Excluded Medication List for Clients with Advanced Control Specialty

July 2021

Excluded Medication List for Clients with Advanced ® Control Specialty Formulary

Below is a list of medicines by drug class that have been removed from the HealthChoice formulary. If you continue using one of the drugs listed below and identified as an excluded medication, you may be required to pay the full cost.

If you are currently using one of the excluded medications listed below, ask your doctor to choose one of the preferred options listed below.

Category Excluded Medications Preferred Alternatives Drug Class Acromegaly SANDOSTATIN LAR 1 SOMATULINE DEPOT SIGNIFOR LAR 1 SOMAVERT 1

Allergies dexchlorpheniramine levocetirizine Antihistamines Diphen Elixir RyClora CARBINOXAMINE TABLET 6 MG

Allergies BECONASE AQ flunisolide spray, fluticasone spray, mometasone spray, DYMISTA Nasal Steroids / Combinations OMNARIS QNASL ZETONNA

Anticonvulsants topiramate ext-rel capsule carbamazepine, carbamazepine ext-rel, clobazam, divalproex sodium, (generics for QUDEXY XR only) divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, rufinamide, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

BANZEL SUSPENSION clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR ONFI

SABRIL 1 vigabatrin

ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext- rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

Anti-infectives, Antibacterials E.E.S. GRANULES erythromycins Erythromycins / Macrolides ERYPED Anti-infectives, Antibacterials doxycycline hyclate delayed-rel tablet 50 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline Tetracyclines doxycycline hyclate delayed-rel tablet 200 mg doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only) doxycycline hyclate tablet 75 mg doxycycline hyclate tablet 150 mg doxycycline monohydrate capsule 75 mg doxycycline monohydrate capsule 150 mg minocycline ext-rel CoreMino Mondoxyne NL capsule 75 mg ACTICLATE DORYX DORYX MPC MINOCIN TARGADOX

Category Excluded Medications Preferred Alternatives Drug Class

Anti-infectives, Antibacterials nitrofurantoin (NDC^ 70408023932 only) nitrofurantoin (except NDC^ 70408023932) Miscellaneous MACRODANTIN

Anti-infectives, Antifungals flucytosine capsule 500 mg fluconazole posaconazole delayed-rel tablet fluconazole, itraconazole NOXAFIL

CRESEMBA itraconazole

Anti-infectives, APTIVUS 1 Consult doctor Antiretroviral Agents INVIRASE 1 atazanavir, lopinavir-ritonavir solution, EVOTAZ, PREZCOBIX, PREZISTA Protease Inhibitors LEXIVA 1 VIRACEPT 1

Anti-infectives, Antivirals VALCYTE valganciclovir Cytomegalovirus *

Anti-infectives, Antivirals BARACLUDE TABLET 1 entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, Hepatitis B * EPIVIR HBV 1 VEMLIDY HEPSERA 1

Anti-infectives, Antivirals MAVYRET 1 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2 Hepatitis C * VIEKIRA PAK 1 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) ZEPATIER 1 Anti-infectives, Antivirals acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir Herpes * VALTREX

Anti-infectives, Antivirals COMPLERA 1 efavirenz-emtricitabine-tenofovir disoproxil fumarate, HIV STRIBILD 1 efavirenz-lamivudine-tenofovir disoproxil fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ

Anti-infectives DARAPRIM pyrimethamine Miscellaneous

Anxiety * ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam Benzodiazepines XANAX XANAX XR

Asthma * PROAIR HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol Beta Agonists, Short-Acting PROAIR RESPICLICK PROVENTIL HFA VENTOLIN HFA XOPENEX HFA

Asthma * zileuton ext-rel montelukast, zafirlukast Leukotriene Modulators SINGULAIR

Asthma * ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, Steroid Inhalants ASMANEX PULMICORT FLEXHALER, QVAR REDIHALER ASMANEX HFA

Asthma * or Chronic Obstructive DULERA ADVAIR DISKUS, ADVAIR HFA †, BREO ELLIPTA †, SYMBICORT Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations

Category Excluded Medications Preferred Alternatives Drug Class

Attention Deficit Hyperactivity ADDERALL amphetamine-dextroamphetamine mixed salts, methylphenidate Disorder * EVEKEO ADZENYS ER amphetamine-dextroamphetamine mixed salts ext-rel †, dexmethylphenidate ext-rel, ADZENYS XR-ODT methylphenidate ext-rel †, MYDAYIS, VYVANSE APTENSIO XR DAYTRANA FOCALIN XR

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel †, atomoxetine, dexmethylphenidate ext-rel, guanfacine ext-rel, methylphenidate ext- rel †, MYDAYIS, VYVANSE

Autoimmune Agents ACTEMRA INTRAVENOUS 1 REMICADE, SIMPONI ARIA Physician-Administered Agents ORENCIA INTRAVENOUS 1 AVSOLA 1 REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS CIMZIA LYOPHILIZED POWDER 1 INFLECTRA 1 RENFLEXIS 1

ENTYVIO (For Crohn’s Disease Only) 1 REMICADE, STELARA INTRAVENOUS

ILUMYA 1 REMICADE

Autoimmune Agents CIMZIA PREFILLED SYRINGE 1 COSENTYX, ENBREL, HUMIRA Self-Administered Agents SIMPONI 1 TALTZ 1 Ankylosing Spondylitis *

Autoimmune Agents CIMZIA PREFILLED SYRINGE 1 HUMIRA, STELARA SUBCUTANEOUS # Self-Administered Agents # After failure of HUMIRA Crohn's Disease *

Autoimmune Agents CIMZIA PREFILLED SYRINGE 1 HUMIRA, OTEZLA, SKYRIZI, STELARA SUBCUTANEOUS, TALTZ, TREMFYA Self-Administered Agents COSENTYX 1 ENBREL 1 Psoriasis *

Autoimmune Agents CIMZIA PREFILLED SYRINGE 1 COSENTYX, ENBREL, HUMIRA, OTEZLA Self-Administered Agents ORENCIA CLICKJECT 1 ORENCIA SUBCUTANEOUS 1 Psoriatic Arthritis * SIMPONI 1 STELARA SUBCUTANEOUS 1 TALTZ 1 TREMFYA 1 XELJANZ 1 XELJANZ XR 1

Autoimmune Agents ACTEMRA ACTPEN 1 ENBREL, HUMIRA, KEVZARA, ORENCIA CLICKJECT, Self-Administered Agents ACTEMRA SUBCUTANEOUS 1 ORENCIA SUBCUTANEOUS, RINVOQ, XELJANZ, XELJANZ XR CIMZIA PREFILLED SYRINGE 1 Rheumatoid Arthritis * KINERET 1 SIMPONI 1

Autoimmune Agents SIMPONI 1 HUMIRA, STELARA SUBCUTANEOUS #, XELJANZ #, XELJANZ XR # Self-Administered Agents # After failure of HUMIRA Ulcerative Colitis *

Autoimmune Agents ACTEMRA ACTPEN 1 ENBREL, HUMIRA Self-Administered Agents ACTEMRA SUBCUTANEOUS 1 KINERET 1 All Other Conditions * ORENCIA CLICKJECT 1 ORENCIA SUBCUTANEOUS 1

Cancer RIABNI 1 RUXIENCE Biosimilars TRUXIMA 1

Cancer GLEEVEC 1 imatinib mesylate, BOSULIF, SPRYCEL Chronic Myelogenous TASIGNA 1 Leukemia *

Category Excluded Medications Preferred Alternatives Drug Class

Cancer ALIQOPA 1 COPIKTRA Follicular Lymphoma * ZYDELIG 1 PI3K Inhibitors

Cancer AVASTIN 1 ZIRABEV Monoclonal Antibodies HERCEPTIN 1 KANJINTI, TRAZIMERA HERCEPTIN HYLECTA 1

RITUXAN 1 RUXIENCE

Cancer BORTEZOMIB 1 NINLARO, VELCADE Multiple Myeloma * KYPROLIS 1 Proteasome Inhibitors

Cancer NILANDRON abiraterone, bicalutamide, XTANDI, YONSA Prostate * ZYTIGA 1 Antiandrogens

Cancer LUPRON DEPOT 1 ELIGARD, FIRMAGON Prostate * TRELSTAR MIXJECT 1 ZOLADEX 1 Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

Cardiovascular BETAPACE sotalol Antiarrhythmics BETAPACE AF NORPACE disopyramide

Cardiovascular ZETIA ezetimibe Antilipemics Cholesterol Absorption Inhibitors Cardiovascular fenofibrate capsule 50 mg fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), Antilipemics fenofibrate capsule 130 mg fenofibric acid delayed-rel fenofibrate tablet 40 mg Fibrates fenofibrate tablet 120 mg FENOGLIDE TABLET 120 MG TRICOR

Cardiovascular ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, Antilipemics CRESTOR simvastatin LESCOL XL HMG-CoA Reductase Inhibitors LIPITOR (HMGs or Statins) / Combinations 3 LIVALO

Cardiovascular niacin tablet 500 mg niacin ext-rel Antilipemics Niacor Niacins Cardiovascular icosapent ethyl omega-3 acid ethyl esters, VASCEPA Antilipemics Omega-3 Fatty Acids Cardiovascular REPATHA 1 PRALUENT Antilipemics PCSK9 Inhibitors

Cardiovascular LANOXIN TABLET digoxin Digitalis Glycosides (125 MCG and 250 MCG only)

Cardiovascular DYRENIUM amiloride, triamterene Diuretics

Cardiovascular isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate Nitrates

Category Excluded Medications Preferred Alternatives Drug Class

Cardiovascular LETAIRIS 1 ambrisentan, bosentan, OPSUMIT Pulmonary Arterial Hypertension TRACLEER 1 Endothelin Receptor Antagonists

Cardiovascular ADCIRCA 1 sildenafil, tadalafil Pulmonary Arterial Hypertension REVATIO 1 Phosphodiesterase Inhibitors Cardiovascular REMODULIN 1 treprostinil Pulmonary Arterial Hypertension Prostaglandin Vasodilators

Carnitine Deficiency CARNITOR levocarnitine CARNITOR SF

Central Precocious Puberty LUPRON DEPOT-PED 1 SUPPRELIN LA, TRIPTODUR

Chronic Obstructive Pulmonary INCRUSE ELLIPTA SPIRIVA, YUPELRI Disease (COPD) * TUDORZA Anticholinergics

Chronic Obstructive Pulmonary BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT Disease (COPD) * Anticholinergic / Beta Agonist Combinations Long Acting Contraceptives BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, Monophasic MINASTRIN 24 FE ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron TAYTULLA YASMIN YAZ

Contraceptives NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, Four Phase ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE

Contraceptives SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, Extended Cycle ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Contraceptives LILETTA 1 KYLEENA, MIRENA, SKYLA Progestin Intrauterine Devices

Contraceptives NUVARING ethinyl estradiol-etonogestrel, ANNOVERA Vaginal

Cystic Fibrosis * TOBI 1 tobramycin inhalation solution, BETHKIS Inhaled Antibiotics TOBI PODHALER 1

Dental PREVIDENT Consult doctor Cavity/Caries Prevention

Depression * fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, Antidepressants, Selective LEXAPRO fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, PAXIL sertraline, TRINTELLIX Serotonin Reuptake Inhibitors PAXIL CR (SSRIs) PEXEVA PROZAC VIIBRYD ZOLOFT

Category Excluded Medications Preferred Alternatives Drug Class

Depression * venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule Antidepressants, Serotonin CYMBALTA EFFEXOR XR Norepinephrine Reuptake PRISTIQ Inhibitors (SNRIs) Depression * bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) Antidepressants, OLEPTRO trazodone Miscellaneous Agents

Depression and/or Schizophrenia * ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, Antipsychotics, Atypicals FANAPT ziprasidone, LATUDA, VRAYLAR SEROQUEL XR

Dermatology clindamycin gel (NDC^ 68682046275 only) adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), Acne * Vanoxide-HC clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, ACANYA erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON AZELEX BENZACLIN DIFFERIN LOTION FABIOR TAZORAC VELTIN ZIANA

Dermatology fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, Actinic Keratosis * CARAC ZYCLARA Dermatology NEO-SYNALAR desonide or hydrocortisone WITH gentamicin Anti-infective / Anti-inflammatory Dermatology mupirocin cream gentamicin, mupirocin ointment Antibiotics Dermatology calcipotriene cream calcipotriene ointment, calcipotriene solution Antipsoriatics calcitriol ointment SORILUX TAZORAC VECTICAL

calcipotriene-betamethasone calcipotriene ointment or calcipotriene solution WITH desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%) or BRYHALI

Dermatology doxepin cream desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA Atopic Dermatitis * ELIDEL pimecrolimus, tacrolimus, EUCRISA

Dermatology doxycycline monohydrate ORACEA Rosacea * delayed-rel capsule FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA MIRVASO NORITATE

Dermatology BEAU RX Consult doctor Scars CICATRACE POLYTOZA RECEDO SCARSILK PAD SIL-K PAD SILIVEX SILTREX Dermatology ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5% Seborrheic Dermatitis * Ketodan XOLEGEL ciclopirox, ketoconazole cream 2%

Category Excluded Medications Preferred Alternatives Drug Class

Dermatology clobetasol spray clobetasol foam Skin Inflammation and Hives * CLOBEX SPRAY OLUX-E Corticosteroids fluocinonide cream 0.1% clobetasol cream

flurandrenolide cream desonide, hydrocortisone flurandrenolide lotion Nolix

clocortolone cream hydrocortisone butyrate cream, hydrocortisone butyrate ointment, desoximetasone ointment 0.05% hydrocortisone butyrate solution, mometasone, triamcinolone cream, flurandrenolide ointment triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate lotion triamcinolone aerosol 0.2% triamcinolone ointment 0.05% Trianex CORDRAN OINTMENT

diflorasone cream desoximetasone (except desoximetasone ointment 0.05%), diflorasone ointment fluocinonide (except fluocinonide cream 0.1%), BRYHALI halcinonide cream APEXICON E PSORCON

Dermatology VEREGEN imiquimod Warts Dermatology ALEVICYN GEL desonide, hydrocortisone Wound Care Products ALEVICYN SG ALEVICYN SOLUTION

Dermatology ALCORTIN A desonide, hydrocortisone Miscellaneous Skin Conditions ATOPADERM BENSAL HP EPICERAM KAMDOY NOVACORT SYNERDERM

luliconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, NAFTIN oxiconazole (NDCs^ 00168035830, 51672135902 only)

Diabetes * metformin ext-rel (generics for FORTAMET and metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) Biguanides GLUMETZA only) FORTAMET GLUMETZA RIOMET

Diabetes * NESINA JANUVIA Dipeptidyl Peptidase-4 ONGLYZA TRADJENTA (DPP-4) Inhibitors Diabetes * JENTADUETO JANUMET, JANUMET XR Dipeptidyl Peptidase-4 JENTADUETO XR KAZANO (DPP-4) Inhibitor Combinations KOMBIGLYZE XR

OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone

Diabetes * BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA Injectable Incretin Mimetics BYETTA

Category Excluded Medications Preferred Alternatives Drug Class

Diabetes * APIDRA FIASP, NOVOLOG Insulins HUMALOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 4 NOVOLIN 70/30 4

HUMULIN N 4 NOVOLIN N 4

HUMULIN R 4 NOVOLIN R 4

NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered.

Diabetes * LANTUS BASAGLAR, LEVEMIR Long Acting Insulins 5

Diabetes * ACTOS pioglitazone Insulin Sensitizers

Diabetes * INVOKANA FARXIGA, JARDIANCE Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors Diabetes * INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR Sodium-Glucose INVOKAMET XR Co-transporter 2 (SGLT2) Inhibitor / Biguanide Combinations Diabetes * QTERN GLYXAMBI Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor / Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations Diabetes * NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES Supplies, Needles 6 OWEN MUMFORD NEEDLES PERRIGO NEEDLES ULTIMED NEEDLES All other insulin needles that are not BD ULTRAFINE brand

Diabetes * ALLISON MEDICAL INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES Supplies, Syringes 6 TRIVIDIA INSULIN SYRINGES ULTIMED INSULIN SYRINGES All other insulin syringes that are not BD ULTRAFINE brand

Category Excluded Medications Preferred Alternatives Drug Class

Diabetes * BREEZE 2 STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 7, Supplies, Test Strips and Kits 7, 8 CONTOUR NEXT STRIPS AND KITS ACCU-CHEK COMPACT PLUS STRIPS AND KITS 7, CONTOUR STRIPS AND KITS ACCU-CHEK GUIDE STRIPS AND KITS 7, FREESTYLE STRIPS AND KITS ACCU-CHEK SMARTVIEW STRIPS AND KITS 7, All other test strips that are not ONETOUCH ULTRA STRIPS AND KITS 7, ACCU-CHEK or ONETOUCH brand ONETOUCH VERIO STRIPS AND KITS 7

ENLITE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM GLUCOSE MONITORING SYSTEM EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING SYSTEM GUARDIAN CONNECT CONTINUOUS GLUCOSE MONITORING SYSTEM GUARDIAN REAL-TIME CONTINUOUS GLUCOSE MONITORING SYSTEM All other continuous glucose monitoring systems that are not DEXCOM brand

Dietary Supplements FOSTEUM alendronate, ibandronate, risedronate FOSTEUM PLUS

Activite folic acid Dexifol Folvite-D Genicin Vita-S HylaVite Lorid TronVite Vitasure Xvite FERIVA 21/7 FOLIC-K NICADAN NICAPRIN NICAZEL NICAZEL FORTE NICOMIDE OMNIVEX ORTHO D ORTHO DF RHEUMATE RIBOZEL TALIVA XYZBAC ZYVIT

MultiPro Consult doctor PRODIGEN VASCULERA

Endocrine and Metabolic PROMETRIUM medroxyprogesterone; progesterone, micronized Progestins

Endometriosis * LUPRON DEPOT 1 ORILISSA ZOLADEX 1

Fertility * FOLLISTIM AQ 1 GONAL-F

CHORIONIC GONADOTROPIN 1 OVIDREL NOVAREL 1 PREGNYL 1

Category Excluded Medications Preferred Alternatives Drug Class

Gastrointestinal chlordiazepoxide-clidinium dicyclomine Anticholinergics (NDCs^ 11534019701, 42494040901, 51293069601, 51293069610 only) hyoscyamine sulfate ext-rel Oscimin SR Symax-SR GLYCOPYRROLATE TABLET 1.5 MG LIBRAX

Gastrointestinal ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG Antidiarrheals MYTESI diphenoxylate-atropine, loperamide

Gastrointestinal TRANSDERM SCOP meclizine, scopolamine transdermal Antiemetics ZUPLENZ granisetron, ondansetron, SANCUSO

Gastrointestinal AMITIZA LINZESS, MOVANTIK, SYMPROIC Irritable Bowel Syndrome

Gastrointestinal LACTULOSE PAK lactulose solution Laxatives GOLYTELY peg 3350-electrolytes, CLENPIQ MOVIPREP OSMOPREP SUPREP

Gastrointestinal Lactojen Consult doctor Probiotics PROVAD ZELAC

Gastrointestinal omeprazole-sodium bicarbonate esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, Proton Pump Inhibitors (PPIs) pantoprazole delayed-rel suspension pantoprazole delayed-rel tablet, DEXILANT ACIPHEX ACIPHEX SPRINKLE NEXIUM PREVACID PRILOSEC PROTONIX ZEGERID

Gastrointestinal sucralfate suspension sucralfate tablet Ulcer Treatment CARAFATE

Gaucher Disease ELELYSO 1 CERDELGA, CEREZYME Genitourinary ELMIRON Consult doctor Interstitial Cystitis RIMSO-50 Genitourinary LITHOSTAT Consult doctor Miscellaneous THIOLA THIOLA EC

Gout * colchicine capsule colchicine tablet, MITIGARE COLCRYS

ULORIC allopurinol

Growth Hormones GENOTROPIN 1 NORDITROPIN HUMATROPE 1 NUTROPIN AQ 1 OMNITROPE 1 SAIZEN 1

Hematologic PRADAXA warfarin, ELIQUIS, XARELTO Anticoagulants (oral)

Category Excluded Medications Preferred Alternatives Drug Class

Hematologic CUPRIMINE penicillamine capsule Chelating Agents DESFERAL 1 deferasirox, deferiprone, deferoxamine EXJADE 1 FERRIPROX 1 JADENU 1

SYPRINE trientine

Hematologic EPOGEN 1 ARANESP, RETACRIT Erythropoiesis-Stimulating Agents PROCRIT 1

Hematologic ALPROLIX 1 Consult doctor Hemophilia B

Hematologic FULPHILA 1 ZIEXTENZO Neutropenia Colony NEULASTA 1 NEULASTA ONPRO 1 Stimulating Factors UDENYCA 1

GRANIX 1 NIVESTYM NEUPOGEN 1 ZARXIO 1 Hematologic PLAVIX clopidogrel, prasugrel, BRILINTA Platelet Aggregation Inhibitors ZONTIVITY Consult doctor

High Blood Pressure * ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide, ACE Inhibitor / quinapril-hydrochlorothiazide Diuretic Combinations

High Blood Pressure * ATACAND candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan Angiotensin II Receptor BENICAR COZAAR Antagonists DIOVAN EDARBI MICARDIS

High Blood Pressure * ATACAND HCT candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, Angiotensin II Receptor BENICAR HCT losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, DIOVAN HCT telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide Antagonist / Diuretic Combinations EDARBYCLOR HYZAAR MICARDIS HCT High Blood Pressure * AZOR amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan Angiotensin II Receptor EXFORGE Antagonist / Calcium Channel Blocker Combinations

High Blood Pressure * EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine- Angiotensin II Receptor hydrochlorothiazide Antagonist / Calcium Channel Blocker / Diuretic Combinations High Blood Pressure * COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, Beta-blockers INDERAL LA metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC INDERAL XL INNOPRAN XL TOPROL-XL

High Blood Pressure * DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide Beta-blocker Combinations

Category Excluded Medications Preferred Alternatives Drug Class

High Blood Pressure * NORVASC amlodipine Calcium Channel Blockers diltiazem ext-rel diltiazem ext-rel (except generics for CARDIZEM LA) (generics for CARDIZEM LA only) Matzim LA CARDIZEM CARDIZEM CD CARDIZEM LA

High Blood Pressure * CONSENSI amlodipine WITH celecoxib Calcium Channel Blocker / Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Combinations

Huntington's Disease XENAZINE 1 tetrabenazine, AUSTEDO

Immunology CELLCEPT 1 mycophenolate mofetil, mycophenolate sodium Antimetabolites MYFORTIC 1

Immunology ASTAGRAF XL 1 tacrolimus Calcineurin Inhibitors ENVARSUS XR 1

Immunology OTREXUP 1 RASUVO Disease Modifying Antirheumatic Agents

Immunology BERINERT 1 icatibant, RUCONEST Hereditary Angioedema *

Immunology RAPAMUNE 1 everolimus, sirolimus Rapamycin Derivatives ZORTRESS 1

Inflammatory Bowel Disease (IBD) mesalamine delayed-rel tablet 800 mg balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 Ulcerative Colitis * COLAZAL mg), mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, DELZICOL PENTASA Aminosalicylates LIALDA

Interferons * PEGASYS 1 Consult doctor

Kidney Disease * lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO Phosphate Binders FOSRENOL Menopausal Symptom Agents paroxetine mesylate capsule 7.5 mg paroxetine HCl Oral MENEST estradiol OSPHENA PREMARIN

Menopausal Symptom Agents MINIVELLE estradiol, DIVIGEL, EVAMIST Transdermal VIVELLE-DOT

Menopausal Symptom Agents estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM Vaginal Yuvafem ESTRING FEMRING INTRAROSA PREMARIN CREAM

Multiple Sclerosis AVONEX 1 dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, EXTAVIA 1 GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, PLEGRIDY 1 ZEPOSIA TECFIDERA 1

Category Excluded Medications Preferred Alternatives Drug Class

Musculoskeletal carisoprodol 250 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) chlorzoxazone 375 mg chlorzoxazone 500 mg (NDC^ 73007001303 only) chlorzoxazone 750 mg cyclobenzaprine ext-rel capsule cyclobenzaprine tablet 7.5 mg metaxalone 400 mg methocarbamol 500 mg (NDC^ 69036091010 only) methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only) orphenadrine-aspirin-caffeine Fexmid Lorzone Orphengesic Forte AMRIX CHLORZOXAZONE 250 MG NORGESIC FORTE

Narcolepsy NUVIGIL armodafinil, modafinil, SUNOSI Wakefulness Promoters PROVIGIL Nephropathic Cystinosis PROCYSBI 1 CYSTAGON

Ophthalmic ALREX azelastine, cromolyn sodium, olopatadine Allergies BEPREVE LASTACAFT ZERVIATE

Ophthalmic AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin, Anti-infectives CILOXAN sulfacetamide, tobramycin, BESIVANCE Ophthalmic TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone, Anti-infective / Anti-inflammatory ZYLET neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT

Ophthalmic ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA Anti-inflammatory, Nonsteroidal BROMSITE NEVANAC

Ophthalmic FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL Anti-inflammatory, Steroidal FML FORTE FML LIQUIFILM FML S.O.P. INVELTYS LOTEMAX LOTEMAX SM MAXIDEX PRED FORTE PRED MILD

Ophthalmic ZIRGAN trifluridine Antivirals

Ophthalmic LACRISERT RESTASIS, XIIDRA Artificial Tears Ophthalmic bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN Glaucoma TRAVATAN Z BETIMOL timolol maleate solution, BETOPTIC S TIMOPTIC OCUDOSE

Ophthalmic AVENOVA Consult doctor Miscellaneous

Opioid Dependency SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV

Category Excluded Medications Preferred Alternatives Drug Class

Osteoarthritis * GEL-ONE 1 DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX Viscosupplements HYALGAN 1 MONOVISC 1 ORTHOVISC 1 SYNVISC 1 SYNVISC-ONE 1 VISCO-3 1

Osteoporosis * MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, Calcium Regulators TYMLOS MIACALCIN NASAL SPRAY calcitonin-salmon

Otic CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic Anti-infective / Anti-inflammatory CIPRODEX Overactive Bladder / Incontinence * DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, Urinary Antispasmodics ENABLEX trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ OXYTROL

Pain butalbital-acetaminophen tablet 50-300 mg diclofenac sodium, ibuprofen, Headache * butalbital-acetaminophen-caffeine capsule naproxen (except naproxen CR or naproxen suspension) Bupap BUTALBITAL-ACETAMINOPHEN (NDC^ 69499034230 only) CAMBIA FIORICET CAPSULE

dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ergotamine-caffeine ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, Migergot ZOMIG NASAL SPRAY CAFERGOT MAXALT MAXALT-MLT

sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR or TREXIMET naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY

Pain LYRICA duloxetine, pregabalin Neuropathic Pain *

Pain BUTRANS buprenorphine transdermal, BELBUCA Opioid Analgesics LAZANDA fentanyl transmucosal lozenge, SUBSYS

levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, oxymorphone ext-rel morphine ext-rel, NUCYNTA ER, XTAMPZA ER HYSINGLA ER OXYCONTIN ZOHYDRO ER

PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA

tramadol (NDC^ 52817019610 only) tramadol (except NDC^ 52817019610), tramadol ext-rel tablet tramadol ext-rel capsule

Pain LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine Topical Local Anesthetics (NDC^ 71800063115 only) LIDOTREX

Pain and Inflammation * MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, Corticosteroids RAYOS prednisone

Category Excluded Medications Preferred Alternatives Drug Class

Pain and Inflammation * ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or Nonsteroidal Anti-inflammatory naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, Drugs (NSAIDs) / Combinations pantoprazole delayed-rel tablet or DEXILANT

CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, Diclosaicin meloxicam, naproxen (except naproxen CR or naproxen suspension) Inflammacin NuDiclo SoluPak NuDiclo TabPak PENNSAID

fenoprofen diclofenac sodium, ibuprofen, meloxicam, indomethacin capsule 20 mg naproxen (except naproxen CR or naproxen suspension) ketoprofen capsule 25 mg ketoprofen ext-rel capsule mefenamic acid (NDC^ 69336012830 only) naproxen CR naproxen suspension FENOPROFEN CAPSULE INDOCIN NAPRELAN SPRIX ZORVOLEX

naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or DEXILANT

Parkinson’s Disease APOKYN 1 INBRIJA, KYNMOBI NOURIANZ amantadine, entacapone, pramipexole, pramipexole ext-rel, rasagiline, ropinirole, ropinirole ext-rel, selegiline, NEUPRO

RYTARY carbidopa-levodopa, carbidopa-levodopa ext-rel

Phenylketonuria KUVAN 1 sapropterin Postherpetic Neuralgia HORIZANT gabapentin, GRALISE

Premenstrual Dysphoric Disorder fluoxetine tablet (generics for SARAFEM fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for (PMDD) only) SARAFEM]), paroxetine HCl ext-rel, sertraline

Prenatal Vitamins 9 AZESCO prenatal vitamins, CITRANATAL PRENATAL PLUS TRINAZ VITAFOL-ONE ZALVIT All other brand prenatal vitamins that are not CITRANATAL

Prostate Condition JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, Benign Prostatic Hyperplasia * silodosin, tamsulosin or terazosin RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin UROXATRAL

Respiratory ARALAST NP 1 PROLASTIN-C Alpha-1 Antitrypsin Deficiency GLASSIA 1 ZEMAIRA 1

Respiratory benzonatate benzonatate (except NDCs^ 69336012615, 69499032915) Cough (NDCs^ 69336012615, 69499032915 only) Respiratory THEO-24 ipratropium inhalation solution, PERFOROMIST, SEREVENT, SPIRIVA, Xanthines STRIVERDI RESPIMAT, YUPELRI

Category Excluded Medications Preferred Alternatives Drug Class

Sleep Disorder quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA Hypnotics, Non-benzodiazepines zolpidem sublingual LUNESTA ROZEREM SILENOR ZOLPIMIST

Testosterone Replacement * testosterone gel 1% (authorized generics for testosterone gel (except authorized generics for TESTIM and VOGELXO), Androgens TESTIM and VOGELXO only) testosterone solution, ANDRODERM, NATESTO ANDROGEL FORTESTA TESTIM VOGELXO

Thyroid Supplements CYTOMEL levothyroxine, liothyronine, SYNTHROID NATURE-THROID WESTHROID WP THYROID

TIROSINT levothyroxine, SYNTHROID

Transplant * PROGRAF 1 tacrolimus Immunosuppressants, Calcineurin Inhibitors

Urea Cycle Disorders BUPHENYL 1 sodium phenylbutyrate RAVICTI 1

Uterine Fibroids * LUPRON DEPOT 1 ORIAHNN

Category Other Considerations Drug Class

All Drugs On a quarterly basis, new and existing products - including limited source generics, products with significant cost inflation, and specialty and non-specialty products - may be re-evaluated to determine appropriate formulary placement. These evaluations will assess whether clinically appropriate and cost-effective options remain available on the formulary and may result in removal, addition or deletion of a product.

Autoimmune and Hepatitis C * For some clients, an Indication-Based Formulary will be utilized for products in these classes and may result in additional removals for certain conditions only.

Drugs for Infusion into Spaces A drug that must be infused into a space other than the blood will generally not be covered under the prescription drug benefit. Other Than the Blood

New-to-Market Agents 1 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.

The listed formulary options are subject to change. List of Excluded Medications ABILIFY ADZENYS XR-ODT APIDRA ACANYA ALCORTIN A APOKYN 1 ACIPHEX ALEVICYN GEL APTENSIO XR ACIPHEX SPRINKLE ALEVICYN SG APTIVUS 1 ACTEMRA ACTPEN 1 ALEVICYN SOLUTION ARALAST NP 1 ACTEMRA INTRAVENOUS 1 ALIQOPA 1 ARTHROTEC ACTEMRA SUBCUTANEOUS 1 ALLISON MEDICAL INSULIN SYRINGES 6 ASMANEX ACTICLATE ALPROLIX 1 ASMANEX HFA Activite ALREX ASTAGRAF XL 1 ACTOS ALTOPREV ATACAND ACUVAIL ALVESCO ATACAND HCT acyclovir cream AMITIZA ATIVAN ADCIRCA 1 AMRIX ATOPADERM ADDERALL ANDROGEL AVASTIN 1 ADZENYS ER APEXICON E AVENOVA

AVONEX 1 CoreMino FENOPROFEN CAPSULE AVSOLA 1 COZAAR FERIVA 21/7 AZASITE CRESEMBA FERRIPROX 1 AZELEX CRESTOR Fexmid AZESCO CUPRIMINE FINACEA GEL AZOR cyclobenzaprine ext-rel capsule FIORICET CAPSULE BANZEL SUSPENSION cyclobenzaprine tablet 7.5 mg FLAREX BARACLUDE TABLET 1 CYMBALTA flucytosine capsule 500 mg BEAU RX CYTOMEL fluocinonide cream 0.1% BECONASE AQ DARAPRIM fluorouracil cream 0.5% BENICAR DAYTRANA fluoxetine tablet (generics for SARAFEM only) BENICAR HCT DELZICOL fluoxetine tablet 60 mg BENSAL HP DESFERAL 1 flurandrenolide cream BENZACLIN desoximetasone ointment 0.05% flurandrenolide lotion benzonatate (NDCs^ 69336012615, 69499032915 only) DETROL LA flurandrenolide ointment BEPREVE dexchlorpheniramine FML FORTE BERINERT 1 Dexifol FML LIQUIFILM BETAPACE Diclofex DC (NDC^ 51021037201 only) FML S.O.P. BETAPACE AF Diclosaicin FOCALIN XR BETIMOL DIFFERIN LOTION FOLIC-K BEVESPI AEROSPHERE diflorasone cream FOLLISTIM AQ 1 BEYAZ diflorasone ointment Folvite-D bimatoprost solution 0.03% dihydroergotamine spray FORTAMET BORTEZOMIB 1 diltiazem ext-rel (generics for CARDIZEM LA only) FORTESTA BREEZE 2 STRIPS AND KITS 8 DIOVAN FOSRENOL BROMSITE DIOVAN HCT FOSTEUM Bupap Diphen Elixir FOSTEUM PLUS BUPHENYL 1 DORYX FREESTYLE LIBRE CONTINUOUS bupropion ext-rel tablet 450 mg DORYX MPC GLUCOSE MONITORING SYSTEM butalbital-acetaminophen tablet 50-300 mg doxepin cream FREESTYLE STRIPS AND KITS 8 BUTALBITAL-ACETAMINOPHEN doxycycline hyclate delayed-rel tablet 50 mg FULPHILA 1 (NDC^ 69499034230 only) doxycycline hyclate delayed-rel tablet 200 mg GEL-ONE 1 butalbital-acetaminophen-caffeine capsule doxycycline hyclate tablet 50 mg Genicin Vita-S BUTRANS (NDC^ 72143021160 only) GENOTROPIN 1 BYDUREON doxycycline hyclate tablet 75 mg GLASSIA 1 BYETTA doxycycline hyclate tablet 150 mg GLEEVEC 1 CAFERGOT doxycycline monohydrate capsule 75 mg GLUMETZA calcipotriene cream doxycycline monohydrate capsule 150 mg GLYCOPYRROLATE TABLET 1.5 MG calcipotriene-betamethasone doxycycline monohydrate delayed-rel capsule GOLYTELY calcitriol ointment DULERA GRANIX 1 CAMBIA DUTOPROL GUARDIAN CONNECT CONTINUOUS CARAC DYRENIUM GLUCOSE MONITORING SYSTEM CARAFATE EDARBI GUARDIAN REAL-TIME CONTINUOUS CARBINOXAMINE TABLET 6 MG EDARBYCLOR GLUCOSE MONITORING SYSTEM CARDIZEM E.E.S. GRANULES halcinonide cream CARDIZEM CD EFFEXOR XR HEPSERA 1 CARDIZEM LA ELELYSO 1 HERCEPTIN 1 carisoprodol 250 mg ELIDEL HERCEPTIN HYLECTA 1 CARNITOR ELMIRON HORIZANT CARNITOR SF ENABLEX HUMALOG CELEBREX ENLITE CONTINUOUS HUMALOG MIX 50/50 CELLCEPT 1 GLUCOSE MONITORING SYSTEM HUMALOG MIX 75/25 chlordiazepoxide-clidinium (NDCs^ 11534019701, ENTERAGAM HUMATROPE 1 42494040901, 51293069601, 51293069610 only) ENTYVIO (For Crohn's Disease Only) 1 HUMULIN 70/30 4 CHLORZOXAZONE 250 MG ENVARSUS XR 1 HUMULIN N 4 chlorzoxazone 375 mg EPICERAM HUMULIN R 4 chlorzoxazone 500 mg (NDC^ 73007001303 only) EPIVIR HBV 1 HYALGAN 1 chlorzoxazone 750 mg EPOGEN 1 hydrocortisone butyrate lipophilic cream 0.1% CHORIONIC GONADOTROPIN 1 ergotamine-caffeine hydrocortisone butyrate lotion CICATRACE ERYPED HylaVite CILOXAN estradiol vaginal tablet hyoscyamine sulfate ext-rel CIMZIA LYOPHILIZED POWDER 1 ESTRING HYSINGLA ER CIMZIA PREFILLED SYRINGE 1 EVEKEO HYZAAR CIPRO HC EVERSENSE CONTINUOUS icosapent ethyl CIPRODEX GLUCOSE MONITORING SYSTEM ILUMYA 1 clindamycin gel (NDC^ 68682046275 only) EXFORGE INCRUSE ELLIPTA clobetasol spray EXFORGE HCT INDERAL LA CLOBEX SPRAY EXJADE 1 INDERAL XL clocortolone cream EXTAVIA 1 INDOCIN COLAZAL FABIOR indomethacin capsule 20 mg colchicine capsule FANAPT Inflammacin COLCRYS FEMRING INFLECTRA 1 COMPLERA 1 fenofibrate capsule 50 mg INNOPRAN XL CONSENSI fenofibrate capsule 130 mg INTRAROSA CONTOUR NEXT STRIPS AND KITS 8 fenofibrate tablet 40 mg INTUNIV CONTOUR STRIPS AND KITS 8 fenofibrate tablet 120 mg INVELTYS CORDRAN OINTMENT FENOGLIDE TABLET 120 MG INVIRASE 1 COREG CR fenoprofen INVOKAMET

INVOKAMET XR mupirocin cream PRED FORTE INVOKANA MYFORTIC 1 PRED MILD isosorbide dinitrate 40 mg MYTESI PREGNYL 1 JADENU 1 NAPRELAN PREMARIN JALYN naproxen-esomeprazole PREMARIN CREAM JENTADUETO naproxen CR PRENATAL PLUS JENTADUETO XR naproxen suspension PREVACID KAMDOY NATAZIA PREVIDENT KAZANO NATURE-THROID PRILOSEC ketoconazole foam 2% NEO-SYNALAR PRISTIQ Ketodan NESINA PROAIR HFA ketoprofen capsule 25 mg NEULASTA 1 PROAIR RESPICLICK ketoprofen ext-rel capsule NEULASTA ONPRO 1 PROCRIT 1 KINERET 1 NEUPOGEN 1 PROCYSBI 1 KOMBIGLYZE XR NEVANAC PRODIGEN KUVAN 1 NEXIUM PROGRAF 1 KYPROLIS 1 niacin tablet 500 mg PROMETRIUM LACRISERT Niacor PROTONIX Lactojen NICADAN PROVAD LACTULOSE PAK NICAPRIN PROVENTIL HFA LANOXIN TABLET (125 MCG and 250 MCG only) NICAZEL PROVIGIL lanthanum carbonate NICAZEL FORTE PROZAC LANTUS NICOMIDE PSORCON LASTACAFT NILANDRON QNASL LAZANDA nitrofurantoin (NDC^ 70408023932 only) QTERN LESCOL XL Nolix quazepam LETAIRIS 1 NORGESIC FORTE RAPAFLO levorphanol NORITATE RAPAMUNE 1 LEXAPRO NORPACE RAVICTI 1 LEXIVA 1 NORVASC RAYOS LIALDA NOURIANZ RECEDO LIBRAX NOVACORT REMODULIN 1 LIDOCAINE-TETRACAINE CREAM NOVAREL 1 RENFLEXIS 1 (NDC^ 71800063115 only) NOVO NORDISK NEEDLES 6 REPATHA 1 LIDOTREX NOXAFIL REVATIO 1 LILETTA 1 NuDiclo SoluPak RHEUMATE LIPITOR NuDiclo TabPak RIABNI 1 LITHOSTAT NUTROPIN AQ 1 RIBOZEL LIVALO NUVARING RIMSO-50 Lorid NUVIGIL RIOMET Lorzone OLEPTRO RITUXAN 1 LOTEMAX OLUX-E ROZEREM LOTEMAX SM omeprazole-sodium bicarbonate RyClora luliconazole OMNARIS RYTARY LUNESTA OMNITROPE 1 SABRIL 1 LUPRON DEPOT 1 OMNIVEX SAIZEN 1 LUPRON DEPOT-PED 1 ONFI SANDOSTATIN LAR 1 LYRICA ONGLYZA SCARSILK PAD MACRODANTIN ORENCIA INTRAVENOUS 1 SEASONIQUE Matzim LA orphenadrine-aspirin-caffeine SEROQUEL XR MAVYRET 1 Orphengesic Forte SIGNIFOR LAR 1 MAXALT ORTHO D SIL-K PAD MAXALT-MLT ORTHO DF SILENOR MAXIDEX ORTHOVISC 1 SILIVEX mefenamic acid (NDC^ 69336012830 only) Oscimin SR SILTREX MENEST OSENI SIMPONI 1 mesalamine delayed-rel tablet 800 mg OSMOPREP SINGULAIR metaxalone 400 mg OSPHENA SOMAVERT 1 metformin ext-rel OTREXUP 1 SORILUX (generics for FORTAMET and GLUMETZA only) OWEN MUMFORD NEEDLES 6 SPRIX methocarbamol 500 mg (NDC^ 69036091010 only) oxiconazole (NDCs^ 00168035830, 51672135902 only) STRIBILD 1 methocarbamol 750 mg OXYCONTIN SUBOXONE (NDCs^ 69036093090, 70868090190 only) oxymorphone ext-rel sucralfate suspension MIACALCIN INJECTION OXYTROL sumatriptan-naproxen MIACALCIN NASAL SPRAY pantoprazole delayed-rel suspension SUPREP MICARDIS paroxetine mesylate capsule 7.5 mg Symax-SR MICARDIS HCT PAXIL SYNERDERM Migergot PAXIL CR SYNVISC 1 MILLIPRED PEGASYS 1 SYNVISC-ONE 1 MINASTRIN 24 FE PENNSAID SYPRINE MINIVELLE PERCOCET TALIVA MINOCIN PERRIGO NEEDLES 6 TARGADOX minocycline ext-rel PEXEVA TASIGNA 1 MIRVASO PLAVIX TAYTULLA Mondoxyne NL capsule 75 mg PLEGRIDY 1 TAZORAC MONOVISC 1 POLYTOZA TECFIDERA 1 MOVIPREP posaconazole delayed-rel tablet TESTIM MultiPro PRADAXA testosterone gel 1%

(authorized generics for TESTIM and VOGELXO only) ULTIMED INSULIN SYRINGES 6 YAZ THEO-24 ULTIMED NEEDLES 6 Yuvafem THIOLA UROXATRAL ZALVIT THIOLA EC VALCYTE ZARXIO 1 TIMOPTIC OCUDOSE VALTREX ZEGERID TIROSINT Vanoxide-HC ZELAC TOBI 1 VASCULERA ZEMAIRA 1 TOBI PODHALER 1 VECTICAL ZEPATIER 1 TOBRADEX ST VELTIN ZERVIATE topiramate ext-rel capsule (generics for QUDEXY XR only) venlafaxine ext-rel tablet (except 225 mg) ZESTORETIC TOPROL-XL VENTOLIN HFA ZETIA TRACLEER 1 VEREGEN ZETONNA TRADJENTA VIEKIRA PAK 1 ZIANA tramadol (NDC^ 52817019610 only) VIIBRYD zileuton ext-rel tramadol ext-rel capsule VIRACEPT 1 ZIRGAN TRANSDERM SCOP VISCO-3 1 ZOHYDRO ER TRAVATAN Z VITAFOL-ONE ZOLADEX 1 TRELSTAR MIXJECT 1 Vitasure ZOLOFT TREXIMET VIVELLE-DOT zolpidem sublingual triamcinolone aerosol 0.2% VOGELXO ZOLPIMIST triamcinolone ointment 0.05% WESTHROID ZONEGRAN Trianex WP THYROID ZONTIVITY TRICOR XANAX ZORTRESS 1 TRINAZ XANAX XR ZORVOLEX TRIVIDIA INSULIN SYRINGES 6 XENAZINE 1 ZUPLENZ TronVite XOLEGEL ZYDELIG 1 TRUXIMA 1 XOPENEX HFA ZYLET TUDORZA Xvite ZYTIGA 1 UDENYCA 1 XYZBAC ZYVIT ULORIC YASMIN

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 covered options. Log in to Caremark.com to check coverage and copay 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. CVS Caremark assumes no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.

Subject to applicable laws and regulations.

* This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. † Listing does not include certain NDCs^. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. 1 An exception process may exist for specific clinical or regulatory circumstances that may require coverage of a non-covered medication. If your doctor believes you have a specific clinical need for a non-covered product, he or she should fax an exception request to 1-888-487-9257. 2 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). 3 If approved for coverage and prescribed for primary prevention of cardiovascular disease, may be covered without cost sharing through an exceptions process. 4 Rebranded or private label formulations are not covered (i.e., RELION). 5 Long Acting Insulins - First Generation. 6 BD ULTRAFINE syringes and needles are the only preferred options. 7 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or ONETOUCH. For more information on how to obtain a blood glucose meter, call 1-877-418-4746. 8 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 9 Generic prenatal vitamins and CITRANATAL are the only preferred options.

This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. 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 doctor.