Formulary Drug List

July 2020 Performance Drug List - Standard Control for Clients ® with Advanced Control Specialty Formulary

The CVS Caremark® Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary® is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by CVS Caremark. Ask your doctor to consider administered by CVS Caremark. As a way to help manage health prescribing, when medically appropriate, a preferred medicine from care costs, authorize generic substitution whenever possible. If you this list. Take this list along when you or a covered family member believe a brand-name product is necessary, consider prescribing a sees a doctor. brand name on this list. Please note: Please note:

• Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food • This drug list represents a summary of prescription coverage. and Drug Administration (FDA) may not be covered upon It is not all-inclusive and does not guarantee coverage. The release to the market. member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their • You may be responsible for the full cost of non-formulary appearance in this document. Products recently approved by products that are removed from coverage. the FDA may not be covered upon release to the market. • For specific information regarding your prescription benefit The member's prescription benefit plan may have a different 1 • coverage and copay information, please visit Caremark.com or copay1 for specific products on the list. contact a CVS Caremark Customer Care representative. • Unless specifically indicated, drug list products will include all • CVS Caremark may contact your doctor after receiving your dosage forms. prescription to request consideration of a drug list product or 1 generic equivalent. This may result in your doctor prescribing, • Log in to Caremark.com to check coverage and copay when medically appropriate, a different brand-name product or information for a specific medicine. generic equivalent in place of your original prescription.

• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non- preferred option upon release of the generic product to the market.

ANALGESICS § GOUT BELBUCA § FLUOROQUINOLONES ANTIVIRALS allopurinol NUCYNTA ciprofloxacin § CYTOMEGALOVIRUS § NSAIDs colchicine tablet NUCYNTA ER levofloxacin AGENTS diclofenac sodium SUBSYS probenecid moxifloxacin valganciclovir ibuprofen XTAMPZA ER meloxicam § OPIOID ANALGESICS § PENICILLINS § HERPES AGENTS naproxen 2 ANTI-INFECTIVES buprenorphine transdermal amoxicillin acyclovir capsule, tablet

codeine-acetaminophen amoxicillin-clavulanate § NSAIDs, COMBINATIONS ANTIBACTERIALS valacyclovir fentanyl transdermal dicloxacillin § CEPHALOSPORINS diclofenac sodium- fentanyl transmucosal penicillin VK § INFLUENZA AGENTS

misoprostol lozenge cefdinir oseltamivir cefprozil § TETRACYCLINES § NSAIDs, TOPICAL hydrocodone-acetaminophen RELENZA hydromorphone cefuroxime axetil doxycycline hyclate 20 mg diclofenac sodium hydromorphone ext-rel cephalexin doxycycline hyclate capsule § MISCELLANEOUS gel 1% (except NDC^ 69499031866) methadone SUPRAX minocycline clindamycin diclofenac sodium solution morphine tetracycline ivermectin § ERYTHROMYCINS / morphine ext-rel linezolid § COX-2 INHIBITORS MACROLIDES § ANTIFUNGALS morphine suppository metronidazole celecoxib azithromycin fluconazole oxycodone nitrofurantoin clarithromycin oxycodone-acetaminophen itraconazole sulfamethoxazole- clarithromycin ext-rel tramadol (except NDC^ 52817019610) terbinafine tablet trimethoprim erythromycins tramadol ext-rel vancomycin capsule DIFICID

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.

EMVERM ANTILIPEMICS spironolactone- ANTIDEPRESSANTS guanfacine ext-rel XIFAXAN 550 MG § BILE ACID RESINS hydrochlorothiazide § SELECTIVE SEROTONIN methylphenidate torsemide methylphenidate ext-rel † cholestyramine REUPTAKE INHIBITORS ANTINEOPLASTIC triamterene MYDAYIS colesevelam (SSRIs) AGENTS triamterene- VYVANSE citalopram § CHOLESTEROL hydrochlorothiazide HORMONAL escitalopram ABSORPTION INHIBITORS § FIBROMYALGIA ANTINEOPLASTIC AGENTS fluoxetine 5 HEART FAILURE pregabalin ezetimibe § ANTIANDROGENS paroxetine HCl BIDIL paroxetine HCl ext-rel HYPNOTICS bicalutamide § FIBRATES CORLANOR sertraline § NONBENZODIAZEPINES fenofibrate 3 ENTRESTO § MISCELLANEOUS TRINTELLIX fenofibric acid delayed-rel eszopiclone § NITRATES VIIBRYD VISTOGARD ramelteon

§ HMG-CoA REDUCTASE nitroglycerin lingual spray § SEROTONIN zolpidem CARDIOVASCULAR INHIBITORS / nitroglycerin sublingual NOREPINEPHRINE zolpidem ext-rel

COMBINATIONS zolpidem sublingual § ACE INHIBITORS § MISCELLANEOUS REUPTAKE INHIBITORS fosinopril atorvastatin (SNRIs) BELSOMRA ranolazine ext-rel ezetimibe-simvastatin lisinopril desvenlafaxine ext-rel TRICYCLICS fluvastatin quinapril CENTRAL NERVOUS duloxetine lovastatin SILENOR ramipril SYSTEM venlafaxine pravastatin venlafaxine ext-rel capsule MIGRAINE § ACE INHIBITOR / rosuvastatin ANTIANXIETY ACUTE MIGRAINE AGENTS DIURETIC COMBINATIONS simvastatin § BENZODIAZEPINES § MISCELLANEOUS fosinopril-hydrochlorothiazide AGENTS Newer Agents § NIACINS alprazolam NURTEC ODT lisinopril-hydrochlorothiazide clonazepam bupropion quinapril-hydrochlorothiazide niacin ext-rel bupropion ext-rel 6 REYVOW diazepam UBRELVY lorazepam mirtazapine § ANGIOTENSIN II § OMEGA-3 FATTY ACIDS trazodone omega-3 acid ethyl esters oxazepam § Triptans RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS VASCEPA § ANTICONVULSANTS § ANTIPARKINSONIAN eletriptan candesartan / candesartan- AGENTS naratriptan § BETA-BLOCKERS carbamazepine

hydrochlorothiazide amantadine rizatriptan carbamazepine ext-rel atenolol eprosartan carbidopa-levodopa sumatriptan clobazam carvedilol irbesartan / irbesartan- carbidopa-levodopa ext-rel zolmitriptan diazepam rectal gel carvedilol phosphate ext-rel hydrochlorothiazide carbidopa-levodopa- ONZETRA XSAIL divalproex sodium metoprolol succinate ext-rel losartan / losartan- entacapone ZEMBRACE SYMTOUCH metoprolol tartrate divalproex sodium ext-rel ZOMIG NASAL SPRAY hydrochlorothiazide ethosuximide entacapone nadolol olmesartan / olmesartan- pramipexole pindolol gabapentin PREVENTIVE MIGRAINE hydrochlorothiazide pramipexole ext-rel propranolol lamotrigine AGENTS telmisartan / telmisartan- lamotrigine ext-rel rasagiline propranolol ext-rel Monoclonal Antibodies hydrochlorothiazide ropinirole BYSTOLIC levetiracetam valsartan / valsartan- levetiracetam ext-rel ropinirole ext-rel AIMOVIG hydrochlorothiazide § CALCIUM CHANNEL oxcarbazepine selegiline AJOVY

BLOCKERS phenobarbital NEUPRO EMGALITY § ANGIOTENSIN II RECEPTOR ANTAGONIST / amlodipine phenytoin ANTIPSYCHOTICS § MUSCULOSKELETAL 4 phenytoin sodium extended CALCIUM CHANNEL diltiazem ext-rel § ATYPICALS THERAPY AGENTS primidone BLOCKER COMBINATIONS nifedipine ext-rel 7 aripiprazole cyclobenzaprine verapamil ext-rel tiagabine amlodipine-olmesartan clozapine topiramate § NARCOLEPSY amlodipine-telmisartan § CALCIUM CHANNEL valproic acid olanzapine amlodipine-valsartan armodafinil BLOCKER / ANTILIPEMIC zonisamide quetiapine SUNOSI COMBINATIONS quetiapine ext-rel § ANGIOTENSIN II FYCOMPA risperidone RECEPTOR ANTAGONIST / amlodipine-atorvastatin OXTELLAR XR POSTHERPETIC ziprasidone CALCIUM CHANNEL TROKENDI XR NEURALGIA (PHN) § DIGITALIS GLYCOSIDES ABILIFY MAINTENA BLOCKER / DIURETIC VIMPAT GRALISE ARISTADA COMBINATIONS digoxin § ANTIDEMENTIA ARISTADA INITIO PSYCHOTHERAPEUTIC - amlodipine-valsartan- § DIRECT RENIN donepezil LATUDA MISCELLANEOUS hydrochlorothiazide INHIBITORS / DIURETIC galantamine VRAYLAR § OPIOID ANTAGONISTS olmesartan-amlodipine- COMBINATIONS galantamine ext-rel hydrochlorothiazide § ATTENTION DEFICIT naloxone injection aliskiren memantine NARCAN NASAL SPRAY HYPERACTIVITY DISORDER § ANTIARRHYTHMICS TEKTURNA HCT rivastigmine

rivastigmine transdermal amphetamine- § PARTIAL OPIOID AGONIST / sotalol § DIURETICS NAMZARIC dextroamphetamine MULTAQ OPIOID ANTAGONIST amiloride mixed salts COMBINATIONS furosemide amphetamine- buprenorphine-naloxone hydrochlorothiazide dextroamphetamine sublingual metolazone mixed salts ext-rel † ZUBSOLV atomoxetine

PSEUDOBULBAR AFFECT § INSULIN SENSITIZER / § CARNITINE DEFICIENCY methylprednisolone INFLAMMATORY BOWEL AGENTS SULFONYLUREA AGENTS prednisolone solution DISEASE NUEDEXTA COMBINATIONS levocarnitine prednisone § ORAL AGENTS

pioglitazone-glimepiride balsalazide § VASOMOTOR SYMPTOM CONTRACEPTIVES GLUCOSE ELEVATING budesonide capsule AGENTS § MEGLITINIDES § MONOPHASIC AGENTS budesonide ext-rel paroxetine mesylate nateglinide BAQSIMI ethinyl estradiol- mesalamine delayed-rel repaglinide GLUCAGEN HYPOKIT drospirenone mesalamine ext-rel ENDOCRINE AND GLUCAGON ethinyl estradiol- sulfasalazine SODIUM-GLUCOSE EMERGENCY KIT METABOLIC drospirenone-levomefolate CO-TRANSPORTER 2 sulfasalazine delayed-rel ethinyl estradiol- § ANDROGENS (SGLT2) INHIBITORS § PHOSPHATE BINDER PENTASA norethindrone acetate testosterone gel 8 AGENTS FARXIGA ethinyl estradiol- § RECTAL AGENTS testosterone solution calcium acetate JARDIANCE norethindrone acetate-iron hydrocortisone enema

ANDRODERM sevelamer carbonate mesalamine suppository SODIUM-GLUCOSE BIPHASIC PHOSLYRA ANTIDIABETICS mesalamine suspension CO-TRANSPORTER 2 VELPHORO

LO LOESTRIN FE CORTIFOAM AMYLIN ANALOGS (SGLT2) INHIBITOR / POTASSIUM-REMOVING SYMLINPEN BIGUANIDE COMBINATIONS § TRIPHASIC § IRRITABLE BOWEL AGENTS SYNJARDY SYNDROME § BIGUANIDES ethinyl estradiol-norgestimate SYNJARDY XR LOKELMA alosetron metformin XIGDUO XR § EXTENDED CYCLE VELTASSA 9 AMITIZA metformin ext-rel ethinyl estradiol- SODIUM-GLUCOSE PROGESTINS LINZESS levonorgestrel VIBERZI § BIGUANIDE / CO-TRANSPORTER 2 § ORAL SULFONYLUREA (SGLT2) INHIBITOR / § TRANSDERMAL medroxyprogesterone § LAXATIVES COMBINATIONS DIPEPTIDYL PEPTIDASE-4 ethinyl estradiol- megestrol acetate lactulose solution glipizide-metformin (DPP-4) INHIBITOR norelgestromin progesterone, micronized peg 3350-electrolytes COMBINATIONS DIPEPTIDYL PEPTIDASE-4 VAGINAL SUPREP GLYXAMBI § VAGINAL (DPP-4) INHIBITORS ethinyl estradiol-etonogestrel CRINONE OPIOID-INDUCED JANUVIA § SULFONYLUREAS ENDOMETRIN CONSTIPATION

glimepiride ENDOMETRIOSIS DIPEPTIDYL PEPTIDASE-4 MOVANTIK ORILISSA § SELECTIVE ESTROGEN glipizide (DPP-4) INHIBITOR / RECEPTOR MODULATORS SYMPROIC glipizide ext-rel BIGUANIDE COMBINATIONS ESTROGENS raloxifene PANCREATIC ENZYMES JANUMET SUPPLIES § ORAL OSPHENA CREON

JANUMET XR ACCU-CHEK AVIVA PLUS estradiol § THYROID SUPPLEMENTS VIOKACE STRIPS AND KITS 10 INCRETIN MIMETIC AGENTS PREMARIN ZENPEP ACCU-CHEK COMPACT levothyroxine OZEMPIC PLUS STRIPS AND KITS 10 § TRANSDERMAL liothyronine § PROTON PUMP RYBELSUS ACCU-CHEK GUIDE estradiol SYNTHROID INHIBITORS TRULICITY 10 STRIPS AND KITS DIVIGEL esomeprazole VICTOZA ACCU-CHEK SMARTVIEW EVAMIST GASTROINTESTINAL lansoprazole 10 INCRETIN MIMETIC AGENT / STRIPS AND KITS § ANTIEMETICS omeprazole BD ULTRAFINE § VAGINAL INSULIN COMBINATIONS doxylamine-pyridoxine pantoprazole

INSULIN SYRINGES estradiol SOLIQUA delayed-rel DEXILANT AND NEEDLES ESTRING XULTOPHY dronabinol PREMARIN CREAM § STEROIDS, RECTAL DEXCOM CONTINUOUS granisetron GLUCOSE PROCTOFOAM-HC INSULINS ESTROGEN / PROGESTINS meclizine MONITORING SYSTEM BASAGLAR metoclopramide OMNIPOD INSULIN § ORAL § ULCER THERAPY FIASP ondansetron INFUSION PUMP estradiol-norethindrone COMBINATIONS HUMULIN R U-500 prochlorperazine V-GO INSULIN PREMPHASE PYLERA LEVEMIR promethazine INFUSION PUMP PREMPRO

NOVOLIN 70/30 scopolamine transdermal § MISCELLANEOUS NOVOLIN N trimethobenzamide ANTIOBESITY TRANSDERMAL sucralfate NOVOLIN R SANCUSO SAXENDA CLIMARA PRO NOVOLOG COMBIPATCH VARUBI GENITOURINARY NOVOLOG MIX 70/30 CALCIUM REGULATORS § ANTISPASMODICS § BENIGN PROSTATIC TRESIBA § BISPHOSPHONATES ESTROGEN / SELECTIVE ESTROGEN RECEPTOR dicyclomine HYPERPLASIA § INSULIN SENSITIZERS alendronate MODULATOR alfuzosin ext-rel ibandronate § H2 RECEPTOR pioglitazone COMBINATIONS doxazosin risedronate ANTAGONISTS dutasteride § INSULIN SENSITIZER / DUAVEE famotidine dutasteride-tamsulosin BIGUANIDE COMBINATIONS § CALCITONINS § GLUCOCORTICOIDS finasteride pioglitazone-metformin calcitonin-salmon silodosin dexamethasone fludrocortisone tamsulosin hydrocortisone terazosin

ERECTILE DYSFUNCTION § ANTICHOLINERGICS PHOSPHODIESTERASE-4 § ANTISEBORRHEICS § ANTI-INFECTIVE / ALPROSTADIL AGENTS ipratropium INHIBITORS ketoconazole shampoo 2% ANTI-INFLAMMATORY COMBINATIONS MUSE inhalation solution DALIRESP selenium sulfide lotion 2.5% INCRUSE ELLIPTA neomycin-polymyxin B- STEROID / BETA AGONIST § ATOPIC DERMATITIS § PHOSPHODIESTERASE SPIRIVA bacitracin-hydrocortisone COMBINATIONS INHIBITORS YUPELRI pimecrolimus neomycin-polymyxin B- sildenafil ADVAIR DISKUS tacrolimus dexamethasone ANTICHOLINERGIC / BETA tadalafil ADVAIR HFA EUCRISA tobramycin-dexamethasone AGONIST COMBINATIONS BREO ELLIPTA TOBRADEX OINTMENT CORTICOSTEROIDS § URINARY § SHORT ACTING SYMBICORT TOBRADEX ST ANTISPASMODICS ipratropium-albuterol § Low Potency § STEROID INHALANTS ANTI-INFLAMMATORIES darifenacin ext-rel inhalation solution desonide oxybutynin budesonide hydrocortisone § Nonsteroidal LONG ACTING oxybutynin ext-rel inhalation suspension bromfenac § Medium Potency solifenacin ANORO ELLIPTA ARNUITY ELLIPTA diclofenac tolterodine BEVESPI AEROSPHERE FLOVENT DISKUS hydrocortisone butyrate ketorolac tolterodine ext-rel STIOLTO RESPIMAT FLOVENT HFA cream, lotion, ointment, ACUVAIL trospium PULMICORT FLEXHALER solution ILEVRO ANTICHOLINERGIC / BETA QVAR REDIHALER trospium ext-rel mometasone NEVANAC AGONIST / STEROID MYRBETRIQ triamcinolone cream, lotion, INHALANT COMBINATIONS TOVIAZ TOPICAL ointment § Steroidal

TRELEGY ELLIPTA DERMATOLOGY dexamethasone § High Potency HEMATOLOGIC loteprednol § ANTIHISTAMINES, ACNE desoximetasone prednisolone acetate 1% § ANTICOAGULANTS LOW SEDATING § Topical 11 fluocinonide DUREZOL warfarin levocetirizine adapalene BRYHALI FML FORTE ELIQUIS benzoyl peroxide FML S.O.P. XARELTO § ANTITUSSIVES § Very High Potency clindamycin gel (except NDC^ MAXIDEX benzonatate (except NDCs^ clobetasol cream, foam, gel, § PLATELET AGGREGATION 68682046275) PRED MILD 69336012615, 69499032915) clindamycin solution lotion, ointment, shampoo INHIBITORS clindamycin-benzoyl BETA-BLOCKERS clopidogrel BETA AGONISTS, § LOCAL ANESTHETICS peroxide § Nonselective dipyridamole ext-rel-aspirin INHALANTS lidocaine-prilocaine erythromycin solution timolol maleate solution prasugrel § SHORT ACTING erythromycin-benzoyl § ROSACEA BETIMOL BRILINTA albuterol inhalation solution peroxide azelaic acid gel albuterol sulfate tretinoin Selective IMMUNOLOGIC doxycycline monohydrate CFC-free aerosol EPIDUO BETOPTIC S AGENTS delayed-rel capsule levalbuterol tartrate ONEXTON metronidazole ALLERGENIC EXTRACTS CFC-free aerosol TAZORAC § CARBONIC ANHYDRASE FINACEA FOAM INHIBITORS GRASTEK LONG ACTING § ACTINIC KERATOSIS SOOLANTRA RAGWITEK dorzolamide Hand-held Active Inhalation fluorouracil cream 5% MOUTH / THROAT / AZOPT NUTRITIONAL / SEREVENT fluorouracil solution DENTAL AGENTS STRIVERDI RESPIMAT imiquimod § CARBONIC ANHYDRASE SUPPLEMENTS PROTECTANTS PICATO INHIBITOR / BETA- § ELECTROLYTES Nebulized Passive Inhalation TOLAK EPISIL BLOCKER COMBINATIONS potassium chloride liquid PERFOROMIST ZYCLARA dorzolamide-timolol OPHTHALMIC VITAMINS AND MINERALS § LEUKOTRIENE § ANTIBIOTICS § ANTIALLERGICS CARBONIC ANHYDRASE § FOLIC ACID / MODULATORS gentamicin azelastine INHIBITOR / COMBINATIONS montelukast mupirocin ointment cromolyn sodium SYMPATHOMIMETIC COMBINATIONS folic acid zafirlukast olopatadine § ANTIFUNGALS zileuton ext-rel LASTACAFT SIMBRINZA § PRENATAL VITAMINS ciclopirox PAZEO § NASAL ANTIHISTAMINES DRY EYE DISEASE prenatal vitamins clotrimazole § ANTI-INFECTIVES CITRANATAL azelastine econazole RESTASIS olopatadine ketoconazole cream 2% ciprofloxacin XIIDRA

RESPIRATORY luliconazole erythromycin § NASAL STEROIDS / § PROSTAGLANDINS nystatin gentamicin § ANAPHYLAXIS COMBINATIONS NAFTIN levofloxacin latanoprost TREATMENT AGENTS flunisolide moxifloxacin LUMIGAN epinephrine auto-injector fluticasone § ANTIPSORIATICS ofloxacin TRAVATAN Z

EPIPEN mometasone acitretin sulfacetamide RHO KINASE INHIBITORS EPIPEN JR DYMISTA calcipotriene ointment, tobramycin

SYMJEPI RHOPRESSA solution BESIVANCE

methoxsalen CILOXAN OINTMENT

MOXEZA

RHO KINASE INHIBITOR / § SYMPATHOMIMETICS SYMPATHOMIMETIC / BETA- OTIC

PROSTAGLANDIN brimonidine BLOCKER COMBINATIONS § ANTI-INFECTIVE / COMBINATIONS ALPHAGAN P COMBIGAN ANTI-INFLAMMATORY ROCKLATAN COMBINATIONS CIPRODEX QUICK REFERENCE DRUG LIST

A azithromycin ciclopirox dipyridamole ext-rel-aspirin ethinyl estradiol- AZOPT CILOXAN OINTMENT divalproex sodium norethindrone acetate ABILIFY MAINTENA CIPRODEX divalproex sodium ext-rel ethinyl estradiol- ACCU-CHEK AVIVA PLUS B ciprofloxacin DIVIGEL norethindrone acetate-iron STRIPS AND KITS 10 citalopram donepezil ethinyl estradiol-norgestimate ACCU-CHEK COMPACT balsalazide CITRANATAL dorzolamide ethosuximide PLUS STRIPS AND KITS 10 BAQSIMI ACCU-CHEK GUIDE BASAGLAR clarithromycin dorzolamide-timolol EUCRISA clarithromycin ext-rel doxazosin EVAMIST STRIPS AND KITS 10 BD ULTRAFINE ACCU-CHEK SMARTVIEW INSULIN SYRINGES CLIMARA PRO doxycycline hyclate 20 mg ezetimibe 10 AND NEEDLES clindamycin doxycycline hyclate capsule ezetimibe-simvastatin STRIPS AND KITS clindamycin gel (except NDC^ doxycycline monohydrate acitretin BELBUCA BELSOMRA 68682046275) delayed-rel capsule F ACUVAIL benzonatate (except NDCs^ clindamycin solution doxylamine-pyridoxine famotidine acyclovir capsule, tablet 69336012615, 69499032915) clindamycin-benzoyl delayed-rel FARXIGA adapalene benzoyl peroxide peroxide dronabinol fenofibrate 3 ADVAIR DISKUS BESIVANCE clobazam DUAVEE fenofibric acid delayed-rel ADVAIR HFA BETIMOL clobetasol cream, foam, gel, duloxetine fentanyl transdermal AIMOVIG BETOPTIC S lotion, ointment, shampoo DUREZOL fentanyl transmucosal AJOVY BEVESPI AEROSPHERE clonazepam dutasteride lozenge albuterol inhalation solution clopidogrel dutasteride-tamsulosin albuterol sulfate bicalutamide FIASP BIDIL clotrimazole DYMISTA FINACEA FOAM CFC-free aerosol clozapine alendronate BREO ELLIPTA finasteride codeine-acetaminophen E alfuzosin ext-rel BRILINTA FLOVENT DISKUS colchicine tablet aliskiren brimonidine econazole FLOVENT HFA colesevelam allopurinol bromfenac eletriptan fluconazole COMBIGAN alosetron BRYHALI ELIQUIS fludrocortisone COMBIPATCH ALPHAGAN P budesonide capsule EMGALITY flunisolide CORLANOR 11 alprazolam budesonide ext-rel EMVERM fluocinonide budesonide CORTIFOAM ENDOMETRIN fluorouracil cream 5% amantadine inhalation suspension CREON entacapone fluorouracil solution amiloride buprenorphine transdermal CRINONE ENTRESTO fluoxetine 5 AMITIZA cromolyn sodium buprenorphine-naloxone EPIDUO fluticasone amlodipine 7 sublingual cyclobenzaprine epinephrine auto-injector fluvastatin amlodipine-atorvastatin bupropion EPIPEN FML FORTE amlodipine-olmesartan bupropion ext-rel 6 D EPIPEN JR FML S.O.P. amlodipine-telmisartan BYSTOLIC DALIRESP EPISIL folic acid amlodipine-valsartan amlodipine-valsartan- darifenacin ext-rel eprosartan fosinopril C desonide erythromycin fosinopril-hydrochlorothiazide hydrochlorothiazide amoxicillin calcipotriene ointment, desoximetasone erythromycin solution furosemide amoxicillin-clavulanate solution desvenlafaxine ext-rel erythromycin-benzoyl FYCOMPA amphetamine- calcitonin-salmon dexamethasone peroxide G dextroamphetamine calcium acetate DEXCOM CONTINUOUS erythromycins

mixed salts candesartan GLUCOSE escitalopram gabapentin amphetamine- candesartan- MONITORING SYSTEM esomeprazole galantamine dextroamphetamine hydrochlorothiazide DEXILANT estradiol galantamine ext-rel diazepam estradiol-norethindrone mixed salts ext-rel † carbamazepine gentamicin diazepam rectal gel ESTRING ANDRODERM carbamazepine ext-rel glimepiride diclofenac eszopiclone ANORO ELLIPTA carbidopa-levodopa glipizide diclofenac sodium ethinyl estradiol- aripiprazole carbidopa-levodopa ext-rel glipizide ext-rel diclofenac sodium drospirenone ARISTADA carbidopa-levodopa- glipizide-metformin gel 1% (except NDC^ 69499031866) ethinyl estradiol- ARISTADA INITIO entacapone GLUCAGEN HYPOKIT diclofenac sodium solution drospirenone-levomefolate armodafinil carvedilol GLUCAGON diclofenac sodium- ethinyl estradiol-etonogestrel ARNUITY ELLIPTA carvedilol phosphate ext-rel EMERGENCY KIT misoprostol ethinyl estradiol- atenolol cefdinir GLYXAMBI atomoxetine cefprozil dicloxacillin levonorgestrel GRALISE atorvastatin cefuroxime axetil dicyclomine ethinyl estradiol- granisetron azelaic acid gel celecoxib DIFICID norelgestromin GRASTEK azelastine cephalexin digoxin guanfacine ext-rel 4 cholestyramine diltiazem ext-rel

H lovastatin NUCYNTA prenatal vitamins sulfamethoxazole- luliconazole NUCYNTA ER primidone trimethoprim HUMULIN R U-500 LUMIGAN NUEDEXTA probenecid sulfasalazine hydrochlorothiazide NURTEC ODT prochlorperazine sulfasalazine delayed-rel hydrocodone-acetaminophen M nystatin PROCTOFOAM-HC sumatriptan hydrocortisone progesterone, micronized SUNOSI hydrocortisone butyrate MAXIDEX O promethazine SUPRAX cream, lotion, ointment, meclizine propranolol SUPREP solution medroxyprogesterone ofloxacin propranolol ext-rel SYMBICORT hydrocortisone enema megestrol acetate olanzapine PULMICORT FLEXHALER SYMJEPI hydromorphone meloxicam olmesartan memantine olmesartan-amlodipine- PYLERA SYMLINPEN hydromorphone ext-rel mesalamine delayed-rel hydrochlorothiazide SYMPROIC Q I mesalamine ext-rel olmesartan- SYNJARDY mesalamine suppository hydrochlorothiazide quetiapine SYNJARDY XR ibandronate mesalamine suspension olopatadine quetiapine ext-rel SYNTHROID ibuprofen metformin omega-3 acid ethyl esters quinapril ILEVRO metformin ext-rel 9 omeprazole quinapril-hydrochlorothiazide T imiquimod methadone OMNIPOD INSULIN QVAR REDIHALER tacrolimus INCRUSE ELLIPTA methoxsalen INFUSION PUMP tadalafil ipratropium methylphenidate ondansetron R tamsulosin inhalation solution methylphenidate ext-rel † ONEXTON TAZORAC ipratropium-albuterol RAGWITEK methylprednisolone ONZETRA XSAIL raloxifene TEKTURNA HCT inhalation solution metoclopramide ORILISSA telmisartan irbesartan ramelteon metolazone oseltamivir telmisartan- irbesartan- ramipril metoprolol succinate ext-rel OSPHENA hydrochlorothiazide hydrochlorothiazide ranolazine ext-rel metoprolol tartrate oxazepam terazosin itraconazole rasagiline metronidazole oxcarbazepine terbinafine tablet RELENZA ivermectin 8 minocycline OXTELLAR XR repaglinide testosterone gel J mirtazapine oxybutynin RESTASIS testosterone solution mometasone oxybutynin ext-rel REYVOW tetracycline JANUMET montelukast oxycodone RHOPRESSA tiagabine JANUMET XR morphine oxycodone-acetaminophen risedronate timolol maleate solution JANUVIA morphine ext-rel OZEMPIC risperidone TOBRADEX OINTMENT JARDIANCE morphine suppository rivastigmine TOBRADEX ST P K MOVANTIK rivastigmine transdermal tobramycin MOXEZA pantoprazole rizatriptan tobramycin-dexamethasone ketoconazole cream 2% moxifloxacin paroxetine HCl ROCKLATAN TOLAK ketoconazole shampoo 2% MULTAQ paroxetine HCl ext-rel ropinirole tolterodine ketorolac mupirocin ointment tolterodine ext-rel paroxetine mesylate ropinirole ext-rel MUSE topiramate L PAZEO rosuvastatin MYDAYIS peg 3350-electrolytes RYBELSUS torsemide lactulose solution MYRBETRIQ penicillin VK TOVIAZ lamotrigine PENTASA S tramadol (except NDC^ 52817019610) lamotrigine ext-rel N PERFOROMIST SANCUSO tramadol ext-rel lansoprazole nadolol phenobarbital SAXENDA TRAVATAN Z LASTACAFT NAFTIN phenytoin scopolamine transdermal trazodone latanoprost naloxone injection phenytoin sodium extended selegiline TRELEGY ELLIPTA LATUDA NAMZARIC PHOSLYRA selenium sulfide lotion 2.5% TRESIBA levalbuterol tartrate 2 naproxen PICATO SEREVENT tretinoin CFC-free aerosol naratriptan pimecrolimus sertraline triamcinolone cream, lotion, LEVEMIR NARCAN NASAL SPRAY pindolol sevelamer carbonate ointment levetiracetam nateglinide pioglitazone sildenafil triamterene levetiracetam ext-rel neomycin-polymyxin B- pioglitazone-glimepiride SILENOR triamterene- levocarnitine bacitracin-hydrocortisone pioglitazone-metformin silodosin hydrochlorothiazide levocetirizine neomycin-polymyxin B- potassium chloride liquid SIMBRINZA trimethobenzamide levofloxacin dexamethasone pramipexole simvastatin TRINTELLIX levothyroxine NEUPRO pramipexole ext-rel solifenacin TROKENDI XR lidocaine-prilocaine NEVANAC prasugrel SOLIQUA trospium linezolid niacin ext-rel pravastatin SOOLANTRA trospium ext-rel LINZESS nifedipine ext-rel PRED MILD sotalol TRULICITY liothyronine nitrofurantoin prednisolone acetate 1% SPIRIVA lisinopril nitroglycerin lingual spray prednisolone solution spironolactone- U lisinopril-hydrochlorothiazide nitroglycerin sublingual prednisone hydrochlorothiazide UBRELVY LO LOESTRIN FE NOVOLIN 70/30 pregabalin STIOLTO RESPIMAT LOKELMA NOVOLIN N PREMARIN STRIVERDI RESPIMAT V lorazepam NOVOLIN R PREMARIN CREAM SUBSYS valacyclovir losartan NOVOLOG PREMPHASE sucralfate valganciclovir losartan-hydrochlorothiazide NOVOLOG MIX 70/30 PREMPRO sulfacetamide valproic acid loteprednol

valsartan V-GO INSULIN W Y zolpidem valsartan-hydrochlorothiazide INFUSION PUMP zolpidem ext-rel warfarin YUPELRI vancomycin capsule VIBERZI zolpidem sublingual VARUBI VICTOZA X Z ZOMIG NASAL SPRAY VASCEPA VIIBRYD zonisamide XARELTO zafirlukast VELPHORO VIMPAT ZUBSOLV XIFAXAN 550 MG ZEMBRACE SYMTOUCH VELTASSA VIOKACE ZYCLARA XIGDUO XR ZENPEP venlafaxine VISTOGARD XIIDRA zileuton ext-rel venlafaxine ext-rel capsule VRAYLAR XTAMPZA ER ziprasidone verapamil ext-rel VYVANSE XULTOPHY zolmitriptan PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, quetiapine, quetiapine ext-rel, risperidone, meloxicam or naproxen (except naproxen CR or ziprasidone, LATUDA, VRAYLAR naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or ACANYA adapalene, benzoyl peroxide, DEXILANT clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- ASACOL HD balsalazide, mesalamine delayed-rel, benzoyl peroxide, erythromycin solution, mesalamine ext-rel, sulfasalazine, erythromycin-benzoyl peroxide, tretinoin, sulfasalazine delayed-rel, PENTASA EPIDUO, ONEXTON, TAZORAC ASCENSIA STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, ACIPHEX, ACIPHEX SPRINKLE esomeprazole, lansoprazole, omeprazole, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, pantoprazole, DEXILANT ACCU-CHEK GUIDE STRIPS AND KITS 10, ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate capsule, ASMANEX, ASMANEX HFA ARNUITY ELLIPTA, FLOVENT DISKUS, minocycline, tetracycline FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER Activite folic acid ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, ACTOS pioglitazone eprosartan, irbesartan, acyclovir cream acyclovir capsule, acyclovir tablet, irbesartan-hydrochlorothiazide, losartan, valacyclovir losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, ALCORTIN A desonide, hydrocortisone telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ALEVICYN GEL, ALEVICYN SG, desonide, hydrocortisone ALEVICYN SOLUTION ATOPADERM desonide, hydrocortisone ALLISON MEDICAL INSULIN SYRINGES 12 BD ULTRAFINE INSULIN SYRINGES ATROVENT HFA ipratropium inhalation solution, INCRUSE ELLIPTA, SPIRIVA, YUPELRI ALORA estradiol, DIVIGEL, EVAMIST AVENOVA Consult doctor ALREX azelastine, cromolyn sodium, olopatadine, LASTACAFT, PAZEO AZELEX adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), ALTOPREV atorvastatin, ezetimibe-simvastatin, clindamycin solution, clindamycin- fluvastatin, lovastatin, pravastatin, benzoyl peroxide, erythromycin solution, rosuvastatin, simvastatin erythromycin-benzoyl peroxide, tretinoin, ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, EPIDUO, ONEXTON, TAZORAC FLOVENT HFA, PULMICORT FLEXHALER, BEAU RX Consult doctor QVAR REDIHALER BECONASE AQ flunisolide, fluticasone, mometasone, AMRIX cyclobenzaprine DYMISTA (except cyclobenzaprine tablet 7.5 mg) BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, ANDROGEL 1% testosterone gel (except authorized generics eprosartan, irbesartan, for TESTIM and VOGELXO), irbesartan-hydrochlorothiazide, losartan, testosterone solution, ANDRODERM losartan-hydrochlorothiazide, olmesartan, ANGELIQ estradiol-norethindrone, PREMPHASE, olmesartan-hydrochlorothiazide, telmisartan, PREMPRO telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ANTARA fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel BENSAL HP desonide, hydrocortisone APEXICON E desoximetasone, fluocinonide BENZAC AC adapalene, benzoyl peroxide, (except fluocinonide cream 0.1%), clindamycin gel (except NDC^ 68682046275), BRYHALI clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, APIDRA FIASP, NOVOLOG erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON, TAZORAC ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* BENZACLIN adapalene, benzoyl peroxide, CIALIS sildenafil, tadalafil clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- CICATRACE Consult doctor benzoyl peroxide, erythromycin solution, CLINDAGEL erythromycin solution erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON, TAZORAC clindamycin gel (NDC^ 68682046275 only) adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), BENZIQ adapalene, benzoyl peroxide, clindamycin solution, clindamycin- clindamycin gel (except NDC^ 68682046275), benzoyl peroxide, erythromycin solution, clindamycin solution, clindamycin- erythromycin-benzoyl peroxide, tretinoin, benzoyl peroxide, erythromycin solution, EPIDUO, ONEXTON, TAZORAC erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON, TAZORAC clobetasol spray clobetasol foam benzonatate benzonatate CLOBEX SPRAY clobetasol foam (NDCs^ 69336012615, 69499032915 only) (except NDCs^ 69336012615, 69499032915) COLAZAL balsalazide BETAPACE, BETAPACE AF sotalol COLCRYS colchicine tablet BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, COMBIVENT RESPIMAT ipratropium-albuterol inhalation solution, ethinyl estradiol-norethindrone acetate, ANORO ELLIPTA, ethinyl estradiol-norethindrone acetate-iron BEVESPI AEROSPHERE, STIOLTO RESPIMAT bimatoprost solution 0.03% latanoprost, LUMIGAN, TRAVATAN Z CONSENSI amlodipine WITH celecoxib BREEZE 2 STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, 13 10 ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, CONTOUR NEXT STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS , 10 ACCU-CHEK GUIDE STRIPS AND KITS 10, ACCU-CHEK COMPACT PLUS STRIPS AND KITS , 10 ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 ACCU-CHEK GUIDE STRIPS AND KITS , ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel 13 10 (except bupropion ext-rel tablet 450 mg) CONTOUR STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, BUTALBITAL-ACETAMINOPHEN diclofenac sodium, ibuprofen, ACCU-CHEK GUIDE STRIPS AND KITS 10, (NDC^ 69499034230 only) naproxen (except naproxen CR or ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 naproxen suspension) CONTRAVE SAXENDA butalbital-acetaminophen-caffeine capsule diclofenac sodium, ibuprofen, naproxen (except naproxen CR or CORDRAN OINTMENT hydrocortisone butyrate cream, naproxen suspension) hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, BUTRANS buprenorphine transdermal, BELBUCA hydrocortisone butyrate solution, mometasone, triamcinolone cream, BYDUREON OZEMPIC, RYBELSUS, TRULICITY, triamcinolone lotion, triamcinolone ointment VICTOZA CoreMino doxycycline hyclate 20 mg, BYETTA OZEMPIC, RYBELSUS, TRULICITY, doxycycline hyclate capsule, minocycline, VICTOZA tetracycline CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, COUMADIN warfarin zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, CRESTOR atorvastatin, ezetimibe-simvastatin, ZEMBRACE SYMTOUCH, fluvastatin, lovastatin, pravastatin, ZOMIG NASAL SPRAY rosuvastatin, simvastatin calcipotriene cream calcipotriene ointment, calcipotriene solution cyclobenzaprine ext-rel capsule, cyclobenzaprine cyclobenzaprine tablet 7.5 mg (except cyclobenzaprine tablet 7.5 mg) calcitriol ointment calcipotriene ointment, calcipotriene solution CYMBALTA desvenlafaxine ext-rel, duloxetine, CAMBIA diclofenac sodium, ibuprofen, meloxicam, venlafaxine, venlafaxine ext-rel capsule naproxen (except naproxen CR or naproxen suspension) DELZICOL balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, CARAC fluorouracil cream 5%, fluorouracil solution, sulfasalazine delayed-rel, PENTASA imiquimod, PICATO, TOLAK, ZYCLARA DETROL LA darifenacin ext-rel, oxybutynin ext-rel, CARAFATE sucralfate solifenacin, tolterodine, tolterodine ext-rel, CARBINOXAMINE TABLET 6 MG levocetirizine trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ CARDIZEM, CARDIZEM CD, diltiazem ext-rel CARDIZEM LA (except generic CARDIZEM LA) dexchlorpheniramine levocetirizine CARNITOR, CARNITOR SF levocarnitine Dexifol folic acid chlordiazepoxide-clidinium dicyclomine Dexpak dexamethasone, hydrocortisone, (NDC^ 42494040901 only) methylprednisolone, prednisolone solution, prednisone chlorzoxazone 375 mg, chlorzoxazone 750 mg, cyclobenzaprine CHLORZOXAZONE 250 MG (except cyclobenzaprine tablet 7.5 mg)

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* diclofenac sodium gel 1% diclofenac sodium, diclofenac sodium gel 1% EDLUAR eszopiclone, ramelteon, zolpidem, (NDC^ 69499031866 only) (except NDC^ 69499031866), zolpidem ext-rel, zolpidem sublingual, diclofenac sodium solution, ibuprofen, BELSOMRA, SILENOR meloxicam, naproxen (except naproxen CR or naproxen suspension) E.E.S. GRANULES erythromycins Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1% EFFEXOR XR desvenlafaxine ext-rel, duloxetine, (except NDC^ 69499031866), venlafaxine, venlafaxine ext-rel capsule 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, Diclosaicin diclofenac sodium, diclofenac sodium gel 1% TOVIAZ (except NDC^ 69499031866), ENLITE CONTINUOUS DEXCOM CONTINUOUS diclofenac sodium solution, ibuprofen, GLUCOSE MONITORING SYSTEM GLUCOSE MONITORING SYSTEM meloxicam, naproxen (except naproxen CR or naproxen suspension) ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG diflorasone cream, diflorasone ointment desoximetasone, fluocinonide EPICERAM desonide, hydrocortisone (except fluocinonide cream 0.1%), BRYHALI ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, ONZETRA XSAIL, REYVOW, UBRELVY, zolmitriptan, NURTEC ODT, ZEMBRACE SYMTOUCH, ONZETRA XSAIL, REYVOW, UBRELVY, ZOMIG NASAL SPRAY ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY ERYPED erythromycins diltiazem ext-rel diltiazem ext-rel EVEKEO amphetamine- (generic CARDIZEM LA only) (except generic CARDIZEM LA) dextroamphetamine mixed salts, methylphenidate DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, EVZIO naloxone injection, NARCAN NASAL SPRAY irbesartan-hydrochlorothiazide, losartan, EXFORGE amlodipine-olmesartan, losartan-hydrochlorothiazide, olmesartan, amlodipine-telmisartan, amlodipine-valsartan olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, valsartan-hydrochlorothiazide olmesartan-amlodipine-hydrochlorothiazide DORAL eszopiclone, ramelteon, zolpidem, FANAPT aripiprazole, clozapine, olanzapine, zolpidem ext-rel, zolpidem sublingual, quetiapine, quetiapine ext-rel, risperidone, BELSOMRA, SILENOR ziprasidone, LATUDA, VRAYLAR DORYX, DORYX MPC doxycycline hyclate 20 mg, FEMRING estradiol, ESTRING, PREMARIN CREAM doxycycline hyclate capsule, minocycline, tetracycline fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel doxepin cream desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel doxycycline hyclate delayed-rel tablet 200 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, fenoprofen capsule diclofenac sodium, ibuprofen, meloxicam, tetracycline naproxen (except naproxen CR or naproxen suspension) doxycycline hyclate tablet 50 mg doxycycline hyclate 20 mg, (NDC^ 72143021160 only), doxycycline hyclate capsule, minocycline, FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, doxycycline hyclate tablet 75 mg, tetracycline naproxen (except naproxen CR or doxycycline hyclate tablet 150 mg naproxen suspension) doxycycline monohydrate capsule 75 mg, doxycycline hyclate 20 mg, FERIVA 21/7 folic acid doxycycline monohydrate capsule 150 mg doxycycline hyclate capsule, minocycline, FETZIMA desvenlafaxine ext-rel, duloxetine, tetracycline venlafaxine, venlafaxine ext-rel capsule DULERA ADVAIR DISKUS, ADVAIR HFA, Fexmid cyclobenzaprine BREO ELLIPTA, SYMBICORT (except cyclobenzaprine tablet 7.5 mg) DUTOPROL metoprolol succinate ext-rel WITH FINACEA GEL azelaic acid gel, metronidazole, hydrochlorothiazide FINACEA FOAM, SOOLANTRA DYRENIUM amiloride, triamterene FIORICET CAPSULE diclofenac sodium, ibuprofen, EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, naproxen (except naproxen CR or eprosartan, irbesartan, naproxen suspension) irbesartan-hydrochlorothiazide, losartan, FLAREX dexamethasone, loteprednol, losartan-hydrochlorothiazide, olmesartan, prednisolone acetate 1%, DUREZOL, olmesartan-hydrochlorothiazide, telmisartan, FML FORTE, FML S.O.P., MAXIDEX, telmisartan-hydrochlorothiazide, valsartan, PRED MILD valsartan-hydrochlorothiazide flucytosine capsule 500 mg fluconazole

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* fluocinonide cream 0.1% clobetasol cream hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate cream, hydrocortisone butyrate lotion, fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, hydrocortisone butyrate ointment, imiquimod, PICATO, TOLAK, ZYCLARA hydrocortisone butyrate solution, fluoxetine tablet 60 mg citalopram, escitalopram, mometasone, triamcinolone cream, fluoxetine (except fluoxetine tablet 60 mg), triamcinolone lotion, triamcinolone ointment paroxetine HCl, paroxetine HCl ext-rel, HylaVite folic acid sertraline, TRINTELLIX, VIIBRYD HYSINGLA ER fentanyl transdermal, hydromorphone ext-rel, flurandrenolide lotion desonide, hydrocortisone methadone, morphine ext-rel, NUCYNTA ER, (NDC^ 24470092112 only) XTAMPZA ER flurandrenolide ointment hydrocortisone butyrate cream, INDOCIN diclofenac sodium, ibuprofen, meloxicam, hydrocortisone butyrate lotion, naproxen (except naproxen CR or hydrocortisone butyrate ointment, naproxen suspension) hydrocortisone butyrate solution, mometasone, triamcinolone cream, Inflammacin diclofenac sodium, diclofenac sodium gel 1% triamcinolone lotion, triamcinolone ointment (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, FML LIQUIFILM dexamethasone, loteprednol, meloxicam, naproxen (except naproxen CR or prednisolone acetate 1%, DUREZOL, naproxen suspension) FML FORTE, FML S.O.P., MAXIDEX, PRED MILD INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, FOLIC-K folic acid metoprolol succinate ext-rel, Folvite-D folic acid metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC FORTAMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) INTERMEZZO eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, FORTESTA testosterone gel (except authorized generics BELSOMRA, SILENOR for TESTIM and VOGELXO), testosterone solution, ANDRODERM INTUNIV amphetamine- dextroamphetamine mixed salts ext-rel †, FOSAMAX PLUS D alendronate, ibandronate, risedronate atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, FOSRENOL calcium acetate, sevelamer carbonate, VYVANSE PHOSLYRA, VELPHORO INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate INVOKANA FARXIGA, JARDIANCE FREESTYLE LIBRE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM GLUCOSE MONITORING SYSTEM ISTALOL timolol maleate solution, BETIMOL, BETOPTIC S FREESTYLE STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, JALYN dutasteride-tamsulosin; dutasteride or ACCU-CHEK GUIDE STRIPS AND KITS 10, finasteride WITH alfuzosin ext-rel, doxazosin, ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 silodosin, tamsulosin or terazosin FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, KAMDOY desonide, hydrocortisone ZEMBRACE SYMTOUCH, KAZANO JANUMET, JANUMET XR ZOMIG NASAL SPRAY ketoconazole foam 2% ketoconazole shampoo 2%, Genicin Vita-S folic acid selenium sulfide lotion 2.5% GLUMETZA metformin, metformin ext-rel (except generics Ketodan ketoconazole shampoo 2%, for FORTAMET and GLUMETZA) selenium sulfide lotion 2.5% GLYCOPYRROLATE TABLET 1.5 MG dicyclomine ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, GUARDIAN CONNECT CONTINUOUS DEXCOM CONTINUOUS naproxen (except naproxen CR or GLUCOSE MONITORING SYSTEM GLUCOSE MONITORING SYSTEM naproxen suspension) HORIZANT gabapentin, GRALISE ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or HUMALOG FIASP, NOVOLOG naproxen suspension) HUMALOG MIX 50/50 NOVOLOG MIX 70/30 KOMBIGLYZE XR JANUMET, JANUMET XR HUMALOG MIX 75/25 NOVOLOG MIX 70/30 LACTULOSE PAK lactulose solution HUMULIN 70/30 NOVOLIN 70/30

HUMULIN N NOVOLIN N HUMULIN R NOVOLIN R

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* LAMICTAL, LAMICTAL ODT, LAMICTAL XR carbamazepine, carbamazepine ext-rel, MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, divalproex sodium, divalproex sodium ext-rel, eprosartan, irbesartan, gabapentin, lamotrigine, lamotrigine ext-rel, irbesartan-hydrochlorothiazide, losartan, levetiracetam, levetiracetam ext-rel, losartan-hydrochlorothiazide, olmesartan, oxcarbazepine, phenobarbital, phenytoin, olmesartan-hydrochlorothiazide, telmisartan, phenytoin sodium extended, primidone, telmisartan-hydrochlorothiazide, valsartan, tiagabine, topiramate, valproic acid, valsartan-hydrochlorothiazide zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, LANOXIN TABLET digoxin ONZETRA XSAIL, REYVOW, UBRELVY, (125 MCG and 250 MCG only) ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, LANTUS BASAGLAR, LEVEMIR prednisone LAZANDA fentanyl transmucosal lozenge, SUBSYS MINASTRIN 24 FE ethinyl estradiol-drospirenone, LESCOL XL atorvastatin, ezetimibe-simvastatin, ethinyl estradiol-drospirenone-levomefolate, fluvastatin, lovastatin, pravastatin, ethinyl estradiol-norethindrone acetate, rosuvastatin, simvastatin ethinyl estradiol-norethindrone acetate-iron levorphanol fentanyl transdermal, hydromorphone ext-rel, MINIVELLE estradiol, DIVIGEL, EVAMIST methadone, morphine ext-rel, NUCYNTA ER, MINOCIN doxycycline hyclate 20 mg, XTAMPZA ER doxycycline hyclate capsule, minocycline, LEXAPRO citalopram, escitalopram, tetracycline fluoxetine (except fluoxetine tablet 60 mg), minocycline ext-rel tablet doxycycline hyclate 20 mg, paroxetine HCl, paroxetine HCl ext-rel, doxycycline hyclate capsule, minocycline, sertraline, TRINTELLIX, VIIBRYD tetracycline LIALDA balsalazide, mesalamine delayed-rel, Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, mesalamine ext-rel, sulfasalazine, doxycycline hyclate capsule, minocycline, sulfasalazine delayed-rel, PENTASA tetracycline LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine MOVIPREP peg 3350-electrolytes, SUPREP LIDOTREX lidocaine-prilocaine mupirocin cream gentamicin, mupirocin ointment LIPITOR atorvastatin, ezetimibe-simvastatin, NAPRELAN diclofenac sodium, ibuprofen, meloxicam, fluvastatin, lovastatin, pravastatin, naproxen (except naproxen CR or rosuvastatin, simvastatin naproxen suspension) LIVALO atorvastatin, ezetimibe-simvastatin, naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or fluvastatin, lovastatin, pravastatin, naproxen (except naproxen CR or rosuvastatin, simvastatin naproxen suspension) WITH esomeprazole, Lorid folic acid lansoprazole, omeprazole, pantoprazole or DEXILANT Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) naproxen CR diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, naproxen suspension) prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, naproxen suspension ibuprofen PRED MILD NATAZIA ethinyl estradiol-drospirenone, LUNESTA eszopiclone, ramelteon, zolpidem, ethinyl estradiol-drospirenone-levomefolate, zolpidem ext-rel, zolpidem sublingual, ethinyl estradiol-levonorgestrel, BELSOMRA, SILENOR ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, MACRODANTIN nitrofurantoin ethinyl estradiol-norgestimate, LO LOESTRIN FE Matzim LA diltiazem ext-rel (except generic CARDIZEM LA) NATESTO testosterone gel (except authorized generics for TESTIM and VOGELXO), MENEST estradiol, PREMARIN testosterone solution, ANDRODERM MENOSTAR estradiol NESINA JANUVIA metformin ext-rel metformin, metformin ext-rel (except generics NEXIUM esomeprazole, lansoprazole, omeprazole, (generics for FORTAMET and GLUMETZA only) for FORTAMET and GLUMETZA) pantoprazole, DEXILANT MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, NICADAN folic acid risedronate, FORTEO, PROLIA, TYMLOS NICAPRIN folic acid MIACALCIN NASAL SPRAY calcitonin-salmon NICAZEL, NICAZEL FORTE folic acid

NICOMIDE folic acid

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* NILANDRON abiraterone, bicalutamide, XTANDI, YONSA PANCREAZE CREON, VIOKACE, ZENPEP NITROMIST nitroglycerin lingual spray, PENNSAID diclofenac sodium, diclofenac sodium gel 1% nitroglycerin sublingual (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, NORGESIC FORTE cyclobenzaprine meloxicam, naproxen (except naproxen CR or (except cyclobenzaprine tablet 7.5 mg) naproxen suspension) NORITATE azelaic acid gel, metronidazole, PERCOCET hydrocodone-acetaminophen, FINACEA FOAM, SOOLANTRA hydromorphone, morphine, NORVASC amlodipine oxycodone-acetaminophen, NUCYNTA 12 NOVACORT desonide, hydrocortisone PERRIGO NEEDLES BD ULTRAFINE NEEDLES NOVO NORDISK NEEDLES 12 BD ULTRAFINE NEEDLES PERTZYE CREON, VIOKACE, ZENPEP NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1% PEXEVA citalopram, escitalopram, (except NDC^ 69499031866), fluoxetine (except fluoxetine tablet 60 mg), diclofenac sodium solution, ibuprofen, paroxetine HCl, paroxetine HCl ext-rel, meloxicam, naproxen (except naproxen CR or sertraline, TRINTELLIX, VIIBRYD naproxen suspension) PLAVIX clopidogrel, prasugrel, BRILINTA NUVIGIL armodafinil, SUNOSI POLYTOZA Consult doctor Okebo doxycycline hyclate 20 mg, posaconazole delayed-rel tablet fluconazole, itraconazole doxycycline hyclate capsule, minocycline, tetracycline PRADAXA warfarin, ELIQUIS, XARELTO OLEPTRO trazodone PRECISION XTRA STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, OLUX-E clobetasol foam ACCU-CHEK GUIDE STRIPS AND KITS 10, 10 omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole, ACCU-CHEK SMARTVIEW STRIPS AND KITS pantoprazole, DEXILANT PRED FORTE dexamethasone, loteprednol, OMNARIS flunisolide, fluticasone, mometasone, prednisolone acetate 1%, DUREZOL, DYMISTA FML FORTE, FML S.O.P., MAXIDEX, PRED MILD OMNIVEX folic acid PREFEST estradiol-norethindrone, PREMPHASE, ONETOUCH ULTRA STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, PREMPRO ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, ACCU-CHEK GUIDE STRIPS AND KITS 10, PRENATAL PLUS generic prenatal vitamins, CITRANATAL 10 ACCU-CHEK SMARTVIEW STRIPS AND KITS PREVACID esomeprazole, lansoprazole, omeprazole, ONETOUCH VERIO STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, pantoprazole, DEXILANT 10 ACCU-CHEK COMPACT PLUS STRIPS AND KITS , PREVIDENT Consult doctor ACCU-CHEK GUIDE STRIPS AND KITS 10, ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 PRIMLEV hydrocodone-acetaminophen, hydromorphone, morphine, ONFI clobazam, lamotrigine, topiramate, oxycodone-acetaminophen, NUCYNTA TROKENDI XR PRISTIQ desvenlafaxine ext-rel, duloxetine, ONGLYZA JANUVIA venlafaxine, venlafaxine ext-rel capsule orphenadrine-aspirin-caffeine cyclobenzaprine PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol, (except cyclobenzaprine tablet 7.5 mg) levalbuterol tartrate CFC-free aerosol Orphengesic Forte cyclobenzaprine PRODIGEN Consult doctor (except cyclobenzaprine tablet 7.5 mg) PROTONIX esomeprazole, lansoprazole, omeprazole, ORTHO D folic acid pantoprazole, DEXILANT ORTHO DF folic acid PROTOPIC pimecrolimus, tacrolimus, EUCRISA ORTHO TRI-CYCLEN LO ethinyl estradiol-norgestimate PROVENTIL HFA albuterol sulfate CFC-free aerosol, OSENI JANUMET, JANUMET XR; JANUVIA WITH levalbuterol tartrate CFC-free aerosol pioglitazone PROZAC citalopram, escitalopram, OSMOPREP peg 3350-electrolytes, SUPREP fluoxetine (except fluoxetine tablet 60 mg), paroxetine HCl, paroxetine HCl ext-rel, OWEN MUMFORD NEEDLES 12 BD ULTRAFINE NEEDLES sertraline, TRINTELLIX, VIIBRYD OXYCONTIN fentanyl transdermal, hydromorphone ext-rel, PSORCON desoximetasone, fluocinonide methadone, morphine ext-rel, NUCYNTA ER, (except fluocinonide cream 0.1%), XTAMPZA ER BRYHALI OXYTROL darifenacin ext-rel, oxybutynin ext-rel, QNASL flunisolide, fluticasone, mometasone, solifenacin, tolterodine, tolterodine ext-rel, DYMISTA trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ QSYMIA SAXENDA QTERN GLYXAMBI

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, TESTIM testosterone gel (except authorized generics tamsulosin, terazosin for TESTIM and VOGELXO), testosterone solution, ANDRODERM RAYOS dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, testosterone gel 1% testosterone gel (except authorized generics prednisone (authorized generics for TESTIM and for TESTIM and VOGELXO), VOGELXO only) testosterone solution, ANDRODERM RECEDO Consult doctor TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, RELION INSULIN NOVOLIN INSULIN BETOPTIC S RHEUMATE folic acid TIROSINT levothyroxine, SYNTHROID RIBOZEL folic acid TOPROL-XL atenolol, carvedilol, RIMSO-50 Consult doctor carvedilol phosphate ext-rel, metoprolol succinate ext-rel, RIOMET metformin, metformin ext-rel (except generics metoprolol tartrate, nadolol, pindolol, for FORTAMET and GLUMETZA) propranolol, propranolol ext-rel, BYSTOLIC ROZEREM eszopiclone, ramelteon, zolpidem, TOUJEO TRESIBA zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR TRADJENTA JANUVIA RyClora levocetirizine tramadol (NDC^ 52817019610 only) tramadol (except NDC^ 52817019610), tramadol ext-rel SCARSILK PAD Consult doctor TRANSDERM SCOP meclizine, scopolamine transdermal SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, TREXIMET diclofenac sodium, ibuprofen or ziprasidone, LATUDA, VRAYLAR naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, SIL-K PAD Consult doctor naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, SILIVEX Consult doctor ONZETRA XSAIL, REYVOW, UBRELVY, SILTREX Consult doctor ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY SINGULAIR montelukast, zafirlukast, zileuton ext-rel triamcinolone acetonide aerosol 0.2% hydrocortisone butyrate cream, SORILUX calcipotriene ointment, calcipotriene solution hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, SPRIX diclofenac sodium, ibuprofen, meloxicam, hydrocortisone butyrate solution, naproxen (except naproxen CR or mometasone, triamcinolone cream, naproxen suspension) triamcinolone lotion, triamcinolone ointment STENDRA sildenafil, tadalafil TRICOR fenofibrate (except fenofibrate tablet 120 mg), STRIANT testosterone gel (except authorized generics fenofibric acid delayed-rel for TESTIM and VOGELXO), TRIGLIDE fenofibrate (except fenofibrate tablet 120 mg), testosterone solution, ANDRODERM fenofibric acid delayed-rel SUBOXONE buprenorphine-naloxone sublingual, TRILIPIX fenofibrate (except fenofibrate tablet 120 mg), ZUBSOLV fenofibric acid delayed-rel sumatriptan-naproxen diclofenac sodium, ibuprofen or TRIVIDIA INSULIN SYRINGES 12 BD ULTRAFINE INSULIN SYRINGES naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, TronVite folic acid naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TRUETEST STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, ONZETRA XSAIL, REYVOW, UBRELVY, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, ZEMBRACE SYMTOUCH or ACCU-CHEK GUIDE STRIPS AND KITS 10, ZOMIG NASAL SPRAY ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 SURE-TEST STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, TRUETRACK STRIPS AND KITS 13 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, 10 ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, ACCU-CHEK COMPACT PLUS STRIPS AND KITS , ACCU-CHEK GUIDE STRIPS AND KITS 10, ACCU-CHEK GUIDE STRIPS AND KITS 10, 10 ACCU-CHEK SMARTVIEW STRIPS AND KITS 10 ACCU-CHEK SMARTVIEW STRIPS AND KITS SYNERDERM desonide, hydrocortisone TUDORZA INCRUSE ELLIPTA, SPIRIVA, YUPELRI TALIVA folic acid ULTIMED INSULIN SYRINGES 12 BD ULTRAFINE INSULIN SYRINGES TARGADOX doxycycline hyclate 20 mg, ULTIMED NEEDLES 12 BD ULTRAFINE NEEDLES doxycycline hyclate capsule, minocycline, UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tetracycline tamsulosin, terazosin TAYTULLA ethinyl estradiol-drospirenone, VALCYTE valganciclovir ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, VALTREX acyclovir capsule, acyclovir tablet, ethinyl estradiol-norethindrone acetate-iron valacyclovir

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* Vanatol LQ, Vanatol S diclofenac sodium, ibuprofen, ZEGERID esomeprazole, lansoprazole, omeprazole, naproxen (except naproxen CR or pantoprazole, DEXILANT naproxen suspension) ZETIA ezetimibe Vanoxide-HC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), ZETONNA flunisolide, fluticasone, mometasone, clindamycin solution, clindamycin- DYMISTA benzoyl peroxide, erythromycin solution, ZIANA adapalene, benzoyl peroxide, erythromycin-benzoyl peroxide, tretinoin, clindamycin gel (except NDC^ 68682046275), EPIDUO, ONEXTON, TAZORAC clindamycin solution, clindamycin- VASCULERA Consult doctor benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, VECTICAL calcipotriene ointment, calcipotriene solution EPIDUO, ONEXTON, TAZORAC VELTIN adapalene, benzoyl peroxide, ZOHYDRO ER fentanyl transdermal, hydromorphone ext-rel, clindamycin gel (except NDC^ 68682046275), methadone, morphine ext-rel, NUCYNTA ER, clindamycin solution, clindamycin- XTAMPZA ER benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ZOLPIMIST eszopiclone, ramelteon, zolpidem, EPIDUO, ONEXTON, TAZORAC zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, VENTOLIN HFA albuterol sulfate CFC-free aerosol, gabapentin, lamotrigine, lamotrigine ext-rel, levalbuterol tartrate CFC-free aerosol levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, VEREGEN imiquimod phenytoin sodium extended, primidone, VIAGRA sildenafil, tadalafil tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, VITAFOL-ONE generic prenatal vitamins, CITRANATAL TROKENDI XR, VIMPAT Vitasure folic acid ZONTIVITY Consult doctor VIVELLE-DOT estradiol, DIVIGEL, EVAMIST ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or VOGELXO testosterone gel (except authorized generics naproxen suspension) for TESTIM and VOGELXO), testosterone solution, ANDRODERM ZUPLENZ granisetron, ondansetron, SANCUSO XANAX, XANAX XR alprazolam, clonazepam, diazepam, ZYFLO montelukast, zafirlukast, zileuton ext-rel lorazepam, oxazepam ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, XOLEGEL ciclopirox, ketoconazole cream 2% neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, XOPENEX HFA albuterol sulfate CFC-free aerosol, TOBRADEX OINTMENT, TOBRADEX ST levalbuterol tartrate CFC-free aerosol ZYVIT folic acid Xvite folic acid

XYZBAC folic acid YAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay1 information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. † Listing does not include certain NDCs^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 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. 2 Listing does not include naproxen CR or naproxen suspension. 3 Listing does not include fenofibrate tablet 120 mg. 4 Listing does not include generic CARDIZEM LA. 5 Listing does not include fluoxetine tablet 60 mg. 6 Listing does not include bupropion ext-rel tablet 450 mg. 7 Listing does not include cyclobenzaprine tablet 7.5 mg. 8 Listing does not include the authorized generics for TESTIM and VOGELXO. 9 Listing does not include generics for FORTAMET and GLUMETZA. 10 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 11 Listing does not include fluocinonide cream 0.1%. 12 BD ULTRAFINE syringes and needles are the only preferred options. 13 ACCU-CHEK brand test strips are the only preferred options.

CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. 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.