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Carefirst Preferred Drug List - Formulary 2

Carefirst Preferred Drug List - Formulary 2

October 2019

CareFirst Preferred Drug List - Formulary 2

The CareFirst Preferred Drug List is a guide to help you identify products that are both clinically appropriate and cost-effective. These drugs are selected for their quality, effectiveness and cost based on current medical research and input from a committee of doctors and pharmacies who serve the CareFirst region.

The drugs on the Preferred Drug List are grouped into therapeutic categories for representational purposes only. This list represents brand- name drugs in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generic drugs should be considered the first line of prescribing; however, if there is no generic available, there may be more than one brand-name drug to treat a condition.

Please note this list does not include all covered drugs and is subject to change.

PLAN MEMBER HEALTH CARE PROVIDER Ask your doctor to consider prescribing, when appropriate, a As a way to help manage health care costs, authorize generic preferred drug from this list. Take this list along when you or substitution whenever possible. If you believe a brand-name product a covered family member sees a doctor. is necessary, consider prescribing a brand name on this list.

Please note: Please note: ®,1 • Our Pharmacy Benefit Manager, CVS Caremark may contact • Generics should be considered the first line of prescribing. your doctor after receiving your prescription to request consideration of a generic equivalent or preferred brand drug, • This drug list represents a summary of prescription coverage. which may lower your out-of-pocket costs. It does not include all covered drugs and does not guarantee coverage. The member’s specific prescription benefit plan • In most cases, when a generic becomes available for a brand- design may not cover certain products or categories, regardless name drug, the brand-name drug is moved to the non-preferred of their appearance in this document. Products recently brand category, which may have a higher cost-share. approved by the FDA may not be covered upon release to the • Check your specific prescription benefit plan design to market. determine your cost-share for a specific product on this list. • The member's prescription benefit plan may have a different • Your specific prescription benefit plan design may not cover copay/coinsurance for specific products on the list. certain products or categories, regardless of their appearance in • Unless specifically indicated, drug list products will include all this document. Products recently approved by the U.S. dosage forms. and Drug Administration (FDA) may not be covered upon release to the market. • To learn more about your specific drug benefit, log into My Account at www.carefirst.com/myaccount and click on Drug & Pharmacy Resources under Quick Links or call CareFirst Pharmacy Services at 800-241-3371.

ANALGESICS probenecid HYSINGLA ER § FLUOROQUINOLONES ULORIC NUCYNTA § NSAIDs NUCYNTA ER ciprofloxacin ext-rel § OPIOID ANALGESICS diclofenac sodium OXYCONTIN codeine-acetaminophen SUBSYS moxifloxacin meloxicam fentanyl transdermal naproxen 2 fentanyl transmucosal lozenge ANTI-INFECTIVES §

hydrocodone-acetaminophen amoxicillin § NSAIDs, COMBINATIONS ANTIBACTERIALS hydromorphone amoxicillin-clavulanate § CEPHALOSPORINS diclofenac sodium-misoprostol hydromorphone ext-rel dicloxacillin

methadone cefdinir § NSAIDs, TOPICAL VK morphine cefprozil diclofenac sodium gel 1% (except NDC^ morphine ext-rel cefuroxime axetil § 69499031866) morphine suppository cephalexin hyclate diclofenac sodium solution oxycodone SUPRAX

oxycodone-acetaminophen § COX-2 INHIBITORS § / MACROLIDES tramadol celecoxib tramadol ext-rel azithromycin §

ABSTRAL clarithromycin fluconazole § GOUT BELBUCA clarithromycin ext-rel itraconazole allopurinol BUTRANS erythromycins terbinafine tablet colchicine tablet EMBEDA DIFICID

ANTIRETROVIRAL AGENTS ANTINEOPLASTIC AGENTS § ANGIOTENSIN II DIRECT RENIN INHIBITORS / § ANTIRETROVIRAL ANTAGONIST / CHANNEL DIURETIC COMBINATIONS HORMONAL ANTINEOPLASTIC COMBINATIONS BLOCKER / DIURETIC TEKTURNA / TEKTURNA HCT AGENTS COMBINATIONS abacavir-lamivudine § § DIURETICS ATRIPLA amlodipine-valsartan- amiloride BIKTARVY abiraterone hydrochlorothiazide CIMDUO bicalutamide olmesartan-amlodipine- hydrochlorothiazide COMPLERA ERLEADA hydrochlorothiazide metolazone DESCOVY XTANDI § ANTIARRHYTHMICS -hydrochlorothiazide EVOTAZ § KINASE INHIBITORS sotalol torsemide GENVOYA imatinib mesylate MULTAQ triamterene-hydrochlorothiazide ODEFSEY AFINITOR PREZCOBIX BOSULIF ANTILIPEMICS HEART FAILURE STRIBILD CABOMETYX § RESINS BIDIL SYMFI IBRANCE CORLANOR SYMFI LO cholestyramine IRESSA colesevelam ENTRESTO TRIUMEQ KISQALI TRUVADA § NITRATES KISQALI FEMARA CO-PACK § CHOLESTEROL ABSORPTION INTEGRASE INHIBITORS RYDAPT INHIBITORS nitroglycerin lingual spray nitroglycerin sublingual ISENTRESS SPRYCEL ezetimibe

TIVICAY § MISCELLANEOUS § FIBRATES PULMONARY ARTERIAL HYPERTENSION § NUCLEOSIDE REVERSE ODOMZO fenofibrate 4 TRANSCRIPTASE INHIBITORS VISTOGARD fenofibric acid ENDOTHELIN RECEPTOR ANTAGONISTS abacavir tablet ZEJULA § HMG-CoA REDUCTASE LETAIRIS lamivudine INHIBITORS / COMBINATIONS CARDIOVASCULAR OPSUMIT § PROTEASE INHIBITORS atorvastatin TRACLEER § ACE INHIBITORS NORVIR ezetimibe-simvastatin fosinopril § PHOSPHODIESTERASE PREZISTA fluvastatin lisinopril INHIBITORS REYATAZ lovastatin quinapril pravastatin sildenafil ANTIVIRALS ramipril PROSTACYCLIN RECEPTOR § CYTOMEGALOVIRUS AGENTS simvastatin § ACE INHIBITOR / DIURETIC valganciclovir COMBINATIONS § NIACINS UPTRAVI fosinopril-hydrochlorothiazide § B AGENTS niacin ext-rel lisinopril-hydrochlorothiazide § PROSTAGLANDIN entecavir quinapril-hydrochlorothiazide § OMEGA-3 FATTY VASODILATORS lamivudine omega-3 acid ethyl esters ORENITRAM VEMLIDY § ANGIOTENSIN II RECEPTOR VASCEPA ANTAGONISTS / DIURETIC SOLUBLE GUANYLATE CYCLASE § HEPATITIS C AGENTS COMBINATIONS PCSK9 INHIBITORS STIMULATORS ribavirin candesartan / candesartan- REPATHA ADEMPAS EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) hydrochlorothiazide HARVONI (genotypes 1, 4, 5, 6) eprosartan § BETA-BLOCKERS § MISCELLANEOUS VOSEVI 3

irbesartan / irbesartan- ranolazine ext-rel

§ HERPES AGENTS hydrochlorothiazide carvedilol losartan / losartan- carvedilol phosphate ext-rel acyclovir hydrochlorothiazide metoprolol succinate ext-rel valacyclovir ANTIANXIETY olmesartan / olmesartan- metoprolol tartrate § BENZODIAZEPINES § INFLUENZA AGENTS hydrochlorothiazide nadolol pindolol alprazolam oseltamivir telmisartan / telmisartan- propranolol clonazepam RELENZA hydrochlorothiazide valsartan / valsartan- propranolol ext-rel diazepam § MISCELLANEOUS hydrochlorothiazide BYSTOLIC lorazepam oxazepam § ANGIOTENSIN II RECEPTOR § CALCIUM CHANNEL BLOCKERS ivermectin § ANTICONVULSANTS ANTAGONIST / CALCIUM CHANNEL linezolid amlodipine BLOCKER COMBINATIONS 5 carbamazepine metronidazole diltiazem ext-rel nifedipine ext-rel carbamazepine ext-rel nitrofurantoin amlodipine-olmesartan verapamil ext-rel clobazam sulfamethoxazole-trimethoprim amlodipine-telmisartan diazepam rectal gel EMVERM amlodipine-valsartan § CALCIUM CHANNEL BLOCKER / divalproex sodium XIFAXAN 550 MG ANTILIPEMIC COMBINATIONS divalproex sodium ext-rel amlodipine-atorvastatin ethosuximide gabapentin § DIGITALIS GLYCOSIDES lamotrigine digoxin lamotrigine ext-rel

levetiracetam olanzapine BETASERON VICTOZA levetiracetam ext-rel quetiapine COPAXONE oxcarbazepine quetiapine ext-rel GILENYA INCRETIN MIMETIC AGENT / INSULIN COMBINATIONS phenobarbital REBIF ziprasidone TECFIDERA SOLIQUA phenytoin sodium extended ABILIFY MAINTENA INSULINS primidone ARISTADA § MUSCULOSKELETAL THERAPY AGENTS tiagabine LATUDA BASAGLAR topiramate VRAYLAR cyclobenzaprine FIASP valproic acid HUMULIN R U-500 § ATTENTION DEFICIT § NARCOLEPSY vigabatrin LEVEMIR HYPERACTIVITY DISORDER zonisamide armodafinil NOVOLIN 70/30 amphetamine-dextroamphetamine NOVOLIN N FYCOMPA POSTHERPETIC NEURALGIA (PHN) OXTELLAR XR mixed salts NOVOLIN R GRALISE amphetamine-dextroamphetamine NOVOLOG TROKENDI XR NOVOLOG MIX 70/30 VIMPAT mixed salts ext-rel PSYCHOTHERAPEUTIC - atomoxetine TRESIBA MISCELLANEOUS § ANTIDEMENTIA guanfacine ext-rel § OPIOID ANTAGONISTS § INSULIN SENSITIZERS donepezil methylphenidate galantamine methylphenidate ext-rel naloxone pioglitazone galantamine ext-rel MYDAYIS NARCAN NASAL SPRAY § INSULIN SENSITIZER / BIGUANIDE memantine VYVANSE § PARTIAL OPIOID / COMBINATIONS rivastigmine FIBROMYALGIA OPIOID ANTAGONIST pioglitazone-metformin rivastigmine transdermal COMBINATIONS NAMZARIC LYRICA § INSULIN SENSITIZER / buprenorphine-naloxone sublingual SULFONYLUREA COMBINATIONS ANTIDEPRESSANTS § HUNTINGTON'S AGENTS ZUBSOLV pioglitazone-glimepiride § SELECTIVE SEROTONIN tetrabenazine PSEUDOBULBAR AFFECT AGENTS REUPTAKE INHIBITORS (SSRIs) AUSTEDO § MEGLITINIDES NUEDEXTA citalopram HYPNOTICS nateglinide escitalopram § NONBENZODIAZEPINES § VASOMOTOR SYMPTOM AGENTS repaglinide fluoxetine paroxetine mesylate paroxetine HCl eszopiclone SODIUM-GLUCOSE zolpidem paroxetine HCl ext-rel ENDOCRINE AND CO-TRANSPORTER 2 (SGLT2) zolpidem ext-rel sertraline METABOLIC INHIBITORS zolpidem sublingual TRINTELLIX FARXIGA BELSOMRA ACROMEGALY VIIBRYD JARDIANCE SOMAVERT § SEROTONIN NOREPINEPHRINE TRICYCLICS SODIUM-GLUCOSE REUPTAKE INHIBITORS (SNRIs) SILENOR § CO-TRANSPORTER 2 (SGLT2)

gel INHIBITOR / BIGUANIDE desvenlafaxine ext-rel MIGRAINE duloxetine testosterone solution COMBINATIONS § ERGOTAMINE DERIVATIVES venlafaxine ANDRODERM SYNJARDY venlafaxine ext-rel capsule ergotamine-caffeine SYNJARDY XR ANTIDIABETICS MONOCLONAL ANTIBODIES XIGDUO XR § MISCELLANEOUS AGENTS AMYLIN ANALOGS bupropion AJOVY SYMLINPEN SODIUM-GLUCOSE bupropion ext-rel EMGALITY CO-TRANSPORTER 2 (SGLT2) mirtazapine § BIGUANIDES INHIBITOR / DIPEPTIDYL § SELECTIVE SEROTONIN metformin PEPTIDASE-4 (DPP-4) INHIBITOR trazodone AGONISTS metformin ext-rel 6 COMBINATIONS § ANTIPARKINSONIAN AGENTS eletriptan GLYXAMBI naratriptan § BIGUANIDE / SULFONYLUREA amantadine QTERN carbidopa-levodopa rizatriptan COMBINATIONS carbidopa-levodopa ext-rel sumatriptan glipizide-metformin § SULFONYLUREAS carbidopa-levodopa-entacapone glimepiride ONZETRA XSAIL DIPEPTIDYL PEPTIDASE-4 (DPP-4) entacapone glipizide INHIBITORS pramipexole ZEMBRACE SYMTOUCH glipizide ext-rel pramipexole ext-rel ZOMIG NASAL SPRAY JANUVIA rasagiline SUPPLIES SELECTIVE SEROTONIN AGONIST / DIPEPTIDYL PEPTIDASE-4 (DPP-4) ropinirole ACCU-CHEK AVIVA PLUS STRIPS 7 ANTI- INHIBITOR / BIGUANIDE ropinirole ext-rel ACCU-CHEK COMPACT PLUS INFLAMMATORY DRUG (NSAID) COMBINATIONS selegiline STRIPS 7 COMBINATIONS NEUPRO JANUMET ACCU-CHEK GUIDE STRIPS 7 TREXIMET JANUMET XR ACCU-CHEK SMARTVIEW STRIPS 7 ANTIPSYCHOTICS § MULTIPLE SCLEROSIS AGENTS INCRETIN MIMETIC AGENTS BD ULTRAFINE INSULIN SYRINGES § ATYPICALS AND NEEDLES glatiramer OZEMPIC aripiprazole DEXCOM CONTINUOUS GLUCOSE AUBAGIO TRULICITY clozapine MONITORING SYSTEM

ANTIOBESITY § VAGINAL ENDOMETRIN lansoprazole

INJECTABLE § SELECTIVE ESTRING pantoprazole SAXENDA RECEPTOR MODULATORS PREMARIN CREAM DEXILANT ORAL ESTROGEN / PROGESTINS OSPHENA § , RECTAL BELVIQ PROCTOFOAM-HC § ORAL BELVIQ XR § THYROID SUPPLEMENTS estradiol-norethindrone CALCIUM RECEPTOR levothyroxine § ULCER THERAPY COMBINATIONS PREMPHASE ANTAGONISTS liothyronine PYLERA PREMPRO SYNTHROID

SENSIPAR TRANSDERMAL GENITOURINARY CALCIUM REGULATORS GASTROINTESTINAL CLIMARA PRO § BENIGN PROSTATIC § BISPHOSPHONATES COMBIPATCH § ANTIEMETICS HYPERPLASIA alendronate dronabinol alfuzosin ext-rel ESTROGEN / SELECTIVE ibandronate granisetron doxazosin risedronate meclizine MODULATOR COMBINATIONS dutasteride-tamsulosin § CALCITONINS DUAVEE ondansetron calcitonin-salmon prochlorperazine silodosin REGULATORS promethazine tamsulosin PARATHYROID GNRH / LHRH ANTAGONISTS trimethobenzamide terazosin FORTEO CETROTIDE DICLEGIS TYMLOS SANCUSO STIMULANTS, § CARNITINE DEFICIENCY AGENTS VARUBI ALPROSTADIL AGENTS MUSE levocarnitine GONAL-F § ANTISPASMODICS

OVIDREL CONTRACEPTIVES dicyclomine § PHOSPHODIESTERASE INHIBITORS § MONOPHASIC GAUCHER DISEASE § H2 RECEPTOR ANTAGONISTS sildenafil ethinyl estradiol- CERDELGA ranitidine tadalafil ethinyl estradiol-drospirenone- § levomefolate INFLAMMATORY BOWEL DISEASE § URINARY ANTISPASMODICS dexamethasone ethinyl estradiol-norethindrone § ORAL AGENTS darifenacin ext-rel fludrocortisone acetate balsalazide oxybutynin ethinyl estradiol-norethindrone capsule oxybutynin ext-rel methylprednisolone acetate-iron budesonide ext-rel solifenacin prednisolone solution SAFYRAL sulfasalazine tolterodine prednisone § BIPHASIC sulfasalazine delayed-rel tolterodine ext-rel GLUCOSE ELEVATING AGENTS APRISO trospium LO LOESTRIN FE PENTASA trospium ext-rel GLUCAGEN HYPOKIT MYRBETRIQ § TRIPHASIC GLUCAGON EMERGENCY KIT § RECTAL AGENTS TOVIAZ ethinyl estradiol- HEREDITARY TYROSINEMIA TYPE 1 hydrocortisone enema FOUR PHASE AGENTS mesalamine suppository HEMATOLOGIC mesalamine suspension NATAZIA ORFADIN § CORTIFOAM § EXTENDED CYCLE HUMAN GROWTH HORMONES § IRRITABLE BOWEL SYNDROME ELIQUIS ethinyl estradiol- HUMATROPE alosetron XARELTO

§ TRANSDERMAL § PHOSPHATE BINDER AGENTS AMITIZA HEMATOPOIETIC GROWTH LINZESS ethinyl estradiol- calcium acetate FACTORS lanthanum carbonate VIBERZI ARANESP VAGINAL sevelamer carbonate § LAXATIVES NEULASTA NUVARING PHOSLYRA lactulose solution NIVESTYM VELPHORO ENDOMETRIOSIS peg 3350-electrolytes RETACRIT

ORILISSA POTASSIUM-REMOVING AGENTS SUPREP UDENYCA

LOKELMA OPIOID-INDUCED HEREDITARY VELTASSA § ORAL MOVANTIK RUCONEST PROGESTINS estradiol PANCREATIC § PLATELET AGGREGATION PREMARIN § ORAL INHIBITORS CREON § TRANSDERMAL VIOKACE clopidogrel acetate ZENPEP dipyridamole ext-rel- estradiol , micronized prasugrel DIVIGEL § PROTON PUMP INHIBITORS BRILINTA EVAMIST VAGINAL CRINONE

THROMBOCYTOPENIA AGENTS § , LOW SEDATING QVAR § Very High Potency MULPLETA levocetirizine QVAR REDIHALER clobetasol cream, foam, gel, lotion,

ointment, shampoo IMMUNOLOGIC AGENTS § ANTITUSSIVES TOPICAL benzonatate (except NDCs^ 69336012615, § LOCAL ANESTHETICS ALLERGENIC EXTRACTS lidocaine-prilocaine 69499032915) GRASTEK ORALAIR BETA AGONISTS, INHALANTS § Topical § ROSACEA RAGWITEK § SHORT ACTING doxycycline monohydrate delayed-rel

capsule AUTOIMMUNE AGENTS albuterol inhalation solution metronidazole clindamycin solution albuterol sulfate CFC-free aerosol COSENTYX FINACEA FOAM clindamycin-benzoyl peroxide levalbuterol tartrate CFC-free aerosol ENBREL SOOLANTRA solution PROAIR HFA HUMIRA erythromycin-benzoyl peroxide KEVZARA PROAIR RESPICLICK MOUTH / THROAT / OTEZLA DENTAL AGENTS LONG ACTING EPIDUO SKYRIZI Hand-held Active Inhalation RETIN-A MICRO PROTECTANTS

STELARA SUBCUTANEOUS TAZORAC EPISIL SEREVENT XELJANZ MUGARD

XELJANZ XR STRIVERDI RESPIMAT § ACTINIC KERATOSIS

fluorouracil cream 5% OPHTHALMIC § DISEASE-MODIFYING Nebulized Passive Inhalation fluorouracil solution § ANTIALLERGICS ANTIRHEUMATIC DRUGS PERFOROMIST imiquimod (DMARDs) azelastine § CYSTIC FIBROSIS PICATO cromolyn sodium RASUVO TOLAK tobramycin inhalation solution olopatadine ZYCLARA NUTRITIONAL / BETHKIS LASTACAFT

SUPPLEMENTS PAZEO § LEUKOTRIENE MODULATORS § § ELECTROLYTES montelukast gentamicin § ANTI-INFECTIVES mupirocin ointment ciprofloxacin potassium chloride liquid erythromycin zileuton ext-rel § ANTIFUNGALS VITAMINS AND MINERALS gentamicin § FOLIC ACID / COMBINATIONS § NASAL ANTIHISTAMINES levofloxacin folic acid azelastine moxifloxacin econazole olopatadine § PRENATAL VITAMINS § NASAL STEROIDS / luliconazole prenatal vitamins tobramycin COMBINATIONS nystatin CITRANATAL BESIVANCE

flunisolide JUBLIA CILOXAN OINTMENT

RESPIRATORY fluticasone NAFTIN MOXEZA

§ ANTIPSORIATICS § ANAPHYLAXIS TREATMENT triamcinolone § ANTI-INFECTIVE / AGENTS DYMISTA acitretin ANTI-INFLAMMATORY epinephrine auto-injector calcipotriene ointment, solution COMBINATIONS EPIPEN PHOSPHODIESTERASE-4 methoxsalen neomycin-polymyxin B-bacitracin-

EPIPEN JR INHIBITORS ATOPIC DERMATITIS hydrocortisone DALIRESP neomycin-polymyxin B- § ANTICHOLINERGICS Injectable dexamethasone AGENTS ipratropium inhalation solution DUPIXENT tobramycin-dexamethasone ESBRIET INCRUSE ELLIPTA TOBRADEX OINTMENT OFEV § Topical SPIRIVA TOBRADEX ST SEVERE ASTHMA AGENTS ZYLET ANTICHOLINERGIC / BETA ELIDEL AGONIST COMBINATIONS DUPIXENT EUCRISA ANTI-INFLAMMATORIES § SHORT ACTING / BETA AGONIST CORTICOSTEROIDS § Nonsteroidal ipratropium-albuterol inhalation COMBINATIONS § Low Potency bromfenac solution diclofenac ADVAIR DISKUS desonide COMBIVENT RESPIMAT ketorolac ADVAIR HFA hydrocortisone ACUVAIL LONG ACTING BREO ELLIPTA § Medium Potency ILEVRO ANORO ELLIPTA SYMBICORT NEVANAC clocortolone BEVESPI AEROSPHERE § STEROID INHALANTS STIOLTO RESPIMAT hydrocortisone butyrate § Steroidal budesonide inhalation suspension mometasone dexamethasone ANTICHOLINERGIC / BETA ARNUITY ELLIPTA triamcinolone prednisolone acetate 1% AGONIST / STEROID INHALANT ASMANEX DUREZOL COMBINATIONS FLOVENT DISKUS § High Potency FLAREX TRELEGY ELLIPTA FLOVENT HFA desoximetasone FML FORTE PULMICORT FLEXHALER fluocinonide 8 FML S.O.P.

MAXIDEX AZOPT § PROSTAGLANDINS SYMPATHOMIMETIC / BETA-

PRED MILD latanoprost BLOCKER COMBINATIONS § CARBONIC ANHYDRASE LUMIGAN COMBIGAN BETA-BLOCKERS INHIBITOR / BETA-BLOCKER TRAVATAN Z § Nonselective COMBINATIONS OTIC timolol maleate solution dorzolamide-timolol RHO KINASE INHIBITORS § ANTI-INFECTIVE /

BETIMOL RHOPRESSA ANTI-INFLAMMATORY CARBONIC ANHYDRASE INHIBITOR / COMBINATIONS Selective SYMPATHOMIMETIC COMBINATIONS § SYMPATHOMIMETICS CIPRODEX BETOPTIC S SIMBRINZA

ALPHAGAN P § CARBONIC ANHYDRASE DRY EYE DISEASE INHIBITORS RESTASIS dorzolamide XIIDRA

QUICK REFERENCE DRUG LIST

A armodafinil calcipotriene ointment, solution CORTIFOAM ARNUITY ELLIPTA calcitonin-salmon COSENTYX abacavir tablet ASMANEX calcium acetate CREON abacavir-lamivudine atenolol candesartan CRINONE ABILIFY MAINTENA atomoxetine candesartan-hydrochlorothiazide cromolyn sodium abiraterone atorvastatin carbamazepine cyclobenzaprine ABSTRAL 7 ATRIPLA carbamazepine ext-rel ACCU-CHEK AVIVA PLUS STRIPS D ACCU-CHEK COMPACT PLUS AUBAGIO carbidopa-levodopa AUSTEDO carbidopa-levodopa ext-rel STRIPS 7 DALIRESP azelastine carbidopa-levodopa-entacapone ACCU-CHEK GUIDE STRIPS 7 darifenacin ext-rel azithromycin carvedilol ACCU-CHEK SMARTVIEW STRIPS 7 DESCOVY AZOPT carvedilol phosphate ext-rel desonide acitretin cefdinir desoximetasone ACUVAIL B cefprozil desvenlafaxine ext-rel acyclovir balsalazide cefuroxime axetil dexamethasone adapalene BASAGLAR celecoxib DEXCOM CONTINUOUS GLUCOSE ADEMPAS BD ULTRAFINE INSULIN SYRINGES cephalexin MONITORING SYSTEM ADVAIR DISKUS AND NEEDLES CERDELGA DEXILANT ADVAIR HFA BELBUCA CETROTIDE diazepam AFINITOR BELSOMRA cholestyramine diazepam rectal gel AJOVY BELVIQ ciclopirox DICLEGIS albuterol inhalation solution CILOXAN OINTMENT albuterol sulfate CFC-free aerosol BELVIQ XR diclofenac CIMDUO alendronate benzonatate (except NDCs^ 69336012615, diclofenac sodium CIPRODEX alfuzosin ext-rel 69499032915) diclofenac sodium gel 1% ciprofloxacin allopurinol benzoyl peroxide (except NDC^ 69499031866) ciprofloxacin ext-rel alosetron BESIVANCE diclofenac sodium solution citalopram ALPHAGAN P BETASERON diclofenac sodium-misoprostol CITRANATAL alprazolam BETHKIS dicloxacillin clarithromycin amantadine BETIMOL dicyclomine clarithromycin ext-rel amiloride BETOPTIC S DIFICID CLIMARA PRO AMITIZA BEVESPI AEROSPHERE digoxin clindamycin 5 amlodipine bicalutamide diltiazem ext-rel clindamycin solution amlodipine-atorvastatin BIDIL dipyridamole ext-rel-aspirin clindamycin-benzoyl peroxide amlodipine-olmesartan BIKTARVY divalproex sodium clobazam amlodipine-telmisartan BOSULIF divalproex sodium ext-rel clobetasol cream, foam, gel, lotion, amlodipine-valsartan BREO ELLIPTA DIVIGEL ointment, shampoo amlodipine-valsartan- BRILINTA donepezil clocortolone hydrochlorothiazide brimonidine dorzolamide clonazepam amoxicillin bromfenac dorzolamide-timolol clopidogrel amoxicillin-clavulanate budesonide capsule doxazosin clotrimazole amphetamine-dextroamphetamine budesonide ext-rel doxycycline hyclate clozapine mixed salts budesonide inhalation suspension doxycycline monohydrate delayed-rel codeine-acetaminophen amphetamine-dextroamphetamine buprenorphine-naloxone sublingual capsule colchicine tablet mixed salts ext-rel bupropion dronabinol colesevelam ANDRODERM bupropion ext-rel DUAVEE COMBIGAN ANORO ELLIPTA BUTRANS duloxetine COMBIPATCH APRISO BYSTOLIC DUPIXENT COMBIVENT RESPIMAT ARANESP DUREZOL COMPLERA aripiprazole C dutasteride COPAXONE ARISTADA CABOMETYX dutasteride-tamsulosin CORLANOR

DYMISTA fluorouracil cream 5% J metoprolol tartrate fluorouracil solution metronidazole JANUMET E fluoxetine minocycline JANUMET XR econazole fluticasone mirtazapine JANUVIA eletriptan fluvastatin mometasone JARDIANCE ELIDEL FML FORTE montelukast JUBLIA ELIQUIS FML S.O.P. morphine EMBEDA folic acid K morphine ext-rel EMGALITY FORTEO morphine suppository ketoconazole EMVERM fosinopril MOVANTIK ketorolac ENBREL fosinopril-hydrochlorothiazide MOXEZA KEVZARA ENDOMETRIN furosemide moxifloxacin KISQALI entacapone FYCOMPA MUGARD KISQALI FEMARA CO-PACK entecavir MULPLETA G ENTRESTO L MULTAQ EPCLUSA gabapentin mupirocin ointment lactulose solution EPIDUO galantamine MUSE lamivudine epinephrine auto-injector galantamine ext-rel MYDAYIS lamotrigine EPIPEN gentamicin MYRBETRIQ lamotrigine ext-rel EPIPEN JR GENVOYA lansoprazole EPISIL GILENYA N lanthanum carbonate eprosartan glatiramer nadolol LASTACAFT ergotamine-caffeine glimepiride NAFTIN latanoprost ERLEADA glipizide naloxone injection LATUDA erythromycin glipizide ext-rel NAMZARIC LETAIRIS erythromycin solution glipizide-metformin naproxen 2 levalbuterol tartrate CFC-free aerosol erythromycin-benzoyl peroxide GLUCAGEN HYPOKIT naratriptan LEVEMIR erythromycins GLUCAGON EMERGENCY KIT NARCAN NASAL SPRAY levetiracetam ESBRIET GLYXAMBI NATAZIA levetiracetam ext-rel escitalopram GONAL-F nateglinide levocarnitine esomeprazole GRALISE neomycin-polymyxin B-bacitracin- levocetirizine estradiol granisetron hydrocortisone levofloxacin estradiol-norethindrone GRASTEK neomycin-polymyxin B- levothyroxine ESTRING guanfacine ext-rel dexamethasone lidocaine-prilocaine eszopiclone NEULASTA linezolid ethinyl estradiol-drospirenone H NEUPRO LINZESS ethinyl estradiol-drospirenone- HARVONI NEVANAC liothyronine levomefolate HUMATROPE niacin ext-rel lisinopril ethinyl estradiol-levonorgestrel HUMIRA nifedipine ext-rel lisinopril-hydrochlorothiazide ethinyl estradiol-norelgestromin HUMULIN R U-500 nitrofurantoin LO LOESTRIN FE ethinyl estradiol-norethindrone hydrochlorothiazide nitroglycerin lingual spray LOKELMA acetate hydrocodone-acetaminophen nitroglycerin sublingual lorazepam ethinyl estradiol-norethindrone hydrocortisone NIVESTYM losartan acetate-iron hydrocortisone butyrate NORVIR losartan-hydrochlorothiazide ethinyl estradiol-norgestimate hydrocortisone enema NOVOLIN 70/30 lovastatin ethosuximide hydromorphone NOVOLIN N luliconazole EUCRISA hydromorphone ext-rel NOVOLIN R LUMIGAN EVAMIST HYSINGLA ER NOVOLOG LYRICA EVOTAZ NOVOLOG MIX 70/30 ezetimibe I M NUCYNTA ezetimibe-simvastatin ibandronate NUCYNTA ER MAXIDEX IBRANCE NUEDEXTA F meclizine ibuprofen NUVARING medroxyprogesterone FARXIGA ILEVRO nystatin 4 fenofibrate imatinib mesylate meloxicam O fenofibric acid imiquimod memantine fentanyl transdermal INCRUSE ELLIPTA ODEFSEY mesalamine suppository fentanyl transmucosal lozenge ipratropium inhalation solution ODOMZO mesalamine suspension FIASP ipratropium-albuterol inhalation OFEV metformin FINACEA FOAM solution ofloxacin metformin ext-rel 6 finasteride irbesartan olanzapine methadone FLAREX irbesartan-hydrochlorothiazide olmesartan methoxsalen FLOVENT DISKUS IRESSA olmesartan-amlodipine- methylphenidate FLOVENT HFA ISENTRESS hydrochlorothiazide methylphenidate ext-rel fluconazole itraconazole olmesartan-hydrochlorothiazide methylprednisolone fludrocortisone ivermectin olopatadine metoclopramide flunisolide omega-3 acid ethyl esters metolazone fluocinonide 8 omeprazole metoprolol succinate ext-rel

ondansetron PULMICORT FLEXHALER STIOLTO RESPIMAT TRULICITY ONZETRA XSAIL PYLERA STRIBILD TRUVADA OPSUMIT STRIVERDI RESPIMAT TYMLOS ORALAIR Q SUBSYS ORENITRAM QTERN sulfacetamide U ORFADIN quetiapine sulfamethoxazole-trimethoprim UDENYCA ORILISSA quetiapine ext-rel sulfasalazine ULORIC oseltamivir quinapril sulfasalazine delayed-rel UPTRAVI OSPHENA quinapril-hydrochlorothiazide sumatriptan OTEZLA QVAR SUPRAX V OVIDREL QVAR REDIHALER SUPREP valacyclovir oxazepam SYMBICORT valganciclovir oxcarbazepine R SYMFI valproic acid OXTELLAR XR RAGWITEK SYMFI LO valsartan oxybutynin raloxifene SYMLINPEN valsartan-hydrochlorothiazide oxybutynin ext-rel ramipril SYNJARDY VARUBI oxycodone ranitidine SYNJARDY XR VASCEPA oxycodone-acetaminophen ranolazine ext-rel SYNTHROID VELPHORO

OXYCONTIN rasagiline VELTASSA T OZEMPIC RASUVO VEMLIDY

REBIF tacrolimus venlafaxine P RELENZA tadalafil venlafaxine ext-rel capsule pantoprazole repaglinide tamsulosin verapamil ext-rel paroxetine HCl REPATHA TAZORAC VIBERZI paroxetine HCl ext-rel RESTASIS TECFIDERA VICTOZA paroxetine mesylate RETACRIT TEKTURNA vigabatrin PAZEO RETIN-A MICRO TEKTURNA HCT VIIBRYD peg 3350-electrolytes REYATAZ telmisartan VIMPAT penicillin VK RHOPRESSA telmisartan-hydrochlorothiazide VIOKACE PENTASA ribavirin terazosin VISTOGARD PERFOROMIST risedronate terbinafine tablet VOSEVI 3 phenobarbital risperidone testosterone gel VRAYLAR phenytoin rivastigmine testosterone solution VYVANSE phenytoin sodium extended rivastigmine transdermal tetrabenazine PHOSLYRA rizatriptan tetracycline W PICATO ropinirole tiagabine warfarin pindolol ropinirole ext-rel timolol maleate solution pioglitazone rosuvastatin TIVICAY X pioglitazone-glimepiride RUCONEST TOBRADEX OINTMENT XARELTO pioglitazone-metformin RYDAPT TOBRADEX ST XELJANZ potassium chloride liquid tobramycin XELJANZ XR S pramipexole tobramycin inhalation solution XIFAXAN 550 MG pramipexole ext-rel SAFYRAL tobramycin-dexamethasone XIGDUO XR prasugrel SANCUSO TOLAK XIIDRA pravastatin SAXENDA tolterodine XTANDI PRED MILD selegiline tolterodine ext-rel prednisolone acetate 1% SENSIPAR topiramate Z prednisolone solution torsemide SEREVENT zafirlukast prednisone TOVIAZ sertraline ZEJULA PREMARIN TRACLEER sevelamer carbonate ZEMBRACE SYMTOUCH PREMARIN CREAM tramadol sildenafil ZENPEP PREMPHASE tramadol ext-rel SILENOR zileuton ext-rel PREMPRO TRAVATAN Z silodosin ziprasidone prenatal vitamins trazodone SIMBRINZA zolmitriptan PREZCOBIX TRELEGY ELLIPTA simvastatin zolpidem PREZISTA TRESIBA SKYRIZI zolpidem ext-rel primidone tretinoin solifenacin zolpidem sublingual PROAIR HFA TREXIMET SOLIQUA ZOMIG NASAL SPRAY PROAIR RESPICLICK triamcinolone SOMAVERT zonisamide probenecid triamterene-hydrochlorothiazide SOOLANTRA ZUBSOLV prochlorperazine trimethobenzamide sotalol ZYCLARA PROCTOFOAM-HC TRINTELLIX SPIRIVA ZYLET progesterone, micronized spironolactone-hydrochlorothiazide TRIUMEQ promethazine SPRYCEL TROKENDI XR propranolol STELARA SUBCUTANEOUS trospium propranolol ext-rel trospium ext-rel

PREFERRED OPTIONS LIST NON-PREFERRED OR PREFERRED OPTION(S)† NON-PREFERRED OR PREFERRED OPTION(S)† EXCLUDED DRUG(S) EXCLUDED DRUG(S) ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, AZELEX adapalene, benzoyl peroxide, clindamycin solution, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, clindamycin-benzoyl peroxide, erythromycin solution, VRAYLAR erythromycin-benzoyl peroxide, tretinoin, EPIDUO, RETIN-A MICRO, TAZORAC ACANYA adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, BARACLUDE TABLET entecavir, lamivudine, VEMLIDY erythromycin-benzoyl peroxide, tretinoin, EPIDUO, RETIN-A MICRO, TAZORAC BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA ACIPHEX, ACIPHEX SPRINKLE esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, ACTEMRA ENBREL, HUMIRA, KEVZARA, XELJANZ, losartan, losartan-hydrochlorothiazide, olmesartan, XELJANZ XR olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, ACTICLATE doxycycline hyclate, minocycline, tetracycline valsartan-hydrochlorothiazide ACTOS pioglitazone BENSAL HP desonide, hydrocortisone ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel, BENZAC AC adapalene, benzoyl peroxide, clindamycin solution, methylphenidate ext-rel, MYDAYIS, VYVANSE clindamycin-benzoyl peroxide, erythromycin solution, ALCORTIN A desonide, hydrocortisone erythromycin-benzoyl peroxide, tretinoin, EPIDUO, RETIN-A MICRO, TAZORAC Alevicyn solution, desonide, hydrocortisone ALEVICYN GEL, BENZACLIN adapalene, benzoyl peroxide, clindamycin solution, ALEVICYN KIT, ALEVICYN SG clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES RETIN-A MICRO, TAZORAC INSULIN SYRINGES 9 BENZIQ adapalene, benzoyl peroxide, clindamycin solution, ALORA estradiol, DIVIGEL, EVAMIST clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, RETIN-A MICRO, TAZORAC lovastatin, pravastatin, rosuvastatin, simvastatin benzonatate benzonatate (except NDCs^ 69336012615, ALVESCO ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, (NDCs^ 69336012615, 69499032915) FLOVENT HFA, PULMICORT FLEXHALER, QVAR, 69499032915 only) QVAR REDIHALER BERINERT RUCONEST AMRIX cyclobenzaprine BETAPACE, BETAPACE AF sotalol ANDROGEL 1% testosterone gel, testosterone solution, ANDRODERM BEYAZ ethinyl estradiol-drospirenone, ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO ethinyl estradiol-drospirenone-levomefolate, ANTARA fenofibrate (except fenofibrate tablet 120 mg), ethinyl estradiol-norethindrone acetate, fenofibric acid ethinyl estradiol-norethindrone acetate-iron, SAFYRAL APEXICON E desoximetasone, BREEZE 2 STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, fluocinonide (except fluocinonide cream 0.1%) ACCU-CHEK COMPACT PLUS STRIPS 7, ACCU-CHEK GUIDE STRIPS 7, APIDRA FIASP, NOVOLOG ACCU-CHEK SMARTVIEW STRIPS 7 ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID butalbital-acetaminophen diclofenac sodium, ibuprofen, (NDC^ 69499034230 only) naproxen (except naproxen CR or naproxen suspension) ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen butalbital-acetaminophen- diclofenac sodium, ibuprofen, suspension) WITH esomeprazole, lansoprazole, caffeine capsule naproxen (except naproxen CR or naproxen suspension) omeprazole, pantoprazole or DEXILANT BYDUREON OZEMPIC, TRULICITY, VICTOZA ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, PENTASA BYETTA OZEMPIC, TRULICITY, VICTOZA ASCENSIA STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, CAFERGOT eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, ACCU-CHEK COMPACT PLUS STRIPS 7, sumatriptan, zolmitriptan, ONZETRA XSAIL, ACCU-CHEK GUIDE STRIPS 7, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY 7 ACCU-CHEK SMARTVIEW STRIPS calcipotriene cream calcipotriene ointment, calcipotriene solution ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, calcitriol ointment calcipotriene ointment, calcipotriene solution eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, CAMBIA diclofenac sodium, ibuprofen, meloxicam, olmesartan-hydrochlorothiazide, telmisartan, naproxen (except naproxen CR or naproxen suspension) telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA ATROVENT HFA ipratropium inhalation solution, INCRUSE ELLIPTA, SPIRIVA carbinoxamine tablet 6 mg levocetirizine AVENOVA Consult doctor CARDIZEM, CARDIZEM CD, diltiazem ext-rel (except generic CARDIZEM LA) CARDIZEM LA (and its generics)

NON-PREFERRED OR PREFERRED OPTION(S)† NON-PREFERRED OR PREFERRED OPTION(S)† EXCLUDED DRUG(S) EXCLUDED DRUG(S) CARNITOR, CARNITOR SF levocarnitine DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, CHLORZOXAZONE 250 MG cyclobenzaprine losartan, losartan-hydrochlorothiazide, olmesartan, (NDCs^ 46672086046, olmesartan-hydrochlorothiazide, telmisartan, 69499033060 only) telmisartan-hydrochlorothiazide, valsartan, CIALIS sildenafil, tadalafil valsartan-hydrochlorothiazide CIMZIA COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, DORAL eszopiclone, zolpidem, zolpidem ext-rel, SKYRIZI, STELARA SUBCUTANEOUS, XELJANZ, zolpidem sublingual, BELSOMRA, SILENOR XELJANZ XR DORYX, DORYX MPC doxycycline hyclate, minocycline, tetracycline CLINDAGEL erythromycin solution doxepin cream desonide, hydrocortisone, tacrolimus, ELIDEL, clobetasol spray clobetasol foam EUCRISA CLOBEX SPRAY clobetasol foam DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT COLAZAL balsalazide DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide COLCRYS colchicine tablet DYRENIUM amiloride CONTOUR NEXT STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, ACCU-CHEK COMPACT PLUS STRIPS 7, EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, ACCU-CHEK GUIDE STRIPS 7, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, ACCU-CHEK SMARTVIEW STRIPS 7 losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, CONTOUR STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, telmisartan-hydrochlorothiazide, valsartan, ACCU-CHEK COMPACT PLUS STRIPS 7, valsartan-hydrochlorothiazide ACCU-CHEK GUIDE STRIPS 7, ACCU-CHEK SMARTVIEW STRIPS 7 EDLUAR eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR CONTRAVE BELVIQ, BELVIQ XR, SAXENDA E.E.S. GRANULES erythromycins CORDRAN OINTMENT clocortolone, hydrocortisone butyrate, mometasone, triamcinolone EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule COUMADIN warfarin ENABLEX darifenacin ext-rel, oxybutynin ext-rel, solifenacin, CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, lovastatin, pravastatin, rosuvastatin, simvastatin MYRBETRIQ, TOVIAZ CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, EPOGEN ARANESP, RETACRIT venlafaxine ext-rel capsule ERYPED erythromycins DAKLINZA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) EVEKEO amphetamine-dextroamphetamine mixed salts, methylphenidate DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, PENTASA EVZIO naloxone injection, NARCAN NASAL SPRAY DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, amlodipine-valsartan MYRBETRIQ, TOVIAZ EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, Dexifol folic acid olmesartan-amlodipine-hydrochlorothiazide Dexpak dexamethasone, hydrocortisone, methylprednisolone, EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE, prednisolone solution, prednisone GILENYA, REBIF, TECFIDERA diclofenac sodium gel 1% diclofenac sodium, diclofenac sodium gel 1% (except FANAPT aripiprazole, clozapine, olanzapine, quetiapine, (NDC^ 69499031866 only) NDC^ 69499031866), diclofenac sodium solution, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, ibuprofen, meloxicam, naproxen (except naproxen CR VRAYLAR or naproxen suspension) FEMRING estradiol, ESTRING, PREMARIN CREAM Diclofex DC diclofenac sodium, diclofenac sodium gel 1% (except fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), (NDC^ 51021037201 only) NDC^ 69499031866), diclofenac sodium fenofibric acid solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid Diclosaicin diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium fenoprofen capsule diclofenac sodium, ibuprofen, meloxicam, solution, ibuprofen, meloxicam, naproxen (except naproxen (except naproxen CR or naproxen suspension) naproxen CR or naproxen suspension) FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, diflorasone cream, desoximetasone, fluocinonide (except fluocinonide naproxen (except naproxen CR or naproxen suspension) diflorasone ointment cream 0.1%) FERIVA 21/7 folic acid dihydroergotamine spray eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY venlafaxine ext-rel capsule FINACEA GEL metronidazole, FINACEA FOAM, SOOLANTRA

NON-PREFERRED OR PREFERRED OPTION(S)† NON-PREFERRED OR PREFERRED OPTION(S)† EXCLUDED DRUG(S) EXCLUDED DRUG(S) FIORICET CAPSULE diclofenac sodium, ibuprofen, INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, naproxen (except naproxen CR or naproxen suspension) metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC fluocinonide cream 0.1% clobetasol cream INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, zolpidem sublingual, BELSOMRA, SILENOR PICATO, TOLAK, ZYCLARA INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel, flurandrenolide ointment clocortolone, hydrocortisone butyrate, mometasone, atomoxetine, guanfacine ext-rel, triamcinolone methylphenidate ext-rel, MYDAYIS, VYVANSE FML LIQUIFILM dexamethasone, prednisolone acetate 1%, DUREZOL, INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD INVOKANA FARXIGA, JARDIANCE FOLIC-K folic acid ISTALOL timolol maleate solution, BETIMOL FOLIKA-D folic acid JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, Folika-T folic acid tamsulosin or terazosin FOLIKA-V folic acid JENTADUETO, JANUMET, JANUMET XR FOLLISTIM AQ GONAL-F JENTADUETO XR FORTAMET (and its generic) metformin, metformin ext-rel (except generic KAZANO JANUMET, JANUMET XR FORTAMET or GLUMETZA) KINERET ENBREL, HUMIRA, KEVZARA, XELJANZ, FORTESTA testosterone gel, testosterone solution, ANDRODERM XELJANZ XR FOSAMAX PLUS D alendronate, ibandronate, risedronate KOMBIGLYZE XR JANUMET, JANUMET XR FOSRENOL calcium acetate, lanthanum carbonate, lactulose pak lactulose solution sevelamer carbonate, PHOSLYRA, VELPHORO LAMICTAL, LAMICTAL ODT, carbamazepine, carbamazepine ext-rel, FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate LAMICTAL XR divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, FREESTYLE STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, levetiracetam, levetiracetam ext-rel, oxcarbazepine, ACCU-CHEK COMPACT PLUS STRIPS 7, phenobarbital, phenytoin, phenytoin sodium extended, ACCU-CHEK GUIDE STRIPS 7, primidone, tiagabine, topiramate, valproic acid, ACCU-CHEK SMARTVIEW STRIPS 7 zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, LANOXIN TABLET digoxin ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY (125 MCG and 250 MCG only) FULPHILA NEULASTA, UDENYCA LANTUS BASAGLAR, LEVEMIR, TRESIBA GENOTROPIN HUMATROPE LAZANDA fentanyl transmucosal lozenge, ABSTRAL, SUBSYS Genicin Vita-S folic acid LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL fentanyl transdermal, hydromorphone ext-rel, GLUMETZA (and its generic) metformin, metformin ext-rel (except generic methadone, morphine ext-rel, EMBEDA, FORTAMET or GLUMETZA) HYSINGLA ER, NUCYNTA ER, OXYCONTIN GLYCOPYRROLATE dicyclomine LEXAPRO citalopram, escitalopram, fluoxetine, paroxetine HCl, TABLET 1.5 MG paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD GRANIX NIVESTYM LIALDA balsalazide, sulfasalazine, sulfasalazine delayed-rel, HORIZANT gabapentin, GRALISE APRISO, PENTASA HUMALOG FIASP, NOVOLOG LIDOCAINE-TETRACAINE lidocaine-prilocaine CREAM HUMALOG MIX 50/50 NOVOLOG MIX 70/30 LIDOTREX lidocaine-prilocaine HUMALOG MIX 75/25 NOVOLOG MIX 70/30 LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, HUMULIN 70/30 NOVOLIN 70/30 lovastatin, pravastatin, rosuvastatin, simvastatin HUMULIN N NOVOLIN N LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin HUMULIN R NOVOLIN R Lorid folic acid HylaVite folic acid LUNESTA eszopiclone, zolpidem, zolpidem ext-rel, INDOCIN diclofenac sodium, ibuprofen, meloxicam, zolpidem sublingual, BELSOMRA, SILENOR naproxen (except naproxen CR or naproxen suspension) MACRODANTIN nitrofurantoin Inflammacin diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, Matzim LA diltiazem ext-rel (except generic CARDIZEM LA) ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

NON-PREFERRED OR PREFERRED OPTION(S)† NON-PREFERRED OR PREFERRED OPTION(S)† EXCLUDED DRUG(S) EXCLUDED DRUG(S) MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), OMNARIS flunisolide, fluticasone, mometasone, triamcinolone, HARVONI (genotypes 1, 4, 5, 6), VOSEVI 3 DYMISTA MEBOLIC folic acid OMNITROPE HUMATROPE MENEST estradiol, PREMARIN OMNIVEX folic acid MENOSTAR estradiol ONETOUCH ULTRA STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, ACCU-CHEK COMPACT PLUS STRIPS 7, MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, ACCU-CHEK GUIDE STRIPS 7, risedronate, FORTEO, TYMLOS ACCU-CHEK SMARTVIEW STRIPS 7 MIACALCIN NASAL SPRAY calcitonin-salmon ONETOUCH VERIO STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, 7 MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, ACCU-CHEK COMPACT PLUS STRIPS , 7 eprosartan, irbesartan, irbesartan-hydrochlorothiazide, ACCU-CHEK GUIDE STRIPS , 7 losartan, losartan-hydrochlorothiazide, olmesartan, ACCU-CHEK SMARTVIEW STRIPS olmesartan-hydrochlorothiazide, telmisartan, ONEXTON adapalene, benzoyl peroxide, clindamycin solution, telmisartan-hydrochlorothiazide, valsartan, clindamycin-benzoyl peroxide, erythromycin solution, valsartan-hydrochlorothiazide erythromycin-benzoyl peroxide, tretinoin, EPIDUO, MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, RETIN-A MICRO, TAZORAC prednisolone solution, prednisone ONFI clobazam, lamotrigine, topiramate, TROKENDI XR MINASTRIN 24 FE ethinyl estradiol-drospirenone, ONGLYZA JANUVIA ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ORENCIA CLICKJECT, COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, ethinyl estradiol-norethindrone acetate-iron, SAFYRAL ORENCIA INTRAVENOUS, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR ORENCIA SUBCUTANEOUS MINIVELLE estradiol, DIVIGEL, EVAMIST ORTHO DF folic acid MINOCIN doxycycline hyclate, minocycline, tetracycline ORTHO TRI-CYCLEN LO ethinyl estradiol-norgestimate mupirocin cream gentamicin, mupirocin ointment OSENI JANUMET, JANUMET XR NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) OWEN MUMFORD NEEDLES 9 BD ULTRAFINE NEEDLES naproxen CR diclofenac sodium, ibuprofen, meloxicam, OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, naproxen (except naproxen CR or naproxen suspension) tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ naproxen suspension ibuprofen PANCREAZE CREON, VIOKACE, ZENPEP NATESTO testosterone gel, testosterone solution, ANDRODERM PENNSAID diclofenac sodium, diclofenac sodium gel 1% (except NESINA JANUVIA NDC^ 69499031866), diclofenac sodium solution, NEUPOGEN NIVESTYM ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA NICAPRIN folic acid PERRIGO NEEDLES 9 BD ULTRAFINE NEEDLES NICAZEL, NICAZEL FORTE folic acid PERTZYE CREON, VIOKACE, ZENPEP NILANDRON abiraterone, bicalutamide, XTANDI PEXEVA citalopram, escitalopram, fluoxetine, paroxetine HCl, NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD NORDITROPIN HUMATROPE PLAVIX clopidogrel, prasugrel, BRILINTA NORITATE metronidazole, FINACEA FOAM, SOOLANTRA PRADAXA warfarin, ELIQUIS, XARELTO NORVASC amlodipine PRALUENT REPATHA NOVACORT desonide, hydrocortisone PRECISION XTRA STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, ACCU-CHEK COMPACT PLUS STRIPS 7, 9 NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES ACCU-CHEK GUIDE STRIPS 7, NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1% (except ACCU-CHEK SMARTVIEW STRIPS 7 NDC^ 69499031866), diclofenac sodium solution, PRED FORTE dexamethasone, prednisolone acetate 1%, DUREZOL, ibuprofen, meloxicam, naproxen (except naproxen CR FLAREX, FML FORTE, FML S.O.P., MAXIDEX, or naproxen suspension) PRED MILD NUTROPIN AQ HUMATROPE PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO NUVIGIL armodafinil PRENATAL PLUS generic prenatal vitamins, CITRANATAL OLEPTRO trazodone PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, OLUX-E clobetasol foam DEXILANT omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole, pantoprazole, PREVIDENT Consult doctor DEXILANT

NON-PREFERRED OR PREFERRED OPTION(S)† NON-PREFERRED OR PREFERRED OPTION(S)† EXCLUDED DRUG(S) EXCLUDED DRUG(S) PRIMLEV hydrocodone-acetaminophen, hydromorphone, TARGADOX doxycycline hyclate, minocycline, tetracycline morphine, oxycodone-acetaminophen, NUCYNTA TASIGNA imatinib mesylate, BOSULIF, SPRYCEL PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule TESTIM testosterone gel, testosterone solution, ANDRODERM 11 PROCRIT ARANESP, RETACRIT testosterone gel 1% testosterone gel, testosterone solution, ANDRODERM PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, TIROSINT levothyroxine, SYNTHROID DEXILANT TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS PROTOPIC tacrolimus, ELIDEL, EUCRISA TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, PROVENTIL HFA albuterol sulfate CFC-free aerosol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, levalbuterol tartrate CFC-free aerosol, PROAIR HFA, pindolol, propranolol, propranolol ext-rel, BYSTOLIC PROAIR RESPICLICK TOUJEO BASAGLAR, LEVEMIR, TRESIBA PROZAC citalopram, escitalopram, fluoxetine, paroxetine HCl, TRADJENTA JANUVIA paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD TRICOR fenofibrate (except fenofibrate tablet 120 mg), PSORCON desoximetasone, fenofibric acid fluocinonide (except fluocinonide cream 0.1%) TRIGLIDE fenofibrate (except fenofibrate tablet 120 mg), QNASL flunisolide, fluticasone, mometasone, triamcinolone, fenofibric acid DYMISTA TRILIPIX fenofibrate (except fenofibrate tablet 120 mg), QSYMIA BELVIQ, BELVIQ XR, SAXENDA fenofibric acid RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, TRIVIDIA INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES terazosin TronVite folic acid RAYOS dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone TRUETEST STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, ACCU-CHEK COMPACT PLUS STRIPS 7, RELION INSULIN NOVOLIN INSULIN ACCU-CHEK GUIDE STRIPS 7, 7 RELISTOR MOVANTIK ACCU-CHEK SMARTVIEW STRIPS 10 7 RHEUMATE folic acid TRUETRACK STRIPS ACCU-CHEK AVIVA PLUS STRIPS , ACCU-CHEK COMPACT PLUS STRIPS 7, RIBOZEL folic acid ACCU-CHEK GUIDE STRIPS 7, ACCU-CHEK SMARTVIEW STRIPS 7 RIOMET metformin, metformin ext-rel (except generic FORTAMET or GLUMETZA) TUDORZA INCRUSE ELLIPTA, SPIRIVA ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, ULTIMED INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES zolpidem sublingual, BELSOMRA, SILENOR ULTIMED NEEDLES 9 BD ULTRAFINE NEEDLES SABRIL vigabatrin UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, SAIZEN HUMATROPE terazosin SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, VALCYTE valganciclovir quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR VALTREX acyclovir, valacyclovir SIMPONI COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, VANATOL LQ, VANATOL S diclofenac sodium, ibuprofen, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR naproxen (except naproxen CR or naproxen suspension) SINGULAIR montelukast, zafirlukast, zileuton ext-rel Vanoxide-HC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, SORILUX calcipotriene ointment, calcipotriene solution erythromycin-benzoyl peroxide, tretinoin, EPIDUO, RETIN-A MICRO, TAZORAC SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) VASCULERA Consult doctor STENDRA sildenafil, tadalafil VECTICAL calcipotriene ointment, calcipotriene solution STRIANT testosterone gel, testosterone solution, ANDRODERM VELTIN adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV erythromycin-benzoyl peroxide, tretinoin, EPIDUO, SURE-TEST STRIPS 10 ACCU-CHEK AVIVA PLUS STRIPS 7, RETIN-A MICRO, TAZORAC 7 ACCU-CHEK COMPACT PLUS STRIPS , venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, 7 ACCU-CHEK GUIDE STRIPS , (except 225 mg) venlafaxine ext-rel capsule ACCU-CHEK SMARTVIEW STRIPS 7 VENTOLIN HFA albuterol sulfate CFC-free aerosol, SYNERDERM desonide, hydrocortisone levalbuterol tartrate CFC-free aerosol, PROAIR HFA, TALIVA folic acid PROAIR RESPICLICK TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, VIAGRA sildenafil, tadalafil STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

NON-PREFERRED OR PREFERRED OPTION(S)† NON-PREFERRED OR PREFERRED OPTION(S)† EXCLUDED DRUG(S) EXCLUDED DRUG(S) VITAFOL-ONE generic prenatal vitamins, CITRANATAL ZETIA ezetimibe VIVELLE-DOT estradiol, DIVIGEL, EVAMIST ZETONNA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA VOGELXO testosterone gel, testosterone solution, ANDRODERM ZIANA adapalene, benzoyl peroxide, clindamycin solution, XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, clindamycin-benzoyl peroxide, erythromycin solution, oxazepam erythromycin-benzoyl peroxide, tretinoin, EPIDUO, Xelitral diclofenac sodium, diclofenac sodium gel 1% (except RETIN-A MICRO, TAZORAC NDC^ 69499031866), diclofenac sodium solution, ZOLPIMIST eszopiclone, zolpidem, zolpidem ext-rel, ibuprofen, meloxicam, naproxen (except naproxen CR zolpidem sublingual, BELSOMRA, SILENOR or naproxen suspension) ZONEGRAN carbamazepine, carbamazepine ext-rel, XENAZINE tetrabenazine, AUSTEDO divalproex sodium, divalproex sodium ext-rel, XOLEGEL ciclopirox, ketoconazole gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, XOPENEX HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate phenobarbital, phenytoin, phenytoin sodium extended, CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, Xvite folic acid TROKENDI XR, VIMPAT XYZBAC folic acid ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, YAZ ethinyl estradiol-drospirenone, naproxen (except naproxen CR or naproxen suspension) ethinyl estradiol-drospirenone-levomefolate, ZUPLENZ granisetron, ondansetron, SANCUSO ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, SAFYRAL ZYFLO, ZYFLO CR montelukast, zafirlukast, zileuton ext-rel ZARXIO NIVESTYM ZYTIGA abiraterone, bicalutamide, XTANDI ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, ZYVIT folic acid DEXILANT

ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It does not list all covered drugs and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace may 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 and will be removed from the Preferred Drug List. 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/coinsurance 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. To learn more about your specific drug benefit, log into My Account at www.carefirst.com/myaccount and click on Drug & Pharmacy Resources under Quick Links or call CareFirst Pharmacy Services at 800-241-3371.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication. † The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. § 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. 1 CVS Caremark is an independent company that provides pharmacy benefit management services. 2 Listing does not include naproxen CR or naproxen suspension. 3 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). 4 Listing does not include fenofibrate tablet 120 mg. 5 Listing does not include generic CARDIZEM LA. 6 Listing does not include generic FORTAMET or GLUMETZA. 7 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 8 Listing does not include fluocinonide cream 0.1%. 9 BD ULTRAFINE syringes and needles are the only preferred options. 10 ACCU-CHEK brand test strips are the only preferred options. 11 Listing reflects the authorized generics for TESTIM and VOGELXO.

Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, 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.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc. ©2019. All rights reserved. SUM2665-1P (10/01/19)

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