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-drug benefit 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.

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-drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for CLINICAL FOCUS (2020) your prescription-drug benefit program. For specific questions about your coverage, please call the phone number printed on your member ID card.

A . ATRIPLAQL, † cinacalcet hclPA, † donepezil hclQL FLOVENT HFAQL I . abiraterone acetateQL, PA, ATROVENT HFAQL CIPRODEX dorzolamide hcl-timolol fluconazole ibandronate sodiumQL, PA, † AUBAGIOQL, PA, † ciprofloxacin hcl mal acetate † acetaminophen-codeine AZASITE ciprofloxacin doxazosin mesylate fluocinonide ICLUSIGQL, PA, † ACTEMRAPA, † azathioprine citalopram doxepin hcl ILEVRO acyclovir azelaic acidAE hydrobromideQL doxycycline hyclate fluorouracil† imatinib mesylateQL, PA, † adapalene-benzoyl azelastine hcl clarithromycin doxycycline fluoxetine hcl indomethacin peroxideAE azithromycin clindamycin hcl monohydrate -salmeterolQL INLYTAQL, PA, † ADEMPASQL, PA, † clindamycin phos- DUAVEEQL fluvoxamine maleate ipratropium bromide ADVAIR DISKUSQL B . benzoyl peroxAE duloxetine hclQL folic acid ipratropium-albuterol ADVAIR HFAQL baclofen clindamycin phosphate DUPIXENTQL, PA, † FORTEOQL, PA, † irbesartan- AFSTYLA† benazepril hcl propionate dutasterideQL FRAGMINQL hydrochlorothiazide AIMOVIGQL, PA, † benazepril- clonazepam DYMISTAQL furosemide irbesartan AJOVYQL, PA, † hydrochlorothiazide clonidine hcl FYCOMPAQL IRESSAQL, PA, † AKYNZEOQL, PA BEPREVE clonidine E . isosorbide dinitrate albuterol sulfate BESIVANCEST clopidogrel bisulfate econazole nitrate G . isosorbide mononitrate alendronate sodium BETASERONQL, PA, † clotrimazole- ELIQUISQL gabapentin er alfuzosin hcl er BETHKISQL, PA, † ELMIRON GELNIQUE isotretinoinAE aliskiren fumarateQL bimatoprostST clotrimazole EMGALITYQL, PA, †, AE gemfibrozil allopurinol bisoprolol- COLCRYSQL enalapril maleate GENERESS FE J . ALPHAGAN P hydrochlorothiazide colestipol hcl enalapril- GENOTROPINPA, † JANUMET XRQL alprazolam bosentanQL, PA, † COMBIGAN hydrochlorothiazide gentamicin sulfate JANUMETQL ALREX BREO ELLIPTAQL COMBIPATCHQL ENBRELQL, PA, † GENVOYAQL, † JANUVIAQL ambrisentanQL, PA, † BRILINTAQL COMBIVENT ENJUVIA GILENYAQL, PA, † JARDIANCEQL amiodarone hcl brimonidine tartrate RESPIMATQL enoxaparin sodium GILOTRIFQL, PA, † AMITIZAQL, PA er CORLANORQL, PA ENSTILARQL glatiramer acetateQL, PA, † K . amitriptyline hcl budesonideQL COSENTYXPA, † ENTRESTOQL, PA glatopaQL, PA, † KALBITORPA, † amlodipine besy- buprenorphineQL CREON EPIDUO FORTEAE glimepiride benazepril hclST bupropion hcl er CRINONE epinephrineQL [INJ] glipizide er ketorolac tromethamine amlodipine besylate- (smoking det)QL cyanocobalamin [INJ] EPIPEN 2-PAKQL [INJ] glipizide xl KISQALI 200 DOSEQL, PA, † valsartanQL, ST bupropion hcl er (sr) cyclobenzaprine hcl EPIPEN JR 2-PAKQL glipizide KISQALI 400 DOSEQL, PA, amlodipine besylate bupropion hcl er (xl) cyproheptadine hcl [INJ] GLUCAGON † amoxicillin-pot bupropion hcl ergocalciferol EMERGENCYQL [INJ] KISQALI 600 DOSEQL, PA, clavulanate buspirone hcl D . erlotinib hclQL, PA, † glyburide † amoxicillin butalbital-apap- dalfampridine erQL, PA, † erythromycin GLYXAMBIQL KITABIS PAKQL, PA, † amphetamine sulfateQL, caffeineQL DALIRESPQL, PA escitalopram oxalate GONAL-F RFF† KOVALTRY† AE butalbital-asa-caffeineQL DAYTRANAQL, AE esomeprazole GONAL-F† [INJ] amphetamine- BYSTOLICQL, ST DESCOVYQL, † magnesiumQL, ST GRANIXPA, † L . dextroamphet erAE desloratadineQL estradiolQL guanfacine hcl erQL labetalol hcl amphetamine- C . ESTROSTEP FE guanfacine hcl lactulose dextroamphetamineAE cabergoline desvenlafaxine eszopicloneQL, ST lamotrigine anastrozole calcitriol succinate erQL, ST etodolac H . lansoprazole ANORO ELLIPTAQL CANASA EUFLEXXAQL, PA, † HUMIRAPA, † LANTUS aprepitantQL carbamazepine dexmethylphenidate hcl exemestane hydralazine hcl latanoprost APRISOQL carbidopa-levodopa er erQL, AE ezetimibe-simvastatinQL, hydrochlorothiazide LATUDAQL ARCAPTA NEOHALERQL carbidopa-levodopa dexmethylphenidate ST hydrocodone- LAZANDAQL, PA aripiprazoleQL carvedilol hclQL, AE ezetimibeQL, ST acetaminophen leflunomide ARISTADAQL, PA cefadroxil diazepam hydrocodone-ibuprofen letrozole armodafinilQL, PA cefdinir diclofenac sodium F . LEVEMIR ARMOUR THYROID cefuroxime axetil dicyclomine hcl FARXIGAQL hydromorphone hcl levetiracetam ARNUITY ELLIPTAQL celecoxibQL digoxin febuxostat hydroxychloroquine levocetirizine ASMANEX HFAQL cephalexin diltiazem hcl er fenofibrate micronizedQL sulfate dihydrochloride atenolol-chlorthalidone CETROTIDEPA, † diphenoxylate-atropine fentanylQL hydroxyzine hcl levofloxacin atenolol CHANTIXQL divalproex sodium er FETZIMAQL hyoscyamine sulfate levothyroxine sodium atomoxetine hclQL, AE chlorhexidine gluconate divalproex sodium finasteride HYSINGLA ERQL viscous hcl atorvastatin calcium ciclopirox DIVIGEL FLOVENT DISKUSQL lidocaineQL

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©2020 All Rights Reserved THIS DOCUMENT LIST IS EFFECTIVE 1/1/2020 THROUGH 12/31/2020. UPDATED ON 1/1/2020. THIS LIST IS SUBJECT TO CHANGE. LINZESSQL, PA NEUPOGENPA, † [INJ] potassium citrate er solifenacin succinateQL, TRUVADAQL, † liothyronine sodium NEVANAC pramipexole ST TYMLOSQL, PA, † lisinopril nifedipine er dihydrochloride SOMATULINE DEPOTQL, lithium carbonate er nitrofurantoin prasugrel hclQL PA, † U . lithium carbonate nitroglycerin pravastatin sodium sotalol hcl UPTRAVIQL, PA, † LIVALOQL, ST nortriptyline hcl prazosin hcl SPIRIVA HANDIHALERQL LO LOESTRIN FE NOVOEIGHT† SPIRIVA RESPIMATQL V . lorazepam NOVOLIN 70/30 spironolactone valacyclovir hcl losartan potassium-hctz NOVOLIN N pregabalinQL, ST SPRYCELQL, PA, † valsartan- losartan potassium NOVOLIN R [INJ] PREMARINQL STELARAPA, † hydrochlorothiazide etabonate NOVOLOG FLEXPEN PREMPROQL STIOLTO RESPIMATQL valsartan lovastatin NOVOLOG PREPOPIK STRIBILDQL, † VELTASSAQL LUMIGANST NOXAFILPA PROAIR HFAQL SUBOXONEQL venlafaxine hcl er NUCALAPA, † PROAIR RESPICLICKQL sucralfate venlafaxine hcl M . NUCYNTA ERQL prochlorperazine sulfamethoxazole- verapamil hcl er MAKENAQL, † NUCYNTAQL PROCRITPA, † [INJ] trimethoprim VIBERZIQL, PA MAVYRETQL, PA, † NUVARINGQL sulfasalazine VICTOZAQL, PA meclizine hcl nystatin micronized sumatriptanQL VIIBRYDQL, ST medroxyprogesterone progesterone SUPREP BOWEL PREP VIMPATQL acetateQL O . PROLENSA KIT VIOKACE meloxicam OFEVQL, PA, † promethazine hcl SYMBICORTQL VIREADQL, † memantine hcl erQL, ST olanzapineQL promethazine-codeine SYNJARDY XRQL VIVITROLPA, † memantine hclQL olmesartan medoxomil- promethazine-dm SYNJARDYQL VYVANSEQL, AE mercaptopurine hctzQL, ST propranolol hcl er SYNTHROID mesalamineQL olmesartan propranolol hcl W . metformin hcl erQL medoxomilQL, ST PULMICORT T . warfarin sodium metformin hcl olmesartan-amlodipine- FLEXHALERQL TACLONEX wixela inhubQL methadone hcl hctzQL, ST tacrolimus methimazole olopatadine hcl Q . tadalafilQL X . methocarbamol omega-3-acid ethyl QNASLQL tamoxifen citrate XARELTOQL methotrexate estersQL quetiapine fumarate erQL tamsulosin hcl XELJANZ XRQL, PA, † methylphenidate hcl ondansetron quetiapine fumarateQL TAZORACAE XELJANZQL, PA, † erQL, AE ONETOUCH ULTRA quinapril hcl TECFIDERAQL, PA, † XIFAXANQL, PA methylphenidate hclQL, AE BLUEQL QVAR REDIHALERQL TEKTURNA HCTQL, ST XIGDUO XRQL ONETOUCH VERIOQL temazepam XIIDRAQL, PA metoclopramide hcl OPDIVOPA, † R . tenofovir disoproxil XOLAIRPA, † metoprolol succinate er ORTHOVISCQL, PA, † raloxifene hclQL fumarateQL, † XULTOPHYQL metoprolol tartrate oseltamivir phosphateQL ramipril terazosin hcl metronidazole OTEZLAQL, PA, † ranolazine erQL terbinafine hcl Z . MINIVELLEQL oxcarbazepine rasagiline mesylateQL terconazole zaleplon minocycline hcl oxybutynin chloride er RASUVOQL, PA, † testosterone cypionate ZENPEP MIRENA (52 MG) oxybutynin chloride REBIFQL, PA, † testosteronePA zolmitriptanQL mirtazapine oxycodone hcl RELISTORQL, PA timolol maleate zolpidem tartrate erQL, ST MIRVASOQL, PA oxycodone- REMICADEPA, † TIVICAYQL, † zolpidem tartrateQL misoprostol acetaminophenQL REPATHAQL, PA, † tizanidine hclQL ZOMIGQL modafinilQL, PA OXYCONTINQL RESTASISQL, PA TOBI PODHALERQL, PA, † zonisamide furoate OZEMPICQL, PA REVLIMIDQL, PA, † TOBRADEX ST ZONTIVITYQL MONOVISCQL, PA, † risperidone tobramycin- ZYLET montelukast sodium P . ritonavirQL, † dexamethasone morphine sulfate erQL paliperidone erQL rizatriptan benzoateQL tobramycin morphine sulfate pantoprazole sodium ropinirole hcl erQL tolterodine tartrate erQL, MOVANTIKQL, PA paroxetine hcl erST ropinirole hcl ST MOXEZAST paroxetine hcl rosuvastatin calciumQL, ST tolterodine tartrate moxifloxacin hclST PAZEO topiramate mupirocin peg 3350/electrolytes S . TOUJEO SOLOSTAR mycophenolate mofetil penicillin v potassium SANCUSOQL, PA TOVIAZQL, ST MYRBETRIQQL, ST PENTASA SAVELLAQL tramadol hcl PERFOROMIST SEREVENT DISKUSQL tramadol- N . permethrin sertraline hcl acetaminophen nabumetone phenazopyridine hcl sevelamer carbonate TRAVATAN ZST naltrexone hclQL phenytoin SIGNIFOR LARQL, PA, † trazodone hcl NAMZARICQL, ST pimecrolimus SIGNIFORQL, PA, † TRESIBA FLEXTOUCH naproxen pioglitazone hcl sildenafil citrateQL acetonide naratriptan hclQL polymyxin b- silodosin triamterene-hctz NARCAN trimethoprim simvastatin triazolam neomycin-polymyxin-hc posaconazolePA sodium fluoride TRIUMEQQL, † NEULASTAPA, † potassium chloride er sodium sulfacetamide TRULICITYQL, PA

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©2020 All Rights Reserved THIS DOCUMENT LIST IS EFFECTIVE 1/1/2020 THROUGH 12/31/2020. UPDATED ON 1/1/2020. THIS LIST IS SUBJECT TO CHANGE. Examples of Excluded Medications with Selected Formulary Alternatives The following is a list of some excluded brand-name medications with examples of selected covered formulary alternatives. This is not an all-inclusive list.

Excluded Medication(s) Selected Preferred Alternative(s) ACANYA and ONEXTON (clindamycin phosphate-benzoyl peroxide) clindamycin and benzoyl peroxide (separate agents) ADMELOG (insulin lispro) NOVOLOG AEROSPAN () ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL AIRDUO (fluticasone-salmeterol 55-14 mcg, 113-14 mcg, 232-14 mcg) fluticasone-salmeterolQL (100-50 mcg, 250-50 mcg, 500-50 mcg), wixelaQL, ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL ALVESCO () ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL APIDRA, APIDRA SOLOSTAR (insulin glulisine) NOVOLOG AUVI-Q (epinephrine solution) epinephrine 0.15 mgQL, epinephrine 0.3 mgQL, EPIPENQL, EPIPEN JRQL BASAGLAR (insulin glargine) LANTUS, LEVEMIR, TOUJEO, TRESIBA BELSOMRA (suvorexant) zolpidem IRQL, zaleplon BONJESTA and DICLEGIS (doxylamine-pyridoxine) OTC doxylamine and OTC pyridoxine BRAVELLE† (urofollitropin) GONAL-F†, GONAL-F RFF† BYETTA (exenatide) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL BYDUREON (exenatide extended-release) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL CAMBIA (diclofenac) diclofenac sodium DR DENAVIR (penciclovir) acyclovir ointment DEXILANT (dexlansoprazole) lansoprazole, omeprazole, pantoprazole DIABETES TEST STRIPS (e.g., Accu-Chek, Ascensia, Breeze, Contour, ONETOUCHQL Freestyle, etc.) DORYX (doxycycline hyclate DR) doxycycline hyclate DULERA (mometasone-formoterol) fluticasone-salmeterolQL (100-50 mcg, 250-50 mcg, 500-50 mcg), wixelaQL, ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL DUREZOL () ophth solution EXTAVIA† BETASERON† PA QL, REBIF† PA QL FOLLISTIM AQ† (follitropin beta) GONAL-F†, GONAL-F RFF† FORFIVO XL (bupropion ER) bupropion ER GLUMETZA and FORTAMET (metformin ER modified/osmotic) metformin ER (generic Glucophage XR) GRALISE (gabapentin) gabapentin HORIZANT (gabapentin ER) gabapentin HUMALOG(insulin lispro) NOVOLOG HUMULIN N(insulin isophane), HUMULIN R (insulin regular), NOVOLIN N, NOVOLIN R, NOVOLIN 70/30 HUMULIN 70/30 (insulin NPH and regular) INCRUSE ELLIPTA (umeclidinium) SPIRIVAQL INVOKANA (canagliflozin) FARXIGAQL, JARDIANCEQL INVOKAMET (canagliflozin-metformin), INVOKAMET XR SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL (canagliflozin-metformin ER) JENTADUETO,JENTADUETO XR (linagliptin and metformin) JANUMETQL, JANUMET XRQL JUBLIA (eficonazole) ciclopirox KAZANO (alogliptin-metformin) JANUMETQL, JANUMET XRQL KERYDIN (tavaborole) ciclopirox KOMBIGLYZE XR (saxagliptin-metformin ER) JANUMETQL, JANUMET XRQL NASCOBAL (cyanocobalamin nasal) OTC vitamin B12 NESINA (alogliptin) JANUVIAQL NORDITROPIN† (somatropin) GENOTROPIN†, PA

(Continued)

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©2020 All Rights Reserved THIS DOCUMENT LIST IS EFFECTIVE 1/1/2020 THROUGH 12/31/2020. UPDATED ON 1/1/2020. THIS LIST IS SUBJECT TO CHANGE. Excluded Medication(s) Selected Preferred Alternative(s) ONGLYZA (saxagliptin) JANUVIAQL OSENI (alogliptin-pioglitazone) JANUVIAQL and pioglitazone PANCREAZE (pancrelipase DR) CREON, ZENPEP PERTZYE (pancrelipase DR) CREON, ZENPEP PROVENTIL HFA (albuterol) PROAIR HFAQL QTERN (dapagliflozin-saxagliptin) GLYXAMBIQL SEGLUROMET (ertugliflozin-metformin) SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL STEGLATRO (ertugliflozin) FARXIGAQL, JARDIANCEQL STEGLUJAN (ertugliflozin-sitagliptin) GLYXAMBIQL SOLARAZE (diclofenac 3% gel) Fluorouracil 5% cream SOLIQUA (insulin glargine-lixisenatide) XULTOPHYPA QL SOLODYN (minocycline ER) minocycline SOOLANTRA (ivermectin cream) metronidazole cream TIROSINT (levothyroxine) levothyroxine, SYNTHROID TRADJENTA (linagliptin) JANUVIAQL TREXIMET (sumatriptan-naproxen) sumatriptanQL and naproxen (separate agents) TUDORZA PRESSAIR (aclidinium) SPIRIVAQL VENTOLIN HFA (albuterol sulfate) PROAIR HFAQL VIMOVO (esomeprazole-naproxen) OTC esomeprazole and OTC naproxen XOPENEX HFA (levalbuterol) PROAIR HFAQL ZEGERID (omeprazole-sodium bicarbonate) OTC omeprazole-sodium bicarbonate ZIANA and VELTIN (clindamycin phosphate-tretinoin) clindamycin and tretinoinAE (separate agents) ZIOPTAN (tafluprost) latanoprost ZORVOLEX (diclofenac) diclofenac sodium DR ZOVIRAX CREAM acyclovir ointment

For the member: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the US Food and Drug Administration (FDA) may not be [INJ] = Injectable Drug covered upon release to market.

ER = Extended-Release WellDyneRx may contact your provider after receiving a prescription to request consideration of a drug list product or generic equivalent. This may result in your provider prescribing, when medically appropriate, a different brand-name DR = Delayed Release product or generic equivalent in place of the original prescription. Generic medications contain the same active ingredi- ents as their corresponding brand-name medications, although they may look different in color or shape. They have been AE = Age Edit FDA-approved under strict standards.

KEY LD = Limited Distribution In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-pre- ferred or excluded option upon release of the generic product to the market. PA = Prior Authorization

QL = Quantity Limits For the physician: Generics should be considered the first-line of prescribing. Please prescribe preferred products and allow generic substitutions when medically appropriate. Brand-name drugs are listed in CAPITAL letters; generic drugs are listed in lower case ST = Step Therapy letters.

† Indicates specialty medications This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to market.

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©2020 All Rights Reserved THIS DOCUMENT LIST IS EFFECTIVE 1/1/2020 THROUGH 12/31/2020. UPDATED ON 1/1/2020. THIS LIST IS SUBJECT TO CHANGE.