Preferred Drug List

October 2021

Preferred Drug List

The Preferred Drug List, administered by CVS Caremark® on behalf of Siemens, 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 administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a doctor. 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 drug list represents a summary of prescription coverage. It is this document. Products recently approved by the U.S. Food and not all-inclusive and does not guarantee coverage. The member’s Drug Administration (FDA) may not be covered upon release specific prescription benefit plan design may not cover certain to the market. products or categories, regardless of their appearance in this • You may be responsible for the full cost of non-formulary products document. Products recently approved by the FDA may not be that are not covered without a prior authorization for medical covered upon release to the market. necessity. • The member's prescription benefit plan may have a different • For specific information regarding your prescription benefit copay for specific products on the list. coverage and copay1 information, please visit Caremark.com • Unless specifically indicated, drug list products will include all or contact a CVS Caremark Customer Care representative dosage forms. at 1-866-478-5802. • 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 fentanyl transdermal SUPRAX itraconazole fentanyl transmucosal terbinafine tablet ANTINEOPLASTIC § ERYTHROMYCINS / § COX-2 INHIBITORS lozenge AGENTS MACROLIDES ANTIVIRALS celecoxib hydrocodone ext-rel HORMONAL hydrocodone-acetaminophen azithromycin § CYTOMEGALOVIRUS § GOUT ANTINEOPLASTIC AGENTS hydromorphone clarithromycin AGENTS § ANTIANDROGENS allopurinol hydromorphone ext-rel clarithromycin ext-rel valganciclovir colchicine tablet methadone erythromycins bicalutamide probenecid morphine DIFICID § HERPES AGENTS CARDIOVASCULAR MITIGARE morphine ext-rel acyclovir capsule, tablet § FLUOROQUINOLONES morphine suppository valacyclovir § ACE INHIBITORS § NSAIDs oxycodone ciprofloxacin diclofenac sodium § INFLUENZA AGENTS fosinopril oxycodone-acetaminophen levofloxacin ibuprofen lisinopril tramadol (except NDC^ 52817019610) moxifloxacin oseltamivir meloxicam tablet quinapril tramadol ext-rel tablet RELENZA naproxen (except naproxen CR or § PENICILLINS ramipril BELBUCA naproxen suspension) amoxicillin § MISCELLANEOUS NUCYNTA § ACE INHIBITOR / amoxicillin-clavulanate clindamycin § NSAIDs, COMBINATIONS NUCYNTA ER DIURETIC COMBINATIONS dicloxacillin ivermectin SUBSYS fosinopril-hydrochlorothiazide diclofenac sodium- penicillin VK linezolid

XTAMPZA ER lisinopril-hydrochlorothiazide misoprostol metronidazole § TETRACYCLINES quinapril-hydrochlorothiazide ANTI-INFECTIVES nitrofurantoin (except NDC^ § NSAIDs, TOPICAL doxycycline hyclate 20 mg 70408023932) § ANGIOTENSIN II diclofenac sodium gel 1% ANTIBACTERIALS doxycycline hyclate capsule pyrimethamine RECEPTOR ANTAGONISTS / diclofenac sodium solution § CEPHALOSPORINS minocycline sulfamethoxazole- DIURETIC COMBINATIONS tetracycline cefdinir trimethoprim § OPIOID ANALGESICS candesartan / candesartan- cefprozil vancomycin capsule buprenorphine transdermal § ANTIFUNGALS hydrochlorothiazide cefuroxime axetil EMVERM codeine-acetaminophen fluconazole irbesartan / irbesartan- cephalexin XIFAXAN 550 MG

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.

hydrochlorothiazide lorazepam § MISCELLANEOUS MIGRAINE § BETA-BLOCKERS losartan / losartan- oxazepam AGENTS ACUTE MIGRAINE AGENTS atenolol hydrochlorothiazide bupropion § Triptans carvedilol § ANTICONVULSANTS olmesartan / olmesartan- bupropion ext-rel (except carvedilol phosphate ext-rel carbamazepine eletriptan hydrochlorothiazide bupropion ext-rel tablet 450 mg) metoprolol succinate ext-rel carbamazepine ext-rel naratriptan telmisartan / telmisartan- mirtazapine metoprolol tartrate clobazam rizatriptan hydrochlorothiazide trazodone sumatriptan valsartan / valsartan- nadolol diazepam rectal gel zolmitriptan hydrochlorothiazide pindolol divalproex sodium § ANTIPARKINSONIAN propranolol divalproex sodium ext-rel AGENTS ONZETRA XSAIL § ANGIOTENSIN II ZEMBRACE SYMTOUCH propranolol ext-rel ethosuximide amantadine RECEPTOR ANTAGONIST / ZOMIG NASAL SPRAY BYSTOLIC gabapentin carbidopa-levodopa CALCIUM CHANNEL lamotrigine carbidopa-levodopa ext-rel § CALCIUM CHANNEL Miscellaneous BLOCKER COMBINATIONS lamotrigine ext-rel carbidopa-levodopa- BLOCKERS NURTEC ODT amlodipine-olmesartan levetiracetam entacapone amlodipine REYVOW amlodipine-telmisartan levetiracetam ext-rel entacapone UBRELVY diltiazem ext-rel (except generics amlodipine-valsartan oxcarbazepine pramipexole

for CARDIZEM LA) phenobarbital pramipexole ext-rel PREVENTIVE MIGRAINE § ANGIOTENSIN II nifedipine ext-rel phenytoin rasagiline AGENTS RECEPTOR ANTAGONIST / verapamil ext-rel phenytoin sodium extended ropinirole CALCIUM CHANNEL Monoclonal Antibodies primidone ropinirole ext-rel BLOCKER / DIURETIC § CALCIUM CHANNEL AIMOVIG rufinamide selegiline COMBINATIONS BLOCKER / ANTILIPEMIC AJOVY tiagabine NEUPRO COMBINATIONS EMGALITY amlodipine-valsartan- topiramate

hydrochlorothiazide amlodipine-atorvastatin valproic acid ANTIPSYCHOTICS § MUSCULOSKELETAL olmesartan-amlodipine- § DIGITALIS GLYCOSIDES zonisamide § ATYPICALS THERAPY AGENTS hydrochlorothiazide FYCOMPA aripiprazole digoxin cyclobenzaprine (except NAYZILAM § ANTIARRHYTHMICS clozapine cyclobenzaprine tablet 7.5 mg) § DIRECT RENIN OXTELLAR XR olanzapine disopyramide INHIBITORS / DIURETIC TROKENDI XR quetiapine § NARCOLEPSY sotalol VALTOCO COMBINATIONS quetiapine ext-rel armodafinil MULTAQ VIMPAT aliskiren risperidone modafinil XCOPRI ziprasidone SUNOSI ANTILIPEMICS TEKTURNA HCT

ACL INHIBITORS / § ANTIDEMENTIA ABILIFY MAINTENA § DIURETICS LATUDA POSTHERPETIC COMBINATIONS donepezil amiloride PERSERIS NEURALGIA (PHN) NEXLETOL galantamine furosemide VRAYLAR GRALISE NEXLIZET galantamine ext-rel hydrochlorothiazide memantine § ATTENTION DEFICIT PSYCHOTHERAPEUTIC - § BILE ACID RESINS metolazone rivastigmine spironolactone- HYPERACTIVITY DISORDER MISCELLANEOUS cholestyramine rivastigmine transdermal hydrochlorothiazide amphetamine- § OPIOID ANTAGONISTS colesevelam NAMZARIC dextroamphetamine mixed torsemide naloxone injection § CHOLESTEROL triamterene ANTIDEPRESSANTS salts NARCAN NASAL SPRAY ABSORPTION INHIBITORS triamterene- amphetamine- § SELECTIVE SEROTONIN dextroamphetamine mixed § PARTIAL OPIOID AGONIST ezetimibe hydrochlorothiazide REUPTAKE INHIBITORS salts ext-rel † / OPIOID ANTAGONIST (SSRIs) § FIBRATES HEART FAILURE atomoxetine COMBINATIONS citalopram fenofibrate (except fenofibrate capsule BIDIL dexmethylphenidate ext-rel buprenorphine-naloxone escitalopram 50 mg, 130 mg; fenofibrate tablet 40 mg, CORLANOR guanfacine ext-rel sublingual fluoxetine (except fluoxetine tablet 60 120 mg) ENTRESTO methylphenidate ZUBSOLV mg, fluoxetine tablet [generics for † fenofibric acid delayed-rel methylphenidate ext-rel § NITRATES SARAFEM]) MYDAYIS PSEUDOBULBAR AFFECT § HMG-CoA REDUCTASE isosorbide dinitrate (except paroxetine HCl VYVANSE AGENTS INHIBITORS / isosorbide dinitrate 40 mg) paroxetine HCl ext-rel (except NUEDEXTA

COMBINATIONS isosorbide mononitrate NDC^ 60505367503) § FIBROMYALGIA ENDOCRINE AND atorvastatin nitroglycerin lingual spray sertraline pregabalin METABOLIC ezetimibe-simvastatin nitroglycerin sublingual TRINTELLIX HYPNOTICS fluvastatin § MISCELLANEOUS § SEROTONIN § NONBENZODIAZEPINES § ANDROGENS lovastatin ranolazine ext-rel NOREPINEPHRINE testosterone gel (except authorized pravastatin eszopiclone REUPTAKE INHIBITORS generics for TESTIM and VOGELXO) rosuvastatin ramelteon CENTRAL NERVOUS (SNRIs) testosterone solution simvastatin zolpidem ANDRODERM SYSTEM desvenlafaxine ext-rel zolpidem ext-rel NATESTO § NIACINS duloxetine ANTIANXIETY BELSOMRA venlafaxine niacin ext-rel ANTIDIABETICS § BENZODIAZEPINES venlafaxine ext-rel capsule § TRICYCLICS AMYLIN ANALOGS § OMEGA-3 FATTY ACIDS alprazolam doxepin omega-3 acid ethyl esters clonazepam SYMLINPEN

VASCEPA diazepam

§ BIGUANIDES SODIUM-GLUCOSE § CALCITONINS EVAMIST INFLAMMATORY BOWEL metformin CO-TRANSPORTER 2 calcitonin-salmon DISEASE § VAGINAL metformin ext-rel (except generics (SGLT2) INHIBITOR / § ORAL AGENTS BIGUANIDE COMBINATIONS § CARNITINE DEFICIENCY estradiol vaginal cream for FORTAMET and GLUMETZA) balsalazide AGENTS IMVEXXY SYNJARDY budesonide capsule § BIGUANIDE / levocarnitine VAGIFEM SYNJARDY XR budesonide ext-rel SULFONYLUREA XIGDUO XR § PHOSPHATE BINDER mesalamine delayed-rel COMBINATIONS CONTRACEPTIVES AGENTS (except mesalamine delayed-rel tablet glipizide-metformin SODIUM-GLUCOSE § MONOPHASIC 800 mg) CO-TRANSPORTER 2 calcium acetate ethinyl estradiol- mesalamine ext-rel DIPEPTIDYL PEPTIDASE-4 (SGLT2) INHIBITOR / sevelamer carbonate drospirenone sulfasalazine (DPP-4) INHIBITORS DIPEPTIDYL PEPTIDASE-4 PHOSLYRA ethinyl estradiol- sulfasalazine delayed-rel VELPHORO JANUVIA (DPP-4) INHIBITOR drospirenone-levomefolate ASACOL HD COMBINATIONS ethinyl estradiol- DIPEPTIDYL PEPTIDASE-4 POTASSIUM-REMOVING PENTASA GLYXAMBI norethindrone acetate (DPP-4) INHIBITOR / AGENTS ethinyl estradiol- § RECTAL AGENTS BIGUANIDE COMBINATIONS SODIUM-GLUCOSE LOKELMA norethindrone acetate-iron hydrocortisone enema JANUMET CO-TRANSPORTER 2 VELTASSA mesalamine suppository JANUMET XR (SGLT2) INHIBITOR / BIPHASIC PROGESTINS mesalamine suspension DIPEPTIDYL PEPTIDASE-4 LO LOESTRIN FE INCRETIN MIMETIC AGENTS § ORAL CORTIFOAM (DPP-4) INHIBITOR / OZEMPIC BIGUANIDE COMBINATIONS § TRIPHASIC medroxyprogesterone § IRRITABLE BOWEL RYBELSUS TRIJARDY XR ethinyl estradiol-norgestimate megestrol acetate SYNDROME TRULICITY progesterone, micronized alosetron VICTOZA § SULFONYLUREAS § EXTENDED CYCLE VAGINAL lubiprostone glimepiride ethinyl estradiol- INCRETIN MIMETIC AGENT / LINZESS levonorgestrel CRINONE glipizide INSULIN COMBINATIONS VIBERZI glipizide ext-rel § SELECTIVE ESTROGEN SOLIQUA § TRANSDERMAL RECEPTOR MODULATORS § LAXATIVES XULTOPHY SUPPLIES ethinyl estradiol- lactulose solution norelgestromin raloxifene ACCU-CHEK AVIVA PLUS INSULINS peg 3350-electrolytes STRIPS AND KITS 2 CLENPIQ § VAGINAL § THYROID SUPPLEMENTS BASAGLAR ACCU-CHEK COMPACT levothyroxine FIASP PLUS STRIPS AND KITS 2 ethinyl estradiol-etonogestrel OPIOID-INDUCED HUMULIN R U-500 ACCU-CHEK GUIDE ANNOVERA liothyronine CONSTIPATION SYNTHROID LEVEMIR 2 STRIPS AND KITS MOVANTIK NOVOLIN 70/30 ENDOMETRIOSIS ACCU-CHEK SMARTVIEW UTERINE FIBROIDS SYMPROIC ORILISSA NOVOLIN N STRIPS AND KITS 2 ORIAHNN NOVOLIN R PANCREATIC ENZYMES BD ULTRAFINE INSULIN § GLUCOCORTICOIDS NOVOLOG SYRINGES AND GASTROINTESTINAL CREON NOVOLOG MIX 70/30 dexamethasone NEEDLES VIOKACE TOUJEO fludrocortisone DEXCOM CONTINUOUS § ANTIDIARRHEALS ZENPEP hydrocortisone TRESIBA GLUCOSE MONITORING diphenoxylate-atropine methylprednisolone SYSTEM loperamide § PROTON PUMP § INSULIN SENSITIZERS prednisolone solution OMNIPOD DASH INSULIN INHIBITORS pioglitazone prednisone § ANTIEMETICS esomeprazole delayed-rel INFUSION PUMP § INSULIN SENSITIZER / OMNIPOD INSULIN GLUCOSE ELEVATING aprepitant lansoprazole delayed-rel BIGUANIDE COMBINATIONS INFUSION PUMP AGENTS doxylamine-pyridoxine omeprazole delayed-rel ONETOUCH ULTRA delayed-rel pantoprazole delayed-rel pioglitazone-metformin BAQSIMI STRIPS AND KITS 2 dronabinol tablet GLUCAGEN HYPOKIT § INSULIN SENSITIZER / ONETOUCH VERIO STRIPS granisetron DEXILANT GLUCAGON EMERGENCY SULFONYLUREA AND KITS 2 meclizine KIT § STEROIDS, RECTAL V-GO INSULIN INFUSION metoclopramide COMBINATIONS GVOKE

PUMP ondansetron PROCTOFOAM-HC pioglitazone-glimepiride prochlorperazine MENOPAUSAL SYMPTOM § ULCER THERAPY § MEGLITINIDES ANTIOBESITY promethazine AGENTS COMBINATIONS INJECTABLE nateglinide § ORAL scopolamine transdermal PYLERA SAXENDA trimethobenzamide repaglinide estradiol

SANCUSO § MISCELLANEOUS SODIUM-GLUCOSE ORAL estradiol-norethindrone DUAVEE § ANTISPASMODICS sucralfate tablet CO-TRANSPORTER 2 QSYMIA PREMPHASE (SGLT2) INHIBITORS dicyclomine CALCIUM REGULATORS PREMPRO GENITOURINARY FARXIGA § H2 RECEPTOR § BISPHOSPHONATES § BENIGN PROSTATIC JARDIANCE § TRANSDERMAL ANTAGONISTS HYPERPLASIA alendronate estradiol famotidine ibandronate CLIMARA PRO alfuzosin ext-rel

risedronate COMBIPATCH doxazosin

DIVIGEL dutasteride dutasteride-tamsulosin

finasteride SYMJEPI STEROID / BETA AGONIST CORTICOSTEROIDS ANTI-INFLAMMATORIES silodosin COMBINATIONS § Low Potency § Nonsteroidal § ANTICHOLINERGICS tamsulosin ADVAIR DISKUS desonide bromfenac terazosin ipratropium inhalation † ADVAIR HFA hydrocortisone diclofenac solution † BREO ELLIPTA ketorolac ERECTILE DYSFUNCTION SPIRIVA § Medium Potency SYMBICORT ILEVRO ALPROSTADIL AGENTS YUPELRI hydrocortisone butyrate PROLENSA § STEROID INHALANTS MUSE cream, ointment, solution ANTICHOLINERGIC / BETA budesonide inhalation mometasone § Steroidal § PHOSPHODIESTERASE AGONIST COMBINATIONS suspension triamcinolone cream, lotion, dexamethasone INHIBITORS § SHORT ACTING ARNUITY ELLIPTA ointment (except triamcinolone loteprednol sildenafil ipratropium-albuterol FLOVENT DISKUS ointment 0.05%) prednisolone acetate 1% tadalafil inhalation solution FLOVENT HFA DUREZOL

PULMICORT FLEXHALER § High Potency § URINARY LONG ACTING QVAR REDIHALER desoximetasone § ANTIVIRALS ANTISPASMODICS ANORO ELLIPTA fluocinonide (except fluocinonide trifluridine darifenacin ext-rel STIOLTO RESPIMAT TOPICAL cream 0.1%) oxybutynin BETA-BLOCKERS ANTICHOLINERGIC / BETA DERMATOLOGY BRYHALI oxybutynin ext-rel § Nonselective AGONIST / STEROID solifenacin ACNE § Very High Potency INHALANT COMBINATIONS timolol maleate solution tolterodine § Topical clobetasol cream, foam, gel, BREZTRI AEROSPHERE tolterodine ext-rel adapalene lotion, ointment, shampoo Selective TRELEGY ELLIPTA trospium benzoyl peroxide BETOPTIC S trospium ext-rel § LOCAL ANALGESICS § ANTIHISTAMINES, clindamycin gel (except NDC^ § CARBONIC ANHYDRASE MYRBETRIQ 68682046275) lidocaine patch LOW SEDATING INHIBITORS TOVIAZ clindamycin solution levocetirizine § LOCAL ANESTHETICS

clindamycin-benzoyl brinzolamide HEMATOLOGIC lidocaine-prilocaine § ANTITUSSIVES peroxide dorzolamide

erythromycin solution § ANTICOAGULANTS benzonatate (except NDCs^ § ROSACEA § CARBONIC ANHYDRASE erythromycin-benzoyl warfarin 69336012615, 69499032915) azelaic acid gel INHIBITOR / BETA- peroxide ELIQUIS metronidazole BLOCKER COMBINATIONS BETA AGONISTS, tretinoin XARELTO FINACEA FOAM INHALANTS EPIDUO dorzolamide-timolol ORACEA § PLATELET AGGREGATION § SHORT ACTING ONEXTON SOOLANTRA CARBONIC ANHYDRASE INHIBITORS albuterol inhalation solution § ACTINIC KERATOSIS INHIBITOR / clopidogrel albuterol sulfate CFC-free MOUTH / THROAT / SYMPATHOMIMETIC fluorouracil cream 5% dipyridamole ext-rel-aspirin aerosol DENTAL AGENTS COMBINATIONS fluorouracil solution prasugrel levalbuterol tartrate CFC-free PROTECTANTS imiquimod SIMBRINZA BRILINTA aerosol PICATO EPISIL DRY EYE DISEASE IMMUNOLOGIC LONG ACTING TOLAK OPHTHALMIC RESTASIS AGENTS ZYCLARA Hand-held Active Inhalation § ANTIALLERGICS XIIDRA

ALLERGENIC EXTRACTS SEREVENT § ANTIBIOTICS azelastine § PROSTAGLANDINS STRIVERDI RESPIMAT GRASTEK gentamicin cromolyn sodium latanoprost olopatadine RAGWITEK Nebulized Passive Inhalation mupirocin ointment travoprost NUTRITIONAL / PERFOROMIST § ANTIFUNGALS § ANTI-INFECTIVES LUMIGAN

SUPPLEMENTS ciclopirox ciprofloxacin ZIOPTAN § LEUKOTRIENE clotrimazole erythromycin § ELECTROLYTES MODULATORS RHO KINASE INHIBITORS econazole gentamicin montelukast RHOPRESSA potassium chloride liquid ketoconazole cream 2% levofloxacin zafirlukast nystatin moxifloxacin VITAMINS AND MINERALS RHO KINASE INHIBITOR / § NASAL ANTIHISTAMINES NAFTIN ofloxacin PROSTAGLANDIN § FOLIC ACID / sulfacetamide azelastine COMBINATIONS COMBINATIONS § ANTIPSORIATICS tobramycin olopatadine ROCKLATAN folic acid acitretin BESIVANCE calcipotriene ointment, § PRENATAL VITAMINS § NASAL STEROIDS / § SYMPATHOMIMETICS solution § ANTI-INFECTIVE / COMBINATIONS brimonidine prenatal vitamins methoxsalen ANTI-INFLAMMATORY azelastine-fluticasone ALPHAGAN P COMBINATIONS CITRANATAL flunisolide § ANTISEBORRHEICS neomycin-polymyxin B- SYMPATHOMIMETIC / BETA- fluticasone RESPIRATORY ketoconazole shampoo 2% bacitracin-hydrocortisone BLOCKER COMBINATIONS mometasone

selenium sulfide lotion 2.5% neomycin-polymyxin B- § ANAPHYLAXIS COMBIGAN dexamethasone TREATMENT AGENTS PHOSPHODIESTERASE-4 § ATOPIC DERMATITIS INHIBITORS tobramycin-dexamethasone OTIC epinephrine auto-injector pimecrolimus TOBRADEX OINTMENT DALIRESP § ANTI-INFECTIVES EPIPEN tacrolimus acetic acid EPIPEN JR EUCRISA ofloxacin otic

§ ANTI-INFECTIVE / ciprofloxacin-dexamethasone ANTI-INFLAMMATORY neomycin-polymyxin B- COMBINATIONS hydrocortisone QUICK REFERENCE DRUG LIST

A B CITRANATAL DIVIGEL F clarithromycin donepezil ABILIFY MAINTENA balsalazide famotidine clarithromycin ext-rel dorzolamide ACCU-CHEK AVIVA PLUS BAQSIMI FARXIGA CLENPIQ dorzolamide-timolol STRIPS AND KITS 2 BASAGLAR fenofibrate (except fenofibrate capsule CLIMARA PRO doxazosin ACCU-CHEK COMPACT BD ULTRAFINE INSULIN 50 mg, 130 mg; fenofibrate tablet 40 mg, clindamycin doxepin PLUS STRIPS AND KITS 2 SYRINGES AND 120 mg) clindamycin gel (except NDC^ doxycycline hyclate 20 mg ACCU-CHEK GUIDE NEEDLES fenofibric acid delayed-rel 68682046275) doxycycline hyclate capsule STRIPS AND KITS 2 BELBUCA fentanyl transdermal clindamycin solution doxylamine-pyridoxine ACCU-CHEK SMARTVIEW BELSOMRA fentanyl transmucosal clindamycin-benzoyl delayed-rel STRIPS AND KITS 2 benzonatate (except NDCs^ lozenge peroxide dronabinol acetic acid 69336012615, 69499032915) FIASP clobazam DUAVEE acitretin benzoyl peroxide FINACEA FOAM clobetasol cream, foam, gel, duloxetine acyclovir capsule, tablet BESIVANCE finasteride lotion, ointment, shampoo DUREZOL adapalene BETOPTIC S FLOVENT DISKUS clonazepam dutasteride ADVAIR DISKUS bicalutamide FLOVENT HFA clopidogrel dutasteride-tamsulosin ADVAIR HFA † BIDIL fluconazole clotrimazole AIMOVIG BREO ELLIPTA † fludrocortisone clozapine E AJOVY BREZTRI AEROSPHERE flunisolide codeine-acetaminophen econazole albuterol inhalation solution BRILINTA fluocinonide (except fluocinonide colchicine tablet eletriptan albuterol sulfate CFC-free brimonidine cream 0.1%) colesevelam ELIQUIS aerosol brinzolamide fluorouracil cream 5% COMBIGAN EMGALITY alendronate bromfenac fluorouracil solution COMBIPATCH EMVERM alfuzosin ext-rel BRYHALI fluoxetine (except fluoxetine tablet 60 CORLANOR entacapone aliskiren budesonide capsule mg, fluoxetine tablet [generics for CORTIFOAM ENTRESTO allopurinol budesonide ext-rel SARAFEM]) CREON EPIDUO alosetron budesonide inhalation fluticasone CRINONE epinephrine auto-injector ALPHAGAN P suspension fluvastatin cromolyn sodium EPIPEN alprazolam buprenorphine transdermal folic acid cyclobenzaprine (except EPIPEN JR amantadine buprenorphine-naloxone fosinopril cyclobenzaprine tablet 7.5 mg) EPISIL amiloride sublingual fosinopril-hydrochlorothiazide erythromycin amlodipine bupropion furosemide D erythromycin solution amlodipine-atorvastatin bupropion ext-rel (except FYCOMPA DALIRESP erythromycin-benzoyl amlodipine-olmesartan bupropion ext-rel tablet 450 mg) darifenacin ext-rel peroxide amlodipine-telmisartan BYSTOLIC G desonide erythromycins amlodipine-valsartan gabapentin desoximetasone escitalopram amlodipine-valsartan- C galantamine desvenlafaxine ext-rel esomeprazole delayed-rel hydrochlorothiazide calcipotriene ointment, galantamine ext-rel dexamethasone estradiol amoxicillin solution gentamicin DEXCOM CONTINUOUS estradiol vaginal cream amoxicillin-clavulanate calcitonin-salmon glimepiride GLUCOSE MONITORING estradiol-norethindrone amphetamine- calcium acetate glipizide SYSTEM eszopiclone dextroamphetamine mixed candesartan glipizide ext-rel DEXILANT ethinyl estradiol- salts candesartan- glipizide-metformin dexmethylphenidate ext-rel drospirenone amphetamine- hydrochlorothiazide GLUCAGEN HYPOKIT diazepam ethinyl estradiol- dextroamphetamine mixed carbamazepine GLUCAGON EMERGENCY † diazepam rectal gel drospirenone-levomefolate salts ext-rel carbamazepine ext-rel KIT diclofenac ethinyl estradiol-etonogestrel ANDRODERM carbidopa-levodopa GLYXAMBI diclofenac sodium ethinyl estradiol- ANNOVERA carbidopa-levodopa ext-rel GRALISE diclofenac sodium gel 1% levonorgestrel ANORO ELLIPTA carbidopa-levodopa- granisetron diclofenac sodium solution ethinyl estradiol- aprepitant entacapone GRASTEK diclofenac sodium- norelgestromin aripiprazole carvedilol guanfacine ext-rel misoprostol ethinyl estradiol- armodafinil carvedilol phosphate ext-rel GVOKE dicloxacillin norethindrone acetate ARNUITY ELLIPTA cefdinir dicyclomine ethinyl estradiol- ASACOL HD cefprozil H DIFICID norethindrone acetate-iron atenolol cefuroxime axetil HUMULIN R U-500 digoxin ethinyl estradiol-norgestimate atomoxetine celecoxib hydrochlorothiazide diltiazem ext-rel (except generics ethosuximide atorvastatin cephalexin hydrocodone ext-rel for CARDIZEM LA) EUCRISA azelaic acid gel cholestyramine hydrocodone-acetaminophen diphenoxylate-atropine EVAMIST azelastine ciclopirox hydrocortisone dipyridamole ext-rel-aspirin ezetimibe azelastine-fluticasone ciprofloxacin hydrocortisone butyrate disopyramide ezetimibe-simvastatin azithromycin ciprofloxacin-dexamethasone cream, ointment, solution divalproex sodium citalopram hydrocortisone enema divalproex sodium ext-rel

hydromorphone M nitroglycerin sublingual pioglitazone-metformin silodosin hydromorphone ext-rel NOVOLIN 70/30 potassium chloride liquid SIMBRINZA meclizine NOVOLIN N pramipexole simvastatin medroxyprogesterone I NOVOLIN R pramipexole ext-rel solifenacin megestrol acetate ibandronate NOVOLOG prasugrel SOLIQUA meloxicam tablet ibuprofen NOVOLOG MIX 70/30 pravastatin SOOLANTRA memantine NUCYNTA prednisolone acetate 1% sotalol ILEVRO mesalamine delayed-rel imiquimod NUCYNTA ER prednisolone solution SPIRIVA (except mesalamine delayed-rel tablet IMVEXXY NUEDEXTA prednisone spironolactone- 800 mg) ipratropium inhalation NURTEC ODT pregabalin hydrochlorothiazide mesalamine ext-rel solution nystatin PREMPHASE STIOLTO RESPIMAT mesalamine suppository ipratropium-albuterol PREMPRO STRIVERDI RESPIMAT mesalamine suspension inhalation solution O prenatal vitamins SUBSYS metformin irbesartan ofloxacin primidone sucralfate tablet metformin ext-rel (except generics irbesartan- ofloxacin otic probenecid sulfacetamide for FORTAMET and GLUMETZA) hydrochlorothiazide olanzapine prochlorperazine sulfamethoxazole- methadone isosorbide dinitrate (except olmesartan PROCTOFOAM-HC trimethoprim methoxsalen isosorbide dinitrate 40 mg) olmesartan-amlodipine- progesterone, micronized sulfasalazine methylphenidate isosorbide mononitrate hydrochlorothiazide PROLENSA sulfasalazine delayed-rel methylphenidate ext-rel † itraconazole olmesartan- promethazine sumatriptan methylprednisolone ivermectin hydrochlorothiazide propranolol SUNOSI metoclopramide olopatadine propranolol ext-rel SUPRAX metolazone J omega-3 acid ethyl esters PULMICORT FLEXHALER SYMBICORT metoprolol succinate ext-rel omeprazole delayed-rel PYLERA SYMJEPI JANUMET metoprolol tartrate pyrimethamine SYMLINPEN JANUMET XR OMNIPOD DASH INSULIN metronidazole INFUSION PUMP SYMPROIC JANUVIA minocycline OMNIPOD INSULIN Q SYNJARDY JARDIANCE mirtazapine INFUSION PUMP QSYMIA SYNJARDY XR MITIGARE K SYNTHROID ondansetron quetiapine modafinil ONETOUCH ULTRA quetiapine ext-rel ketoconazole cream 2% mometasone STRIPS AND KITS 2 quinapril T ketoconazole shampoo 2% montelukast ONETOUCH VERIO STRIPS quinapril-hydrochlorothiazide tacrolimus ketorolac morphine AND KITS 2 QVAR REDIHALER tadalafil morphine ext-rel ONEXTON tamsulosin L morphine suppository ONZETRA XSAIL R TEKTURNA HCT lactulose solution MOVANTIK ORACEA telmisartan lamotrigine moxifloxacin RAGWITEK ORIAHNN telmisartan- lamotrigine ext-rel MULTAQ raloxifene ORILISSA hydrochlorothiazide lansoprazole delayed-rel mupirocin ointment ramelteon oseltamivir terazosin latanoprost MUSE ramipril oxazepam terbinafine tablet LATUDA MYDAYIS ranolazine ext-rel oxcarbazepine testosterone gel (except authorized levalbuterol tartrate CFC-free MYRBETRIQ rasagiline

aerosol OXTELLAR XR RELENZA generics for TESTIM and VOGELXO) oxybutynin testosterone solution LEVEMIR N repaglinide oxybutynin ext-rel RESTASIS tetracycline levetiracetam nadolol oxycodone REYVOW tiagabine levetiracetam ext-rel NAFTIN oxycodone-acetaminophen RHOPRESSA timolol maleate solution levocarnitine naloxone injection levocetirizine OZEMPIC risedronate TOBRADEX OINTMENT NAMZARIC risperidone tobramycin levofloxacin naproxen (except naproxen CR or P rivastigmine tobramycin-dexamethasone levothyroxine naproxen suspension) pantoprazole delayed-rel rivastigmine transdermal TOLAK lidocaine patch naratriptan tablet rizatriptan tolterodine lidocaine-prilocaine NARCAN NASAL SPRAY paroxetine HCl ROCKLATAN tolterodine ext-rel linezolid nateglinide paroxetine HCl ext-rel (except ropinirole topiramate LINZESS NATESTO NDC^ 60505367503) ropinirole ext-rel torsemide liothyronine NAYZILAM TOUJEO lisinopril neomycin-polymyxin B- peg 3350-electrolytes rosuvastatin penicillin VK rufinamide TOVIAZ lisinopril-hydrochlorothiazide bacitracin-hydrocortisone tramadol (except NDC^ 52817019610) LO LOESTRIN FE neomycin-polymyxin B- PENTASA RYBELSUS PERFOROMIST tramadol ext-rel tablet LOKELMA dexamethasone S travoprost loperamide neomycin-polymyxin B- PERSERIS phenobarbital trazodone lorazepam hydrocortisone SANCUSO phenytoin TRELEGY ELLIPTA losartan NEUPRO SAXENDA phenytoin sodium extended TRESIBA losartan-hydrochlorothiazide NEXLETOL scopolamine transdermal PHOSLYRA tretinoin loteprednol NEXLIZET selegiline PICATO triamcinolone cream, lotion, lovastatin niacin ext-rel selenium sulfide lotion 2.5% pimecrolimus ointment (except triamcinolone lubiprostone nifedipine ext-rel SEREVENT pindolol ointment 0.05%) LUMIGAN nitrofurantoin (except NDC^ sertraline pioglitazone triamterene 70408023932) sevelamer carbonate pioglitazone-glimepiride triamterene- nitroglycerin lingual spray sildenafil

hydrochlorothiazide V venlafaxine ext-rel capsule X Z trifluridine verapamil ext-rel VAGIFEM XARELTO zafirlukast TRIJARDY XR V-GO INSULIN INFUSION valacyclovir XCOPRI ZEMBRACE SYMTOUCH trimethobenzamide PUMP valganciclovir XIFAXAN 550 MG ZENPEP TRINTELLIX VIBERZI valproic acid XIGDUO XR ZIOPTAN TROKENDI XR VICTOZA valsartan XIIDRA ziprasidone trospium VIMPAT valsartan-hydrochlorothiazide XTAMPZA ER zolmitriptan trospium ext-rel VIOKACE VALTOCO XULTOPHY zolpidem TRULICITY VRAYLAR vancomycin capsule zolpidem ext-rel VYVANSE VASCEPA Y ZOMIG NASAL SPRAY U VELPHORO YUPELRI zonisamide UBRELVY W VELTASSA ZUBSOLV warfarin venlafaxine ZYCLARA

PREFERRED OPTIONS LIST NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) ABILIFY Ø aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, APEXICON E Ø desoximetasone (except desoximetasone ointment 0.05%), risperidone, ziprasidone, LATUDA, VRAYLAR fluocinonide (except fluocinonide cream 0.1%), BRYHALI ACANYA Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ APIDRA Ø FIASP, NOVOLOG 68682046275), clindamycin solution, clindamycin-benzoyl † peroxide, erythromycin solution, erythromycin-benzoyl peroxide, APTENSIO XR Ø amphetamine-dextroamphetamine mixed salts ext-rel , † tretinoin, EPIDUO, ONEXTON dexmethylphenidate ext-rel, methylphenidate ext-rel , MYDAYIS, VYVANSE ACIPHEX Ø, ACIPHEX esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole SPRINKLE Ø delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID ACTICLATE Ø doxycycline hyclate 20 mg, doxycycline hyclate capsule, ARTHROTEC Ø celecoxib; diclofenac sodium, ibuprofen, meloxicam tablet or minocycline, tetracycline naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole Activite Ø folic acid delayed-rel, pantoprazole delayed-rel tablet or DEXILANT ACTOS Ø pioglitazone ASCENSIA STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE ACUVAIL Ø bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND acyclovir cream Ø acyclovir capsule, acyclovir tablet, valacyclovir KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 ADDERALL Ø amphetamine-dextroamphetamine mixed salts, methylphenidate ASMANEX Ø, ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, ADZENYS ER Ø, amphetamine-dextroamphetamine mixed salts ext-rel †, ASMANEX HFA Ø PULMICORT FLEXHALER, QVAR REDIHALER ADZENYS XR-ODT Ø dexmethylphenidate ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE ATACAND Ø, candesartan, candesartan-hydrochlorothiazide, irbesartan, ATACAND HCT Ø irbesartan-hydrochlorothiazide, losartan, losartan- ALCORTIN A Ø desonide, hydrocortisone hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan- ALEVICYN GEL Ø, desonide, hydrocortisone hydrochlorothiazide ALEVICYN SG, ALEVICYN SOLUTION ATIVAN Ø alprazolam, clonazepam, diazepam, lorazepam, oxazepam Ø ATOPADERM Ø desonide, hydrocortisone ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES INSULIN SYRINGES 3 Ø ATROVENT HFA ipratropium inhalation solution, SPIRIVA, YUPELRI ALORA estradiol, DIVIGEL, EVAMIST AVENOVA Ø Consult doctor ALREX Ø azelastine, cromolyn sodium, olopatadine AZASITE Ø ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE ALTOPREV Ø atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin AZELEX Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl ALVESCO Ø ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, peroxide, erythromycin solution, erythromycin-benzoyl peroxide, PULMICORT FLEXHALER, QVAR REDIHALER tretinoin, EPIDUO, ONEXTON AMITIZA Ø lubiprostone, LINZESS, MOVANTIK, SYMPROIC AZESCO 5 Ø prenatal vitamins, CITRANATAL AMRIX Ø cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) AZOR Ø amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- valsartan ANDROGEL Ø testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM, NATESTO BANZEL SUSPENSION clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR Ø ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO BEAU RX Ø Consult doctor ANTARA fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel BECONASE AQ Ø azelastine-fluticasone, flunisolide, fluticasone, mometasone

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) BENICAR Ø, BENICAR candesartan, candesartan-hydrochlorothiazide, irbesartan, BYETTA Ø OZEMPIC, RYBELSUS, TRULICITY, VICTOZA HCT Ø irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, CAFERGOT Ø eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan- NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, hydrochlorothiazide ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY BENSAL HP Ø desonide, hydrocortisone calcipotriene cream Ø , calcipotriene ointment, calcipotriene solution calcipotriene foam Ø, BENZAC AC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ CALCIPOTRIENE 68682046275), clindamycin solution, clindamycin-benzoyl FOAM Ø peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON calcipotriene- calcipotriene ointment or calcipotriene solution WITH betamethasone Ø desoximetasone (except desoximetasone ointment 0.05%), BENZACLIN Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ fluocinonide (except fluocinonide cream 0.1%) or BRYHALI 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, calcitriol ointment Ø calcipotriene ointment, calcipotriene solution tretinoin, EPIDUO, ONEXTON CAMBIA Ø diclofenac sodium, ibuprofen, naproxen (except naproxen CR or benzonatate benzonatate (except NDCs^ 69336012615, 69499032915) naproxen suspension) (NDCs^ 69336012615, CARAC Ø fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, 69499032915 only) Ø TOLAK, ZYCLARA BEPREVE Ø azelastine, cromolyn sodium, olopatadine CARAFATE Ø sucralfate tablet betamethasone acetate- dexamethasone, hydrocortisone, methylprednisolone, CARBINOXAMINE levocetirizine betamethasone sodium prednisolone solution, prednisone TABLET 6 MG Ø phosphate (NDC^ 71283062002 only) Ø, CARDIZEM Ø, diltiazem ext-rel BETAMETHASONE CARDIZEM CD Ø, (except generics for CARDIZEM LA) ACETATE- CARDIZEM LA Ø BETAMETHASONE SODIUM PHOSPHATE carisoprodol 250 mg Ø cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) Ø CARNITOR Ø, levocarnitine BETAPACE Ø, sotalol CARNITOR SF Ø BETAPACE AF Ø CELEBREX Ø celecoxib, diclofenac sodium, ibuprofen, meloxicam tablet, BETIMOL Ø timolol maleate solution, BETOPTIC S naproxen (except naproxen CR or naproxen suspension) BEVESPI ANORO ELLIPTA, STIOLTO RESPIMAT chlordiazepoxide- dicyclomine AEROSPHERE Ø clidinium (NDCs^ 11534019701, BEYAZ Ø ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- 42494040901, levomefolate, ethinyl estradiol-norethindrone acetate, 51293069601, ethinyl estradiol-norethindrone acetate-iron 51293069610, 67877073101, bimatoprost solution latanoprost, travoprost, LUMIGAN, ZIOPTAN 70700018501 only) Ø 0.03% Ø chlorzoxazone 375 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) BREEZE 2 STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK Ø, chlorzoxazone 500 KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE mg (NDC^ 73007001303 STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND only) Ø, chlorzoxazone KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH 750 mg Ø, VERIO STRIPS AND KITS 2 CHLORZOXAZONE 250 BROMSITE Ø bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA MG Ø Bupap Ø diclofenac sodium, ibuprofen, naproxen (except naproxen CR or CIALIS Ø sildenafil, tadalafil naproxen suspension) CICATRACE Ø Consult doctor bupropion ext-rel tablet bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 CILOXAN Ø ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, 450 mg Ø mg) ofloxacin, sulfacetamide, tobramycin, BESIVANCE butalbital- diclofenac sodium, ibuprofen, naproxen (except naproxen CR or CIPRO HC Ø ciprofloxacin-dexamethasone, ofloxacin otic acetaminophen tablet naproxen suspension) 50-300 mg Ø, CIPRODEX Ø ciprofloxacin-dexamethasone, ofloxacin otic BUTALBITAL- ACETAMINOPHEN CLINDAGEL erythromycin solution (NDC^ 69499034230 clindamycin gel (NDC^ adapalene, benzoyl peroxide, clindamycin gel (except NDC^ only) Ø 68682046275 only) Ø 68682046275), clindamycin solution, clindamycin-benzoyl butalbital- diclofenac sodium, ibuprofen, naproxen (except naproxen CR or peroxide, erythromycin solution, erythromycin-benzoyl peroxide, acetaminophen-caffeine naproxen suspension) tretinoin, EPIDUO, ONEXTON capsule Ø clobetasol spray Ø clobetasol foam BUTRANS Ø buprenorphine transdermal, BELBUCA CLOBEX SPRAY Ø clobetasol foam BYDUREON BCISE Ø OZEMPIC, RYBELSUS, TRULICITY, VICTOZA clocortolone cream Ø hydrocortisone butyrate cream, hydrocortisone butyrate ointment,

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) hydrocortisone butyrate solution, mometasone, triamcinolone DETROL LA Ø darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, cream, triamcinolone lotion, triamcinolone ointment (except tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, triamcinolone ointment 0.05%) TOVIAZ COLAZAL Ø balsalazide, mesalamine delayed-rel (except mesalamine dexchlorpheniramine Ø levocetirizine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA Dexifol Ø folic acid colchicine capsule Ø colchicine tablet, MITIGARE DIFFERIN LOTION Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- COLCRYS Ø colchicine tablet, MITIGARE benzoyl peroxide, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, EPIDUO, ONEXTON CONSENSI Ø amlodipine WITH celecoxib diflorasone cream Ø, desoximetasone (except desoximetasone ointment 0.05%), 2 CONTOUR NEXT ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU-CHEK diflorasone ointment Ø fluocinonide (except fluocinonide cream 0.1%), BRYHALI STRIPS AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH Ø NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, VERIO STRIPS AND KITS 2 ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY CONTOUR STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK diltiazem ext-rel diltiazem ext-rel AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE (generics for CARDIZEM (except generics for CARDIZEM LA) STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND LA only) Ø KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 DIOVAN Ø, candesartan, candesartan-hydrochlorothiazide, irbesartan, DIOVAN HCT Ø irbesartan-hydrochlorothiazide, losartan, losartan- CONTRAVE Ø QSYMIA, SAXENDA hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan- CORDRAN CREAM Ø, desonide, hydrocortisone hydrochlorothiazide CORDRAN LOTION Ø Diphen Elixir Ø levocetirizine

CORDRAN OINTMENT hydrocortisone butyrate cream, hydrocortisone butyrate ointment, Ø hydrocortisone butyrate solution, mometasone, triamcinolone DORAL doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, cream, triamcinolone lotion, triamcinolone ointment (except BELSOMRA triamcinolone ointment 0.05%) DORYX Ø, DORYX doxycycline hyclate 20 mg, doxycycline hyclate capsule, CORDRAN TAPE Ø clobetasol cream, clobetasol foam, clobetasol gel, clobetasol MPC Ø minocycline, tetracycline lotion, clobetasol ointment doxepin cream Ø desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA COREG CR Ø atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, doxycycline hyclate doxycycline hyclate 20 mg, doxycycline hyclate capsule, propranolol, propranolol ext-rel, BYSTOLIC delayed-rel tablet 50 mg, minocycline, tetracycline 100 mg, 200 mg Ø CoreMino Ø doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline doxycycline hyclate doxycycline hyclate 20 mg, doxycycline hyclate capsule, tablet 50 mg (NDC^ minocycline, tetracycline COZAAR Ø candesartan, irbesartan, losartan, olmesartan, telmisartan, 72143021160 only) Ø, valsartan doxycycline hyclate tablet 75 mg Ø, CRESEMBA Ø itraconazole doxycycline hyclate CRESTOR Ø atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, tablet 150 mg Ø pravastatin, rosuvastatin, simvastatin doxycycline doxycycline hyclate 20 mg, doxycycline hyclate capsule, cyclobenzaprine ext-rel cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) monohydrate capsule 75 minocycline, tetracycline capsule Ø, mg Ø, cyclobenzaprine tablet doxycycline 7.5 mg Ø monohydrate capsule 150 mg Ø CYMBALTA Ø desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- rel capsule doxycycline ORACEA monohydrate delayed-rel CYTOMEL Ø levothyroxine, liothyronine, SYNTHROID capsule Ø DARAPRIM Ø pyrimethamine DULERA Ø ADVAIR DISKUS, ADVAIR HFA †, BREO ELLIPTA †, SYMBICORT DAYTRANA Ø amphetamine-dextroamphetamine mixed salts ext-rel †, dexmethylphenidate ext-rel, methylphenidate ext-rel †, MYDAYIS, DUTOPROL Ø metoprolol succinate ext-rel WITH hydrochlorothiazide VYVANSE DYRENIUM Ø amiloride, triamterene DELZICOL Ø balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, EDARBI Ø, candesartan, candesartan-hydrochlorothiazide, irbesartan, sulfasalazine delayed-rel, ASACOL HD, PENTASA EDARBYCLOR Ø irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, desoximetasone hydrocortisone butyrate cream, hydrocortisone butyrate ointment, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan- ointment 0.05% Ø hydrocortisone butyrate solution, mometasone, triamcinolone hydrochlorothiazide cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel,

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) BELSOMRA FLAREX Ø dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL E.E.S. GRANULES Ø erythromycins flucytosine capsule 500 fluconazole EFFEXOR XR Ø desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- mg Ø rel capsule fluocinonide cream 0.1% clobetasol cream ELIDEL Ø pimecrolimus, tacrolimus, EUCRISA Ø ELMIRON Ø Consult doctor fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ENABLEX Ø darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, Ø TOLAK, ZYCLARA tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet TOVIAZ (generics for SARAFEM [generics for SARAFEM]), paroxetine HCl ext-rel (except NDC^ ENLITE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM only) Ø 60505367503), sertraline GLUCOSE MONITORING SYSTEM Ø fluoxetine tablet 60 mg Ø citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 ENTERAGAM Ø alosetron, VIBERZI, XIFAXAN 550 MG mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, EPICERAM Ø desonide, hydrocortisone TRINTELLIX ergotamine-caffeine Ø eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, flurandrenolide cream Ø, desonide, hydrocortisone NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, flurandrenolide lotion Ø ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate ointment, ERYPED Ø erythromycins Ø hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except estradiol vaginal tablet Ø estradiol vaginal cream, IMVEXXY, VAGIFEM triamcinolone ointment 0.05%) ESTRING Ø estradiol vaginal cream, IMVEXXY, VAGIFEM FML FORTE Ø, FML dexamethasone, loteprednol, prednisolone acetate 1%, EVEKEO Ø amphetamine-dextroamphetamine mixed salts, methylphenidate LIQUIFILM Ø, FML DUREZOL S.O.P. Ø EVERSENSE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM CONTINUOUS FOCALIN XR Ø amphetamine-dextroamphetamine mixed salts ext-rel †, GLUCOSE dexmethylphenidate ext-rel, methylphenidate ext-rel †, MYDAYIS, MONITORING SYSTEM VYVANSE Ø FOLIC-K Ø folic acid EXFORGE Ø amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- Folvite-D Ø folic acid valsartan FORTAMET Ø metformin, metformin ext-rel (except generics for FORTAMET and EXFORGE HCT Ø amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine- GLUMETZA) hydrochlorothiazide FORTESTA Ø testosterone gel (except authorized generics for TESTIM and FABIOR Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ VOGELXO), testosterone solution, ANDRODERM, NATESTO 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, FOSAMAX PLUS D alendronate, ibandronate, risedronate tretinoin, EPIDUO, ONEXTON FOSRENOL Ø calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO FANAPT Ø aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR FOSTEUM Ø, alendronate, ibandronate, risedronate FOSTEUM PLUS Ø FEMRING Ø estradiol vaginal cream, IMVEXXY, VAGIFEM FREESTYLE LIBRE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM fenofibrate capsule 50 fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate CONTINUOUS mg, 130 mg Ø; tablet 40 mg, 120 mg), fenofibric acid delayed-rel GLUCOSE fenofibrate tablet 40 mg, MONITORING SYSTEM 120 mg Ø Ø FENOGLIDE TABLET fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate FREESTYLE STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK 120 MG Ø tablet 40 mg, 120 mg), fenofibric acid delayed-rel AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND fenoprofen Ø, diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH FENOPROFEN naproxen CR or naproxen suspension) VERIO STRIPS AND KITS 2 CAPSULE Ø FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, FERIVA 21/7 Ø folic acid NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY rel capsule Genicin Vita-S Ø folic acid Fexmid Ø cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) GLUMETZA Ø metformin, metformin ext-rel (except generics for FORTAMET and FINACEA GEL Ø azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA GLUMETZA) FIORICET CAPSULE Ø diclofenac sodium, ibuprofen, naproxen (except naproxen CR or GLYCOPYRROLATE dicyclomine naproxen suspension) TABLET 1.5 MG Ø

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) GOLYTELY Ø peg 3350-electrolytes, CLENPIQ solution, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) GUARDIAN CONNECT DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM CONTINUOUS INNOPRAN XL Ø atenolol, carvedilol, carvedilol phosphate ext-rel, GLUCOSE metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, MONITORING SYSTEM propranolol, propranolol ext-rel, BYSTOLIC Ø INTRAROSA Ø estradiol vaginal cream, IMVEXXY, VAGIFEM GUARDIAN REAL-TIME DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM † CONTINUOUS INTUNIV Ø amphetamine-dextroamphetamine mixed salts ext-rel , GLUCOSE atomoxetine, dexmethylphenidate ext-rel, guanfacine ext-rel, † MONITORING SYSTEM methylphenidate ext-rel , MYDAYIS, VYVANSE Ø INVELTYS Ø dexamethasone, loteprednol, prednisolone acetate 1%, halcinonide cream Ø desoximetasone (except desoximetasone ointment 0.05%), DUREZOL fluocinonide (except fluocinonide cream 0.1%), BRYHALI INVOKAMET Ø, SYNJARDY, SYNJARDY XR, XIGDUO XR HALOG Ø desoximetasone (except desoximetasone ointment 0.05%), INVOKAMET XR Ø fluocinonide (except fluocinonide cream 0.1%), BRYHALI INVOKANA Ø FARXIGA, JARDIANCE heparin sodium in 5% Consult doctor isosorbide dinitrate 40 isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide dextrose Ø, HEPARIN mg Ø mononitrate SODIUM IN 5% DEXTROSE Ø ISTALOL timolol maleate solution, BETOPTIC S HORIZANT Ø gabapentin, GRALISE JALYN Ø dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin HUMALOG Ø FIASP, NOVOLOG JENTADUETO Ø, JANUMET, JANUMET XR HUMALOG MIX 50/50 Ø NOVOLOG MIX 70/30 JENTADUETO XR Ø HUMALOG MIX 75/25 Ø NOVOLOG MIX 70/30 KAMDOY Ø desonide, hydrocortisone HUMULIN 70/30 Ø NOVOLIN 70/30 KAZANO Ø JANUMET, JANUMET XR HUMULIN N Ø NOVOLIN N ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5% HUMULIN R Ø NOVOLIN R Ø hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate ointment, Ketodan Ø ketoconazole shampoo 2%, selenium sulfide lotion 2.5% lipophilic cream 0.1% Ø hydrocortisone butyrate solution, mometasone, triamcinolone ketoprofen capsule 25 diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except cream, triamcinolone lotion, triamcinolone ointment (except mg Ø naproxen CR or naproxen suspension) triamcinolone ointment 0.05%) ketoprofen ext-rel diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate ointment, capsule Ø naproxen CR or naproxen suspension) lotion Ø hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except KOMBIGLYZE XR Ø JANUMET, JANUMET XR triamcinolone ointment 0.05%) LACRISERT Ø RESTASIS, XIIDRA HylaVite Ø folic acid Lactojen Ø Consult doctor hyoscyamine sulfate ext- dicyclomine rel Ø LACTULOSE PAK Ø lactulose solution HYSINGLA ER Ø fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, LANOXIN TABLET digoxin methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER (125 MCG and 250 MCG only) Ø HYZAAR Ø candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, lanthanum carbonate Ø calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO losartan-hydrochlorothiazide, LANTUS 6 Ø BASAGLAR, LEVEMIR olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, LASTACAFT Ø azelastine, cromolyn sodium, olopatadine valsartan-hydrochlorothiazide LAZANDA Ø fentanyl transmucosal lozenge, SUBSYS icosapent ethyl Ø omega-3 acid ethyl esters, VASCEPA LESCOL XL Ø atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, INCRUSE ELLIPTA Ø SPIRIVA, YUPELRI pravastatin, rosuvastatin, simvastatin INDERAL LA Ø, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol levorphanol Ø fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, INDERAL XL Ø succinate ext-rel, metoprolol tartrate, nadolol, pindolol, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER propranolol, propranolol ext-rel, BYSTOLIC LEXAPRO Ø citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 INDOCIN Ø diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, naproxen CR or naproxen suspension) paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, TRINTELLIX indomethacin capsule 20 diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except mg Ø naproxen CR or naproxen suspension) LIALDA Ø balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, Inflammacin Ø diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) sulfasalazine delayed-rel, ASACOL HD, PENTASA MICARDIS HCT Ø irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, LIBRAX Ø dicyclomine telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan- LIDOCAINE- lidocaine-prilocaine hydrochlorothiazide TETRACAINE CREAM Migergot Ø eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, (NDC^ 71800063115 NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, only) Ø ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY LIDOTREX Ø lidocaine-prilocaine MILLIPRED Ø dexamethasone, hydrocortisone, methylprednisolone, LIPITOR Ø atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, prednisolone solution, prednisone pravastatin, rosuvastatin, simvastatin MINASTRIN 24 FE Ø ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- LITHOSTAT Ø Consult doctor levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron LIVALO Ø atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin MINIVELLE Ø estradiol, DIVIGEL, EVAMIST Lorid Ø folic acid MINOCIN Ø doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline Lorzone Ø cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) minocycline ext-rel Ø doxycycline hyclate 20 mg, doxycycline hyclate capsule, LOTEMAX Ø, dexamethasone, loteprednol, prednisolone acetate 1%, minocycline, tetracycline LOTEMAX SM Ø DUREZOL MIRVASO Ø azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA luliconazole Ø ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, NAFTIN Mondoxyne NL capsule doxycycline hyclate 20 mg, doxycycline hyclate capsule, 75 mg Ø minocycline, tetracycline LUNESTA Ø doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA MOVIPREP Ø peg 3350-electrolytes, CLENPIQ LYRICA Ø duloxetine, pregabalin MultiPro Ø Consult doctor MACRODANTIN Ø nitrofurantoin (except NDC^ 70408023932) mupirocin cream Ø gentamicin, mupirocin ointment Matzim LA Ø diltiazem ext-rel (except generics for CARDIZEM LA) MYTESI Ø diphenoxylate-atropine, loperamide MAXALT Ø, MAXALT- eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NAPRELAN Ø diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except MLT Ø NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, naproxen CR or naproxen suspension) ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY naproxen CR Ø diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except MAXIDEX Ø dexamethasone, loteprednol, prednisolone acetate 1%, naproxen CR or naproxen suspension) DUREZOL naproxen suspension Ø diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except mefenamic acid (NDC^ diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) 69336012830 only) Ø naproxen CR or naproxen suspension) naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam tablet or naproxen Ø (except naproxen CR or naproxen suspension) WITH meloxicam capsule Ø diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole naproxen CR or naproxen suspension) delayed-rel, pantoprazole delayed-rel tablet or DEXILANT MENEST Ø estradiol NATAZIA Ø ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol- MENOSTAR estradiol norethindrone acetate, ethinyl estradiol-norethindrone acetate- iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE mesalamine delayed-rel balsalazide, mesalamine delayed-rel (except mesalamine tablet 800 mg Ø delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, NATURE-THROID Ø levothyroxine, liothyronine, SYNTHROID sulfasalazine delayed-rel, ASACOL HD, PENTASA NEO-SYNALAR Ø desonide or hydrocortisone WITH gentamicin metaxalone 400 mg Ø cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) NESINA Ø JANUVIA metformin ext-rel metformin, metformin ext-rel (except generics for FORTAMET and (generics for GLUMETZA) NEVANAC Ø bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA FORTAMET and NEXIUM Ø esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole GLUMETZA only) Ø delayed-rel, pantoprazole delayed-rel tablet, DEXILANT methocarbamol 500 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) niacin tablet 500 mg Ø niacin ext-rel (NDC^ 69036091010 only) Ø, methocarbamol Niacor Ø niacin ext-rel 750 mg (NDCs^ 69036093090, NICADAN Ø folic acid 70868090190 only) Ø NICAPRIN Ø folic acid MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, NICAZEL Ø, NICAZEL folic acid Ø FORTEO, PROLIA, TYMLOS FORTE Ø MIACALCIN NASAL calcitonin-salmon NICOMIDE Ø folic acid SPRAY Ø NILANDRON Ø abiraterone, bicalutamide, XTANDI, YONSA MICARDIS Ø, candesartan, candesartan-hydrochlorothiazide, irbesartan,

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) nitrofurantoin (NDC^ nitrofurantoin (except NDC^ 70408023932) pantoprazole delayed-rel esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole 70408023932 only) Ø suspension Ø delayed-rel, pantoprazole delayed-rel tablet, DEXILANT NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual paroxetine HCl ext-rel citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 (NDC^ 60505367503 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, Nolix Ø desonide, hydrocortisone only) Ø paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, NORGESIC FORTE Ø cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) TRINTELLIX

NORITATE Ø azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA paroxetine mesylate paroxetine HCl NORPACE Ø disopyramide capsule 7.5 mg Ø NORVASC Ø amlodipine PAXIL Ø, PAXIL CR Ø citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, NOURIANZ Ø amantadine, entacapone, pramipexole, pramipexole ext-rel, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, rasagiline, ropinirole, ropinirole ext-rel, selegiline, NEUPRO TRINTELLIX NOVACORT Ø desonide, hydrocortisone NOVO NORDISK BD ULTRAFINE NEEDLES PENNSAID Ø diclofenac sodium, diclofenac sodium gel 1%, NEEDLES 3 Ø diclofenac sodium solution, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) NOXAFIL Ø fluconazole, itraconazole PERCOCET Ø hydrocodone-acetaminophen, hydromorphone, morphine, NuDiclo SoluPak Ø, diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium oxycodone-acetaminophen, NUCYNTA NuDiclo TabPak Ø solution, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) PERRIGO NEEDLES 3 Ø BD ULTRAFINE NEEDLES NUVARING Ø ethinyl estradiol-etonogestrel, ANNOVERA PERTZYE CREON, VIOKACE, ZENPEP NUVIGIL Ø armodafinil, modafinil, SUNOSI PEXEVA Ø citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, OLEPTRO Ø trazodone paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, TRINTELLIX OLUX-E Ø clobetasol foam omeprazole-sodium esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole PLAVIX Ø clopidogrel, prasugrel, BRILINTA bicarbonate Ø delayed-rel, pantoprazole delayed-rel tablet, DEXILANT POLYTOZA Ø Consult doctor OMNARIS Ø azelastine-fluticasone, flunisolide, fluticasone, mometasone posaconazole delayed- fluconazole, itraconazole OMNIVEX Ø folic acid rel tablet Ø ONFI Ø clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR PRADAXA Ø warfarin, ELIQUIS, XARELTO ONGLYZA Ø JANUVIA PRECISION XTRA ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK orphenadrine-aspirin- cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) STRIPS AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE caffeine Ø STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH Orphengesic Forte Ø cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) VERIO STRIPS AND KITS 2 ORTHO D Ø folic acid PRED FORTE Ø, PRED dexamethasone, loteprednol, prednisolone acetate 1%, MILD Ø DUREZOL ORTHO DF Ø folic acid PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO Oscimin SR Ø dicyclomine PREMARIN Ø estradiol OSENI Ø JANUMET, JANUMET XR; JANUVIA WITH pioglitazone PREMARIN CREAM Ø estradiol vaginal cream, IMVEXXY, VAGIFEM OSMOPREP Ø peg 3350-electrolytes, CLENPIQ PRENATAL PLUS 5 Ø prenatal vitamins, CITRANATAL OSPHENA Ø estradiol PREVACID Ø esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole OWEN MUMFORD BD ULTRAFINE NEEDLES delayed-rel, pantoprazole delayed-rel tablet, DEXILANT NEEDLES 3 Ø PREVIDENT Ø Consult doctor oxiconazole (NDCs^ ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, 00168035830, NAFTIN PRILOSEC Ø esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole 51672135902 only) Ø delayed-rel, pantoprazole delayed-rel tablet, DEXILANT OXYCONTIN Ø fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, PRISTIQ Ø desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER rel capsule oxymorphone ext-rel Ø fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, PROAIR HFA Ø, albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER PROAIR RESPICLICK Ø free aerosol OXYTROL Ø darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, PRODIGEN Ø Consult doctor tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ PROMETRIUM Ø medroxyprogesterone; progesterone, micronized PANCREAZE CREON, VIOKACE, ZENPEP PROTONIX Ø esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) delayed-rel, pantoprazole delayed-rel tablet, DEXILANT sumatriptan-naproxen Ø diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, PROTOPIC pimecrolimus, tacrolimus, EUCRISA sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, PROVAD Ø Consult doctor REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY PROVENTIL HFA Ø albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- free aerosol SUPREP Ø peg 3350-electrolytes, CLENPIQ PROVIGIL Ø armodafinil, modafinil, SUNOSI SURE-TEST STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE PROZAC Ø citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, VERIO STRIPS AND KITS 2 TRINTELLIX Symax-SR Ø dicyclomine PSORCON Ø desoximetasone (except desoximetasone ointment 0.05%), SYNERDERM Ø desonide, hydrocortisone fluocinonide (except fluocinonide cream 0.1%), BRYHALI TALIVA Ø folic acid QNASL Ø azelastine-fluticasone, flunisolide, fluticasone, mometasone TARGADOX Ø doxycycline hyclate 20 mg, doxycycline hyclate capsule, QTERN Ø GLYXAMBI minocycline, tetracycline quazepam Ø doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, TAYTULLA Ø ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- BELSOMRA levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron RAPAFLO Ø alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin TAZORAC Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ RAYOS Ø dexamethasone, hydrocortisone, methylprednisolone, 68682046275), clindamycin solution, clindamycin-benzoyl prednisolone solution, prednisone peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON; calcipotriene ointment, RECEDO Ø Consult doctor calcipotriene solution RELION INSULIN Ø NOVOLIN INSULIN TESTIM Ø testosterone gel (except authorized generics for TESTIM and RHEUMATE Ø folic acid VOGELXO), testosterone solution, ANDRODERM, NATESTO RIBOZEL Ø folic acid testosterone gel 1% testosterone gel (except authorized generics for TESTIM and (authorized generics for VOGELXO), testosterone solution, ANDRODERM, NATESTO RIMSO-50 Ø Consult doctor TESTIM and VOGELXO only) Ø RIOMET Ø metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) THEO-24 Ø ipratropium inhalation solution, PERFOROMIST, SEREVENT, SPIRIVA, STRIVERDI RESPIMAT, YUPELRI ROZEREM Ø doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S Ø RyClora Ø levocetirizine TIROSINT Ø levothyroxine, SYNTHROID RYTARY Ø carbidopa-levodopa, carbidopa-levodopa ext-rel TOBRADEX ST Ø neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin- SCARSILK PAD Ø Consult doctor polymyxin B-dexamethasone, tobramycin- SEASONIQUE Ø ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- dexamethasone, TOBRADEX OINTMENT levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol- topiramate ext-rel carbamazepine, carbamazepine ext-rel, clobazam, norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron capsule (generics for divalproex sodium, divalproex sodium ext-rel, gabapentin, SEROQUEL XR Ø aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, QUDEXY XR only) Ø lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext- risperidone, ziprasidone, LATUDA, VRAYLAR rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, rufinamide, tiagabine, SILENOR Ø doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, topiramate, valproic acid, zonisamide, FYCOMPA, BELSOMRA OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI SIL-K PAD Ø Consult doctor TOPROL-XL Ø atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, SILIVEX Ø Consult doctor propranolol, propranolol ext-rel, BYSTOLIC SILTREX Ø Consult doctor TRADJENTA Ø JANUVIA SINGULAIR Ø montelukast, zafirlukast tramadol (NDC^ tramadol (except NDC^ 52817019610), tramadol ext-rel tablet SORILUX Ø calcipotriene ointment, calcipotriene solution 52817019610 only) Ø, tramadol ext-rel SPRIX Ø diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except capsule Ø naproxen CR or naproxen suspension) TRANSDERM SCOP Ø meclizine, scopolamine transdermal STENDRA Ø sildenafil, tadalafil TRAVATAN Z Ø latanoprost, travoprost, LUMIGAN, ZIOPTAN SUBOXONE Ø buprenorphine-naloxone sublingual, ZUBSOLV TREXIMET Ø diclofenac sodium, ibuprofen or naproxen (except naproxen CR or sucralfate suspension Ø sucralfate tablet naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL,

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG VEREGEN Ø imiquimod NASAL SPRAY VIAGRA Ø sildenafil, tadalafil triamcinolone aerosol hydrocortisone butyrate cream, hydrocortisone butyrate ointment, 0.2% Ø hydrocortisone butyrate solution, mometasone, triamcinolone VIIBRYD Ø citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 cream, triamcinolone lotion, triamcinolone ointment (except mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, triamcinolone ointment 0.05%) paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, TRINTELLIX triamcinolone ointment hydrocortisone butyrate cream, hydrocortisone butyrate ointment, 0.05% Ø hydrocortisone butyrate solution, mometasone, triamcinolone 5 cream, triamcinolone lotion, triamcinolone ointment (except VITAFOL-ONE Ø prenatal vitamins, CITRANATAL triamcinolone ointment 0.05%) Vitasure Ø folic acid Trianex Ø hydrocortisone butyrate cream, hydrocortisone butyrate ointment, VIVELLE-DOT Ø estradiol, DIVIGEL, EVAMIST hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except VOGELXO Ø testosterone gel (except authorized generics for TESTIM and triamcinolone ointment 0.05%) VOGELXO), testosterone solution, ANDRODERM, NATESTO TRICOR Ø fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate WESTHROID Ø levothyroxine, liothyronine, SYNTHROID tablet 40 mg, 120 mg), fenofibric acid delayed-rel WP THYROID Ø levothyroxine, liothyronine, SYNTHROID TRILIPIX fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel XANAX Ø, XANAX XR Ø alprazolam, clonazepam, diazepam, lorazepam, oxazepam TRINAZ 5 Ø prenatal vitamins, CITRANATAL XENICAL Ø QSYMIA, SAXENDA TRIVIDIA INSULIN BD ULTRAFINE INSULIN SYRINGES XOLEGEL Ø ciclopirox, ketoconazole cream 2% SYRINGES 3 Ø XOPENEX HFA Ø albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- TronVite Ø folic acid free aerosol TRUETEST STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK Xvite Ø folic acid AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE XYZBAC Ø folic acid STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH YASMIN Ø ethinyl estradiol-drospirenone, VERIO STRIPS AND KITS 2 ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol- norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron TRUETRACK STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK AND KITS 4 Ø COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE YAZ Ø ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND levomefolate, ethinyl estradiol-norethindrone acetate, KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH ethinyl estradiol-norethindrone acetate-iron VERIO STRIPS AND KITS 2 Yuvafem Ø estradiol vaginal cream, IMVEXXY, VAGIFEM TUDORZA Ø SPIRIVA, YUPELRI ZALVIT 5 Ø prenatal vitamins, CITRANATAL ULORIC Ø allopurinol ZEGERID Ø esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole ULTIMED INSULIN BD ULTRAFINE INSULIN SYRINGES delayed-rel, pantoprazole delayed-rel tablet, DEXILANT SYRINGES 3 Ø ZELAC Ø Consult doctor ULTIMED NEEDLES 3 Ø BD ULTRAFINE NEEDLES ZERVIATE Ø azelastine, cromolyn sodium, olopatadine ULTRAVATE Ø clobetasol cream, clobetasol foam, clobetasol gel, clobetasol lotion, clobetasol ointment ZESTORETIC Ø fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide, quinapril-hydrochlorothiazide UROXATRAL Ø alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin ZETIA Ø ezetimibe VALCYTE Ø valganciclovir ZETONNA Ø azelastine-fluticasone, flunisolide, fluticasone, mometasone VALTREX Ø acyclovir capsule, acyclovir tablet, valacyclovir ZIANA Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ Vanoxide-HC Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON tretinoin, EPIDUO, ONEXTON zileuton ext-rel Ø montelukast, zafirlukast VASCULERA Ø Consult doctor ZIRGAN Ø trifluridine VECTICAL Ø calcipotriene ointment, calcipotriene solution ZOHYDRO ER Ø fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, VELTIN Ø adapalene, benzoyl peroxide, clindamycin gel (except NDC^ methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, ZOLOFT Ø citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 tretinoin, EPIDUO, ONEXTON mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline, venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- TRINTELLIX (except 225 mg) Ø rel capsule VENTOLIN HFA Ø albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- zolpidem sublingual Ø doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, free aerosol BELSOMRA

NON-PREFERRED OR PREFERRED OPTION(S)* NON-PREFERRED OR PREFERRED OPTION(S)* PRIOR PRIOR AUTHORIZATION AUTHORIZATION REQUIRED DRUG(S) REQUIRED DRUG(S) ZOLPIMIST Ø doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, ZYFLO montelukast, zafirlukast BELSOMRA ZYLET Ø neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin- ZONEGRAN Ø carbamazepine, carbamazepine ext-rel, divalproex sodium, polymyxin B-dexamethasone, tobramycin-dexamethasone, divalproex sodium ext-rel, gabapentin, lamotrigine, TOBRADEX OINTMENT lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, ZYVIT Ø folic acid phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI ZONTIVITY Ø Consult doctor ZORVOLEX Ø diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) ZUPLENZ Ø granisetron, ondansetron, SANCUSO

This is not an all-inclusive list of drugs that may require Prior Authorization. Certain plan restrictions may apply to all products, whether listed on this document or not. Plan restrictions may include Utilization Management (UM) programs such as Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or Specialty Guideline Management (SGM).

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 copay 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 copay information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication. Ø These medications will not be covered without a prior authorization for medical necessity. If you are currently using one of these drugs, ask your doctor to choose one of the generic or brand options listed under Preferred Option(s). If your doctor believes you have a specific clinical need for one of these products, he or she should contact the Prior Authorization department at: 1-855-240-0536. § 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 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. 3 BD ULTRAFINE syringes and needles are the only preferred options. 4 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 5 Generic prenatal vitamins and CITRANATAL are the only preferred options. 6 Long Acting Insulins - First Generation.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

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