The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.

2021 Express Scripts PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by National Preferred Formulary all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY BAQSIMI COMBIPATCH ergocalciferol GENVOYA [INJ] - Injectable Drug BARACLUDE SOLUTION COMBIVENT RESPIMAT ERIVEDGE GILENYA Brand-name drugs are listed BAXDELA COMETRIQ ERLEADA GLASSIA [INJ] in CAPITAL letters. BD AUTOSHIELD CORLANOR erythromycin eye ointment glimepiride Generic drugs are listed DUO NEEDLES CREON ESBRIET glipizide in lower case letters. BD ULTRAFINE cyanocobalamin [INJ] escitalopram glipizide ext-release INSULIN SYRINGES cyclobenzaprine esomeprazole magnesium GLUCAGEN [INJ] A BD ULTRAFINE PEN NEEDLES delayed-release GLUCAGON [INJ] BELBUCA D ESPEROCT [INJ] glyburide ABILIFY MAINTENA [INJ] benazepril estradiol GLYXAMBI acetaminophen/codeine benzonatate DALIRESP estradiol patches GONAL-F, GONAL-F RFF, ACTEMRA [INJ] BETASERON [INJ] DAYTRANA estradiol/norethindrone GONAL-F RFF acyclovir BEVESPI AEROSPHERE DESCOVY acetate REDI-JECT [INJ] ADEMPAS BIKTARVY desloratadine ESTRING GRASTEK ADVAIR HFA bisoprolol/hctz desvenlafaxine succinate eszopiclone guanfacine ext-release ADVATE [INJ] blisovi fe ext-release -ee vaginal ring GVOKE [INJ] ADYNOVATE [INJ] BOSULIF EUFLEXXA [INJ] AFSTYLA [INJ] BREO ELLIPTA DEXCOM RECEIVER, SENSOR, ezetimibe H AIMOVIG [INJ] BREZTRI AEROSPHERE TRANSMITTER ezetimibe/simvastatin AJOVY [INJ] BRILINTA dexmethylphenidate HARVONI albuterol nebulization nebulization ext-release F HUMALOG [INJ] solution suspension dextroamphetamine/ HUMIRA [INJ] albuterol sulfate hfa (by bupropion amphetamine famotidine HUMULIN [INJ] Cipla, Lupin, Par, Perrigo, bupropion ext-release dextroamphetamine/ FARXIGA hydralazine Proficient Rx & Teva) buspirone amphetamine ext-release FASENRA [INJ] hydrochlorothiazide ALECENSA butalbital/acetaminophen/ diazepam fenofibrate hydrocodone/acetaminophen alendronate caffeine diclofenac sodium fenofibrate micronized hydrocodone/ allopurinol BYDUREON [INJ] delayed-release fenofibric acid chlorpheniramine polistirex ALPHAGAN P 0.1% BYETTA [INJ] dicyclomine delayed-release ext-release alprazolam BYSTOLIC digoxin fentanyl patches topical ALUNBRIG diltiazem ext-release FETZIMA hydromorphone amiodarone C dimethyl fumarate FINACEA FOAM hydroxychloroquine amitriptyline diphenoxylate/atropine finasteride hydroxyzine hcl amlodipine CABOMETYX divalproex delayed-release FLECTOR hydroxyzine pamoate amlodipine/benazepril carbidopa/levodopa divalproex ext-release FLOVENT DISKUS HYSINGLA ER amlodipine/valsartan carvedilol DIVIGEL FLOVENT HFA amoxicillin cefdinir donepezil fluconazole I amoxicillin/potassium cefuroxime axetil doxazosin clavulanate celecoxib doxycycline hyclate fluoxetine ibandronate AMZEEQ cephalexin doxycycline monohydrate nasal spray IBRANCE anastrozole CERDELGA DUAVEE folic acid ibuprofen ANDRODERM CEREZYME [INJ] DULERA FORTEO [INJ] INBRIJA ANORO ELLIPTA CETROTIDE [INJ] duloxetine delayed-release FRAGMIN [INJ] INCRUSE ELLIPTA ARALAST NP [INJ] CHANTIX DUPIXENT [INJ] FREESTYLE KITS/METERS: indomethacin ARIKAYCE chlorhexidine gluconate DYANAVEL XR FREESTYLE FREEDOM, INLYTA aripiprazole chlorthalidone FREESTYLE FREEDOM LITE, INVELTYS ARISTADA [INJ] CIMDUO E FREESTYLE INSULINX, INVOKAMET ARNUITY ELLIPTA ciprofloxacin FREESTYLE LITE INVOKAMET XR ASMANEX HFA citalopram EDARBI FREESTYLE LIBRE & LIBRE 2 INVOKANA ASMANEX TWISTHALER clarithromycin EDARBYCLOR READER, SENSOR irbesartan atenolol CLENPIQ ELIQUIS FREESTYLE TEST STRIPS: IRESSA atenolol/chlorthalidone clindamycin hcl ELOCTATE [INJ] FREESTYLE, isosorbide mononitrate atomoxetine clindamycin phosphate EMGALITY [INJ] FREESTYLE INSULINX, ext-release atorvastatin topical EMVERM FREESTYLE LITE AUSTEDO clindamycin phosphate/ enalapril FULPHILA J AVONEX [INJ] benzoyl peroxide ENBREL [INJ] furosemide AZASITE propionate ENDOMETRIN FYCOMPA JANUMET, JANUMET XR azelastine nasal spray clomiphene citrate enoxaparin [INJ] JANUVIA azithromycin clonazepam ENSTILAR G JARDIANCE AZOPT clonidine ENTRESTO JIVI [INJ] clopidogrel EPCLUSA gabapentin JULUCA B clotrimazole/ EPIDIOLEX GAMMACORE junel dipropionate epinephrine auto-injector GELNIQUE junel fe baclofen colchicine tablets (by Mylan, Teva) [INJ] gemfibrozil BAFIERTAM COMBIGAN EPIPEN, EPIPEN JR [INJ] GENOTROPIN [INJ] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. CRP2005_003097.1 #1702 NP-A All trademarks are the property of their respective owners. Page 1 PRMT22157-21 (01/01/21) K montelukast P S TRESIBA [INJ] morphine sulfate ext-release topical KESIMPTA [INJ] MOVANTIK PANCREAZE SAVELLA triamterene/hctz topical moxifloxacin eye solution pantoprazole delayed-release SEGLUROMET TRIJARDY XR ketorolac mupirocin paroxetine hcl SEREVENT DISKUS tri-lo-marzia KITABIS PAK MUSE penicillin v potassium sertraline TRIPTODUR [INJ] KOGENATE FS [INJ] MVASI [INJ] PENTASA sildenafil tri-sprintec KOVALTRY [INJ] MYDAYIS PERFOROMIST SIMPONI 100 MG (for TRIUMEQ KYLEENA MYRBETRIQ PHOSLYRA ulcerative colitis only) [INJ] TRULANCE KYNMOBI pioglitazone simvastatin TRULICITY [INJ] N PLEGRIDY [INJ] SKYLA TYMLOS [INJ] L polymyxin/trimethoprim SKYRIZI [INJ] nabumetone eye solution SOLIQUA [INJ] U labetalol NAMZARIC POMALYST SOLOSEC lamotrigine naproxen, naproxen sodium potassium chloride SOMATULINE DEPOT [INJ] UCERIS FOAM lansoprazole delayed-release NARCAN NASAL SPRAY ext-release SPIRIVA HANDIHALER UPTRAVI LANTUS [INJ] NASCOBAL pramipexole SPIRIVA RESPIMAT latanoprost eye solution NATESTO pravastatin spironolactone V LATUDA NAYZILAM PRECISION XTRA METERS, sprintec LEVEMIR [INJ] neomycin/polymyxin/ TEST STRIPS, SPRYCEL valacyclovir levetiracetam hydrocortisone ear solution B-KETONE STRIPS STEGLATRO valsartan levocetirizine NEXLETOL acetate STEGLUJAN valsartan/hctz levofloxacin NEXLIZET eye suspension STELARA SC [INJ] VARUBI levothyroxine sodium niacin ext-release prednisolone sodium STIOLTO RESPIMAT VASCEPA LICART nifedipine ext-release phosphate STRENSIQ [INJ] VELPHORO lidocaine patches NINLARO SUBLOCADE [INJ] venlafaxine LINZESS nitrofurantoin macrocrystal pregabalin sulfamethoxazole/ venlafaxine ext-release liothyronine NITYR PREMARIN CREAM trimethoprim verapamil ext-release LIPOFEN NIVESTYM [INJ] PREMARIN TABLETS sumatriptan VERZENIO lisinopril NORDITROPIN [INJ] PREMPHASE SUNOSI VIBERZI lisinopril/hctz nortriptyline PREMPRO SUPREP VIIBRYD LIVALO NOVAREL [INJ] PROCRIT [INJ] SUTENT VIMPAT LO LOESTRIN FE NOVOEIGHT [INJ] micronized SYMBICORT VIOKACE LOKELMA NOVOFINE AUTOSHIELD PROLASTIN C [INJ] SYMFI VIZIMPRO lorazepam NEEDLES promethazine SYMFI LO VOSEVI LORBRENA NOVOFINE NEEDLES promethazine/ SYMJEPI [INJ] VUMERITY losartan NOVOTWIST NEEDLES dextromethorphan SYMLINPEN [INJ] VYVANSE losartan/hctz NUBEQA propranolol SYMPROIC LOTEMAX GEL, OINTMENT NUCALA [INJ] propranolol ext-release SYMTUZA W LOTEMAX SM NUEDEXTA PULMICORT FLEXHALER SYNJARDY, SYNJARDY XR eye suspension nystatin warfarin lovastatin nystatin topical Q T LUMIGAN X LUPANETA PACK [INJ] O QNASL tacrolimus topical LUPRON DEPOT QUDEXY XR tadalafil XALKORI 3.75 MG, 11.25 MG [INJ] ODACTRA quetiapine TAKHZYRO [INJ] XARELTO LUPRON DEPOT-PED [INJ] ODEFSEY QUILLICHEW ER TALICIA XELJANZ, XELJANZ XR LYNPARZA ODOMZO QUILLIVANT XR TALTZ [INJ] XIFAXAN LYUMJEV [INJ] OFEV quinapril TALZENNA XIGDUO XR ofloxacin QVAR REDIHALER tamoxifen XIIDRA M olanzapine tamsulosin ext-release XOLAIR [INJ] olmesartan R TASIGNA XTANDI MAYZENT olmesartan/hctz TAYTULLA XULTOPHY [INJ] meclizine omega-3 acid ethyl esters rabeprazole delayed-release TAZORAC GEL XYREM medroxyprogesterone omeprazole delayed-release RAGWITEK TAZORAC 0.05% CREAM XYWAV meloxicam ondansetron raloxifene TEGSEDI [INJ] metaxalone ondansetron orally ramipril TEKTURNA HCT Y metformin disintegrating tablets RASUVO [INJ] TEMIXYS metformin ext-release ONETOUCH KITS/METERS: REBIF [INJ] terazosin YONSA methimazole ULTRA 2, ULTRAMINI, RECTIV terconazole vaginal YUPELRI methocarbamol VERIO, VERIO FLEX RELISTOR [INJ] testosterone cypionate [INJ] yuvafem methotrexate ONETOUCH TEST STRIPS: RELISTOR TABLETS THALOMID methylphenidate ULTRA, VERIO REMICADE [INJ] timolol maleate eye solution Z methylphenidate ext-release ONEXTON REPATHA [INJ] tizanidine OPSUMIT RESTASIS TOBI PODHALER ZARXIO [INJ] metoclopramide ORALAIR RETACRIT [INJ] TOBRADEX OINTMENT ZEJULA metoprolol succinate ORIAHNN REVLIMID TOBRADEX ST ZENPEP ext-release ORILISSA RHOPRESSA tobramycin eye solution ZEPATIER metoprolol tartrate ORTHOVISC [INJ] RINVOQ ER tobramycin/dexamethasone ZEPOSIA metronidazole oseltamivir risperidone eye suspension ZERVIATE metronidazole topical OTEZLA rizatriptan topiramate ZIEXTENZO [INJ] metronidazole vaginal OTOVEL ropinirole TOUJEO [INJ] ZIOPTAN microgestin fe OVIDREL [INJ] rosuvastatin TOVIAZ ZIRABEV [INJ] minocycline oxcarbazepine RUBRACA TRACLEER SUSPENSION zolpidem MIRENA oxybutynin ext-release RUCONEST [INJ] tramadol zolpidem ext-release mirtazapine oxycodone RUXIENCE [INJ] travoprost eye solution ZOMIG NASAL MIRVASO oxycodone/acetaminophen RYBELSUS TRAZIMERA [INJ] ZTLIDO MITIGARE OXYCONTIN trazodone ZUBSOLV OZEMPIC [INJ] TRELEGY ELLIPTA ZYLET MONOVISC [INJ] TREMFYA [INJ] ZYTIGA 500 MG

Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2020 Express Scripts. All Rights Reserved. CRP2005_003097.1 #1702 NP-A All trademarks are the property of their respective owners. Page 2 PRMT22157-21 (01/01/21) 2021 National Preferred Formulary Exclusions

The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans.

Drug Class Excluded Medications Preferred Alternatives

ANTIINFECTIVES FIRVANQ vancomycin capsules, vancomycin oral solution Antibiotic Agents - Vancomycins (Oral)

Antifungal Agents (Oral) TOLSURA itraconazole

Antivirals (Oral) SITAVIG acyclovir oral or cream, famciclovir, valacyclovir

AUTONOMIC & CENTRAL NERVOUS SYSTEM LUCEMYRA clonidine Alpha-2 Adrenergic Agonists (for Opioid Withdrawal)

carbamazepine, oxcarbazepine, pregabalin, topiramate, APTIOM VIMPAT Anticonvulsants FINTEPLA DIACOMIT, EPIDIOLEX

TOPIRAMATE ER CAPSULES topiramate tablets, QUDEXY XR

Antimigraine Agents VYEPTI AIMOVIG, AJOVY, EMGALITY

amantadine capsules, amantadine tablets, GOCOVRI ER Antiparkinsonism Agents amantadine oral solution XADAGO, ZELAPAR rasagiline, selegiline

aripiprazole, olanzapine, quetiapine er, quetiapine fumarate, Antipsychotics (Oral) CAPLYTA risperidone, ziprasidone, LATUDA

Antispasmodic Agents OZOBAX baclofen, tizanidine

dextroamphetamine er, dextroamphetamine/amphetamine er, Central Nervous System Stimulants AMPHETAMINE ER SUSPENSION DYANAVEL XR, MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE

EMFLAZA prednisone solution, prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51, VILTEPSO, VYONDYS 53 No alternatives recommended

Lambert-Eaton Myasthenic Syndrome Agents FIRDAPSE RUZURGI

MORPHABOND ER, NUCYNTA ER, OXYCODONE ER, hydromorphone er, morphine sulfate er, oxymorphone er, Long-Acting Opioid Oral Analgesics XTAMPZA ER HYSINGLA ER, OXYCONTIN

AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, Multiple Sclerosis (Beta Interferons) EXTAVIA PLEGRIDY, REBIF, REBIF REBIDOSE

APADAZ, BENZHYDROCODONE/ACETAMINOPHEN hydrocodone/acetaminophen

hydrocodone/acetaminophen, morphine sulfate, oxycodone, Narcotic Analgesics & Combinations NUCYNTA tramadol, tramadol/acetaminophen

PRIMLEV oxycodone/acetaminophen

BUNAVAIL buprenorphine/naloxone, ZUBSOLV Narcotic Antagonists EVZIO, NALOXONE AUTO-INJECTOR naloxone syringes, NARCAN NASAL SPRAY

Neuropathic Agents LYRICA CR gabapentin, pregabalin

Sedative-Hypnotic Agents DORAL, QUAZEPAM estazolam, lorazepam

Continued

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AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) Serotonin/Norepinephrine Reuptake Inhibitor DRIZALMA SPRINKLE desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA Antidepressants

Tardive Dyskinesia Therapy INGREZZA AUSTEDO

FENTANYL CITRATE BUCCAL TABLETS, FENTORA, Transmucosal Fentanyl Analgesics fentanyl citrate lozenges LAZANDA, SUBSYS

olanzapine/fluoxetine, bupropion, desvenlafaxine er, Miscellaneous Antidepressants SPRAVATO duloxetine, escitalopram, mirtazapine, sertraline

CARDIOVASCULAR EPANED enalapril ACE Inhibitors QBRELIS lisinopril

Anticoagulants PRADAXA, SAVAYSA ELIQUIS, XARELTO

INDERAL XL, INNOPRAN XL propranolol er

KAPSPARGO SPRINKLE metoprolol succinate Beta Blockers & Combinations metoprolol tartrate/hydrochlorothiazide, DUTOPROL metoprolol succinate er plus hydrochlorothiazide

Calcium Channel Blockers KATERZIA amlodipine

atorvastatin, fluvastatin er, lovastatin, pravastatin, HMG & Cholesterol Inhibitor Combinations ALTOPREV, EZALLOR SPRINKLE rosuvastatin, simvastatin tablets, LIVALO

PCSK9 Inhibitors PRALUENT REPATHA

DERMATOLOGICAL MINOCYCLINE ER CAPSULES, XIMINO minocycline er tablets Oral Agents for Acne

Rosacea Agents (Oral) DOXYCYCLINE 40 MG CAPSULES doxycycline hyclate, doxycycline monohydrate

Topical Acne Combinations EPIDUO FORTE adapalene/benzoyl peroxide

clindamycin/benzoyl peroxide, clindamycin/tretinoin, Topical Acne/Antibiotic Combinations VELTIN erythromycin/benzoyl peroxide, ONEXTON

CARAC, FLUOROURACIL 0.5% CREAM, diclofenac 3% gel, fluorouracil 2% solution, Topical Agents for Actinic Keratosis IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA fluorouracil 5% cream, imiquimod 5% cream

CLINDAGEL, Topical Antibiotics for Acne clindamycin phosphate gel, erythromycin gel, AMZEEQ CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE)

Topical Antifungals ECOZA, LULICONAZOLE, SULCONAZOLE, XOLEGEL ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

, acetonide, CLOCORTOLONE Topical 0.05% cream/lotion/ointment, VERDESO FOAM 0.25% cream/ointment

Vitamin D Analogs (Topical) CALCIPOTRIENE FOAM calcipotriene, calcitriol

ALCORTIN A hydrocortisone, mupirocin Miscellaneous Topical Dermatological Agents LIDOCAINE/TETRACAINE lidocaine cream, lidocaine/prilocaine cream

FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE ASCENSIA (CONTOUR) FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, ROCHE (ACCU-CHEK) DIABETES FREESTYLE LITE TRIVIDIA (TRUETEST, TRUETRACK) Blood Glucose Meters & Test Strips ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, ALL OTHER METERS & TEST STRIPS VERIO FLEX THAT ARE NOT LISTED AS PREFERRED ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS

Continued

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ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA JANUVIA

DIABETES (continued) ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, JANUMET, JANUMET XR Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations KAZANO, KOMBIGLYZE XR

ALOGLIPTIN/PIOGLITAZONE pioglitazone plus JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose QTERN GLYXAMBI, STEGLUJAN Co-Transporter-2 (SGLT-2) Inhibitors Combinations

Glucagon-Like Peptide-1 Agonists ADLYXIN, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY

NOVOLIN, RELION NOVOLIN HUMULIN

ADMELOG, APIDRA, FIASP, INSULIN ASPART, Insulins HUMALOG, LYUMJEV INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG

SEMGLEE LANTUS, LEVEMIR, TOUJEO, TRESIBA

EAR/NOSE BECONASE AQ, OMNARIS, ZETONNA budesonide, , fluticasone, mometasone, QNASL Nasal

Otic Fluoroquinolone Antibiotics CIPROFLOXACIN/FLUOCINOLONE OTIC ciprofloxacin/dexamethasone otic, OTOVEL

ENDOCRINE (OTHER) Gonadotropin-Releasing Hormone (GnRH) Analogs FENSOLVI LUPRON DEPOT-PED, TRIPTODUR (for Central Precocious Puberty)

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, Growth Hormones GENOTROPIN, NORDITROPIN FLEXPRO SAIZEN, SAIZENPREP, ZOMACTON

Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT

Testosterone Products AVEED testosterone cypionate, testosterone enanthate

Miscellaneous Endocrine Drugs KORLYM ketoconazole, LYSODREN, SIGNIFOR

GASTROINTESTINAL MYTESI diphenoxylate/atropine, loperamide Antidiarrheal Agents

AKYNZEO CAPSULES granisetron, ondansetron, aprepitant, VARUBI TABLETS Antiemetics (Oral) EMEND POWDER PACKETS aprepitant, VARUBI TABLETS

Bowel Evacuants OSMOPREP peg-electrolyte solution, CLENPIQ, SUPREP

Corticosteroids (Rectal Formulations) CORTIFOAM hydrocortisone enema, UCERIS FOAM

Helicobacter Pylori Agents HELIDAC, PYLERA lansoprazole/amoxicillin/clarithromycin, TALICIA

Hemorrhoidal Preparations PROCTOFOAM-HC pramoxine/hydrocortisone

balsalazide disodium, mesalamine dr, mesalamine er, Inflammatory Bowel Agents DIPENTUM sulfasalazine, PENTASA

Irritable Bowel Syndrome & Chronic Constipation Agents AMITIZA LINZESS, TRULANCE

Pancreatic Enzymes PERTZYE CREON, PANCREAZE, ZENPEP

ACIPHEX SPRINKLE, ESOMEPRAZOLE STRONTIUM, esomeprazole magnesium, lansoprazole, omeprazole, Proton Pump Inhibitors NEXIUM PACKETS, PRILOSEC SUSPENSION, pantoprazole, rabeprazole RABEPRAZOLE DR SPRINKLE

HEMATOLOGICAL aspirin plus omeprazole, esomeprazole, lansoprazole, ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR Antiplatelet Agents pantoprazole or rabeprazole

Erythropoiesis-Stimulating Agents ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT

ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI, Factor VIII Recombinant Products NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE KOGENATE FS, KOVALTRY, NOVOEIGHT

Continued

© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612 All trademarks are the property of their respective owners. Page 5 DL44109Q-SD-21 (12/01/2020) Drug Class Excluded Medications Preferred Alternatives

HEMATOLOGICAL (continued) GRANIX, NEUPOGEN NIVESTYM, ZARXIO Granulocyte Colony Stimulating Factors NEULASTA, UDENYCA FULPHILA, ZIEXTENZO

Iron Replacement Agents MONOFERRIC sodium ferric gluconate complex, VENOFER

OXBRYTA hydroxyurea, ADAKVEO, DROXIA Sickle Cell Disease Agents SIKLOS DROXIA

MULPLETA DOPTELET Thrombocytopenia Agents TAVALISSE DOPTELET, PROMACTA, NPLATE

HEPATITIS LEDIPASVIR/SOFOSBUVIR, MAVYRET, EPCLUSA, HARVONI, VOSEVI, ZEPATIER Hepatitis C SOFOSBUVIR/VELPATASVIR, SOVALDI

efavirenz/emtricitabine/tenofovir disoproxil fumarate, efavirenz/lamivudine/tenofovir disoproxil fumarate, DELSTRIGO BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ

COMPLERA ODEFSEY HIV Antiretrovirals PIFELTRO efavirenz, EDURANT Note: Current patients established on therapy are allowed to continue therapy. PREZCOBIX atazanavir, ritonavir, KALETRA TABLETS, PREZISTA

Coverage may be approved for the treatment of human RUKOBIA ER immunodeficiency virus-1 infection in heavily treatment- experienced patients with multidrug-resistant infection.

STRIBILD BIKTARVY, GENVOYA

MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE CAPSULES colchicine tablets, MITIGARE Gout Therapy

DICLOFENAC 35 MG CAPSULES, diclofenac, etodolac, ibuprofen, indomethacin, INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY, meloxicam, nabumetone, naproxen, piroxicam TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) fenoprofen calcium tablets, diclofenac, ibuprofen, FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES indomethacin, meloxicam, nabumetone, naproxen

nabumetone, diclofenac, ibuprofen, indomethacin, RELAFEN DS meloxicam, naproxen, piroxicam

diclofenac sodium topical, Topical Anti-Inflammatory Drugs (NSAIDs) DICLOFENAC EPOLAMINE PATCHES, PENNSAID FLECTOR PATCHES, LICART PATCHES

OBSTETRICAL & GYNECOLOGICAL CLIMARA PRO COMBIPATCH Combination Patches

Barrier methods of contraception, such as condoms, PHEXXI diaphragms, spermicides or sponges. Contraceptives generic oral and ring contraceptives, xulane patches, TWIRLA LO LOESTRIN FE, TAYTULLA

estradiol cream, estradiol patches, estradiol tablets, Estrogen & Estrogen Modifiers for Vaginal Symptoms FEMRING, INTRAROSA yuvafem, ESTRING, PREMARIN CREAM, PREMARIN TABLETS

Human Chorionic Gonadotropin CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL

Ovulatory Stimulants (Follitropins) FOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT

Prenatal Vitamins PREGENNA, TRINAZ generic prenatal vitamins

Topical Estrogen Gels ELESTRIN, ESTROGEL DIVIGEL

CRINONE 4% medroxyprogesterone, megestrol, norethindrone, progesterone Vaginal CRINONE 8% ENDOMETRIN

Continued

© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612 All trademarks are the property of their respective owners. Page 6 DL44109Q-SD-21 (12/01/2020) Drug Class Excluded Medications Preferred Alternatives

ONCOLOGY AVASTIN MVASI, ZIRABEV Bevacizumab-Containing Agents

Breast Cancer Agents KISQALI, KISQALI FEMARA CO-PACK, PIQRAY IBRANCE, VERZENIO

Chronic Lymphocytic Leukemia (CLL) Agents CALQUENCE IMBRUVICA, VENCLEXTA

DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, Multiple Myeloma Agents BLENREP, XPOVIO THALOMID, VELCADE

Myelodysplastic Syndrome Agents INQOVI decitabine

Myelofibrosis Agents INREBIC JAKAFI

Prostate Cancer Agents TRELSTAR ELIGARD, FIRMAGON

Rituximab-Containing Agents RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE

HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, OGIVRI, KANJINTI, TRAZIMERA Trastuzumab-Containing Agents ONTRUZANT PHESGO PERJETA plus KANJINTI or TRAZIMERA

imatinib, NEXAVAR, SPRYCEL, STIVARGA, SUTENT, TASIGNA, Tyrosine Kinase Inhibitors QINLOCK VOTRIENT

betaxolol drops, brimonidine 0.15% drops, OPHTHALMIC TIMOPTIC OCUDOSE brimonidine 0.2% drops, levobunolol drops, timolol drops, Antiglaucoma Drugs (Non-Prostaglandins) ALPHAGAN P 0.1%, AZOPT, COMBIGAN

bimatoprost drops, latanoprost drops, travoprost drops, Antiglaucoma Drugs (Ophthalmic Prostaglandins) DURYSTA, XELPROS LUMIGAN, ZIOPTAN

Blepharoptosis Agents UPNEEQ No alternatives recommended

Ophthalmic Agents - Other CYSTADROPS CYSTARAN

azelastine drops, cromolyn drops, epinastine drops, Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, LASTACAFT, PAZEO ketotifen drops, olopatadine drops, ZERVIATE

dexamethasone drops, drops, Ophthalmic Anti-Inflammatory FML FORTE, FML S.O.P., MAXIDEX, PRED MILD loteprednol drops, prednisolone drops, INVELTYS, LOTEMAX GEL/OINTMENT

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs ACUVAIL, NEVANAC bromfenac drops, diclofenac drops, ketorolac drops (NSAIDs)

ciprofloxacin drops, gatifloxacin drops, levofloxacin drops, Ophthalmic Quinolone Antibiotics CILOXAN OINTMENT moxifloxacin drops, ofloxacin drops

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, OSTEOARTHRITIS HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, EUFLEXXA, MONOVISC, ORTHOVISC Hyaluronic Acid Derivatives SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3

OSTEOPOROSIS alendronate, ibandronate, risedronate, zoledronic acid, EVENITY, PROLIA Bone Modifiers FORTEO, TYMLOS

RENAL DISEASE PROCYSBI CYSTAGON Nephropathic Cystinosis Medications

lanthanum, sevelamer carbonate, sevelamer hcl, Phosphate Binders FOSRENOL POWDER PACKETS PHOSLYRA, VELPHORO

RESPIRATORY epinephrine auto-injector (by Mylan, Teva), AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX) Epinephrine Auto-Injector Systems EPIPEN, EPIPEN JR

Immunological Agents for Asthma CINQAIR DUPIXENT, FASENRA, NUCALA

Long-Acting Beta Agonist Inhalers STRIVERDI RESPIMAT SEREVENT DISKUS

Long-Acting Muscarinic Antagonist Inhalers TUDORZA PRESSAIR INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT

Continued

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RESPIRATORY (continued) Long-Acting Muscarinic Antagonist/ DUAKLIR PRESSAIR ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT Long-Acting Beta-Agonist Combination Inhalers

ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, Pulmonary Anti-Inflammatory Inhalers ARMONAIR DIGIHALER FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER

AIRDUO DIGIHALER, AIRDUO RESPICLICK, Pulmonary Anti-Inflammatory/ fluticasone/salmeterol (by Prasco, Proficient Rx), BUDESONIDE/FORMOTEROL, Beta-Agonist Combination Inhalers ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT FLUTICASONE/SALMETEROL (BY A-S MEDICATION, TEVA)

ALBUTEROL SULFATE HFA (BY A-S MEDICATION, PRASCO), albuterol sulfate hfa (by Cipla, Lupin, Par, Perrigo, Short-Acting Beta -Agonist Inhalers LEVALBUTEROL HFA, PROAIR DIGIHALER, PROAIR RESPICLICK, 2 Proficient Rx & Teva) VENTOLIN HFA, XOPENEX HFA

MISCELLANEOUS AGENTS PALFORZIA No alternatives recommended Allergen Immunotherapy

Cushing’s Agents ISTURISA SIGNIFOR

Gaucher Disease Agents ELELYSO CEREZYME

Hereditary Angioedema BERINERT RUCONEST

CUTAQUIG SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY

IV: GAMMAGARD LIQUID, GAMMAGARD S-D, GAMUNEX-C Immune Globulins GAMMAKED SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY

HIZENTRA SC: XEMBIFY

OTREXUP RASUVO Immunosuppressant Agents XATMEP methotrexate

Neuromyelitis Optica Spectrum Disorder Agents UPLIZNA ENSPRYNG

Nocturnal Polyuria Agents NOCTIVA desmopressin tablets

Polyneuropathy of Hereditary ONPATTRO TEGSEDI Transthyretin-Mediated Amyloidosis

Potassium Binders VELTASSA LOKELMA

Indication Based Management Drug Class Excluded Medications Preferred Alternatives

Spinal Conditions (nr-axSpA) COSENTYX TALTZ, CIMZIA

TALTZ, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SC, Inflammatory Conditions‡ where COSENTYX is indicated COSENTYX TREMFYA, XELJANZ, XELJANZ XR

Drug Class Nonpreferred Medications Preferred Alternatives

All other Brand Name medications for Inflammatory Preferred: ENBREL, HUMIRA, OTEZLA, RINVOQ ER, SKYRIZI, Conditions are Nonpreferred. Approval may be granted STELARA SC, TALTZ, TREMFYA, XELJANZ, XELJANZ XR following a coverage review. A trial of one or more Preferred Inflammatory Conditions‡ medications is required prior to initiating therapy with a Preferred after Step through HUMIRA: ACTEMRA Nonpreferred medication. A formulary exception may be granted for a patient already established on therapy with a ULCERATIVE COLITIS ONLY Preferred after Step through Nonpreferred medication. HUMIRA: SIMPONI 100 MG, XELJANZ, XELJANZ XR

‡ Please note that product placement for treatment of Inflammatory Conditions in the Inflammatory Conditions Care Value (ICCV) Program are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.

Continued

© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612 All trademarks are the property of their respective owners. Page 8 DL44109Q-SD-21 (12/01/2020) Excluded Medications/Products at a Glance

ABILIFY^ CUPRIMINE^ INDERAL XL, INNOPRAN XL ONGLYZA TEKTURNA^ ACANYA^ CUTAQUIG INDOMETHACIN 20 MG CAPSULES ONPATTRO TESTIM^ ACIPHEX^ CYMBALTA^ INGREZZA ONTRUZANT TIKOSYN^ ACIPHEX SPRINKLE CYSTADROPS INQOVI OSMOPREP TIMOPTIC OCUDOSE ACUVAIL CYTOMEL^ INREBIC OTREXUP TIVORBEX ADCIRCA^ DELSTRIGO INSULIN ASPART, OXBRYTA TOBI SOLUTION^ ADDERALL^ DELZICOL^ INSULIN ASPART PROTAMINE OXYCODONE ER TOLSURA ADLYXIN DETROL^, DETROL LA^ INSULIN LISPRO OZOBAX TOPAMAX^ ADMELOG DICLOFENAC 35 MG CAPSULES INTRAROSA PALFORZIA TOPICORT SPRAY^ AGGRENOX^ DICLOFENAC EPOLAMINE PATCHES INTUNIV^ PATADAY^ TOPIRAMATE ER CAPSULES AIRDUO DIGIHALER, DIOVAN^, DIOVAN HCT^ ISTALOL^ PAZEO TOPROL XL^ AIRDUO RESPICLICK DIPENTUM ISTURISA PENNSAID TRADJENTA AKYNZEO CAPSULES DORAL JADENU^, JADENU SPRINKLE^ PERCOCET^ TRANSDERM-SCOP^ ALBUTEROL SULFATE HFA DOXYCYCLINE 40 MG CAPSULES JENTADUETO, JENTADUETO XR PERTZYE TRAVATAN Z^ (BY A-S MEDICATION, PRASCO) DRIZALMA SPRINKLE KAPSPARGO SPRINKLE PHESGO TRELSTAR ALCORTIN A DUAKLIR PRESSAIR KATERZIA PHEXXI TREXIMET^ ALOCRIL DURAGESIC^ KAZANO PIFELTRO TRIBENZOR^ ALOGLIPTIN DUROLANE KEPPRA^, KEPPRA XR^ PIQRAY TRICOR^ ALOGLIPTIN/METFORMIN DURYSTA KETOROLAC NASAL SPRAY PLAQUENIL^ TRILEPTAL^ ALOGLIPTIN/PIOGLITAZONE DUTOPROL KISQALI, KISQALI FEMARA CO-PACK PLAVIX^ TRILURON ALOMIDE ECOZA KOMBIGLYZE XR PRADAXA TRINAZ ALTOPREV EFFEXOR XR^ KORLYM PRALUENT TRIVIDIA (TRUETEST, TRUETRACK) AMBIEN^, AMBIEN CR^ ELELYSO LAMICTAL^, LAMICTAL ODT^, PRAVACHOL^ TRIVISC AMITIZA ELESTRIN LAMICTAL XR^ PRED MILD TRUXIMA AMPHETAMINE ER SUSPENSION ELIDEL^ LASTACAFT PREGENNA TUDORZA PRESSAIR AMPYRA^ EMEND CAPSULES^, TRIFOLD PACK^ LAZANDA PREGNYL TWIRLA AMRIX^ EMEND POWDER PACKETS LEDIPASVIR/SOFOSBUVIR PREVACID^, PREVACID SOLUTAB^ UDENYCA ANDROGEL^ EMFLAZA LETAIRIS^ PREZCOBIX ULORIC^ ANUSOL-HC^ EPANED LEVALBUTEROL HFA PRILOSEC SUSPENSION UPLIZNA APADAZ EPIDUO^ LEXAPRO^ PRIMLEV UPNEEQ APIDRA EPIDUO FORTE LIALDA^ PRISTIQ^ UROXATRAL^ APTIOM EPINEPHRINE AUTO-INJECTOR LIBRAX^ PROAIR DIGIHALER, VAGIFEM^ ARANESP (BY IMPAX) LIDOCAINE/TETRACAINE PROAIR RESPICLICK VALIUM^ ARIMIDEX^ EPOGEN LIDODERM^ PROAIR HFA^ VALTREX^ ARMONAIR DIGIHALER ESOMEPRAZOLE STRONTIUM LIPITOR^ PROCTOFOAM-HC VANOS^ ASACOL HD^ ESTRACE CREAM^ LOCOID^, LOCOID LIPOCREAM^ PROCYSBI VELTASSA ASCENSIA (CONTOUR) ESTROGEL LOESTRIN^, LOESTRIN FE^ PROLIA VELTIN ASPIRIN/OMEPRAZOLE DR ESTROSTEP FE^ LOTREL^ PROTONIX^ VENTOLIN HFA ATACAND^, ATACAND HCT^ EVENITY LOTRONEX^ PROVENTIL HFA^ VERDESO FOAM ATRALIN^ EVZIO LOVENOX^ PROVIGIL^ VESICARE^ ATRIPLA^ EXFORGE^, EXFORGE HCT^ LUCEMYRA PROZAC^ VIAGRA^ AUVI-Q EXJADE^ LULICONAZOLE PULMICORT RESPULES^ VICTOZA AVALIDE^, AVAPRO^ EXONDYS 51 LUNESTA^ PYLERA VILTEPSO AVASTIN EXTAVIA LYRICA^ QBRELIS VISCO-3 AVEED EZALLOR SPRINKLE LYRICA CR QINLOCK VIVELLE-DOT^ AVODART^ FEMRING MAVYRET QTERN VIVLODEX AZOR^ FENOPROFEN CAPSULES MAXALT^, MAXALT MLT^ QUARTETTE^ VYEPTI BARACLUDE TABLETS^ FENORTHO MAXIDEX QUAZEPAM VYONDYS 53 BECONASE AQ FENSOLVI MESTINON^ RABEPRAZOLE DR SPRINKLE VYTORIN^ BENICAR^, BENICAR HCT^ FENTANYL CITRATE BUCCAL TABLETS MICARDIS^, MICARDIS HCT^ RANEXA^ WELCHOL 3.75 GM PACKETS^ BENZHYDROCODONE/ FENTORA MINASTRIN 24 FE^ RAPAFLO^ WELLBUTRIN SR^, WELLBUTRIN XL^ ACETAMINOPHEN FIASP MINIVELLE^ RECOMBINATE XADAGO BERINERT FINTEPLA MINOCYCLINE ER CAPSULES RELAFEN DS XALATAN^ BLENREP FIRAZYR^ MIRCERA RENAGEL^ XANAX^, XANAX XR^ BRISDELLE^ FIRDAPSE MIRCETTE^ RETIN-A MICRO 0.04% & 0.1%^ XATMEP BUDESONIDE/FORMOTEROL FIRVANQ MONOFERRIC RITUXAN, RITUXAN HYCELA XELPROS BUNAVAIL FLUOROURACIL 0.5% CREAM MORPHABOND ER ROCHE (ACCU-CHEK) XENAZINE^ BUPAP^ FLUTICASONE/SALMETEROL MOVIPREP^ ROZEREM^ XIMINO BUTRANS^ (BY A-S MEDICATION, TEVA) MULPLETA RUKOBIA ER XOLEGEL CALCIPOTRIENE FOAM FML FORTE, FML S.O.P. MYTESI SAFYRAL^ XOPENEX HFA CALQUENCE FOCALIN^, FOCALIN XR^ NALFON CAPSULES SAIZEN, SAIZENPREP XPOVIO CAPLYTA FOLLISTIM AQ NALOXONE AUTO-INJECTOR SANDOSTATIN LAR DEPOT XTAMPZA ER CARAC FOSRENOL CHEWABLE TABLETS^ NAMENDA XR^ SAVAYSA XYNTHA, XYNTHA SOLOFUSE CELEBREX^ FOSRENOL POWDER PACKETS NASONEX^ SEASONIQUE^, LOSEASONIQUE^ YASMIN^ CELEXA^ GAMMAKED NATROBA^ SEMGLEE YOSPRALA DR CHORIONIC GONADOTROPIN GANIRELIX ACETATE^ NESINA SENSIPAR^ ZAVESCA^ CIALIS^ GEL-ONE NEULASTA SEROQUEL^, SEROQUEL XR^ ZEGERID^ CILOXAN OINTMENT GELSYN-3 NEUPOGEN SIGNIFOR LAR ZELAPAR CINQAIR GENERESS FE^ NEURONTIN^ SIKLOS ZETIA^ CIPROFLOXACIN/FLUOCINOLONE OTIC GENVISC 850 NEVANAC SINGULAIR^ ZETONNA CLIMARA PRO GLEEVEC^ NEXIUM CAPSULES^ SITAVIG ZIPSOR CLINDAGEL GLUCOPHAGE^, GLUCOPHAGE XR^ NEXIUM PACKETS SODIUM HYALURONATE ZOCOR^ CLINDAMYCIN PHOSPHATE 1% GEL GLUMETZA^ NOCTIVA SOFOSBUVIR/VELPATASVIR ZOHYDRO ER^ (BY OCEANSIDE) GOCOVRI ER NORCO^ SOVALDI ZOLOFT^ CLOCORTOLONE GRANIX NORVASC^ SPRAVATO ZOMACTON COLCHICINE CAPSULES HELIDAC NOVOLIN, RELION NOVOLIN STRATTERA^ ZOMIG TABLETS^, ZOMIG ZMT^ COMPLERA HERCEPTIN, HERCEPTIN HYLECTA NOVOLOG STRIBILD ZONEGRAN^ CONCERTA^ HERZUMA NOXAFIL TABLETS^ STRIVERDI RESPIMAT ZORVOLEX COREG^ HIZENTRA NUCYNTA, NUCYNTA ER SUBSYS ZOVIRAX OINTMENT^ CORTIFOAM HUMATROPE NUTROPIN AQ NUSPIN SULCONAZOLE ZYCLARA COSENTYX HYALGAN NUVIGIL^ SUPARTZ FX ZYTIGA 250 MG^ COSOPT^ HYMOVIS NUWIQ SYNVISC, SYNVISC-ONE COZAAR^, HYZAAR^ IMIQUIMOD 3.75% CREAM PUMP OGIVRI TARGRETIN CAPSULES^ CRESTOR^ IMITREX^ OMNARIS TAVALISSE CRINONE INDERAL LA^ OMNITROPE TAZORAC 0.1% CREAM^ ^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.

© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612 All trademarks are the property of their respective owners. Page 9 DL44109Q-SD-21 (12/01/2020)