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Express Scripts 2021 Basic Formulary List

Express Scripts 2021 Basic Formulary List

2021 Express Scripts Basic Formulary List

The 2021 Basic Formulary drug list is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. 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 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 For the member: FDA-approved generic medications meet strict standards and [INJ] – Injectable Drug contain the same active ingredients as their corresponding brand-name medications, [OTC] – Over-the-counter Product although they may have a different appearance. [SP] – Specialty Drug For the physician: Please prescribe preferred products and allow generic Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA substitutions when medically appropriate. Generic drugs are listed in lower-case letters. Example: ibuprofen

A ADEMPAS [SP] ALUNBRIG [SP] ANDRODERM adenosine [INJ] alyacen ANORO ELLIPTA abacavir [SP] ADVAIR HFA amabelz APLISOL [INJ] abacavir/lamivudine [SP] ADVATE [INJ] [SP] amantadine APOKYN [INJ] [SP] abacavir/lamivudine/zidovudine [SP] ADYNOVATE [INJ] [SP] AMBISOME [INJ] apraclonidine eye solution ABELCET [INJ] AFINITOR 10 MG TABLETS [SP] ambrisentan [SP] aprepitant ABILIFY MAINTENA [INJ] AFINITOR DISPERZ [SP] apri abiraterone [SP] afirmelle amethia APTIVUS [SP] ABRAXANE [INJ] [SP] AFLURIA QUAD [INJ] amethia lo AQUASOL A [INJ] acamprosate delayed-release AFSTYLA [INJ] [SP] amethyst ARALAST NP [INJ] [SP] acarbose AIMOVIG [INJ] amifostine [INJ] aranelle ACCU-CHEK FASTCLIX LANCETS [OTC] AJOVY [INJ] amikacin [INJ] ARANESP [INJ] [SP] ACCU-CHEK MULTICLIX LANCET KIT [OTC] albendazole amiloride ARIKAYCE [SP] ACCU-CHEK MULTICLIX LANCETS [OTC] albumin human [INJ] amiloride/hydrochlorothiazide aripiprazole ACCU-CHEK SOFTCLIX LANCET KIT [OTC] albuterol aminocaproic acid aripiprazole orally disintegrating tablets ACCU-CHEK SOFTCLIX LANCETS [OTC] albuterol ext-release aminocaproic acid [INJ] ARISTADA [INJ] acebutolol albuterol nebulization solution aminophylline [INJ] ARISTOSPAN [INJ] acetaminophen/codeine albuterol sulfate hfa (by Cipla, Lupin, AMINOSYN [INJ] armodafinil acetazolamide Par, Perrigo, Proficient Rx & Teva) amiodarone ARMOUR THYROID acetazolamide ext-release amiodarone [INJ] ARNUITY ELLIPTA acetazolamide sodium [INJ] ALDURAZYME [INJ] [SP] amitriptyline ARRANON [INJ] [SP] acetic acid ear solution ALECENSA [SP] amitriptyline/chlordiazepoxide arsenic trioxide [INJ] acetic acid irrigation solution alendronate amlodipine ascorbic acid [INJ] acetic acid/ ear solution alfentanil [INJ] amlodipine/atorvastatin ashlyna acetic acid/oxyquinoline vaginal ALFERON N [INJ] amlodipine/benazepril ASMANEX HFA acetylcysteine [INJ] alfuzosin ext-release amlodipine/olmesartan ASMANEX TWISTHALER acetylcysteine inhalation solution ALIMTA [INJ] amlodipine/valsartan aspirin/dipyridamole ext-release acitretin ALINIA amlodipine/valsartan/hydrochlorothiazide atazanavir [SP] ACTEMRA [INJ] [SP] ALIQOPA [INJ] [SP] ammonium lactate 12% topical atenolol ACTHIB [INJ] aliskiren amoxapine atenolol/chlorthalidone ACTHREL [INJ] allopurinol amoxicillin ATGAM [INJ] ACTIMMUNE [INJ] [SP] allopurinol sodium [INJ] amoxicillin/potassium clavulanate atomoxetine ACTIVASE [INJ] almotriptan amoxicillin/potassium clavulanate atorvastatin acyclovir alosetron ext-release atovaquone acyclovir ointment ALPHAGAN P 0.1% amphetamine sulfate atovaquone/proguanil acyclovir sodium [INJ] ALPHANATE [INJ] [SP] amphotericin [INJ] atropine [INJ] ADACEL [INJ] ALPHANINE SD [INJ] [SP] ampicillin atropine sulfate eye ointment ADAKVEO [INJ] [SP] alprazolam ampicillin sodium [INJ] atropine sulfate eye solution adapalene alprazolam ext-release ampicillin sodium/sulbactam [INJ] aubra adapalene/benzoyl peroxide alprazolam orally disintegrating tablets AMYTAL [INJ] aubra eq ADCETRIS [INJ] [SP] ALPROLIX [INJ] [SP] AMZEEQ AUGMENTIN 125-31.25 MG/5 ML ADDAMEL N [INJ] alprostadil [INJ] anagrelide aurovela adefovir altavera anastrozole aurovela 24 fe (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 1 COMP2225A-21 (11/01/20) aurovela fe calcitonin salmon nasal charlotte 24 fe AUSTEDO [SP] BICILLIN C-R [INJ] calcitriol chateal aviane BICILLIN L-A [INJ] calcitriol [INJ] chateal eq AVONEX [INJ] [SP] BIKTARVY [SP] calcitriol ointment CHEMET AVYCAZ [INJ] bimatoprost eye solution calcium acetate CHENODAL [SP] ayuna biolon [INJ] calcium chloride [INJ] chloramphenicol [INJ] azacitidine [INJ] [SP] BIOTHRAX [INJ] CALCIUM DISODIUM VERSENATE [INJ] chlordiazepoxide AZASITE bisoprolol [INJ] chlordiazepoxide/clidinium [SP] bisoprolol/hydrochlorothiazide CALDOLOR VIALS [INJ] chlorhexidine gluconate azathioprine sodium [INJ] [SP] bivalirudin [INJ] camila chloroprocaine hcl [INJ] AZEDRA [INJ] [SP] blanche camrese chloroquine azelaic acid bleomycin [INJ] camrese lo chlorothiazide azelastine eye solution BLINCYTO [INJ] [SP] candesartan chlorothiazide sodium [INJ] azelastine nasal spray blisovi 24 fe candesartan/hydrochlorothiazide chlorpromazine azelastine/ blisovi fe CAPASTAT SULFATE [INJ] chlorpromazine [INJ] azithromycin BOOSTRIX [INJ] capecitabine [SP] chlorthalidone azithromycin [INJ] bosentan [SP] CAPRELSA [SP] chlorzoxazone AZOPT BOSULIF [SP] captopril CHOLBAM [SP] aztreonam [INJ] BOTOX [INJ] [SP] captopril/hydrochlorothiazide cholestyramine azurette BREO ELLIPTA carbachol [INJ] cholestyramine light bretylium tosylate [INJ] CARBAGLU [SP] choline salicylate/magnesium salicylate B BREVITAL [INJ] carbamazepine chromium chloride [INJ] BREZTRI AEROSPHERE carbamazepine ext-release bacitracin [INJ] briellyn carbidopa ciclopirox shampoo bacitracin eye ointment BRILINTA carbidopa/levodopa cidofovir [INJ] bacitracin/polymyxin eye ointment eye solution carbidopa/levodopa ext-release cilostazol baclofen BRINEURA [INJ] [SP] carbidopa/levodopa orally CIMDUO [SP] baclofen [INJ] bromfenac eye solution disintegrating tablets cimetidine BAL IN OIL [INJ] bromocriptine carbidopa/levodopa/entacapone cinacalcet balanced salt eye irrigation solution brompheniramine/pseudoephedrine/ carbinoxamine CINRYZE [INJ] [SP] bal-care dha prenatal vitamins codeine carboplatin [INJ] CINVANTI [INJ] balsalazide brompheniramine/pseudoephedrine/ carmustine [INJ] ciprofloxacin BALVERSA [SP] dextromethorphan carteolol eye solution ciprofloxacin ear solution balziva ext-release carvedilol ciprofloxacin eye solution BANZEL budesonide nebulization suspension carvedilol phosphate ext-release ciprofloxacin lactate/dextrose [INJ] BAQSIMI bumetanide caspofungin [INJ] ciprofloxacin/ BARACLUDE SOLUTION bumetanide [INJ] CATHFLO ACTIVASE [INJ] ear suspension BAVENCIO [INJ] [SP] bupivacaine [INJ] CAVERJECT [INJ] cisplatin [INJ] BAXDELA bupivacaine/dextrose [INJ] CAYSTON [SP] citalopram BAXDELA [INJ] bupivacaine/epinephrine [INJ] caziant [INJ] b-complex [INJ] buprenorphine cefaclor clarithromycin BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine [INJ] cefaclor ext-release clarithromycin ext-release BD NANO 2ND GEN PEN NEEDLES buprenorphine patches cefadroxil clemastine BD ULTRAFINE INSULIN SYRINGES [OTC] buprenorphine/naloxone cefazolin [INJ] CLENPIQ BD ULTRAFINE PEN NEEDLES [OTC] bupropion cefdinir clindamycin hcl bekyree bupropion ext-release cefditoren clindamycin palmitate BELBUCA bupropion ext-release (smoking deterrent) cefepime [INJ] clindamycin phosphate [INJ] benazepril buspirone cefepime/dextrose [INJ] clindamycin phosphate topical benazepril/hydrochlorothiazide busulfan [INJ] cefixime clindamycin phosphate vaginal BENDEKA [INJ] [SP] butalbital/acetaminophen cefotaxime [INJ] clindamycin phosphate/benzoyl peroxide BENEFIX [INJ] [SP] butalbital/acetaminophen/caffeine cefotetan [INJ] clindamycin phosphate/dextrose [INJ] BENLYSTA [INJ] [SP] butalbital/acetaminophen/caffeine/ cefoxitin [INJ] clindamycin phosphate/tretinoin BENZNIDAZOLE codeine cefoxitin/dextrose [INJ] CLINIMIX [INJ] benzonatate butalbital/aspirin/caffeine cefpodoxime CLINIMIX E [INJ] benzoyl peroxide butalbital/aspirin/caffeine/codeine cefprozil clobazam benzphetamine butorphanol [INJ] ceftazidime [INJ] propionate benztropine butorphanol nasal CEFTAZIDIME/DEXTROSE [INJ] shampoo benztropine [INJ] BYDUREON [INJ] ceftriaxone [INJ] clobetasol propionate/emollient BESPONSA [INJ] [SP] BYETTA [INJ] ceftriaxone/dextrose [INJ] clofarabine [INJ] acetate/betamethasone BYSTOLIC cefuroxime axetil clomiphene citrate sodium phosphate [INJ] cefuroxime sodium [INJ] clomipramine betamethasone dipropionate C celecoxib clonazepam betamethasone dipropionate augmented CELONTIN clonazepam orally disintegrating tablets cabergoline cephalexin clonidine BETASERON [INJ] [SP] CABLIVI [INJ] [SP] CEPROTIN [INJ] [SP] clonidine [INJ] betaxolol CABOMETYX [SP] CERDELGA [SP] clonidine ext-release betaxolol eye solution caffeine citrated CEREZYME [INJ] [SP] clonidine patches bethanechol caffeine citrated [INJ] cetirizine syrup clopidogrel BEVESPI AEROSPHERE caffeine/sodium benzoate [INJ] CETROTIDE [INJ] [SP] clorazepate bexarotene [SP] calcipotriene cevimeline topical BEXSERO [INJ] calcipotriene/betamethasone dipropionate CHANTIX clotrimazole troche (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 2 COMP2225A-21 (11/01/20) clotrimazole/betamethasone dipropionate darifenacin ext-release digoxin [INJ] efavirenz/lamivudine/ clozapine DARZALEX [INJ] [SP] dihydrocodeine/acetaminophen/caffeine tenofovir disoproxil fumarate [SP] clozapine orally disintegrating tablets dasetta dihydroergotamine [INJ] EGRIFTA [INJ] [SP] c-nate dha prenatal vitamins daunorubicin [INJ] dihydroergotamine nasal EGRIFTA SV [INJ] [SP] COAGADEX [INJ] [SP] daysee DILANTIN 30 MG CAPSULES ELAPRASE [INJ] [SP] COARTEM DAYTRANA DILATRATE-SR electrolyte-48 solution/dextrose [INJ] codeine sulfate DDAVP RHINAL SOLUTION diltiazem eletriptan colchicine tablets deblitane diltiazem [INJ] ELIGARD [INJ] [SP] colchicine/probenecid decitabine [INJ] [SP] diltiazem ext-release elinest colesevelam hcl deferasirox [SP] dimenhydrinate [INJ] ELIQUIS colestipol deferiprone [SP] [SP] ELITEK [INJ] colistimethate [INJ] deferoxamine [INJ] diphenhydramine elite-ob prenatal vitamins COMBIGAN delflex with dextrose [INJ] diphenhydramine [INJ] ELMIRON COMBIPATCH demeclocycline diphenoxylate/atropine ELOCTATE [INJ] [SP] COMBIVENT RESPIMAT DEPO- [INJ] DIPHTHERIA-TETANUS TOXOIDS-PED [INJ] eluryng vaginal ring COMETRIQ [SP] DEPO-PROVERA 400 MG/ML [INJ] dipyridamole ELZONRIS [INJ] [SP] complete natal dha prenatal vitamins DESCOVY [SP] dipyridamole [INJ] EMCYT constulose desipramine disulfiram EMGALITY [INJ] copper chloride [INJ] desloratadine divalproex delayed-release emoquette CORIFACT [INJ] [SP] desloratadine orally disintegrating tablets divalproex ext-release emtricitabine [SP] CORLANOR desmopressin acetate DIVIGEL emtricitabine/ acetate desmopressin acetate [INJ] [SP] dobutamine [INJ] tenofovir disoproxil fumarate [SP] cosyntropin [INJ] desmopressin nasal dobutamine/dextrose [INJ] EMTRIVA SOLUTION [SP] COTELLIC [SP] -ethinyl estradiol DOCEFREZ [INJ] EMVERM CREON docetaxel [INJ] enalapril CRESEMBA DOCETAXEL 200 MG/10 ML [INJ] enalapril/hydrochlorothiazide CRESEMBA [INJ] desvenlafaxine succinate ext-release dofetilide enalaprilat [INJ] CRIXIVAN [SP] dexamethasone donepezil ENBREL [INJ] [SP] CROFAB [INJ] dexamethasone sodium phosphate [INJ] donepezil orally disintegrating tablets ENDOMETRIN [SP] cromolyn sodium eye solution dexamethasone sodium phosphate dopamine [INJ] ENGERIX-B [INJ] cromolyn sodium nebulization solution eye solution dopamine/dextrose [INJ] enoxaparin [INJ] [SP] cromolyn sodium oral solution dexchlorpheniramine DOPTELET [SP] enpresse crotamiton DEXCOM RECEIVER, SENSOR, dorzolamide eye solution enskyce cryselle TRANSMITTER dorzolamide/timolol eye solution ENSPRYNG [INJ] [SP] CRYSVITA [INJ] [SP] dexmedetomidine [INJ] DOVATO [SP] ENSTILAR cyanocobalamin [INJ] dexmedetomidine/nacl [INJ] doxazosin entacapone cyclafem dexmethylphenidate doxepin entecavir cyclobenzaprine dexmethylphenidate ext-release doxepin cream ENTRESTO cyclobenzaprine ext-release dexrazoxane [INJ] doxercalciferol ENTYVIO [INJ] [SP] cyclopentolate eye solution dextran/dextrose [INJ] doxercalciferol [INJ] EOVIST [INJ] cyclopentolate/tropicamide/ dextran/normal saline [INJ] doxorubicin [INJ] EPCLUSA [SP] phenylephrine eye solution dextroamphetamine doxorubicin/liposomal [INJ] ephedrine [INJ] cyclophosphamide [INJ] dextroamphetamine ext-release doxycycline hyclate EPIDIOLEX [SP] cyclophosphamide capsules dextroamphetamine/amphetamine doxycycline hyclate [INJ] epinastine eye solution cyclosporine [INJ] [SP] dextroamphetamine/amphetamine doxycycline hyclate delayed-release epinephrine auto-injector cyclosporine [SP] ext-release doxycycline monohydrate (by Mylan, Teva) [INJ] cyclosporine modified [SP] dextrose/lactated ringers [INJ] doxylamine succinate/vit b6 epinephrine vials, ampules, syringes [INJ] cyproheptadine dextrose/sodium chloride [INJ] D-PENAMINE epinephrine-dextrose [INJ] CYRAMZA [INJ] [SP] dextrose/water [INJ] dronabinol epinephrine-nacl [INJ] cyred DIACOMIT [SP] droperidol [INJ] EPIPEN, EPIPEN JR [INJ] cyred eq diazepam drospirenone-ethinyl estradiol epirubicin [INJ] CYSTADANE [SP] diazepam [INJ] drospirenone-ethinyl EPIVIR HBV SOLUTION CYSTAGON [SP] diazepam rectal gel estradiol-levomefolate eplerenone CYSTARAN [SP] diazoxide DROXIA epoprostenol [INJ] [SP] cytarabine [INJ] diclofenac eye solution DUAVEE epoprostenol diluent [INJ] [SP] CYTOGAM [INJ] [SP] diclofenac potassium DULERA eprosartan diclofenac sodium delayed-release duloxetine delayed-release eptifibatide [INJ] D diclofenac sodium ext-release DUPIXENT [INJ] [SP] ERAXIS [INJ] diclofenac sodium gel ERBITUX [INJ] [SP] dacarbazine [INJ] diclofenac sodium topical solution dutasteride/tamsulosin ext-release ergocalciferol dactinomycin [INJ] diclofenac sodium/misoprostol ext-release DYANAVEL XR ergoloid mesylates dalfampridine ext-release [SP] dicloxacillin ergotamine tartrate/caffeine DALIRESP dicyclomine E ergotamine tartrate/caffeine DALVANCE [INJ] dicyclomine [INJ] suppositories didanosine delayed-release [SP] econazole ERIVEDGE [SP] dantrolene diethylpropion EDARBI ERLEADA [SP] dantrolene [INJ] diethylpropion ext-release EDARBYCLOR erlotinib [SP] dapsone EDURANT [SP] errin dapsone topical diflorasone/emollient efavirenz [SP] ertapenem [INJ] DAPTACEL [INJ] diflunisal efavirenz/emtricitabine/ ERYTHROCIN [INJ] daptomycin [INJ] digoxin tenofovir disoproxil fumarate [SP] erythromycin (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 3 COMP2225A-21 (11/01/20) erythromycin delayed-release fentanyl citrate/nacl [INJ] FREAMINE HBC [INJ] GLYCOPHOS [INJ] erythromycin ethylsuccinate fentanyl patches freamine iii [INJ] glycopyrrolate erythromycin eye ointment FERAHEME [INJ] FREESTYLE FREEDOM KIT [OTC] glycopyrrolate [INJ] erythromycin stearate FERRIPROX 1,000 MG TABLETS, FREESTYLE FREEDOM LITE METER [OTC] glycopyrrolate-water [INJ] erythromycin topical SOLUTION [SP] FREESTYLE INSULINX GLUCOSE GLYXAMBI erythromycin/benzoyl peroxide FETZIMA SYSTEM [OTC] GONAL-F, GONAL-F RFF, ESBRIET [SP] FINACEA FOAM FREESTYLE INSULINX TEST STRIPS [OTC] GONAL-F RFF REDI-JECT [INJ] [SP] escitalopram FREESTYLE LIBRE & LIBRE 2 READER, granisetron esmolol [INJ] FIRMAGON [INJ] [SP] SENSOR granisetron [INJ] esmolol-nacl [INJ] flavoxate FREESTYLE LITE METER [OTC] GRANIX [INJ] [SP] esomeprazole magnesium delayed-release flecainide FREESTYLE LITE TEST STRIPS [OTC] GRASTEK esomeprazole sodium [INJ] FLECTOR FREESTYLE TEST STRIPS [OTC] griseofulvin microsize ESPEROCT [INJ] [SP] FLOLAN [INJ] [SP] frovatriptan griseofulvin ultramicrosize estarylla FLOVENT DISKUS FULPHILA [INJ] [SP] guaifenesin/codeine estazolam FLOVENT HFA fulvestrant [INJ] guaifenesin/phenylephrine esterified /methyltestosterone floxuridine [INJ] furosemide guanfacine estradiol FLUAD [INJ] furosemide [INJ] guanfacine ext-release estradiol cream FLUAD QUAD [INJ] FUZEON [INJ] [SP] guanidine estradiol patches FLUARIX QUAD [INJ] fyavolv GVOKE [INJ] estradiol vaginal FLUBLOK QUAD [INJ] FYCOMPA estradiol valerate [INJ] FLUCELVAX QUAD [INJ] H estradiol/norethindrone acetate fluconazole G ESTRING fluconazole/normal saline [INJ] hailey eszopiclone flucytosine gabapentin hailey 24 fe ethacrynate [INJ] fludarabine [INJ] GABLOFEN SYRINGES [INJ] hailey fe ethacrynic acid acetate galantamine HALAVEN [INJ] [SP] ethambutol FLULAVAL QUAD [INJ] galantamine ext-release ETHAMOLIN [INJ] flumazenil [INJ] GAMASTAN [INJ] [SP] halobetasol ethosuximide nasal spray GAMASTAN S-D [INJ] [SP] haloperidol ethyl alcohol [INJ] GAMIFANT [INJ] [SP] haloperidol decanoate [INJ] ethynodiol-ethinyl estradiol oil ear solution GAMMACORE haloperidol lactate etidronate GAMMAGARD LIQUID [INJ] [SP] haloperidol lactate [INJ] etodolac fluocinonide/emollient GAMMAGARD S-D [INJ] [SP] HARVONI [SP] etodolac ext-release fluorescein [INJ] GAMUNEX-C [INJ] [SP] HAVRIX [INJ] etomidate [INJ] fluorescein eye strips ganciclovir [INJ] heather -ee vaginal ring eye suspension ganirelix acetate [INJ] [SP] HEMABATE [INJ] ETOPOPHOS [INJ] fluorouracil GARDASIL 9 [INJ] HEMLIBRA [INJ] [SP] etoposide fluorouracil [INJ] gatifloxacin eye solution HEMOFIL-M [INJ] [SP] etoposide [INJ] fluoxetine gavilyte-c HEPAGAM B [INJ] EUFLEXXA [INJ] [SP] fluoxetine delayed-release gavilyte-g heparin lock flush [INJ] [SP] fluphenazine decanoate [INJ] gavilyte-n heparin sodium [INJ] exemestane fluphenazine hcl GAZYVA [INJ] [SP] heparin sodium/dextrose [INJ] EXTRANEAL ICODEXTRIN DIALYSIS fluphenazine hcl [INJ] GELNIQUE heparin sodium/nacl [INJ] SOLUTION [INJ] flurandrenolide gemcitabine [INJ] HEPATAMINE [INJ] EYLEA [INJ] [SP] flurazepam gemfibrozil hetastarch/normal saline [INJ] ezetimibe flurbiprofen GENOTROPIN [INJ] [SP] HEXTEND LACTATED ELECTROLYTE [INJ] ezetimibe/simvastatin flurbiprofen sodium eye solution gentamicin [INJ] HIBERIX [INJ] gentamicin eye ointment homatropine eye solution F fluticasone nasal spray gentamicin eye solution HUMALOG [INJ] fluticasone topical gentamicin topical HUMATE-P [INJ] [SP] FABRAZYME [INJ] [SP] fluticasone/salmeterol powder inhaler gentamicin/normal saline [INJ] HUMATROPE [INJ] [SP] falmina fluvastatin GENTAMICIN/NORMAL SALINE HUMIRA [INJ] [SP] famciclovir fluvastatin ext-release 100 MG/50 ML [INJ] HUMULIN [INJ] famotidine fluvoxamine GENVOYA [SP] HUMULIN R 500 UNITS [INJ] famotidine [INJ] fluvoxamine ext-release gianvi HYCAMTIN CAPSULES [SP] famotidine/nacl [INJ] FLUZONE HIGH-DOSE [INJ] GILENYA [SP] hydralazine FARXIGA FLUZONE HIGH-DOSE QUAD [INJ] GILOTRIF [SP] hydralazine [INJ] FASENRA [INJ] [SP] FLUZONE QUAD [INJ] GLASSIA [INJ] [SP] hydrochlorothiazide fayosim folic acid glatiramer [INJ] [SP] hydrocodone ext-release febuxostat folic acid [INJ] glatopa [INJ] [SP] hydrocodone/acetaminophen FEIBA NF [INJ] [SP] folivane-ob prenatal vitamins GLEOSTINE hydrocodone/chlorpheniramine polistirex felbamate FOLOTYN [INJ] [SP] glimepiride ext-release felodipine ext-release fomepizole [INJ] glipizide hydrocodone/homatropine femynor fondaparinux [INJ] [SP] glipizide ext-release hydrocodone/ibuprofen fenofibrate FORTEO [INJ] [SP] glipizide/metformin hydrocortisone fenofibrate micronized fosamprenavir [SP] GLUCAGEN [INJ] suppositories fenofibric acid fosaprepitant [INJ] GLUCAGON [INJ] fenofibric acid delayed-release fosinopril glyburide hydrocortisone butyrate/emollient fenoprofen fosinopril/hydrochlorothiazide glyburide micronized hydrocortisone enema fentanyl citrate [INJ] fosphenytoin [INJ] glyburide/metformin hydrocortisone sodium succinate [INJ] fentanyl citrate lozenges FRAGMIN [INJ] [SP] glycine irrigation solution hydrocortisone topical (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 4 COMP2225A-21 (11/01/20) INVIRASE [SP] KEPIVANCE [INJ] [SP] levofloxacin eye solution hydrocortisone/lidocaine INVOKAMET ketamine [INJ] levofloxacin/dextrose [INJ] hydrocortisone/pramoxine INVOKAMET XR ketamine-nacl [INJ] levoleucovorin [INJ] hydromorphone INVOKANA levonest hydromorphone [INJ] iodine/potassium iodide ketoconazole shampoo levonorgestrel-ethinyl estradiol hydromorphone ext-release iodine/sodium iodide ketoconazole topical levora hydromorphone suppositories IODOPEN [INJ] ketoconazole/skin cleanser kit levorphanol hydromorphone/nacl [INJ] IONOSOL/DEXTROSE [INJ] ketoprofen levothyroxine sodium IPOL [INJ] ketoprofen ext-release levothyroxine sodium [INJ] hydroquinone microspheres ipratropium bromide nasal spray ketorolac LEVSIN [INJ] hydroxocobalamin [INJ] ipratropium bromide nebulization solution ketorolac [INJ] LEXISCAN [INJ] hydroxychloroquine ipratropium/albuterol sulfate nebulization ketorolac eye solution LEXIVA SUSPENSION [SP] hydroxyprogesterone [INJ] solution KEYTRUDA [INJ] [SP] LIBTAYO [INJ] [SP] hydroxyprogesterone [INJ] [SP] irbesartan KINEVAC [INJ] LICART hydroxyurea irbesartan/hydrochlorothiazide KITABIS PAK [SP] lidocaine [INJ] hydroxyzine hcl IRESSA [SP] KOGENATE FS [INJ] [SP] lidocaine jelly hydroxyzine hcl [INJ] irinotecan [INJ] KOVALTRY [INJ] [SP] lidocaine patches hydroxyzine pamoate ISENTRESS [SP] K-PHOS ORIGINAL lidocaine topical hyophen isibloom KRYSTEXXA [INJ] [SP] lidocaine viscous hyoscyamine ISOLYTE [INJ] kurvelo lidocaine/dextrose [INJ] hyoscyamine ext-release isoniazid KYLEENA [SP] lidocaine/epinephrine [INJ] hyoscyamine orally disintegrating tablets isoniazid [INJ] KYMRIAH [INJ] [SP] lidocaine/hydrocortisone HYPERHEP B S-D [INJ] isoproterenol [INJ] KYNMOBI lidocaine/prilocaine HYPERRAB [INJ] isosorbide dinitrate KYPROLIS [INJ] [SP] lillow HYPERRAB S-D [INJ] isosorbide dinitrate ext-release lincomycin [INJ] HYPERRHO S-D [INJ] isosorbide mononitrate L lindane shampoo HYPERTET S-D [INJ] isosorbide mononitrate ext-release linezolid HYSINGLA ER labetalol linezolid [INJ] isoxsuprine labetalol [INJ] linezolid/nacl [INJ] I isradipine lactulose LINZESS ISTODAX [INJ] [SP] lamivudine [SP] LIORESAL [INJ] ibandronate itraconazole lamivudine hbv liothyronine ibandronate [INJ] [SP] ivermectin lamivudine/zidovudine [SP] liothyronine [INJ] IBRANCE [SP] IXEMPRA [INJ] [SP] lamotrigine LIPOFEN ibuprofen IXIARO [INJ] lamotrigine ext-release lisinopril ibuprofen lysine [INJ] IXINITY [INJ] [SP] lamotrigine orally disintegrating tablets lisinopril/hydrochlorothiazide ibutilide [INJ] LANOXIN PEDIATRIC AMPULES [INJ] carbonate icatibant [INJ] [SP] J lansoprazole delayed-release lithium carbonate ext-release ICLUSIG [SP] lansoprazole delayed-release lithium citrate idarubicin [INJ] jaimiess +amoxicillin+clarithromycin LIVALO IDHIFA [SP] JAKAFI [SP] lansoprazole orally disintegrating tablets LO LOESTRIN FE ifosfamide [INJ] JANUMET lanthanum lojaimiess ILARIS [INJ] [SP] JANUMET XR LANTUS [INJ] LOKELMA imatinib [SP] JANUVIA lapatinib [SP] LONSURF [SP] IMBRUVICA [SP] JARDIANCE larin loperamide IMFINZI [INJ] [SP] jasmiel larin fe lopinavir/ritonavir [SP] imipenem/cilastatin [INJ] jencycla larissia lopreeza imipramine hcl JENTADUETO latanoprost eye solution lorazepam imipramine pamoate JENTADUETO XR LATUDA lorazepam [INJ] imiquimod JETREA [INJ] [SP] layolis fe LORBRENA [SP] IMOGAM RABIES-HT [INJ] JEVTANA [INJ] [SP] leena loryna IMOVAX RABIES VACCINE [INJ] jinteli losartan IMPAVIDO JIVI [INJ] [SP] LENVIMA [SP] losartan/hydrochlorothiazide INBRIJA [SP] jolessa lessina LOTEMAX GEL, OINTMENT incassia juleber letrozole LOTEMAX SM INCRELEX [INJ] [SP] JULUCA [SP] leucovorin eye suspension INCRUSE ELLIPTA junel leucovorin [INJ] lovastatin indapamide junel fe LEUKERAN low-ogestrel indomethacin JUXTAPID [SP] LEUKINE [INJ] [SP] loxapine indomethacin ext-release leuprolide [INJ] [SP] lo-zumandimine indomethacin sodium [INJ] K levalbuterol nebulization solution LUCEMYRA INFANRIX [INJ] LEVEMIR [INJ] LUMIGAN infed [INJ] KADCYLA [INJ] [SP] levetiracetam LUMIZYME [INJ] [SP] INFUMORPH [INJ] kaitlib fe levetiracetam [INJ] LUPANETA PACK [INJ] [SP] INFUVITE [INJ] KALETRA TABLETS [SP] levetiracetam ext-release LUPRON DEPOT 3.75 MG, 11.25 MG INLYTA [SP] kalliga levetiracetam-nacl [INJ] [INJ] [SP] INTELENCE [SP] KALYDECO [SP] levobunolol eye solution LUPRON DEPOT-PED [INJ] [SP] intralipid 20% [INJ] KANJINTI [INJ] [SP] levocarnitine LUTATHERA [INJ] [SP] INTRON A [INJ] [SP] KANUMA [INJ] [SP] levocetirizine lutera introvale kariva levofloxacin LUXTURNA [INJ] [SP] INVELTYS kelnor levofloxacin [INJ] LYNPARZA [SP] (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 5 COMP2225A-21 (11/01/20) LYSODREN methyldopa/hydrochlorothiazide morphine sulfate ext-release neomycin/polymyxin/hydrocortisone LYUMJEV [INJ] methyldopate [INJ] morphine sulfate suppositories ear solution lyza methylergonovine morphine sulfate/nacl [INJ] neomycin/polymyxin/hydrocortisone methylergonovine [INJ] MOVANTIK ear suspension M methylphenidate moxifloxacin neomycin/polymyxin/hydrocortisone methylphenidate ext-release MOXIFLOXACIN [INJ] eye suspension m.v.i. adult [INJ] moxifloxacin eye solution neostigmine [INJ] M.V.I. PEDIATRIC [INJ] methylprednisolone acetate [INJ] moxifloxacin-nacl [INJ] NEPHRAMINE [INJ] M.V.I.-12 [INJ] methylprednisolone sodium MOZOBIL [INJ] [SP] NERLYNX [SP] mafenide succinate [INJ] MULTI-LANCET DEVICE [OTC] NEULASTA [INJ] [SP] magnesium chloride [INJ] methyltestosterone MULTITRACE-4 [INJ] NEUPOGEN [INJ] [SP] [INJ] metipranolol eye solution MULTITRACE-5 [INJ] nevirapine [SP] MAGNESIUM/DEXTROSE metoclopramide mupirocin nevirapine ext-release [SP] 1 GM/100 ML [INJ] metoclopramide [INJ] MUSE newgen prenatal vitamins malathion metoclopramide orally MVASI [INJ] [SP] NEXAVAR [SP] manganese chloride [INJ] disintegrating tablets MYALEPT [INJ] [SP] NEXLETOL manganese sulfate [INJ] metolazone mycophenolate mofetil [SP] NEXLIZET mannitol [INJ] metoprolol succinate ext-release mycophenolate mofetil hcl [INJ] [SP] NEXPLANON [INJ] [SP] maprotiline metoprolol tartrate delayed-release [SP] NEXTERONE [INJ] marlissa metoprolol tartrate [INJ] MYDAYIS niacin MARQIBO [INJ] [SP] metoprolol/hydrochlorothiazide MYLERAN niacin ext-release MATULANE [SP] metronidazole MYLOTARG [INJ] [SP] nicardipine MAYZENT [SP] metronidazole topical mynatal advance prenatal vitamins nicardipine [INJ] meclizine metronidazole vaginal mynatal plus prenatal vitamins nifedipine ext-release meclofenamate metronidazole/nacl [INJ] mynatal prenatal vitamins nikki medroxyprogesterone metyrosine mynatal ultracaplet prenatal vitamins nilutamide medroxyprogesterone (contraceptive) [INJ] mexiletine mynatal-z prenatal vitamins nimodipine mefenamic acid MIACALCIN [INJ] mynate 90 plus prenatal vitamins NINLARO [SP] mefloquine mibelas 24 fe MYOBLOC [INJ] [SP] nisoldipine ext-release megestrol micafungin [INJ] MYRBETRIQ nitisinone [SP] MEKINIST [SP] vaginal nitrofurantoin melodetta 24 fe microgestin N nitrofurantoin macrocrystal meloxicam microgestin fe nitrofurantoin monohydrate/macrocrystal melphalan midazolam nabumetone nitroglycerin [INJ] melphalan [INJ] midazolam [INJ] nadolol nitroglycerin ext-release memantine midazolam/nacl [INJ] nadolol/bendroflumethiazide nitroglycerin ointment memantine ext-release midodrine nafcillin [INJ] nitroglycerin patches MENACTRA [INJ] nafcillin/dextrose [INJ] nitroglycerin spray MENOPUR [INJ] [SP] miglitol naftifine nitroglycerin/dextrose [INJ] mepivacaine [INJ] miglustat [SP] NAGLAZYME [INJ] [SP] nitroprusside sodium [INJ] MEPSEVII [INJ] [SP] mili nalbuphine [INJ] NITYR [SP] mercaptopurine milrinone [INJ] naloxone [INJ] NIVESTYM [INJ] [SP] meropenem [INJ] milrinone/dextrose [INJ] naltrexone nizatidine MEROPENEM/NACL [INJ] mimvey NAMZARIC nora-be mesalamine delayed-release MINIMED INFUSION SETS naproxen NORDITROPIN [INJ] [SP] mesalamine enema MINIMED RESERVOIR naproxen delayed-release norepinephrine [INJ] mesalamine ext-release MINOCIN [INJ] naproxen sodium norepinephrine/dextrose [INJ] mesalamine kit minocycline naproxen sodium ext-release norepinephrine/nacl [INJ] mesalamine suppositories minocycline ext-release naproxen/esomeprazole magnesium norethindrone mesna [INJ] ext-release norethindrone acetate MESNEX TABLETS MIRENA [SP] naratriptan norethindrone acetate-ethinyl estradiol metaproterenol mirtazapine NARCAN NASAL SPRAY norethindrone acetate-ethinyl estradiol metaxalone mirtazapine orally disintegrating tablets NASCOBAL + iron metformin MIRVASO NATACYN norgestimate-ethinyl estradiol metformin ext-release misoprostol nateglinide norlyda methadone MITIGARE NATESTO NORMOSOL-M AND DEXTROSE [INJ] methadone [INJ] mitomycin [INJ] NATPARA [INJ] [SP] NORMOSOL-R AND DEXTROSE [INJ] methamphetamine mitoxantrone [INJ] [SP] NAYZILAM NORMOSOL-R PH 7.4 [INJ] methazolamide M-M-R II [INJ] necon nortrel methenamine hippurate m-natal prenatal vitamins neomycin nortriptyline methenamine mandelate modafinil neomycin/bacitracin/polymyxin NORVIR PACKETS [SP] methenamine/sodium phosphate/ moexipril eye ointment NORVIR SOLUTION [SP] methylene blue/hyoscyamine molindone neomycin/bacitracin/polymyxin/ NOVAREL [INJ] [SP] methimazole hydrocortisone eye ointment NOVOEIGHT [INJ] [SP] METHITEST mometasone nasal spray neomycin/polymyxin irrigation solution NOVOFINE AUTOSHIELD NEEDLES [OTC] methocarbamol mono-linyah neomycin/polymyxin/dexamethasone NOVOFINE NEEDLES [OTC] methocarbamol [INJ] MONONINE [INJ] [SP] eye ointment NOVOSEVEN RT [INJ] [SP] MONOVISC [INJ] [SP] neomycin/polymyxin/dexamethasone NOVOTWIST NEEDLES [OTC] methotrexate [INJ] montelukast eye suspension NOXAFIL [INJ] methoxsalen morphine sulfate neomycin/polymyxin/gramicidin NOXAFIL SUSPENSION methyldopa morphine sulfate [INJ] eye solution NPLATE [INJ] [SP] (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 6 COMP2225A-21 (11/01/20) NUBEQA [SP] ORTHOVISC [INJ] [SP] PERFOROMIST potassium chloride [INJ] NUCALA [INJ] [SP] oseltamivir perindopril potassium chloride ext-release NUEDEXTA OTEZLA [SP] PERJETA [INJ] [SP] potassium chloride oral solution NULOJIX [INJ] [SP] OTOVEL permethrin potassium chloride powder packets for nutrilyte [INJ] OTREXUP [INJ] perphenazine solution nystatin OVIDREL [INJ] [SP] perphenazine/amitriptyline potassium chloride/dextrose [INJ] nystatin topical oxacillin [INJ] phenazopyridine potassium chloride/dextrose/nacl [INJ] nystatin/ oxacillin/dextrose [INJ] phendimetrazine potassium chloride/lactated ringers/ oxaliplatin [INJ] phendimetrazine ext-release dextrose [INJ] O oxandrolone phenelzine potassium chloride/nacl [INJ] oxaprozin phenobarbital potassium chloride/water [INJ] OBIZUR [INJ] [SP] oxcarbazepine phenobarbital sodium [INJ] potassium citrate ext-release obstetrix dha prenatal vitamins OXERVATE [SP] phenobarbital/hyoscyamine/atropine/ potassium citrate/citric acid OCALIVA [SP] oxiconazole scopolamine potassium iodide/iodine solution ocella oxybutynin phenoxybenzamine potassium phosphate [INJ] OCREVUS [INJ] [SP] oxybutynin ext-release phentermine POTELIGEO [INJ] [SP] octreotide [INJ] [SP] oxycodone phentolamine [INJ] pr natal 400 ec prenatal vitamins ODACTRA oxycodone/acetaminophen phenylbutyrate pr natal 400 prenatal vitamins ODEFSEY [SP] oxycodone/aspirin phenylephrine [INJ] pr natal 430 ec prenatal vitamins ODOMZO [SP] oxycodone/ibuprofen phenylephrine eye solution pr natal 430 prenatal vitamins OFEV [SP] OXYCONTIN phenylephrine/chlorpheniramine pramipexole OFIRMEV [INJ] oxymorphone phenylephrine/dextrose [INJ] pramipexole ext-release ofloxacin oxymorphone ext-release phenylephrine/nacl [INJ] prasugrel ofloxacin ear solution oxytocin [INJ] phenytoin pravastatin ofloxacin eye solution OZEMPIC [INJ] phenytoin sodium [INJ] praziquantel ogestrel OZURDEX [INJ] [SP] phenytoin sodium extended prazosin olanzapine philith PRECISION XTRA B-KETONE STRIPS [OTC] olanzapine [INJ] P PHOSLYRA PRECISION XTRA MONITOR [OTC] olanzapine orally disintegrating tablets phosphasal PRECISION XTRA TEST STRIPS [OTC] olanzapine/fluoxetine paclitaxel [INJ] PHOSPHOLINE IODIDE olmesartan paliperidone ext-release PHOTOFRIN [INJ] olmesartan/amlodipine/ palonosetron [INJ] physostigmine [INJ] eye suspension hydrochlorothiazide PALYNZIQ [INJ] [SP] phytonadione prednisolone sodium phosphate olmesartan/hydrochlorothiazide pamidronate [INJ] phytonadione [INJ] prednisolone sodium phosphate olopatadine eye solution PANCREAZE PHYTONADIONE 1 MG/0.5 ML disintegrating tablets olopatadine nasal spray pantoprazole [INJ] SYRINGES [INJ] prednisolone sodium phosphate OLUMIANT [SP] pantoprazole delayed-release PICATO eye solution omega-3 ethyl esters pantoprazole suspension pilocarpine omeprazole delayed-release papaverine [INJ] pilocarpine eye solution pregabalin omeprazole/sodium bicarbonate PARADIGM INFUSION SETS pimecrolimus PREMARIN [INJ] OMNIPAQUE [INJ] PARADIGM RESERVOIRS pimozide PREMARIN CREAM OMNIPOD PARADIGM SILHOUETTE SETS pimtrea PREMARIN TABLETS OMNIPOD DASH paregoric pindolol premasol [INJ] ONCASPAR [INJ] paricalcitol pioglitazone PREMASOL 6% [INJ] ondansetron paricalcitol [INJ] pioglitazone/glimepiride PREMPHASE ondansetron [INJ] paromomycin pioglitazone/metformin PREMPRO ondansetron orally disintegrating tablets paroxetine hcl piperacillin/tazobactam [INJ] prena1 chew prenatal vitamins ONETOUCH DELICA LANCETS [OTC] paroxetine hcl ext-release pirmella prena1 pearl prenatal vitamins ONETOUCH DELICA PLUS LANCETS [OTC] paroxetine mesylate piroxicam prena1 true prenatal vitamins ONETOUCH ULTRA 2 SYSTEM [OTC] PAZEO PLASMA-LYTE [INJ] prenaissance plus prenatal vitamins ONETOUCH ULTRA TEST STRIPS [OTC] PEDIARIX [INJ] plasmanate [INJ] prenaissance prenatal vitamins ONETOUCH ULTRAMINI METER [OTC] PEDITRACE [INJ] PLEGRIDY [INJ] [SP] prenatabs fa prenatal vitamins ONETOUCH ULTRASOFT LANCETS [OTC] PEDVAXHIB [INJ] plenamine [INJ] prenatabs rx prenatal vitamins ONETOUCH VERIO FLEX [OTC] peg 3350/electrolytes powder for 4000 ml PNEUMOVAX 23 [INJ] prenatal low iron prenatal vitamins ONETOUCH VERIO IQ METER [OTC] solution pnv 29-1 prenatal vitamins prenatal plus iron prenatal vitamins ONETOUCH VERIO TEST STRIPS [OTC] PEGANONE pnv-dha + docusate prenatal vitamins prenatal plus prenatal vitamins ONEXTON PEGASYS [INJ] [SP] pnv-dha prenatal vitamins prenatal-u prenatal vitamins ONIVYDE [INJ] [SP] peg-prep kit pnv-omega prenatal vitamins preplus prenatal vitamins OPDIVO [INJ] [SP] penicillamine pnv-select prenatal vitamins PREPOPIK opium tincture penicillin g potassium [INJ] podofilox pretab 29-1 prenatal vitamins opium/belladonna alkaloids suppositories penicillin g procaine [INJ] POLOCAINE [INJ] previfem OPSUMIT [SP] penicillin g sodium [INJ] polyethylene glycol 3350 PREVNAR 13 [INJ] ORALAIR [SP] PENICILLIN GK/DEXTROSE [INJ] POLYFIN QR INFUSION SETS PREVYMIS ORBACTIV [INJ] penicillin v potassium polymyxin [INJ] PREVYMIS [INJ] ORIAHNN PENTACEL [INJ] polymyxin/trimethoprim eye solution PREZISTA [SP] ORILISSA PENTACEL ACTHIB COMPONENT [INJ] POMALYST [SP] PRIALT [INJ] [SP] ORKAMBI [SP] pentamidine [INJ] portia PRIFTIN orphenadrine [INJ] pentamidine inhalation posaconazole PRIMAQUINE orphenadrine ext-release PENTASA potassium acetate [INJ] primaquine phosphate orphenadrine/aspirin/caffeine pentobarbital [INJ] potassium bicarbonate/citric acid primidone orsythia pentoxifylline ext-release effervescent tablets probenecid (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 7 COMP2225A-21 (11/01/20) procainamide [INJ] RADICAVA [INJ] [SP] S SOMAVERT [INJ] [SP] PROCALAMINE [INJ] RAGWITEK sotalol prochlorperazine edisylate [INJ] raloxifene salsalate SOTALOL [INJ] prochlorperazine maleate ramelteon SAMSCA 15 MG TABLETS [SP] SOTRADECOL 1% [INJ] prochlorperazine maleate suppositories ramipril SANDIMMUNE SOLUTION [SP] SOTYLIZE PROCRIT [INJ] [SP] ranolazine ext-release SANTYL spinosad PROFILNINE SD [INJ] [SP] RAPIVAB [INJ] sapropterin [SP] SPINRAZA [INJ] [SP] in oil [INJ] [SP] rasagiline SAVELLA SPIRIVA HANDIHALER progesterone micronized RASUVO [INJ] scopolamine patches SPIRIVA RESPIMAT PROGRAF [INJ] [SP] RAVICTI [SP] secobarbital PROGRAF PACKETS [SP] REBIF [INJ] [SP] SEGLUROMET spironolactone/hydrochlorothiazide PROLASTIN C [INJ] [SP] reclipsen selegiline sprintec PROLEUKIN [INJ] [SP] RECOMBIVAX HB [INJ] selenium [INJ] SPRYCEL [SP] PROMACTA [SP] RECTIV selenium sulfide sronyx promethazine REGRANEX selenium sulfide shampoo STAMARIL [INJ] promethazine [INJ] RELISTOR [INJ] SELZENTRY [SP] stavudine [SP] promethazine suppositories RELISTOR TABLETS se-natal 19 prenatal vitamins STEGLATRO promethazine/codeine REMICADE [INJ] [SP] SENSORCAINE-EPI 0.75%-0.0005% [INJ] STEGLUJAN promethazine/dextromethorphan remifentanil [INJ] SEREVENT DISKUS STELARA SC [INJ] [SP] promethazine/phenylephrine RENACIDIN SEROSTIM [INJ] [SP] STIMATE [SP] promethazine/phenylephrine/codeine repaglinide sertraline STIOLTO RESPIMAT propafenone repaglinide/metformin hcl setlakin STIVARGA [SP] propafenone ext-release REPATHA [INJ] sevelamer carbonate STRENSIQ [INJ] [SP] proparacaine eye solution RESCRIPTOR [SP] sevelamer hcl STREPTOMYCIN SULFATE [INJ] proparacaine/fluorescein eye solution RESECTISOL sharobel STRIVERDI RESPIMAT propofol [INJ] RESTASIS SHINGRIX [INJ] SUBLOCADE [INJ] [SP] propranolol RETROVIR [INJ] [SP] SIGNIFOR [INJ] [SP] SUCRAID [SP] propranolol [INJ] REVCOVI [INJ] [SP] sildenafil sucralfate propranolol ext-release REVLIMID [SP] sildenafil [INJ] [SP] sufentanil [INJ] propranolol/hydrochlorothiazide REYATAZ PACKETS [SP] sildenafil [SP] sulfacetamide eye ointment propylthiouracil R-GENE 10 [INJ] SILHOUETTE INFUSION SETS sulfacetamide eye solution PROQUAD [INJ] RHOPRESSA silodosin sulfacetamide sodium shampoo PROSOL [INJ] RIASTAP [INJ] [SP] silver sulfadiazine sulfacetamide sodium topical protamine [INJ] ribavirin [SP] simliya sulfacetamide sodium/ PROTOPAM [INJ] ribavirin nebulization solution simpesse sulfacetamide/prednisolone eye solution protriptyline RIDAURA SIMPONI 100 MG [INJ] [SP] sulfadiazine PROVENGE [INJ] [SP] rifabutin SIMULECT [INJ] [SP] sulfamethoxazole/trimethoprim pseudoephedrine/chlorpheniramine/ rifampin simvastatin sulfamethoxazole/trimethoprim [INJ] methscopolamine ext-release rifampin [INJ] [SP] SULFAMYLON CREAM pseudoephedrine/codeine/guaifenesin riluzole SIRTURO sulfasalazine PULMICORT FLEXHALER rimantadine SKYLA [SP] sulfasalazine delayed-release PULMOZYME [SP] ringers irrigation solution SKYRIZI [INJ] [SP] sulindac PURIXAN [SP] ringers lactated irrigation solution sodium acetate [INJ] sumatriptan pyrazinamide ringers solution [INJ] sodium benzoate/ sumatriptan [INJ] pyridostigmine ringers solution lactated [INJ] sodium phenylacetate [INJ] sumatriptan nasal pyridostigmine [INJ] RINVOQ ER [SP] sodium bicarbonate [INJ] sumatriptan/naproxen sodium pyridostigmine ext-release risedronate sodium bicarbonate/dextrose [INJ] SUNOSI pyridoxine [INJ] risedronate delayed-release sodium chloride [INJ] SUPREP pyrimethamine [SP] RISPERDAL CONSTA [INJ] sodium chloride 0.45 % [INJ] SURE-T INFUSION SETS risperidone sodium chloride 0.9 % [INJ] SUTENT [SP] Q risperidone orally disintegrating tablets sodium chloride 3 % [INJ] syeda ritonavir [SP] sodium chloride 5 % [INJ] SYLATRON [INJ] [SP] QNASL rivastigmine sodium chloride irrigation solution SYLVANT [INJ] [SP] QUADRACEL DTAP-IPV [INJ] rivastigmine patches sodium chloride nebulization solution SYMBICORT QUDEXY XR rivelsa sodium chloride, bacteriostatic [INJ] SYMDEKO [SP] quetiapine rizatriptan sodium ferric gluconate complex [INJ] SYMFI [SP] quetiapine ext-release rizatriptan orally disintegrating tablets sodium fluoride dental cream, gel SYMFI LO [SP] QUICK RELEASE TEFLON CANNULA ropinirole sodium phosphate [INJ] SYMJEPI [INJ] QUILLICHEW ER ropinirole ext-release sodium polystyrene sulfonate SYMLINPEN [INJ] QUILLIVANT XR ropivacaine/nacl [INJ] sodium polystyrene sulfonate rectal SYMPROIC quinapril rosuvastatin sodium tetradecyl sulfate [INJ] SYMTUZA [SP] quinapril/hydrochlorothiazide ROTATEQ sodium thiosulfate [INJ] SYNAGIS [INJ] [SP] quinidine gluconate ext-release ROZLYTREK [SP] SOF-SET MICRO INFUSION SETS SYNAREL quinidine sulfate RUBRACA [SP] SOF-SET ULTIMATE QR SETS SYNERCID [INJ] quinine sulfate RUCONEST [INJ] [SP] SOFT TOUCH LANCETS [OTC] SYNJARDY QVAR REDIHALER RUXIENCE [INJ] [SP] solifenacin SYNJARDY XR RUZURGI [SP] SOLIQUA [INJ] SYNRIBO [INJ] [SP] R RYBELSUS SOLIRIS [INJ] [SP] RYDAPT [SP] SOLOSEC RABAVERT [INJ] SOLU-CORTEF [INJ] rabeprazole delayed-release SOMATULINE DEPOT [INJ] [SP] (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 8 COMP2225A-21 (11/01/20) T TIVICAY PD [SP] trimethoprim VARUBI tizanidine tri-mili VASCEPA [SP] TOBI PODHALER [SP] trimipramine vasopressin/nacl [INJ] tacrolimus topical TOBRADEX OINTMENT TRIMO-SAN VAXCHORA VACCINE tadalafil TOBRADEX ST trinatal rx 1 prenatal vitamins VECTIBIX [INJ] [SP] tadalafil [SP] tobramycin [INJ] trinate prenatal vitamins VELCADE [INJ] [SP] TAFINLAR [SP] tobramycin eye solution tri-previfem velivet TAGRISSO [SP] tobramycin nebulization solution [SP] TRIPTODUR [INJ] [SP] VELPHORO TALICIA tobramycin/dexamethasone tri-sprintec VEMLIDY TALTZ [INJ] [SP] eye suspension TRIUMEQ [SP] VENCLEXTA [SP] TALZENNA [SP] tobramycin/nacl [INJ] triveen-duo dha prenatal vitamins venlafaxine tamoxifen tolcapone trivora venlafaxine ext-release tamsulosin ext-release tolmetin tri-vylibra VENOFER [INJ] TARGRETIN GEL [SP] tolterodine TROGARZO [INJ] [SP] VENTOLIN HFA tarina fe tolterodine ext-release TROPHAMINE [INJ] verapamil taron-c dha prenatal vitamins tolvaptan [SP] tropicamide eye solution verapamil [INJ] taron-prex dha prenatal vitamins topiramate trospium verapamil ext-release TASIGNA [SP] topotecan [INJ] [SP] trospium ext-release veripred TAYTULLA toremifene TRULANCE VERZENIO [SP] tazarotene torsemide TRULICITY [INJ] VGO TAZORAC 0.05% CREAM TOUJEO [INJ] TRUMENBA [INJ] VIBATIV [INJ] TAZORAC GEL TOVIAZ trust natal dha prenatal vitamins VIBERZI TECENTRIQ [INJ] [SP] TPN ELECTROLYTES [INJ] TRUVADA 100 MG-150 MG, VICTOZA [INJ] TECHLITE BLOOD LANCETS [OTC] TRACE ELEMENTS-4 [INJ] 133 MG-200 MG, 167 MG-250 MG VIDEX SOLUTION [SP] TEFLARO [INJ] TRACLEER SUSPENSION [SP] TABLETS [SP] vienva TEGSEDI [INJ] [SP] TRADJENTA TUBERSOL [INJ] vigabatrin [SP] TEKTURNA HCT tramadol tulana VIIBRYD telmisartan tramadol ext-release TWINRIX [INJ] vilamit mb telmisartan/amlodipine tramadol/acetaminophen tydemy vilevev mb telmisartan/hydrochlorothiazide trandolapril TYMLOS [INJ] [SP] VIMIZIM [INJ] [SP] TEMIXYS [SP] trandolapril/verapamil ext-release TYPHIM VI [INJ] VIMPAT TEMODAR [INJ] [SP] tranexamic acid TYSABRI [INJ] [SP] VIMPAT [INJ] temozolomide [SP] tranexamic acid [INJ] TYVASO [SP] vinblastine [INJ] [INJ] [SP] tranylcypromine vincristine [INJ] TENIPOSIDE [INJ] travasol [INJ] U vinorelbine [INJ] tenofovir disoproxil fumarate [SP] travoprost eye solution VIOKACE terazosin TRAZIMERA [INJ] [SP] UCERIS FOAM viorele terbinafine trazodone UDENYCA [INJ] [SP] VIRACEPT [SP] terbutaline TREANDA [INJ] [SP] UNITUXIN [INJ] [SP] VIREAD 150 MG, 200 MG, 250 MG terbutaline [INJ] TRELEGY ELLIPTA UPTRAVI [SP] TABLETS [SP] terconazole vaginal TREMFYA [INJ] [SP] uretron d-s VIREAD POWDER [SP] testosterone treprostinil diluent [INJ] [SP] urimar-t virt-c dha prenatal vitamins testosterone cypionate [INJ] treprostinil sodium [INJ] [SP] urin d.s. virt-nate dha prenatal vitamins testosterone enanthate [INJ] TRESIBA [INJ] uro-458 virt-pn dha prenatal vitamins TETANUS DIPHTHERIA TOXOIDS [INJ] tretinoin urogesic virt-pn plus prenatal vitamins tetrabenazine [SP] tretinoin microspheres uro-mp VISTOGARD [SP] tetracaine [INJ] tretinoin topical ursodiol VISUDYNE [INJ] [SP] tetracaine eye solution tretinoin/emollient uryl VITRAKVI [SP] tetracycline TRETTEN [INJ] [SP] ustell VIVITROL [INJ] [SP] THALOMID [SP] tri femynor utira-c VIVOTIF theophylline triamcinolone [INJ] UVADEX [INJ] VIZIMPRO [SP] theophylline ext-release triamcinolone dental paste volnea theophylline/dextrose [INJ] triamcinolone topical V VOLUVEN [INJ] THERACYS [INJ] triamterene VONVENDI [INJ] [SP] thiamine [INJ] triamterene/hydrochlorothiazide valacyclovir VORAXAZE [INJ] thioridazine triazolam VALCHLOR [SP] voriconazole thiotepa [INJ] trientine valganciclovir voriconazole [INJ] thiothixene tri-estarylla valproate sodium [INJ] VOSEVI [SP] THROMBATE III [INJ] trifluoperazine valproic acid VOTRIENT [SP] THYMOGLOBULIN [INJ] [SP] trifluridine eye solution valrubicin [SP] vp-ch-pnv prenatal vitamins THYROGEN [INJ] [SP] trihexyphenidyl valsartan VUMERITY [SP] thyroid TRIJARDY XR valsartan/hydrochlorothiazide vyfemla tiagabine TRIKAFTA [SP] vancomycin vylibra TIBSOVO [SP] tri-legest fe vancomycin [INJ] VYNDAMAX [SP] TICE BCG [INJ] tri-linyah VANCOMYCIN/DEXTROSE [INJ] VYNDAQEL [SP] tigecycline [INJ] tri-lo-estarylla VANCOMYCIN/NACL [INJ] VYVANSE tilia fe tri-lo-marzia VANTAS [SP] VYXEOS LIPOSOME [INJ] [SP] timolol maleate tri-lo-mili vardenafil timolol maleate eye solution tri-lo-sprintec vardenafil orally disintegrating tablets tinidazole trilyte with flavor packets VARIVAX [INJ] TIVICAY [SP] trimethobenzamide VARIZIG [INJ] (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 9 COMP2225A-21 (11/01/20) W XOLAIR [INJ] [SP] ZARXIO [INJ] [SP] ZOLGENSMA [INJ] [SP] XOSPATA [SP] zatean-pn dha prenatal vitamins ZOLINZA [SP] warfarin XTANDI [SP] zatean-pn plus prenatal vitamins zolmitriptan water for injection, bacteriostatic [INJ] xulane patches ZEJULA [SP] zolmitriptan orally disintegrating tablets water for injection, sterile [INJ] XULTOPHY [INJ] ZELBORAF [SP] zolpidem water for irrigation, sterile XURIDEN [SP] ZEMAIRA [INJ] [SP] zolpidem ext-release wera XYREM [SP] ZENPEP ZOMIG NASAL WILATE [INJ] [SP] ZEPATIER [SP] zonisamide wixela inhub Y ZEPOSIA [SP] ZORTRESS 1 MG TABLETS [SP] wymzya fe ZERBAXA [INJ] ZOSYN GALAXY BAGS [INJ] YERVOY [INJ] [SP] ZERVIATE zovia X YESCARTA [INJ] [SP] ZEVALIN [INJ] ZTLIDO YF-VAX [INJ] zidovudine [SP] ZUBSOLV XALKORI [SP] YONDELIS [INJ] [SP] ZIEXTENZO [INJ] [SP] ZULRESSO [INJ] [SP] XARELTO YONSA [SP] zileuton ext-release zumandimine XELJANZ [SP] YUPELRI zinc chloride [INJ] ZYDELIG [SP] XELJANZ XR [SP] yuvafem zinc sulfate [INJ] ZYKADIA [SP] XEMBIFY [INJ] [SP] zingiber prenatal vitamins ZYLET XERMELO [SP] Z ZIOPTAN ZYTIGA 500 MG [SP] XGEVA [INJ] [SP] ziprasidone XIAFLEX [INJ] [SP] zafirlukast ziprasidone mesylate [INJ] XIFAXAN zaleplon ZIRABEV [INJ] [SP] XIGDUO XR ZALTRAP [INJ] [SP] ZOLADEX [INJ] [SP] XIIDRA ZANOSAR [INJ] zoledronic acid [INJ] [SP] XOFIGO [INJ] [SP] zarah zoledronic acid/mannitol [INJ] [SP]

Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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. CRP2010_005630.1 #2225 BASIC-A All trademarks are the property of their respective owners. Page 10 COMP2225A-21 (11/01/20)

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