(FEHB) Program Prescription Drug Formulary, Effective August 1, 2018

2018

MVP Federal Employee Health Benefits (FEHB) Program PRESCRIPTION DRUG FORMULARY

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Effective August 1, 2018

2018 PRESCRIPTION DRUG FORMULARY EFFECTIVE August 1, 2018

Your physician is the person best suited to help you make decisions about prescription drugs, and the prescription drug information below is intended for consumer guidance only. This information relates to the Prescription Drug Formulary, generally, and may not describe your particular coverage. Your FEHB Program Brochure determines your benefits, limitations and exclusions.

While every effort has been made to insure accuracy, some information may be out of date. The Formulary is subject to change based on decisions made by the Pharmacy & Therapeutics (P&T) committee. Medications with an over-the- counter equivalent are not a covered benefit. Under the Brand/Generic Difference Program, if there is an A-rated generic drug, and you receive the brand name drug, you will be responsible for the difference in cost between the generic and the brand name drug plus your generic copayment. Generic drugs on the formulary may not have the equivalent brand name product listed.

Products are listed in their most represented tier. Certain drugs may have a generic name but are a brand drug and will process as tier 3 product. For example a drug may be listed in tier 1 but a certain strength, dosage form or manufacturer may be considered a brand drug and will process at tier 3.

Certain drugs are subject to prior authorization, step therapy or quantity limits. All new drugs require prior authorization for a minimum of six (6) months from when they become available on the market. To find out if the drug you take is subject to one of these management tools or if you must obtain your medication from a specialty pharmacy, check the formulary at www.mvphealthcare.com or call our Customer Care Center at 1-888-687-6277.

DRUG TIER 1 TIER 2 TIER 3 TIER 4 MEDICAL (M) CATEGORY Includes most generic drugs. Includes preferred brand Includes non-preferred brand Includes non-preferred name drugs, select high name drugs. specialty drugs. cost generics drugs, and preferred specialty drugs. ACE Inhibitors** benazepril/HCTZ None Accupril (blood pressure captopril/HCTZ Accuretic lowering, enalapril/HCTZ Aceon includescombinati fosinopril/HCTZ Altace on products) lisinopril/HCTZ Epaned moexipril/HCTZ Lotensin perindopril Mavik quinapril/HCTZ Prestalia ramipril Prinivil trandolapril Qbrelis trandolapril-verapamil Vasotec Zestril Zestoretic EX

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

2 Adrenal cortisone None Cortef Acthar HP # Hormones dexamethasone Dexpak Oral** Emflaza # Medrol fludrocortisone Millipred hydrocortisone Orapred ODT methylprednisolone Prelone prednisolone prednisone Adrenergic clonidine None Cardura/XL Antagonists** clonidine patch Catapres/TTS EX doxazosin Minipress guanfacine Tenex methyldopa/HCTZ midodrine prazosin reserpine terazosin Alzheimer’s donepezil Aricept Agents** ergoloid Exelon patch memantine/XR Namenda IR/XR galantamine Namzaric rivastigmine oral/patch Razadyne ER Androgens danazol Androgel *,q Anadrol-50 # Aveed # (male hormones) oxandrolone q Androderm #*,q Testopel q testosterone inj q Android q # * testosterone gel q * Axiron # * q testosterone TD soln q Delatestryl # q Depo-Testosterone # q Fortesta # *,q Methitest q# * Natesto #q Oxandrin q # Striant # *,q Testim #,q Testred # *,q Vogelxo #q * ARBs/Renin candesartan/HCTZ None Atacand Inhibitors** eprosartan/HCTZ Avalide (includes irbesartan/HCTZ Avapro combination losartan/HCTZ Azor EX products) olmesartan/HCTZ Benicar/HCT olmesartan/amlodipine Byvalson telmisartan/amlodipine Cozaar valsartan Diovan/HCT valsartan/amlodipine Edarbi valsartan/amlodipine/HCT Edarbyclor Entresto Exforge/HCT Hyzaar Micardis/HCT Tekturna Teveten Tribenzor Twynsta Anti -Anxiety alprazolam/ER None Agents** buspirone Tranxene-T chlordiazepoxide Valium clorazepate Xanax/XR diazepam hydroxyzine pamoate lorazepam

3 oxazepam Antiarrhythmics** amiodarone None Betapace/AF (heart rhythm) disopyramide Cordarone dofetilide Multaq flecainide Norpace/CR mexiletine Rythmol SR Pacerone Sotylize propafenone/SR Tikosyn quinidine sotalol/AF Antibiotics amoxicillin Cefaclor ER Acticlate EX Baxdela Inj # amoxicillin/ clavulanate Adoxa Dalvance amoxicillin/clavulanate XR Augmentin/ES/XR Orbactiv # ampicillin Avelox Rocephin (for Lyme Avidoxy Bactrim/DS azithromycin Baxdela tabs Disease) Sivextro inj # cefaclor/ER Biaxin XL Teflaro cefadroxil Cedax Vibativ cefdinir Ceftin Zyvox Inj # cefditoren Cipro Zerbaxa cefpodoxime Cleocin/Susp cefprozil Cleocin Vaginal cefuroxime Dificid cephalexin caps Doryx # ciprofloxacin/ER E.E.S. Susp clarithromycin/ER Eryped clindamycin Ery-Tab Erythromycin demeclocycline Base dicloxacillin Factive doxycycline IR # # Firvanq doxycycline DR Keflex Erythrocin Levaquin erythromycin Minocin EX levofloxacin Monodox linezolid Moxatag minocycline IR caps # # Oracea minocycline ER PCE # moxifloxacin Rocephin (for Lyme neomycin Disease) ofloxacin Sivextro tablets paromomycin Solodyn # penicillin Spectracef sulfa/trimeth DS/SS Sulfadiazine tetracycline Suprax vancomycin Vancocin Vibramycin Xifaxan # Zithromax Z-Max Zyvox Anticoagulants heparin Coumadin* Arixtra enoxaparin Eliquis* Bevyxxa fondaparinux Xarelto* Fragmin Jantoven* Iprivask warfarin* Lovenox Pradaxa EX Savaysa EX Anticonvulsants** carbamazepine/XR Dilantin Aptiom Sabril + (seizures) clonazepam Vimpat Banzel diazepam rectal Briviact divalproex/ER Carbatrol #Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

4 Epitol Celontin ethosuximide Depakene felbamate Depakote/ER gabapentin Diastat lamotrigine/XR/ODT Felbatol EX levetiracetam/ SR Fycompa oxcarbazepine Gabitril Keppra/XR phenobarbital Klonopin phenytoin Lamictal/XR/ODT primidone Lyrica tiagabine Lyrica CR # topiramate Mysoline EX valproic acid Neurontin vigabatrin + Onfi zonisamide Oxtellar XR Peganone Phenytek Potiga Qudexy XR Tegretol/XR Topamax Trileptal Trokendi XR Zarontin Zonegran Antidepressants** amitriptyline Pristiq ER Anafranil amoxapine Aplenzin EX bupropion/SR/XL Celexa citalopram Cymbalta clomipramine Desvenlafaxine ER (brand) desipramine Duloxetine 40mg # desvenlafaxine ER (generic) Effexor/XR doxepin Emsam duloxetine Fetzima escitalopram Forfivo XL fluoxetine Khedezla fluvoxamine/CR Lexapro imipramine HCl Marplan imipramine pamoate Nardil maprotiline Norpramin mirtazapine Oleptro ER nefazodone Pamelor nortriptyline Parnate olanzepine/ Paxil/CR fluoxetine Pexeva paroxetine/ER Prozac/Weekly phenelzine Remeron protriptyline Sarafem sertraline Surmontil tranylcypromine Tofranil/PM trazodone Trintellix trimipramine Venlafaxine ER (brand) venlafaxine/ER (generic) Viibryd Wellbutrin/SR/XL Zoloft

Antiemetics aprepitant q Anzemet q Akynzeo # (nausea) Compro Bonjesta # Aloxi Inj dronabinol Cesamet Cinvanti # granisetron q Diclegis q Emend Inj # ondansetron q Emend q Sustol Inj #

5 prochlorperazine Marinol Varubi inj # promethazine Akynzeo qSancuso q trimethobenzamide Syndros # scopolamine patch Tigan Transderm-Scop Varubi q Zofran/ODT q Zuplenz EX,q Antifungal clotrimazole oral None Ancobon caspofungin Agents fluconazole Cresemba griseofulvin Diflucan itraconazole # Grifulvin V ketoconazole tabs Gris-Peg nystatin Jublia # terbinafine q Kerydin # voriconazole Lamisil Granules q Lamisil q Nizoral Noxafil Onmel # Oravig Sporanox # Vfend Antihistamines** azelastine Astepro Clarinex chlorpheniramine Patanase clemastine Xyzal cyproheptadine desloratadine hydroxyzine levocetirizine olopatadine nasal promethazine Antihistamine/ Various generics None Various brands # Decongestant Clarinex D EX Combinations Semprex-DEX Antihypertensive amlodipine/atorvastatin None Bidil Combinations** amlodipine/benazepril Caduet (blood pressure atenolol/chlorthalidone Corzide lowering) Clorpres Lopressor HCT nadolol/bendroflumethiazide Lotrel Tarka Tenoretic Ziac Antimalarials atovaquone/proguanil q None Coartem q chloroquine q Daraprim q hydroxychloroquine* Malarone q mefloquine q Plaquenil* quinine sulfate q Primaquine q Qualaquin q Anti - ethambutol Priftin Mycobutin mycobacterials** isoniazid Paser (TB) pyrazinamide Rifater rifampin Rifamate Sirturo Trecator Antiparasitics Atovaquone q None Albenza Dapsone Alinia metronidazole tabs Benznidazole # paromomycin Biltricide tinidazole Flagyl/ER ivermectin Mepron # #Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

6 Solosec # Stromectol Tindamax Antiplatelet anagrelide None Aggrenox Praxbind Agents** aspirin-dipyridamole Agrylin cilostazol Brilinta clopidogrel Effient dipyridamole Persantine pentoxifylline Plavix prasugrel Pletal Zontivity Antipsychotics** Aripiprazole/ODT Latuda Abilify Nuplazid # Abilify- Maintena

chlorpromazine Clozaril Aristada clozapine/ODT Equetro Invega- fluphenazine Fanapt Sustenna Invega Trinza haloperidol FazaClo Risperdal- lithium Geodon Consta loxapine Invega Zyprexa- olanzapine/ODT Lithium solution Relprevv olanzapine/fluoxetine Lithobid perphenazine Orap paliperidone ER Rexulti pimozide Risperdal quetiapine/XR Saphris risperidone/ ODT Seroquel/XR thioridazine Symbyax # thiothixene Vraylar trifluoperazine Versacloz ziprasidone Zyprexa Antiretrovirals/ abacavir Aptivus Biktarvy # Egrifta + Trogarzo # HIV abacavir/lamiv/zidov Atripla Cimduo # atazanavir Crixivan Combivir didanosine Emtriva Complera efavirenz Epzicom Descovy fosamprenavir Fuzeon + Edurant lamivudine Invirase Epivir tabs lamivudine soln Isentress Epivir soln lamivudine/zidovudine Norvir Epivir HBV soln lopinavir/ritonavir Prezista Evotaz nevirapine Rescriptor Genvoya ritonavir Selzentry Intelence stavudine Truvada Lexiva tenofovir Viracept Juluca zidovudine Viread tabs Kaletra Odefsey Prezcobix Retrovir Reyataz Stribild Sustiva Symfi/Lo # Tivicay Triumeq Trizivir Tybost Videx-EC Viramune/XR Viread Powder Vitekta Zerit Ziagen

7 Antispasmodic bethanechol Myrbetriq Anaspaz Agents** clidinium/chlordiazepoxide Toviaz Bentyl darifenacin Vesicare Cantil dicyclomine Detrol/LA flavoxate Ditropan XL hyoscyamine Enablex oxybutynin/ER Gelnique propantheline Levbid tolterodine/ER Levsin/SL trospium Pamine/Forte Robinul/Forte Symax/Duotab Antitussives & Benzonatate 100mg, 200mg None Entex (all) Expectorants codeine combinations Rezira # hydrocodone combinations Tussionex # Tuzistra XR # Antiviral Agents acyclovir Relenza q Denavir Prevymis IV # amantadine Famvir Rapivab famciclovir Flumadine oseltamivir q Prevymis tabs rimantadine Tamiflu q valacyclovir Valcyte susp EX valgancyclovir Valtrex Zovirax

Arthritis Agents azathioprine* Ridaura* Arava* (non-biological) hydroxychloroquine* Rheumatrex* leflunomide* Trexall* methotrexate* sulfasalazine*

Benign Prostatic alfuzosin* None Avodart* Hypertrophy doxazosin* Cardura/XL* (BPH) Agents dutasteride * Cialis 2.5 mg # (prostate) dutasteride/tamsulosin Cialis 5 mg # finasteride* Flomax* tamsulosin* Jalyn* terazosin caps* Proscar* Rapaflo* Uroxatral* Beta -Blocking acebutolol None Betapace/AF Agents** atenolol Bystolic (blood pressure betaxolol Coreg/CR lowering) bisoprolol Corgard carvedilol/ER Dutoprol EX labetalol Inderal LA EX metoprolol/XL Innopran XL EX nadolol Lopressor/HCT pindolol Sectral propranolol/LA Tenormin EX sotalol/AF Toprol XL timolol Trandate Zebeta Biologic Disease - Psoriasis: Actemra IV # Modifying Agents Humira #,+ Ilaris # Stelara #, + (after Orencia IV # failure of Humira) Remicade # Rituxan # #Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

8 Taltz #, + (after failure Simponi Aria # of Humira) All other conditions:

Actemra SQ #,+ All other conditions: Cimzia #,+ #, + Enbrel Cosentyx #,+ #, + Humira Kevzara #,+ Kineret #,+ Olumiant # Orencia #,+ Otezla #,+ Stelara #,+ Simponi #,+ Taltz #,+ Xeljanz #,+ Blood Modifiers None Procrit Aranesp Leukine + Granix Doptelet # Mozobil + NPlate Epogen Promacta + Mircera Neulasta Neupogen Retacrit # Tavalisse # Zarxio Botulinum Toxins None None None Botox # Dysport # Myobloc # Xeomin #+ Calcium Channel amlodipine None Adalat CC Blocking Agents diltiazem/ER/XT Calan/SR (CCB)** felodipine Cardizem/CD/LA (blood pressure isradipine Norvasc lowering) nicardipine Nymalize nifedipine/ER Procardia/XL nimodipine Sular nisoldipine Tiazac verapamil/ SR/PM Verelan/PM

9 Cancer Drugs anastrozole* Alkeran Afinitor Adcetris (oral drugs are bexarotene + Emcyt Alecensa Aliqopa covered under the bicalutamide* Fareston* Alunbrig Bavencio chemotherapy capecitabine + Gleevec + Arimidex* Beleodaq benefit and may be etoposide* Hexalen Aromasin* Bendeka subject to a exemestane* Leukeran Bosulif Besponsa copayment that flutamide Lomustine Cabometyx Blincyto differs from the hydroxyurea Lysodren Calquence # Clolar # pharmacy benefit) imatinib Matulane Caprelsa Cyramza letrozole* Myleran Casodex Darzalex leucovorin Tabloid* Cometriq # Empliciti megestrol Cotellic Erwinaze melphalan cyclophosphamide Evomela mercaptopurine* Droxia Folotyn # methotrexate* Erivedge Fusilev # # nilutamide Erleada Gazyva # tamoxifen* Farydak Halaven temozolomide + Femara* Imfinzi tretinoin Gilotrif Imlygic Gleostine Ixempra Hycamtin Kadcyla Hydrea Keytruda Ibrance Kyprolis Iclusig Kymriah #

Idhifa Lartruvo

Imbruvica Lutathera # Inlyta Marqibo

Iressa Mylotarg # Jakafi Onivyde

Kisqali Opdivo

Lenvima Perjeta

Lonsurf Portrazza Lynparza Rituxan Hycela Megace Synribo Megace ES* Tecentriq Mekinist Temodar IV Mesnex Torisel

Nerlynx Treanda Nexavar Vyxeos Nilandron Yervoy Ninlaro Yescarta #

Odomzo Pomalyst Yondelis Purixan Zaltrap Rubraca Rydapt Soltamox* Sprycel Stivarga Sutent Sylatron Tafinlar Tagrisso Tarceva Targretin Tasigna Temodar Tykerb Venclexta Verzenio Votrient Xalkori #Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

10 Xeloda Zelboraf Zolinza # Zejula Zydelig

Cardiac digoxin Lanoxin EX None Glycosides** digoxin elixir (heart) CNS Stimulants amphetamine Vyvanse* q Adderall (ex: ADHD) combination Adderall XR* q amphetamine Adzenys XR EX combination/XR* q Aptensio XR q armodafinil q Concerta* q atomoextine q Daytrana* clonidine ER* Dexedrine* q dexmethylphenidate* Evekeo EX dexmethylphenidate XR* q Focalin dextroamphetamine* Focalin XR* q Metadate ER* q Intuniv* methylphenidate* Kapvay* methylphenidate CD*q Metadate CD* q methylphenidate chew* Methylin* methylphenidate ER 24 hour* q Nuvigil q * q modafinil * Provigil q * guanfacine ER* Quillivant XR*q Ritalin LA* q Strattera q Xyrem # Compounds None None • All compounds > coverage for $100 require prior compounded medications is subject to criteria listed authorization in the Compounded • All compounds are Medications policy. Tier 3 Contraceptives Aftera Ella (Emergency) Econtra EZ Fallback Levonorgestrel My Way Option 2 #Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

11 Contraceptives Altavera* Lo Loestrin FE* Balcoltra # Kyleena (Prevention -- Alyacen* Nuvaring* Beyaz* Liletta Oral/Topical/ Amethia/Lo* Brevicon* Mirena Other) Amethyst* Cyclessa* Nexplanon For plans following Apri* Depo-Provera Skyla Affordable Care Act Aranelle* Depo-SQ Provera (ACA) coverage, Aubra* Desogen* copays are subject to Aviane* Estrostep FE* standard ACA rules. Brand products Azurette* Femcon Fe* with a generic Balziva* Generess Fe* available will not be Briellyn* Loestrin/FE* covered at no cost Camila* Lomedia 24 FE* # share, unless prior Camrese/Lo* LoSeasonique* authorization has Caziant* Minastrin 24 FE* been obtained. Chateal* Mircette* Cryselle* Modicon* Cyclafem Natazia* Dasetta* Norinyl* Daysee* Nor-QD* Delyla* Ortho Novum* drospir/estra Ortho Tri-Cyclen* drospir/ethin* Ortho Tri-Cyclen Lo* drospir/ethin/levome* Ortho-Cyclen* Elinest* Ovcon* Emoquette* Quartette* Enpresse* Plan B One Step Enskyce* Safyral* Errin* Seasonique* Estarylla* Taytulla ethinyl est-norgest LO Tri-Norinyl* Falmina* Yasmin* Gianvi* Yaz* Gildagia* Heather* Introvale* Jencycla* Jolessa* Jolivette* Junel/Fe* Kariva* Kelnor* Kurvelo* Larin/Fe* Leena* Lessina* Levonest* levonorgestrel/EE* Levora* Lomedia* Loryna* Low-Ogestrel* Lutera* Lyza* Marlissa* medroxyprogesterone/inj q Microgestin/Fe* Mibelas 24 Fe * Mono-Linyah* Mononessa* Myzilra*

12 Necon* Nikki* Nora-Be* norelgest-EE* noreth-EE-FF Norlyroc* Nortrel* Ocella* Ogestrel* Orsythia* Philith* Pirmella* Portia* Previfem* Quasense* Reclipsen* Rivelsa Solia* Sprintec* Sronyx* Syeda* Take Action Tilia Fe* Trinessa* Tri-Legest Fe* Tri-Linyah* Tri-Lo Sprintec* Tri-Previfem* Tri-Sprintec* Trivora* Velivet* Viorele* Vyfemla* Wera* Wymzya Fe* Xulane* Zarah* Zenchent/Fe* Zovia* Cough/Cold Various generics All brands required All brands require prior prior authorization authorization Diabetic Agents: None Basaglar Admelog # Insulin** Fiasp Adlyxin • Subject to diabetic Humulin R U-500 Afrezza copay outlined in Lantus Soliqua the benefits /Solostar section of the Levemir brochure Novolin/Pen Novolog Mix Novolog/Pen Toujeo Tresiba Diabetic Agents: acarbose ActoplusMet XR Actoplus Met Other** alogliptan EX Bydureon Amaryl EX • Subject to diabetic alogliptan/metformin Byetta Cycloset copay outlined in alogliptan/pioglitazone EX Farxiga Diabeta the benefits glimepiride Glucagen Duetact section of the glimepiride/pioglitazone Glucagon Fortamet # brochure glipizide ER/metformin Glyset Glucophage/XR glyburide Invokamet/XR Glucotrol/ XL glyburide , micro nized Invokana Glucovance

13 glyburide/metformin Janumet/XR Glumetza # metformin/ER (generic Januvia Glynase Glucophage/XR) Jentadueto/XR Glyxambi metforminER (generic Ozempic Jardiance Glumetza, Fortamet)# Proglycem Kazano EX miglitol Riomet Kombiglyze XR EX nateglinide Symlin Nesina EX pioglitazone Tradjenta Onglyza EX pioglitazone-metformin Victoza Oseni EX repaglinide Xigduo XR Precose repaglinide-metformin Starlix tolazamide Synjardy/XR tolbutamide Tanzeum Trulicity Xultophy Diabetic Meters & Preferred Meters: Preferred Strips: Strips One Touch Ultra Brand One Touch • Subject to Meters UltraTest Strips diabetic copay One Touch Verio One Touch outlined in the Brand Meters Verio Test Strips benefits section of the brochure All test strips are subject to quantity limits • All other test strips are excluded Digestants/ pancrelipase Creon Pancreaze Enzymes** Pertzye Ultresa Viokace Zenpep Diuretics** acetazolamide None Aldactone amiloride/HCTZ Demadex bumetanide Diuril chlorthalidone Dyazide chlorothiazide Dyrenium eplerenone Inspra EX ethacrynic acid Lasix furosemide Maxzide hydrochlorothiazide Microzide indapamide methazolamide methyclothiazide metolazone spironolactone/HCTZ torsemide triamterene/HCTZ Enteral Therapy All products not listed All products not All products not listed All products not in the MVP policy listed in the MVP in the MVP policy listed in the MVP require prior policy require prior require prior policy require authorization authorization authorization prior authorization

Epinephrine epinephrine auto- Epipen q Adrenaclick q # Products injector q Erectile sildenafil 25mg, 50mg, Caverject q Dysfunction 100mg q Cialis 10 & 20mg q,EX yohimbine Edex q #Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

14 Levitra q,EX Muse q Staxyn q,EX Stendra q,EX Viagra q Fertility Agents clomiphene Follistim AQ # + Bravelle # + Leuprolide SQ # + Cetrotide # + Ganirelix #+ Gonal-F# + HCG + Lutrepulse # + Menopur # + Novarel + Ovidrel + Pregnyl + Repronex # + Gaucher’s miglustat # None Zavesca # Cerdelga # + Cerezyme # Disease Elelyso # Vpriv # GI: Ulcer/ cimetidine Carafate susp Aciphex q,# Heartburn esomeprazole q Carafate Tabs Agents** famotidine Dexilant q,# lansoprazole q First-Lansoprazole # q lansoprazole STB First-Omeprazole # nizatidine Nexium #,q omeprazole Omeclamox #Pepcid omeprazole/sod bicarb q,# Prevpac q pantoprazole Prevacid ODT q q rabeprazole Prevacid Cap q,# ranitidine tabs Prilosec q,# sucralfate tabs Protonix q,# Pylera Zantac Zegerid #,q GI: Inflammatory Alosetron # * Canasa* Actigall* Ocaliva #+ Entyvio # Bowel & GI Misc. balsalazide* Delzicol* Amitiza Cimzia #,+ Stelara IV vial # budesonide Movantik Analpram- E/HC mesalamine Pentasa* Apriso* mesalamine DR/ HD Asacol HD* metoclopramide Azulfidine/EN* misoprostol* Chenodal sulfasalazine/EN* Colazal* ursodiol* Cortifoam Cytotec* Dipentum* Entocort EC* Gattex + Giazo Linzess Lialda Lotronex # Metozolv ODT EX * Prepopik Proctofoam HC Relistor EX Rowasa*. Suprep Symproic Trulance Uceris Urso/Forte*

15 Viberzi # Xermelo Gout allopurinol None Colcrys q Krystexxa # colchicine q Duzallo # probenecid/colchicine Mitigare q Uloric # Zurampic # Zyloprim Growth Failure None Nutropin AQ #,+ Genotropin #,+ #,+ #,+ Agents Nutropin Nuspin Humatrope Increlex #,+ Norditropin #,+ Omnitrope #,+ Saizen #,+ #,+ Serostim Zorbtive + Hormone Covaryx/HS Climara Pro Activella Makena Replacement estradiol tabs Crinone Alora Therapy** estradiol/norethindrone Estring Angeliq estradiol patch Premarin Climara estrogen & Premphase Combipatch methyltestosterone Prempro Divigel estradiol vaginal crm Duavee estropipate Elestrin Gel Jinteli Endometrin medroxyprogesterone Enjuvia Mimvey/Lo Estrace/Vaginal norethindrone Estrogel progesterone oral Evamist Yuvafem FemHRT Femring Intrarosa Menest Menostar Minivelle Osphena Prefest Prometrium Provera Vagifem Vivelle-Dot Immunoglobulin None None None Carimune # Therapy Cuvitru # Obtain through Flebogamma # specialty pharmacy GamaSTAN # Gammagard # Gamunex C# Hizentra # Privigen # HyQvia #

Immuno - None None Thalomid + modulators Revlimid +

Immuno - azathioprine None Astagraf XL Nulojix suppressants cyclosporine/modified Azasan Gengraf Cellcept mycophenolate Envarsus XR mycophenolic acid Imuran sirolimus Myfortic tacrolimus Neoral

16 Prograf Rapamune Sandimmune Zortress Interferons/Other adefovir dipivoxil + Epclusa #+ Baraclude + for Hepatitis entecavir+ Harvoni #,+ Copegus #,+ lamivudine + Mavyret #,+ Epivir-HBV + Moderiba #+ Pegasys #,+ Hepsera + Ribasphere #,+ Ribapak #, + Intron-A+ ribavirin #,+ Vosevi #,+ Moderiba Pak #+ Peg-Intron #,+ Rebetol #,+ Ribatab #,+ Sovaldi #,+ Tyzeka + Vemlidy +

Intranasal budesonide Beconase AQ # Propel Imp Corticosteroids** flunisolide Dymista # Sinuva # mometasone Nasonex # Omnaris # Qnasl # Rhinocort AQ # Xhance # Zetonna # Iron Toxicity deferoxamine + Ferriprox Desferal + Agents Exjade # + Jadenu + Lipid/Cholesterol - atorvastatin Welchol Altocor Kynamro # + Lowering Agents** cholestyramine Antara Praluent # + colestipol Colestid Repatha #+ ezetimibe Crestor ezetimibe-simvastatin Fibricor fenofibrate Juxtapid # fenofibrate 40mg, 120mg EX Lescol/XL fenofibric acid Lipitor fluvastatin/XL Lipofen gemfibrozil Livalo lovastatin Lofibra niacin/ext-release Lopid Niacor Lovaza # omega-3 acid ethyl est # Niaspan pravastatin Pravachol Prevalite Questran/Light rosuvastatin Tricor simvastatin Triglide TriLipix Vascepa # Vytorin Zetia Zocor Zypitamag # Migraine Agents almotriptan q Aimovig # apap/isometh/dichloral Allzital EX butalbit/apap/caff Alsuma q # dihydroergotamine # Amerge q # eletriptan q Axert #,q ergotamine w/caff Cambia q frovatriptan q DHEA-45 # Migergot supp Ergomar naratriptan q Esgic

17 rizatriptan q Fioricet EX sumatriptan q Fiorinal EX sumatriptan-naproxen #,q Frova #,q zolmitriptan q Imitrex q # Imitrex Inj q # Imitrex Nasal #,q Maxalt/MLT q # Migranal #,q Onzetra #,q Relpax #,q Sumavel DosePro #,q Treximet #,q Zembrace #,q Zomig/ZMT #,q Miscellaneous cabergoline Austedo #,+ Addyi # Actimmune + Adagen # Agents (in various desmopressin Somavert + Brisdelle Arcalyst #+ Aldurazyme # classes) fluorouracil crm Stimate + Carbaglu # Benlysta SQ #,+ Aralast-NP paroxetine 7.5mg Cholbam # Cystagon + Benlysta # phytonadione Corlanor Firazyr # + Berinert # riluzole Cuprimine #* Haegarda #,+ Brineura # tetrabenazine #, + Cuvposa Kuvan #,+ Ceprotin # tranexamic acid DDAVP Lupaneta Pack + Cinryze # trientine # Depen Natpara + Crysvita # Endari Nityr # Defitelio Gralise # Orfadin # Elaprase # Horizant # Ravicti # + Exondys 51 # Impavido # Samsca q+ Eskata # Ingrezza # Sensipar + Fabrazyme Jynarque # Xenazine #,+ Feraheme Korlym # Glassia Lysteda Goprelto # Methergine q Injectafer Myalept # Kalbitor # Noctiva # Kanuma # Northera + Kcentra # Nuedexta # Lumizyme # Palynziq # Mepsevii # Procysbi # Myozyme # Savella Naglazyme # Siklos # Parsabiv # Strensiq # Prolastin-C Syprine # Radicava # Veltassa Soliris # Xuriden # Spinraza # Zutripro # Supprelin-LA Sylvant # Triferic Triptodur Vimizim # Vistogard Voraxaze Xiaflex Zemaira Zilretta EX Zinplava # MS Agents glatiramer + Aubagio + Baclofen 5mg # Ampyra #,+ Ocrevus Avonex + Betaseron + # Tysabri # Copaxone 20mg + Plegridy # + Lemtrada # Copaxone 40mg + Rebif + # Gilenya + Zinbryta #+ Tecfidera +

18 Muscle Relaxants baclofen None Amrix EX carisoprodol Dantrium chlorzoxazone Fexmid cyclobenzaprine Parafon Forte DSC dantrolene Robaxin meprobamate Skelaxin metaxalone Soma methocarbamol Zanaflex orphenadrine tizanidine tablets Nitrates/Angina isosorbide dinitrate Nitrostat Dilatrate-SR Others** (heart) isosorbide mononitrate Gonitro EX nitroglycerin SL Isordil/SL nitroglycerin patches Minitran Nitrobid topical Nitro-Dur Ranexa NSAIDS (pain & celecoxib * Voltaren Gel Anaprox DS * inflammation, diclofenac tabs * Arthrotec EX arthritis) diclofenac 1% gel Daypro * etodolac/XL * Duexis EX Feldene * flurbiprofen * Flector ibuprofen * Mobic * indomethacin * Nalfon * ketoprofen/ER * Celebrex * ketorolac * Naprosyn * meclofenamate * Naprelan EX mefenamic acid * Pennsaid EX meloxicam * Ponstel * nabumetone * Sprix # naproxen * Vimovo EX naproxen DR Voltaren XR * naproxen CR/ER EX oxaprozin * piroxicam * salsalate * sulindac * tolmetin * Ophthalmic: Anti - bac/neo/polym/HC AzaSite Infective Agents bacitracin Besivance ciprofloxacin Bleph-10 erythromycin Blephamide gatifloxacin Ciloxan gentamicin Moxeza levofloxacin Natacyn moxifloxacin Ocuflox ofloxacin Polytrim polym/trimeth Tobrex sulfacetamide Vigamox tobramycin Viroptic trifluridine Zirgan Zymaxid Ophthalmic: apraclonidine Alphagan-P Azopt Glaucoma betaxolol Lumigan Betagan Agents** bimatoprost Travatan Z Betimol brimonidine Betoptic-S carteolol Combigan dipivefrin Cosopt/PF dorzolamide Iopidine latanoprost Isopto Carpine

19 levobunolol Istalol metipranolol Rhopressa # pilocarpine Simbrinza timolol/XE Timoptic/XE timolol/dorzolamide Trusopt Vyzulta EX Xalatan Zioptan

Ophthalmic: azelastine Lotemax Acular/LS Cystaran #,+ Eylea Steroids, bromfenac Tobradex Oint Acuvail Dexycu # Antiinflammatory cromolyn Xiidra Alocril Jetrea & Misc. Agents dexamethasone Alomide Lucentis diclofenac Alrex Luxturna # epinastine Bepreve Retisert # fluorometholone Durezol flurbiprofen Elestat ketorolac Emadine naphazoline Flarex prednisolone FML/Forte/SOP olopatadine Ilevro tobramycin/dexamethasone Lastacaft Maxidex Maxitrol Nevanac Omnipred Pataday Patanol Pred Forte Pred Mild Pred-G Prolensa Tobradex Susp Tobradex ST Zylet Osteoporosis/ alendronate* Forteo + Actonel* Boniva IV Paget’s Agents calcitonin nasal spray* Fortical* Atelvia* Prolia etidronate* Tymlos + Binosto* Reclast ibandronate* Boniva Tabs* Xgeva raloxifene* Evista* zoledronic acid risedronate Fosamax/D* Fosamax Weekly* Miacalcin Nasal* Otic Preparations acetic acid/ Ciprodex Cetraxal Otiprio (ear) hydrocortisone Cipro HC antipyrine/benzo/ Coly-Mycin S glycerin Cortane-B benzocaine Cortisporin/TC carbamide peroxide Dermotic ciprofloxacin Otovel fluocinolone neo/polym/HC ofloxacin Pain Relievers apap/codeine All brands (narcotic) buprenorphine patch q,st Abstral q,# butorphanol q Actiq q,# codeine Arymo ER st fentanyl patch q,st Belbucaq (12mcg, 25mcg, Butrans q,st 50mcg, 75mcg, Conzip q

20 100mcg q,st ) Demerol fentanyl oral q,# Dilaudid hydrocodone/apap Dolophine hydrocodone/ibuprofen Duragesic q,st hydromorphone Embeda st,q Lortab Exalgo q,st meperidine Fentora q,# methadone # Fiorinal/w cod EX morphine ER/24HR q,st hydromorphone supp morphine IR/rectal Hysingla ER st,q oxycodone/APAP Kadian q,st oxycodone/aspirin Lazanda # oxycodone/ER q,st MS Contin q,st oxycodone/ibuprofen Morphabond st,q oxymorphone ER q,st Norco pentazocine/naloxone Nucynta Roxicet tabs Nucynta ER q tramadol Opana tramadol ER q Opana ER q,st Vicodin/ES/HP Oxycontin q,st Primlev Reprexain Roxicodone Roxybond Subsys # Synalgos-DC Tylenol w cod Ultracet Ultram/ER q Vicoprofen Xartemis XR st,q Xtampza ER st,q Zohydro ER st,q Pain Relievers: Various generics None All brands Miscellaneous** choline mag trisalicylate diflunisal salsalate Parkinson’s amantadine* None Azilect* Apokyn # + Agents benztropine* Comtan* bromocriptine* Duopa* carbidopa* Eldepryl* carbidopa/levodopa/ER* Lodosyn* carbidopa/levodopa/ Mirapex/ER* entacapone* Neupro* entacapone* Osmolex ER # pramipexole/SR* Parlodel* rasagiline Requip/XL* ropinirole/XL* Rytary* selegiline* Sinemet/CR* tolcapone* Stalevo* trihexyphenidyl* Tasmar* Xadago Zelapar*

Phosphate Calcium acetate Velphoro Eliphos Binders lanthanum carb chew Fosrenol* sevelamer Phoslo Phoslyra Renagel* Renvela* Potassium Various generics None All brands

21 Supplements** K-Tab Prostate Cancer None None Yonsa # Xtandi + Eligard Zytiga ,+ Firmagon Jevtana Lupron Depot Provenge # Trelstar Vantas Xofigo Zoladex Respiratory: Beta albuterol Anoro Ellipta Arcapta Agonists (Oral, ipratropium/albuterol Serevent* Brovana* Inhaled) levalbuterol Ventolin HFA Perforomist metaproterenol ProAir HFA EX terbutaline* ProAir Respiclick EX Proventil HFA EX Vospire ER* Xopenex HFA EX Respiratory: budesonide Advair/HFA Aerospan EX Inhaled fluticasone-salmeterol Asmanex/HFA Alvesco EX Corticosteroids** Breo Ellipta Armonair Flovent/HFA Arnuity Ellipta Pulmicort Flexhaler Dulera Qvar Striverdi Respimat Symbicort Respiratory: montelukast Accolate Leukotriene zafirlukast Singulair Modifiers** Zyflo CR EX Respiratory: aminophylline* Combivent Atrovent HFA * Adcirca #,+ Cinqair # #,+ Miscellaneous cromolyn* Respimat* Bevespi Aerosphere Adempas epoprostenol # ipratropium soln* Pulmozyme #,+ Cayston # Bethkis #,+ # # + # + Fasenra sildenafil 20mg Spiriva* Daliresp* Esbriet Flolan # theophylline* Trelegy Ellipta Grastek # Kalydeco # # #,+ EX #,+ Nucala tobramycin inh Incruse Ellipta Kitabis Pak Remodulin # Lonhala Magnair # Letairis #,+ # # #+ Revatio Inj Odactra Ofev Xolair # Ragwitek # Opsumit #,+ # #,+ Veletri Seebri Neohaler Oralair Stiolto Respimat Orenitram XR # + Theo-24* Orkambi # Tudorza EX Revatio #,+ Utibron Neohaler Symdeko #,+ TOBI #,+ TOBI Podhaler #,+ Tracleer #,+ Tyvaso #,+ Uptravi #+ Ventavis #,+ RSV None None None Synagis # Sedative/ estazolam q Rozerem q,st Ambien/CR q,st Hetlioz #,+ Hypnotics (sleep eszopiclone q Butisol aids) flurazepam q Doral q temazepam q Edluar q,st triazolam q Halcion q zaleplon q Belsomra st zolpidem/CR q Intermezzo q,st zolpidem SL st,q Lunesta q,st Restoril q Silenor # Sonata q,st Zolpimist q,st

22 Smoking bupropion SR q Chantix q Nicotrol q Cessation Agents Zyban q Somatostatin octreotide + Signifor # Sandostatin + Sandostatin LAR + Analogs Somatuline Depot + Signifor LAR + Substance Use acamprosate Narcan Nasal Antabuse Probuphine Disorder buprenorphine/naloxone Suboxone Film Bunavail Sublocade naltrexone Evzio EX Vivitrol Lucemyra # Revia Zubsolv EX

Thyroid** levothyroxine Synthroid Armour Thyroid Levoxyl Cytomel liothyronine Nature-Throid methimazole Tapazole NP Thyroid Thyrolar propylthiouracil Tirosint Unithroid Westhroid WP Thyroid Topical ciclopirox soln q None Ecoza Antifungals econazole Ertaczo ketoconazole Exelderm crm/shampoo Lotrisone naftifine Luzu nystatin Naftin Nizoral Oxistat Penlac # Topical Anti - erythromycin Altabax Infectives gentamicin Bactroban metronidazole Centany mupirocin Cortisporin Gynazole-1 Klaron Rhofade Topical/Oral/ acitretin Dovonex Injectable anthralin EpiFoam Antipsoriatic & calcipotriene Pramosone/E Antiseborrheic calcipotriene/ Soriatane (non-biological) betamethasone selenium sulfide

Topical aluminum chloride soln Condylox gel Aldara Dupixent #,+ Miscellaneous doxepin cream # tacrolimus oint. Condylox soln imiquimod Drysol diclofenac gel 3% # Efudex lidocaine/patch Elidel lidocaine/tetracaine cream Eucrisa # mafenide packet Lidoderm podofilox Metrocream Metrogel Metrolotion Mirvaso Picato Podocon-25 Protopic Prudoxin # Rectiv Santyl q Solaraze # Sulfamylon

23 Tolak Umecta/PD Valchlor # Veregen Zonalon # Zyclara Topical lindane None Eurax Scabicides/ malathion Natroba Pediculicides permethrin Ovide spinosad Sklice Ulesfia

Topical Steroids alclometasone 1 Amcinonide oint 3 Apexicon E 1 Low Potency amcinonide 3 Clobex 4 2 Medium Potency betamethasone Cutivate 2 3 1 High Potency 2,4 Derma-Smoothe/FS 4 dip/aug 2 Very High betamethasone Dermatop Potency 3,4 Desonate 1 valerate 1 clobetasol 4 Desowen 4 Diprolene/AF 3,4 Cormax 2 desonide 1 Elocon 2,3 Kenalog 2,3 desoximetasone 2 diflorasone 3,4 Luxiq 1,2 Pandel 2 fluocinolone 4 fluocinonide 3 Temovate 2 Texacort 1 flurandrenolide 4 fluticasone 2 Ultravate 4 Verdeso 1 halobetasol 2 hydrocortisone 1 Westcort hydrocortisone butyrate 2 hydrocortisone valerate 2 mometasone 2 prednicarbate 2 triamcinolone 2,3 triamcinolone aerosol triamcinolone dental Topical/Oral Adapalene Avita Acne Products Adapalene-benzoyl Clarifoam EF peroxide Cleocin-T Amnesteem Evoclin Claravis Finacea clindamycin gel Klaron clindamycin/benzoyl Tazorac peroxide Vanoxide HC dapsone gel erythromycin isotretinoin Myorisan sulfacetamide tretinoin crm/gel tazarotene 0.1% cr Zenatane Urinary Tract methenamine None Elmiron Agents nitrofurantoin Furadantin phenazopyridine/plus Hiprex trimethoprim Macrobid potassium citrate Macrodantin Monurol Primsol #Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order st Step therapy edits apply **All drugs in the category are available through Mail Order + Obtain through CVS Specialty EX - Excluded drug-medical exception approval required M These drugs are not covered under the pharmacy benefit. For more information regarding coverage of these agents, please see the benefits section of the brochure. If provider does not buy and bill drug must be obtained from CVS Specialty or other contracted Specialty provider

24 Vitamin D Analogs doxercalciferol Hectorol paricalcitol Rayaldee Zemplar Weight benzphetamine q None Adipex-P#, q Management diethylpropion q Belviq #, q Agents phendimetrazine q Bontril-PDM#, q phentermine q Contrave #, q Lomaira #, q Qsymia #, q Regimex #, q Saxenda #, q Suprenza #, q Xenical #, q

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