2019 EMI Express Scripts Formulary Prescriptions

The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. 2019 Express Scripts PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic National Preferred Formulary version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered For EMI Health and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY BD AUTOSHIELD clonidine enalapril GENOTROPIN [INJ] [INJ] - Injectable Drug DUO NEEDLES clopidogrel ENBREL [INJ] GENVOYA Brand-name drugs are listed BD ULTRAFINE clotrimazole/betamethasone enoxaparin [INJ] GILENYA in CAPITAL letters. INSULIN SYRINGES dipropionate ENSTILAR GILOTRIF Generic drugs are listed BD ULTRAFINE PEN NEEDLES COLCRYS ENTRESTO glimepiride in lower case letters. BELBUCA COMBIGAN EPCLUSA glipizide benazepril COMBIPATCH EPIDIOLEX glipizide ext-release A benzonatate COMBIVENT RESPIMAT EPIDUO FORTE GLUCAGEN [INJ] BEPREVE COPAXONE 40 MG [INJ] epinephrine autoinjector GLUCAGON [INJ] ABILIFY MAINTENA [INJ] BETASERON [INJ] CORLANOR (by Mylan) [INJ] glyburide ABSORICA BETHKIS COSENTYX [INJ] EPIPEN, EPIPEN JR [INJ] GLYXAMBI ACANYA BEVESPI AEROSPHERE CREON ergocalciferol GONAL-F, GONAL-F RFF, acetaminophen/codeine BIKTARVY CRINONE ERIVEDGE GONAL-F RFF ACTEMRA [INJ] bisoprolol/hctz cyanocobalamin [INJ] ERLEADA REDI-JECT [INJ] acyclovir blisovi fe cyclobenzaprine erythromycin eye ointment GRALISE ADEMPAS BOSULIF ESBRIET GRANIX [INJ] ADVAIR DISKUS BREO ELLIPTA D escitalopram GRASTEK ADVAIR HFA BRILINTA esomeprazole magnesium guanfacine ext-release AFSTYLA [INJ] budesonide nebulization DALIRESP delayed-release AIMOVIG [INJ] suspension DARAPRIM estradiol H AKYNZEO bupropion DAYTRANA estradiol patches albuterol nebulization bupropion ext-release DESCOVY estradiol/norethindrone HARVONI solution buspirone desloratadine acetate HELIXATE FS [INJ] alendronate butalbital/acetaminophen/ desvenlafaxine succinate ESTRING HUMALOG [INJ] allopurinol caffeine ext-release eszopiclone HUMIRA [INJ] ALPHAGAN P 0.1% BYDUREON [INJ] dexamethasone EUFLEXXA [INJ] HUMULIN [INJ] alprazolam BYETTA [INJ] DEXCOM RECEIVER, SENSOR, ezetimibe hydralazine ALREX BYSTOLIC TRANSMITTER ezetimibe/simvastatin hydrochlorothiazide amiodarone BYVALSON dexmethylphenidate hydrocodone/acetaminophen AMITIZA ext-release F hydrocodone/ amitriptyline C dextroamphetamine/ chlorpheniramine polistirex amlodipine amphetamine famotidine ext-release amlodipine/benazepril CABOMETYX dextroamphetamine/ FARXIGA hydrocortisone topical amlodipine/valsartan CANASA amphetamine ext-release fenofibrate hydromorphone amoxicillin CARAC diazepam fenofibrate micronized hydroxychloroquine amoxicillin/potassium CARAFATE SUSPENSION diclofenac sodium fenofibric acid hydroxyzine hcl clavulanate carbidopa/levodopa delayed-release delayed-release hydroxyzine pamoate anastrozole carvedilol dicyclomine fentanyl patches HYSINGLA ER ANDRODERM cefdinir digoxin FETZIMA ANORO ELLIPTA cefuroxime axetil diltiazem ext-release FINACEA FOAM I APRISO celecoxib diphenoxylate/atropine finasteride ARCAPTA NEOHALER cephalexin divalproex delayed-release FIRAZYR [INJ] ibandronate ARIKAYCE CERDELGA divalproex ext-release FLECTOR IBRANCE aripiprazole CEREZYME [INJ] DIVIGEL FLOVENT DISKUS ibuprofen ARISTADA [INJ] CETROTIDE [INJ] donepezil FLOVENT HFA ILEVRO ARMONAIR RESPICLICK CHANTIX doxazosin fluconazole INCRUSE ELLIPTA ARNUITY ELLIPTA chlorhexidine gluconate doxycycline hyclate fluocinonide indomethacin ASMANEX HFA chlorthalidone doxycycline monohydrate fluoxetine INLYTA ASMANEX TWISTHALER CIMDUO DUAVEE fluticasone nasal spray INVOKAMET atenolol CIPRODEX DULERA folic acid INVOKAMET XR atenolol/chlorthalidone ciprofloxacin duloxetine delayed-release FORTEO [INJ] INVOKANA atomoxetine citalopram DUPIXENT [INJ] FRAGMIN [INJ] irbesartan atorvastatin clarithromycin DYMISTA FREESTYLE LIBRE READER, IRESSA AVONEX [INJ] CLENPIQ SENSOR isosorbide mononitrate AZASITE clindamycin hcl E furosemide ext-release azelastine nasal spray clindamycin phosphate FYCOMPA azithromycin topical EDARBI J clindamycin phosphate/ EDARBYCLOR G B benzoyl peroxide ELIDEL JANUMET, JANUMET XR clobetasol propionate ELIQUIS gabapentin JANUVIA baclofen clomiphene citrate EMGALITY [INJ] GELNIQUE JARDIANCE BARACLUDE SOLUTION clonazepam EMVERM gemfibrozil JENTADUETO (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2019 Express Scripts. All Rights Reserved. 2477, 2478 NP-A All trademarks are the property of their respective owners. Page 1 PRMTEMIANP-19 (01/01/19) JENTADUETO XR MONOVISC [INJ] P ropinirole TRESIBA [INJ] JIVI [INJ] montelukast rosuvastatin triamcinolone topical junel morphine sulfate ext-release pantoprazole delayed-release RUCONEST [INJ] triamterene/hctz junel fe MOVANTIK paroxetine hcl tri-lo-marzia MOXEZA PAZEO S trinessa K moxifloxacin eye solution penicillin v potassium TRIPTODUR [INJ] mupirocin PENTASA SANCUSO tri-sprintec ketoconazole topical MUSE PERFOROMIST SAVELLA TRULANCE ketorolac MYDAYIS PHOSLYRA SEGLUROMET TRULICITY [INJ] KITABIS PAK MYRBETRIQ PICATO SEREVENT DISKUS TUDORZA PRESSAIR KOGENATE FS [INJ] pioglitazone sertraline TYMLOS [INJ] KOVALTRY [INJ] N PLEGRIDY [INJ] SIMPONI 100 MG (for KYLEENA polymyxin/trimethoprim ulcerative colitis only) [INJ] U nabumetone eye solution simvastatin L NAMZARIC POMALYST SKYLA UCERIS FOAM naproxen, naproxen sodium potassium chloride SOLIQUA [INJ] ULORIC labetalol neomycin/polymyxin/ ext-release SOLODYN UPTRAVI lamotrigine hydrocortisone ear solution PRALUENT [INJ] SOMATULINE DEPOT [INJ] lansoprazole delayed-release NEXIUM PACKETS pramipexole SOOLANTRA V LANTUS [INJ] niacin ext-release pravastatin SPIRIVA RESPIMAT latanoprost eye solution nifedipine ext-release prednisolone acetate spironolactone valacyclovir LATUDA nitrofurantoin macrocrystal eye suspension sprintec valsartan LETAIRIS NITYR prednisolone sodium SPRYCEL valsartan/hctz LEVEMIR [INJ] NORDITROPIN [INJ] phosphate STEGLATRO VARUBI levetiracetam nortriptyline prednisone STELARA SC [INJ] VASCEPA levocetirizine NOVAREL [INJ] PREMARIN CREAM STIOLTO RESPIMAT VELPHORO levofloxacin NOVOEIGHT [INJ] PREMARIN TABLETS STRENSIQ [INJ] VELTASSA levothyroxine sodium NOVOFINE AUTOSHIELD PREMPHASE STRIVERDI RESPIMAT venlafaxine lidocaine patches NEEDLES PREMPRO SUBOXONE SL FILM venlafaxine ext-release LINZESS NOVOFINE NEEDLES PREPOPIK sulfamethoxazole/ VENTOLIN HFA liothyronine NOVOTWIST NEEDLES PROAIR HFA trimethoprim verapamil ext-release LIPOFEN NUCALA [INJ] PROAIR RESPICLICK sumatriptan VESICARE lisinopril NUCYNTA, NUCYNTA ER PROCRIT [INJ] SUPREP VIBERZI lisinopril/hctz NUEDEXTA progesterone micronized SUTENT VIIBRYD LIVALO NUVARING PROLASTIN C [INJ] SYMBICORT VIMPAT LO LOESTRIN FE NUWIQ [INJ] PROLENSA SYMFI VIOKACE LOKELMA nystatin promethazine SYMFI LO VOSEVI lorazepam nystatin topical promethazine/ SYMLINPEN [INJ] VYVANSE losartan dextromethorphan SYMPROIC losartan/hctz O propranolol SYNJARDY, SYNJARDY XR W LOTEMAX propranolol ext-release lovastatin ODACTRA PULMICORT FLEXHALER T warfarin LUMIGAN OFEV PYLERA LYRICA ofloxacin TACLONEX SUSPENSION X olanzapine Q tacrolimus topical M olmesartan tamoxifen XALKORI olmesartan/hctz QBREXZA tamsulosin ext-release XARELTO meclizine olopatadine eye solution QNASL TARCEVA XELJANZ, XELJANZ XR medroxyprogesterone omega-3 acid ethyl esters QUDEXY XR TASIGNA XIFAXAN meloxicam omeprazole delayed-release quetiapine TAYTULLA XIGDUO XR MESTINON SYRUP ondansetron QUILLICHEW ER TAZORAC GEL XIIDRA metaxalone ondansetron orally QUILLIVANT XR TAZORAC 0.05% CREAM XOFLUZA metformin disintegrating tablets quinapril TECFIDERA XOLAIR [INJ] metformin ext-release ONETOUCH KITS/METERS; QVAR TEKTURNA, TEKTURNA HCT XTANDI methimazole ULTRA 2, ULTRAMINI, QVAR REDIHALER terazosin XULTOPHY [INJ] methocarbamol VERIO, VERIO FLEX, terconazole vaginal methotrexate VERIO IQ, VERIO SYNC R testosterone cypionate [INJ] Y methylphenidate ONETOUCH TEST STRIPS; THALOMID methylphenidate ext-release ULTRA, VERIO rabeprazole delayed-release timolol maleate eye solution YONSA methylprednisolone ONEXTON RAGWITEK tizanidine yuvafem metoclopramide OPSUMIT raloxifene TOBI PODHALER metoprolol succinate ORACEA ramipril TOBRADEX OINTMENT Z ext-release ORFADIN RANEXA TOBRADEX ST metoprolol tartrate ORTHOVISC [INJ] ranitidine tobramycin eye solution ZARXIO [INJ] metronidazole oseltamivir RAPAFLO tobramycin/dexamethasone ZENPEP metronidazole topical OTEZLA RASUVO [INJ] eye suspension ZEPATIER metronidazole vaginal OTOVEL REBIF [INJ] topiramate zolpidem microgestin fe OTREXUP [INJ] RECTIV TOUJEO [INJ] zolpidem ext-release MINIVELLE OVIDREL [INJ] RELISTOR [INJ] TOVIAZ ZOMIG NASAL minocycline oxcarbazepine REMICADE [INJ] TRACLEER ZONTIVITY MIRENA oxybutynin ext-release RESTASIS TRADJENTA ZOVIRAX CREAM mirtazapine oxycodone RETACRIT [INJ] tramadol ZTLIDO MIRVASO oxycodone/acetaminophen REVLIMID TRAVATAN Z ZUBSOLV MITIGARE OXYCONTIN RHOPRESSA trazodone ZYLET moderiba OZEMPIC [INJ] risperidone TRELEGY ELLIPTA ZYTIGA mometasone rizatriptan TREMFYA [INJ] Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2019 Express Scripts. All Rights Reserved. 2477, 2478 NP-A All trademarks are the property of their respective owners. Page 2 PRMTEMIANP-19 (01/01/19) 2019 EMI Health Preferred Drug List Exclusions The excluded medications shown below are not covered on the EMI Health drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. Drug Class Excluded Medications Preferred Alternatives

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

Anti-Migraine Therapy SUMAVEL DOSEPRO sumatriptan injection

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

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

Calcitonin Gene-Related Peptide Antagonists AJOVY AIMOVIG, EMGALITY

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

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

Narcotic Analgesics BUTRANS BELBUCA

Neuropathic Agents LYRICA CR gabapentin, GRALISE, LYRICA

Transmucosal Fentanyl Analgesics ABSTRAL, FENTORA, LAZANDA fentanyl citrate lozenges

CARDIOVASCULAR PRADAXA, SAVAYSA ELIQUIS, XARELTO Anticoagulants

Beta Blockers KAPSPARGO SPRINKLE metoprolol succinate

HMG & Cholesterol Inhibitor Combinations ALTOPREV, ZYPITAMAG atorvastatin, lovastatin, rosuvastatin, simvastatin, LIVALO

PCSK9 Inhibitors REPATHA PRALUENT

DERMATOLOGICAL MINOCYCLINE ER 55 MG TABLETS, MINOLIRA minocycline ER Oral Agents for Acne

Oral Agents for Rosacea DOXYCYCLINE 40 MG CAPSULES ORACEA

Topical Acne PLIXDA adapalene

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

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

Topical Antifungals LULICONAZOLE ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

acyclovir capsules, acyclovir tablets, famciclovir tablets, Topical Antiviral Agents XERESE CREAM valacyclovir tablets, ZOVIRAX CREAM

desonide 0.05% cream/lotion/ointment, Topical Corticosteroids TOPICORT SPRAY, VERDESO FOAM desoximetasone 0.25% cream/ointment

Miscellaneous Topical Dermatological Agents ALCORTIN A hydrocortisone, mupirocin

Continued

© 2018 Express Scripts. All Rights Reserved. 2477, 2478 All trademarks are the property of their respective owners. Page 3 DL44109Q-EMI-19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

ABBOTT (FREESTYLE, PRECISION), BAYER (BREEZE, CONTOUR), NATIONAL MEDICAL (ADVOCATE), OMNIS DIABETES HEALTH (EMBRACE, VICTORY), ROCHE (ACCU-CHEK), LIFESCAN (ONETOUCH) Blood Glucose Meters & Test Strips TRIVIDIA (TRUETEST, TRUETRACK), UNISTRIP ALL OTHER METERS & STRIPS THAT ARE NOT LIFESCAN BRAND

ALOGLIPTIN, NESINA, ONGLYZA JANUVIA, TRADJENTA Dipeptidyl Peptidase-4 Inhibitors & Combinations ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

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

NOVOLIN HUMULIN Insulins ADMELOG, APIDRA, FIASP, NOVOLOG HUMALOG

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

ciprofloxacin ear solution, ofloxacin ear solution, Otic Fluoroquinolone Antibiotics CETRAXAL CIPRODEX, OTOVEL

ENDOCRINE (OTHER) CLIMARA PRO COMBIPATCH Combination Patches

estradiol patches, estradiol tablets, yuvafem, Estrogen and Estrogen Modifiers for Vaginal Symptoms FEMRING ESTRING, PREMARIN CREAM, PREMARIN TABLETS

Gonadotropin Releasing Hormone (GnRH) Agonists LUPRON DEPOT-PED TRIPTODUR (for Central Precocious Puberty)

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

Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT

Topical Estrogen Gels ESTROGEL DIVIGEL

GASTROINTESTINAL CORTIFOAM hydrocortisone enema, UCERIS FOAM Corticosteroids (Rectal Formulations)

balsalazide disodium, mesalamine 1.2 gm delayed release, Inflammatory Bowel Agents DELZICOL, DIPENTUM sulfasalazine, APRISO, PENTASA

Pancreatic Enzymes PANCREAZE, PERTZYE CREON, ZENPEP

ACIPHEX SPRINKLE, PRILOSEC SUSPENSION, esomeprazole, lansoprazole, omeprazole, pantoprazole, Proton Pump Inhibitors PROTONIX SUSPENSION rabeprazole, NEXIUM PACKETS

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

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

Granulocyte Colony Stimulating Factors NEUPOGEN, NIVESTYM GRANIX, ZARXIO

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

BIKTARVY, GENVOYA, ODEFSEY, STRIBILD, SYMFI, SYMFI LO, ATRIPLA, DELSTRIGO, SYMTUZA HIV TRIUMEQ Antiretrovirals PIFELTRO efavirenz, nevirapine ER, EDURANT, INTELENCE, RESCRIPTOR

MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE COLCRYS, MITIGARE Gout Therapy DUZALLO, ZURAMPIC allopurinol, probenecid

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

OBSTETRICAL & GYNECOLOGICAL Gonadotropin-Releasing Hormone (GnRH) GANIRELIX ACETATE CETROTIDE Antagonists (for Infertility)

Continued

© 2018 Express Scripts. All Rights Reserved. 2477, 2478 All trademarks are the property of their respective owners. Page 4 DL44109Q-EMI-19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

OBSTETRICAL & GYNECOLOGICAL (continued) Gonadotropin-Releasing Hormone (GnRH) ORILISSA LUPRON DEPOT, SYNAREL, ZOLADEX Receptor Antagonists (for Endometriosis)

Human Chorionic Gonadotropin CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL

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

Vaginal Progesterones ENDOMETRIN CRINONE 8% GEL

OPHTHALMIC betaxolol drops, levobunolol drops, timolol drops, TIMOPTIC OCUDOSE Antiglaucoma Drugs (Beta-Adrenergic Blockers) ALPHAGAN P 0.1%, COMBIGAN

Antiglaucoma Drugs (Ophthalmic Prostaglandins) ZIOPTAN bimatoprost drops, latanoprost drops, LUMIGAN, TRAVATAN Z

azelastine drops, cromolyn drops, olopatadine drops, Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, EMADINE ALREX, BEPREVE, PAZEO

dexamethasone drops, fluorometholone drops, Ophthalmic Anti-Inflammatory FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD prednisolone drops, LOTEMAX

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

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

RENAL DISEASE FOSRENOL POWDER PACKETS, RENAGEL lanthanum, sevelamer carbonate, PHOSLYRA, VELPHORO Phosphate Binders

RESPIRATORY AUVI-Q, EPINEPHRINE AUTO-INJECTOR EPINEPHRINE AUTO-INJECTOR (BY MYLAN), Epinephrine Auto-Injector Systems (BY A-S MEDICATION, IMPAX & LINEAGE) EPIPEN, EPIPEN JR

Long-Acting Beta Agonist Nebulized BROVANA PERFOROMIST

ARMONAIR RESPICLICK, ARNUITY ELLIPTA, Pulmonary Anti-Inflammatory Inhalers ALVESCO ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR

Short-Acting Beta 2-Agonist Inhalers LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA HYDROXYPROGESTERONE 1,250 MG/5 ML hydroxyprogesterone caproate 250 mg/ml (single dose vial)

MISCELLANEOUS AGENTS SIKLOS DROXIA

NOCTIVA desmopressin tablets

Hereditary Angioedema BERINERT RUCONEST

Polyneuropathy of Hereditary ONPATTRO No alternatives recommended Transthyretin-Mediated Amyloidosis

Indication Based Management Drug Class Nonpreferred Medications Preferred Alternatives

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted ACTEMRA, COSENTYX, ENBREL, HUMIRA, following a coverage review. A trial of one or more Preferred INFLECTRA, OTEZLA, REMICADE, RENFLEXIS, INFLAMMATORY CONDITIONS‡ medications is required prior to initiating therapy with a SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY), Nonpreferred medication. A formulary exception may be STELARA SC, TREMFYA*, XELJANZ, XELJANZ XR granted for patients already established on therapy with a Nonpreferred medication.

‡ Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches. * This medication may be subject to step therapy.

Continued

ABBOTT (FREESTYLE, PRECISION) FLAREX PLAQUENIL^ ABILIFY^ FLUOROURACIL 0.5% CREAM PLAVIX^ ABSTRAL FML FORTE, FML S.O.P. PLIXDA ACIPHEX^ FOLLISTIM AQ PRADAXA ACIPHEX SPRINKLE FOSRENOL CHEWABLE TABLETS^ PRED MILD ACUVAIL FOSRENOL POWDER PACKETS PREGNYL ADCIRCA^ GANIRELIX ACETATE PREVACID^, PREVACID SOLUTAB^ ADDERALL^ GEL-ONE PRILOSEC SUSPENSION ADLYXIN GELSYN-3 PRISTIQ^ ADMELOG GENVISC 850 PROTONIX^ AJOVY GLEEVEC^ PROTONIX SUSPENSION AKTIPAK GLUCOPHAGE^, GLUCOPHAGE XR^ PROVENTIL HFA ALCORTIN A GLUMETZA^ PROVIGIL^ ALOCRIL GOCOVRI ER PROZAC^ ALOGLIPTIN HUMATROPE PULMICORT RESPULES^ ALOGLIPTIN/METFORMIN HYALGAN RECOMBINATE ALOMIDE HYDROXYPROGESTERONE 1,250 MG/5 ML RENAGEL ALTOPREV HYMOVIS REPATHA ALVESCO IMIQUIMOD 3.75% CREAM PUMP ROCHE (ACCU-CHEK) ANDROGEL 1%^ IMITREX^ SAIZEN, SAIZENPREP ANUSOL-HC^ INDERAL LA^ SANDOSTATIN LAR DEPOT APIDRA INTUNIV^ SAVAYSA ARANESP ISTALOL^ SEROQUEL^, SEROQUEL XR^ ARIMIDEX^ KAPSPARGO SPRINKLE SIGNIFOR LAR ASACOL HD^ KAZANO SIKLOS ATACAND^, ATACAND HCT^ KEPPRA^, KEPPRA XR^ SINGULAIR^ ATRIPLA KOMBIGLYZE XR SOFOSBUVIR/VELPATASVIR AUVI-Q LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ SOVALDI AVALIDE^, AVAPRO^ LAZANDA STRATTERA^ AVODART^ LEDIPASVIR/SOFOSBUVIR SUMAVEL DOSEPRO AZOR^ LEVALBUTEROL HFA SUPARTZ FX BAYER (BREEZE, CONTOUR) LEXAPRO^ SYMTUZA BECONASE AQ LIBRAX^ SYNVISC, SYNVISC-ONE BENICAR^, BENICAR HCT^ LIDODERM^ TANZEUM BERINERT LIPITOR^ TESTIM^ BRAVELLE LOESTRIN^, LOESTRIN FE^ TIKOSYN^ BRISDELLE^ LOTREL^ TIMOPTIC OCUDOSE BROVANA LOVENOX^ TOBI SOLUTION^ BUPAP^ LUCEMYRA TOPAMAX^ BUTRANS LULICONAZOLE TOPICORT SPRAY CELEBREX^ LUNESTA^ TRIBENZOR^ CELEXA^ LUPRON DEPOT-PED TRICOR^ CETRAXAL LYRICA CR TRILEPTAL^ CHORIONIC GONADOTROPIN MAVYRET TRIVIDIA (TRUETEST, TRUETRACK) CLIMARA PRO MAXALT^, MAXALT MLT^ TRIVISC COLCHICINE MAXIDEX UNISTRIP COREG^ MICARDIS^, MICARDIS HCT^ UROXATRAL^ CORTIFOAM MINASTRIN 24 FE^ VAGIFEM^ COSOPT^ MINOCYCLINE ER 55 MG TABLETS VALIUM^ COZAAR^, HYZAAR^ MINOLIRA VALTREX^ CRESTOR^ MIRCERA VELTIN CYMBALTA^ NALFON CAPSULES VERDESO FOAM CYTOMEL^ NAMENDA XR^ VICTOZA DAKLINZA NASONEX^ VISCO-3 DELSTRIGO NATIONAL MEDICAL (ADVOCATE) VIVELLE-DOT^ DELZICOL NESINA VYTORIN^ DETROL^, DETROL LA^ NEUPOGEN WELLBUTRIN SR^ DIOVAN^, DIOVAN HCT^ NEURONTIN^ XADAGO DIPENTUM NEVANAC XALATAN^ DOXYCYCLINE 40 MG CAPSULES NIVESTYM XANAX^, XANAX XR^ DUROLANE NOCTIVA XENAZINE^ DUZALLO NORCO^ XERESE CREAM EFFEXOR XR^ NORVASC^ XOPENEX HFA ELOCTATE NOVOLIN XYNTHA, XYNTHA SOLOFUSE EMADINE NOVOLOG YASMIN^ EMBEDA NUTROPIN AQ NUSPIN ZEGERID^ EMFLAZA NUVIGIL^ ZETIA^ ENDOMETRIN OLYSIO ZETONNA EPINEPHRINE AUTO-INJECTOR OMNARIS ZIOPTAN (BY A-S MEDICATION, IMPAX & LINEAGE) OMNIS HEALTH (EMBRACE, VICTORY) ZOCOR^ EPOGEN OMNITROPE ZOLOFT^ ESTROGEL ONGLYZA ZOMACTON EXFORGE^, EXFORGE HCT^ ONPATTRO ZOMIG TABLETS^, ZOMIG ZMT^ EXONDYS 51 ORILISSA ZONEGRAN^ EXTAVIA ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ ZURAMPIC FEMRING OSMOLEX ER ZYCLARA FENOPROFEN CAPSULES OXYCODONE ER ZYFLO CR^ FENORTHO PANCREAZE ZYPITAMAG FENTORA PERTZYE FIASP PIFELTRO ^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.