2021 NATIONAL EX FORMULARY The following is a list of the most commonly prescribed brand and generic medications. It represents an abbreviated version of the formulary list that is at the core of y our prescription drug benefit plan. The list is not all-inclusive and does not guarantee coverage. Some preferred medications overlap with other clinical programs and may not be covered. In addition to drugs on this list, the majority of generic medications are covered under your plan and you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. Search complete formulary drug information at elixirsolutions.com. PLEASE NOTE: Preferred brand drugs may move to non-preferred status if a generic version becomes available during the year. Any medication approved to enter the market will not be covered until reviewed by Elixir. Not all drugs listed are covered by all prescription drug benefit programs. For specific questions about your coverage, please visit elixirsolutions.com.
A ASMANEX carbidopa-levodopa DEXCOM CONTINUOUS GLUCOSE abacavir tablet atazanavir carbidopa-levodopa ER MONITORING SYSTEM abacavir-lamivudine atenolol carbidopa-levodopa-entacapone DEXILANT ABILIFY MAINTENA [INJ] atomoxetine carvedilol diazepam abiraterone atorvastatin carvedilol phosphate ER diazepam rectal gel ABSORICA ATROVENT HFA cefdinir diclofenac ACCU-CHEK AVIVA PLUS AUBAGIO* cefprozil diclofenac sodium STRIPS AND KITS AUSTEDO* cefuroxime axetil diclofenac sodium gel 1% ACCU-CHEK COMPACT PLUS azelaic acid gel celecoxib diclofenac sodium solution STRIPS AND KITS azelastine cephalexin dicloxacillin ACCU-CHEK GUIDE STRIPS AND KITS azithromycin CERDELGA* DIFICID ACCU-CHEK SMARTVIEW AZOPT CEREZYME [INJ]* digoxin STRIPS AND KITS CETROTIDE [INJ]* diltiazem ER acetic acid acitretin B cholestyramine dimethyl fumarate DR ACUVAIL balsalazide ciclopirox diphenoxylate-atropine acyclovir capsule, tablet BAQSIMI CILOXAN OINTMENT dipyridamole ER-aspirin adapalene BASAGLAR [INJ] CIMDUO divalproex sodium ADEMPAS* BD ULTRAFINE INSULIN cinacalcet divalproex sodium ER ADDERAL XR SYRINGES AND NEEDLES CIPRODEX DIVIGEL ADVAIR DISKUS BELBUCA ciprofloxacin donepezil ADVAIR HFA BELSOMRA ciprofloxacin-dexamethasone DOPTELET* ADYNOVATE* benzoyl peroxide citalopram dorzolamide AFINITOR* BESIVANCE CITRANATAL dorzolamide-timolol AIMOVIG [INJ] BETASERON [INJ]* clarithromycin DOVATO AJOVY [INJ] BETHKIS* clarithromycin ER doxazosin albuterol inhalation solution BETIMOL CLIMARA PRO doxepin albuterol sulfate CFC-free aerosol BETOPTIC S clindamycin doxycycline hyclate ALECENSA* BEVESPI AEROSPHERE clindamycin gel, solution doxycycline monohydrate DR capsule alendronate bicalutamide clindamycin-benzoyl peroxide dronabinol alfuzosin ER BIDIL clobazam DUAVEE aliskiren BIKTARVY clobetasol cream, foam, gel, lotion, duloxetine allopurinol bosentan* ointment, shampoo DUPIXENT [INJ]* alosetron BOSULIF* clonazepam DUREZOL ALPHAGAN P BREO ELLIPTA clopidogrel DUROLANE alprazolam BREZTRI AEROSPHERE clotrimazole dutasteride ALUNBRIG* BRILINTA clozapine dutasteride-tamsulosin amantadine brimonidine codeine-acetaminophen DYMISTA ambrisentan bromfenac colchicine tablet amiloride BRYHALI colesevelam E AMITIZA budesonide capsule COMBIGAN econazole amlodipine budesonide ER COMBIPATCH efavirenz/emtricitabine/tenofovir amlodipine-atorvastatin budesonide inhalation suspension COMPLERA efavirenz/lamivudine/tenofovir amlodipine-olmesartan BUNAVAIL CONCERTA ELIGARD [INJ]* amlodipine-telmisartan buprenorphine transdermal COPAXONE [INJ]* ELIQUIS amlodipine-valsartan buprenorphine-naloxone sublingual COPIKTRA* EMGALITY [INJ] amlodipine-valsartan-HCTZ bupropion CORLANOR EMVERM amoxicillin bupropion ER CORTIFOAM ENBREL [INJ]* ENDOMETRIN amoxicillin-clavulanate BYSTOLIC COSENTYX [INJ]* ENSTILAR amphetamine-dextroamphetamine CREON entacapone mixed salts C CRINONE entecavir ANDRODERM CABOMETYX* cromolyn sodium ENTRESTO ANNOVERA calcipotriene cyclobenzaprine EPCLUSA* ANORO ELLIPTA calcipotriene-betamethasone EPIDUO aprepitant calcitonin-salmon D ARANESP [INJ]* calciumacetate DALIRESP epinephrine auto-injector [INJ] EPIPEN [INJ] aripiprazole candesartan darifenacin ER EPIPEN JR [INJ] ARISTADA [INJ] candesartan-HCTZ DESCOVY EPISIL ARISTADA INITIO [INJ] carbamazepine desonide armodafinil carbamazepine ER desoximetasone ergotamine-caffeine ERIVEDGE* ARNUITY ELLIPTA desvenlafaxine ER dexamethasone
[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary
2021 NATIONAL EX FORMULARY Continued
ERLEADA* GILENYA* K metoclopramide erlotinib glatiramer KESIMPTA [INJ]* metolazone erythromycin glimepiride ketoconazole metoprolol succinate ER erythromycin solution glipizide ketoconazole shampoo 2% metoprolol tartrate erythromycin-benzoyl peroxide glipizide ER ketorolac metronidazole erythromycins glipizide-metformin KEVZARA [INJ]* minocycline ESBRIET* GLUCAGEN HYPOKIT [INJ] KISQALI* MIRENA* escitalopram GLUCAGON EMERGENCY KIT [INJ] KISQALI FEMARA CO-PACK mirtazapine esomeprazole GLYXAMBI KITABIS PAK* misoprostol estradiol GONAL-F [INJ]* KOGENATE FS [INJ]* mometasone estradiol-norethindrone GRALISE KOVALTRY [INJ]* montelukast ESTRING granisetron KYLEENA* morphine eszopiclone GRANIX [INJ]* morphine ER ethinyl estradiol-drospirenone GRASTEK L morphine suppository ethinyl estradiol-drospirenone-levomefolate guanfacine ER lactulose solution MOVANTIK ethinyl estradiol-etonogestrel GVOKE [INJ] lamivudine moxifloxacin ethinyl estradiol-levonorgestrel lamotrigine MULPLETA* ethinyl estradiol-norelgestromin H lamotrigine ER MULTAQ ethinyl estradiol-norethindrone acetate HARVONI* lansoprazole mupirocin ointment ethinyl estradiol-norethindrone acetate-iron hydrochlorothiazide lanthanum carbonate MUSE ethinyl estradiol-norgestimate HUMALOG [INJ] LANTUS [INJ] MYDAYIS ethosuximide HUMALOG MIX [INJ] LASTACAFT MYRBETRIQ EUCRISA HUMATROPE [INJ]* latanoprost EUFLEXXA [INJ]* HUMIRA [INJ]* LATUDA N EVAMIST HUMULIN 70/30 [INJ] levalbuterol tartrate CFC-free aerosol nadolol everolimus* HUMULIN N [INJ] LEVEMIR [INJ] NAFTIN EVOTAZ HUMULIN R [INJ] levetiracetam naloxone injection ezetimibe HUMULIN R U-500 [INJ] levetiracetam ER NAMZARIC ezetimibe-simvastatin hydrocodone ER levocarnitine naproxen hydrocodone-acetaminophen levofloxacin naratriptan F hydrocortisone levothyroxine NARCAN NASAL SPRAY famotidine hydrocortisone butyrate LIALDA NATAZIA FARXIGA hydrocortisone enema linezolid nateglinide FASENRA [INJ]* hydromorphone LINZESS neomycin-polymyx in B-bacitracin- fenofibrate hydromorphone ER liothyronine hydrocortisone fenofibric acid DR HYSINGLA ER lisinopril neomycin-polymyx in B-dexamethasone fentanyl transdermal lisinopril-HCTZ neomycin-polymyx in B-hydrocortisone fentanyl transmucosal lozenge I LO LOESTRIN FE NEULASTA [INJ]* FETZIMA ibandronate LOKELMA NEULASTA ONPRO [INJ]* FIASP [INJ] IBRANCE* loperamide NEUPOGEN [INJ]* FINACEA FOAM ibuprofen lorazepam NEUPRO finasteride ILEVRO losartan NEVANAC FIRAZYR [INJ]* imatinib mesylate losartan-HCTZ NEXLETOL FLOVENT DISKUS imiquimod loteprednol NEXLIZET FLOVENT HFA INCRUSE ELLIPTA lovastatin niacin ER fluconazole INGREZZA* luliconazole nifedipine ER fludrocortisone INSULIN LISPRO [INJ] LUMIGAN NINLARO* flunisolide INVOKAMET LUPRON DEPOT [INJ]* nitrofurantoin fluocinonide INVOKAMET XR LYNPARZA* nitroglycerin lingual spray fluorouracil cream 5% INVOKANA LYRICA CR nitroglycerin sublingual fluorouracil solution Ipratropium inhalation solution LYUMJEV NIVESTYM [INJ]* fluoxetine ipratropium-albuterol inhalation solution NORDITROPIN [INJ]* fluticasone irbesartan M NORVIR fluvastatin irbesartan-HCTZ MAXIDEX NOVOEIGHT* FML FORTE IRESSA* MAYZENT* NOVOLIN 70/30 [INJ] FML S.O.P. ISENTRESS meclizine NOVOLIN N [INJ] FORTEO [INJ]* isosorbide dinitrate medroxyprogesterone NOVOLIN R [INJ] fosinopril isosorbide mononitrate megestrol acetate NOVOLOG [INJ] fosinopril-HCTZ itraconazole meloxicam NOVOLOG MIX 70/30 [INJ] FREESTYLE LIBRE CONTINUOUS ivermectin memantine NUBEQA* GLUCOSE MONITORING SYSTEM mesalamine DR NUCALA [INJ]* furosemide J mesalamine ER NUCYNTA FYCOMPA JANUMET mesalamine suppository NUCYNTA ER JANUMET XR mesalamine suspension NUEDEXTA G JANUVIA metformin NURTEC ODT gabapentin JARDIANCE metformin ER NUWIQ [INJ]* galantamine JENTADUETO methadone nystatin galantamine ER JENTADUETO XR methoxsalen GELSYN-3 [INJ]* JIVI* methylphenidate O gentamicin methylprednisolone OCREVUS [INJ]* GENVOYA ODEFSEY
[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary
2021 NATIONAL EX FORMULARY Continued
ODOMZO* PREMPHASE silodosin tolterodine OFEV* PREMPRO SIMBRINZA tolterodine ER ofloxacin prenatal vitamins SIMPONI [INJ]* topiramate ofloxacin otic PREZCOBIX simvastatin torsemide olanzapine PREZISTA SKYLA TOUJEO [INJ] olmesartan primidone SKYRIZI [INJ]* TOVIAZ olmesartan-amlodipine-HCTZ probenecid solifenacin TRADJENTA olmesartan-HCTZ prochlorperazine SOLIQUA [INJ] tramadol olopatadine PROCRIT [INJ]* SOMATULINE DEPOT [INJ]* tramadol ER omega-3 acid ethyl esters PROCTOFOAM-HC SOMAVERT travoprost omeprazole progesterone, micronized SOOLANTRA trazodone OMNIPOD DASH INSULIN PROLASTIN-C [INJ]* sotalol TRELEGY ELLIPTA INFUSION PUMP PROLIA [INJ]* SPIRIVA TREMFYA [INJ]* OMNIPOD INSULIN INFUSION PUMP promethazine spironolactone-HCTZ TRESIBA [INJ] ondansetron propranolol SPRYCEL* tretinoin ONETOUCH ULTRA STRIPS AND KITS propranolol ER STELARA SC [INJ]* triamcinolone ONETOUCH VERIO STRIPS AND KITS PULMICORT FLEXHALER STIOLTO RESPIMAT triamterene ONEXTON PYLERA STRIBILD triamterene-HCTZ ONZETRA XSAIL pyrimethamine STRIVERDI RESPIMAT trifluridine OPSUMIT* SUBSYS TRIJARDY XR ORALAIR Q sucralfate trimethobenzamide ORENITRAM* QTERN sulfacetamide TRINTELLIX ORILISSA quetiapine sulfamethoxazole-trimethoprim TRIUMEQ oseltamivir quetiapine ER sulfasalazine TROKENDI XR OSPHENA quinapril sulfasalazine DR trospium OTEZLA* quinapril-HCTZ sulfide lotion 2.5% trospium ER OVIDREL [INJ]* QVAR REDIHALER sumatriptan TRULICITY [INJ] oxazepam SUNOSI TRUVADA oxcarbazepine R SUPARTZ FX TYMLOS [INJ]* OXTELLAR XR RAGWITEK SUPRAX TYSABRI [INJ]* oxybutynin raloxifene SUPREP oxybutynin ER ramelteon SUTENT U oxycodone ramipril SYMBICORT UBRELVY oxycodone-acetaminophen ranolazine ER SYMJEPI [INJ] UDENYCA [INJ]* OXYCONTIN rasagiline SYMLINPEN [INJ] UPTRAVI* OZEMPIC [INJ] RASUVO [INJ] SYMTUZA REBIF [INJ]* SYNJARDY V P REBINYN* SYNJARDY XR valacyclovir pantoprazole RELENZA SYNTHROID valganciclovir paroxetine HCl repaglinide valproic acid paroxetine HCl ER REPATHA [INJ] T valsartan paroxetine mesylate RESTASIS tacrolimus valsartan-HCTZ PAZEO RETACRIT [INJ]* tadalafil vancomycin capsule peg 3350-electrolytes REYVOW TAKHZYRO [INJ]* VARUBI penicillin VK RHOPRESSA TALTZ [INJ]* VASCEPA PENTASA ribavirin tamsulosin VELPHORO PERFOROMIST RINVOQ* TAYTULLA VELTASSA phenobarbital risedronate TAZORAC VEMLIDY phenytoin risperidone TEGSEDI [INJ]* venlafaxine phenytoin sodium ER rivastigmine TEKTURNA HCT venlafaxine ER capsule PHESGO rivastigmine transdermal telmisartan verapamil ER PHOSLYRA rizatriptan telmisartan-HCTZ V-GO INSULIN INFUSION PUMP PICATO ROCKLATAN TEMIXYS VIBERZI pimecrolimus ropinirole terazosin VICTOZA [INJ] pindolol ropinirole ER terbinafine tablet vigabatrin pioglitazone rosuvastatin testosterone gel VIIBRYD pioglitazone-glimepiride RUBRACA* testosterone solution VIMPAT pioglitazone-metformin RUCONEST [INJ]* tetrabenazine VIOKACE potassium chloride liquid RYBELSUS tetracycline VISTOGARD PRALUENT [INJ] RYDAPT tiagabine VOSEVI* pramipexole timolol maleate solution VOTRIENT* pramipexole ER S TIVICAY VRAYLAR prasugrel SANCUSO TOBI PODHALER* VUMERITY* pravastatin sapropterin* TOBRADEX OINTMENT VYVANSE PRED MILD SAVELLA TOBRADEX ST prednisolone acetate 1% SAXENDA tobramycin W prednisolone solution scopolamine transdermal tobramycin inhalation solution warfarin prednisone selegiline selenium tobramycin-dexamethasone pregabalin SEREVENT TOLAK X PREMARIN sertraline XARELTO PREMARIN CREAM sevelamer carbonate XELJANZ XR* sildenafil
[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary
2021 NATIONAL EX FORMULARY Continued
XELJANZ* XIFAXAN 550 MG XIGDUO XR XIIDRA XOLAIR [INJ]* XOSPATA XTAMPZA ER XTANDI* XULTOPHY [INJ]
Y YONSA* YUPELRI
Z zafirlukast ZARXIO [INJ]* ZEJULA* ZEMBRACE SYMTOUCH ZENPEP ZEPOSIA* ZIEXTENZO zileuton ER ZIOPTAN ziprasidone zolmitriptan zolpidem zolpidem ER zolpidem sublingual ZOMIG NASAL SPRAY zonisamide ZUBSOLV ZYCLARA
[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary 2021 NATIONAL EX FORMULARY Continued
STEP THERAPIES *Requires trial and failure of one primary treatment product THERAPEUTIC CATEGORY PRIMARY TREATMENT SECONDARY TREATMENT*
ANTICOAGULANTS
Anticoagulants Eliquis, Xarelto Pradaxa DIABETES
Diabetic Test Strips OneTouch Products All other products not OneTouch Dipeptidyl Peptidase-4 Inhibitors (DPP-4) Januvia, Janumet, Janumet XR, Tradjenta, Jentadueto, Kazano, Kombiglyze XR, Nesina, Onglyza & Combinations Jentadueto XR Glucagon-Like Peptide-1 Agonists (GLP-1) Ozempic, Rybelsus, Trulicity, Victoza Bydureon, Byetta Insulin Humulin, Novolin Novolin Relion Rapid Acting Insulin Fiasp, Humalog, Insulin Lispro, Novolog Apidra RESPIRATORY
Long Acting Muscarinic Antagonist Atrovent HFA, Incruse Eliipta, Spiriva, Yupelri Tudorza Pressair
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