloxacin ear solution, ofloxacin ear solution, Otic Fluoroquinolone Antibiotics CETRAXAL CIPRODEX, OTOVEL

ENDOCRINE (OTHER) CLIMARA PRO COMBIPATCH Combination Patches

estradiol patches, estradiol tablets, yuvafem, Estrogen and Estrogen Modifiers for Vaginal Symptoms FEMRING ESTRING, PREMARIN CREAM, PREMARIN TABLETS

Gonadotropin Releasing Hormone (GnRH) Agonists LUPRON DEPOT-PED TRIPTODUR (for Central Precocious Puberty)

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, Growth Hormones GENOTROPIN, NORDITROPIN FLEXPRO SAIZEN, SAIZENPREP, ZOMACTON

Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT

Topical Estrogen Gels ESTROGEL DIVIGEL

GASTROINTESTINAL CORTIFOAM hydrocortisone enema, UCERIS FOAM Corticosteroids (Rectal Formulations)

balsalazide disodium, mesalamine 1.2 gm delayed release, Inflammatory Bowel Agents DELZICOL, DIPENTUM sulfasalazine, APRISO, PENTASA

Pancreatic Enzymes PANCREAZE, PERTZYE CREON, ZENPEP

ACIPHEX SPRINKLE, PRILOSEC SUSPENSION, esomeprazole, lansoprazole, omeprazole, pantoprazole, Proton Pump Inhibitors PROTONIX SUSPENSION rabeprazole, NEXIUM PACKETS

HEMATOLOGICAL ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT Erythropoiesis-Stimulating Agents

ADVATE, ADYNOVATE, AFSTYLA, HELIXATE FS, JIVI, Factor VIII Recombinant Products ELOCTATE, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ

Granulocyte Colony Stimulating Factors NEUPOGEN, NIVESTYM GRANIX, ZARXIO

HEPATITIS DAKLINZA, LEDIPASVIR/SOFOSBUVIR, MAVYRET, OLYSIO, EPCLUSA, HARVONI, VOSEVI, ZEPATIER Hepatitis C SOFOSBUVIR/VELPATASVIR, SOVALDI

BIKTARVY, GENVOYA, ODEFSEY, STRIBILD, SYMFI, SYMFI LO, ATRIPLA, DELSTRIGO, SYMTUZA HIV TRIUMEQ Antiretrovirals PIFELTRO efavirenz, nevirapine ER, EDURANT, INTELENCE, RESCRIPTOR

MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE COLCRYS, MITIGARE Gout Therapy DUZALLO, ZURAMPIC allopurinol, probenecid

fenoprofen calcium tablets, diclofenac, ibuprofen, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES indomethacin, meloxicam, nabumetone, naproxen

OBSTETRICAL & GYNECOLOGICAL Gonadotropin-Releasing Hormone (GnRH) GANIRELIX ACETATE CETROTIDE Antagonists (for Infertility)

Continued

© 2018 Express Scripts. All Rights Reserved. 204612 All trademarks are the property of their respective owners. Page 4 DL44109Q-SD-19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

OBSTETRICAL & GYNECOLOGICAL (continued) Gonadotropin-Releasing Hormone (GnRH) ORILISSA LUPRON DEPOT, SYNAREL, ZOLADEX Receptor Antagonists (for Endometriosis)

Human Chorionic Gonadotropin CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL

Ovulatory Stimulants (Follitropins) BRAVELLE, FOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT

Vaginal Progesterones ENDOMETRIN CRINONE 8% GEL

OPHTHALMIC betaxolol drops, levobunolol drops, timolol drops, TIMOPTIC OCUDOSE Antiglaucoma Drugs (Beta-Adrenergic Blockers) ALPHAGAN P 0.1%, COMBIGAN

Antiglaucoma Drugs (Ophthalmic Prostaglandins) ZIOPTAN bimatoprost drops, latanoprost drops, LUMIGAN, TRAVATAN Z

azelastine drops, cromolyn drops, olopatadine drops, Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, EMADINE ALREX, BEPREVE, PAZEO

dexamethasone drops, fluorometholone drops, Ophthalmic Anti-Inflammatory FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD prednisolone drops, LOTEMAX

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs bromfenac drops, diclofenac drops, ketorolac drops, ACUVAIL, NEVANAC (NSAIDs) ILEVRO, PROLENSA

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, OSTEOARTHRITIS HYMOVIS, SUPARTZ FX, SYNVISC, SYNVISC-ONE, TRIVISC, EUFLEXXA, MONOVISC, ORTHOVISC Hyaluronic Acid Derivatives VISCO-3

RENAL DISEASE FOSRENOL POWDER PACKETS, RENAGEL lanthanum, sevelamer carbonate, PHOSLYRA, VELPHORO Phosphate Binders

RESPIRATORY AUVI-Q, EPINEPHRINE AUTO-INJECTOR EPINEPHRINE AUTO-INJECTOR (BY MYLAN), Epinephrine Auto-Injector Systems (BY A-S MEDICATION, IMPAX & LINEAGE) EPIPEN, EPIPEN JR

Long-Acting Beta Agonist Nebulized BROVANA PERFOROMIST

ARMONAIR RESPICLICK, ARNUITY ELLIPTA, Pulmonary Anti-Inflammatory Inhalers ALVESCO ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR

Short-Acting Beta 2-Agonist Inhalers LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA

WEIGHT LOSS CONTRAVE ER, QSYMIA benzphetamine, diethylpropion, phentermine Weight Loss Agents

HYDROXYPROGESTERONE 1,250 MG/5 ML hydroxyprogesterone caproate 250 mg/ml (single dose vial)

MISCELLANEOUS AGENTS SIKLOS DROXIA

NOCTIVA desmopressin tablets

Hereditary Angioedema BERINERT RUCONEST

Polyneuropathy of Hereditary ONPATTRO No alternatives recommended Transthyretin-Mediated Amyloidosis

Indication Based Management Drug Class Nonpreferred Medications Preferred Alternatives

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted ACTEMRA, COSENTYX, ENBREL, HUMIRA, following a coverage review. A trial of one or more Preferred INFLECTRA, OTEZLA, REMICADE, RENFLEXIS, INFLAMMATORY CONDITIONS‡ medications is required prior to initiating therapy with a SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY), Nonpreferred medication. A formulary exception may be STELARA SC, TREMFYA*, XELJANZ, XELJANZ XR granted for patients already established on therapy with a Nonpreferred medication.

‡ Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches. * This medication may be subject to step therapy.

Continued

ABBOTT (FREESTYLE, PRECISION) FIASP PLAQUENIL^ ABILIFY^ FLAREX PLAVIX^ ABSTRAL FLUOROURACIL 0.5% CREAM PLIXDA ACIPHEX^ FML FORTE, FML S.O.P. PRADAXA ACIPHEX SPRINKLE FOLLISTIM AQ PRED MILD ACUVAIL FOSRENOL CHEWABLE TABLETS^ PREGNYL ADCIRCA^ FOSRENOL POWDER PACKETS PREVACID^, PREVACID SOLUTAB^ ADDERALL^ GANIRELIX ACETATE PRILOSEC SUSPENSION ADLYXIN GEL-ONE PRISTIQ^ ADMELOG GELSYN-3 PROTONIX^ AJOVY GENVISC 850 PROTONIX SUSPENSION AKTIPAK GLEEVEC^ PROVENTIL HFA ALCORTIN A GLUCOPHAGE^, GLUCOPHAGE XR^ PROVIGIL^ ALOCRIL GLUMETZA^ PROZAC^ ALOGLIPTIN GOCOVRI ER PULMICORT RESPULES^ ALOGLIPTIN/METFORMIN HUMATROPE QSYMIA ALOMIDE HYALGAN RECOMBINATE ALTOPREV HYDROXYPROGESTERONE 1,250 MG/5 ML RENAGEL ALVESCO HYMOVIS REPATHA ANDROGEL 1%^ IMIQUIMOD 3.75% CREAM PUMP ROCHE (ACCU-CHEK) ANUSOL-HC^ IMITREX^ SAIZEN, SAIZENPREP APIDRA INDERAL LA^ SANDOSTATIN LAR DEPOT ARANESP INTUNIV^ SAVAYSA ARIMIDEX^ ISTALOL^ SEROQUEL^, SEROQUEL XR^ ASACOL HD^ KAPSPARGO SPRINKLE SIGNIFOR LAR ATACAND^, ATACAND HCT^ KAZANO SIKLOS ATRIPLA KEPPRA^, KEPPRA XR^ SINGULAIR^ AUVI-Q KOMBIGLYZE XR SOFOSBUVIR/VELPATASVIR AVALIDE^, AVAPRO^ LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ SOVALDI AVODART^ LAZANDA STRATTERA^ AZOR^ LEDIPASVIR/SOFOSBUVIR SUMAVEL DOSEPRO BAYER (BREEZE, CONTOUR) LEVALBUTEROL HFA SUPARTZ FX BECONASE AQ LEXAPRO^ SYMTUZA BENICAR^, BENICAR HCT^ LIBRAX^ SYNVISC, SYNVISC-ONE BERINERT LIDODERM^ TANZEUM BRAVELLE LIPITOR^ TESTIM^ BRISDELLE^ LOESTRIN^, LOESTRIN FE^ TIKOSYN^ BROVANA LOTREL^ TIMOPTIC OCUDOSE BUPAP^ LOVENOX^ TOBI SOLUTION^ BUTRANS LUCEMYRA TOPAMAX^ CELEBREX^ LULICONAZOLE TOPICORT SPRAY CELEXA^ LUNESTA^ TRIBENZOR^ CETRAXAL LUPRON DEPOT-PED TRICOR^ CHORIONIC GONADOTROPIN LYRICA CR TRILEPTAL^ CLIMARA PRO MAVYRET TRIVIDIA (TRUETEST, TRUETRACK) COLCHICINE MAXALT^, MAXALT MLT^ TRIVISC CONTRAVE ER MAXIDEX UNISTRIP COREG^ MICARDIS^, MICARDIS HCT^ UROXATRAL^ CORTIFOAM MINASTRIN 24 FE^ VAGIFEM^ COSOPT^ MINOCYCLINE ER 55 MG TABLETS VALIUM^ COZAAR^, HYZAAR^ MINOLIRA VALTREX^ CRESTOR^ MIRCERA VELTIN CYMBALTA^ NALFON CAPSULES VERDESO FOAM CYTOMEL^ NAMENDA XR^ VIAGRA^ DAKLINZA NASONEX^ VICTOZA DELSTRIGO NATIONAL MEDICAL (ADVOCATE) VISCO-3 DELZICOL NESINA VIVELLE-DOT^ DETROL^, DETROL LA^ NEUPOGEN VYTORIN^ DIOVAN^, DIOVAN HCT^ NEURONTIN^ WELLBUTRIN SR^ DIPENTUM NEVANAC XADAGO DOXYCYCLINE 40 MG CAPSULES NIVESTYM XALATAN^ DUROLANE NOCTIVA XANAX^, XANAX XR^ DUZALLO NORCO^ XENAZINE^ EFFEXOR XR^ NORVASC^ XERESE CREAM ELOCTATE NOVOLIN XOPENEX HFA EMADINE NOVOLOG XYNTHA, XYNTHA SOLOFUSE EMBEDA NUTROPIN AQ NUSPIN YASMIN^ EMFLAZA NUVIGIL^ ZEGERID^ ENDOMETRIN OLYSIO ZETIA^ EPINEPHRINE AUTO-INJECTOR OMNARIS ZETONNA (BY A-S MEDICATION, IMPAX & LINEAGE) OMNIS HEALTH (EMBRACE, VICTORY) ZIOPTAN EPOGEN OMNITROPE ZOCOR^ ESTROGEL ONGLYZA ZOLOFT^ EVZIO ONPATTRO ZOMACTON EXFORGE^, EXFORGE HCT^ ORILISSA ZOMIG TABLETS^, ZOMIG ZMT^ EXONDYS 51 ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ ZONEGRAN^ EXTAVIA OSMOLEX ER ZURAMPIC FEMRING OXYCODONE ER ZYCLARA FENOPROFEN CAPSULES PANCREAZE ZYFLO CR^ FENORTHO PERTZYE ZYPITAMAG FENTORA PIFELTRO ^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.