Healthchoice Standard Medication List Is a Guide Within Select Therapeutic Categories for Clients, Plan Members and Health Care Providers

July 2021 HealthChoice Standard Medication

List

The HealthChoice Standard Medication List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand -name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all -inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER HEALTH CARE PROVIDER HealthChoice provides you with prescription benefits administered by Your patient is covered under HealthChoice prescription benefits CVS Caremark®. Ask your doctor to consider prescribing, when administered by CVS Caremark. As a way to help manage health medically appropriate, a preferred medicine from this list. Take this care costs, we encourage you to authorize generic substitutions list along when you or a covered family member sees a doctor. whenever possible. If you believe a brand -name product is necessary, consider prescribing a brand -name product on this list.

Please note: Please note: • Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in • This drug list represents a summary of prescription coverage. It is this document. Products recently approved by the U.S. not all-inclusive and does not guarantee coverage. HealthChoice Food and Drug Administration (FDA) may not be covered prescription benefits may not cover certain products or upon release to the market. categories, regardless of their appearance in this document. • You may be responsible for the full cost of non -formulary Products recently approved by the FDA may not be covered products that are removed from coverage. upon release to the market. • For specific information regarding your prescription benefit • HealthChoice may have a different copay 1 for specific products coverage and copay1 information, please visit Caremark.com on the list. or contact a CVS Caremark Customer Care representative • Unless specifically indicated, drug list products will include all at 1-877-720-9375. If you have a hearing impairment dosage forms. and need telecommunications device (TDD) assistance, • Log on to Caremark.com to check coverage and copay please dial 1-800-863-5488. information for a specific medicine. • CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand -name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.

ANALGESICS § COX-2 INHIBITORS hydromorphone ANTI-INFECTIVES § FLUOROQUINOLONES celecoxib hydromorphone ext-rel ciprofloxacin § NSAIDs ANTIBACTERIALS methadone levofloxacin § GOUT diclofenac sodium morphine § CEPHALOSPORINS moxifloxacin ibuprofen allopurinol morphine ext-rel cefdinir meloxicam colchicine tablet morphine suppository cefprozil § PENICILLINS naproxen (except naproxen CR or probenecid oxycodone cefuroxime axetil amoxicillin naproxen suspension) MITIGARE oxycodone-acetaminophen cephalexin amoxicillin-clavulanate

tramadol (except NDC^ 52817019610) SUPRAX dicloxacillin § NSAIDs, COMBINATIONS § OPIOID ANALGESICS tramadol ext-rel tablet penicillin VK diclofenac sodium- buprenorphine transdermal BELBUCA § ERYTHROMYCINS / misoprostol codeine-acetaminophen NUCYNTA MACROLIDES § TETRACYCLINES

fentanyl transdermal NUCYNTA ER azithromycin doxycycline hyclate 20 mg § NSAIDs, TOPICAL fentanyl transmucosal SUBSYS clarithromycin doxycycline hyclate capsule diclofenac sodium gel 1% lozenge XTAMPZA ER clarithromycin ext-rel minocycline diclofenac sodium solution hydrocodone ext-rel erythromycins tetracycline

hydrocodone-acetaminophen DIFICID

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.

§ ANTIFUNGALS valsartan / valsartan- nadolol diazepam rectal gel § ANTIPARKINSONIAN fluconazole hydrochlorothiazide pindolol divalproex sodium AGENTS itraconazole propranolol divalproex sodium ext-rel amantadine § ANGIOTENSIN II terbinafine tablet propranolol ext-rel ethosuximide carbidopa-levodopa RECEPTOR ANTAGONIST / BYSTOLIC gabapentin carbidopa-levodopa ext-rel CALCIUM CHANNEL ANTIVIRALS lamotrigine carbidopa-levodopa- BLOCKER COMBINATIONS § CALCIUM CHANNEL § CYTOMEGALOVIRUS lamotrigine ext-rel entacapone amlodipine-olmesartan BLOCKERS AGENTS levetiracetam entacapone amlodipine-telmisartan amlodipine valganciclovir levetiracetam ext-rel pramipexole (except generics amlodipine-valsartan diltiazem ext-rel oxcarbazepine pramipexole ext-rel

§ HERPES AGENTS for CARDIZEM LA) phenobarbital § ANGIOTENSIN II rasagiline acyclovir capsule, tablet nifedipine ext-rel phenytoin ropinirole RECEPTOR ANTAGONIST / valacyclovir verapamil ext-rel phenytoin sodium extended ropinirole ext-rel CALCIUM CHANNEL primidone BLOCKER / DIURETIC § CALCIUM CHANNEL selegiline § INFLUENZA AGENTS rufinamide COMBINATIONS BLOCKER / ANTILIPEMIC NEUPRO oseltamivir tiagabine COMBINATIONS RELENZA amlodipine-valsartan- topiramate ANTIPSYCHOTICS

hydrochlorothiazide amlodipine-atorvastatin valproic acid § ATYPICALS § MISCELLANEOUS olmesartan-amlodipine- § DIGITALIS GLYCOSIDES zonisamide aripiprazole clindamycin hydrochlorothiazide FYCOMPA clozapine ivermectin digoxin § ANTIARRHYTHMICS NAYZILAM olanzapine linezolid OXTELLAR XR disopyramide § DIRECT RENIN quetiapine metronidazole TROKENDI XR sotalol INHIBITORS / DIURETIC quetiapine ext-rel nitrofurantoin (except NDC^ VALTOCO MULTAQ COMBINATIONS risperidone 70408023932) VIMPAT aliskiren ziprasidone pyrimethamine ANTILIPEMICS XCOPRI ABILIFY MAINTENA sulfamethoxazole- TEKTURNA HCT ACL INHIBITORS / LATUDA trimethoprim § ANTIDEMENTIA COMBINATIONS § DIURETICS PERSERIS vancomycin capsule donepezil amiloride VRAYLAR EMVERM NEXLETOL galantamine furosemide XIFAXAN 550 MG NEXLIZET galantamine ext-rel § ATTENTION DEFICIT hydrochlorothiazide memantine HYPERACTIVITY DISORDER § BILE ACID RESINS metolazone ANTINEOPLASTIC rivastigmine amphetamine- cholestyramine spironolactone- AGENTS rivastigmine transdermal dextroamphetamine mixed colesevelam hydrochlorothiazide NAMZARIC salts HORMONAL torsemide amphetamine- ANTINEOPLASTIC AGENTS § CHOLESTEROL triamterene ANTIDEPRESSANTS § ANTIANDROGENS ABSORPTION INHIBITORS triamterene- dextroamphetamine mixed § SELECTIVE SEROTONIN † hydrochlorothiazide salts ext-rel bicalutamide ezetimibe REUPTAKE INHIBITORS atomoxetine (SSRIs) § MISCELLANEOUS § FIBRATES HEART FAILURE dexmethylphenidate ext-rel citalopram VISTOGARD fenofibrate (except fenofibrate capsule BIDIL guanfacine ext-rel 50 mg, 130 mg; fenofibrate tablet 40 mg, CORLANOR escitalopram methylphenidate fluoxetine (except fluoxetine tablet 60 † CARDIOVASCULAR 120 mg) ENTRESTO methylphenidate ext-rel mg, fluoxetine tablet [generics for fenofibric acid delayed-rel MYDAYIS § ACE INHIBITORS § NITRATES SARAFEM]) VYVANSE fosinopril § HMG-CoA REDUCTASE isosorbide dinitrate (except paroxetine HCl lisinopril INHIBITORS / isosorbide dinitrate 40 mg) paroxetine HCl ext-rel § FIBROMYALGIA quinapril COMBINATIONS isosorbide mononitrate sertraline pregabalin ramipril atorvastatin nitroglycerin lingual spray TRINTELLIX HYPNOTICS ezetimibe-simvastatin nitroglycerin sublingual § SEROTONIN § ACE INHIBITOR / fluvastatin § NONBENZODIAZEPINES § MISCELLANEOUS NOREPINEPHRINE DIURETIC COMBINATIONS lovastatin eszopiclone REUPTAKE INHIBITORS fosinopril-hydrochlorothiazide pravastatin ranolazine ext-rel ramelteon (SNRIs) lisinopril-hydrochlorothiazide rosuvastatin zolpidem CENTRAL NERVOUS quinapril-hydrochlorothiazide simvastatin desvenlafaxine ext-rel zolpidem ext-rel

SYSTEM duloxetine BELSOMRA § ANGIOTENSIN II § NIACINS venlafaxine RECEPTOR ANTAGONISTS / ANTIANXIETY niacin ext-rel venlafaxine ext-rel capsule § TRICYCLICS § BENZODIAZEPINES DIURETIC COMBINATIONS doxepin candesartan / candesartan- § OMEGA-3 FATTY ACIDS alprazolam § MISCELLANEOUS AGENTS hydrochlorothiazide omega-3 acid ethyl esters clonazepam MIGRAINE irbesartan / irbesartan- VASCEPA diazepam bupropion ACUTE MIGRAINE AGENTS

hydrochlorothiazide lorazepam bupropion ext-rel (except § Triptans losartan / losartan- § BETA-BLOCKERS oxazepam bupropion ext-rel tablet 450 mg) eletriptan hydrochlorothiazide atenolol mirtazapine § ANTICONVULSANTS naratriptan olmesartan / olmesartan- carvedilol trazodone rizatriptan hydrochlorothiazide carvedilol phosphate ext-rel carbamazepine sumatriptan metoprolol succinate ext-rel carbamazepine ext-rel telmisartan / telmisartan- zolmitriptan hydrochlorothiazide metoprolol tartrate clobazam

ONZETRA XSAIL (DPP-4) INHIBITOR PROGESTINS DIPEPTIDYL PEPTIDASE-4 § TRIPHASIC ZEMBRACE SYMTOUCH COMBINATIONS § ORAL (DPP-4) INHIBITORS ZOMIG NASAL SPRAY ethinyl estradiol-norgestimate GLYXAMBI medroxyprogesterone JANUVIA megestrol acetate Miscellaneous SODIUM-GLUCOSE § EXTENDED CYCLE DIPEPTIDYL PEPTIDASE-4 progesterone, micronized NURTEC ODT CO-TRANSPORTER 2 ethinyl estradiol- REYVOW (DPP-4) INHIBITOR / (SGLT2) INHIBITOR / levonorgestrel VAGINAL UBRELVY BIGUANIDE COMBINATIONS DIPEPTIDYL PEPTIDASE-4 § TRANSDERMAL CRINONE JANUMET (DPP-4) INHIBITOR / PREVENTIVE MIGRAINE ENDOMETRIN JANUMET XR BIGUANIDE COMBINATIONS ethinyl estradiol- AGENTS norelgestromin TRIJARDY XR § SELECTIVE ESTROGEN Monoclonal Antibodies INCRETIN MIMETIC AGENTS § VAGINAL RECEPTOR MODULATORS OZEMPIC § SULFONYLUREAS AIMOVIG raloxifene RYBELSUS ethinyl estradiol-etonogestrel AJOVY glimepiride TRULICITY ANNOVERA EMGALITY glipizide § THYROID SUPPLEMENTS VICTOZA glipizide ext-rel ENDOMETRIOSIS levothyroxine § MUSCULOSKELETAL liothyronine THERAPY AGENTS INCRETIN MIMETIC AGENT / SUPPLIES ORILISSA INSULIN COMBINATIONS SYNTHROID cyclobenzaprine (except ACCU-CHEK AVIVA PLUS § GLUCOCORTICOIDS cyclobenzaprine tablet 7.5 mg) SOLIQUA STRIPS AND KITS 2 UTERINE FIBROIDS dexamethasone XULTOPHY ACCU-CHEK COMPACT fludrocortisone ORIAHNN § NARCOLEPSY PLUS STRIPS AND KITS 2 INSULINS hydrocortisone armodafinil ACCU-CHEK GUIDE GASTROINTESTINAL BASAGLAR methylprednisolone modafinil STRIPS AND KITS 2 FIASP prednisolone solution § ANTIDIARRHEALS SUNOSI ACCU-CHEK SMARTVIEW HUMULIN R U-500 prednisone diphenoxylate-atropine STRIPS AND KITS 2 POSTHERPETIC LEVEMIR BD ULTRAFINE INSULIN GLUCOSE ELEVATING loperamide NEURALGIA (PHN) NOVOLIN 70/30 SYRINGES AND AGENTS NOVOLIN N § ANTIEMETICS GRALISE NEEDLES NOVOLIN R BAQSIMI aprepitant DEXCOM CONTINUOUS PSYCHOTHERAPEUTIC - NOVOLOG GLUCAGEN HYPOKIT doxylamine-pyridoxine GLUCOSE MONITORING MISCELLANEOUS NOVOLOG MIX 70/30 GLUCAGON EMERGENCY delayed-rel SYSTEM TOUJEO KIT dronabinol § OPIOID ANTAGONISTS OMNIPOD DASH INSULIN TRESIBA GVOKE granisetron naloxone injection INFUSION PUMP meclizine NARCAN NASAL SPRAY OMNIPOD INSULIN MENOPAUSAL SYMPTOM § INSULIN SENSITIZERS metoclopramide INFUSION PUMP AGENTS § PARTIAL OPIOID AGONIST pioglitazone ondansetron ONETOUCH ULTRA § ORAL / OPIOID ANTAGONIST prochlorperazine § INSULIN SENSITIZER / STRIPS AND KITS 2 COMBINATIONS estradiol promethazine BIGUANIDE COMBINATIONS ONETOUCH VERIO STRIPS estradiol-norethindrone scopolamine transdermal buprenorphine-naloxone AND KITS 2 pioglitazone-metformin DUAVEE trimethobenzamide sublingual V-GO INSULIN INFUSION PREMPHASE SANCUSO ZUBSOLV § INSULIN SENSITIZER / PUMP PREMPRO

PSEUDOBULBAR AFFECT SULFONYLUREA § ANTISPASMODICS COMBINATIONS CALCIUM REGULATORS § TRANSDERMAL AGENTS dicyclomine pioglitazone-glimepiride § BISPHOSPHONATES estradiol NUEDEXTA alendronate CLIMARA PRO § H2 RECEPTOR § MEGLITINIDES ENDOCRINE AND ibandronate COMBIPATCH ANTAGONISTS nateglinide METABOLIC risedronate DIVIGEL famotidine

repaglinide EVAMIST § ANDROGENS § CALCITONINS INFLAMMATORY BOWEL SODIUM-GLUCOSE testosterone gel (except authorized calcitonin-salmon § VAGINAL DISEASE CO-TRANSPORTER 2 generics for TESTIM and VOGELXO) estradiol vaginal cream § ORAL AGENTS (SGLT2) INHIBITORS § CARNITINE DEFICIENCY testosterone solution IMVEXXY balsalazide FARXIGA AGENTS ANDRODERM VAGIFEM budesonide capsule JARDIANCE levocarnitine NATESTO budesonide ext-rel § PHOSPHATE BINDER mesalamine delayed-rel ANTIDIABETICS SODIUM-GLUCOSE CONTRACEPTIVES AGENTS CO-TRANSPORTER 2 (except mesalamine delayed-rel tablet AMYLIN ANALOGS § MONOPHASIC calcium acetate (SGLT2) INHIBITOR / 800 mg) ethinyl estradiol- sevelamer carbonate SYMLINPEN BIGUANIDE COMBINATIONS mesalamine ext-rel drospirenone PHOSLYRA sulfasalazine § BIGUANIDES SYNJARDY ethinyl estradiol- VELPHORO sulfasalazine delayed-rel metformin SYNJARDY XR drospirenone-levomefolate POTASSIUM-REMOVING ASACOL HD metformin ext-rel (except generics XIGDUO XR ethinyl estradiol- PENTASA norethindrone acetate AGENTS for FORTAMET and GLUMETZA) SODIUM-GLUCOSE ethinyl estradiol- LOKELMA CO-TRANSPORTER 2 § RECTAL AGENTS § BIGUANIDE / VELTASSA norethindrone acetate-iron hydrocortisone enema SULFONYLUREA (SGLT2) INHIBITOR / mesalamine suppository COMBINATIONS DIPEPTIDYL PEPTIDASE-4 BIPHASIC mesalamine suspension glipizide-metformin LO LOESTRIN FE

CORTIFOAM HEMATOLOGIC § ANTIHISTAMINES, 68682046275) § LOCAL ANALGESICS

LOW SEDATING clindamycin solution lidocaine patch § IRRITABLE BOWEL § ANTICOAGULANTS levocetirizine clindamycin-benzoyl SYNDROME warfarin peroxide § LOCAL ANESTHETICS alosetron ELIQUIS § ANTITUSSIVES erythromycin solution lidocaine-prilocaine LINZESS XARELTO benzonatate (except NDCs^ erythromycin-benzoyl

VIBERZI 69336012615, 69499032915) peroxide § ROSACEA § CHELATING AGENTS tretinoin azelaic acid gel § LAXATIVES penicillamine capsule BETA AGONISTS, EPIDUO metronidazole lactulose solution trientine INHALANTS ONEXTON FINACEA FOAM peg 3350-electrolytes § SHORT ACTING ORACEA CLENPIQ § PLATELET AGGREGATION § ACTINIC KERATOSIS albuterol inhalation solution SOOLANTRA INHIBITORS albuterol sulfate CFC-free fluorouracil cream 5% OPIOID-INDUCED clopidogrel MOUTH / THROAT / aerosol fluorouracil solution CONSTIPATION dipyridamole ext-rel-aspirin DENTAL AGENTS levalbuterol tartrate CFC-free imiquimod MOVANTIK prasugrel aerosol PICATO PROTECTANTS SYMPROIC BRILINTA TOLAK EPISIL LONG ACTING ZYCLARA PANCREATIC ENZYMES IMMUNOLOGIC Hand-held Active Inhalation OPHTHALMIC CREON AGENTS § ANTIBIOTICS SEREVENT § ANTIALLERGICS VIOKACE gentamicin ALLERGENIC EXTRACTS azelastine ZENPEP STRIVERDI RESPIMAT mupirocin ointment GRASTEK cromolyn sodium Nebulized Passive Inhalation § PROTON PUMP RAGWITEK § ANTIFUNGALS olopatadine INHIBITORS PERFOROMIST ciclopirox § ANTI-INFECTIVES esomeprazole delayed-rel NUTRITIONAL / § LEUKOTRIENE clotrimazole ciprofloxacin lansoprazole delayed-rel SUPPLEMENTS MODULATORS econazole erythromycin omeprazole delayed-rel § ELECTROLYTES ketoconazole cream 2% pantoprazole delayed-rel montelukast gentamicin potassium chloride liquid zafirlukast nystatin levofloxacin tablet NAFTIN moxifloxacin DEXILANT VITAMINS AND MINERALS § NASAL ANTIHISTAMINES § ANTIPSORIATICS ofloxacin § STEROIDS, RECTAL § FOLIC ACID / azelastine sulfacetamide acitretin COMBINATIONS olopatadine tobramycin PROCTOFOAM-HC calcipotriene ointment, folic acid BESIVANCE § NASAL STEROIDS / § ULCER THERAPY solution § PRENATAL VITAMINS COMBINATIONS methoxsalen § ANTI-INFECTIVE / COMBINATIONS prenatal vitamins flunisolide ANTI-INFLAMMATORY PYLERA § ANTISEBORRHEICS CITRANATAL fluticasone COMBINATIONS ketoconazole shampoo 2% § MISCELLANEOUS mometasone neomycin-polymyxin B-

RESPIRATORY DYMISTA selenium sulfide lotion 2.5% sucralfate tablet bacitracin-hydrocortisone neomycin-polymyxin B- § ANAPHYLAXIS PHOSPHODIESTERASE-4 § ATOPIC DERMATITIS GENITOURINARY dexamethasone TREATMENT AGENTS INHIBITORS pimecrolimus tobramycin-dexamethasone § BENIGN PROSTATIC epinephrine auto-injector tacrolimus DALIRESP TOBRADEX OINTMENT HYPERPLASIA EPIPEN EUCRISA alfuzosin ext-rel EPIPEN JR STEROID / BETA AGONIST ANTI-INFLAMMATORIES COMBINATIONS CORTICOSTEROIDS doxazosin SYMJEPI § Nonsteroidal

ADVAIR DISKUS § Low Potency dutasteride bromfenac § ANTICHOLINERGICS ADVAIR HFA † desonide dutasteride-tamsulosin † diclofenac finasteride ipratropium inhalation BREO ELLIPTA hydrocortisone ketorolac silodosin solution SYMBICORT § Medium Potency ILEVRO tamsulosin SPIRIVA § STEROID INHALANTS hydrocortisone butyrate PROLENSA terazosin YUPELRI budesonide inhalation cream, ointment, solution ANTICHOLINERGIC / BETA § Steroidal § URINARY suspension mometasone dexamethasone ANTISPASMODICS AGONIST COMBINATIONS ARNUITY ELLIPTA triamcinolone cream, lotion, loteprednol § SHORT ACTING FLOVENT DISKUS ointment (except triamcinolone darifenacin ext-rel prednisolone acetate 1% oxybutynin ipratropium-albuterol FLOVENT HFA ointment 0.05%) DUREZOL oxybutynin ext-rel inhalation solution PULMICORT FLEXHALER § High Potency solifenacin QVAR REDIHALER § ANTIVIRALS LONG ACTING desoximetasone tolterodine trifluridine fluocinonide (except fluocinonide tolterodine ext-rel ANORO ELLIPTA TOPICAL cream 0.1%) trospium STIOLTO RESPIMAT BETA-BLOCKERS DERMATOLOGY BRYHALI trospium ext-rel ANTICHOLINERGIC / BETA ACNE § Nonselective MYRBETRIQ AGONIST / STEROID § Very High Potency timolol maleate solution TOVIAZ § Topical INHALANT COMBINATIONS clobetasol cream, foam, gel, adapalene Selective BREZTRI AEROSPHERE lotion, ointment, shampoo benzoyl peroxide BETOPTIC S TRELEGY ELLIPTA clindamycin gel (except NDC^

§ CARBONIC ANHYDRASE SYMPATHOMIMETIC ZIOPTAN ALPHAGAN P § ANTI-INFECTIVE / INHIBITORS COMBINATIONS ANTI-INFLAMMATORY RHO KINASE INHIBITORS SYMPATHOMIMETIC / BETA- dorzolamide SIMBRINZA COMBINATIONS RHOPRESSA BLOCKER COMBINATIONS AZOPT ciprofloxacin-dexamethasone DRY EYE DISEASE COMBIGAN RHO KINASE INHIBITOR / neomycin-polymyxin B- § CARBONIC ANHYDRASE RESTASIS PROSTAGLANDIN OTIC hydrocortisone INHIBITOR / BETA- XIIDRA BLOCKER COMBINATIONS COMBINATIONS § ANTI-INFECTIVES § PROSTAGLANDINS ROCKLATAN acetic acid dorzolamide-timolol latanoprost ofloxacin otic § SYMPATHOMIMETICS CARBONIC ANHYDRASE travoprost brimonidine INHIBITOR / LUMIGAN QUICK REFERENCE DRUG LIST

A atenolol carbidopa-levodopa ext-rel DEXCOM CONTINUOUS EPIPEN atomoxetine carbidopa-levodopa- GLUCOSE MONITORING EPIPEN JR ABILIFY MAINTENA ACCU-CHEK AVIVA PLUS atorvastatin entacapone SYSTEM EPISIL azelaic acid gel carvedilol DEXILANT erythromycin STRIPS AND KITS 2 azelastine carvedilol phosphate ext-rel dexmethylphenidate ext-rel erythromycin solution ACCU-CHEK COMPACT azithromycin cefdinir diazepam erythromycin-benzoyl PLUS STRIPS AND KITS 2 AZOPT cefprozil diazepam rectal gel peroxide ACCU-CHEK GUIDE cefuroxime axetil diclofenac erythromycins STRIPS AND KITS 2 B celecoxib diclofenac sodium escitalopram ACCU-CHEK SMARTVIEW balsalazide cephalexin diclofenac sodium gel 1% esomeprazole delayed-rel STRIPS AND KITS 2 cholestyramine diclofenac sodium solution estradiol acetic acid BAQSIMI ciclopirox diclofenac sodium- estradiol vaginal cream acitretin BASAGLAR ciprofloxacin misoprostol estradiol-norethindrone acyclovir capsule, tablet BD ULTRAFINE INSULIN ciprofloxacin-dexamethasone dicloxacillin eszopiclone adapalene SYRINGES AND citalopram dicyclomine ethinyl estradiol- ADVAIR DISKUS NEEDLES CITRANATAL DIFICID drospirenone ADVAIR HFA † BELBUCA clarithromycin digoxin ethinyl estradiol- AIMOVIG BELSOMRA (except NDCs^ clarithromycin ext-rel diltiazem ext-rel (except generics drospirenone-levomefolate AJOVY benzonatate 69336012615, 69499032915) CLENPIQ for CARDIZEM LA) ethinyl estradiol-etonogestrel albuterol inhalation solution CLIMARA PRO diphenoxylate-atropine ethinyl estradiol- albuterol sulfate CFC-free benzoyl peroxide BESIVANCE clindamycin dipyridamole ext-rel-aspirin levonorgestrel aerosol clindamycin gel (except NDC^ disopyramide ethinyl estradiol- alendronate BETOPTIC S 68682046275) divalproex sodium norelgestromin alfuzosin ext-rel bicalutamide clindamycin solution divalproex sodium ext-rel ethinyl estradiol- aliskiren BIDIL † clindamycin-benzoyl DIVIGEL norethindrone acetate allopurinol BREO ELLIPTA peroxide donepezil ethinyl estradiol- alosetron BREZTRI AEROSPHERE clobazam dorzolamide norethindrone acetate-iron ALPHAGAN P BRILINTA clobetasol cream, foam, gel, dorzolamide-timolol ethinyl estradiol-norgestimate alprazolam brimonidine lotion, ointment, shampoo doxazosin ethosuximide amantadine bromfenac BRYHALI clonazepam doxepin EUCRISA amiloride budesonide capsule clopidogrel doxycycline hyclate 20 mg EVAMIST amlodipine budesonide ext-rel clotrimazole doxycycline hyclate capsule ezetimibe amlodipine-atorvastatin budesonide inhalation clozapine doxylamine-pyridoxine ezetimibe-simvastatin amlodipine-olmesartan codeine-acetaminophen delayed-rel amlodipine-telmisartan suspension colchicine tablet dronabinol F amlodipine-valsartan buprenorphine transdermal amlodipine-valsartan- buprenorphine-naloxone colesevelam DUAVEE famotidine COMBIGAN duloxetine hydrochlorothiazide sublingual FARXIGA COMBIPATCH DUREZOL (except fenofibrate capsule amoxicillin bupropion fenofibrate (except CORLANOR dutasteride 50 mg, 130 mg; fenofibrate tablet 40 mg, amoxicillin-clavulanate bupropion ext-rel CORTIFOAM dutasteride-tamsulosin amphetamine- bupropion ext-rel tablet 450 mg) 120 mg) BYSTOLIC CREON DYMISTA fenofibric acid delayed-rel dextroamphetamine mixed CRINONE fentanyl transdermal salts C cromolyn sodium E amphetamine- fentanyl transmucosal dextroamphetamine mixed calcipotriene ointment, cyclobenzaprine (except econazole lozenge † solution cyclobenzaprine tablet 7.5 mg) eletriptan FIASP salts ext-rel

ANDRODERM calcitonin-salmon ELIQUIS FINACEA FOAM D ANNOVERA calcium acetate EMGALITY finasteride

ANORO ELLIPTA candesartan DALIRESP EMVERM FLOVENT DISKUS aprepitant candesartan- darifenacin ext-rel ENDOMETRIN FLOVENT HFA aripiprazole hydrochlorothiazide desonide entacapone fluconazole armodafinil carbamazepine desoximetasone ENTRESTO fludrocortisone desvenlafaxine ext-rel EPIDUO flunisolide ARNUITY ELLIPTA carbamazepine ext-rel dexamethasone epinephrine auto-injector fluocinonide (except fluocinonide ASACOL HD carbidopa-levodopa

cream 0.1%) JARDIANCE modafinil ONETOUCH ULTRA quinapril fluorouracil cream 5% mometasone STRIPS AND KITS 2 quinapril-hydrochlorothiazide fluorouracil solution K montelukast ONETOUCH VERIO STRIPS QVAR REDIHALER fluoxetine (except fluoxetine tablet 60 ketoconazole cream 2% morphine AND KITS 2 mg, fluoxetine tablet [generics for ketoconazole shampoo 2% morphine ext-rel ONEXTON R SARAFEM]) ketorolac morphine suppository ONZETRA XSAIL RAGWITEK fluticasone MOVANTIK ORACEA raloxifene fluvastatin L moxifloxacin ORIAHNN ramelteon folic acid lactulose solution MULTAQ ORILISSA ramipril fosinopril lamotrigine mupirocin ointment oseltamivir ranolazine ext-rel fosinopril-hydrochlorothiazide lamotrigine ext-rel MYDAYIS oxazepam rasagiline furosemide lansoprazole delayed-rel MYRBETRIQ oxcarbazepine RELENZA

FYCOMPA latanoprost OXTELLAR XR repaglinide N LATUDA oxybutynin RESTASIS G levalbuterol tartrate CFC-free nadolol oxybutynin ext-rel REYVOW gabapentin aerosol NAFTIN oxycodone RHOPRESSA galantamine LEVEMIR naloxone injection oxycodone-acetaminophen risedronate galantamine ext-rel levetiracetam NAMZARIC OZEMPIC risperidone gentamicin levetiracetam ext-rel naproxen (except naproxen CR or rivastigmine P glimepiride levocarnitine naproxen suspension) rivastigmine transdermal glipizide levocetirizine naratriptan pantoprazole delayed-rel rizatriptan glipizide ext-rel levofloxacin NARCAN NASAL SPRAY tablet ROCKLATAN glipizide-metformin levothyroxine nateglinide paroxetine HCl ropinirole GLUCAGEN HYPOKIT lidocaine patch NATESTO paroxetine HCl ext-rel ropinirole ext-rel GLUCAGON EMERGENCY lidocaine-prilocaine NAYZILAM peg 3350-electrolytes rosuvastatin KIT linezolid neomycin-polymyxin B- penicillamine capsule rufinamide GLYXAMBI LINZESS bacitracin-hydrocortisone penicillin VK RYBELSUS

GRALISE liothyronine neomycin-polymyxin B- PENTASA granisetron lisinopril dexamethasone PERFOROMIST S GRASTEK lisinopril-hydrochlorothiazide neomycin-polymyxin B- PERSERIS SANCUSO guanfacine ext-rel LO LOESTRIN FE hydrocortisone phenobarbital scopolamine transdermal GVOKE LOKELMA NEUPRO phenytoin selegiline

loperamide NEXLETOL phenytoin sodium extended selenium sulfide lotion 2.5% H lorazepam NEXLIZET PHOSLYRA SEREVENT HUMULIN R U-500 losartan niacin ext-rel PICATO sertraline hydrochlorothiazide losartan-hydrochlorothiazide nifedipine ext-rel pimecrolimus sevelamer carbonate hydrocodone ext-rel loteprednol nitrofurantoin (except NDC^ pindolol silodosin hydrocodone-acetaminophen lovastatin 70408023932) pioglitazone SIMBRINZA hydrocortisone LUMIGAN nitroglycerin lingual spray pioglitazone-glimepiride simvastatin hydrocortisone butyrate nitroglycerin sublingual pioglitazone-metformin solifenacin cream, ointment, solution M NOVOLIN 70/30 potassium chloride liquid SOLIQUA hydrocortisone enema meclizine NOVOLIN N pramipexole SOOLANTRA hydromorphone medroxyprogesterone NOVOLIN R pramipexole ext-rel sotalol hydromorphone ext-rel megestrol acetate NOVOLOG prasugrel SPIRIVA

meloxicam NOVOLOG MIX 70/30 pravastatin spironolactone- I memantine NUCYNTA prednisolone acetate 1% hydrochlorothiazide ibandronate mesalamine delayed-rel NUCYNTA ER prednisolone solution STIOLTO RESPIMAT ibuprofen (except mesalamine delayed-rel tablet NUEDEXTA prednisone STRIVERDI RESPIMAT ILEVRO 800 mg) NURTEC ODT pregabalin SUBSYS imiquimod mesalamine ext-rel nystatin PREMPHASE sucralfate tablet

IMVEXXY mesalamine suppository PREMPRO sulfacetamide O ipratropium inhalation mesalamine suspension prenatal vitamins sulfamethoxazole- solution metformin ofloxacin primidone trimethoprim ipratropium-albuterol metformin ext-rel (except generics ofloxacin otic probenecid sulfasalazine inhalation solution for FORTAMET and GLUMETZA) olanzapine prochlorperazine sulfasalazine delayed-rel irbesartan methadone olmesartan PROCTOFOAM-HC sumatriptan irbesartan- methoxsalen olmesartan-amlodipine- progesterone, micronized SUNOSI hydrochlorothiazide methylphenidate hydrochlorothiazide PROLENSA SUPRAX isosorbide dinitrate (except methylphenidate ext-rel † olmesartan- promethazine SYMBICORT isosorbide dinitrate 40 mg) methylprednisolone hydrochlorothiazide propranolol SYMJEPI isosorbide mononitrate metoclopramide olopatadine propranolol ext-rel SYMLINPEN itraconazole metolazone omega-3 acid ethyl esters PULMICORT FLEXHALER SYMPROIC ivermectin metoprolol succinate ext-rel omeprazole delayed-rel PYLERA SYNJARDY metoprolol tartrate OMNIPOD DASH INSULIN pyrimethamine SYNJARDY XR

J metronidazole INFUSION PUMP SYNTHROID Q JANUMET minocycline OMNIPOD INSULIN T JANUMET XR mirtazapine INFUSION PUMP quetiapine JANUVIA MITIGARE ondansetron quetiapine ext-rel tacrolimus

tamsulosin TOUJEO trospium verapamil ext-rel XULTOPHY

TEKTURNA HCT TOVIAZ trospium ext-rel V-GO INSULIN INFUSION telmisartan tramadol (except NDC^ 52817019610) TRULICITY PUMP Y telmisartan- tramadol ext-rel tablet VIBERZI YUPELRI hydrochlorothiazide travoprost U VICTOZA terazosin trazodone UBRELVY VIMPAT Z terbinafine tablet TRELEGY ELLIPTA VIOKACE zafirlukast testosterone gel (except authorized TRESIBA V VISTOGARD ZEMBRACE SYMTOUCH generics for TESTIM and VOGELXO) tretinoin VAGIFEM VRAYLAR ZENPEP testosterone solution triamcinolone cream, lotion, valacyclovir VYVANSE ZIOPTAN tetracycline ointment (except triamcinolone valganciclovir ziprasidone W tiagabine ointment 0.05%) valproic acid zolmitriptan timolol maleate solution triamterene valsartan warfarin zolpidem

TOBRADEX OINTMENT triamterene- valsartan-hydrochlorothiazide zolpidem ext-rel tobramycin hydrochlorothiazide VALTOCO X ZOMIG NASAL SPRAY tobramycin-dexamethasone trientine vancomycin capsule XARELTO zonisamide TOLAK trifluridine VASCEPA XCOPRI ZUBSOLV tolterodine TRIJARDY XR VELPHORO XIFAXAN 550 MG ZYCLARA tolterodine ext-rel trimethobenzamide VELTASSA XIGDUO XR topiramate TRINTELLIX venlafaxine XIIDRA torsemide TROKENDI XR venlafaxine ext-rel capsule XTAMPZA ER PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO rel, risperidone, ziprasidone, LATUDA, VRAYLAR ANTARA fenofibrate (except fenofibrate capsule 50 mg, 130 mg; ACANYA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, APEXICON E desoximetasone (except desoximetasone ointment 0.05%), tretinoin, EPIDUO, ONEXTON fluocinonide (except fluocinonide cream 0.1%), BRYHALI ACIPHEX, ACIPHEX esomeprazole delayed-rel, lansoprazole delayed-rel, APIDRA FIASP, NOVOLOG SPRINKLE omeprazole delayed-rel, pantoprazole delayed-rel tablet, APTENSIO XR amphetamine-dextroamphetamine mixed salts ext-rel †, DEXILANT dexmethylphenidate ext-rel, methylphenidate ext-rel †, ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate capsule, MYDAYIS, VYVANSE minocycline, tetracycline ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID Activite folic acid ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or ACTOS pioglitazone naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA omeprazole delayed-rel, pantoprazole delayed-rel tablet or DEXILANT acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir ASCENSIA STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK ADDERALL amphetamine-dextroamphetamine mixed salts, methylphenidate KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE ADZENYS ER, ADZENYS amphetamine-dextroamphetamine mixed salts ext-rel †, STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND 2 2 XR-ODT dexmethylphenidate ext-rel, methylphenidate ext-rel †, KITS , ONETOUCH ULTRA STRIPS AND KITS , ONETOUCH MYDAYIS, VYVANSE VERIO STRIPS AND KITS 2 ALCORTIN A desonide, hydrocortisone ASMANEX, ASMANEX ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, HFA PULMICORT FLEXHALER, QVAR REDIHALER ALEVICYN GEL, desonide, hydrocortisone ALEVICYN SG, ATACAND, candesartan, candesartan-hydrochlorothiazide, irbesartan, ALEVICYN SOLUTION ATACAND HCT irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan- ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES hydrochlorothiazide, telmisartan, telmisartan- INSULIN SYRINGES 3 hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ALORA estradiol, DIVIGEL, EVAMIST ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam ALREX azelastine, cromolyn sodium, olopatadine ATOPADERM desonide, hydrocortisone ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, ATROVENT HFA ipratropium inhalation solution, SPIRIVA, YUPELRI pravastatin, rosuvastatin, simvastatin AVENOVA Consult doctor ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE AMITIZA LINZESS, MOVANTIK, SYMPROIC AZELEX adapalene, benzoyl peroxide, clindamycin gel (except NDC^ AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, testosterone gel ANDROGEL (except authorized generics for TESTIM and tretinoin, EPIDUO, ONEXTON VOGELXO), testosterone solution, ANDRODERM, NATESTO

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* AZESCO 5 prenatal vitamins, CITRANATAL calcipotriene- calcipotriene ointment or calcipotriene solution WITH betamethasone desoximetasone (except desoximetasone ointment 0.05%), AZOR amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- fluocinonide (except fluocinonide cream 0.1%) or BRYHALI valsartan calcitriol ointment calcipotriene ointment, calcipotriene solution BANZEL SUSPENSION clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or BEAU RX Consult doctor naproxen suspension) BECONASE AQ flunisolide, fluticasone, mometasone, DYMISTA CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, TOLAK, ZYCLARA irbesartan-hydrochlorothiazide, losartan, losartan- CARAFATE sucralfate tablet hydrochlorothiazide, olmesartan, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- CARBINOXAMINE levocetirizine hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide TABLET 6 MG BENSAL HP desonide, hydrocortisone CARDIZEM, CARDIZEM diltiazem ext-rel CD, (except generics for CARDIZEM LA) BENZAC AC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ CARDIZEM LA 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, carisoprodol 250 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) tretinoin, EPIDUO, ONEXTON CARNITOR, CARNITOR levocarnitine BENZACLIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ SF 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam, naproxen tretinoin, EPIDUO, ONEXTON (except naproxen CR or naproxen suspension) benzonatate benzonatate (except NDCs^ 69336012615, 69499032915) chlordiazepoxide-clidinium dicyclomine (NDCs^ 69336012615, (NDCs^ 11534019701, 69499032915 only) 42494040901, 51293069601, BEPREVE azelastine, cromolyn sodium, olopatadine 51293069610 only) BETAPACE, sotalol chlorzoxazone 375 mg, cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) BETAPACE AF chlorzoxazone 500 mg (NDC^ 73007001303 BETIMOL timolol maleate solution, BETOPTIC S only), chlorzoxazone 750 BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT mg, CHLORZOXAZONE 250 MG BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-norethindrone acetate, CICATRACE Consult doctor ethinyl estradiol-norethindrone acetate-iron CILOXAN ciprofloxacin, erythromycin, gentamicin, levofloxacin, bimatoprost solution latanoprost, travoprost, LUMIGAN, ZIOPTAN moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE 0.03% CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic 2 BREEZE 2 STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU-CHEK CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND CLINDAGEL erythromycin solution KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 clindamycin gel (NDC^ adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275 only) 68682046275), clindamycin solution, clindamycin-benzoyl BROMSITE bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON Bupap diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) clobetasol spray clobetasol foam bupropion ext-rel tablet bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 CLOBEX SPRAY clobetasol foam 450 mg mg) clocortolone cream hydrocortisone butyrate cream, hydrocortisone butyrate butalbital-acetaminophen diclofenac sodium, ibuprofen, naproxen (except naproxen CR or ointment, hydrocortisone butyrate solution, mometasone, tablet 50-300 mg, naproxen suspension) triamcinolone cream, triamcinolone lotion, triamcinolone BUTALBITAL- ointment (except triamcinolone ointment 0.05%) ACETAMINOPHEN (NDC^ 69499034230 only) COLAZAL balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, butalbital-acetaminophen- diclofenac sodium, ibuprofen, naproxen (except naproxen CR or sulfasalazine delayed-rel, ASACOL HD, PENTASA caffeine capsule naproxen suspension) colchicine capsule colchicine tablet, MITIGARE BUTRANS buprenorphine transdermal, BELBUCA COLCRYS colchicine tablet, MITIGARE BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA CONSENSI amlodipine WITH celecoxib BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA CONTOUR NEXT STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, AND KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 calcipotriene cream calcipotriene ointment, calcipotriene solution

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* CONTOUR STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK (generics for CARDIZEM (except generics for CARDIZEM LA) KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE LA only) STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, VERIO STRIPS AND KITS 2 irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan- CORDRAN OINTMENT hydrocortisone butyrate cream, hydrocortisone butyrate hydrochlorothiazide, telmisartan, telmisartan- ointment, hydrocortisone butyrate solution, mometasone, hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) Diphen Elixir levocetirizine

COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, DORAL doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, pindolol, propranolol, propranolol ext-rel, BYSTOLIC BELSOMRA CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule, DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline minocycline, tetracycline COZAAR candesartan, irbesartan, losartan, olmesartan, telmisartan, doxepin cream desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA valsartan doxycycline hyclate doxycycline hyclate 20 mg, doxycycline hyclate capsule, CRESEMBA itraconazole delayed-rel tablet 50 mg, minocycline, tetracycline 200 mg CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin doxycycline hyclate tablet doxycycline hyclate 20 mg, doxycycline hyclate capsule, 50 mg (NDC^ minocycline, tetracycline CUPRIMINE penicillamine capsule 72143021160 only), doxycycline hyclate tablet cyclobenzaprine ext-rel cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) 75 mg, doxycycline capsule, hyclate tablet 150 mg cyclobenzaprine tablet 7.5 mg doxycycline monohydrate doxycycline hyclate 20 mg, doxycycline hyclate capsule, capsule 75 mg, minocycline, tetracycline CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- doxycycline monohydrate rel capsule capsule 150 mg CYTOMEL levothyroxine, liothyronine, SYNTHROID doxycycline monohydrate ORACEA DARAPRIM pyrimethamine delayed-rel capsule † † DAYTRANA amphetamine-dextroamphetamine mixed salts ext-rel †, DULERA ADVAIR DISKUS, ADVAIR HFA , BREO ELLIPTA , dexmethylphenidate ext-rel, methylphenidate ext-rel †, SYMBICORT MYDAYIS, VYVANSE DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide DELZICOL balsalazide, mesalamine delayed-rel (except mesalamine DYRENIUM amiloride, triamterene delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- desoximetasone ointment hydrocortisone butyrate cream, hydrocortisone butyrate hydrochlorothiazide, olmesartan, olmesartan- 0.05% ointment, hydrocortisone butyrate solution, mometasone, hydrochlorothiazide, telmisartan, telmisartan- triamcinolone cream, triamcinolone lotion, triamcinolone hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ointment (except triamcinolone ointment 0.05%) EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, BELSOMRA tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ E.E.S. GRANULES erythromycins dexchlorpheniramine levocetirizine EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- rel capsule Dexifol folic acid ELIDEL pimecrolimus, tacrolimus, EUCRISA Diclofex diclofenac sodium, diclofenac sodium gel 1%, DC (NDC^ 51021037201 diclofenac sodium solution, ibuprofen, meloxicam, ELMIRON Consult doctor only) naproxen (except naproxen CR or naproxen suspension) ENABLEX darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, diclofenac sodium solution, ibuprofen, meloxicam, TOVIAZ naproxen (except naproxen CR or naproxen suspension) ENLITE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM DIFFERIN LOTION adapalene, benzoyl peroxide, clindamycin gel (except NDC^ GLUCOSE MONITORING 68682046275), clindamycin solution, clindamycin- SYSTEM benzoyl peroxide, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, EPIDUO, ONEXTON ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG diflorasone cream, desoximetasone (except desoximetasone ointment 0.05%), EPICERAM desonide, hydrocortisone diflorasone ointment fluocinonide (except fluocinonide cream 0.1%), BRYHALI ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY ERYPED erythromycins diltiazem ext-rel diltiazem ext-rel estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ESTRING estradiol vaginal cream, IMVEXXY, VAGIFEM FORTAMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) EVEKEO amphetamine-dextroamphetamine mixed salts, methylphenidate FORTESTA testosterone gel (except authorized generics for TESTIM and EVERSENSE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM VOGELXO), testosterone solution, ANDRODERM, NATESTO CONTINUOUS GLUCOSE MONITORING SYSTEM FOSAMAX PLUS D alendronate, ibandronate, risedronate EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- FOSRENOL calcium acetate, sevelamer carbonate, PHOSLYRA, valsartan VELPHORO EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan- FOSTEUM, FOSTEUM alendronate, ibandronate, risedronate amlodipine-hydrochlorothiazide PLUS FABIOR adapalene, benzoyl peroxide, clindamycin gel (except NDC^ FREESTYLE LIBRE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 68682046275), clindamycin solution, clindamycin-benzoyl CONTINUOUS GLUCOSE peroxide, erythromycin solution, erythromycin-benzoyl peroxide, MONITORING SYSTEM tretinoin, EPIDUO, ONEXTON FREESTYLE STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK FANAPT aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- AND KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE rel, risperidone, ziprasidone, LATUDA, VRAYLAR STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH FEMRING estradiol vaginal cream, IMVEXXY, VAGIFEM VERIO STRIPS AND KITS 2 fenofibrate capsule 50 mg, fenofibrate (except fenofibrate capsule 50 mg, 130 mg; FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, 130 mg; fenofibrate tablet fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, 40 mg, 120 mg ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY FENOGLIDE TABLET 120 fenofibrate (except fenofibrate capsule 50 mg, 130 mg; Genicin Vita-S folic acid MG fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel GLUMETZA metformin, metformin ext-rel (except generics for FORTAMET fenoprofen, diclofenac sodium, ibuprofen, meloxicam, naproxen (except and GLUMETZA) FENOPROFEN CAPSULE naproxen CR or naproxen suspension) GLYCOPYRROLATE dicyclomine FERIVA 21/7 folic acid TABLET 1.5 MG FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- GOLYTELY peg 3350-electrolytes, CLENPIQ rel capsule GUARDIAN DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM Fexmid cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) CONNECT CONTINUOUS FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA GLUCOSE MONITORING SYSTEM FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) GUARDIAN REAL-TIME DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM CONTINUOUS GLUCOSE FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, MONITORING SYSTEM DUREZOL halcinonide cream desoximetasone (except desoximetasone ointment 0.05%), flucytosine capsule 500 fluconazole fluocinonide (except fluocinonide cream 0.1%), BRYHALI mg HORIZANT gabapentin, GRALISE fluocinonide cream 0.1% clobetasol cream HUMALOG FIASP, NOVOLOG fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA HUMALOG MIX 50/50 NOVOLOG MIX 70/30 fluoxetine tablet (generics fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet HUMALOG MIX 75/25 NOVOLOG MIX 70/30 for SARAFEM only) [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline HUMULIN 70/30 NOVOLIN 70/30

HUMULIN N NOVOLIN N fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 HUMULIN R NOVOLIN R mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate lipophilic cream 0.1% ointment, hydrocortisone butyrate solution, mometasone, flurandrenolide cream, desonide, hydrocortisone triamcinolone cream, triamcinolone lotion, triamcinolone flurandrenolide lotion ointment (except triamcinolone ointment 0.05%) flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, lotion ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) ointment (except triamcinolone ointment 0.05%) FML FORTE, FML dexamethasone, loteprednol, prednisolone acetate 1%, HylaVite folic acid LIQUIFILM, FML S.O.P. DUREZOL hyoscyamine sulfate ext- dicyclomine FOCALIN XR amphetamine-dextroamphetamine mixed salts ext-rel †, rel dexmethylphenidate ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER FOLIC-K folic acid HYZAAR candesartan-hydrochlorothiazide, irbesartan- Folvite-D folic acid hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan- LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, hydrochlorothiazide pravastatin, rosuvastatin, simvastatin icosapent ethyl omega-3 acid ethyl esters, VASCEPA levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER INCRUSE ELLIPTA SPIRIVA, YUPELRI LEXAPRO citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 INDERAL LA, INDERAL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, XL succinate ext-rel, metoprolol tartrate, nadolol, pindolol, paroxetine HCl ext-rel, sertraline, TRINTELLIX propranolol, propranolol ext-rel, BYSTOLIC LIALDA balsalazide, mesalamine delayed-rel (except mesalamine INDOCIN diclofenac sodium, ibuprofen, meloxicam, naproxen (except delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, naproxen CR or naproxen suspension) sulfasalazine delayed-rel, ASACOL HD, PENTASA indomethacin capsule 20 diclofenac sodium, ibuprofen, meloxicam, naproxen (except LIBRAX dicyclomine mg naproxen CR or naproxen suspension) LIDOCAINE- lidocaine-prilocaine TETRACAINE CREAM Inflammacin diclofenac sodium, diclofenac sodium gel 1%, (NDC^ 71800063115 only) diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) LIDOTREX lidocaine-prilocaine INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pravastatin, rosuvastatin, simvastatin pindolol, propranolol, propranolol ext-rel, BYSTOLIC LITHOSTAT Consult doctor INTRAROSA estradiol vaginal cream, IMVEXXY, VAGIFEM LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel †, pravastatin, rosuvastatin, simvastatin atomoxetine, dexmethylphenidate ext-rel, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE Lorid folic acid INVELTYS dexamethasone, loteprednol, prednisolone acetate 1%, Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) DUREZOL LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone acetate 1%, INVOKAMET, SYNJARDY, SYNJARDY XR, XIGDUO XR DUREZOL INVOKAMET XR luliconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, INVOKANA FARXIGA, JARDIANCE NAFTIN isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, isosorbide mononitrate BELSOMRA ISTALOL timolol maleate solution, BETOPTIC S LYRICA duloxetine, pregabalin JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH MACRODANTIN nitrofurantoin (except NDC^ 70408023932) alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin Matzim LA diltiazem ext-rel (except generics for CARDIZEM LA) JENTADUETO, JANUMET, JANUMET XR MAXALT, MAXALT-MLT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, JENTADUETO XR NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, KAMDOY desonide, hydrocortisone ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY KAZANO JANUMET, JANUMET XR MAXIDEX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5% mefenamic acid (NDC^ diclofenac sodium, ibuprofen, meloxicam, naproxen (except Ketodan ketoconazole shampoo 2%, selenium sulfide lotion 2.5% 69336012830 only) naproxen CR or naproxen suspension) ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) MENEST estradiol ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except MENOSTAR estradiol naproxen CR or naproxen suspension) mesalamine delayed-rel balsalazide, mesalamine delayed-rel (except mesalamine KOMBIGLYZE XR JANUMET, JANUMET XR tablet 800 mg delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA LACRISERT RESTASIS, XIIDRA metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) Lactojen Consult doctor metformin ext-rel metformin, metformin ext-rel (except generics for FORTAMET LACTULOSE PAK lactulose solution (generics for FORTAMET and GLUMETZA) LANOXIN TABLET digoxin and GLUMETZA only) (125 MCG and 250 MCG methocarbamol 500 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) only) (NDC^ 69036091010 lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, only), methocarbamol 750 VELPHORO mg (NDCs^ 69036093090, 70868090190 only) LANTUS 6 BASAGLAR, LEVEMIR MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, LASTACAFT azelastine, cromolyn sodium, olopatadine FORTEO, PROLIA, TYMLOS LAZANDA fentanyl transmucosal lozenge, SUBSYS MIACALCIN NASAL calcitonin-salmon

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* SPRAY nitrofurantoin (NDC^ nitrofurantoin (except NDC^ 70408023932) 70408023932 only) MICARDIS, candesartan, candesartan-hydrochlorothiazide, irbesartan, MICARDIS HCT irbesartan-hydrochlorothiazide, losartan, losartan- NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual hydrochlorothiazide, olmesartan, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- Nolix desonide, hydrocortisone hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NORITATE azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY NORPACE disopyramide MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, NORVASC amlodipine prednisolone solution, prednisone NOURIANZ amantadine, entacapone, pramipexole, pramipexole ext-rel, MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- rasagiline, ropinirole, ropinirole ext-rel, selegiline, NEUPRO levomefolate, ethinyl estradiol-norethindrone acetate, desonide, hydrocortisone ethinyl estradiol-norethindrone acetate-iron NOVACORT MINIVELLE estradiol, DIVIGEL, EVAMIST NOVO NORDISK BD ULTRAFINE NEEDLES NEEDLES 3 MINOCIN doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline NOXAFIL fluconazole, itraconazole NuDiclo SoluPak, NuDiclo diclofenac sodium, diclofenac sodium gel 1% minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, , minocycline, tetracycline TabPak diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) MIRVASO azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA NUVARING ethinyl estradiol-etonogestrel, ANNOVERA Mondoxyne NL capsule 75 doxycycline hyclate 20 mg, doxycycline hyclate capsule, armodafinil, modafinil, mg minocycline, tetracycline NUVIGIL SUNOSI OLEPTRO trazodone MOVIPREP peg 3350-electrolytes, CLENPIQ clobetasol foam MultiPro Consult doctor OLUX-E omeprazole-sodium esomeprazole delayed-rel, lansoprazole delayed-rel, mupirocin cream gentamicin, mupirocin ointment bicarbonate omeprazole delayed-rel, pantoprazole delayed-rel tablet, MYTESI diphenoxylate-atropine, loperamide DEXILANT NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except OMNARIS flunisolide, fluticasone, mometasone, DYMISTA naproxen CR or naproxen suspension) OMNIVEX folic acid naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except ONFI clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, ONGLYZA JANUVIA pantoprazole delayed-rel tablet or DEXILANT orphenadrine-aspirin- cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) naproxen CR diclofenac sodium, ibuprofen, meloxicam, naproxen (except caffeine naproxen CR or naproxen suspension) Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) ORTHO D folic acid NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- ORTHO DF folic acid levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol- norethindrone acetate, ethinyl estradiol-norethindrone acetate- Oscimin SR dicyclomine iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone NATURE-THROID levothyroxine, liothyronine, SYNTHROID OSMOPREP peg 3350-electrolytes, CLENPIQ NEO-SYNALAR desonide or hydrocortisone WITH gentamicin OSPHENA estradiol NESINA JANUVIA OWEN MUMFORD BD ULTRAFINE NEEDLES NEEDLES 3 NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA oxiconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel, (NDCs^ omeprazole delayed-rel, pantoprazole delayed-rel tablet, 00168035830, NAFTIN DEXILANT 51672135902 only) fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- niacin tablet 500 mg niacin ext-rel OXYCONTIN rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER Niacor niacin ext-rel oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- NICADAN folic acid rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER NICAPRIN folic acid OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, NICAZEL, NICAZEL folic acid TOVIAZ FORTE PANCREAZE CREON, VIOKACE, ZENPEP NICOMIDE folic acid pantoprazole delayed-rel esomeprazole delayed-rel, lansoprazole delayed-rel, NILANDRON abiraterone, bicalutamide, XTANDI, YONSA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* suspension omeprazole delayed-rel, pantoprazole delayed-rel tablet, mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, DEXILANT paroxetine HCl ext-rel, sertraline, TRINTELLIX paroxetine mesylate paroxetine HCl PSORCON desoximetasone (except desoximetasone ointment 0.05%), capsule 7.5 mg fluocinonide (except fluocinonide cream 0.1%), BRYHALI PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 QNASL flunisolide, fluticasone, mometasone, DYMISTA mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX QTERN GLYXAMBI PENNSAID diclofenac sodium, diclofenac sodium gel 1%, quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, diclofenac sodium solution, ibuprofen, meloxicam, BELSOMRA naproxen (except naproxen CR or naproxen suspension) RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, RAYOS dexamethasone, hydrocortisone, methylprednisolone, oxycodone-acetaminophen, NUCYNTA prednisolone solution, prednisone PERRIGO NEEDLES 3 BD ULTRAFINE NEEDLES RECEDO Consult doctor PERTZYE CREON, VIOKACE, ZENPEP RELION INSULIN NOVOLIN INSULIN PEXEVA citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 RHEUMATE folic acid mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX RIBOZEL folic acid PLAVIX clopidogrel, prasugrel, BRILINTA RIMSO-50 Consult doctor POLYTOZA Consult doctor RIOMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) posaconazole delayed-rel fluconazole, itraconazole tablet ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA PRADAXA warfarin, ELIQUIS, XARELTO RyClora levocetirizine PRECISION XTRA ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK STRIPS AND KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE RYTARY carbidopa-levodopa, carbidopa-levodopa ext-rel STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH SCARSILK PAD Consult doctor VERIO STRIPS AND KITS 2 SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol- PRED FORTE, PRED dexamethasone, loteprednol, prednisolone acetate 1%, MILD DUREZOL norethindrone acetate, ethinyl estradiol-norethindrone acetate- iron PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- PREMARIN estradiol rel, risperidone, ziprasidone, LATUDA, VRAYLAR PREMARIN CREAM estradiol vaginal cream, IMVEXXY, VAGIFEM SILENOR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA PRENATAL PLUS 5 prenatal vitamins, CITRANATAL SIL-K PAD Consult doctor PREVACID esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, SILIVEX Consult doctor DEXILANT SILTREX Consult doctor PREVIDENT Consult doctor SINGULAIR montelukast, zafirlukast PRILOSEC esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, SORILUX calcipotriene ointment, calcipotriene solution DEXILANT SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR naproxen suspension PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- or ) rel capsule SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV PROAIR HFA, PROAIR albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- sucralfate suspension sucralfate tablet RESPICLICK free aerosol sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR PRODIGEN Consult doctor or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA PROMETRIUM medroxyprogesterone; progesterone, micronized XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or PROTONIX esomeprazole delayed-rel, lansoprazole delayed-rel, ZOMIG NASAL SPRAY omeprazole delayed-rel, pantoprazole delayed-rel tablet, peg 3350-electrolytes, DEXILANT SUPREP CLENPIQ SURE-TEST STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK PROTOPIC pimecrolimus, tacrolimus, EUCRISA AND KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE PROVAD Consult doctor STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH PROVENTIL HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- VERIO STRIPS AND KITS 2 free aerosol Symax-SR dicyclomine PROVIGIL armodafinil, modafinil, SUNOSI SYNERDERM desonide, hydrocortisone PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* SYPRINE trientine TRICOR fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel TALIVA folic acid TRILIPIX fenofibrate (except fenofibrate capsule 50 mg, 130 mg; TARGADOX doxycycline hyclate 20 mg, doxycycline hyclate capsule, fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel minocycline, tetracycline TRINAZ 5 prenatal vitamins, CITRANATAL TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-norethindrone acetate, TRIVIDIA INSULIN BD ULTRAFINE INSULIN SYRINGES ethinyl estradiol-norethindrone acetate-iron SYRINGES 3 TAZORAC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ TronVite folic acid 68682046275), clindamycin solution, clindamycin-benzoyl 2 peroxide, erythromycin solution, erythromycin-benzoyl peroxide, TRUETEST STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU-CHEK 4 2 tretinoin, EPIDUO, ONEXTON; calcipotriene ointment, KITS COMPACT PLUS STRIPS AND KITS , ACCU-CHEK GUIDE 2 calcipotriene solution STRIPS AND KITS , ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH TESTIM testosterone gel (except authorized generics for TESTIM and VERIO STRIPS AND KITS 2 VOGELXO), testosterone solution, ANDRODERM, NATESTO TRUETRACK STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK testosterone gel 1% testosterone gel (except authorized generics for TESTIM and AND KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE (authorized generics for VOGELXO), testosterone solution, ANDRODERM, NATESTO STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND TESTIM and VOGELXO KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH only) VERIO STRIPS AND KITS 2 THEO-24 ipratropium inhalation solution, PERFOROMIST, SEREVENT, TUDORZA SPIRIVA, YUPELRI SPIRIVA, STRIVERDI RESPIMAT, YUPELRI ULORIC allopurinol THIOLA, THIOLA EC Consult doctor ULTIMED INSULIN BD ULTRAFINE INSULIN SYRINGES TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S SYRINGES 3 TIROSINT levothyroxine, SYNTHROID ULTIMED NEEDLES 3 BD ULTRAFINE NEEDLES TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin- UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin polymyxin B-dexamethasone, tobramycin- dexamethasone, TOBRADEX OINTMENT VALCYTE valganciclovir topiramate ext-rel capsule carbamazepine, carbamazepine ext-rel, clobazam, VALTREX acyclovir capsule, acyclovir tablet, valacyclovir (generics for QUDEXY XR divalproex sodium, divalproex sodium ext-rel, gabapentin, Vanoxide-HC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ only) lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext- 68682046275), clindamycin solution, clindamycin-benzoyl rel, oxcarbazepine, phenobarbital, phenytoin, peroxide, erythromycin solution, erythromycin-benzoyl peroxide, phenytoin sodium extended, primidone, rufinamide, tiagabine, tretinoin, EPIDUO, ONEXTON topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI VASCULERA Consult doctor TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, VECTICAL calcipotriene ointment, calcipotriene solution metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC VELTIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl TRADJENTA JANUVIA peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON tramadol (NDC^ tramadol (except NDC^ 52817019610), tramadol ext-rel tablet 52817019610 venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- only), tramadol ext-rel (except 225 mg) rel capsule capsule VENTOLIN HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- TRANSDERM SCOP meclizine, scopolamine transdermal free aerosol TRAVATAN Z latanoprost, travoprost, LUMIGAN, ZIOPTAN VEREGEN imiquimod TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR VIIBRYD citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 or naproxen suspension) WITH eletriptan, naratriptan, mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA paroxetine HCl ext-rel, sertraline, TRINTELLIX XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or 5 prenatal vitamins ZOMIG NASAL SPRAY VITAFOL-ONE , CITRANATAL Vitasure folic acid triamcinolone aerosol hydrocortisone butyrate cream, hydrocortisone butyrate 0.2% ointment, hydrocortisone butyrate solution, mometasone, VIVELLE-DOT estradiol, DIVIGEL, EVAMIST triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) VOGELXO testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM, NATESTO triamcinolone ointment hydrocortisone butyrate cream, hydrocortisone butyrate 0.05% ointment, hydrocortisone butyrate solution, mometasone, WESTHROID levothyroxine, liothyronine, SYNTHROID triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) WP THYROID levothyroxine, liothyronine, SYNTHROID Trianex hydrocortisone butyrate cream, hydrocortisone butyrate XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam ointment, hydrocortisone butyrate solution, mometasone, XOLEGEL ciclopirox, ketoconazole cream 2% triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) XOPENEX HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- free aerosol

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* Xvite folic acid ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER XYZBAC folic acid ZOLOFT citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 YASMIN ethinyl estradiol-drospirenone, mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol- paroxetine HCl ext-rel, sertraline, TRINTELLIX norethindrone acetate, ethinyl estradiol-norethindrone acetate- iron zolpidem sublingual doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA YAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-norethindrone acetate, ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, ethinyl estradiol-norethindrone acetate-iron BELSOMRA Yuvafem estradiol vaginal cream, IMVEXXY, VAGIFEM ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, 5 ZALVIT prenatal vitamins, CITRANATAL lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, ZEGERID esomeprazole delayed-rel, lansoprazole delayed-rel, oxcarbazepine, phenobarbital, phenytoin, omeprazole delayed-rel, pantoprazole delayed-rel tablet, phenytoin sodium extended, primidone, tiagabine, topiramate, DEXILANT valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI ZELAC Consult doctor ZONTIVITY Consult doctor ZERVIATE azelastine, cromolyn sodium, olopatadine ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide, naproxen CR or naproxen suspension) quinapril-hydrochlorothiazide ZUPLENZ granisetron, ondansetron, SANCUSO ZETIA ezetimibe ZYFLO montelukast, zafirlukast ZETONNA flunisolide, fluticasone, mometasone, DYMISTA ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin- ZIANA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ polymyxin B-dexamethasone, tobramycin-dexamethasone, 68682046275), clindamycin solution, clindamycin-benzoyl TOBRADEX OINTMENT peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON ZYVIT folic acid zileuton ext-rel montelukast, zafirlukast ZIRGAN trifluridine

You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. † Listing does not include certain NDCs^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a per centage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter othe r than ACCU-CHEK or ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 3 BD ULTRAFINE syringes and needles are the only preferred options. 4 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 5 Generic prenatal vitamins and CITRANATAL are the only preferred options. 6 Long Acting Insulins - First Generation.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and manda tory generics whenever applicable.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.