Performance Drug List - Standard Control

July 2021 Performance Drug List - Standard Control

The CVS Caremark® Performance Drug List - Standard Control 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 Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a doctor. 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 • The member's prescription benefit plan design may alter coverage this document. Products recently approved by the U.S. Food and of certain products or vary copay amounts based on the condition Drug Administration (FDA) may not be covered upon release being treated. to the market. • This drug list represents a summary of prescription coverage. It is • Your prescription benefit plan design may alter coverage of certain not all-inclusive and does not guarantee coverage. The member’s products or vary copay1 amounts based on the condition being specific prescription benefit plan design may not cover certain treated. products or categories, regardless of their appearance in this • You may be responsible for the full cost of non-formulary products document. Products recently approved by the FDA may not be that are removed from coverage. covered upon release to the market. • For specific information regarding your prescription benefit • The member's prescription benefit plan may have a different coverage and copay information, please visit Caremark.com copay for specific products on the list. or contact a CVS Caremark Customer Care representative. • Unless specifically indicated, drug list products will include all • CVS Caremark may contact your doctor after receiving your dosage forms. prescription to request consideration of a drug list product or • Log in to Caremark.com to check coverage and copay generic equivalent. This may result in your doctor prescribing, information for a specific medicine. 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 § OPIOID ANALGESICS VISCOSUPPLEMENTS § FLUOROQUINOLONES ANTIRETROVIRAL AGENTS buprenorphine transdermal DUROLANE ciprofloxacin § ANTIRETROVIRAL § NSAIDs codeine-acetaminophen EUFLEXXA levofloxacin COMBINATIONS diclofenac sodium fentanyl transdermal GELSYN-3 moxifloxacin abacavir-lamivudine ibuprofen fentanyl transmucosal SUPARTZ FX efavirenz-emtricitabine- meloxicam § PENICILLINS lozenge tenofovir disoproxil fumarate naproxen (except naproxen CR or hydrocodone ext-rel ANTI-INFECTIVES amoxicillin efavirenz-lamivudine- naproxen suspension) hydrocodone-acetaminophen amoxicillin-clavulanate ANTIBACTERIALS tenofovir disoproxil fumarate dicloxacillin § NSAIDs, COMBINATIONS hydromorphone BIKTARVY § CEPHALOSPORINS penicillin VK hydromorphone ext-rel CIMDUO diclofenac sodium- cefdinir methadone COMPLERA misoprostol § TETRACYCLINES cefprozil morphine DESCOVY cefuroxime axetil doxycycline hyclate 20 mg § NSAIDs, TOPICAL morphine ext-rel DOVATO morphine suppository cephalexin doxycycline hyclate capsule diclofenac sodium gel 1% EVOTAZ SUPRAX minocycline oxycodone diclofenac sodium solution GENVOYA oxycodone-acetaminophen tetracycline § ERYTHROMYCINS / ODEFSEY tramadol (except NDC^ 52817019610) § COX-2 INHIBITORS MACROLIDES § ANTIFUNGALS PREZCOBIX celecoxib tramadol ext-rel tablet STRIBILD azithromycin fluconazole BELBUCA SYMTUZA clarithromycin itraconazole § GOUT NUCYNTA TEMIXYS terbinafine tablet clarithromycin ext-rel allopurinol NUCYNTA ER TRIUMEQ erythromycins colchicine tablet SUBSYS TRUVADA DIFICID XTAMPZA ER probenecid

MITIGARE

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.

INTEGRASE INHIBITORS ERLEADA § ANGIOTENSIN II § NIACINS PULMONARY ARTERIAL ISENTRESS NUBEQA RECEPTOR ANTAGONISTS / niacin ext-rel HYPERTENSION TIVICAY XTANDI DIURETIC COMBINATIONS § ENDOTHELIN RECEPTOR YONSA candesartan / candesartan- § OMEGA-3 FATTY ACIDS ANTAGONISTS § NUCLEOSIDE REVERSE hydrochlorothiazide omega-3 acid ethyl esters § KINASE INHIBITORS ambrisentan TRANSCRIPTASE VASCEPA irbesartan / irbesartan- bosentan INHIBITORS imatinib mesylate hydrochlorothiazide PCSK9 INHIBITORS OPSUMIT abacavir tablet AFINITOR losartan / losartan- ALECENSA lamivudine hydrochlorothiazide PRALUENT § PHOSPHODIESTERASE

ALUNBRIG olmesartan / olmesartan- INHIBITORS § PROTEASE INHIBITORS BOSULIF § BETA-BLOCKERS hydrochlorothiazide sildenafil atazanavir CABOMETYX telmisartan / telmisartan- atenolol COPIKTRA carvedilol NORVIR hydrochlorothiazide PROSTACYCLIN RECEPTOR PREZISTA IBRANCE valsartan / valsartan- carvedilol phosphate ext-rel AGONISTS IRESSA metoprolol succinate ext-rel hydrochlorothiazide UPTRAVI ANTIVIRALS KISQALI metoprolol tartrate § CYTOMEGALOVIRUS KISQALI FEMARA § ANGIOTENSIN II nadolol § PROSTAGLANDIN AGENTS CO-PACK RECEPTOR ANTAGONIST / pindolol VASODILATORS valganciclovir RYDAPT CALCIUM CHANNEL propranolol treprostinil SPRYCEL BLOCKER COMBINATIONS propranolol ext-rel ORENITRAM § HEPATITIS B AGENTS STIVARGA amlodipine-olmesartan BYSTOLIC entecavir XOSPATA SOLUBLE GUANYLATE amlodipine-telmisartan § CALCIUM CHANNEL lamivudine CYCLASE STIMULATORS amlodipine-valsartan BLOCKERS VEMLIDY MONOCLONAL ANTIBODIES ADEMPAS PERJETA § ANGIOTENSIN II amlodipine § HEPATITIS C AGENTS PHESGO RECEPTOR ANTAGONIST / diltiazem ext-rel (except § MISCELLANEOUS ribavirin CALCIUM CHANNEL generics for CARDIZEM LA) ranolazine ext-rel MULTIPLE MYELOMA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) BLOCKER / DIURETIC nifedipine ext-rel HARVONI (genotypes 1, 4, 5, 6) IMMUNOMODULATORS COMBINATIONS verapamil ext-rel CENTRAL NERVOUS 2 VOSEVI POMALYST amlodipine-valsartan- SYSTEM § CALCIUM CHANNEL REVLIMID hydrochlorothiazide § HERPES AGENTS BLOCKER / ANTILIPEMIC ANTIANXIETY THALOMID olmesartan-amlodipine- acyclovir capsule, tablet COMBINATIONS § BENZODIAZEPINES hydrochlorothiazide valacyclovir PROTEASOME INHIBITORS amlodipine-atorvastatin alprazolam

NINLARO § ANTIARRHYTHMICS clonazepam § INFLUENZA AGENTS § DIGITALIS GLYCOSIDES VELCADE disopyramide diazepam oseltamivir digoxin lorazepam sotalol RELENZA PROSTATE CANCER MULTAQ oxazepam § DIRECT RENIN § LUTEINIZING HORMONE- INHIBITORS / DIURETIC § MISCELLANEOUS RELEASING HORMONE ANTILIPEMICS § ANTICONVULSANTS COMBINATIONS clindamycin (LHRH) AGONISTS ACL INHIBITORS / carbamazepine ivermectin aliskiren carbamazepine ext-rel ELIGARD COMBINATIONS linezolid TEKTURNA HCT clobazam NEXLETOL metronidazole LUTEINIZING HORMONE- diazepam rectal gel NEXLIZET § DIURETICS nitrofurantoin (except RELEASING HORMONE divalproex sodium amiloride NDC^ 70408023932) (LHRH) ANTAGONISTS § BILE ACID RESINS divalproex sodium ext-rel pyrimethamine furosemide ethosuximide FIRMAGON cholestyramine sulfamethoxazole- hydrochlorothiazide gabapentin colesevelam

trimethoprim § MISCELLANEOUS metolazone lamotrigine spironolactone- vancomycin capsule ERIVEDGE § CHOLESTEROL lamotrigine ext-rel hydrochlorothiazide EMVERM LYNPARZA ABSORPTION INHIBITORS levetiracetam torsemide XIFAXAN 550 MG ODOMZO ezetimibe levetiracetam ext-rel triamterene RUBRACA oxcarbazepine triamterene- ANTINEOPLASTIC VISTOGARD § FIBRATES phenobarbital hydrochlorothiazide AGENTS ZEJULA fenofibrate (except phenytoin

ANTIMETABOLITES fenofibrate capsule 50 mg, 130 mg; HEART FAILURE phenytoin sodium extended CARDIOVASCULAR fenofibrate tablet 40 mg, 120 mg) primidone LONSURF BIDIL fenofibric acid delayed-rel rufinamide § ACE INHIBITORS CORLANOR BIOSIMILARS tiagabine ENTRESTO fosinopril § HMG-CoA REDUCTASE topiramate KANJINTI lisinopril INHIBITORS / § NITRATES valproic acid RUXIENCE quinapril COMBINATIONS vigabatrin TRAZIMERA ramipril isosorbide dinitrate (except atorvastatin zonisamide ZIRABEV isosorbide dinitrate 40 mg) ezetimibe-simvastatin FYCOMPA § ACE INHIBITOR / isosorbide mononitrate HORMONAL fluvastatin NAYZILAM DIURETIC COMBINATIONS nitroglycerin lingual spray ANTINEOPLASTIC AGENTS lovastatin OXTELLAR XR fosinopril-hydrochlorothiazide nitroglycerin sublingual pravastatin TROKENDI XR § ANTIANDROGENS lisinopril-hydrochlorothiazide rosuvastatin VALTOCO abiraterone quinapril-hydrochlorothiazide simvastatin bicalutamide

VIMPAT ABILIFY MAINTENA AUBAGIO DIPEPTIDYL PEPTIDASE-4 SODIUM-GLUCOSE XCOPRI LATUDA BETASERON (DPP-4) INHIBITORS CO-TRANSPORTER 2

PERSERIS COPAXONE JANUVIA (SGLT2) INHIBITOR / § ANTIDEMENTIA VRAYLAR GILENYA DIPEPTIDYL PEPTIDASE-4 donepezil KESIMPTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR § ATTENTION DEFICIT galantamine MAYZENT (DPP-4) INHIBITOR / COMBINATIONS galantamine ext-rel HYPERACTIVITY DISORDER BIGUANIDE COMBINATIONS OCREVUS GLYXAMBI memantine amphetamine- REBIF JANUMET rivastigmine dextroamphetamine TYSABRI JANUMET XR SODIUM-GLUCOSE rivastigmine transdermal mixed salts VUMERITY CO-TRANSPORTER 2 NAMZARIC amphetamine- ZEPOSIA INCRETIN MIMETIC AGENTS (SGLT2) INHIBITOR /

dextroamphetamine OZEMPIC DIPEPTIDYL PEPTIDASE-4 ANTIDEPRESSANTS † mixed salts ext-rel § MUSCULOSKELETAL RYBELSUS (DPP-4) INHIBITOR / § SELECTIVE SEROTONIN atomoxetine THERAPY AGENTS TRULICITY BIGUANIDE COMBINATIONS REUPTAKE INHIBITORS dexmethylphenidate ext-rel cyclobenzaprine (except VICTOZA TRIJARDY XR (SSRIs) guanfacine ext-rel cyclobenzaprine tablet 7.5 mg) INCRETIN MIMETIC AGENT / citalopram methylphenidate § SULFONYLUREAS † § NARCOLEPSY INSULIN COMBINATIONS escitalopram methylphenidate ext-rel glimepiride fluoxetine (except fluoxetine tablet 60 mg, MYDAYIS armodafinil SOLIQUA glipizide fluoxetine tablet [generics for SARAFEM]) VYVANSE modafinil XULTOPHY glipizide ext-rel paroxetine HCl SUNOSI § FIBROMYALGIA INSULINS SUPPLIES paroxetine HCl ext-rel POSTHERPETIC sertraline pregabalin BASAGLAR ACCU-CHEK AVIVA PLUS NEURALGIA (PHN) 3 TRINTELLIX FIASP STRIPS AND KITS HYPNOTICS GRALISE HUMULIN R U-500 ACCU-CHEK COMPACT

§ SEROTONIN § NONBENZODIAZEPINES LEVEMIR PLUS STRIPS AND KITS 3 PSYCHOTHERAPEUTIC - NOREPINEPHRINE eszopiclone NOVOLIN 70/30 ACCU-CHEK GUIDE MISCELLANEOUS REUPTAKE INHIBITORS ramelteon NOVOLIN N STRIPS AND KITS 3 § OPIOID ANTAGONISTS (SNRIs) zolpidem NOVOLIN R ACCU-CHEK SMARTVIEW desvenlafaxine ext-rel zolpidem ext-rel naloxone injection NOVOLOG STRIPS AND KITS 3 duloxetine BELSOMRA NARCAN NASAL SPRAY NOVOLOG MIX 70/30 BD ULTRAFINE venlafaxine TOUJEO INSULIN SYRINGES § TRICYCLICS § PARTIAL OPIOID AGONIST / venlafaxine ext-rel capsule TRESIBA AND NEEDLES OPIOID ANTAGONIST doxepin DEXCOM CONTINUOUS COMBINATIONS § INSULIN SENSITIZERS § MISCELLANEOUS GLUCOSE AGENTS MIGRAINE buprenorphine-naloxone pioglitazone MONITORING SYSTEM bupropion ACUTE MIGRAINE AGENTS sublingual § INSULIN SENSITIZER / OMNIPOD DASH INSULIN bupropion ext-rel (except § Triptans ZUBSOLV INFUSION PUMP BIGUANIDE COMBINATIONS bupropion ext-rel tablet 450 mg) eletriptan OMNIPOD INSULIN PSEUDOBULBAR AFFECT pioglitazone-metformin mirtazapine INFUSION PUMP naratriptan AGENTS trazodone rizatriptan § INSULIN SENSITIZER / ONETOUCH ULTRA NUEDEXTA STRIPS AND KITS 3 § ANTIPARKINSONIAN sumatriptan SULFONYLUREA zolmitriptan COMBINATIONS ONETOUCH VERIO AGENTS ENDOCRINE AND 3 ONZETRA XSAIL STRIPS AND KITS amantadine METABOLIC pioglitazone-glimepiride ZEMBRACE SYMTOUCH V-GO INSULIN carbidopa-levodopa ZOMIG NASAL SPRAY ACROMEGALY § MEGLITINIDES INFUSION PUMP carbidopa-levodopa ext-rel SOMATULINE DEPOT nateglinide carbidopa-levodopa- Miscellaneous ANTIOBESITY repaglinide

entacapone NURTEC ODT § ANDROGENS INJECTABLE entacapone REYVOW testosterone gel (except authorized SODIUM-GLUCOSE SAXENDA pramipexole UBRELVY generics for TESTIM and VOGELXO) CO-TRANSPORTER 2 pramipexole ext-rel testosterone solution (SGLT2) INHIBITORS ORAL rasagiline PREVENTIVE MIGRAINE ANDRODERM FARXIGA QSYMIA ropinirole AGENTS NATESTO JARDIANCE ropinirole ext-rel Monoclonal Antibodies § CALCIUM RECEPTOR ANTIDIABETICS ANTAGONISTS selegiline AIMOVIG SODIUM-GLUCOSE

INBRIJA AJOVY AMYLIN ANALOGS CO-TRANSPORTER 2 cinacalcet KYNMOBI (SGLT2) INHIBITOR / EMGALITY SYMLINPEN CALCIUM REGULATORS NEUPRO BIGUANIDE COMBINATIONS § MOVEMENT DISORDERS § BIGUANIDES § BISPHOSPHONATES ANTIPSYCHOTICS SYNJARDY tetrabenazine metformin SYNJARDY XR alendronate § ATYPICALS AUSTEDO metformin ext-rel (except generics XIGDUO XR ibandronate aripiprazole INGREZZA for FORTAMET and GLUMETZA) risedronate clozapine olanzapine § MULTIPLE SCLEROSIS § BIGUANIDE / § CALCITONINS quetiapine AGENTS SULFONYLUREA calcitonin-salmon

COMBINATIONS quetiapine ext-rel dimethyl fumarate risperidone delayed-rel glipizide-metformin ziprasidone glatiramer

PARATHYROID HORMONES § GLUCOCORTICOIDS PROGESTINS § IRRITABLE BOWEL trospium FORTEO dexamethasone § ORAL SYNDROME trospium ext-rel MYRBETRIQ TYMLOS fludrocortisone medroxyprogesterone alosetron TOVIAZ hydrocortisone megestrol acetate LINZESS MISCELLANEOUS methylprednisolone progesterone, micronized VIBERZI HEMATOLOGIC PROLIA prednisolone solution § LAXATIVES prednisone VAGINAL § ANTICOAGULANTS § CARNITINE DEFICIENCY CRINONE lactulose solution AGENTS GLUCOSE ELEVATING warfarin ENDOMETRIN peg 3350-electrolytes ELIQUIS levocarnitine AGENTS CLENPIQ XARELTO BAQSIMI § SELECTIVE ESTROGEN CENTRAL PRECOCIOUS OPIOID-INDUCED GLUCAGEN HYPOKIT RECEPTOR MODULATORS § CHELATING AGENTS PUBERTY CONSTIPATION GLUCAGON raloxifene deferasirox SUPPRELIN LA EMERGENCY KIT MOVANTIK deferiprone TRIPTODUR GVOKE § THYROID SUPPLEMENTS SYMPROIC deferoxamine levothyroxine CONTRACEPTIVES PANCREATIC ENZYMES penicillamine capsule HEREDITARY TYROSINEMIA liothyronine trientine § MONOPHASIC TYPE 1 AGENTS CREON SYNTHROID ethinyl estradiol- ORFADIN VIOKACE HEMATOPOIETIC GROWTH UTERINE FIBROIDS drospirenone ZENPEP FACTORS ethinyl estradiol- HUMAN GROWTH ORIAHNN § PROTON PUMP ARANESP drospirenone-levomefolate HORMONES INHIBITORS NIVESTYM ethinyl estradiol- GENOTROPIN GASTROINTESTINAL RETACRIT norethindrone acetate NORDITROPIN esomeprazole delayed-rel § ANTIDIARRHEALS ZIEXTENZO lansoprazole delayed-rel ethinyl estradiol- MENOPAUSAL SYMPTOM diphenoxylate-atropine norethindrone acetate-iron omeprazole delayed-rel HEMOPHILIA A AGENTS AGENTS loperamide pantoprazole delayed-rel ADVATE BIPHASIC § ORAL tablet § ANTIEMETICS ADYNOVATE LO LOESTRIN FE estradiol DEXILANT aprepitant AFSTYLA estradiol-norethindrone § TRIPHASIC doxylamine-pyridoxine § STEROIDS, RECTAL ELOCTATE DUAVEE ESPEROCT delayed-rel PROCTOFOAM-HC ethinyl estradiol-norgestimate PREMPHASE dronabinol JIVI PREMPRO § ULCER THERAPY KOGENATE FS § EXTENDED CYCLE granisetron ethinyl estradiol- § TRANSDERMAL meclizine COMBINATIONS KOVALTRY metoclopramide PYLERA NOVOEIGHT levonorgestrel estradiol ondansetron NUWIQ CLIMARA PRO PROGESTIN INTRAUTERINE prochlorperazine § MISCELLANEOUS COMBIPATCH HEMOPHILIA B AGENTS DEVICES promethazine sucralfate tablet DIVIGEL KYLEENA scopolamine transdermal REBINYN EVAMIST GENITOURINARY MIRENA trimethobenzamide § PLATELET AGGREGATION SKYLA § VAGINAL SANCUSO § BENIGN PROSTATIC INHIBITORS estradiol vaginal cream § TRANSDERMAL § ANTISPASMODICS HYPERPLASIA clopidogrel IMVEXXY alfuzosin ext-rel ethinyl estradiol- dicyclomine dipyridamole ext-rel-aspirin VAGIFEM doxazosin prasugrel norelgestromin § PHENYLKETONURIA § H2 RECEPTOR dutasteride BRILINTA § VAGINAL ANTAGONISTS dutasteride-tamsulosin TREATMENT AGENTS THROMBOCYTOPENIA ethinyl estradiol-etonogestrel famotidine finasteride sapropterin AGENTS ANNOVERA silodosin § PHOSPHATE BINDER INFLAMMATORY BOWEL tamsulosin DOPTELET ENDOMETRIOSIS AGENTS DISEASE terazosin MULPLETA

ORILISSA § ORAL AGENTS calcium acetate ERECTILE DYSFUNCTION IMMUNOLOGIC balsalazide FERTILITY REGULATORS sevelamer carbonate ALPROSTADIL AGENTS AGENTS PHOSLYRA budesonide capsule GNRH / LHRH MUSE VELPHORO budesonide ext-rel ALLERGENIC EXTRACTS ANTAGONISTS mesalamine delayed-rel (except § PHOSPHODIESTERASE GRASTEK CETROTIDE POLYNEUROPATHY mesalamine delayed-rel tablet 800 mg) INHIBITORS ORALAIR TEGSEDI mesalamine ext-rel RAGWITEK OVULATION STIMULANTS, sildenafil sulfasalazine GONADOTROPINS tadalafil POTASSIUM-REMOVING sulfasalazine delayed-rel AUTOIMMUNE AGENTS

GONAL-F AGENTS ASACOL HD § URINARY (PHYSICIAN- OVIDREL LOKELMA PENTASA ANTISPASMODICS ADMINISTERED)

VELTASSA REMICADE GAUCHER DISEASE § RECTAL AGENTS darifenacin ext-rel SIMPONI ARIA CERDELGA oxybutynin hydrocortisone enema STELARA INTRAVENOUS oxybutynin ext-rel CEREZYME mesalamine suppository solifenacin mesalamine suspension tolterodine CORTIFOAM tolterodine ext-rel

AUTOIMMUNE AGENTS ANTICHOLINERGIC / BETA PULMONARY FIBROSIS § ANTIPSORIATICS § ANTI-INFECTIVES 4 (SELF-ADMINISTERED) AGONIST COMBINATIONS AGENTS acitretin ciprofloxacin COSENTYX § SHORT ACTING ESBRIET calcipotriene ointment, erythromycin ENBREL ipratropium-albuterol OFEV solution gentamicin

HUMIRA inhalation solution methoxsalen levofloxacin SEVERE ASTHMA AGENTS OTEZLA moxifloxacin § ANTISEBORRHEICS RINVOQ LONG ACTING DUPIXENT ofloxacin SKYRIZI ANORO ELLIPTA FASENRA ketoconazole shampoo 2% sulfacetamide STELARA STIOLTO RESPIMAT NUCALA selenium sulfide lotion 2.5% tobramycin

SUBCUTANEOUS XOLAIR BESIVANCE ATOPIC DERMATITIS TREMFYA ANTICHOLINERGIC / BETA STEROID / BETA AGONIST § ANTI-INFECTIVE / XELJANZ AGONIST / STEROID Injectable COMBINATIONS ANTI-INFLAMMATORY XELJANZ XR INHALANT COMBINATIONS DUPIXENT BREZTRI AEROSPHERE ADVAIR DISKUS COMBINATIONS † § Topical § DISEASE-MODIFYING TRELEGY ELLIPTA ADVAIR HFA neomycin-polymyxin B- † ANTIRHEUMATIC DRUGS BREO ELLIPTA pimecrolimus bacitracin-hydrocortisone (DMARDs) § ANTIHISTAMINES, LOW SYMBICORT tacrolimus neomycin-polymyxin B-

RASUVO SEDATING EUCRISA dexamethasone § STEROID INHALANTS levocetirizine tobramycin-dexamethasone § HEREDITARY CORTICOSTEROIDS budesonide TOBRADEX OINTMENT ANGIOEDEMA § ANTITUSSIVES inhalation suspension § Low Potency icatibant benzonatate (except ARNUITY ELLIPTA desonide ANTI-INFLAMMATORIES RUCONEST NDCs^ 69336012615, 69499032915) FLOVENT DISKUS hydrocortisone § Nonsteroidal FLOVENT HFA TAKHZYRO bromfenac BETA AGONISTS, PULMICORT FLEXHALER § Medium Potency diclofenac IMMUNOMODULATORS INHALANTS QVAR REDIHALER hydrocortisone butyrate ketorolac IMMUNE GLOBULINS § SHORT ACTING cream, ointment, solution ILEVRO TOPICAL CUTAQUIG albuterol inhalation solution mometasone PROLENSA albuterol sulfate DERMATOLOGY triamcinolone cream, lotion, IMMUNOSUPPRESSANTS CFC-free aerosol ointment (except § Steroidal ACNE § RAPAMYCIN DERIVATIVES levalbuterol tartrate triamcinolone ointment 0.05%) dexamethasone § Topical everolimus CFC-free aerosol loteprednol § High Potency adapalene prednisolone acetate 1% LONG ACTING NUTRITIONAL / benzoyl peroxide desoximetasone DUREZOL SUPPLEMENTS Hand-held Active Inhalation clindamycin gel (except fluocinonide (except SEREVENT NDC^ 68682046275) fluocinonide cream 0.1%) § ANTIVIRALS § ELECTROLYTES STRIVERDI RESPIMAT clindamycin solution BRYHALI trifluridine potassium chloride liquid clindamycin-benzoyl § Very High Potency Nebulized Passive Inhalation peroxide BETA-BLOCKERS VITAMINS AND MINERALS PERFOROMIST erythromycin solution clobetasol cream, foam, gel, § Nonselective § FOLIC ACID / erythromycin-benzoyl lotion, ointment, shampoo timolol maleate solution

COMBINATIONS § CYSTIC FIBROSIS peroxide § LOCAL ANALGESICS folic acid tobramycin tretinoin Selective

inhalation solution EPIDUO lidocaine patch BETOPTIC S § PRENATAL VITAMINS BETHKIS ONEXTON § LOCAL ANESTHETICS prenatal vitamins § CARBONIC ANHYDRASE CITRANATAL § LEUKOTRIENE § ACTINIC KERATOSIS lidocaine-prilocaine INHIBITORS MODULATORS fluorouracil cream 5% § ROSACEA dorzolamide RESPIRATORY montelukast fluorouracil solution AZOPT azelaic acid gel ALPHA-1 ANTITRYPSIN zafirlukast imiquimod metronidazole § CARBONIC ANHYDRASE PICATO DEFICIENCY AGENTS § NASAL ANTIHISTAMINES FINACEA FOAM INHIBITOR / BETA- TOLAK PROLASTIN-C azelastine ORACEA BLOCKER COMBINATIONS ZYCLARA SOOLANTRA § ANAPHYLAXIS olopatadine dorzolamide-timolol § ANTIBIOTICS TREATMENT AGENTS § NASAL STEROIDS / MOUTH / THROAT / CARBONIC ANHYDRASE gentamicin epinephrine auto-injector COMBINATIONS DENTAL AGENTS INHIBITOR / mupirocin ointment EPIPEN flunisolide PROTECTANTS SYMPATHOMIMETIC EPIPEN JR fluticasone § ANTIFUNGALS EPISIL COMBINATIONS SYMJEPI mometasone ciclopirox MUGARD SIMBRINZA

§ ANTICHOLINERGICS DYMISTA clotrimazole OPHTHALMIC DRY EYE DISEASE econazole ipratropium PHOSPHODIESTERASE-4 ketoconazole cream 2% § ANTIALLERGICS RESTASIS inhalation solution INHIBITORS nystatin azelastine XIIDRA SPIRIVA DALIRESP NAFTIN cromolyn sodium YUPELRI olopatadine

§ PROSTAGLANDINS RHO KINASE INHIBITORS SYMPATHOMIMETIC / BETA- § ANTI-INFECTIVE / latanoprost RHOPRESSA BLOCKER COMBINATIONS ANTI-INFLAMMATORY travoprost COMBIGAN COMBINATIONS RHO KINASE INHIBITOR / LUMIGAN ciprofloxacin-dexamethasone PROSTAGLANDIN OTIC ZIOPTAN neomycin-polymyxin B- COMBINATIONS § ANTI-INFECTIVES hydrocortisone RETINAL DISORDERS ROCKLATAN acetic acid

EYLEA ofloxacin otic § SYMPATHOMIMETICS LUCENTIS

brimonidine

ALPHAGAN P QUICK REFERENCE DRUG LIST

A amphetamine- buprenorphine transdermal clonazepam diphenoxylate-atropine dextroamphetamine buprenorphine-naloxone clopidogrel dipyridamole ext-rel-aspirin abacavir tablet mixed salts ext-rel † sublingual clotrimazole disopyramide abacavir-lamivudine ANDRODERM bupropion clozapine divalproex sodium ABILIFY MAINTENA ANNOVERA bupropion ext-rel (except codeine-acetaminophen divalproex sodium ext-rel abiraterone ANORO ELLIPTA bupropion ext-rel tablet 450 mg) colchicine tablet DIVIGEL ACCU-CHEK AVIVA PLUS aprepitant BYSTOLIC colesevelam donepezil STRIPS AND KITS 3 ARANESP COMBIGAN DOPTELET ACCU-CHEK COMPACT aripiprazole C COMBIPATCH dorzolamide PLUS STRIPS AND KITS 3 ACCU-CHEK GUIDE armodafinil CABOMETYX COMPLERA dorzolamide-timolol ARNUITY ELLIPTA calcipotriene ointment, COPAXONE DOVATO STRIPS AND KITS 3 ACCU-CHEK SMARTVIEW ASACOL HD solution COPIKTRA doxazosin atazanavir calcitonin-salmon CORLANOR doxepin STRIPS AND KITS 3 atenolol calcium acetate CORTIFOAM doxycycline hyclate 20 mg acetic acid atomoxetine candesartan COSENTYX doxycycline hyclate capsule acitretin atorvastatin candesartan- CREON doxylamine-pyridoxine acyclovir capsule, tablet AUBAGIO hydrochlorothiazide CRINONE delayed-rel adapalene AUSTEDO carbamazepine cromolyn sodium dronabinol ADEMPAS azelaic acid gel carbamazepine ext-rel CUTAQUIG DUAVEE ADVAIR DISKUS azelastine carbidopa-levodopa cyclobenzaprine (except duloxetine ADVAIR HFA † azithromycin carbidopa-levodopa ext-rel cyclobenzaprine tablet 7.5 mg) DUPIXENT ADVATE AZOPT carbidopa-levodopa- DUREZOL ADYNOVATE entacapone D DUROLANE AFINITOR B carvedilol DALIRESP dutasteride AFSTYLA balsalazide carvedilol phosphate ext-rel darifenacin ext-rel dutasteride-tamsulosin AIMOVIG DYMISTA BAQSIMI cefdinir deferasirox AJOVY BASAGLAR cefprozil deferiprone albuterol inhalation solution E albuterol sulfate BD ULTRAFINE cefuroxime axetil deferoxamine INSULIN SYRINGES celecoxib DESCOVY econazole CFC-free aerosol AND NEEDLES cephalexin desonide efavirenz-emtricitabine- ALECENSA BELBUCA CERDELGA desoximetasone tenofovir disoproxil fumarate alendronate BELSOMRA CEREZYME desvenlafaxine ext-rel efavirenz-lamivudine- alfuzosin ext-rel benzonatate (except NDCs^ CETROTIDE dexamethasone tenofovir disoproxil fumarate aliskiren 69336012615, 69499032915) cholestyramine DEXCOM CONTINUOUS eletriptan allopurinol benzoyl peroxide ciclopirox GLUCOSE ELIGARD alosetron BESIVANCE CIMDUO MONITORING SYSTEM ELIQUIS ALPHAGAN P BETASERON cinacalcet DEXILANT ELOCTATE alprazolam BETHKIS ciprofloxacin dexmethylphenidate ext-rel EMGALITY ALUNBRIG BETOPTIC S ciprofloxacin-dexamethasone diazepam EMVERM amantadine bicalutamide citalopram diazepam rectal gel ENBREL ambrisentan BIDIL CITRANATAL diclofenac ENDOMETRIN amiloride BIKTARVY clarithromycin diclofenac sodium entacapone amlodipine bosentan clarithromycin ext-rel diclofenac sodium gel 1% entecavir amlodipine-atorvastatin BOSULIF CLENPIQ diclofenac sodium solution ENTRESTO amlodipine-olmesartan BREO ELLIPTA † CLIMARA PRO diclofenac sodium- EPCLUSA amlodipine-telmisartan BREZTRI AEROSPHERE clindamycin misoprostol EPIDUO amlodipine-valsartan amlodipine-valsartan- BRILINTA clindamycin gel (except NDC^ dicloxacillin epinephrine auto-injector brimonidine 68682046275) dicyclomine EPIPEN hydrochlorothiazide bromfenac clindamycin solution DIFICID EPIPEN JR amoxicillin BRYHALI clindamycin-benzoyl digoxin EPISIL amoxicillin-clavulanate amphetamine- budesonide capsule peroxide diltiazem ext-rel (except ERIVEDGE dextroamphetamine budesonide ext-rel clobazam generics for CARDIZEM LA) ERLEADA budesonide inhalation clobetasol cream, foam, gel, dimethyl fumarate erythromycin mixed salts suspension lotion, ointment, shampoo delayed-rel erythromycin solution

erythromycin-benzoyl furosemide J mesalamine suppository NOVOLIN N peroxide FYCOMPA mesalamine suspension NOVOLIN R JANUMET erythromycins metformin NOVOLOG JANUMET XR ESBRIET G metformin ext-rel (except generics NOVOLOG MIX 70/30 JANUVIA escitalopram gabapentin for FORTAMET and GLUMETZA) NUBEQA JARDIANCE esomeprazole delayed-rel galantamine methadone NUCALA JIVI ESPEROCT galantamine ext-rel methoxsalen NUCYNTA estradiol GELSYN-3 K methylphenidate NUCYNTA ER † estradiol vaginal cream GENOTROPIN methylphenidate ext-rel NUEDEXTA KANJINTI estradiol-norethindrone gentamicin methylprednisolone NURTEC ODT KESIMPTA eszopiclone GENVOYA metoclopramide NUWIQ ketoconazole cream 2% ethinyl estradiol- GILENYA metolazone nystatin ketoconazole shampoo 2% drospirenone glatiramer metoprolol succinate ext-rel ketorolac ethinyl estradiol- glimepiride metoprolol tartrate O KISQALI drospirenone-levomefolate glipizide metronidazole OCREVUS KISQALI FEMARA ethinyl estradiol-etonogestrel glipizide ext-rel minocycline ODEFSEY CO-PACK ethinyl estradiol- glipizide-metformin MIRENA ODOMZO KOGENATE FS levonorgestrel GLUCAGEN HYPOKIT mirtazapine OFEV KOVALTRY ethinyl estradiol- GLUCAGON MITIGARE ofloxacin KYLEENA norelgestromin EMERGENCY KIT modafinil ofloxacin otic KYNMOBI ethinyl estradiol- GLYXAMBI mometasone olanzapine norethindrone acetate GONAL-F L montelukast olmesartan ethinyl estradiol- GRALISE morphine olmesartan-amlodipine- lactulose solution norethindrone acetate-iron granisetron morphine ext-rel hydrochlorothiazide lamivudine ethinyl estradiol-norgestimate GRASTEK morphine suppository olmesartan- lamotrigine ethosuximide guanfacine ext-rel MOVANTIK hydrochlorothiazide lamotrigine ext-rel EUCRISA GVOKE moxifloxacin olopatadine lansoprazole delayed-rel EUFLEXXA MUGARD omega-3 acid ethyl esters latanoprost EVAMIST H MULPLETA omeprazole delayed-rel LATUDA everolimus HARVONI MULTAQ OMNIPOD DASH INSULIN levalbuterol tartrate EVOTAZ HUMIRA mupirocin ointment INFUSION PUMP CFC-free aerosol EYLEA HUMULIN R U-500 MUSE OMNIPOD INSULIN LEVEMIR ezetimibe hydrochlorothiazide MYDAYIS INFUSION PUMP levetiracetam ezetimibe-simvastatin hydrocodone ext-rel MYRBETRIQ ondansetron levetiracetam ext-rel hydrocodone-acetaminophen ONETOUCH ULTRA F levocarnitine N 3 hydrocortisone STRIPS AND KITS levocetirizine famotidine hydrocortisone butyrate nadolol ONETOUCH VERIO levofloxacin 3 FARXIGA cream, ointment, solution NAFTIN STRIPS AND KITS levothyroxine FASENRA hydrocortisone enema naloxone injection ONEXTON lidocaine patch fenofibrate (except hydromorphone NAMZARIC ONZETRA XSAIL lidocaine-prilocaine fenofibrate capsule 50 mg, 130 mg; hydromorphone ext-rel naproxen (except naproxen CR or OPSUMIT linezolid fenofibrate tablet 40 mg, 120 mg) naproxen suspension) ORACEA LINZESS fenofibric acid delayed-rel I naratriptan ORALAIR liothyronine fentanyl transdermal ibandronate NARCAN NASAL SPRAY ORENITRAM lisinopril fentanyl transmucosal IBRANCE nateglinide ORFADIN lisinopril-hydrochlorothiazide lozenge ibuprofen NATESTO ORIAHNN LO LOESTRIN FE FIASP icatibant NAYZILAM ORILISSA LOKELMA FINACEA FOAM ILEVRO neomycin-polymyxin B- oseltamivir LONSURF finasteride imatinib mesylate bacitracin-hydrocortisone OTEZLA loperamide FIRMAGON imiquimod neomycin-polymyxin B- OVIDREL lorazepam FLOVENT DISKUS IMVEXXY dexamethasone oxazepam losartan FLOVENT HFA INBRIJA neomycin-polymyxin B- oxcarbazepine losartan-hydrochlorothiazide fluconazole INGREZZA hydrocortisone OXTELLAR XR loteprednol fludrocortisone ipratropium NEUPRO oxybutynin lovastatin flunisolide inhalation solution NEXLETOL oxybutynin ext-rel LUCENTIS fluocinonide (except ipratropium-albuterol NEXLIZET oxycodone LUMIGAN fluocinonide cream 0.1%) inhalation solution niacin ext-rel oxycodone-acetaminophen LYNPARZA fluorouracil cream 5% irbesartan nifedipine ext-rel OZEMPIC fluorouracil solution irbesartan- M NINLARO P fluoxetine (except fluoxetine tablet 60 mg, hydrochlorothiazide nitrofurantoin (except MAYZENT fluoxetine tablet [generics for SARAFEM]) IRESSA NDC^ 70408023932) pantoprazole meclizine fluticasone ISENTRESS nitroglycerin lingual spray delayed-rel tablet medroxyprogesterone fluvastatin isosorbide dinitrate (except nitroglycerin sublingual paroxetine HCl megestrol acetate folic acid isosorbide dinitrate 40 mg) NIVESTYM paroxetine HCl ext-rel meloxicam FORTEO isosorbide mononitrate NORDITROPIN peg 3350-electrolytes memantine fosinopril itraconazole NORVIR penicillamine capsule mesalamine delayed-rel (except fosinopril-hydrochlorothiazide ivermectin NOVOEIGHT penicillin VK mesalamine delayed-rel tablet 800 mg) NOVOLIN 70/30 PENTASA mesalamine ext-rel

PERFOROMIST ramipril SPRYCEL tolterodine verapamil ext-rel PERJETA ranolazine ext-rel STELARA INTRAVENOUS tolterodine ext-rel V-GO INSULIN PERSERIS rasagiline STELARA topiramate INFUSION PUMP phenobarbital RASUVO SUBCUTANEOUS torsemide VIBERZI phenytoin REBIF STIOLTO RESPIMAT TOUJEO VICTOZA phenytoin sodium extended REBINYN STIVARGA TOVIAZ vigabatrin PHESGO RELENZA STRIBILD tramadol (except NDC^ 52817019610) VIMPAT PHOSLYRA REMICADE STRIVERDI RESPIMAT tramadol ext-rel tablet VIOKACE PICATO repaglinide SUBSYS travoprost VISTOGARD pimecrolimus RESTASIS sucralfate tablet TRAZIMERA VOSEVI 2 pindolol RETACRIT sulfacetamide trazodone VRAYLAR pioglitazone REVLIMID sulfamethoxazole- TRELEGY ELLIPTA VUMERITY pioglitazone-glimepiride REYVOW trimethoprim TREMFYA VYVANSE pioglitazone-metformin RHOPRESSA sulfasalazine treprostinil POMALYST ribavirin sulfasalazine delayed-rel TRESIBA W potassium chloride liquid RINVOQ sumatriptan tretinoin warfarin PRALUENT risedronate SUNOSI triamcinolone cream, lotion, pramipexole risperidone SUPARTZ FX ointment (except X pramipexole ext-rel rivastigmine SUPPRELIN LA triamcinolone ointment 0.05%) XARELTO prasugrel rivastigmine transdermal SUPRAX triamterene XCOPRI pravastatin rizatriptan SYMBICORT triamterene- XELJANZ prednisolone acetate 1% ROCKLATAN SYMJEPI hydrochlorothiazide XELJANZ XR prednisolone solution ropinirole SYMLINPEN trientine XIFAXAN 550 MG prednisone ropinirole ext-rel SYMPROIC trifluridine XIGDUO XR pregabalin rosuvastatin SYMTUZA TRIJARDY XR XIIDRA PREMPHASE RUBRACA SYNJARDY trimethobenzamide XOLAIR PREMPRO RUCONEST SYNJARDY XR TRINTELLIX XOSPATA prenatal vitamins rufinamide SYNTHROID TRIPTODUR XTAMPZA ER

PREZCOBIX RUXIENCE TRIUMEQ XTANDI T PREZISTA RYBELSUS TROKENDI XR XULTOPHY primidone RYDAPT tacrolimus trospium probenecid tadalafil trospium ext-rel Y S prochlorperazine TAKHZYRO TRULICITY YONSA

PROCTOFOAM-HC SANCUSO tamsulosin TRUVADA YUPELRI progesterone, micronized sapropterin TEGSEDI TYMLOS PROLASTIN-C SAXENDA TEKTURNA HCT TYSABRI Z

PROLENSA scopolamine transdermal telmisartan zafirlukast PROLIA selegiline telmisartan- U ZEJULA promethazine selenium sulfide lotion 2.5% hydrochlorothiazide UBRELVY ZEMBRACE SYMTOUCH propranolol SEREVENT TEMIXYS UPTRAVI ZENPEP propranolol ext-rel sertraline terazosin ZEPOSIA PULMICORT FLEXHALER V sevelamer carbonate terbinafine tablet ZIEXTENZO PYLERA sildenafil testosterone gel (except authorized VAGIFEM ZIOPTAN pyrimethamine silodosin generics for TESTIM and VOGELXO) valacyclovir ziprasidone

SIMBRINZA testosterone solution valganciclovir ZIRABEV Q SIMPONI ARIA tetrabenazine valproic acid zolmitriptan

QSYMIA simvastatin tetracycline valsartan zolpidem quetiapine SKYLA THALOMID valsartan-hydrochlorothiazide zolpidem ext-rel quetiapine ext-rel SKYRIZI tiagabine VALTOCO ZOMIG NASAL SPRAY quinapril solifenacin timolol maleate solution vancomycin capsule zonisamide quinapril-hydrochlorothiazide SOLIQUA TIVICAY VASCEPA ZUBSOLV QVAR REDIHALER SOMATULINE DEPOT TOBRADEX OINTMENT VELCADE ZYCLARA

SOOLANTRA tobramycin VELPHORO R sotalol tobramycin VELTASSA RAGWITEK SPIRIVA inhalation solution VEMLIDY raloxifene spironolactone- tobramycin-dexamethasone venlafaxine ramelteon hydrochlorothiazide TOLAK venlafaxine ext-rel capsule

PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, APEXICON E desoximetasone (except quetiapine ext-rel, risperidone, ziprasidone, desoximetasone ointment 0.05%), LATUDA, VRAYLAR fluocinonide (except fluocinonide cream 0.1%), BRYHALI ACANYA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), APIDRA FIASP, NOVOLOG clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, APOKYN INBRIJA, KYNMOBI erythromycin-benzoyl peroxide, tretinoin, APTENSIO XR amphetamine- EPIDUO, ONEXTON dextroamphetamine mixed salts ext-rel †, ACIPHEX, ACIPHEX SPRINKLE esomeprazole delayed-rel, lansoprazole dexmethylphenidate ext-rel, † delayed-rel, omeprazole delayed-rel, methylphenidate ext-rel , MYDAYIS, pantoprazole delayed-rel tablet, DEXILANT VYVANSE ACTEMRA ACTPEN, ENBREL, HUMIRA, RINVOQ, XELJANZ, APTIVUS Consult doctor ACTEMRA SUBCUTANEOUS XELJANZ XR ARALAST NP PROLASTIN-C ACTEMRA INTRAVENOUS REMICADE, SIMPONI ARIA ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID ACTICLATE doxycycline hyclate 20 mg, ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, doxycycline hyclate capsule, minocycline, meloxicam or naproxen (except naproxen CR tetracycline or naproxen suspension) WITH esomeprazole Activite folic acid delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole ACTOS pioglitazone delayed-rel tablet or DEXILANT ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, ASCENSIA STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, PROLENSA ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, ACCU-CHEK GUIDE STRIPS AND KITS 3, acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, 3 ADDERALL amphetamine-dextroamphetamine mixed salts, ONETOUCH ULTRA STRIPS AND KITS , methylphenidate ONETOUCH VERIO STRIPS AND KITS 3 ADZENYS ER, ADZENYS XR-ODT amphetamine- ASMANEX, ASMANEX HFA ARNUITY ELLIPTA, FLOVENT DISKUS, dextroamphetamine mixed salts ext-rel †, FLOVENT HFA, PULMICORT FLEXHALER, dexmethylphenidate ext-rel, QVAR REDIHALER † methylphenidate ext-rel , MYDAYIS, ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, VYVANSE irbesartan, irbesartan-hydrochlorothiazide, ALCORTIN A desonide, hydrocortisone losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, ALEVICYN GEL, ALEVICYN SG, desonide, hydrocortisone telmisartan, telmisartan-hydrochlorothiazide, ALEVICYN SOLUTION valsartan, valsartan-hydrochlorothiazide ALIQOPA COPIKTRA ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam ALLISON MEDICAL INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES ATOPADERM desonide, hydrocortisone ALORA estradiol, DIVIGEL, EVAMIST ATROVENT HFA ipratropium inhalation solution, SPIRIVA, ALPROLIX Consult doctor YUPELRI ALREX azelastine, cromolyn sodium, olopatadine AVASTIN ZIRABEV ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, AVENOVA Consult doctor lovastatin, pravastatin, rosuvastatin, simvastatin AVONEX dimethyl fumarate delayed-rel, glatiramer, ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, AUBAGIO, BETASERON, COPAXONE, FLOVENT HFA, PULMICORT FLEXHALER, GILENYA, KESIMPTA, MAYZENT, OCREVUS, QVAR REDIHALER REBIF, TYSABRI, VUMERITY, ZEPOSIA AMITIZA LINZESS, MOVANTIK, SYMPROIC AVSOLA REMICADE, SIMPONI ARIA, AMRIX cyclobenzaprine STELARA INTRAVENOUS (except cyclobenzaprine tablet 7.5 mg) AZASITE ciprofloxacin, erythromycin, gentamicin, ANDROGEL testosterone gel (except authorized generics for levofloxacin, moxifloxacin, ofloxacin, TESTIM and VOGELXO), testosterone solution, sulfacetamide, tobramycin, BESIVANCE ANDRODERM, NATESTO AZELEX adapalene, benzoyl peroxide, ANGELIQ estradiol-norethindrone, PREMPHASE, clindamycin gel (except NDC^ 68682046275), PREMPRO clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, ANTARA fenofibrate (except fenofibrate capsule erythromycin-benzoyl peroxide, tretinoin, 50 mg, 130 mg; fenofibrate tablet 40 mg, EPIDUO, ONEXTON 120 mg), fenofibric acid delayed-rel AZESCO 7 prenatal vitamins, CITRANATAL

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* AZOR amlodipine-olmesartan, amlodipine-telmisartan, BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA amlodipine-valsartan BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA BANZEL SUSPENSION clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, BARACLUDE TABLET entecavir, lamivudine, VEMLIDY REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY BEAU RX Consult doctor calcipotriene cream calcipotriene ointment, calcipotriene solution BECONASE AQ flunisolide, fluticasone, mometasone, DYMISTA calcipotriene-betamethasone calcipotriene ointment or BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, calcipotriene solution WITH desoximetasone irbesartan, irbesartan-hydrochlorothiazide, (except desoximetasone ointment 0.05%), losartan, losartan-hydrochlorothiazide, fluocinonide (except fluocinonide cream 0.1%) olmesartan, olmesartan-hydrochlorothiazide, or BRYHALI telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide calcitriol ointment calcipotriene ointment, calcipotriene solution BENSAL HP desonide, hydrocortisone CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or BENZAC AC adapalene, benzoyl peroxide, naproxen suspension) clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- CARAC fluorouracil cream 5%, fluorouracil solution, benzoyl peroxide, erythromycin solution, imiquimod, PICATO, TOLAK, ZYCLARA erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON CARAFATE sucralfate tablet BENZACLIN adapalene, benzoyl peroxide, CARBINOXAMINE TABLET 6 MG levocetirizine clindamycin gel (except NDC^ 68682046275), CARDIZEM, CARDIZEM CD, diltiazem ext-rel clindamycin solution, clindamycin- CARDIZEM LA (except generics for CARDIZEM LA) benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, carisoprodol 250 mg cyclobenzaprine EPIDUO, ONEXTON (except cyclobenzaprine tablet 7.5 mg) benzonatate benzonatate CARNITOR, CARNITOR SF levocarnitine (NDCs^ 69336012615, 69499032915 only) (except NDCs^ 69336012615, 69499032915) CELEBREX celecoxib, diclofenac sodium, ibuprofen, BEPREVE azelastine, cromolyn sodium, olopatadine meloxicam, naproxen (except naproxen CR or naproxen suspension) BERINERT icatibant, RUCONEST chlordiazepoxide-clidinium dicyclomine BETAPACE, BETAPACE AF sotalol (NDCs^ 11534019701, 42494040901, BETIMOL timolol maleate solution, BETOPTIC S 51293069601, 51293069610 only) BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT chlorzoxazone 375 mg, cyclobenzaprine chlorzoxazone 500 mg (NDC^ 73007001303 only), (except cyclobenzaprine tablet 7.5 mg) BEYAZ ethinyl estradiol-drospirenone, chlorzoxazone 750 mg, ethinyl estradiol-drospirenone-levomefolate, CHLORZOXAZONE 250 MG ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron CIALIS sildenafil, tadalafil bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN CICATRACE Consult doctor BORTEZOMIB NINLARO, VELCADE CILOXAN ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin, BREEZE 2 STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, sulfacetamide, tobramycin, BESIVANCE ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, ACCU-CHEK GUIDE STRIPS AND KITS 3, CIMZIA LYOPHILIZED POWDER REMICADE, SIMPONI ARIA, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, STELARA INTRAVENOUS ONETOUCH ULTRA STRIPS AND KITS 3, CIMZIA PREFILLED SYRINGE COSENTYX, ENBREL, HUMIRA, OTEZLA, 3 ONETOUCH VERIO STRIPS AND KITS RINVOQ, SKYRIZI, BROMSITE bromfenac, diclofenac, ketorolac, ILEVRO, STELARA SUBCUTANEOUS, TREMFYA, PROLENSA XELJANZ, XELJANZ XR Bupap diclofenac sodium, ibuprofen, CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic naproxen (except naproxen CR or CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic naproxen suspension) CLINDAGEL erythromycin solution bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) clindamycin gel (NDC^ 68682046275 only) adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), butalbital-acetaminophen tablet 50-300 mg, diclofenac sodium, ibuprofen, clindamycin solution, clindamycin- BUTALBITAL-ACETAMINOPHEN naproxen (except naproxen CR or benzoyl peroxide, erythromycin solution, (NDC^ 69499034230 only) naproxen suspension) erythromycin-benzoyl peroxide, tretinoin, butalbital-acetaminophen-caffeine capsule diclofenac sodium, ibuprofen, EPIDUO, ONEXTON naproxen (except naproxen CR or clobetasol spray clobetasol foam naproxen suspension) CLOBEX SPRAY clobetasol foam BUTRANS buprenorphine transdermal, BELBUCA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* clocortolone cream hydrocortisone butyrate cream, DESFERAL deferasirox, deferiprone, deferoxamine hydrocortisone butyrate ointment, hydrocortisone butyrate solution, desoximetasone ointment 0.05% hydrocortisone butyrate cream, mometasone, triamcinolone cream, hydrocortisone butyrate ointment, triamcinolone lotion, triamcinolone ointment hydrocortisone butyrate solution, (except triamcinolone ointment 0.05%) mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment COLAZAL balsalazide, mesalamine delayed-rel (except (except triamcinolone ointment 0.05%) mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, DETROL LA darifenacin ext-rel, oxybutynin ext-rel, sulfasalazine delayed-rel, ASACOL HD, solifenacin, tolterodine, tolterodine ext-rel, PENTASA trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ colchicine capsule colchicine tablet, MITIGARE dexchlorpheniramine levocetirizine COLCRYS colchicine tablet, MITIGARE Dexifol folic acid CONSENSI amlodipine WITH celecoxib Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1%, CONTOUR NEXT STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, diclofenac sodium solution, ibuprofen, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, meloxicam, naproxen (except naproxen CR or ACCU-CHEK GUIDE STRIPS AND KITS 3, naproxen suspension) ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, ONETOUCH ULTRA STRIPS AND KITS 3, Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, ONETOUCH VERIO STRIPS AND KITS 3 diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or CONTOUR STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, naproxen suspension) ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, ACCU-CHEK GUIDE STRIPS AND KITS 3, DIFFERIN LOTION adapalene, benzoyl peroxide, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, clindamycin gel (except NDC^ 68682046275), ONETOUCH ULTRA STRIPS AND KITS 3, clindamycin solution, clindamycin- ONETOUCH VERIO STRIPS AND KITS 3 benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, CONTRAVE QSYMIA, SAXENDA EPIDUO, ONEXTON CORDRAN OINTMENT hydrocortisone butyrate cream, diflorasone cream, diflorasone ointment desoximetasone (except hydrocortisone butyrate ointment, desoximetasone ointment 0.05%), hydrocortisone butyrate solution, fluocinonide (except fluocinonide cream 0.1%), mometasone, triamcinolone cream, BRYHALI triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, metoprolol succinate ext-rel, ZOMIG NASAL SPRAY metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC diltiazem ext-rel diltiazem ext-rel (generics for CARDIZEM LA only) (except generics for CARDIZEM LA) CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, COZAAR candesartan, irbesartan, losartan, olmesartan, losartan, losartan-hydrochlorothiazide, telmisartan, valsartan olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, CRESEMBA itraconazole valsartan, valsartan-hydrochlorothiazide CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, Diphen Elixir levocetirizine lovastatin, pravastatin, rosuvastatin, simvastatin DORAL doxepin, eszopiclone, ramelteon, zolpidem, CUPRIMINE penicillamine capsule zolpidem ext-rel, BELSOMRA cyclobenzaprine ext-rel capsule, cyclobenzaprine DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline cyclobenzaprine tablet 7.5 mg (except cyclobenzaprine tablet 7.5 mg) hyclate capsule, minocycline, tetracycline CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, doxepin cream desonide, hydrocortisone, pimecrolimus, venlafaxine ext-rel capsule tacrolimus, EUCRISA CYTOMEL levothyroxine, liothyronine, SYNTHROID doxycycline hyclate delayed-rel tablet doxycycline hyclate 20 mg, doxycycline DARAPRIM pyrimethamine 50 mg, 200 mg hyclate capsule, minocycline, tetracycline DAYTRANA amphetamine- doxycycline hyclate tablet 50 mg doxycycline hyclate 20 mg, doxycycline dextroamphetamine mixed salts ext-rel †, (NDC^ 72143021160 only), hyclate capsule, minocycline, tetracycline dexmethylphenidate ext-rel, doxycycline hyclate tablet 75 mg, methylphenidate ext-rel †, MYDAYIS, doxycycline hyclate tablet 150 mg VYVANSE doxycycline monohydrate capsule 75 mg, doxycycline hyclate 20 mg, doxycycline DELZICOL balsalazide, mesalamine delayed-rel (except doxycycline monohydrate capsule 150 mg hyclate capsule, minocycline, tetracycline mesalamine delayed-rel tablet 800 mg), doxycycline monohydrate delayed-rel capsule ORACEA mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, DULERA ADVAIR DISKUS, ADVAIR HFA †, PENTASA BREO ELLIPTA †, SYMBICORT

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* DUTOPROL metoprolol succinate ext-rel WITH fenofibrate capsule 50 mg, 130 mg; fenofibrate (except fenofibrate capsule 50 mg, hydrochlorothiazide fenofibrate tablet 40 mg, 120 mg 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel DYRENIUM amiloride, triamterene FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate capsule 50 mg, EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, 130 mg; fenofibrate tablet 40 mg, 120 mg), irbesartan, irbesartan-hydrochlorothiazide, fenofibric acid delayed-rel losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, fenoprofen, FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, telmisartan, telmisartan-hydrochlorothiazide, naproxen (except naproxen CR or valsartan, valsartan-hydrochlorothiazide naproxen suspension) EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, FERIVA 21/7 folic acid zolpidem ext-rel, BELSOMRA FERRIPROX deferasirox, deferiprone, deferoxamine E.E.S. GRANULES erythromycins FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule venlafaxine ext-rel capsule Fexmid cyclobenzaprine ELELYSO CERDELGA, CEREZYME (except cyclobenzaprine tablet 7.5 mg) ELIDEL pimecrolimus, tacrolimus, EUCRISA FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA ELMIRON Consult doctor FIORICET CAPSULE diclofenac sodium, ibuprofen, ENABLEX darifenacin ext-rel, oxybutynin ext-rel, naproxen (except naproxen CR or solifenacin, tolterodine, tolterodine ext-rel, naproxen suspension) trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM MONITORING SYSTEM flucytosine capsule 500 mg fluconazole ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG fluocinonide cream 0.1% clobetasol cream ENTYVIO (For Crohn’s Disease Only) REMICADE, STELARA INTRAVENOUS fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA EPICERAM desonide, hydrocortisone fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, EPOGEN ARANESP, RETACRIT (generics for SARAFEM only) fluoxetine tablet [generics for SARAFEM]), ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, paroxetine HCl ext-rel, sertraline zolmitriptan, NURTEC ODT, ONZETRA XSAIL, fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, fluoxetine tablet 60 mg, fluoxetine tablet ZOMIG NASAL SPRAY [generics for SARAFEM]), paroxetine HCl, ERYPED erythromycins paroxetine HCl ext-rel, sertraline, TRINTELLIX estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM flurandrenolide cream, desonide, hydrocortisone flurandrenolide lotion ESTRING estradiol vaginal cream, IMVEXXY, VAGIFEM flurandrenolide ointment hydrocortisone butyrate cream, EVEKEO amphetamine-dextroamphetamine mixed salts, hydrocortisone butyrate ointment, methylphenidate hydrocortisone butyrate solution, mometasone, triamcinolone cream, EVERSENSE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE triamcinolone lotion, triamcinolone ointment MONITORING SYSTEM MONITORING SYSTEM (except triamcinolone ointment 0.05%) EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, FML FORTE, FML LIQUIFILM, FML S.O.P. dexamethasone, loteprednol, amlodipine-valsartan prednisolone acetate 1%, DUREZOL EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, FOCALIN XR amphetamine- olmesartan-amlodipine-hydrochlorothiazide dextroamphetamine mixed salts ext-rel †, EXJADE deferasirox, deferiprone, deferoxamine dexmethylphenidate ext-rel, methylphenidate ext-rel †, MYDAYIS, EXTAVIA dimethyl fumarate delayed-rel, glatiramer, VYVANSE AUBAGIO, BETASERON, COPAXONE, GILENYA, KESIMPTA, MAYZENT, OCREVUS, FOLIC-K folic acid REBIF, TYSABRI, VUMERITY, ZEPOSIA FOLLISTIM AQ GONAL-F FABIOR adapalene, benzoyl peroxide, Folvite-D folic acid clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- FORTAMET metformin, metformin ext-rel (except generics benzoyl peroxide, erythromycin solution, for FORTAMET and GLUMETZA) erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON FORTESTA testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, FANAPT aripiprazole, clozapine, olanzapine, quetiapine, ANDRODERM, NATESTO quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR FOSAMAX PLUS D alendronate, ibandronate, risedronate FEMRING estradiol vaginal cream, IMVEXXY, VAGIFEM

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* FOSRENOL calcium acetate, sevelamer carbonate, hydrocortisone butyrate lotion hydrocortisone butyrate cream, PHOSLYRA, VELPHORO hydrocortisone butyrate ointment, hydrocortisone butyrate solution, FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate mometasone, triamcinolone cream, FREESTYLE LIBRE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE triamcinolone lotion, triamcinolone ointment GLUCOSE MONITORING SYSTEM MONITORING SYSTEM (except triamcinolone ointment 0.05%) FREESTYLE STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, HylaVite folic acid 3 ACCU-CHEK COMPACT PLUS STRIPS AND KITS , hyoscyamine sulfate ext-rel dicyclomine ACCU-CHEK GUIDE STRIPS AND KITS 3, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, ONETOUCH ULTRA STRIPS AND KITS 3, hydromorphone ext-rel, methadone, ONETOUCH VERIO STRIPS AND KITS 3 morphine ext-rel, NUCYNTA ER, XTAMPZA ER FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, HYZAAR candesartan-hydrochlorothiazide, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, irbesartan-hydrochlorothiazide, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, losartan-hydrochlorothiazide, ZOMIG NASAL SPRAY olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, FULPHILA ZIEXTENZO valsartan-hydrochlorothiazide GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, icosapent ethyl omega-3 acid ethyl esters, VASCEPA SUPARTZ FX ILUMYA REMICADE Genicin Vita-S folic acid INCRUSE ELLIPTA SPIRIVA, YUPELRI GLASSIA PROLASTIN-C INDERAL LA, INDERAL XL atenolol, carvedilol, carvedilol phosphate ext-rel, GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL metoprolol succinate ext-rel, metoprolol tartrate, GLUMETZA metformin, metformin ext-rel (except generics nadolol, pindolol, propranolol, for FORTAMET and GLUMETZA) propranolol ext-rel, BYSTOLIC GLYCOPYRROLATE TABLET 1.5 MG dicyclomine INDOCIN diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or GOLYTELY peg 3350-electrolytes, CLENPIQ naproxen suspension) GRANIX NIVESTYM indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or GUARDIAN CONNECT CONTINUOUS DEXCOM CONTINUOUS GLUCOSE naproxen suspension) GLUCOSE MONITORING SYSTEM MONITORING SYSTEM Inflammacin diclofenac sodium, diclofenac sodium gel 1%, GUARDIAN REAL-TIME CONTINUOUS DEXCOM CONTINUOUS GLUCOSE diclofenac sodium solution, ibuprofen, GLUCOSE MONITORING SYSTEM MONITORING SYSTEM meloxicam, naproxen (except naproxen CR or halcinonide cream desoximetasone (except naproxen suspension) desoximetasone ointment 0.05%), INFLECTRA REMICADE, SIMPONI ARIA, fluocinonide (except fluocinonide cream 0.1%), STELARA INTRAVENOUS BRYHALI INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, HERCEPTIN, HERCEPTIN HYLECTA KANJINTI, TRAZIMERA metoprolol succinate ext-rel, metoprolol tartrate, HORIZANT gabapentin, GRALISE nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC HUMALOG FIASP, NOVOLOG INTRAROSA estradiol vaginal cream, IMVEXXY, VAGIFEM HUMALOG MIX 50/50 NOVOLOG MIX 70/30 INTUNIV amphetamine- HUMALOG MIX 75/25 NOVOLOG MIX 70/30 dextroamphetamine mixed salts ext-rel †, atomoxetine, dexmethylphenidate ext-rel, HUMATROPE GENOTROPIN, NORDITROPIN guanfacine ext-rel, methylphenidate ext-rel †, HUMULIN 70/30 NOVOLIN 70/30 MYDAYIS, VYVANSE HUMULIN N NOVOLIN N INVELTYS dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL HUMULIN R NOVOLIN R INVIRASE atazanavir, EVOTAZ, PREZCOBIX, PREZISTA HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate cream, INVOKANA FARXIGA, JARDIANCE hydrocortisone butyrate ointment, isosorbide dinitrate 40 mg isosorbide dinitrate hydrocortisone butyrate solution, (except isosorbide dinitrate 40 mg), mometasone, triamcinolone cream, isosorbide mononitrate triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) ISTALOL timolol maleate solution, BETOPTIC S JADENU deferasirox, deferiprone, deferoxamine

JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) KAMDOY desonide, hydrocortisone LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, KAZANO JANUMET, JANUMET XR prednisolone acetate 1%, DUREZOL ketoconazole foam 2% ketoconazole shampoo 2%, luliconazole ciclopirox, clotrimazole, econazole, selenium sulfide lotion 2.5% ketoconazole cream 2%, NAFTIN Ketodan ketoconazole shampoo 2%, LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, selenium sulfide lotion 2.5% zolpidem ext-rel, BELSOMRA ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, LUPRON DEPOT ELIGARD, FIRMAGON, ORIAHNN, ORILISSA naproxen (except naproxen CR or naproxen suspension) LUPRON DEPOT-PED SUPPRELIN LA, TRIPTODUR ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, LYRICA duloxetine, pregabalin naproxen (except naproxen CR or naproxen suspension) MACRODANTIN nitrofurantoin (except NDC^ 70408023932) KINERET ENBREL, HUMIRA, RINVOQ, XELJANZ, Matzim LA diltiazem ext-rel XELJANZ XR (except generics for CARDIZEM LA) KOMBIGLYZE XR JANUMET, JANUMET XR MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2 KUVAN sapropterin MAXALT, MAXALT-MLT eletriptan, naratriptan, rizatriptan, sumatriptan, KYPROLIS NINLARO, VELCADE zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, LACRISERT RESTASIS, XIIDRA ZOMIG NASAL SPRAY Lactojen Consult doctor MAXIDEX dexamethasone, loteprednol, LACTULOSE PAK lactulose solution prednisolone acetate 1%, DUREZOL LANOXIN TABLET digoxin mefenamic acid (NDC^ 69336012830 only) diclofenac sodium, ibuprofen, meloxicam, (125 MCG and 250 MCG only) naproxen (except naproxen CR or naproxen suspension) lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO MENEST estradiol LANTUS 8 BASAGLAR, LEVEMIR MENOSTAR estradiol LASTACAFT azelastine, cromolyn sodium, olopatadine mesalamine delayed-rel tablet 800 mg balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), LAZANDA fentanyl transmucosal lozenge, SUBSYS mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, PENTASA lovastatin, pravastatin, rosuvastatin, simvastatin metaxalone 400 mg cyclobenzaprine LETAIRIS ambrisentan, bosentan, OPSUMIT (except cyclobenzaprine tablet 7.5 mg) levorphanol fentanyl transdermal, hydrocodone ext-rel, metformin ext-rel metformin, metformin ext-rel (except generics hydromorphone ext-rel, methadone, (generics for FORTAMET and GLUMETZA only) for FORTAMET and GLUMETZA) morphine ext-rel, NUCYNTA ER, XTAMPZA ER methocarbamol 500 mg cyclobenzaprine LEXAPRO citalopram, escitalopram, fluoxetine (except (NDC^ 69036091010 only), (except cyclobenzaprine tablet 7.5 mg) fluoxetine tablet 60 mg, fluoxetine tablet methocarbamol 750 mg [generics for SARAFEM]), paroxetine HCl, (NDCs^ 69036093090, 70868090190 only) paroxetine HCl ext-rel, sertraline, TRINTELLIX MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, LEXIVA atazanavir, EVOTAZ, PREZCOBIX, PREZISTA risedronate, FORTEO, PROLIA, TYMLOS LIALDA balsalazide, mesalamine delayed-rel (except MIACALCIN NASAL SPRAY calcitonin-salmon mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, sulfasalazine delayed-rel, ASACOL HD, irbesartan, irbesartan-hydrochlorothiazide, PENTASA losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, LIBRAX dicyclomine telmisartan, telmisartan-hydrochlorothiazide, LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine valsartan, valsartan-hydrochlorothiazide (NDC^ 71800063115 only) Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, LIDOTREX lidocaine-prilocaine zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, ZOMIG NASAL SPRAY lovastatin, pravastatin, rosuvastatin, simvastatin MILLIPRED dexamethasone, hydrocortisone, LITHOSTAT Consult doctor methylprednisolone, prednisolone solution, prednisone LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lorid folic acid

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* MINASTRIN 24 FE ethinyl estradiol-drospirenone, NICOMIDE folic acid ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, NILANDRON abiraterone, bicalutamide, XTANDI, YONSA ethinyl estradiol-norethindrone acetate-iron nitrofurantoin (NDC^ 70408023932 only) nitrofurantoin (except NDC^ 70408023932) MINIVELLE estradiol, DIVIGEL, EVAMIST NITROMIST nitroglycerin lingual spray, MINOCIN doxycycline hyclate 20 mg, doxycycline nitroglycerin sublingual hyclate capsule, minocycline, tetracycline Nolix desonide, hydrocortisone minocycline ext-rel doxycycline hyclate 20 mg, doxycycline NORGESIC FORTE cyclobenzaprine hyclate capsule, minocycline, tetracycline (except cyclobenzaprine tablet 7.5 mg) MIRVASO azelaic acid gel, metronidazole, NORITATE azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA FINACEA FOAM, SOOLANTRA Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, doxycycline NORPACE disopyramide hyclate capsule, minocycline, tetracycline NORVASC amlodipine MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX NOURIANZ amantadine, entacapone, pramipexole, pramipexole ext-rel, rasagiline, ropinirole, MOVIPREP peg 3350-electrolytes, CLENPIQ ropinirole ext-rel, selegiline, NEUPRO MultiPro Consult doctor NOVACORT desonide, hydrocortisone mupirocin cream gentamicin, mupirocin ointment NOVO NORDISK NEEDLES 5 BD ULTRAFINE NEEDLES MYTESI diphenoxylate-atropine, loperamide NOXAFIL fluconazole, itraconazole NAPRELAN diclofenac sodium, ibuprofen, meloxicam, NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1%, naproxen (except naproxen CR or diclofenac sodium solution, ibuprofen, naproxen suspension) meloxicam, naproxen (except naproxen CR or naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen suspension) naproxen (except naproxen CR or naproxen NUTROPIN AQ GENOTROPIN, NORDITROPIN suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole NUVARING ethinyl estradiol-etonogestrel, ANNOVERA delayed-rel, pantoprazole delayed-rel tablet or DEXILANT NUVIGIL armodafinil, modafinil, SUNOSI naproxen CR diclofenac sodium, ibuprofen, meloxicam, OLEPTRO trazodone naproxen (except naproxen CR or OLUX-E clobetasol foam naproxen suspension) omeprazole-sodium bicarbonate esomeprazole delayed-rel, lansoprazole naproxen suspension diclofenac sodium, ibuprofen, meloxicam, delayed-rel, omeprazole delayed-rel, naproxen (except naproxen CR or pantoprazole delayed-rel tablet, DEXILANT naproxen suspension) OMNARIS flunisolide, fluticasone, mometasone, DYMISTA NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, OMNITROPE GENOTROPIN, NORDITROPIN ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, OMNIVEX folic acid ethinyl estradiol-norethindrone acetate-iron, ONFI clobazam, lamotrigine, rufinamide, topiramate, ethinyl estradiol-norgestimate, TROKENDI XR LO LOESTRIN FE ONGLYZA JANUVIA NATURE-THROID levothyroxine, liothyronine, SYNTHROID ORENCIA CLICKJECT, COSENTYX, ENBREL, HUMIRA, OTEZLA, NEO-SYNALAR desonide or hydrocortisone WITH gentamicin ORENCIA SUBCUTANEOUS RINVOQ, STELARA SUBCUTANEOUS, NESINA JANUVIA XELJANZ, XELJANZ XR NEULASTA, NEULASTA ONPRO ZIEXTENZO ORENCIA INTRAVENOUS REMICADE, SIMPONI ARIA NEUPOGEN NIVESTYM orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, ORTHO D folic acid pantoprazole delayed-rel tablet, DEXILANT ORTHO DF folic acid niacin tablet 500 mg niacin ext-rel ORTHOVISC DUROLANE, EUFLEXXA, GELSYN-3, Niacor niacin ext-rel SUPARTZ FX NICADAN folic acid Oscimin SR dicyclomine NICAPRIN folic acid OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone NICAZEL, NICAZEL FORTE folic acid OSMOPREP peg 3350-electrolytes, CLENPIQ

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* OSPHENA estradiol PREVACID esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, 5 OWEN MUMFORD NEEDLES BD ULTRAFINE NEEDLES pantoprazole delayed-rel tablet, DEXILANT oxiconazole ciclopirox, clotrimazole, econazole, PREVIDENT Consult doctor (NDCs^ 00168035830, 51672135902 only) ketoconazole cream 2%, NAFTIN PRILOSEC esomeprazole delayed-rel, lansoprazole OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, delayed-rel, omeprazole delayed-rel, hydromorphone ext-rel, methadone, pantoprazole delayed-rel tablet, DEXILANT morphine ext-rel, NUCYNTA ER, XTAMPZA ER PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, venlafaxine ext-rel capsule hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, PROCRIT ARANESP, RETACRIT trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ PRODIGEN Consult doctor PANCREAZE CREON, VIOKACE, ZENPEP PROMETRIUM medroxyprogesterone; progesterone, micronized pantoprazole delayed-rel suspension esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, PROTONIX esomeprazole delayed-rel, lansoprazole pantoprazole delayed-rel tablet, DEXILANT delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT paroxetine mesylate capsule 7.5 mg paroxetine HCl PROTOPIC pimecrolimus, tacrolimus, EUCRISA PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet PROVAD Consult doctor [generics for SARAFEM]), paroxetine HCl, PROVENTIL HFA albuterol sulfate CFC-free aerosol, paroxetine HCl ext-rel, sertraline, TRINTELLIX levalbuterol tartrate CFC-free aerosol PENNSAID diclofenac sodium, diclofenac sodium gel 1%, PROVIGIL armodafinil, modafinil, SUNOSI diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or PROZAC citalopram, escitalopram, fluoxetine (except naproxen suspension) fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, PERCOCET hydrocodone-acetaminophen, hydromorphone, paroxetine HCl ext-rel, sertraline, TRINTELLIX morphine, oxycodone-acetaminophen, NUCYNTA PSORCON desoximetasone (except desoximetasone ointment 0.05%), 5 PERRIGO NEEDLES BD ULTRAFINE NEEDLES fluocinonide (except fluocinonide cream 0.1%), PERTZYE CREON, VIOKACE, ZENPEP BRYHALI PEXEVA citalopram, escitalopram, fluoxetine (except QNASL flunisolide, fluticasone, mometasone, DYMISTA fluoxetine tablet 60 mg, fluoxetine tablet QTERN GLYXAMBI [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA PLAVIX clopidogrel, prasugrel, BRILINTA RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, PLEGRIDY dimethyl fumarate delayed-rel, glatiramer, tamsulosin, terazosin AUBAGIO, BETASERON, COPAXONE, GILENYA, KESIMPTA, MAYZENT, OCREVUS, RAYOS dexamethasone, hydrocortisone, REBIF, TYSABRI, VUMERITY, ZEPOSIA methylprednisolone, prednisolone solution, prednisone POLYTOZA Consult doctor RECEDO Consult doctor posaconazole delayed-rel tablet fluconazole, itraconazole RELION INSULIN NOVOLIN INSULIN PRADAXA warfarin, ELIQUIS, XARELTO REMODULIN treprostinil PRECISION XTRA STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, RENFLEXIS REMICADE, SIMPONI ARIA, ACCU-CHEK GUIDE STRIPS AND KITS 3, STELARA INTRAVENOUS ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, ONETOUCH ULTRA STRIPS AND KITS 3, REPATHA PRALUENT ONETOUCH VERIO STRIPS AND KITS 3 RHEUMATE folic acid PRED FORTE, PRED MILD dexamethasone, loteprednol, RIABNI RUXIENCE prednisolone acetate 1%, DUREZOL RIBOZEL folic acid PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO RIMSO-50 Consult doctor PREMARIN estradiol RIOMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) PREMARIN CREAM estradiol vaginal cream, IMVEXXY, VAGIFEM RITUXAN RUXIENCE PRENATAL PLUS 7 prenatal vitamins, CITRANATAL

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, zolpidem ext-rel, BELSOMRA SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR RyClora levocetirizine TARGADOX doxycycline hyclate 20 mg, doxycycline RYTARY carbidopa-levodopa, carbidopa-levodopa ext-rel hyclate capsule, minocycline, tetracycline SABRIL vigabatrin TASIGNA imatinib mesylate, BOSULIF, SPRYCEL SAIZEN GENOTROPIN, NORDITROPIN TAYTULLA ethinyl estradiol-drospirenone, SANDOSTATIN LAR SOMATULINE DEPOT ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, SCARSILK PAD Consult doctor ethinyl estradiol-norethindrone acetate-iron SEASONIQUE ethinyl estradiol-drospirenone, TAZORAC adapalene, benzoyl peroxide, ethinyl estradiol-drospirenone-levomefolate, clindamycin gel (except NDC^ 68682046275), ethinyl estradiol-levonorgestrel, clindamycin solution, clindamycin- ethinyl estradiol-norethindrone acetate, benzoyl peroxide, erythromycin solution, ethinyl estradiol-norethindrone acetate-iron erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON; calcipotriene ointment, SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, calcipotriene solution quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR TECFIDERA dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, SIGNIFOR LAR SOMATULINE DEPOT GILENYA, KESIMPTA, MAYZENT, OCREVUS, SILENOR doxepin, eszopiclone, ramelteon, zolpidem, REBIF, TYSABRI, VUMERITY, ZEPOSIA zolpidem ext-rel, BELSOMRA TESTIM testosterone gel (except authorized generics for SIL-K PAD Consult doctor TESTIM and VOGELXO), testosterone solution, ANDRODERM, NATESTO SILIVEX Consult doctor testosterone gel 1% testosterone gel (except authorized generics for SILTREX Consult doctor (authorized generics for TESTIM and TESTIM and VOGELXO), testosterone solution, VOGELXO only) ANDRODERM, NATESTO SIMPONI COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, THEO-24 ipratropium inhalation solution, XELJANZ, XELJANZ XR PERFOROMIST, SEREVENT, SPIRIVA, STRIVERDI RESPIMAT, YUPELRI SINGULAIR montelukast, zafirlukast THIOLA, THIOLA EC Consult doctor SOMAVERT SOMATULINE DEPOT TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S SORILUX calcipotriene ointment, calcipotriene solution TIROSINT levothyroxine, SYNTHROID SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS naproxen suspension) TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone, STENDRA sildenafil, tadalafil neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV TOBRADEX OINTMENT sucralfate suspension sucralfate tablet topiramate ext-rel capsule (generics for carbamazepine, carbamazepine ext-rel, sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen QUDEXY XR only) clobazam, divalproex sodium, (except naproxen CR or naproxen suspension) divalproex sodium ext-rel, gabapentin, WITH eletriptan, naratriptan, rizatriptan, lamotrigine, lamotrigine ext-rel, levetiracetam, sumatriptan, zolmitriptan, NURTEC ODT, levetiracetam ext-rel, oxcarbazepine, ONZETRA XSAIL, REYVOW, UBRELVY, phenobarbital, phenytoin, ZEMBRACE SYMTOUCH or phenytoin sodium extended, primidone, ZOMIG NASAL SPRAY rufinamide, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, SUPREP peg 3350-electrolytes, CLENPIQ TROKENDI XR, VIMPAT, XCOPRI SURE-TEST STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, metoprolol succinate ext-rel, metoprolol tartrate, ACCU-CHEK GUIDE STRIPS AND KITS 3, nadolol, pindolol, propranolol, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, propranolol ext-rel, BYSTOLIC ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 TRACLEER ambrisentan, bosentan, OPSUMIT Symax-SR dicyclomine TRADJENTA JANUVIA SYNERDERM desonide, hydrocortisone tramadol (NDC^ 52817019610 only), tramadol (except NDC^ 52817019610), tramadol ext-rel capsule tramadol ext-rel tablet SYNVISC, SYNVISC-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX TRANSDERM SCOP meclizine, scopolamine transdermal SYPRINE trientine TRAVATAN Z latanoprost, travoprost, LUMIGAN, ZIOPTAN TALIVA folic acid TRELSTAR MIXJECT ELIGARD, FIRMAGON

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* TREXIMET diclofenac sodium, ibuprofen or naproxen Vanoxide-HC adapalene, benzoyl peroxide, (except naproxen CR or naproxen suspension) clindamycin gel (except NDC^ 68682046275), WITH eletriptan, naratriptan, rizatriptan, clindamycin solution, clindamycin- sumatriptan, zolmitriptan, NURTEC ODT, benzoyl peroxide, erythromycin solution, ONZETRA XSAIL, REYVOW, UBRELVY, erythromycin-benzoyl peroxide, tretinoin, ZEMBRACE SYMTOUCH or EPIDUO, ONEXTON ZOMIG NASAL SPRAY VASCULERA Consult doctor triamcinolone aerosol 0.2% hydrocortisone butyrate cream, hydrocortisone butyrate ointment, VECTICAL calcipotriene ointment, calcipotriene solution hydrocortisone butyrate solution, VELTIN adapalene, benzoyl peroxide, mometasone, triamcinolone cream, clindamycin gel (except NDC^ 68682046275), triamcinolone lotion, triamcinolone ointment clindamycin solution, clindamycin- (except triamcinolone ointment 0.05%) benzoyl peroxide, erythromycin solution, triamcinolone ointment 0.05% hydrocortisone butyrate cream, erythromycin-benzoyl peroxide, tretinoin, hydrocortisone butyrate ointment, EPIDUO, ONEXTON hydrocortisone butyrate solution, venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine, mometasone, triamcinolone cream, venlafaxine ext-rel capsule triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) VENTOLIN HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol Trianex hydrocortisone butyrate cream, hydrocortisone butyrate ointment, VEREGEN imiquimod hydrocortisone butyrate solution, mometasone, triamcinolone cream, VIAGRA sildenafil, tadalafil triamcinolone lotion, triamcinolone ointment VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), (except triamcinolone ointment 0.05%) HARVONI (genotypes 1, 4, 5, 6) TRICOR fenofibrate (except fenofibrate capsule 50 mg, VIIBRYD citalopram, escitalopram, fluoxetine (except 130 mg; fenofibrate tablet 40 mg, 120 mg), fluoxetine tablet 60 mg, fluoxetine tablet fenofibric acid delayed-rel [generics for SARAFEM]), paroxetine HCl, TRILIPIX fenofibrate (except fenofibrate capsule 50 mg, paroxetine HCl ext-rel, sertraline, TRINTELLIX 130 mg; fenofibrate tablet 40 mg, 120 mg), VIRACEPT atazanavir, EVOTAZ, PREZCOBIX, PREZISTA fenofibric acid delayed-rel VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, TRINAZ 7 prenatal vitamins, CITRANATAL SUPARTZ FX 5 TRIVIDIA INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES VITAFOL-ONE 7 prenatal vitamins, CITRANATAL TronVite folic acid Vitasure folic acid TRUETEST STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, VIVELLE-DOT estradiol, DIVIGEL, EVAMIST ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, ACCU-CHEK GUIDE STRIPS AND KITS 3, VOGELXO testosterone gel (except authorized generics for ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, TESTIM and VOGELXO), testosterone solution, ONETOUCH ULTRA STRIPS AND KITS 3, ANDRODERM, NATESTO ONETOUCH VERIO STRIPS AND KITS 3 WESTHROID levothyroxine, liothyronine, SYNTHROID TRUETRACK STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3, WP THYROID levothyroxine, liothyronine, SYNTHROID ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3, ACCU-CHEK GUIDE STRIPS AND KITS 3, XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3, oxazepam ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 XENAZINE tetrabenazine, AUSTEDO TRUXIMA RUXIENCE XENICAL QSYMIA, SAXENDA TUDORZA SPIRIVA, YUPELRI XOLEGEL ciclopirox, ketoconazole cream 2% UDENYCA ZIEXTENZO XOPENEX HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol ULORIC allopurinol Xvite folic acid ULTIMED INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES XYZBAC folic acid ULTIMED NEEDLES 5 BD ULTRAFINE NEEDLES YASMIN ethinyl estradiol-drospirenone, UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, ethinyl estradiol-drospirenone-levomefolate, tamsulosin, terazosin ethinyl estradiol-norethindrone acetate, VALCYTE valganciclovir ethinyl estradiol-norethindrone acetate-iron VALTREX acyclovir capsule, acyclovir tablet, valacyclovir YAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* Yuvafem estradiol vaginal cream, IMVEXXY, VAGIFEM zolpidem sublingual doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA ZALVIT 7 prenatal vitamins, CITRANATAL ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, ZARXIO NIVESTYM zolpidem ext-rel, BELSOMRA ZEGERID esomeprazole delayed-rel, lansoprazole ZONEGRAN carbamazepine, carbamazepine ext-rel, delayed-rel, omeprazole delayed-rel, divalproex sodium, divalproex sodium ext-rel, pantoprazole delayed-rel tablet, DEXILANT gabapentin, lamotrigine, lamotrigine ext-rel, ZELAC Consult doctor levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, ZEMAIRA PROLASTIN-C phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), zonisamide, FYCOMPA, OXTELLAR XR, HARVONI (genotypes 1, 4, 5, 6) TROKENDI XR, VIMPAT, XCOPRI ZERVIATE azelastine, cromolyn sodium, olopatadine ZONTIVITY Consult doctor ZESTORETIC fosinopril-hydrochlorothiazide, ZORTRESS everolimus lisinopril-hydrochlorothiazide, quinapril-hydrochlorothiazide ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or ZETIA ezetimibe naproxen suspension) ZETONNA flunisolide, fluticasone, mometasone, DYMISTA ZUPLENZ granisetron, ondansetron, SANCUSO ZIANA adapalene, benzoyl peroxide, ZYDELIG COPIKTRA clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- ZYFLO montelukast, zafirlukast benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, EPIDUO, ONEXTON neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, zileuton ext-rel montelukast, zafirlukast TOBRADEX OINTMENT ZIRGAN trifluridine ZYTIGA abiraterone, bicalutamide, XTANDI, YONSA ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, ZYVIT folic acid hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER ZOLADEX ELIGARD, FIRMAGON, ORILISSA ZOLOFT citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX

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 percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 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 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. 4 Coverage may be altered or copay amounts may vary based on the condition being treated (e.g., psoriasis). 5 BD ULTRAFINE syringes and needles are the only preferred options. 6 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 7 Generic prenatal vitamins and CITRANATAL are the only preferred options. 8 Long Acting Insulins - First Generation.

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 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 mandatory 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.