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2020 National Preferred Formulary List for BJC Healthcare

2020 National Preferred Formulary List for BJC Healthcare

2020 Express Scripts National Preferred Formulary List For BJC HealthCare

The 2020 National Preferred Formulary drug list for BJC HealthCare is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. 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 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 For the member: FDA-approved generic meet strict standards and [INJ] – Injectable Drug contain the same active ingredients as their corresponding brand-name medications, [OTC] – Over-the-counter Product although they may have a different appearance. [SP] – Specialty Drug For the physician: Please prescribe preferred products and allow generic Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA substitutions when medically appropriate. Generic drugs are listed in lower-case letters. Example: ibuprofen

A ADDAMEL N [INJ] alprazolam orally disintegrating tablets ampicillin adefovir ALPROLIX [INJ] [SP] ampicillin sodium [INJ] abacavir [SP] ADEMPAS [SP] alprostadil [INJ] ampicillin sodium/sulbactam [INJ] abacavir/lamivudine [SP] adenosine [INJ] ALREX AMYTAL [INJ] abacavir/lamivudine/zidovudine [SP] ADVAIR HFA altavera AMZEEQ ABELCET [INJ] ADVATE [INJ] [SP] ALUNBRIG [SP] anagrelide ABILIFY MAINTENA [INJ] ADYNOVATE [INJ] [SP] alyacen anastrozole abiraterone acetate [SP] AFINITOR 10 MG TABLETS [SP] amabelz ANDRODERM ABRAXANE [INJ] [SP] AFINITOR DISPERZ [SP] amantadine ANORO ELLIPTA acamprosate delayed-release afirmelle AMBISOME [INJ] APLISOL [INJ] acarbose AFLURIA [INJ] ambrisentan [SP] APOKYN [INJ] [SP] ACCU-CHEK FASTCLIX LANCETS [OTC] AFLURIA QUAD [INJ] amcinonide apraclonidine eye solution ACCU-CHEK MULTICLIX LANCET KIT [OTC] AFSTYLA [INJ] [SP] amethia aprepitant ACCU-CHEK MULTICLIX LANCETS [OTC] AIMOVIG [INJ] amethia lo apri ACCU-CHEK SOFTCLIX LANCET KIT [OTC] AJOVY [INJ] amethyst APTIVUS [SP] ACCU-CHEK SOFTCLIX LANCETS [OTC] albendazole amifostine [INJ] AQUASOL A [INJ] acebutolol albumin human [INJ] amikacin [INJ] ARALAST NP [INJ] [SP] acetaminophen/ albuterol amiloride aranelle acetazolamide albuterol ext-release amiloride/hydrochlorothiazide ARIKAYCE [SP] acetazolamide ext-release albuterol nebulization solution aminocaproic acid aripiprazole acetazolamide sodium [INJ] albuterol sulfate hfa (by Cipla, Par, aminocaproic acid [INJ] aripiprazole orally disintegrating tablets acetic acid ear solution Perrigo, Proficient Rx & Teva) aminophylline [INJ] ARISTADA [INJ] acetic acid irrigation solution alclometasone AMINOSYN [INJ] ARISTOSPAN [INJ] acetic acid/hydrocortisone ear solution ALDURAZYME [INJ] [SP] amiodarone armodafinil acetic acid/oxyquinoline vaginal alendronate amiodarone [INJ] ARMONAIR RESPICLICK [INJ] alfentanil [INJ] amitriptyline ARMOUR acetylcysteine inhalation solution ALFERON N [INJ] amitriptyline/chlordiazepoxide ARNUITY ELLIPTA acitretin alfuzosin ext-release amlodipine ARRANON [INJ] [SP] ACTEMRA [INJ] [SP] ALIMTA [INJ] amlodipine/atorvastatin arsenic trioxide [INJ] ACTHIB [INJ] ALINIA amlodipine/benazepril ascorbic acid [INJ] ACTHREL [INJ] ALIQOPA [INJ] [SP] amlodipine/olmesartan ashlyna ACTIMMUNE [INJ] [SP] aliskiren amlodipine/valsartan ASMANEX HFA ACTIVASE [INJ] allopurinol amlodipine/valsartan/hydrochlorothiazide ASMANEX TWISTHALER acyclovir allopurinol sodium [INJ] ammonium lactate 12% topical aspirin/dipyridamole ext-release acyclovir ointment almotriptan amoxapine atazanavir [SP] acyclovir sodium [INJ] alosetron amoxicillin atenolol ADACEL [INJ] ALPHAGAN P 0.1% amoxicillin/ clavulanate atenolol/chlorthalidone ADAKVEO [INJ] [SP] ALPHANATE [INJ] [SP] amoxicillin/potassium clavulanate ATGAM [INJ] adapalene ALPHANINE SD [INJ] [SP] ext-release atomoxetine adapalene/benzoyl peroxide alprazolam amphetamine sulfate atorvastatin ADCETRIS [INJ] [SP] alprazolam ext-release amphotericin [INJ] (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 1 COMPBJCANP-20 (07/01/20) atovaquone/proguanil betamethasone valerate C celecoxib [INJ] BETASERON [INJ] [SP] CELONTIN atropine sulfate eye ointment betaxolol cabergoline cephalexin atropine sulfate eye solution betaxolol eye solution CABLIVI [INJ] [SP] CEPROTIN [INJ] [SP] aubra bethanechol CABOMETYX [SP] CERDELGA [SP] aubra eq BETHKIS [SP] caffeine citrated CEREZYME [INJ] [SP] AUGMENTIN 125-31.25 MG/5 ML BEVESPI AEROSPHERE caffeine citrated [INJ] cetirizine syrup aurovela bexarotene [SP] caffeine/sodium benzoate [INJ] CETROTIDE [INJ] [SP] aurovela 24 fe BEXSERO [INJ] calcipotriene cevimeline aurovela fe bicalutamide calcipotriene/betamethasone dipropionate CHANTIX AUSTEDO [SP] BICILLIN C-R [INJ] calcitonin salmon nasal chateal aviane BICILLIN L-A [INJ] calcitriol chateal eq AVONEX [INJ] [SP] BIKTARVY [SP] calcitriol [INJ] CHEMET AVYCAZ [INJ] bimatoprost eye solution calcitriol ointment CHENODAL [SP] ayuna biolon [INJ] calcium acetate chloramphenicol [INJ] azacitidine [INJ] [SP] BIOTHRAX [INJ] calcium [INJ] chlordiazepoxide AZASITE bisoprolol CALCIUM DISODIUM VERSENATE [INJ] chlordiazepoxide/clidinium azathioprine [SP] bisoprolol/hydrochlorothiazide [INJ] chlorhexidine gluconate azathioprine sodium [INJ] [SP] bivalirudin [INJ] CALDOLOR VIALS [INJ] chloroprocaine hcl [INJ] AZEDRA [INJ] [SP] blanche camila chloroquine azelaic acid bleomycin [INJ] camrese chlorothiazide azelastine eye solution BLINCYTO [INJ] [SP] camrese lo chlorothiazide sodium [INJ] azelastine nasal spray blisovi 24 fe candesartan chlorpromazine azelastine/fluticasone blisovi fe candesartan/hydrochlorothiazide chlorpromazine [INJ] azithromycin BOOSTRIX [INJ] CAPASTAT SULFATE [INJ] chlorthalidone azithromycin [INJ] bosentan [SP] capecitabine [SP] chlorzoxazone aztreonam [INJ] BOSULIF [SP] CAPRELSA [SP] CHOLBAM [SP] azurette BOTOX [INJ] [SP] captopril cholestyramine BREO ELLIPTA captopril/hydrochlorothiazide cholestyramine light B bretylium tosylate [INJ] carbachol [INJ] choline salicylate/magnesium salicylate BREVITAL [INJ] CARBAGLU [SP] chromium chloride [INJ] bacitracin [INJ] briellyn carbamazepine bacitracin eye ointment BRILINTA carbamazepine ext-release ciclopirox shampoo bacitracin/polymyxin eye ointment brimonidine eye solution carbidopa cidofovir [INJ] baclofen BRINEURA [INJ] [SP] carbidopa/levodopa cilostazol baclofen [INJ] bromfenac eye solution carbidopa/levodopa ext-release CIMDUO [SP] BAL IN OIL [INJ] bromocriptine carbidopa/levodopa orally cimetidine balanced eye irrigation solution brompheniramine/pseudoephedrine/ disintegrating tablets cinacalcet bal-care dha prenatal vitamins codeine carbidopa/levodopa/entacapone CINRYZE [INJ] [SP] balsalazide brompheniramine/pseudoephedrine/ carbinoxamine CINVANTI [INJ] BALVERSA [SP] carboplatin [INJ] ciprofloxacin balziva budesonide ext-release carmustine [INJ] ciprofloxacin ear solution BANZEL budesonide nebulization suspension carteolol eye solution ciprofloxacin eye solution BAQSIMI bumetanide carvedilol ciprofloxacin lactate/dextrose [INJ] BARACLUDE SOLUTION bumetanide [INJ] carvedilol phosphate ext-release cisplatin [INJ] BAVENCIO [INJ] [SP] bupivacaine [INJ] [INJ] citalopram BAXDELA bupivacaine/dextrose [INJ] CATHFLO ACTIVASE [INJ] cladribine [INJ] BAXDELA [INJ] bupivacaine/epinephrine [INJ] CAVERJECT [INJ] clarithromycin b-complex [INJ] buprenorphine CAYSTON [SP] clarithromycin ext-release BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine [INJ] caziant clemastine BD NANO 2ND GEN PEN NEEDLES buprenorphine patches cefaclor CLENPIQ BD ULTRAFINE INSULIN SYRINGES [OTC] buprenorphine/ cefaclor ext-release clindamycin hcl BD ULTRAFINE PEN NEEDLES [OTC] bupropion cefadroxil clindamycin palmitate bekyree bupropion ext-release cefazolin [INJ] clindamycin phosphate [INJ] BELBUCA bupropion ext-release (smoking deterrent) cefdinir clindamycin phosphate topical benazepril buspirone cefditoren clindamycin phosphate vaginal benazepril/hydrochlorothiazide busulfan [INJ] cefepime [INJ] clindamycin phosphate/benzoyl peroxide BENDEKA [INJ] [SP] butalbital/acetaminophen cefepime/dextrose [INJ] clindamycin phosphate/dextrose [INJ] BENEFIX [INJ] [SP] butalbital/acetaminophen/caffeine cefixime clindamycin phosphate/tretinoin BENLYSTA [INJ] [SP] butalbital/acetaminophen/caffeine/ cefotaxime [INJ] CLINIMIX [INJ] BENZNIDAZOLE codeine cefotetan [INJ] CLINIMIX E [INJ] butalbital/aspirin/caffeine cefoxitin [INJ] clobazam benzoyl peroxide butalbital/aspirin/caffeine/codeine cefoxitin/dextrose [INJ] clobetasol propionate benztropine [INJ] cefpodoxime clobetasol propionate shampoo benztropine [INJ] butorphanol nasal cefprozil clobetasol propionate/emollient BEPREVE BYDUREON [INJ] ceftazidime [INJ] clofarabine [INJ] BESPONSA [INJ] [SP] BYETTA [INJ] CEFTAZIDIME/DEXTROSE [INJ] clomiphene citrate betamethasone acetate/betamethasone BYSTOLIC ceftriaxone [INJ] clomipramine sodium phosphate [INJ] ceftriaxone/dextrose [INJ] clonazepam betamethasone dipropionate cefuroxime axetil clonazepam orally disintegrating tablets betamethasone dipropionate augmented cefuroxime sodium [INJ] clonidine (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 2 COMPBJCANP-20 (07/01/20) clonidine [INJ] dactinomycin [INJ] diclofenac sodium/misoprostol ext-release E clonidine ext-release dalfampridine ext-release [SP] dicloxacillin clonidine patches DALIRESP dicyclomine clopidogrel DALVANCE [INJ] dicyclomine [INJ] EDARBI clorazepate danazol didanosine delayed-release [SP] EDARBYCLOR topical dantrolene diflorasone EDURANT [SP] clotrimazole troche dantrolene [INJ] diflorasone/emollient efavirenz [SP] clotrimazole/betamethasone dipropionate diflunisal EGRIFTA [INJ] [SP] clozapine dapsone topical digoxin EGRIFTA SV [INJ] [SP] clozapine orally disintegrating tablets DAPTACEL [INJ] digoxin [INJ] ELAPRASE [INJ] [SP] c-nate dha prenatal vitamins daptomycin [INJ] /acetaminophen/caffeine electrolyte-48 solution/dextrose [INJ] COAGADEX [INJ] [SP] darifenacin ext-release dihydroergotamine [INJ] eletriptan COARTEM DARZALEX [INJ] [SP] dihydroergotamine nasal ELIGARD [INJ] [SP] codeine sulfate dasetta DILANTIN 30 MG CAPSULES elinest colchicine tablets daunorubicin [INJ] DILATRATE-SR ELIQUIS colchicine/probenecid daysee diltiazem ELITEK [INJ] COLCRYS DAYTRANA diltiazem [INJ] elite-ob prenatal vitamins colesevelam hcl DDAVP RHINAL SOLUTION diltiazem ext-release ELMIRON colestipol deblitane dimenhydrinate [INJ] ELOCTATE [INJ] [SP] colistimethate [INJ] decitabine [INJ] [SP] diphenhydramine eluryng vaginal ring COMBIGAN deferasirox [SP] diphenhydramine [INJ] ELZONRIS [INJ] [SP] COMBIPATCH deferoxamine [INJ] diphenoxylate/atropine EMCYT COMBIVENT RESPIMAT delflex with dextrose [INJ] DIPHTHERIA-TETANUS TOXOIDS-PED [INJ] EMGALITY [INJ] COMETRIQ [SP] demeclocycline dipyridamole emoquette complete natal dha prenatal vitamins DEMSER dipyridamole [INJ] EMTRIVA [SP] constulose DEPO-ESTRADIOL [INJ] disulfiram EMVERM copper chloride [INJ] DEPO-PROVERA 400 MG/ML [INJ] divalproex delayed-release enalapril CORIFACT [INJ] [SP] DESCOVY [SP] divalproex ext-release enalapril/hydrochlorothiazide CORLANOR desipramine DIVIGEL enalaprilat [INJ] cortisone acetate desloratadine dobutamine [INJ] ENBREL [INJ] [SP] COSENTYX [INJ] [SP] desloratadine orally disintegrating tablets dobutamine/dextrose [INJ] ENDOMETRIN [SP] cosyntropin [INJ] desmopressin acetate DOCEFREZ [INJ] ENGERIX-B [INJ] COTELLIC [SP] desmopressin acetate [INJ] [SP] docetaxel [INJ] enoxaparin [INJ] [SP] CREON desmopressin nasal DOCETAXEL 200 MG/10 ML [INJ] enpresse CRESEMBA desogestrel-ethinyl estradiol dofetilide enskyce CRESEMBA [INJ] desonide donepezil ENSTILAR CRINONE 4% desoximetasone donepezil orally disintegrating tablets entacapone CRINONE 8% [SP] desvenlafaxine succinate ext-release dopamine [INJ] entecavir CRIXIVAN [SP] dexamethasone dopamine/dextrose [INJ] ENTRESTO CROFAB [INJ] dexamethasone sodium phosphate [INJ] DOPTELET [SP] ENTYVIO [INJ] [SP] cromolyn sodium eye solution dexamethasone sodium phosphate dorzolamide eye solution EOVIST [INJ] cromolyn sodium nebulization solution eye solution dorzolamide/timolol eye solution EPCLUSA [SP] cromolyn sodium oral solution dexchlorpheniramine DOVATO [SP] ephedrine [INJ] crotamiton DEXCOM RECEIVER, SENSOR, doxazosin EPIDIOLEX [SP] cryselle TRANSMITTER doxepin epinastine eye solution CRYSVITA [INJ] [SP] dexmedetomidine [INJ] doxepin cream epinephrine auto-injector (by Mylan) [INJ] cyanocobalamin [INJ] dexmedetomidine/nacl [INJ] doxercalciferol epinephrine vials, ampules, syringes [INJ] cyclafem dexmethylphenidate doxercalciferol [INJ] EPINEPHRINE-DEXTROSE [INJ] cyclobenzaprine dexmethylphenidate ext-release doxorubicin [INJ] epinephrine-nacl [INJ] cyclobenzaprine ext-release dexrazoxane [INJ] doxorubicin/liposomal [INJ] EPIPEN, EPIPEN JR [INJ] cyclopentolate eye solution dextran/dextrose [INJ] doxycycline hyclate epirubicin [INJ] cyclopentolate/tropicamide/ dextran/normal saline [INJ] doxycycline hyclate [INJ] EPIVIR HBV SOLUTION phenylephrine eye drops dextroamphetamine doxycycline hyclate delayed-release eplerenone cyclophosphamide [INJ] dextroamphetamine ext-release doxycycline monohydrate epoprostenol [INJ] [SP] CYCLOPHOSPHAMIDE CAPSULES dextroamphetamine/amphetamine doxylamine succinate/vit b6 epoprostenol diluent [INJ] [SP] cyclosporine [INJ] [SP] dextroamphetamine/amphetamine D-PENAMINE eprosartan cyclosporine [SP] ext-release dronabinol eptifibatide [INJ] cyclosporine modified [SP] dextrose/lactated ringers [INJ] droperidol [INJ] ERAXIS [INJ] cyproheptadine dextrose/ [INJ] drospirenone-ethinyl estradiol ERBITUX [INJ] [SP] CYRAMZA [INJ] [SP] dextrose/water [INJ] drospirenone-ethinyl ergocalciferol cyred DIACOMIT [SP] estradiol-levomefolate ergoloid mesylates cyred eq DROXIA ergotamine tartrate/caffeine CYSTADANE [SP] diazepam [INJ] DUAVEE ergotamine tartrate/caffeine CYSTAGON [SP] diazepam rectal gel DULERA suppositories CYSTARAN [SP] diazoxide duloxetine delayed-release ERIVEDGE [SP] cytarabine [INJ] diclofenac eye solution DUPIXENT [INJ] [SP] ERLEADA [SP] CYTOGAM [INJ] [SP] diclofenac potassium dutasteride erlotinib [SP] diclofenac sodium delayed-release dutasteride/tamsulosin ext-release errin D diclofenac sodium ext-release DYANAVEL XR ertapenem [INJ] diclofenac sodium gel DYMISTA ERYTHROCIN [INJ] dacarbazine [INJ] diclofenac sodium topical solution erythromycin (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 3 COMPBJCANP-20 (07/01/20) erythromycin delayed-release fentanyl citrate lozenges FRAGMIN [INJ] [SP] GLYCOPHOS [INJ] erythromycin ethylsuccinate fentanyl citrate/nacl [INJ] FREAMINE HBC [INJ] glycopyrrolate erythromycin eye ointment fentanyl patches freamine iii [INJ] glycopyrrolate [INJ] erythromycin stearate FERAHEME [INJ] FREESTYLE FREEDOM KIT [OTC] glycopyrrolate-water [INJ] erythromycin topical FERRIPROX [SP] FREESTYLE FREEDOM LITE METER [OTC] GLYXAMBI erythromycin/benzoyl peroxide FETZIMA FREESTYLE INSULINX GONAL-F, GONAL-F RFF, ESBRIET [SP] FINACEA FOAM SYSTEM [OTC] GONAL-F RFF REDI-JECT [INJ] [SP] escitalopram finasteride FREESTYLE INSULINX TEST STRIPS [OTC] granisetron esmolol [INJ] FIRMAGON [INJ] [SP] FREESTYLE LIBRE granisetron [INJ] esmolol-nacl [INJ] FIRST-MOUTHWASH BLM FREESTYLE LITE METER [OTC] GRASTEK esomeprazole magnesium delayed-release flavoxate FREESTYLE LITE TEST STRIPS [OTC] microsize esomeprazole sodium [INJ] flecainide FREESTYLE TEST STRIPS [OTC] griseofulvin ultramicrosize ESPEROCT [INJ] [SP] FLECTOR frovatriptan /codeine estarylla FLOLAN [INJ] [SP] FULPHILA [INJ] [SP] guaifenesin/phenylephrine estazolam FLOLAN DILUENT [INJ] [SP] fulvestrant [INJ] guanfacine esterified estrogens/methyltestosterone FLOVENT DISKUS furosemide guanfacine ext-release estonogestrel-ee vaginal ring FLOVENT HFA furosemide [INJ] guanidine estradiol floxuridine [INJ] FUZEON [INJ] [SP] GVOKE [INJ] estradiol cream FLUAD [INJ] fyavolv estradiol patches FLUARIX QUAD [INJ] FYCOMPA H estradiol vaginal FLUBLOK QUAD [INJ] estradiol valerate [INJ] FLUCELVAX QUAD [INJ] G hailey estradiol/norethindrone acetate hailey 24 fe ESTRING fluconazole/normal saline [INJ] gabapentin HALAVEN [INJ] [SP] eszopiclone GABLOFEN SYRINGES [INJ] halcinonide ethacrynate [INJ] fludarabine [INJ] galantamine halobetasol ethacrynic acid fludrocortisone acetate galantamine ext-release haloperidol ethambutol FLULAVAL QUAD [INJ] GAMASTAN [INJ] [SP] haloperidol decanoate [INJ] ETHAMOLIN [INJ] [INJ] GAMASTAN S-D [INJ] [SP] haloperidol lactate ethosuximide flunisolide nasal spray GAMIFANT [INJ] [SP] haloperidol lactate [INJ] ethyl [INJ] fluocinolone GAMMACORE HARVONI [SP] ethynodiol-ethinyl estradiol fluocinolone acetonide oil ear solution GAMMAGARD LIQUID [INJ] [SP] HAVRIX [INJ] etidronate fluocinonide GAMMAGARD S-D [INJ] [SP] heather etodolac fluocinonide/emollient GAMUNEX-C [INJ] [SP] HEMABATE [INJ] etodolac ext-release fluorescein [INJ] ganciclovir [INJ] HEMLIBRA [INJ] [SP] etomidate [INJ] fluorescein eye strips ganirelix acetate [INJ] [SP] HEMOFIL-M [INJ] [SP] ETOPOPHOS [INJ] fluorometholone eye suspension GARDASIL 9 [INJ] HEPAGAM B [INJ] etoposide fluorouracil gatifloxacin eye solution lock flush [INJ] etoposide [INJ] fluorouracil [INJ] gavilyte-c heparin sodium [INJ] EUFLEXXA [INJ] [SP] fluoxetine gavilyte-g heparin sodium/dextrose [INJ] everolimus [SP] fluoxetine delayed-release gavilyte-n heparin sodium/nacl [INJ] exemestane fluphenazine decanoate [INJ] GAZYVA [INJ] [SP] HEPATAMINE [INJ] EXTRANEAL ICODEXTRIN DIALYSIS fluphenazine hcl GELNIQUE hetastarch/normal saline [INJ] SOLUTION [INJ] fluphenazine hcl [INJ] gemcitabine [INJ] HEXTEND LACTATED ELECTROLYTE [INJ] EYLEA [INJ] [SP] flurandrenolide gemfibrozil HIBERIX [INJ] ezetimibe flurazepam GENOTROPIN [INJ] [SP] HIZENTRA VIALS [INJ] [SP] ezetimibe/simvastatin flurbiprofen gentamicin [INJ] homatropine eye solution flurbiprofen sodium eye solution gentamicin eye ointment HUMALOG [INJ] F flutamide gentamicin eye solution HUMATE-P [INJ] [SP] fluticasone nasal spray gentamicin topical HUMIRA [INJ] [SP] FABRAZYME [INJ] [SP] fluticasone topical gentamicin/normal saline [INJ] HUMULIN [INJ] falmina FLUTICASONE/SALMETEROL AEROSOL GENTAMICIN/NORMAL SALINE HUMULIN R 500 UNITS [INJ] famciclovir fluticasone/salmeterol powder inhaler 100 MG/50 ML [INJ] HYCAMTIN CAPSULES [SP] famotidine fluvastatin GENVOYA [SP] hydralazine famotidine [INJ] fluvastatin ext-release gianvi hydralazine [INJ] famotidine/nacl [INJ] fluvoxamine GILENYA [SP] hydrochlorothiazide FARXIGA fluvoxamine ext-release GILOTRIF [SP] ext-release FASENRA [INJ] [SP] FLUZONE HIGH-DOSE [INJ] GLASSIA [INJ] [SP] hydrocodone/acetaminophen FASENRA PEN FLUZONE QUAD [INJ] glatiramer [INJ] [SP] hydrocodone/chlorpheniramine polistirex fayosim folic acid glatopa [INJ] [SP] ext-release febuxostat folic acid [INJ] GLEOSTINE hydrocodone/homatropine FEIBA NF [INJ] [SP] folivane-ob prenatal vitamins glimepiride hydrocodone/ibuprofen felbamate FOLOTYN [INJ] [SP] glipizide hydrocortisone felodipine ext-release [INJ] glipizide ext-release hydrocortisone acetate suppositories femynor fondaparinux [INJ] [SP] glipizide/metformin hydrocortisone butyrate fenofibrate FORTEO [INJ] [SP] GLUCAGEN [INJ] hydrocortisone butyrate/emollient fenofibrate micronized fosamprenavir [SP] GLUCAGON [INJ] hydrocortisone enema fenofibric acid fosaprepitant [INJ] glyburide hydrocortisone sodium succinate [INJ] fenofibric acid delayed-release fosinopril glyburide micronized hydrocortisone topical fenoprofen fosinopril/hydrochlorothiazide glyburide/metformin hydrocortisone valerate fentanyl citrate [INJ] fosphenytoin [INJ] glycine irrigation solution hydrocortisone/lidocaine (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 4 COMPBJCANP-20 (07/01/20) hydrocortisone/pramoxine INVIRASE [SP] kelnor levofloxacin [INJ] INVOKAMET KEPIVANCE [INJ] [SP] levofloxacin eye solution hydromorphone [INJ] INVOKAMET XR ketamine [INJ] levofloxacin/dextrose [INJ] hydromorphone ext-release INVOKANA ketamine-nacl [INJ] levoleucovorin [INJ] hydromorphone suppositories /potassium levonest hydromorphone/nacl [INJ] iodine/ ketoconazole shampoo levonorgestrel-ethinyl estradiol hydroquinone IODOPEN [INJ] ketoconazole topical levora hydroquinone microspheres IONOSOL/DEXTROSE [INJ] ketoconazole/skin cleanser kit levorphanol [INJ] IPOL [INJ] ketoprofen levothyroxine sodium hydroxychloroquine ipratropium nasal spray ketoprofen ext-release levothyroxine sodium [INJ] hydroxyprogesterone [INJ] ipratropium bromide nebulization solution ketorolac LEVSIN [INJ] hydroxyprogesterone [INJ] [SP] ipratropium/albuterol sulfate nebulization ketorolac [INJ] LEXISCAN [INJ] hydroxyurea solution ketorolac eye solution LEXIVA SUSPENSION [SP] hydroxyzine hcl irbesartan KEYTRUDA [INJ] [SP] LIBTAYO [INJ] [SP] hydroxyzine hcl [INJ] irbesartan/hydrochlorothiazide KINEVAC [INJ] lidocaine [INJ] hydroxyzine pamoate IRESSA [SP] KITABIS PAK [SP] lidocaine jelly hyophen irinotecan [INJ] KOGENATE FS [INJ] [SP] lidocaine patches hyoscyamine ISENTRESS [SP] KOVALTRY [INJ] [SP] lidocaine topical hyoscyamine ext-release isibloom K-PHOS ORIGINAL lidocaine viscous hyoscyamine orally disintegrating tablets ISOLYTE [INJ] KRYSTEXXA [INJ] [SP] lidocaine/dextrose [INJ] HYPERHEP B S-D [INJ] isoniazid kurvelo lidocaine/epinephrine [INJ] HYPERRAB [INJ] isoniazid [INJ] KUVAN [SP] lidocaine/hydrocortisone HYPERRAB S-D [INJ] isoproterenol [INJ] KYLEENA [SP] lidocaine/prilocaine HYPERRHO S-D [INJ] isosorbide dinitrate KYMRIAH [INJ] [SP] lillow HYPERTET S-D [INJ] isosorbide dinitrate ext-release KYPROLIS [INJ] [SP] lincomycin [INJ] HYSINGLA ER isosorbide mononitrate lindane shampoo isosorbide mononitrate ext-release L linezolid I isotretinoin linezolid [INJ] isoxsuprine labetalol linezolid/nacl [INJ] ibandronate isradipine labetalol [INJ] LINZESS ibandronate [INJ] [SP] ISTODAX [INJ] [SP] lactulose LIORESAL [INJ] IBRANCE [SP] lamivudine [SP] liothyronine ibuprofen ivermectin lamivudine hbv liothyronine [INJ] ibuprofen lysine [INJ] IXEMPRA [INJ] [SP] lamivudine/zidovudine [SP] LIPOFEN ibutilide [INJ] IXIARO [INJ] lamotrigine lisinopril icatibant [INJ] [SP] IXINITY [INJ] [SP] lamotrigine ext-release lisinopril/hydrochlorothiazide ICLUSIG [SP] lamotrigine orally disintegrating tablets lithium carbonate idarubicin [INJ] J LANOXIN PEDIATRIC AMPULES [INJ] lithium carbonate ext-release IDHIFA [SP] lansoprazole delayed-release lithium citrate ifosfamide [INJ] jaimiess lansoprazole delayed-release LIVALO ifosfamide/ [INJ] JAKAFI [SP] +amoxicillin+clarithromycin LO LOESTRIN FE ILARIS [INJ] [SP] JANUMET lansoprazole orally disintegrating tablets lojaimiess ILEVRO JANUMET XR lanthanum LOKELMA imatinib [SP] JANUVIA LANTUS [INJ] LONSURF [SP] IMBRUVICA [SP] JARDIANCE larin loperamide IMFINZI [INJ] [SP] jasmiel larin fe lopinavir/ritonavir [SP] imipenem/cilastatin [INJ] jencycla larissia lopreeza imipramine hcl JENTADUETO latanoprost eye solution lorazepam imipramine pamoate JENTADUETO XR LATUDA lorazepam [INJ] imiquimod JETREA [INJ] [SP] layolis fe LORBRENA [SP] IMOGAM RABIES-HT [INJ] JEVTANA [INJ] [SP] l- [INJ] loryna IMOVAX RABIES VACCINE [INJ] jinteli leena losartan IMPAVIDO JIVI [INJ] [SP] leflunomide losartan/hydrochlorothiazide INBRIJA [SP] jolessa LENVIMA [SP] LOTEMAX GEL, OINTMENT incassia jolivette lessina LOTEMAX SM INCRELEX [INJ] [SP] juleber letrozole loteprednol etabonate eye solution INCRUSE ELLIPTA JULUCA [SP] leucovorin lovastatin indapamide junel leucovorin [INJ] low-ogestrel indomethacin junel fe LEUKERAN loxapine indomethacin ext-release JUXTAPID [SP] LEUKINE [INJ] [SP] lo-zumandimine indomethacin sodium [INJ] leuprolide [INJ] [SP] LUMIZYME [INJ] [SP] INFANRIX [INJ] K levalbuterol nebulization solution LUPANETA PACK [INJ] [SP] infed [INJ] LEVEMIR [INJ] LUPRON DEPOT 3.75 MG, 11.25 MG INFUMORPH [INJ] KADCYLA [INJ] [SP] levetiracetam [INJ] [SP] INFUVITE [INJ] kaitlib fe levetiracetam [INJ] LUPRON DEPOT-PED [INJ] [SP] INLYTA [SP] KALETRA TABLETS [SP] levetiracetam ext-release LUTATHERA [INJ] [SP] INTELENCE [SP] kalliga levetiracetam-nacl [INJ] lutera intralipid 20% [INJ] KALYDECO [SP] levobunolol eye solution LUXTURNA [INJ] [SP] INTRON A [INJ] [SP] KANJINTI [INJ] [SP] levocarnitine LYNPARZA [SP] introvale KANUMA [INJ] [SP] levocetirizine LYSODREN INVELTYS kariva levofloxacin lyza (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 5 COMPBJCANP-20 (07/01/20) M methylphenidate moxifloxacin neomycin/polymyxin/hydrocortisone methylphenidate ext-release MOXIFLOXACIN [INJ] ear suspension m.v.i. adult [INJ] methylprednisolone moxifloxacin eye solution neomycin/polymyxin/hydrocortisone M.V.I. PEDIATRIC [INJ] methylprednisolone acetate [INJ] MOZOBIL [INJ] [SP] eye suspension M.V.I.-12 [INJ] methylprednisolone sodium MULTI-LANCET DEVICE [OTC] neostigmine [INJ] mafenide succinate [INJ] MULTITRACE-4 [INJ] NEPHRAMINE [INJ] [INJ] methyltestosterone MULTITRACE-5 [INJ] NERLYNX [SP] magnesium sulfate [INJ] metipranolol eye solution mupirocin NEULASTA [INJ] [SP] MAGNESIUM/DEXTROSE metoclopramide MUSE NEUT [INJ] 1 GM/100 ML [INJ] metoclopramide [INJ] MVASI [INJ] [SP] nevirapine [SP] malathion metoclopramide orally MYALEPT [INJ] [SP] nevirapine ext-release [SP] manganese chloride [INJ] disintegrating tablets MYCAMINE [INJ] newgen prenatal vitamins manganese sulfate [INJ] metolazone mycophenolate mofetil [SP] NEXAVAR [SP] [INJ] metoprolol succinate ext-release mycophenolate mofetil hcl [INJ] [SP] NEXIUM PACKETS maprotiline metoprolol tartrate mycophenolic acid delayed-release [SP] NEXLETOL marlissa metoprolol tartrate [INJ] MYDAYIS NEXPLANON [INJ] [SP] MARQIBO [INJ] [SP] metoprolol/hydrochlorothiazide MYLERAN NEXTERONE [INJ] MATULANE [SP] metronidazole MYLOTARG [INJ] [SP] niacin MAYZENT [SP] metronidazole topical mynatal advance prenatal vitamins niacin ext-release meclizine metronidazole vaginal mynatal plus prenatal vitamins nicardipine meclofenamate metronidazole/nacl [INJ] mynatal prenatal vitamins nicardipine [INJ] medroxyprogesterone mexiletine mynatal ultracaplet prenatal vitamins nifedipine ext-release medroxyprogesterone (contraceptive) [INJ] MIACALCIN [INJ] mynatal-z prenatal vitamins nikki mefenamic acid mibelas 24 fe mynate 90 plus prenatal vitamins nilutamide mefloquine [INJ] MYOBLOC [INJ] [SP] nimodipine megestrol vaginal MYRBETRIQ NINLARO [SP] MEKINIST [SP] microgestin nisoldipine ext-release melodetta 24 fe microgestin fe N nitisinone [SP] meloxicam midazolam nitrofurantoin melphalan midazolam [INJ] nabumetone nitrofurantoin macrocrystal melphalan [INJ] midazolam/nacl [INJ] nadolol nitrofurantoin monohydrate/macrocrystal memantine midodrine nadolol/bendroflumethiazide nitroglycerin [INJ] memantine ext-release mifepristone nafcillin [INJ] nitroglycerin ext-release MENACTRA [INJ] miglitol nafcillin/dextrose [INJ] nitroglycerin ointment MENOPUR [INJ] [SP] miglustat [SP] nitroglycerin patches mepivacaine [INJ] mili NAGLAZYME [INJ] [SP] nitroglycerin spray MEPSEVII [INJ] [SP] milrinone [INJ] nalbuphine [INJ] nitroglycerin/dextrose [INJ] mercaptopurine milrinone/dextrose [INJ] naloxone [INJ] nitroprusside sodium [INJ] meropenem [INJ] mimvey NITYR [SP] MEROPENEM/NACL [INJ] mimvey lo nandrolone [INJ] NIVESTYM [INJ] [SP] mesalamine delayed-release MINIMED INFUSION SETS naproxen nizatidine mesalamine enema MINIMED RESERVOIR naproxen delayed-release nora-be mesalamine ext-release MINOCIN [INJ] naproxen sodium NORDITROPIN [INJ] [SP] mesalamine kit minocycline naproxen sodium ext-release norepinephrine [INJ] mesalamine suppositories minocycline ext-release naproxen/esomeprazole magnesium norepinephrine/dextrose [INJ] mesna [INJ] minoxidil ext-release norepinephrine/nacl [INJ] MESNEX TABLETS MIRENA [SP] naratriptan norethindrone metaproterenol mirtazapine NARCAN NASAL SPRAY norethindrone acetate metaxalone mirtazapine orally disintegrating tablets NASCOBAL norethindrone acetate-ethinyl estradiol metformin MIRVASO NATACYN norethindrone acetate-ethinyl estradiol metformin ext-release misoprostol nateglinide + iron methadone MITIGARE NATESTO norgestimate-ethinyl estradiol methadone [INJ] mitomycin [INJ] NATPARA [INJ] [SP] norlyda methamphetamine mitoxantrone [INJ] [SP] NATRECOR [INJ] NORMOSOL-M AND DEXTROSE [INJ] methazolamide M-M-R II [INJ] NAYZILAM NORMOSOL-R AND DEXTROSE [INJ] methenamine hippurate m-natal prenatal vitamins necon NORMOSOL-R PH 7.4 [INJ] methenamine mandelate modafinil neomycin nortrel methenamine/sodium phosphate/ moexipril neomycin/bacitracin/polymyxin nortriptyline /hyoscyamine molindone eye ointment NORVIR PACKETS [SP] methimazole mometasone neomycin/bacitracin/polymyxin/ NORVIR SOLUTION [SP] METHITEST mometasone nasal spray hydrocortisone eye ointment NOVAREL [INJ] [SP] methocarbamol mono-linyah neomycin/polymyxin irrigation solution NOVOEIGHT [INJ] [SP] methocarbamol [INJ] MONONINE [INJ] [SP] neomycin/polymyxin/dexamethasone NOVOFINE AUTOSHIELD NEEDLES [OTC] methotrexate MONOVISC [INJ] [SP] eye ointment NOVOFINE NEEDLES [OTC] methotrexate [INJ] montelukast neomycin/polymyxin/dexamethasone NOVOSEVEN RT [INJ] [SP] methoxsalen morphine sulfate eye suspension NOVOTWIST NEEDLES [OTC] methyldopa morphine sulfate [INJ] neomycin/polymyxin/gramicidin NOXAFIL [INJ] methyldopa/hydrochlorothiazide morphine sulfate ext-release eye solution NOXAFIL SUSPENSION methyldopate [INJ] morphine sulfate suppositories neomycin/polymyxin/hydrocortisone NPLATE [INJ] [SP] methylergonovine morphine sulfate/nacl [INJ] ear solution NUBEQA [SP] methylergonovine [INJ] MOVANTIK NUCALA [INJ] [SP] (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 6 COMPBJCANP-20 (07/01/20) NUCYNTA oseltamivir permethrin ext-release NUCYNTA ER OTEZLA [SP] perphenazine potassium chloride oral solution NUEDEXTA OTOVEL perphenazine/amitriptyline potassium chloride powder packets for NULOJIX [INJ] [SP] OTREXUP [INJ] phenazopyridine solution nutrilyte [INJ] OVIDREL [INJ] [SP] phendimetrazine potassium chloride/dextrose [INJ] oxacillin [INJ] phendimetrazine ext-release potassium chloride/dextrose/nacl [INJ] nystatin topical oxacillin/dextrose [INJ] phenelzine potassium chloride/lactated ringers/ nystatin/triamcinolone oxaliplatin [INJ] phenobarbital dextrose [INJ] oxandrolone phenobarbital sodium [INJ] potassium chloride/nacl [INJ] O oxaprozin phenobarbital/hyoscyamine/atropine/ potassium chloride/water [INJ] oxcarbazepine scopolamine ext-release OBIZUR [INJ] [SP] OXERVATE [SP] phenoxybenzamine potassium citrate/citric acid obstetrix dha prenatal vitamins phentolamine [INJ] /iodine solution OCALIVA [SP] oxybutynin phenylbutyrate [INJ] ocella oxybutynin ext-release phenylephrine [INJ] POTELIGEO [INJ] [SP] OCREVUS [INJ] [SP] oxycodone phenylephrine eye solution pr natal 400 ec prenatal vitamins octreotide [INJ] [SP] oxycodone/acetaminophen phenylephrine/chlorpheniramine pr natal 400 prenatal vitamins ODACTRA oxycodone/aspirin phenylephrine/dextrose [INJ] pr natal 430 ec prenatal vitamins ODEFSEY [SP] oxycodone/ibuprofen phenylephrine/nacl [INJ] pr natal 430 prenatal vitamins ODOMZO [SP] OXYCONTIN phenytoin PRALUENT [INJ] OFEV [SP] oxymorphone phenytoin sodium [INJ] pramipexole OFIRMEV [INJ] oxymorphone ext-release phenytoin sodium extended pramipexole ext-release ofloxacin oxytocin [INJ] philith prasugrel ofloxacin ear solution OZEMPIC [INJ] PHOSLYRA pravastatin ofloxacin eye solution OZURDEX [INJ] [SP] phosphasal praziquantel ogestrel PHOSPHOLINE IODIDE prazosin olanzapine P PHOTOFRIN [INJ] PRECISION XTRA B-KETONE STRIPS [OTC] olanzapine [INJ] [INJ] PRECISION XTRA MONITOR [OTC] olanzapine orally disintegrating tablets paclitaxel [INJ] phytonadione PRECISION XTRA TEST STRIPS [OTC] olanzapine/fluoxetine paliperidone ext-release phytonadione [INJ] prednicarbate olmesartan palonosetron [INJ] PHYTONADIONE 1 MG/0.5 ML prednisolone olmesartan/amlodipine/ PALYNZIQ [INJ] [SP] SYRINGES [INJ] prednisolone acetate eye suspension hydrochlorothiazide pamidronate [INJ] PICATO prednisolone sodium phosphate olmesartan/hydrochlorothiazide pantoprazole [INJ] pilocarpine prednisolone sodium phosphate olopatadine eye solution pantoprazole delayed-release pilocarpine eye solution disintegrating tablets olopatadine nasal spray papaverine [INJ] pimecrolimus prednisolone sodium phosphate omega-3 ethyl esters PARADIGM INFUSION SETS pimozide eye solution omeprazole delayed-release PARADIGM RESERVOIRS pimtrea prednisone omeprazole/sodium bicarbonate PARADIGM SILHOUETTE SETS pindolol pregabalin OMNIPAQUE [INJ] paregoric pioglitazone PREMARIN [INJ] OMNIPOD paricalcitol pioglitazone/glimepiride PREMARIN CREAM OMNIPOD DASH paricalcitol [INJ] pioglitazone/metformin PREMARIN TABLETS ONCASPAR [INJ] paromomycin piperacillin/tazobactam [INJ] premasol [INJ] ondansetron paroxetine hcl pirmella PREMASOL 6% [INJ] ondansetron [INJ] paroxetine hcl ext-release piroxicam PREMPHASE ondansetron orally disintegrating tablets paroxetine mesylate PLASMA-LYTE [INJ] PREMPRO ONETOUCH DELICA LANCETS [OTC] PAZEO plasmanate [INJ] prena1 chew prenatal vitamins ONETOUCH DELICA PLUS LANCETS [OTC] PEDIARIX [INJ] PLEGRIDY [INJ] [SP] prena1 pearl prenatal vitamins ONETOUCH ULTRA 2 SYSTEM [OTC] PEDITRACE [INJ] plenamine [INJ] prena1 true prenatal vitamins ONETOUCH ULTRA TEST STRIPS [OTC] PEDVAXHIB [INJ] PNEUMOVAX 23 [INJ] prenaissance plus prenatal vitamins ONETOUCH ULTRAMINI METER [OTC] peg 3350/electrolytes powder for 4000 ml pnv 29-1 prenatal vitamins prenaissance prenatal vitamins ONETOUCH ULTRASOFT LANCETS [OTC] solution pnv ob+dha prenatal vitamins prenatabs fa prenatal vitamins ONETOUCH VERIO FLEX [OTC] PEGANONE pnv-dha + docusate prenatal vitamins prenatabs rx prenatal vitamins ONETOUCH VERIO IQ METER [OTC] PEGASYS [INJ] [SP] pnv-dha prenatal vitamins prenatal low iron prenatal vitamins ONETOUCH VERIO TEST STRIPS [OTC] peg-prep kit pnv-omega prenatal vitamins prenatal plus iron prenatal vitamins ONEXTON penicillamine pnv-select prenatal vitamins prenatal plus prenatal vitamins ONIVYDE [INJ] [SP] penicillin g potassium [INJ] pnv-vp-u prenatal vitamins prenatal-u prenatal vitamins OPDIVO [INJ] [SP] penicillin g procaine [INJ] podofilox preplus prenatal vitamins opium tincture penicillin g sodium [INJ] POLOCAINE [INJ] PREPOPIK opium/belladonna alkaloids suppositories PENICILLIN GK/DEXTROSE [INJ] polyethylene glycol 3350 pretab 29-1 prenatal vitamins OPSUMIT [SP] penicillin v potassium POLYFIN QR INFUSION SET previfem ORACEA PENTACEL [INJ] polymyxin [INJ] PREVNAR 13 [INJ] ORALAIR [SP] PENTACEL ACTHIB COMPONENT [INJ] polymyxin/trimethoprim eye solution PREVYMIS ORBACTIV [INJ] [INJ] POMALYST [SP] PREVYMIS [INJ] ORILISSA pentamidine inhalation portia PREZISTA [SP] ORKAMBI [SP] PENTASA PRIALT [INJ] [SP] orphenadrine [INJ] pentobarbital [INJ] POSACONAZOLE SUSPENSION PRIFTIN orphenadrine ext-release pentoxifylline ext-release [INJ] PRIMAQUINE orphenadrine/aspirin/caffeine PERFOROMIST /citric acid primaquine phosphate orsythia perindopril effervescent tablets primidone ORTHOVISC [INJ] [SP] PERJETA [INJ] [SP] potassium chloride [INJ] PRIVIGEN [INJ] [SP] (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 7 COMPBJCANP-20 (07/01/20) PROAIR HFA R RUZURGI [SP] SOLIQUA [INJ] PROAIR RESPICLICK RYBELSUS SOLIRIS [INJ] [SP] probenecid RABAVERT [INJ] RYDAPT [SP] SOLOSEC procainamide [INJ] rabeprazole delayed-release SOLU-CORTEF [INJ] PROCALAMINE [INJ] RADICAVA [INJ] [SP] S SOMATULINE DEPOT [INJ] [SP] prochlorperazine edisylate [INJ] RAGWITEK SOMAVERT [INJ] [SP] prochlorperazine maleate raloxifene salsalate sotalol prochlorperazine maleate suppositories ramelteon SAMSCA [SP] SOTALOL [INJ] PROCRIT [INJ] [SP] ramipril SANDIMMUNE SOLUTION [SP] SOTRADECOL 1% [INJ] PROFILNINE SD [INJ] [SP] ranolazine ext-release SANTYL SOTYLIZE progesterone in oil [INJ] [SP] RAPIVAB [INJ] SAVELLA spinosad progesterone micronized rasagiline scopolamine patches SPINRAZA [INJ] [SP] PROGRAF [INJ] [SP] RASUVO [INJ] secobarbital SPIRIVA HANDIHALER PROGRAF PACKETS [SP] RAVICTI [SP] SEGLUROMET SPIRIVA RESPIMAT PROLASTIN C [INJ] [SP] REBIF [INJ] [SP] selegiline spironolactone PROLENSA reclipsen selenium [INJ] spironolactone/hydrochlorothiazide PROLEUKIN [INJ] [SP] RECOMBIVAX HB [INJ] selenium sulfide sprintec PROMACTA [SP] RECTIV selenium sulfide shampoo SPRYCEL [SP] promethazine REGRANEX SELZENTRY [SP] sronyx promethazine [INJ] RELISTOR [INJ] se-natal 19 prenatal vitamins STAMARIL [INJ] promethazine suppositories RELISTOR TABLETS SENSORCAINE-EPI 0.75%-0.0005% [INJ] stavudine [SP] promethazine/codeine REMICADE [INJ] [SP] SEREVENT DISKUS STEGLATRO promethazine/dextromethorphan remifentanil [INJ] SEROSTIM [INJ] [SP] STELARA SC [INJ] [SP] promethazine/phenylephrine RENACIDIN sertraline STIMATE [SP] promethazine/phenylephrine/codeine repaglinide setlakin STIOLTO RESPIMAT propafenone repaglinide/metformin hcl sevelamer carbonate STIVARGA [SP] propafenone ext-release REPATHA [INJ] sevelamer hcl STRENSIQ [INJ] [SP] proparacaine eye solution RESCRIPTOR [SP] sharobel STREPTOMYCIN SULFATE [INJ] proparacaine/fluorescein eye solution RESECTISOL SHINGRIX [INJ] SUBLOCADE [INJ] [SP] propofol [INJ] RESTASIS SIGNIFOR [INJ] [SP] SUCRAID [SP] propranolol RETACRIT [INJ] [SP] sildenafil sucralfate propranolol [INJ] RETROVIR [INJ] [SP] sildenafil [INJ] [SP] sufentanil [INJ] propranolol ext-release REVCOVI [INJ] [SP] sildenafil [SP] sulfacetamide eye ointment propranolol/hydrochlorothiazide REVLIMID [SP] SILHOUETTE INFUSION SETS sulfacetamide eye solution propylthiouracil REYATAZ PACKETS [SP] silodosin sulfacetamide sodium shampoo PROQUAD [INJ] R-GENE 10 [INJ] silver sulfadiazine sulfacetamide sodium topical PROSOL [INJ] RHOPRESSA simliya sulfacetamide sodium/sulfur [INJ] RIASTAP [INJ] [SP] simpesse sulfacetamide/prednisolone eye solution PROTOPAM [INJ] ribavirin [SP] SIMPONI 100 MG (for ulcerative sulfadiazine protriptyline ribavirin nebulization solution colitis only) [INJ] [SP] sulfamethoxazole/trimethoprim PROVENGE [INJ] [SP] RIDAURA SIMULECT [INJ] [SP] sulfamethoxazole/trimethoprim [INJ] pseudoephedrine/chlorpheniramine/ rifabutin simvastatin SULFAMYLON CREAM methscopolamine ext-release rifampin sirolimus [SP] sulfasalazine pseudoephedrine/codeine/guaifenesin rifampin [INJ] SIRTURO sulfasalazine delayed-release PULMICORT FLEXHALER riluzole SKYLA [SP] sulindac PULMOZYME [SP] rimantadine SKYRIZI [INJ] [SP] sumatriptan PURIXAN [SP] ringers irrigation solution sodium acetate [INJ] sumatriptan [INJ] pyrazinamide ringers lactated irrigation solution sodium benzoate/ sumatriptan nasal pyridostigmine ringers solution [INJ] sodium phenylacetate [INJ] sumatriptan/naproxen sodium pyridostigmine [INJ] ringers solution lactated [INJ] sodium bicarbonate [INJ] SUNOSI pyridostigmine ext-release RINVOQ ER [SP] sodium bicarbonate/dextrose [INJ] SUPREP pyridoxine [INJ] risedronate sodium chloride [INJ] SURE-T INFUSION SET pyrimethamine [SP] risedronate delayed-release sodium chloride 0.45 % [INJ] SUTENT [SP] RISPERDAL CONSTA [INJ] sodium chloride 0.9 % [INJ] syeda Q risperidone sodium chloride 3 % [INJ] SYLATRON [INJ] [SP] risperidone orally disintegrating tablets sodium chloride 5 % [INJ] SYLVANT [INJ] [SP] QBREXZA ritonavir [SP] sodium chloride irrigation solution SYMBICORT QUADRACEL DTAP-IPV [INJ] rivastigmine sodium chloride nebulization solution SYMDEKO [SP] QUDEXY XR rivastigmine patches sodium chloride, bacteriostatic [INJ] SYMFI [SP] quetiapine rivelsa sodium ferric gluconate complex [INJ] SYMFI LO [SP] quetiapine ext-release rizatriptan sodium fluoride dental cream, gel SYMJEPI [INJ] QUICK RELEASE TEFLON CANNULA rizatriptan orally disintegrating tablets sodium lactate [INJ] SYMLINPEN [INJ] QUILLIVANT XR ropinirole sodium phosphate [INJ] SYMPROIC quinapril ropinirole ext-release sodium polystyrene sulfonate SYMTUZA [SP] quinapril/hydrochlorothiazide ropivacaine/nacl [INJ] sodium polystyrene sulfonate rectal SYNAGIS [INJ] [SP] quinidine gluconate ext-release rosuvastatin sodium tetradecyl sulfate [INJ] SYNAREL quinidine sulfate ROTATEQ sodium [INJ] SYNERCID [INJ] quinine sulfate ROZLYTREK [SP] SOF-SET MICRO INFUSION SET SYNJARDY QVAR REDIHALER RUBRACA [SP] SOF-SET ULTIMATE QR SET SYNJARDY XR RUCONEST [INJ] [SP] SOFT TOUCH LANCETS [OTC] SYNRIBO [INJ] [SP] RUXIENCE [INJ] [SP] solifenacin (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 8 COMPBJCANP-20 (07/01/20) T tinidazole tri-mili vasopressin/nacl [INJ] TIVICAY [SP] trimipramine VAXCHORA VACCINE TACLONEX SUSPENSION tizanidine TRIMO-SAN VECTIBIX [INJ] [SP] tacrolimus [SP] TOBI PODHALER [SP] trinatal rx 1 prenatal vitamins VELCADE [INJ] [SP] tacrolimus topical TOBRADEX OINTMENT trinate prenatal vitamins velivet tadalafil TOBRADEX ST tri-previfem VELPHORO tadalafil [SP] tobramycin [INJ] TRIPTODUR [INJ] [SP] VEMLIDY TAFINLAR [SP] tobramycin eye solution tri-sprintec VENCLEXTA [SP] TAGRISSO [SP] tobramycin nebulization solution [SP] TRIUMEQ [SP] venlafaxine TALICIA tobramycin/dexamethasone triveen-duo dha prenatal vitamins venlafaxine ext-release TALZENNA [SP] eye suspension trivora VENOFER [INJ] tamoxifen tobramycin/nacl [INJ] tri-vylibra VENTOLIN HFA tamsulosin ext-release tolcapone TROGARZO [INJ] [SP] verapamil TARGRETIN GEL [SP] tolmetin TROPHAMINE [INJ] verapamil [INJ] tarina fe tolterodine tropicamide eye solution verapamil ext-release taron-c dha prenatal vitamins tolterodine ext-release trospium veripred taron-prex dha prenatal vitamins topiramate trospium ext-release VERZENIO [SP] TASIGNA [SP] topotecan [INJ] [SP] TRULANCE VGO TAYTULLA toremifene TRULICITY [INJ] VIBATIV [INJ] tazarotene torsemide TRUMENBA [INJ] VIBERZI TAZORAC 0.05% CREAM TOUJEO [INJ] trust natal dha prenatal vitamins VIDEX SOLUTION [SP] TAZORAC GEL TOVIAZ TRUVADA [SP] vienva TECENTRIQ [INJ] [SP] TPN ELECTROLYTES [INJ] TUBERSOL [INJ] vigabatrin [SP] TECFIDERA [SP] TRACE ELEMENTS-4 [INJ] tulana VIIBRYD TECHLITE BLOOD LANCETS [OTC] TRACLEER SUSPENSION [SP] TWINRIX [INJ] vilamit mb TEFLARO [INJ] TRADJENTA tydemy vilevev mb TEGSEDI [INJ] [SP] tramadol TYKERB [SP] VIMIZIM [INJ] [SP] TEKTURNA HCT tramadol ext-release TYMLOS [INJ] [SP] VIMPAT telmisartan tramadol/acetaminophen TYPHIM VI [INJ] VIMPAT [INJ] telmisartan/amlodipine trandolapril TYSABRI [INJ] [SP] vinblastine [INJ] telmisartan/hydrochlorothiazide trandolapril/verapamil ext-release TYVASO [SP] vincristine [INJ] TEMIXYS [SP] tranexamic acid vinorelbine [INJ] TEMODAR [INJ] [SP] tranexamic acid [INJ] U VIOKACE temozolomide [SP] tranylcypromine viorele temsirolimus [INJ] [SP] travasol [INJ] UCERIS FOAM VIRACEPT [SP] TENIPOSIDE [INJ] travoprost eye solution UDENYCA [INJ] [SP] VIREAD 150 MG, 200 MG, 250 MG tenofovir disoproxil fumarate [SP] TRAZIMERA [INJ] [SP] UNITUXIN [INJ] [SP] TABLETS [SP] terazosin trazodone UPTRAVI [SP] VIREAD POWDER [SP] TREANDA [INJ] [SP] uretron d-s virt-c dha prenatal vitamins terbutaline TRELEGY ELLIPTA urimar-t virt-nate dha prenatal vitamins terbutaline [INJ] TREMFYA [INJ] [SP] urin d.s. virt-pn dha prenatal vitamins vaginal treprostinil diluent [INJ] [SP] uro-458 virt-pn plus prenatal vitamins testosterone treprostinil sodium [INJ] [SP] urogesic VISTOGARD [SP] testosterone cypionate [INJ] TRESIBA [INJ] uro-mp VISUDYNE [INJ] [SP] testosterone enanthate [INJ] tretinoin ursodiol VITRAKVI [SP] testosterone propionate [INJ] tretinoin microspheres uryl VIVITROL [INJ] [SP] TETANUS DIPHTHERIA TOXOIDS [INJ] tretinoin topical ustell VIVOTIF tetrabenazine [SP] tretinoin/emollient utira-c VIZIMPRO [SP] tetracaine [INJ] TRETTEN [INJ] [SP] UVADEX [INJ] vol-nate tetracaine eye solution tri femynor volnea tetracycline triamcinolone [INJ] V VOLUVEN [INJ] THALOMID [SP] triamcinolone dental paste VONVENDI [INJ] [SP] theophylline triamcinolone topical valacyclovir VORAXAZE [INJ] theophylline ext-release triamterene VALCHLOR [SP] theophylline/dextrose [INJ] triamterene/hydrochlorothiazide valganciclovir voriconazole [INJ] THERACYS [INJ] triazolam valproate sodium [INJ] VOSEVI [SP] [INJ] trientine valproic acid VOTRIENT [SP] thioridazine tri-estarylla valrubicin [SP] vp-ch-pnv prenatal vitamins thiotepa [INJ] trifluoperazine valsartan VUMERITY [SP] thiothixene trifluridine eye solution valsartan/hydrochlorothiazide vyfemla THROMBATE III [INJ] trihexyphenidyl vancomycin vylibra THYMOGLOBULIN [INJ] [SP] TRIKAFTA [SP] vancomycin [INJ] VYNDAMAX [SP] THYROGEN [INJ] [SP] tri-legest fe VANCOMYCIN/DEXTROSE [INJ] VYNDAQEL [SP] thyroid tri-linyah VANCOMYCIN-NS [INJ] VYVANSE tiagabine tri-lo-estarylla VANTAS [SP] VYXEOS LIPOSOME [INJ] [SP] TIBSOVO [SP] tri-lo-marzia vardenafil TICE BCG [INJ] tri-lo-mili vardenafil orally disintegrating tablets W tigecycline [INJ] tri-lo-sprintec VARIVAX [INJ] tilia fe trilyte with flavor packets VARIZIG [INJ] warfarin timolol maleate trimethobenzamide VARUBI water for injection, bacteriostatic [INJ] timolol maleate eye solution trimethoprim VASCEPA water for injection, sterile [INJ] (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 9 COMPBJCANP-20 (07/01/20) water for irrigation; sterile XTANDI [SP] zarah zoledronic acid [INJ] [SP] wera xulane patches ZARXIO [INJ] [SP] zoledronic acid/mannitol [INJ] [SP] WILATE [INJ] [SP] XULTOPHY [INJ] zatean-pn dha prenatal vitamins ZOLGENSMA [INJ] [SP] wixela inhub XURIDEN [SP] zatean-pn plus prenatal vitamins ZOLINZA [SP] wymzya fe XYREM [SP] ZEJULA [SP] zolmitriptan ZELBORAF [SP] zolmitriptan orally disintegrating tablets X Y ZEMAIRA [INJ] [SP] zolpidem ZENPEP zolpidem ext-release XALKORI [SP] YERVOY [INJ] [SP] ZEPATIER [SP] zonisamide XARELTO YESCARTA [INJ] [SP] ZERBAXA [INJ] ZORTRESS 1 MG TABLETS [SP] XELJANZ [SP] YF-VAX [INJ] ZEVALIN [INJ] ZOSYN GALAXY BAGS [INJ] XELJANZ XR [SP] YONDELIS [INJ] [SP] zidovudine [SP] zovia XEMBIFY [INJ] [SP] YONSA [SP] ZIEXTENZO [INJ] [SP] ZUBSOLV XERMELO [SP] YUPELRI zileuton ext-release ZULRESSO [INJ] [SP] XGEVA [INJ] [SP] yuvafem zinc chloride [INJ] zumandimine XIAFLEX [INJ] [SP] zinc sulfate [INJ] ZYDELIG [SP] XIFAXAN 550 MG TABLETS Z zingiber prenatal vitamins ZYKADIA [SP] XIGDUO XR ZIOPTAN ZYLET XIIDRA zafirlukast ziprasidone ZYTIGA 500 MG [SP] XOFIGO [INJ] [SP] zaleplon ziprasidone mesylate [INJ] XOLAIR [INJ] [SP] ZALTRAP [INJ] [SP] ZIRABEV [INJ] [SP] XOSPATA [SP] ZANOSAR [INJ] ZOLADEX [INJ] [SP]

Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 10 COMPBJCANP-20 (07/01/20) 2020 BJC HealthCare Preferred Drug List Exclusions The excluded medications shown below are not covered on the BJC HealthCare 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. Drug Class Excluded Medications Preferred Alternatives

ACTICLATE doxycycline tablets ANTIINFECTIVES DORYX MPC doxycycline hyclate dr capsules Antibiotics XIFAXAN 200 MG TABLETS azithromycin, ciprofloxacin, levofloxacin, ofloxacin

Antifungal Agents (Oral) TOLSURA itraconazole

Antivirals (Oral) SITAVIG acyclovir oral or cream, famciclovir, valacyclovir

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

Anticonvulsants TOPIRAMATE ER CAPSULES topiramate tablets, QUDEXY XR

Antimigraine Agents VYEPTI AIMOVIG, AJOVY, EMGALITY

amantadine capsules, amantadine tablets, GOCOVRI ER, OSMOLEX ER amantadine oral solution Antiparkinsonism Agents RYTARY carbidopa/levodopa

XADAGO, ZELAPAR rasagiline, selegiline

aripiprazole, olanzapine, quetiapine er, quetiapine fumarate, Antipsychotics (Oral) CAPLYTA risperidone, ziprasidone, LATUDA

Antispasmodic Agents OZOBAX baclofen, tizanidine

APTENSIO XR methylphenidate er capsules Attention Disorders QUILLICHEW ER methylphenidate er

dextroamphetamine er, dextroamphetamine/amphetamine er, Central Nervous System Stimulants AMPHETAMINE ER SUSPENSION DYANAVEL XR, MYDAYIS, QUILLIVANT XR, VYVANSE

EMFLAZA prednisone solution, prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51, VYONDYS 53 No alternatives recommended

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

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

Multiple Sclerosis (Oral) AUBAGIO GILENYA, MAYZENT, TECFIDERA, VUMERITY

APADAZ, BENZHYDROCODONE/ACETAMINOPHEN hydrocodone/acetaminophen Narcotic Analgesics & Combinations PRIMLEV oxycodone/acetaminophen

Narcotic Antagonists EVZIO, NALOXONE AUTO-INJECTOR naloxone syringes, NARCAN NASAL SPRAY

Neuropathic Agents GRALISE, LYRICA CR gabapentin, pregabalin

Sedative-Hypnotic Agents DORAL estazolam, lorazepam

Serotonin/Norepinephrine Reuptake Inhibitor DRIZALMA SPRINKLE desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA Antidepressants

Tardive Dyskinesia Therapy INGREZZA AUSTEDO

Continued

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AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) FENTANYL CITRATE BUCCAL TABLETS, FENTORA, fentanyl citrate lozenges Transmucosal Fentanyl Analgesics LAZANDA, SUBSYS

olanzapine/fluoxetine, bupropion, desvenlafaxine er, Miscellaneous Antidepressants SPRAVATO duloxetine, escitalopram, mirtazapine, sertraline

desmopressin acetate tablets, desmopressin acetate nasal, Miscellaneous Central Nervous System Agents NORTHERA fludrocortisone, indomethacin, midodrine, pyridostigmine

CARDIOVASCULAR EPANED enalapril ACE Inhibitors QBRELIS lisinopril

Anticoagulants PRADAXA, SAVAYSA ELIQUIS, XARELTO

KAPSPARGO SPRINKLE metoprolol succinate

Beta Blockers & Combinations metoprolol tartrate/hydrochlorothiazide, DUTOPROL metoprolol succinate er plus hydrochlorothiazide

Calcium Channel Blockers KATERZIA amlodipine

Diuretics CAROSPIR spironolactone

atorvastatin, fluvastatin er, lovastatin, pravastatin, HMG & Cholesterol Inhibitor Combinations ALTOPREV, EZALLOR SPRINKLE, SIMVASTATIN SUSPENSION rosuvastatin, simvastatin tablets, LIVALO

DERMATOLOGICAL MINOCYCLINE ER CAPSULES, XIMINO minocycline er tablets Oral Agents for Acne

Rosacea Agents (Oral) DOXYCYCLINE 40 MG CAPSULES ORACEA

Topical Acne Combinations EPIDUO FORTE adapalene/benzoyl peroxide

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

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

CLINDAGEL, Topical Antibiotics for Acne clindamycin phosphate gel, erythromycin gel, AMZEEQ CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE)

Topical , ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

betamethasone valerate, fluocinolone acetonide, CLOCORTOLONE triamcinolone acetonide Topical Corticosteroids desonide 0.05% cream/lotion/ointment, TOPICORT SPRAY, VERDESO FOAM desoximetasone 0.25% cream/ointment

Vitamin D Analogs (Topical) CALCIPOTRIENE FOAM calcipotriene, calcitriol

ALCORTIN A hydrocortisone, mupirocin Miscellaneous Topical Dermatological Agents LIDOCAINE/TETRACAINE lidocaine cream, lidocaine/prilocaine cream

FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE ASCENSIA (BREEZE, CONTOUR) FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, ROCHE (ACCU-CHEK) DIABETES FREESTYLE LITE TRIVIDIA (TRUETEST, TRUETRACK) Blood Glucose Meters & Test Strips ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, ALL OTHER METERS & TEST STRIPS VERIO FLEX THAT ARE NOT LISTED AS PREFERRED ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS

ALOGLIPTIN, NESINA, ONGLYZA JANUVIA, TRADJENTA

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

ALOGLIPTIN/PIOGLITAZONE pioglitazone plus JANUVIA or TRADJENTA

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

Continued

© 2020 Express Scripts. All Rights Reserved. #2884 All trademarks are the property of their respective owners. Page 12 DL44109Q-BJC-20 (07/01/2020) Drug Class Excluded Medications Preferred Alternatives

NOVOLIN, RELION NOVOLIN HUMULIN DIABETES (continued) ADMELOG, APIDRA, FIASP, INSULIN ASPART, Insulins HUMALOG INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG

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

CETRAXAL ciprofloxacin ear solution, ofloxacin ear solution, OTOVEL Otic Fluoroquinolone Antibiotics CIPROFLOXACIN/FLUOCINOLONE OTIC 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

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

Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT

AVEED testosterone cypionate, testosterone enanthate Testosterone Products JATENZO testosterone (gel, packets, pump), ANDRODERM

Thyroid Hormones TIROSINT levothyroxine tablets

Topical Estrogen Gels ESTROGEL DIVIGEL

Miscellaneous Endocrine Drugs KORLYM ketoconazole, LYSODREN, SIGNIFOR

AKYNZEO CAPSULES granisetron, ondansetron, aprepitant, VARUBI TABLETS GASTROINTESTINAL BONJESTA, DICLEGIS ondansetron, promethazine Antiemetics (Oral) EMEND POWDER PACKETS aprepitant, VARUBI TABLETS

DUEXIS famotidine plus ibuprofen Anti-Inflammatory/Anti-Ulcer Agents VIMOVO famotidine plus naproxen

Bowel Evacuants OSMOPREP peg-electrolyte solution, CLENPIQ, PREPOPIK, SUPREP

Corticosteroids (Rectal Formulations) CORTIFOAM hydrocortisone enema, UCERIS FOAM

Helicobacter Pylori Agents PYLERA lansoprazole/amoxicillin/clarithromycin, TALICIA

balsalazide disodium, mesalamine dr, mesalamine er, Inflammatory Bowel Agents DIPENTUM sulfasalazine, PENTASA

Pancreatic Enzymes PANCREAZE, PERTZYE CREON, ZENPEP

ACIPHEX SPRINKLE, ESOMEPRAZOLE STRONTIUM, esomeprazole magnesium, lansoprazole, omeprazole, Proton Pump Inhibitors PRILOSEC SUSPENSION, PROTONIX SUSPENSION, pantoprazole, rabeprazole RABEPRAZOLE DR SPRINKLE

HEMATOLOGICAL aspirin plus omeprazole, esomeprazole, lansoprazole, ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR Antiplatelet Agents pantoprazole or rabeprazole

Chelating Agents JADENU, JADENU SPRINKLE deferasirox

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

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

Granulocyte Colony Stimulating Factors GRANIX, NEUPOGEN NIVESTYM, ZARXIO

OXBRYTA hydroxyurea, ADAKVEO, DROXIA Sickle Cell Disease Agents SIKLOS DROXIA

MULPLETA DOPTELET Thrombocytopenia Agents TAVALISSE DOPTELET, PROMACTA, NPLATE

Continued

© 2020 Express Scripts. All Rights Reserved. #2884 All trademarks are the property of their respective owners. Page 13 DL44109Q-BJC-20 (07/01/2020) Drug Class Excluded Medications Preferred Alternatives

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

BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, ATRIPLA, DELSTRIGO TRIUMEQ

HIV COMPLERA ODEFSEY Antiretrovirals Note: Current patients established on therapy PIFELTRO efavirenz, EDURANT are allowed to continue therapy. PREZCOBIX atazanavir, ritonavir, KALETRA TABLETS, PREZISTA

STRIBILD BIKTARVY, GENVOYA

MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE CAPSULES colchicine tablets, MITIGARE Gout Therapy

fenoprofen calcium tablets, diclofenac, ibuprofen, FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES indomethacin, meloxicam, nabumetone, naproxen

INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY, diclofenac, etodolac, ibuprofen, indomethacin, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX meloxicam, nabumetone, naproxen, piroxicam

nabumetone, diclofenac, ibuprofen, indomethacin, RELAFEN DS meloxicam, naproxen, piroxicam

Steroid Anti-Inflammatory RAYOS prednisone

Topical Analgesics ZTLIDO lidocaine transdermal patches

DICLOFENAC EPOLAMINE PATCHES FLECTOR PATCHES Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) PENNSAID diclofenac sodium topical, FLECTOR PATCHES

OBSTETRICAL & GYNECOLOGICAL CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL Human Chorionic Gonadotropin

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

ONCOLOGY ALECENSA If medically necessary, request prior authorization. ALK Positive Lung Cancer Agents

Bevacizumab-Containing Agents AVASTIN MVASI, ZIRABEV

Breast Cancer Agents KISQALI, KISQALI FEMARA CO-PACK, PIQRAY IBRANCE, VERZENIO

DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, Multiple Myeloma Agents XPOVIO THALOMID, VELCADE

Myelofibrosis Agents INREBIC JAKAFI

Prostate Cancer TRELSTAR ELIGARD, FIRMAGON

Rituximab-Containing Agents RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE

Trastuzumab-Containing Agents HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, OGIVRI KANJINTI, TRAZIMERA

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

bimatoprost drops, latanoprost drops, travoprost drops, Antiglaucoma Drugs (Ophthalmic Prostaglandins) XELPROS ZIOPTAN

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

dexamethasone drops, fluorometholone drops, Ophthalmic Anti-Inflammatory FML FORTE, FML S.O.P., MAXIDEX, PRED MILD loteprednol drops, prednisolone drops, INVELTYS, LOTEMAX GEL/OINTMENT

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

Continued

© 2020 Express Scripts. All Rights Reserved. #2884 All trademarks are the property of their respective owners. Page 14 DL44109Q-BJC-20 (07/01/2020) Drug Class Excluded Medications Preferred Alternatives

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

OSTEOPOROSIS alendronate, ibandronate, risedronate, zoledronic acid, EVENITY, PROLIA Bone Modifiers FORTEO, TYMLOS

RENAL DISEASE PROCYSBI CYSTAGON Nephropathic Cystinosis Medications

lanthanum, sevelamer carbonate, sevelamer hcl, Phosphate Binders FOSRENOL POWDER PACKETS PHOSLYRA, VELPHORO

RESPIRATORY AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX) epinephrine auto-injector (by Mylan), EPIPEN, EPIPEN JR Epinephrine Auto-Injector Systems

Immunological Agents for Asthma CINQAIR FASENRA, NUCALA

Long-Acting Beta Agonist Inhalers STRIVERDI RESPIMAT SEREVENT DISKUS

Long-Acting Muscarinic Antagonist Inhalers TUDORZA PRESSAIR INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT

Long-Acting Muscarinic Antagonist/ DUAKLIR PRESSAIR ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT Long-Acting Beta-Agonist Combination Inhalers

Pulmonary Anti-Inflammatory/ BUDESONIDE/FORMOTEROL ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT Beta-Agonist Combination Inhalers

ALBUTEROL SULFATE HFA (BY A-S , PRASCO), albuterol sulfate hfa (by Cipla, Par, Perrigo, Proficient Rx & Short-Acting Beta -Agonist Inhalers LEVALBUTEROL HFA, PROAIR DIGIHALER, PROVENTIL HFA, 2 Teva), PROAIR HFA/RESPICLICK, VENTOLIN HFA XOPENEX HFA

MISCELLANEOUS AGENTS NOCTIVA desmopressin tablets

Allergen Immunotherapy PALFORZIA No alternatives recommended

Cough and Cold Products TUSSICAPS generic tussionex

Hereditary Angioedema BERINERT RUCONEST

Immune Globulins HIZENTRA SYRINGES HIZENTRA VIALS, XEMBIFY

Immunosuppressant Agents ENVARSUS XR, XATMEP methotrexate

Polyneuropathy of Hereditary ONPATTRO TEGSEDI Transthyretin-Mediated Amyloidosis

Potassium Binders VELTASSA LOKELMA

Indication Based Management Drug Class Excluded Medications Preferred Alternatives

COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SC, INFLAMMATORY CONDITIONS TALTZ TREMFYA

Drug Class Nonpreferred Medications Preferred Alternatives

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted following a coverage review. A trial of one or more Preferred ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, INFLAMMATORY CONDITIONS‡ medications is required prior to initiating therapy with a RINVOQ ER, SIMPONI 100 MG (FOR ULCERATIVE COLITIS Nonpreferred medication. A formulary exception may be ONLY), SKYRIZI, 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.

Continued

© 2020 Express Scripts. All Rights Reserved. #2884 All trademarks are the property of their respective owners. Page 15 DL44109Q-BJC-20 (07/01/2020) Excluded Medications/Products at a Glance

ABILIFY^ DOXYCYCLINE 40 MG CAPSULES LULICONAZOLE SIMVASTATIN SUSPENSION ACANYA^ DRIZALMA SPRINKLE LUNESTA^ SINGULAIR^ ACIPHEX^ DUAKLIR PRESSAIR LYRICA^ SITAVIG ACIPHEX SPRINKLE DUEXIS LYRICA CR SODIUM HYALURONATE ACTICLATE DUROLANE MAVYRET SOFOSBUVIR/VELPATASVIR ACUVAIL DUTOPROL MAXALT^, MAXALT MLT^ SOVALDI ADCIRCA^ EFFEXOR XR^ MAXIDEX SPRAVATO ADDERALL^ ELIDEL^ MICARDIS^, MICARDIS HCT^ STRATTERA^ ADLYXIN EMBEDA MINASTRIN 24 FE^ STRIBILD ADMELOG EMEND CAPSULES^, TRIFOLD PACK^ MINOCYCLINE ER CAPSULES STRIVERDI RESPIMAT AGGRENOX^ EMEND POWDER PACKETS MIRCERA SUBSYS AKYNZEO CAPSULES EMFLAZA MULPLETA SULCONAZOLE ALBUTEROL SULFATE HFA ENVARSUS XR NALFON CAPSULES SUPARTZ FX (BY A-S MEDICATION, PRASCO) EPANED NALOXONE AUTO-INJECTOR SYNVISC, SYNVISC-ONE ALCORTIN A EPIDUO^ NAMENDA XR^ TALTZ ALECENSA EPIDUO FORTE NASONEX^ TARGRETIN CAPSULES^ ALOCRIL EPINEPHRINE AUTO-INJECTOR (BY IMPAX) NESINA TAVALISSE ALOGLIPTIN EPOGEN NEUPOGEN TESTIM^ ALOGLIPTIN/METFORMIN ESOMEPRAZOLE STRONTIUM NEURONTIN^ TIKOSYN^ ALOGLIPTIN/PIOGLITAZONE ESTROGEL NEVANAC TIMOPTIC OCUDOSE ALOMIDE EVENITY NOCTIVA TIROSINT ALTOPREV EVZIO NORCO^ TIVORBEX AMBIEN^, AMBIEN CR^ EXFORGE^, EXFORGE HCT^ NORTHERA TOBI SOLUTION^ AMPHETAMINE ER SUSPENSION EXJADE^ NORVASC^ TOLSURA AMPYRA^ EXONDYS 51 NOVOLIN TOPAMAX^ AMRIX^ EXTAVIA NOVOLOG TOPICORT SPRAY ANDROGEL 1%^ EZALLOR SPRINKLE NOXAFIL TABLETS^ TOPIRAMATE ER CAPSULES ANUSOL-HC^ FEMRING NUTROPIN AQ NUSPIN TOPROL XL^ APADAZ FENOPROFEN CAPSULES NUVIGIL^ TRANSDERM-SCOP^ APIDRA FENORTHO NUWIQ TRELSTAR APTENSIO XR FENTANYL CITRATE BUCCAL TABLETS OGIVRI TREXIMET^ ARANESP FENTORA OMNARIS TRIBENZOR^ ARIMIDEX^ FIASP OMNITROPE TRICOR^ ASACOL HD^ FIRAZYR^ ONGLYZA TRILEPTAL^ ASCENSIA (BREEZE, CONTOUR) FLUOROURACIL 0.5% CREAM ONPATTRO TRILURON ASPIRIN/OMEPRAZOLE DR FML FORTE, FML S.O.P. ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ TRIVIDIA (TRUETEST, TRUETRACK) ATACAND^, ATACAND HCT^ FOCALIN^, FOCALIN XR^ OSMOLEX ER TRIVISC ATRALIN^ FOLLISTIM AQ OSMOPREP TRUXIMA ATRIPLA FOSRENOL CHEWABLE TABLETS^ OXBRYTA TUDORZA PRESSAIR AUBAGIO FOSRENOL POWDER PACKETS OXYCODONE ER TUSSICAPS AUVI-Q GANIRELIX ACETATE^ OZOBAX ULORIC^ AVALIDE^, AVAPRO^ GEL-ONE PALFORZIA UROXATRAL^ AVASTIN GELSYN-3 PANCREAZE VAGIFEM^ AVEED GENVISC 850 PATADAY^ VALIUM^ AVODART^ GLEEVEC^ PENNSAID VALTREX^ AZOR^ GLUCOPHAGE^, GLUCOPHAGE XR^ PERCOCET^ VANOS^ BARACLUDE TABLETS^ GLUMETZA^ PERTZYE VELTASSA BECONASE AQ GOCOVRI ER PIFELTRO VELTIN BENICAR^, BENICAR HCT^ GRALISE PIQRAY VERDESO FOAM BENZHYDROCODONE/ACETAMINOPHEN GRANIX PLAQUENIL^ VESICARE^ BERINERT HERCEPTIN, HERCEPTIN HYLECTA PLAVIX^ VIAGRA^ BONJESTA HERZUMA PRADAXA VICTOZA BRISDELLE^ HIZENTRA SYRINGES PRAVACHOL^ VIMOVO BUDESONIDE/FORMOTEROL HUMATROPE PRED MILD VISCO-3 BUPAP^ HYALGAN PREGNYL VIVELLE-DOT^ BUTRANS^ HYMOVIS PREVACID^, PREVACID SOLUTAB^ VIVLODEX CALCIPOTRIENE FOAM IMIQUIMOD 3.75% CREAM PUMP PREZCOBIX VYEPTI CAPLYTA IMITREX^ PRILOSEC SUSPENSION VYONDYS 53 CARAC INDERAL LA^ PRIMLEV VYTORIN^ CAROSPIR INDOMETHACIN 20 MG CAPSULES PRISTIQ^ WELLBUTRIN SR^ CELEBREX^ INGREZZA PROAIR DIGIHALER XADAGO CELEXA^ INREBIC PROCYSBI XALATAN^ CETRAXAL INSULIN ASPART, INSULIN ASPART PROTAMINE PROLIA XANAX^, XANAX XR^ CHORIONIC GONADOTROPIN INSULIN LISPRO PROTONIX^ XATMEP CIALIS^ INTUNIV^ PROTONIX SUSPENSION XELPROS CINQAIR ISTALOL^ PROVENTIL HFA XENAZINE^ CIPROFLOXACIN/FLUOCINOLONE OTIC JADENU, JADENU SPRINKLE PROVIGIL^ XIFAXAN 200 MG TABLETS CLIMARA PRO JATENZO PROZAC^ XIMINO CLINDAGEL KAPSPARGO SPRINKLE PULMICORT RESPULES^ XOPENEX HFA CLINDAMYCIN PHOSPHATE 1% GEL KATERZIA PYLERA XPOVIO (BY OCEANSIDE) KAZANO QBRELIS XTAMPZA ER CLOCORTOLONE KEPPRA^, KEPPRA XR^ QUILLICHEW ER XYNTHA, XYNTHA SOLOFUSE COLCHICINE CAPSULES KETOROLAC NASAL SPRAY RABEPRAZOLE DR SPRINKLE YASMIN^ COMPLERA KISQALI, KISQALI FEMARA CO-PACK RANEXA^ YOSPRALA DR COREG^ KOMBIGLYZE XR RAPAFLO^ ZAVESCA^ CORTIFOAM KORLYM RAYOS ZEGERID^ COSOPT^ LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ RECOMBINATE ZELAPAR COZAAR^, HYZAAR^ LAZANDA RELAFEN DS ZETIA^ CRESTOR^ LEDIPASVIR/SOFOSBUVIR RELION NOVOLIN ZETONNA CUPRIMINE^ LETAIRIS^ RENAGEL^ ZIPSOR CYMBALTA^ LEVALBUTEROL HFA RITUXAN, RITUXAN HYCELA ZOCOR^ CYTOMEL^ LEXAPRO^ ROCHE (ACCU-CHEK) ZOLOFT^ DELSTRIGO LIBRAX^ ROZEREM^ ZOMACTON DELZICOL^ LIDOCAINE/TETRACAINE RYTARY ZOMIG TABLETS^, ZOMIG ZMT^ DETROL^, DETROL LA^ LIDODERM^ SAIZEN, SAIZENPREP ZONEGRAN^ DICLEGIS LIPITOR^ SANDOSTATIN LAR DEPOT ZORVOLEX DICLOFENAC EPOLAMINE PATCHES LOCOID^, LOCOID LIPOCREAM^ SAVAYSA ZOVIRAX OINTMENT^ DIOVAN^, DIOVAN HCT^ LOESTRIN^, LOESTRIN FE^ SENSIPAR^ ZTLIDO DIPENTUM LOTREL^ SEROQUEL^, SEROQUEL XR^ ZYCLARA DORAL LOVENOX^ SIGNIFOR LAR ZYTIGA 250 MG^ DORYX MPC LUCEMYRA SIKLOS ^ 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.

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