Medications Requiring Prior Authorization for Medical Necessity for Standard Option, High Option and High Deductible Health Plan (HDHP) Members

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July 2021 Medications Requiring Prior Authorization for Medical Necessity for Standard Option, High Option and High Deductible Health Plan (HDHP) Members

Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. If you continue using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost.

If you are currently using one of the drugs requiring prior authorization for medical nec essity, ask your doctor to choose one of the generic or brand formulary options listed below.

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Acromegaly SANDOSTATIN LAR SOMATULINE DEPOT SIGNIFOR LAR SOMAVERT Allergies dexchlorpheniramine levocetirizine Diphen Elixir Antihistamines RyClora CARBINOXAMINE TABLET 6 MG Allergies BECONASE AQ flunisolide spray, fluticasone spray, mometasone spray, DYMISTA Nasal Steroids / Combinations OMNARIS QNASL ZETONNA Anticonvulsants topiramate ext-rel capsule carbamazepine, carbamazepine ext-rel, clobazam, divalproex sodium, (generics for QUDEXY XR only) divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, rufinamide, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

BANZEL SUSPENSION clobazam, clonazepam, lamotrigine, rufinamide, topiramate, TROKENDI XR ONFI

SABRIL vigabatrin

ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

Anti-infectives, Antibacterials E.E.S. GRANULES erythromycins Erythromycins / Macrolides ERYPED Anti-infectives, Antibacterials doxycycline hyclate delayed-rel tablet 50 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, Tetracyclines doxycycline hyclate delayed-rel tablet 200 mg tetracycline doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only) doxycycline hyclate tablet 75 mg doxycycline hyclate tablet 150 mg doxycycline monohydrate capsule 75 mg doxycycline monohydrate capsule 150 mg minocycline ext-rel CoreMino Mondoxyne NL capsule 75 mg ACTICLATE DORYX DORYX MPC

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1

MINOCIN TARGADOX Anti-infectives, Antibacterials nitrofurantoin Miscellaneous MACRODANTIN Anti-infectives, Antifungals flucytosine capsule 500 mg fluconazole posaconazole delayed-rel tablet fluconazole, itraconazole

Anti-infectives, Antiretroviral Agents APTIVUS Consult doctor Protease Inhibitors INVIRASE atazanavir, lopinavir-ritonavir solution, EVOTAZ, PREZCOBIX, PREZISTA LEXIVA VIRACEPT Anti-infectives, Antivirals VALCYTE valganciclovir Cytomegalovirus * Anti-infectives, Antivirals BARACLUDE TABLET entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, EPIVIR HBV VEMLIDY Hepatitis B * HEPSERA

Anti-infectives, Antivirals MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2 Hepatitis C * VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) ZEPATIER Anti-infectives, Antivirals acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir Herpes * VALTREX Anti-infectives, Antivirals COMPLERA efavirenz-emtricitabine-tenofovir disoproxil fumarate, HIV STRIBILD efavirenz-lamivudine-tenofovir disoproxil fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ Anti-infectives DARAPRIM pyrimethamine Miscellaneous Anxiety * alprazolam, clonazepam, diazepam, lorazepam, oxazepam XANAX Benzodiazepines XANAX XR Asthma * PROAIR HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol PROAIR RESPICLICK Beta Agonists, Short-Acting PROVENTIL HFA VENTOLIN HFA XOPENEX HFA Asthma * SINGULAIR montelukast, zafirlukast Leukotriene Modulators Asthma * ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, Steroid Inhalants ASMANEX PULMICORT FLEXHALER, QVAR REDIHALER ASMANEX HFA Asthma * or Chronic Obstructive DULERA ADVAIR DISKUS, ADVAIR HFA †, BREO ELLIPTA †, SYMBICORT Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Attention Deficit Hyperactivity amphetamine-dextroamphetamine mixed salts, methylphenidate Disorder * EVEKEO ADZENYS ER amphetamine-dextroamphetamine mixed salts ext-rel †, ADZENYS XR-ODT dexmethylphenidate ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE APTENSIO XR DAYTRANA

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel †, atomoxetine, dexmethylphenidate ext-rel, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE Autoimmune Agents ACTEMRA INTRAVENOUS REMICADE, SIMPONI ARIA Physician-Administered Agents ORENCIA INTRAVENOUS AVSOLA REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS CIMZIA LYOPHILIZED POWDER INFLECTRA RENFLEXIS

ENTYVIO (For Crohn's Disease Only) REMICADE, STELARA INTRAVENOUS

ILUMYA REMICADE Autoimmune Agents CIMZIA PREFILLED SYRINGE COSENTYX, ENBREL, HUMIRA SIMPONI Self-Administered Agents TALTZ Ankylosing Spondylitis * Autoimmune Agents CIMZIA PREFILLED SYRINGE HUMIRA, STELARA SUBCUTANEOUS # Self-Administered Agents # After failure of HUMIRA Crohn's Disease * Autoimmune Agents CIMZIA PREFILLED SYRINGE HUMIRA, OTEZLA, SKYRIZI, STELARA SUBCUTANEOUS, TALTZ, TREMFYA Self-Administered Agents COSENTYX ENBREL Psoriasis * Autoimmune Agents CIMZIA PREFILLED SYRINGE COSENTYX, ENBREL, HUMIRA, OTEZLA ORENCIA CLICKJECT Self-Administered Agents ORENCIA SUBCUTANEOUS Psoriatic Arthritis * SIMPONI STELARA SUBCUTANEOUS TALTZ TREMFYA XELJANZ XELJANZ XR Autoimmune Agents ACTEMRA ACTPEN ENBREL, HUMIRA, KEVZARA, ORENCIA CLICKJECT, ACTEMRA SUBCUTANEOUS ORENCIA SUBCUTANEOUS, RINVOQ, XELJANZ, XELJANZ XR Self-Administered Agents CIMZIA PREFILLED SYRINGE Rheumatoid Arthritis * KINERET SIMPONI Autoimmune Agents SIMPONI HUMIRA, STELARA SUBCUTANEOUS #, XELJANZ #, XELJANZ XR #

Self-Administered Agents # After failure of HUMIRA Ulcerative Colitis * Autoimmune Agents ACTEMRA ACTPEN ENBREL, HUMIRA Self-Administered Agents ACTEMRA SUBCUTANEOUS KINERET All Other Conditions * ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS Cancer RIABNI RUXIENCE Biosimilars TRUXIMA

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Cancer GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL Chronic Myelogenous Leukemia * TASIGNA Cancer ALIQOPA COPIKTRA Follicular Lymphoma * ZYDELIG PI3K Inhibitors Cancer AVASTIN ZIRABEV Monoclonal Antibodies HERCEPTIN KANJINTI, TRAZIMERA HERCEPTIN HYLECTA

RITUXAN RUXIENCE Cancer BORTEZOMIB NINLARO, VELCADE Multiple Myeloma * KYPROLIS Proteasome Inhibitors Cancer NILANDRON abiraterone, bicalutamide, XTANDI, YONSA Prostate * ZYTIGA

Antiandrogens Cancer LUPRON DEPOT ELIGARD, FIRMAGON TRELSTAR MIXJECT Prostate * ZOLADEX Luteinizing Hormone-Releasing Hormone (LHRH) Agonists Cardiovascular BETAPACE sotalol Antiarrhythmics BETAPACE AF Cardiovascular ZETIA ezetimibe Antilipemics Cholesterol Absorption Inhibitors Cardiovascular fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel fenofibrate tablet 120 mg Antilipemics FENOGLIDE TABLET 120 MG Fibrates TRICOR Cardiovascular ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, Antilipemics CRESTOR rosuvastatin, simvastatin LESCOL XL HMG-CoA Reductase Inhibitors LIPITOR (HMGs or Statins) / Combinations 3 LIVALO Cardiovascular niacin tablet 500 mg niacin ext-rel Antilipemics Niacor Niacins Cardiovascular icosapent ethyl omega-3 acid ethyl esters, VASCEPA Antilipemics Omega-3 Fatty Acids Cardiovascular REPATHA PRALUENT Antilipemics PCSK9 Inhibitors Cardiovascular LANOXIN TABLET digoxin Digitalis Glycosides (125 MCG and 250 MCG only)

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Cardiovascular DYRENIUM amiloride, triamterene Diuretics Cardiovascular isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate Nitrates Cardiovascular LETAIRIS ambrisentan, bosentan, OPSUMIT Pulmonary Arterial Hypertension TRACLEER Endothelin Receptor Antagonists Cardiovascular ADCIRCA sildenafil, tadalafil Pulmonary Arterial Hypertension REVATIO

Phosphodiesterase Inhibitors Cardiovascular REMODULIN treprostinil Pulmonary Arterial Hypertension Prostaglandin Vasodilators Carnitine Deficiency CARNITOR levocarnitine CARNITOR SF Central Precocious Puberty LUPRON DEPOT-PED SUPPRELIN LA, TRIPTODUR Chronic Obstructive Pulmonary INCRUSE ELLIPTA SPIRIVA, YUPELRI Disease (COPD) * TUDORZA Anticholinergics Chronic Obstructive Pulmonary BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT Disease (COPD) * Anticholinergic / Beta Agonist Combinations Long Acting Contraceptives BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, Monophasic MINASTRIN 24 FE ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate- TAYTULLA iron

YAZ Contraceptives NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, Four Phase ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE Contraceptives LILETTA KYLEENA, MIRENA, SKYLA Progestin Intrauterine Devices Contraceptives NUVARING ethinyl estradiol-etonogestrel, ANNOVERA Vaginal Cystic Fibrosis * TOBI tobramycin inhalation solution, BETHKIS Inhaled Antibiotics TOBI PODHALER Dental PREVIDENT Consult doctor Cavity/Caries Prevention

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Depression * fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, LEXAPRO fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext- Antidepressants, Selective Serotonin PAXIL rel, sertraline, TRINTELLIX Reuptake Inhibitors (SSRIs) PAXIL CR PEXEVA PROZAC VIIBRYD Depression * venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule CYMBALTA Antidepressants, Serotonin EFFEXOR XR Norepinephrine Reuptake Inhibitors PRISTIQ (SNRIs) Depression * bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) Antidepressants, OLEPTRO trazodone Miscellaneous Agents Depression and/or Schizophrenia * ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, Antipsychotics, Atypicals FANAPT ziprasidone, LATUDA, VRAYLAR SEROQUEL XR Dermatology clindamycin gel (NDC^ 68682046275 only) adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), Acne * Vanoxide-HC clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, ACANYA erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON AZELEX BENZACLIN DIFFERIN LOTION FABIOR TAZORAC VELTIN ZIANA

Dermatology fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, Actinic Keratosis * CARAC ZYCLARA Dermatology mupirocin cream gentamicin, mupirocin ointment Antibiotics Dermatology calcipotriene cream calcipotriene ointment, calcipotriene solution Antipsoriatics calcitriol ointment SORILUX TAZORAC VECTICAL

calcipotriene-betamethasone calcipotriene ointment or calcipotriene solution WITH desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%) or BRYHALI Dermatology doxepin cream desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA Atopic Dermatitis * Dermatology doxycycline monohydrate delayed-rel capsule ORACEA Rosacea * FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA MIRVASO NORITATE

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Dermatology BEAU RX Consult doctor CICATRACE Scars POLYTOZA RECEDO SCARSILK PAD SIL-K PAD SILIVEX SILTREX Dermatology ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5% Seborrheic Dermatitis * Ketodan XOLEGEL ciclopirox, ketoconazole cream 2%

Dermatology clobetasol spray clobetasol foam Skin Inflammation and Hives * CLOBEX SPRAY OLUX-E Corticosteroids fluocinonide cream 0.1% clobetasol cream

flurandrenolide lotion (NDC^ 24470092112 desonide, hydrocortisone only)

flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone aerosol 0.2% triamcinolone lotion, triamcinolone ointment CORDRAN OINTMENT

diflorasone cream desoximetasone (except desoximetasone ointment 0.05%), diflorasone ointment fluocinonide (except fluocinonide cream 0.1%), BRYHALI APEXICON E PSORCON Dermatology VEREGEN imiquimod Warts Dermatology ALEVICYN GEL desonide, hydrocortisone Wound Care Products ALEVICYN SG ALEVICYN SOLUTION Dermatology ALCORTIN A desonide, hydrocortisone Miscellaneous Skin Conditions ATOPADERM BENSAL HP EPICERAM KAMDOY NOVACORT SYNERDERM

oxiconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, luliconazole, (NDCs^ 00168035830, 51672135902 only) NAFTIN Diabetes * metformin ext-rel (generics for FORTAMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) and GLUMETZA only) Biguanides FORTAMET GLUMETZA RIOMET Diabetes * NESINA JANUVIA ONGLYZA Dipeptidyl Peptidase-4 TRADJENTA (DPP-4) Inhibitors

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Diabetes * JENTADUETO JANUMET, JANUMET XR JENTADUETO XR Dipeptidyl Peptidase-4 KAZANO (DPP-4) Inhibitor Combinations KOMBIGLYZE XR

OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone Diabetes * BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA Injectable Incretin Mimetics BYETTA Diabetes * APIDRA FIASP, NOVOLOG Insulins HUMALOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 4 NOVOLIN 70/30 4

HUMULIN N 4 NOVOLIN N 4

HUMULIN R 4 NOVOLIN R 4

NOTE: Humulin R U-500 concentrate will not be subject to prior authorization and will continue to be covered.

Diabetes * LANTUS BASAGLAR, LEVEMIR Long Acting Insulins 5 Diabetes * ACTOS pioglitazone Insulin Sensitizers Diabetes * INVOKANA FARXIGA, JARDIANCE Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors Diabetes * INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR Sodium-Glucose INVOKAMET XR Co-transporter 2 (SGLT2) Inhibitor / Biguanide Combinations Diabetes * QTERN GLYXAMBI Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor / Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations Diabetes * NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES 6 OWEN MUMFORD NEEDLES Supplies, Needles PERRIGO NEEDLES ULTIMED NEEDLES All other insulin needles that are not BD ULTRAFINE brand Diabetes * ALLISON MEDICAL INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES Supplies, Syringes 6 TRIVIDIA INSULIN SYRINGES ULTIMED INSULIN SYRINGES All other insulin syringes that are not BD ULTRAFINE brand

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Diabetes * BREEZE 2 STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 7, 7 7, 8 CONTOUR NEXT STRIPS AND KITS ACCU-CHEK COMPACT PLUS STRIPS AND KITS , Supplies, Test Strips and Kits CONTOUR STRIPS AND KITS ACCU-CHEK GUIDE STRIPS AND KITS 7, FREESTYLE STRIPS AND KITS ACCU-CHEK SMARTVIEW STRIPS AND KITS 7, All other test strips that are not ONETOUCH ULTRA STRIPS AND KITS 7, ACCU-CHEK or ONETOUCH brand ONETOUCH VERIO STRIPS AND KITS 7 Endometriosis * LUPRON DEPOT ORILISSA ZOLADEX

Gastrointestinal chlordiazepoxide-clidinium dicyclomine (NDC^ 42494040901 only) Anticholinergics hyoscyamine sulfate ext-rel Oscimin SR Symax-SR GLYCOPYRROLATE TABLET 1.5 MG Gastrointestinal ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG Antidiarrheals MYTESI diphenoxylate-atropine, loperamide Gastrointestinal TRANSDERM SCOP meclizine, scopolamine transdermal Antiemetics ZUPLENZ granisetron, ondansetron, SANCUSO Gastrointestinal AMITIZA LINZESS, MOVANTIK, SYMPROIC Irritable Bowel Syndrome Gastrointestinal LACTULOSE PAK lactulose solution Laxatives GOLYTELY peg 3350-electrolytes, CLENPIQ MOVIPREP OSMOPREP SUPREP Gastrointestinal omeprazole-sodium bicarbonate esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, ACIPHEX pantoprazole delayed-rel tablet, DEXILANT Proton Pump Inhibitors (PPIs) ACIPHEX SPRINKLE NEXIUM PREVAC PROTONIX ZEGERID Gastrointestinal sucralfate suspension sucralfate tablet Ulcer Treatment CARAFATE Gaucher Disease ELELYSO CERDELGA, CEREZYME Genitourinary RIMSO-50 Consult doctor Interstitial Cystitis Gout * COLCRYS colchicine tablet, MITIGARE ULORIC allopurinol Growth Hormones GENOTROPIN NORDITROPIN HUMATROPE NUTROPIN AQ OMNITROPE SAIZEN Hematologic PRADAXA warfarin, ELIQUIS, XARELTO Anticoagulants (oral) DESFERAL deferasirox, deferiprone, deferoxamine EXJADE

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1

FERRIPROX JADENU Hematologic EPOGEN ARANESP, RETACRIT Erythropoiesis-Stimulating Agents PROCRIT Hematologic ALPROLIX Consult doctor Hemophilia B Hematologic FULPHILA ZIEXTENZO Neutropenia Colony Stimulating NEULASTA NEULASTA ONPRO Factors UDENYCA

GRANIX NIVESTYM NEUPOGEN ZARXIO Hematologic PLAVIX clopidogrel, prasugrel, BRILINTA Platelet Aggregation Inhibitors ZONTIVITY Consult doctor High Blood Pressure * ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide, ACE Inhibitor / Diuretic quinapril-hydrochlorothiazide Combinations High Blood Pressure * ATACAND candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan Angiotensin II Receptor Antagonists BENICAR DIOVAN EDARBI High Blood Pressure * ATACAND HCT candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, Angiotensin II Receptor Antagonist / BENICAR HCT losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, DIOVAN HCT telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide Diuretic Combinations EDARBYCLOR High Blood Pressure * EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan Angiotensin II Receptor Antagonist / Calcium Channel Blocker Combinations High Blood Pressure * EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, Angiotensin II Receptor Antagonist / olmesartan-amlodipine-hydrochlorothiazide Calcium Channel Blocker / Diuretic Combinations High Blood Pressure * INDERAL LA atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, INDERAL XL metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC Beta-blockers INNOPRAN XL TOPROL-XL High Blood Pressure * DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide Beta-blocker Combinations

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 High Blood Pressure * NORVASC amlodipine Calcium Channel Blockers diltiazem ext-rel diltiazem ext-rel (except generics for CARDIZEM LA) (generics for CARDIZEM LA only) Matzim LA CARDIZEM CARDIZEM CD CARDIZEM LA High Blood Pressure * CONSENSI amlodipine WITH celecoxib Calcium Channel Blocker / Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Combinations Huntington's Disease XENAZINE tetrabenazine, AUSTEDO Immunology CELLCEPT mycophenolate mofetil, mycophenolate sodium Antimetabolites MYFORTIC Immunology ASTAGRAF XL tacrolimus Calcineurin Inhibitors ENVARSUS XR Immunology OTREXUP RASUVO Disease Modifying Antirheumatic Agents Immunology BERINERT icatibant, RUCONEST Hereditary Angioedema * Immunology RAPAMUNE everolimus, sirolimus Rapamycin Derivatives ZORTRESS Inflammatory Bowel Disease (IBD) balsalazide, mesalamine delayed-rel Ulcerative Colitis * COLAZAL mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, DELZICOL PENTASA Aminosalicylates LIALDA Interferons * PEGASYS Consult doctor Kidney Disease * lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO Phosphate Binders FOSRENOL Menopausal Symptom Agents MENEST estradiol Oral OSPHENA PREMARIN Menopausal Symptom Agents MINIVELLE estradiol, DIVIGEL, EVAMIST Transdermal VIVELLE-DOT Menopausal Symptom Agents ESTRING estradiol vaginal cream, IMVEXXY, VAGIFEM Vaginal FEMRING INTRAROSA PREMARIN CREAM Multiple Sclerosis AVONEX dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, EXTAVIA COPAXONE, GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, PLEGRIDY VUMERITY, ZEPOSIA TECFIDERA

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Musculoskeletal chlorzoxazone 375 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) chlorzoxazone 500 mg (NDC^ 73007001303 only) chlorzoxazone 750 mg cyclobenzaprine ext-rel capsule cyclobenzaprine tablet 7.5 mg metaxalone 400 mg methocarbamol 500 mg (NDC^ 69036091010 only) methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only) orphenadrine-aspirin-caffeine Fexmid Lorzone Orphengesic Forte AMRIX CHLORZOXAZONE 250 MG NORGESIC FORTE Narcolepsy NUVIGIL armodafinil, modafinil, SUNOSI Wakefulness Promoters Nephropathic Cystinosis PROCYSBI CYSTAGON Ophthalmic ALREX azelastine, cromolyn sodium, olopatadine, LASTACAFT, PAZEO Allergies BEPREVE Ophthalmic neomycin-polymyxin B-bacitracin-hydrocortisone, ZYLET neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, Anti-infective / Anti-inflammatory TOBRADEX OINTMENT, TOBRADEX ST Ophthalmic bromfenac, diclofenac, ketorolac, ACUVAIL, ILEVRO, NEVANAC, PROLENSA BROMSITE Anti-inflammatory, Nonsteroidal Ophthalmic FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML LIQUIFILM FML FORTE, FML S.O.P., MAXIDEX, PRED MILD Anti-inflammatory, Steroidal LOTEMAX LOTEMAX SM PRED FORTE Ophthalmic ZIRGAN trifluridine Antivirals Ophthalmic LACRISERT RESTASIS, XIIDRA Artificial Tears Ophthalmic bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN Glaucoma TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, BETOPTIC S Ophthalmic AVENOVA Consult doctor Miscellaneous Opioid Dependency SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV Osteoarthritis * GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX HYALGAN Viscosupplements MONOVISC ORTHOVISC SYNVISC SYNVISC-ONE VISCO-3

MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, TYMLOS

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Osteoporosis * MIACALCIN NASAL SPRAY calcitonin-salmon Calcium Regulators Otic CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic Anti-infective / Anti-inflammatory CIPRODEX Overactive Bladder / Incontinence * DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, Urinary Antispasmodics ENABLEX trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ OXYTROL Pain butalbital-acetaminophen tablet 50-300 mg diclofenac sodium, ibuprofen, butalbital-acetaminophen-caffeine capsule naproxen (except naproxen CR or naproxen suspension) Headache * Bupap BUTALBITAL-ACETAMINOPHEN (NDC^ 69499034230 only) CAMBIA FIORICET CAPSULE

dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ergotamine-caffeine ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, Migergot ZOMIG NASAL SPRAY CAFERGOT

sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR or TREXIMET naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY Pain BUTRANS buprenorphine transdermal, BELBUCA Opioid Analgesics LAZANDA fentanyl transmucosal lozenge, SUBSYS

levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, oxymorphone ext-rel morphine ext-rel, NUCYNTA ER, XTAMPZA ER HYSINGLA ER OXYCONTIN ZOHYDRO ER

PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA

tramadol (NDC^ 52817019610 only) tramadol (except NDC^ 52817019610), tramadol ext-rel Pain LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine Topical Local Anesthetics (NDC^ 71800063115 only) LIDOTREX Pain and Inflammation * MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, Corticosteroids RAYOS prednisone

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Pain and Inflammation * ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH Nonsteroidal Anti-inflammatory esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, Drugs (NSAIDs) / Combinations pantoprazole delayed-rel tablet or DEXILANT

Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, Diclosaicin ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) Inflammacin NuDiclo SoluPak NuDiclo TabPak PENNSAID

fenoprofen diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or indomethacin capsule 20 mg naproxen suspension) ketoprofen capsule 25 mg ketoprofen ext-rel capsule mefenamic acid (NDC^ 69336012830 only) naproxen CR naproxen suspension FENOPROFEN CAPSULE INDOCIN NAPRELAN SPRIX ZORVOLEX

naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed- rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or DEXILANT Parkinson’s Disease APOKYN INBRIJA, KYNMOBI Phenylketonuria KUVAN sapropterin Postherpetic Neuralgia HORIZANT gabapentin, GRALISE Premenstrual Dysphoric Disorder fluoxetine tablet (generics for SARAFEM fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for (PMDD) only) SARAFEM]), paroxetine HCl ext-rel, sertraline

Prenatal Vitamins 9 AZESCO prenatal vitamins, CITRANATAL PRENATAL PLUS VITAFOL-ONE ZALVIT All other brand prenatal vitamins that are not CITRANATAL

Prostate Condition JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, Benign Prostatic Hyperplasia * doxazosin, silodosin, tamsulosin or terazosin RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin UROXATRAL Respiratory ARALAST NP PROLASTIN-C Alpha-1 Antitrypsin Deficiency GLASSIA ZEMAIRA Respiratory benzonatate benzonatate (except NDCs^ 69336012615, 69499032915) Cough (NDCs^ 69336012615, 69499032915 only) Sleep Disorder quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem Hypnotics, Non-benzodiazepines LUNESTA sublingual, BELSOMRA ROZEREM ZOLPIMIST

Category Drugs Requiring Prior Formulary Options Drug Class Authorization for (May Require Prior Authorization) Medical Necessity 1 Testosterone Replacement * testosterone gel 1% (authorized generics for testosterone gel (except authorized generics for TESTIM and VOGELXO), TESTIM and VOGELXO only) testosterone solution, ANDRODERM, NATESTO Androgens ANDROGEL 1% FORTESTA TESTIM VOGELXO Thyroid Supplements TIROSINT levothyroxine, SYNTHROID Transplant * PROGRAF tacrolimus Immunosuppressants, Calcineurin Inhibitors Urea Cycle Disorders BUPHENYL sodium phenylbutyrate RAVICTI Uterine Fibroids * LUPRON DEPOT ORIAHNN

Category Other Considerations Drug Class All Drugs On a quarterly basis, new and existing products - including limited source generics, products with significant cost inflation, and specialty and non-specialty products - may be re-evaluated to determine appropriate formulary placement. These evaluations will assess whether clinically appropriate and cost-effective options remain available on the formulary and may result in additional products not covered without a medical exception, addition or deletion of a product. Autoimmune and Hepatitis C * For some clients, an Indication-Based Formulary will be utilized for products in these classes and may result in additional products not covered for certain conditions without a medical exception. Drugs for Infusion into Spaces Other A drug that must be infused into a space other than the blood will generally not be covered under the prescription drug benefit. Than the Blood

New-to-Market Agents 1 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.

The listed formulary options are subject to change. List of Drugs Requiring Prior Authorization for Medical Necessity ABILIFY ALREX AVONEX ACANYA ALTOPREV AVSOLA ACIPHEX ALVESCO AZELEX ACIPHEX SPRINKLE AMITIZA AZESCO ACTEMRA ACTPEN AMRIX BANZEL SUSPENSION ACTEMRA INTRAVENOUS ANDROGEL BARACLUDE TABLET ACTEMRA SUBCUTANEOUS APEXICON E BEAU RX ACTICLATE APIDRA BECONASE AQ Activite APOKYN BENICAR ACTOS APTENSIO XR BENICAR HCT acyclovir cream APTIVUS BENSAL HP ADCIRCA ARALAST NP BENZACLIN ADZENYS ER ARTHROTEC benzonatate (NDCs^ 69336012615, 69499032915 only) ADZENYS XR-ODT ASMANEX BEPREVE ALCORTIN A ASMANEX HFA BERINERT ALEVICYN GEL ASTAGRAF XL BETAPACE ALEVICYN SG ATACAND BETAPACE AF ALEVICYN SOLUTION ATACAND HCT BEVESPI AEROSPHERE ALIQOPA ATOPADERM BEYAZ ALLISON MEDICAL INSULIN SYRINGES 6 AVASTIN bimatoprost solution 0.03% ALPROLIX AVENOVA BORTEZOMIB

BREEZE 2 STRIPS AND KITS 8 doxycycline hyclate tablet 75 mg HUMULIN 70/30 4 Bupap doxycycline hyclate tablet 150 mg HUMULIN N 4 BUPHENYL doxycycline monohydrate capsule 75 mg HUMULIN R 4 bupropion ext-rel tablet 450 mg doxycycline monohydrate capsule 150 mg HYALGAN butalbital-acetaminophen tablet 50-300 mg doxycycline monohydrate delayed-rel capsule hydrocortisone butyrate lipophilic cream 0.1% BUTALBITAL-ACETAMINOPHEN DULERA HylaVite (NDC^ 69499034230 only) DUTOPROL hyoscyamine sulfate ext-rel butalbital-acetaminophen-caffeine capsule DYRENIUM HYSINGLA ER BUTRANS EDARBI icosapent ethyl BYDUREON EDARBYCLOR ILUMYA BYETTA E.E.S. GRANULES INCRUSE ELLIPTA CAFERGOT EFFEXOR XR INDERAL LA calcipotriene cream ELELYSO INDERAL XL calcipotriene-betamethasone ELIDEL INDOCIN calcitriol ointment ENABLEX indomethacin capsule 20 mg CAMBIA ENTERAGAM Inflammacin CARAC ENTYVIO (For Crohn's Disease Only) INFLECTRA CARAFATE ENVARSUS XR INNOPRAN XL CARBINOXAMINE TABLET 6 MG EPICERAM INTRAROSA CARDIZEM EPIVIR HBV INTUNIV CARDIZEM CD EPOGEN INVIRASE CARDIZEM LA ergotamine-caffeine INVOKAMET CARNITOR ERYPED INVOKAMET XR CARNITOR SF ESTRING INVOKANA CELLCEPT EVEKEO isosorbide dinitrate 40 mg chlordiazepoxide-clidinium (NDC^, EXFORGE JADENU 42494040901, , only) EXFORGE HCT JALYN CHLORZOXAZONE 250 MG EXJADE JENTADUETO chlorzoxazone 375 mg EXTAVIA JENTADUETO XR chlorzoxazone 500 mg (NDC^ 73007001303 only) FABIOR KAMDOY chlorzoxazone 750 mg FANAPT KAZANO CICATRACE FEMRING ketoconazole foam 2% CIMZIA LYOPHILIZED POWDER fenofibrate tablet 120 mg Ketodan CIMZIA PREFILLED SYRINGE FENOGLIDE TABLET 120 MG ketoprofen capsule 25 mg CIPRO HC fenoprofen ketoprofen ext-rel capsule CIPRODEX FENOPROFEN CAPSULE KINERET clindamycin gel (NDC^ 68682046275 only) FERIVA 21/7 KOMBIGLYZE XR clobetasol spray FERRIPROX KUVAN CLOBEX SPRAY Fexmid KYPROLIS COLAZAL FINACEA GEL LACRISERT COLCRYS FIORICET CAPSULE LACTULOSE PAK COMPLERA flucytosine capsule 500 mg LANOXIN TABLET (125 MCG and 250 MCG only) CONSENSI fluocinonide cream 0.1% lanthanum carbonate CONTOUR NEXT STRIPS AND KITS 8 fluorouracil cream 0.5% LANTUS CONTOUR STRIPS AND KITS 8 fluoxetine tablet (generics for SARAFEM only) LAZANDA CORDRAN OINTMENT fluoxetine tablet 60 mg LESCOL XL CoreMino flurandrenolide lotion (NDC^ 24470092112 only) LETAIRIS CRESTOR flurandrenolide ointment levorphanol cyclobenzaprine ext-rel capsule FML LIQUIFILM LEXAPRO cyclobenzaprine tablet 7.5 mg FOLIC-K LEXIVA CYMBALTA Folvite-D LIALDA DARAPRIM FORTAMET LIDOCAINE-TETRACAINE CREAM DAYTRANA FORTESTA (NDC^ 71800063115 only) DELZICOL FOSRENOL LIDOTREX DESFERAL FOSTEUM LILETTA DETROL LA FOSTEUM PLUS LIPITOR dexchlorpheniramine FREESTYLE STRIPS AND KITS 8 LIVALO Dexifol FULPHILA Lorid Diclofex DC (NDC^ 51021037201 only) GEL-ONE Lorzone Diclosaicin Genicin Vita-S LOTEMAX DIFFERIN LOTION GENOTROPIN LOTEMAX SM diflorasone cream GLASSIA LUNESTA diflorasone ointment GLEEVEC LUPRON DEPOT dihydroergotamine spray GLUMETZA LUPRON DEPOT-PED diltiazem ext-rel (generics for CARDIZEM LA only) GLYCOPYRROLATE TABLET 1.5 MG MACRODANTIN DIOVAN GOLYTELY Matzim LA DIOVAN HCT GRANIX MAVYRET Diphen Elixir HEPSERA mefenamic acid (NDC^ 69336012830 only) DORYX HERCEPTIN MENEST DORYX MPC HERCEPTIN HYLECTA metaxalone 400 mg doxepin cream HORIZANT metformin ext-rel doxycycline hyclate delayed-rel tablet 50 mg HUMALOG (generics for FORTAMET and GLUMETZA only) doxycycline hyclate delayed-rel tablet 200 mg HUMALOG MIX 50/50 methocarbamol 500 mg (NDC^ 69036091010 only) doxycycline hyclate tablet 50 mg HUMALOG MIX 75/25 methocarbamol 750 mg (NDC^ 72143021160 only) HUMATROPE (NDCs^ 69036093090, 70868090190 only)

MIACALCIN INJECTION PERRIGO NEEDLES 6 testosterone gel 1% MIACALCIN NASAL SPRAY PEXEVA (authorized generics for TESTIM and VOGELXO only) Migergot PLAVIX TIMOPTIC OCUDOSE MILLIPRED PLEGRIDY TIROSINT MINASTRIN 24 FE POLYTOZA TOBI MINIVELLE posaconazole delayed-rel tablet TOBI PODHALER MINOCIN PRADAXA topiramate ext-rel capsule (generics for QUDEXY XR only) minocycline ext-rel PRED FORTE TOPROL-XL MIRVASO PREMARIN TRACLEER Mondoxyne NL capsule 75 mg PREMARIN CREAM TRADJENTA MONOVISC PRENATAL PLUS tramadol (NDC^ 52817019610 only) MOVIPREP PREVACID TRANSDERM SCOP MultiPro PREVIDENT TRELSTAR MIXJECT mupirocin cream PRISTIQ TREXIMET MYFORTIC PROAIR HFA triamcinolone aerosol 0.2% MYTESI PROAIR RESPICLICK TRICOR NAPRELAN PROCRIT TRIVIDIA INSULIN SYRINGES 6 naproxen-esomeprazole PROCYSBI TronVite naproxen CR PRODIGEN TRUXIMA naproxen suspension PROGRAF TUDORZA NATAZIA PROTONIX UDENYCA NESINA PROVENTIL HFA ULORIC NEULASTA PROZAC ULTIMED INSULIN SYRINGES 6 NEULASTA ONPRO PSORCON ULTIMED NEEDLES 6 NEUPOGEN QNASL UROXATRAL NEXIUM QTERN VALCYTE niacin tablet 500 mg quazepam VALTREX Niacor RAPAFLO Vanoxide-HC NICADAN RAPAMUNE VASCULERA NICAPRIN RAVICTI VECTICAL NICAZEL RAYOS VELTIN NICAZEL FORTE RECEDO venlafaxine ext-rel tablet (except 225 mg) NICOMIDE REMODULIN VENTOLIN HFA NILANDRON RENFLEXIS VEREGEN nitrofurantoin (NDC^ 70408023932 only) REPATHA VIEKIRA PAK NORGESIC FORTE REVATIO VIIBRYD NORITATE RHEUMATE VIRACEPT NORVASC RIABNI VISCO-3 NOVACORT RIBOZEL VITAFOL-ONE NOVO NORDISK NEEDLES 6 RIMSO-50 Vitasure NuDiclo SoluPak RIOMET VIVELLE-DOT NuDiclo TabPak RITUXAN VOGELXO NUTROPIN AQ ROZEREM XANAX NUVARING RyClora XANAX XR NUVIGIL SABRIL XENAZINE OLEPTRO SAIZEN XOLEGEL OLUX-E SANDOSTATIN LAR XOPENEX HFA omeprazole-sodium bicarbonate SCARSILK PAD Xvite OMNARIS SEROQUEL XR XYZBAC OMNITROPE SIGNIFOR LAR YAZ OMNIVEX SIL-K PAD ZALVIT ONFI SILIVEX ZARXIO ONGLYZA SILTREX ZEGERID ORENCIA INTRAVENOUS SIMPONI ZEMAIRA orphenadrine-aspirin-caffeine SINGULAIR ZEPATIER Orphengesic Forte SOMAVERT ZESTORETIC ORTHO D SORILUX ZETIA ORTHO DF SPRIX ZETONNA ORTHOVISC STRIBILD ZIANA Oscimin SR SUBOXONE ZIRGAN OSENI sucralfate suspension ZOHYDRO ER OSMOPREP sumatriptan-naproxen ZOLADEX OSPHENA SUPREP ZOLOFT OTREXUP Symax-SR ZOLPIMIST OWEN MUMFORD NEEDLES 6 SYNERDERM ZONEGRAN oxiconazole (NDCs^ 00168035830, 51672135902 only) SYNVISC ZONTIVITY OXYCONTIN SYNVISC-ONE ZORTRESS oxymorphone ext-rel TALIVA ZORVOLEX OXYTROL TARGADOX ZUPLENZ PAXIL TASIGNA ZYDELIG PAXIL CR TAYTULLA ZYLET PEGASYS TAZORAC ZYTIGA PENNSAID TECFIDERA ZYVIT PERCOCET TESTIM

There may be additional drugs subject to prior authorization or other plan design restrictions. Please consult your plan for further information.

This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available drug options. Log in to Caremark.com to check coverage and copay information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this in formation and any health-related questions you have. CVS Caremark assumes no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. Thi s list is subject to change.

Subject to applicable laws and regulations.

* This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. † Listing does not include certain NDCs^. ^ 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. 1 If your doctor believes you have a specific clinical need for one of these products, he or she should contact the Prior Autho rization department at: 1-855-240-0536. 2 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1 -6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 3 If approved for coverage and prescribed for primary prevention of cardiovascular disease, may be covered without cost sharing through an exceptions process. 4 Rebranded or private label formulations are not covered without a prior authorization for medical necessity (i.e., RELION). 5 Long Acting Insulins - First Generation. 6 BD ULTRAFINE syringes and needles are the only preferred options. 7 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 8 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 9 Generic prenatal vitamins and CITRANATAL are the only preferred options.

This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.

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