Excelsior Plan Excluded Drug List

January 2021

Below is a list of medicines that are NOT COVERED on your prescription drug benefit. If you continue using any of the drugs listed, you will be required to pay the full cost of non-formulary products that are excluded from coverage unless a request for a medical exception is approved. New prescription drug products may be subject to exclusion upon release to the market.

If you are currently using any of the excluded drugs listed below, you may wish to discuss the preferred generic or brand-name options with your doctor.

LIST OF EXCLUDED DRUGS DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, APEXICON E desoximetasone, fluocinonide (except quetiapine ext-rel, risperidone, ziprasidone, fluocinonide cream 0.1%), BRYHALI LATUDA, VRAYLAR APIDRA FIASP, NOVOLOG ACANYA adapalene, adapalene-benzoyl peroxide, benzoyl peroxide, clindamycin gel (except APLENZIN bupropion, bupropion ext-rel (except bupropion NDC^ 68682046275), clindamycin solution, ext-rel tablet 450 mg) clindamycin-benzoyl peroxide, APOKYN INBRIJA erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ONEXTON APTENSIO XR ADDERALL XR B4G, CONCERTA B4G, MYDAYIS, VYVANSE ACIPHEX, ACIPHEX SPRINKLE esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT APTIOM carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, ACTEMRA ENBREL, HUMIRA, RINVOQ, XELJANZ, gabapentin, lamotrigine, lamotrigine ext-rel, XELJANZ XR levetiracetam, levetiracetam ext-rel, ACTICLATE doxycycline hyclate 20 mg, oxcarbazepine, phenobarbital, phenytoin, doxycycline hyclate capsule, minocycline, phenytoin sodium extended, primidone, tetracycline tiagabine, topiramate, valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, VIMPAT, Activite folic acid XCOPRI ACTOS pioglitazone ARALAST NP PROLASTIN-C acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or ADZENYS ER, ADZENYS XR-ODT ADDERALL XR B4G, CONCERTA B4G, naproxen suspension) WITH esomeprazole, MYDAYIS, VYVANSE lansoprazole, omeprazole, pantoprazole or ALCORTIN A desonide, hydrocortisone DEXILANT ALEVICYN GEL, ALEVICYN SG, desonide, hydrocortisone ASACOL HD balsalazide, mesalamine delayed-rel, ALEVICYN SOLUTION mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA ALIQOPA COPIKTRA ASMANEX, ASMANEX HFA ARNUITY ELLIPTA, FLOVENT DISKUS, ALPROLIX Consult doctor FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER ALREX azelastine, cromolyn sodium, olopatadine, LASTACAFT, PAZEO ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, losartan, losartan-hydrochlorothiazide, lovastatin, pravastatin, rosuvastatin, simvastatin olmesartan, olmesartan-hydrochlorothiazide, ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, telmisartan, telmisartan-hydrochlorothiazide, FLOVENT HFA, PULMICORT FLEXHALER, valsartan, valsartan-hydrochlorothiazide QVAR REDIHALER ATOPADERM desonide, hydrocortisone AMITIZA LINZESS, MOVANTIK, SYMPROIC AVENOVA Consult doctor amphetamine-dextroamphetamine mixed ADDERALL XR B4G AVONEX dimethyl fumarate delayed-rel, glatiramer, salts ext-rel AUBAGIO, BETASERON, COPAXONE, AMRIX cyclobenzaprine (except cyclobenzaprine GILENYA, KESIMPTA, MAYZENT, OCREVUS, tablet 7.5 mg) REBIF, TYSABRI, VUMERITY, ZEPOSIA ANDROGEL 1% testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM

For specific information regarding your prescription benefit coverage, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program.

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* AZELEX adapalene, adapalene-benzoyl peroxide, CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, benzoyl peroxide, clindamycin gel (except NDC^ zolmitriptan, NURTEC ODT, ONZETRA XSAIL, 68682046275), clindamycin solution, REYVOW, UBRELVY, clindamycin-benzoyl peroxide, ZEMBRACE SYMTOUCH, erythromycin solution, erythromycin-benzoyl ZOMIG NASAL SPRAY peroxide, tretinoin, ONEXTON calcipotriene cream calcipotriene ointment, calcipotriene solution AZESCO prenatal vitamins, CITRANATAL calcipotriene-betamethasone calcipotriene ointment or calcipotriene BARACLUDE TABLET entecavir, lamivudine, VEMLIDY solution WITH desoximetasone, fluocinonide (except fluocinonide cream 0.1%) or BRYHALI BEAU RX Consult doctor calcitriol ointment calcipotriene ointment, calcipotriene solution BECONASE AQ azelastine-fluticasone, flunisolide, fluticasone, mometasone CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, CARAC fluorouracil cream 5%, fluorouracil solution, losartan, losartan-hydrochlorothiazide, imiquimod, PICATO, TOLAK olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, CARAFATE sucralfate tablet valsartan, valsartan-hydrochlorothiazide CARBINOXAMINE TABLET 6 MG levocetirizine BENSAL HP desonide, hydrocortisone CARDIZEM, CARDIZEM CD, diltiazem ext-rel (except generics for BENZACLIN adapalene, adapalene-benzoyl peroxide, CARDIZEM LA CARDIZEM LA) benzoyl peroxide, clindamycin gel (except CARNITOR, CARNITOR SF levocarnitine NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, chlordiazepoxide-clidinium (NDC^ dicyclomine erythromycin solution, erythromycin-benzoyl 42494040901 only) peroxide, tretinoin, ONEXTON chlorzoxazone 375 mg, cyclobenzaprine (except benzonatate (NDCs^ 69336012615, benzonatate (except NDCs^ 69336012615, chlorzoxazone 500 mg (NDC^ cyclobenzaprine tablet 7.5 mg) 69499032915 only) 69499032915) 73007001303 only), chlorzoxazone 750 mg, BEPREVE azelastine, cromolyn sodium, olopatadine, CHLORZOXAZONE 250 MG LASTACAFT, PAZEO CIALIS sildenafil, tadalafil BERINERT FIRAZYR, RUCONEST CICATRACE Consult doctor BETAPACE, BETAPACE AF sotalol CIMZIA COSENTYX, ENBREL, HUMIRA, OTEZLA, BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT RINVOQ, SKYRIZI, BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol- STELARA SUBCUTANEOUS, TREMFYA, drospirenone-levomefolate, ethinyl estradiol- XELJANZ, XELJANZ XR norethindrone acetate, ethinyl estradiol- CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic norethindrone acetate-iron CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN clindamycin gel (NDC^ 68682046275 adapalene, adapalene-benzoyl peroxide, BORTEZOMIB NINLARO, VELCADE only) benzoyl peroxide, clindamycin gel (except NDC^ BRIVIACT carbamazepine, carbamazepine ext-rel, 68682046275), clindamycin solution, divalproex sodium, divalproex sodium ext-rel, clindamycin-benzoyl peroxide, erythromycin gabapentin, lamotrigine, lamotrigine ext-rel, solution, erythromycin-benzoyl peroxide, levetiracetam, levetiracetam ext-rel, tretinoin, ONEXTON oxcarbazepine, phenobarbital, phenytoin, clobetasol spray clobetasol foam phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, CLOBEX SPRAY clobetasol foam OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI COLAZAL balsalazide Bupap diclofenac sodium, ibuprofen, naproxen (except COLCRYS colchicine tablet naproxen CR or naproxen suspension) CONSENSI amlodipine WITH celecoxib bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel CONTRAVE SAXENDA (except bupropion ext-rel tablet 450 mg) CORDRAN OINTMENT hydrocortisone butyrate cream, butalbital-acetaminophen tablet 50-300 diclofenac sodium, ibuprofen, naproxen (except hydrocortisone butyrate lotion, mg, BUTALBITAL-ACETAMINOPHEN naproxen CR or naproxen suspension) hydrocortisone butyrate ointment, (NDC^ 69499034230 only) hydrocortisone butyrate solution, mometasone, butalbital-acetaminophen-caffeine capsule diclofenac sodium, ibuprofen, naproxen (except triamcinolone cream, triamcinolone lotion, naproxen CR or naproxen suspension) triamcinolone ointment BUTRANS buprenorphine transdermal, BELBUCA CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA tetracycline BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* cyclobenzaprine ext-rel capsule, cyclobenzaprine (except cyclobenzaprine doxycycline monohydrate capsule 75 mg, doxycycline hyclate 20 mg, cyclobenzaprine tablet 7.5 mg tablet 7.5 mg) doxycycline monohydrate capsule 150 mg doxycycline hyclate capsule, minocycline, tetracycline CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule doxycycline monohydrate delayed-rel ORACEA capsule DARAPRIM pyrimethamine DULERA ADVAIR DISKUS B4G, ADVAIR HFA, DaVite folic acid BREO ELLIPTA DAYTRANA ADDERALL XR B4G, CONCERTA B4G, DUTOPROL metoprolol succinate ext-rel WITH MYDAYIS, VYVANSE hydrochlorothiazide DELZICOL balsalazide, mesalamine delayed-rel, DYRENIUM amiloride, triamterene mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, DETROL LA darifenacin ext-rel, oxybutynin ext-rel, losartan, losartan-hydrochlorothiazide, solifenacin, tolterodine, tolterodine ext-rel, olmesartan, olmesartan-hydrochlorothiazide, trospium, trospium ext-rel, MYRBETRIQ, telmisartan, telmisartan-hydrochlorothiazide, TOVIAZ valsartan, valsartan-hydrochlorothiazide dexchlorpheniramine levocetirizine E.E.S. GRANULES erythromycins Dexifol folic acid EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1%, venlafaxine ext-rel capsule diclofenac sodium solution, ibuprofen, ELELYSO CERDELGA, CEREZYME meloxicam, naproxen (except naproxen CR or naproxen suspension) ELOCTATE ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, ENABLEX darifenacin ext-rel, oxybutynin ext-rel, meloxicam, naproxen (except naproxen CR or solifenacin, tolterodine, tolterodine ext-rel, naproxen suspension) trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ DIFFERIN LOTION adapalene, adapalene-benzoyl peroxide, benzoyl peroxide, clindamycin gel (except ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, ENTYVIO HUMIRA, STELARA SUBCUTANEOUS, erythromycin solution, erythromycin-benzoyl XELJANZ, XELJANZ XR peroxide, tretinoin, ONEXTON EPICERAM desonide, hydrocortisone diflorasone cream, diflorasone ointment desoximetasone, EPOGEN ARANESP, RETACRIT fluocinonide (except fluocinonide cream 0.1%), BRYHALI ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, REYVOW, UBRELVY, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, REYVOW, UBRELVY, ZOMIG NASAL SPRAY ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY ERYPED erythromycins diltiazem ext-rel (generics for diltiazem ext-rel (except generics for ESTRING estradiol, IMVEXXY CARDIZEM LA only) CARDIZEM LA) EVEKEO amphetamine-dextroamphetamine mixed salts, DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, methylphenidate irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, EVERSENSE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE olmesartan, olmesartan-hydrochlorothiazide, MONITORING SYSTEM MONITORING SYSTEM telmisartan, telmisartan-hydrochlorothiazide, EVZIO naloxone injection, NARCAN NASAL SPRAY valsartan, valsartan-hydrochlorothiazide EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, Diphen Elixir levocetirizine amlodipine-valsartan DORYX, DORYX MPC doxycycline hyclate 20 mg, EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, doxycycline hyclate capsule, minocycline, olmesartan-amlodipine-hydrochlorothiazide tetracycline EXTAVIA dimethyl fumarate delayed-rel, glatiramer, doxepin cream desonide, hydrocortisone, pimecrolimus, AUBAGIO, BETASERON, COPAXONE, tacrolimus, EUCRISA GILENYA, KESIMPTA, MAYZENT, OCREVUS, doxycycline hyclate delayed-rel tablet doxycycline hyclate 20 mg, REBIF, TYSABRI, VUMERITY, ZEPOSIA 200 mg doxycycline hyclate capsule, minocycline, FABIOR adapalene, adapalene-benzoyl peroxide, tetracycline benzoyl peroxide, clindamycin gel (except doxycycline hyclate tablet 50 mg (NDC^ doxycycline hyclate 20 mg, NDC^ 68682046275), clindamycin solution, 72143021160 only), doxycycline hyclate doxycycline hyclate capsule, minocycline, clindamycin-benzoyl peroxide, tablet 75 mg, doxycycline hyclate tablet tetracycline erythromycin solution, erythromycin-benzoyl 150 mg peroxide, tretinoin, ONEXTON

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* FANAPT aripiprazole, clozapine, olanzapine, quetiapine, FYCOMPA carbamazepine, carbamazepine ext-rel, quetiapine ext-rel, risperidone, ziprasidone, divalproex sodium, divalproex sodium ext-rel, LATUDA, VRAYLAR gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, FEMRING estradiol, IMVEXXY oxcarbazepine, phenobarbital, phenytoin, fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), phenytoin sodium extended, primidone, fenofibric acid delayed-rel tiagabine, topiramate, valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, VIMPAT, FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate tablet 120 mg), XCOPRI fenofibric acid delayed-rel GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, fenoprofen, FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, SUPARTZ FX naproxen (except naproxen CR or naproxen suspension) Genicin Vita-S folic acid FERIVA 21/7 folic acid GLASSIA PROLASTIN-C Fexmid cyclobenzaprine (except cyclobenzaprine GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL tablet 7.5 mg) GLUMETZA metformin, metformin ext-rel (except generics for FINACEA GEL azelaic acid gel, metronidazole, FORTAMET and GLUMETZA) FINACEA FOAM, SOOLANTRA GLYCOPYRROLATE TABLET 1.5 MG dicyclomine FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except GOLYTELY peg 3350-electrolytes, CLENPIQ naproxen CR or naproxen suspension) GRANIX NIVESTYM flucytosine capsule 500 mg fluconazole HORIZANT gabapentin, GRALISE fluocinonide cream 0.1% clobetasol cream HUMALOG FIASP, NOVOLOG fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK HUMALOG MIX 50/50 NOVOLOG MIX 70/30 fluoxetine tablet (generics for SARAFEM fluoxetine (except fluoxetine tablet 60 mg, HUMALOG MIX 75/25 NOVOLOG MIX 70/30 only) fluoxetine tablet [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline HUMATROPE GENOTROPIN, NORDITROPIN fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except HUMULIN 70/30 NOVOLIN 70/30 fluoxetine tablet 60 mg, fluoxetine tablet HUMULIN N NOVOLIN N [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX HUMULIN R NOVOLIN R flurandrenolide lotion (NDC^ desonide, hydrocortisone HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, 24470092112 only) SUPARTZ FX flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate lipophilic cream hydrocortisone butyrate cream, hydrocortisone butyrate lotion, 0.1% hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone cream, triamcinolone lotion, triamcinolone ointment triamcinolone ointment fluticasone-salmeterol ADVAIR DISKUS B4G HylaVite folic acid FML LIQUIFILM dexamethasone, loteprednol, HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, prednisolone acetate 1%, DUREZOL, hydromorphone ext-rel, methadone, FML FORTE, FML S.O.P., MAXIDEX, morphine ext-rel, NUCYNTA ER, XTAMPZA ER PRED MILD INCRUSE ELLIPTA SPIRIVA, YUPELRI FOLIC-K folic acid INDERAL LA, INDERAL XL atenolol, carvedilol, carvedilol phosphate ext-rel, FOLLISTIM AQ GONAL-F metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext- Folvik-D folic acid rel, BYSTOLIC

INDOCIN diclofenac sodium, ibuprofen, meloxicam, Folvite-D folic acid naproxen (except naproxen CR or naproxen FORTAMET metformin, metformin ext-rel (except generics suspension) for FORTAMET and GLUMETZA) indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, FORTESTA testosterone gel (except authorized generics for naproxen (except naproxen CR or naproxen TESTIM and VOGELXO), testosterone solution, suspension) ANDRODERM Inflammacin diclofenac sodium, diclofenac sodium gel 1%, FOSRENOL calcium acetate, sevelamer carbonate, diclofenac sodium solution, ibuprofen, PHOSLYRA, VELPHORO meloxicam, naproxen (except naproxen CR or naproxen suspension) FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, FULPHILA ZIEXTENZO metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext- rel, BYSTOLIC

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* INTERMEZZO doxepin, eszopiclone, ramelteon, zolpidem, LIDOTREX lidocaine-prilocaine zolpidem ext-rel, zolpidem sublingual, BELSOMRA LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin INTRAROSA estradiol, IMVEXXY LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, INTUNIV atomoxetine, guanfacine ext-rel, lovastatin, pravastatin, rosuvastatin, simvastatin ADDERALL XR B4G, CONCERTA B4G, MYDAYIS, VYVANSE Lorid folic acid INVEGA SUSTENNA ABILIFY MAINTENA, PERSERIS Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, INVOKANA FARXIGA, JARDIANCE prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate PRED MILD 40 mg), isosorbide mononitrate LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, JALYN dutasteride-tamsulosin; dutasteride or finasteride zolpidem ext-rel, zolpidem sublingual, WITH alfuzosin ext-rel, doxazosin, silodosin, BELSOMRA tamsulosin or terazosin MACRODANTIN nitrofurantoin JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR Matzim LA diltiazem ext-rel (except generics for KAMDOY desonide, hydrocortisone CARDIZEM LA) KAZANO JANUMET, JANUMET XR MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), ketoconazole foam 2% ketoconazole shampoo 2%, HARVONI (genotypes 1, 4, 5, 6), VOSEVI 1 selenium sulfide lotion 2.5% mefenamic acid (NDC^ 69336012830 diclofenac sodium, ibuprofen, meloxicam, Ketodan ketoconazole shampoo 2%, only) naproxen (except naproxen CR or naproxen selenium sulfide lotion 2.5% suspension) ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, MENEST estradiol naproxen (except naproxen CR or naproxen metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine suspension) tablet 7.5 mg) ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, methylphenidate ext-rel CONCERTA B4G naproxen (except naproxen CR or naproxen suspension) metformin ext-rel (generics metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA only) for FORTAMET and GLUMETZA) KINERET ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR methocarbamol 500 mg (NDC^ cyclobenzaprine (except cyclobenzaprine tablet 69036091010 only), methocarbamol 750 7.5 mg) KOMBIGLYZE XR JANUMET, JANUMET XR mg (NDCs^ 69036093090, 70868090190 KYPROLIS NINLARO, VELCADE only)

LACRISERT RESTASIS, XIIDRA MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, LACTULOSE PAK lactulose solution risedronate, FORTEO, PROLIA, TYMLOS LANOXIN TABLET (125 MCG and digoxin MIACALCIN NASAL SPRAY calcitonin-salmon 250 MCG only) Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, lanthanum carbonate calcium acetate, sevelamer carbonate, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, PHOSLYRA, VELPHORO REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, 3 LANTUS BASAGLAR, LEVEMIR ZOMIG NASAL SPRAY LAZANDA fentanyl transmucosal lozenge, SUBSYS MILLIPRED dexamethasone, hydrocortisone, LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, methylprednisolone, prednisolone solution, lovastatin, pravastatin, rosuvastatin, simvastatin prednisone LETAIRIS ambrisentan, bosentan, OPSUMIT MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol- drospirenone-levomefolate, ethinyl estradiol- norethindrone acetate, ethinyl estradiol- levorphanol fentanyl transdermal, hydrocodone ext-rel, norethindrone acetate-iron hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER MINIVELLE estradiol, DIVIGEL, EVAMIST LEXAPRO citalopram, escitalopram, fluoxetine (except MINOCIN doxycycline hyclate 20 mg, fluoxetine tablet 60 mg, fluoxetine tablet doxycycline hyclate capsule, minocycline, [generics for SARAFEM]), paroxetine HCl, tetracycline paroxetine HCl ext-rel, sertraline, TRINTELLIX minocycline ext-rel doxycycline hyclate 20 mg, LIALDA balsalazide, mesalamine delayed-rel, doxycycline hyclate capsule, minocycline, mesalamine ext-rel, sulfasalazine, tetracycline sulfasalazine delayed-rel, PENTASA MIRVASO azelaic acid gel, metronidazole, LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine FINACEA FOAM, SOOLANTRA (NDC^ 71800063115 only)

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, OLEPTRO trazodone doxycycline hyclate capsule, minocycline, tetracycline OLUX-E clobetasol foam MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole, SUPARTZ FX pantoprazole, DEXILANT MOVIPREP peg 3350-electrolytes, CLENPIQ OMNARIS azelastine-fluticasone, flunisolide, fluticasone, mometasone MultiPro Consult doctor OMNITROPE GENOTROPIN, NORDITROPIN mupirocin cream gentamicin, mupirocin ointment OMNIVEX folic acid MYTESI diphenoxylate-atropine, loperamide ONFI clobazam, lamotrigine, topiramate, NAPRELAN diclofenac sodium, ibuprofen, meloxicam, TROKENDI XR naproxen (except naproxen CR or naproxen suspension) ONGLYZA JANUVIA naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or ORENCIA CLICKJECT, COSENTYX, ENBREL, HUMIRA, OTEZLA, naproxen (except naproxen CR or naproxen ORENCIA INTRAVENOUS, RINVOQ, STELARA SUBCUTANEOUS, suspension) WITH esomeprazole, lansoprazole, ORENCIA SUBCUTANEOUS XELJANZ, XELJANZ XR omeprazole, pantoprazole or DEXILANT orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine naproxen CR diclofenac sodium, ibuprofen, meloxicam, tablet 7.5 mg) naproxen (except naproxen CR or naproxen Orphengesic Forte cyclobenzaprine (except cyclobenzaprine suspension) tablet 7.5 mg) naproxen suspension diclofenac sodium, ibuprofen, meloxicam, ORTHO D folic acid naproxen (except naproxen CR or naproxen suspension) ORTHO DF folic acid NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol- ORTHOVISC DUROLANE, EUFLEXXA, GELSYN-3, drospirenone-levomefolate, ethinyl estradiol- SUPARTZ FX levonorgestrel, ethinyl estradiol- norethindrone acetate, ethinyl estradiol- OSENI JANUMET, JANUMET XR; JANUVIA WITH norethindrone acetate-iron, ethinyl estradiol- pioglitazone norgestimate, LO LOESTRIN FE OSMOPREP peg 3350-electrolytes, CLENPIQ NATESTO testosterone gel (except authorized generics for OSPHENA estradiol TESTIM and VOGELXO), testosterone solution, ANDRODERM oxiconazole (NDCs^ 00168035830, ciclopirox, clotrimazole, econazole, 51672135902 only) ketoconazole cream 2%, luliconazole NESINA JANUVIA NEULASTA, NEULASTA ONPRO ZIEXTENZO OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, NEUPOGEN NIVESTYM hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, niacin tablet 500 mg niacin ext-rel morphine ext-rel, NUCYNTA ER, XTAMPZA ER Niacor niacin ext-rel OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, NICADAN folic acid trospium, trospium ext-rel, MYRBETRIQ, NICAPRIN folic acid TOVIAZ NICAZEL, NICAZEL FORTE folic acid PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet NICOMIDE folic acid [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX NILANDRON abiraterone, bicalutamide, XTANDI, YONSA PENNSAID diclofenac sodium, diclofenac sodium gel 1%, NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine diclofenac sodium solution, ibuprofen, tablet 7.5 mg) meloxicam, naproxen (except naproxen CR or NORITATE azelaic acid gel, metronidazole, naproxen suspension) FINACEA FOAM, SOOLANTRA PERCOCET hydrocodone-acetaminophen, hydromorphone, NORVASC amlodipine morphine, oxycodone-acetaminophen, NUCYNTA NOVACORT desonide, hydrocortisone PEXEVA citalopram, escitalopram, fluoxetine (except NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1%, fluoxetine tablet 60 mg, fluoxetine tablet diclofenac sodium solution, ibuprofen, [generics for SARAFEM]), paroxetine HCl, meloxicam, naproxen (except naproxen CR or paroxetine HCl ext-rel, sertraline, TRINTELLIX naproxen suspension) PLAVIX clopidogrel, prasugrel, BRILINTA NUTROPIN AQ GENOTROPIN, NORDITROPIN NUVARING ethinyl estradiol-etonogestrel, ANNOVERA NUVIGIL armodafinil, SUNOSI

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* PLEGRIDY dimethyl fumarate delayed-rel, glatiramer, RIMSO-50 Consult doctor AUBAGIO, BETASERON, COPAXONE, GILENYA, KESIMPTA, MAYZENT, OCREVUS, RIOMET metformin, metformin ext-rel (except generics for REBIF, TYSABRI, VUMERITY, ZEPOSIA FORTAMET and GLUMETZA) POLYTOZA Consult doctor ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, posaconazole delayed-rel tablet fluconazole, itraconazole BELSOMRA PRADAXA warfarin, ELIQUIS, XARELTO RyClora levocetirizine PRED FORTE dexamethasone, loteprednol, SABRIL vigabatrin prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, SAIZEN GENOTROPIN, NORDITROPIN PRED MILD SANDOSTATIN LAR SOMATULINE DEPOT PREMARIN estradiol SCARSILK PAD Consult doctor PREMARIN CREAM estradiol, IMVEXXY SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, PREVACID esomeprazole, lansoprazole, omeprazole, quetiapine ext-rel, risperidone, ziprasidone, pantoprazole, DEXILANT LATUDA, VRAYLAR PREVIDENT Consult doctor SIGNIFOR LAR SOMATULINE DEPOT PRIMLEV hydrocodone-acetaminophen, hydromorphone, SIL-K PAD Consult doctor morphine, oxycodone-acetaminophen, SILIVEX Consult doctor NUCYNTA SILTREX Consult doctor PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule SIMPONI COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol, XELJANZ, XELJANZ XR levalbuterol tartrate CFC-free aerosol SINGULAIR montelukast, zafirlukast, zileuton ext-rel PROCRIT ARANESP, RETACRIT SOMAVERT SOMATULINE DEPOT PRODIGEN Consult doctor SORILUX calcipotriene ointment, calcipotriene solution PROLENSA bromfenac, diclofenac, ketorolac, ACUVAIL, ILEVRO, NEVANAC SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen PROTONIX esomeprazole, lansoprazole, omeprazole, suspension) pantoprazole, DEXILANT STENDRA sildenafil, tadalafil PROVAD Consult doctor SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV PROVENTIL HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol sucralfate suspension sucralfate tablet PROZAC citalopram, escitalopram, fluoxetine (except sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen fluoxetine tablet 60 mg, fluoxetine tablet (except naproxen CR or naproxen suspension) [generics for SARAFEM]), paroxetine HCl, WITH eletriptan, naratriptan, rizatriptan, paroxetine HCl ext-rel, sertraline, TRINTELLIX sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, PSORCON desoximetasone, fluocinonide (except ZEMBRACE SYMTOUCH or fluocinonide cream 0.1%), BRYHALI ZOMIG NASAL SPRAY QNASL azelastine-fluticasone, flunisolide, fluticasone, SUPREP peg 3350-electrolytes, CLENPIQ mometasone SYNERDERM desonide, hydrocortisone QSYMIA SAXENDA SYNVISC, SYNVISC-ONE DUROLANE, EUFLEXXA, GELSYN-3, QTERN GLYXAMBI SUPARTZ FX quazepam doxepin, eszopiclone, ramelteon, zolpidem, TALIVA folic acid zolpidem ext-rel, zolpidem sublingual, BELSOMRA TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SUBCUTANEOUS, RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, TREMFYA, XELJANZ, XELJANZ XR tamsulosin, terazosin TARGADOX doxycycline hyclate 20 mg, RAYOS dexamethasone, hydrocortisone, doxycycline hyclate capsule, minocycline, methylprednisolone, prednisolone solution, tetracycline prednisone TASIGNA imatinib mesylate, BOSULIF, SPRYCEL RECEDO Consult doctor TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol- RELION INSULIN NOVOLIN INSULIN drospirenone-levomefolate, ethinyl estradiol- REPATHA PRALUENT norethindrone acetate, ethinyl estradiol- norethindrone acetate-iron RHEUMATE folic acid RIBOZEL folic acid

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* TAZORAC adapalene, adapalene-benzoyl peroxide, Vanoxide-HC adapalene, adapalene-benzoyl peroxide, benzoyl peroxide, clindamycin gel (except NDC^ benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, solution, erythromycin-benzoyl peroxide, tretinoin, ONEXTON; calcipotriene ointment, tretinoin, ONEXTON calcipotriene solution VASCULERA Consult doctor TECFIDERA dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, VECTICAL calcipotriene ointment, calcipotriene solution GILENYA, KESIMPTA, MAYZENT, OCREVUS, VELTIN adapalene, adapalene-benzoyl peroxide, REBIF, TYSABRI, VUMERITY, ZEPOSIA benzoyl peroxide, clindamycin gel (except NDC^ TESTIM testosterone gel (except authorized generics for 68682046275), clindamycin solution, TESTIM and VOGELXO), testosterone solution, clindamycin-benzoyl peroxide, erythromycin ANDRODERM solution, erythromycin-benzoyl peroxide, tretinoin, ONEXTON testosterone gel 1% (authorized generics testosterone gel (except authorized generics for for TESTIM and VOGELXO only) TESTIM and VOGELXO), testosterone solution, venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine, ANDRODERM venlafaxine ext-rel capsule TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, VENTOLIN HFA albuterol sulfate CFC-free aerosol, BETOPTIC S levalbuterol tartrate CFC-free aerosol TIROSINT levothyroxine VEREGEN imiquimod TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS VIAGRA sildenafil, tadalafil TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), metoprolol succinate ext-rel, metoprolol tartrate, HARVONI (genotypes 1, 4, 5, 6) nadolol, pindolol, propranolol, propranolol ext- VIIBRYD citalopram, escitalopram, fluoxetine (except rel, BYSTOLIC fluoxetine tablet 60 mg, fluoxetine tablet TRACLEER ambrisentan, bosentan, OPSUMIT [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX TRADJENTA JANUVIA VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, tramadol (NDC^ 52817019610 only) tramadol (except NDC^ 52817019610), tramadol SUPARTZ FX ext-rel Vitasure folic acid TRANSDERM SCOP meclizine, scopolamine transdermal VIVELLE-DOT estradiol, DIVIGEL, EVAMIST TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) VOGELXO testosterone gel (except authorized generics for WITH eletriptan, naratriptan, rizatriptan, TESTIM and VOGELXO), testosterone solution, sumatriptan, zolmitriptan, NURTEC ODT, ANDRODERM ONZETRA XSAIL, REYVOW, UBRELVY, XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, ZEMBRACE SYMTOUCH or oxazepam ZOMIG NASAL SPRAY XENAZINE tetrabenazine, AUSTEDO triamcinolone acetonide aerosol 0.2% hydrocortisone butyrate cream, hydrocortisone butyrate lotion, XOLEGEL ciclopirox, ketoconazole cream 2% hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, XOPENEX HFA albuterol sulfate CFC-free aerosol, triamcinolone cream, triamcinolone lotion, levalbuterol tartrate CFC-free aerosol triamcinolone ointment Xvite folic acid TRICOR fenofibrate (except fenofibrate tablet 120 mg), XYZBAC folic acid fenofibric acid delayed-rel YAZ ethinyl estradiol-drospirenone, ethinyl estradiol- TronVite folic acid drospirenone-levomefolate, ethinyl estradiol- TRULANCE LINZESS norethindrone acetate, ethinyl estradiol- norethindrone acetate-iron TUDORZA SPIRIVA, YUPELRI ZALVIT prenatal vitamins, CITRANATAL UDENYCA ZIEXTENZO ZARXIO NIVESTYM UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT VALCYTE valganciclovir ZELAC Consult doctor VALTREX acyclovir capsule, acyclovir tablet, valacyclovir ZEMAIRA PROLASTIN-C Vanatol LQ, Vanatol S diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) ZETIA ezetimibe

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ZETONNA azelastine-fluticasone, flunisolide, fluticasone, ZONEGRAN carbamazepine, carbamazepine ext-rel, mometasone divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, ZIANA adapalene, adapalene-benzoyl peroxide, levetiracetam, levetiracetam ext-rel, benzoyl peroxide, clindamycin gel (except NDC^ oxcarbazepine, phenobarbital, phenytoin, 68682046275), clindamycin solution, phenytoin sodium extended, primidone, clindamycin-benzoyl peroxide, erythromycin tiagabine, topiramate, valproic acid, zonisamide, solution, erythromycin-benzoyl peroxide, OXTELLAR XR, TROKENDI XR, VIMPAT, tretinoin, ONEXTON XCOPRI ZIRGAN trifluridine ZONTIVITY Consult doctor ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, ZORTRESS everolimus hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, suspension) zolpidem ext-rel, zolpidem sublingual, BELSOMRA ZUPLENZ granisetron, ondansetron, SANCUSO ZYDELIG COPIKTRA ZYLET neomycin-polymyxin B-bacitracin- hydrocortisone, neomycin-polymyxin B- dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST ZYTIGA abiraterone, bicalutamide, XTANDI, YONSA ZYVIT folic acid

You will be responsible for the full cost of non-formulary products that are excluded from coverage unless a request for a medical exception is approved. Information on the medical exception process can be found below in the For Your Information section. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all- inclusive list of available drug options. Log in to https://www.empireplanrxprogram.com to check coverage and copay2 information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.

The Excelsior Plan Drug List has an additional feature called Brand for Generic (B4G) which saves you money on certain Brand-Name drugs that have a new generic available. When advantageous to the Plan, this feature allows a Brand-Name drug to be placed on Level 1, the lowest copayment level, and the new generic equivalent to be placed on Level 3, the highest copayment level or excluded. These placements are for a limited time, typically six months, and may be revised mid-year when such changes are advantageous to The Empire Plan. You will be notified when B4G savings are available. We will also notify your pharmacist so that the lowest cost option will always be dispensed. Please refer to the Empire Plan Prescription Drug Program website at https://www.empireplanrxprogram.com for the most current information regarding the B4G feature.

The Empire Plan has implemented a medical exception process for prescription drugs that are excluded from the Excelsior Plan Drug List. Enrollees and their physicians must first evaluate whether covered drugs on the Excelsior Plan Drug List are appropriate alternatives. After an appropriate trial of formulary alternatives, an enrollee's physician may submit a letter of medical necessity to CVS Caremark® which details the enrollee's formulary alternative trials and any other clinical documentation supporting medical necessity. The physician can fax the exception request to 1-888-487-9257. If an exception is approved, the Level 1 copay2 will apply for generic drugs and the Level 3 copay (and ancillary charge, if applicable) will apply for brand-name drugs.

* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. ^ 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. B4G Brand for Generic medication (see note above). Brand-name product is dispensed at the generic copayment. 1 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). 2 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

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, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.