Carefirst Formulary 4 Quick Reference List

July 2021

CareFirst Formulary 4 Quick Reference List The CareFirst Formulary 4 Quick Reference List is not an all-inclusive list but represents a summary of prescribed medications within select therapeutic categories. This useful reference tool can assist medical providers in selecting therapeutically appropriate and cost-effective products for their patients. This document represents a closed formulary plan design.

This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Unless specifically indicated, drug list products will include all dosage forms, except for orally disintegrating formulations. Some prescription benefit plan designs may alter coverage of certain products or vary copay amounts based on the condition being treated. This document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, preference for brands and mandatory generics whenever available.

This list is not an all-inclusive list and does not guarantee coverage. Please visit www.carefirst.com/myaccount for a complete list.

ANALGESICS amoxicillin-clavulanate linezolid PA § ANTIARRHYTHMICS amoxicillin-clavulanate ext-rel linezolid inj PA acebutolol § NSAIDs ampicillin metronidazole amiodarone diclofenac dicloxacillin nitrofurantoin ext-rel disopyramide diflunisal penicillin VK nitrofurantoin macrocrystals dofetilide PA, SP etodolac praziquantel QL, PA flecainide § TETRACYCLINES flurbiprofen rifabutin ibutilide doxycycline hyclate caps ibuprofen sulfamethoxazole-trimethoprim propafenone doxycycline hyclate tabs 20 mg, 100 ketoprofen 50 mg, 75 mg vancomycin QL propafenone ext-rel mg ketorolac EMVERM QL, PA sotalol doxycycline monohydrate susp meloxicam NORPACE CR nabumetone minocycline CARDIOVASCULAR naproxen tabs tetracycline ANTILIPEMICS § ACE INHIBITORS oxaprozin § BILE ACID RESINS § ANTIFUNGALS captopril piroxicam cholestyramine enalapril sulindac clotrimazole troches colestipol lisinopril tolmetin fluconazole griseofulvin microsize perindopril § FIBRATES ANTI-INFECTIVES itraconazole ramipril fenofibrate (except fenofibrate capsule 50 mg, nystatin trandolapril ANTIBACTERIALS 130 mg; fenofibrate tablet 40 mg, 120 mg) terbinafine tablet § ACE INHIBITOR / CALCIUM gemfibrozil § CEPHALOSPORINS voriconazole PA CHANNEL BLOCKER cefadroxil § HMG-CoA REDUCTASE ANTIVIRALS COMBINATIONS cefdinir INHIBITORS cefpodoxime § HEPATITIS C AGENTS amlodipine-benazepril atorvastatin cefprozil ribavirin PA, SP § ACE INHIBITOR / DIURETIC pravastatin cefuroxime EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA, SP, COMBINATIONS rosuvastatin cephalexin QL simvastatin captopril-hydrochlorothiazide HARVONI (genotypes 1, 4, 5, 6) PA, SP, QL § ERYTHROMYCINS / MACROLIDES enalapril-hydrochlorothiazide VOSEVI *, PA, SP, QL § NIACINS lisinopril-hydrochlorothiazide azithromycin niacin ext-rel § HERPES AGENTS clarithromycin § ANGIOTENSIN II RECEPTOR OMEGA-3 FATTY ACIDS clarithromycin ext-rel acyclovir ANTAGONISTS / DIURETIC erythromycins famciclovir COMBINATIONS VASCEPA DIFICID PA valacyclovir irbesartan / irbesartan- PCSK9 INHIBITORS hydrochlorothiazide § FLUOROQUINOLONES § INFLUENZA AGENTS PRALUENT PA, QL losartan / losartan- ciprofloxacin oseltamivir QL, PA levofloxacin hydrochlorothiazide § BETA-BLOCKERS moxifloxacin § MISCELLANEOUS olmesartan / olmesartan- atenolol atovaquone hydrochlorothiazide bisoprolol § PENICILLINS clindamycin valsartan / valsartan- carvedilol amoxicillin ivermectin hydrochlorothiazide labetalol

LEGEND PA: Prior Authorization PA, QL: Quantity Limit is applied after Prior Authorization approval QL: Quantity Limit QL, PA: If Quantity Limit is exceeded, Prior Authorization may apply SP: Specialty Drug ST: Step Therapy ST, PA: If Step Therapy requirements are not met, Prior Authorization may apply

metoprolol succinate ext-rel oxazepam QL VUMERITY PA, SP, QL SODIUM-GLUCOSE metoprolol tartrate 25 mg, 50 mg, ZEPOSIA PA, SP, QL CO-TRANSPORTER 2 (SGLT2) § MISCELLANEOUS 100 mg INHIBITOR / BIGUANIDE nadolol buspirone ENDOCRINE AND COMBINATIONS fluvoxamine METABOLIC pindolol SYNJARDY ST, PA propranolol ANTIDEPRESSANTS ANTIDIABETICS SYNJARDY XR ST, PA propranolol ext-rel XIGDUO XR ST, PA § SELECTIVE SEROTONIN AMYLIN ANALOGS § BETA-BLOCKER / DIURETIC REUPTAKE INHIBITORS (SSRIs) SYMLINPEN ST, PA SODIUM-GLUCOSE

COMBINATIONS citalopram CO-TRANSPORTER 2 (SGLT2) § BIGUANIDES atenolol-chlorthalidone escitalopram INHIBITOR / DIPEPTIDYL bisoprolol-hydrochlorothiazide fluoxetine caps, solution metformin PEPTIDASE-4 (DPP-4) INHIBITOR metoprolol-hydrochlorothiazide fluoxetine tabs 10 mg, 20 mg metformin ext-rel (except generics for COMBINATIONS FORTAMET and GLUMETZA) propranolol-hydrochlorothiazide paroxetine HCl ext-rel GLYXAMBI ST, PA

paroxetine HCl tabs § CALCIUM CHANNEL BLOCKERS § BIGUANIDE / SULFONYLUREA SODIUM-GLUCOSE CO- sertraline COMBINATIONS amlodipine TRANSPORTER 2 (SGLT2) diltiazem ext-rel § SEROTONIN NOREPINEPHRINE glipizide-metformin INHIBITOR / DIPEPTIDYL felodipine ext-rel REUPTAKE INHIBITORS (SNRIs) PEPTIDASE-4 (DPP-4) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) isradipine BIGUANIDE COMBINATIONS desvenlafaxine succinate ext-rel INHIBITORS nicardipine duloxetine TRIJARDY XR ST, PA JANUVIA ST, PA nifedipine ext-rel venlafaxine § SULFONYLUREAS verapamil ext-rel venlafaxine ext-rel DIPEPTIDYL PEPTIDASE-4 (DPP-4)

glimepiride § DIGITALIS GLYCOSIDES § MISCELLANEOUS AGENTS INHIBITOR / BIGUANIDE COMBINATIONS glipizide digoxin bupropion glipizide ext-rel JANUMET ST, PA digoxin ped elixir bupropion ext-rel 150 mg, 300 mg JANUMET XR ST, PA mirtazapine SUPPLIES § DIURETICS mirtazapine orally disintegrating tablet INCRETIN MIMETIC AGENTS ACCU-CHEK AVIVA PLUS STRIPS amiloride trazodone AND KITS 1 OZEMPIC ST, PA, QL amiloride-hydrochlorothiazide ACCU-CHEK COMPACT PLUS HYPNOTICS RYBELSUS ST, PA bumetanide STRIPS AND KITS 1 TRULICITY ST, PA, QL chlorthalidone § NONBENZODIAZEPINES ACCU-CHEK GUIDE STRIPS AND VICTOZA ST, PA, QL furosemide 1 ramelteon QL, PA KITS hydrochlorothiazide zaleplon QL, PA INCRETIN MIMETIC AGENT / ACCU-CHEK SMARTVIEW STRIPS 1 indapamide zolpidem QL, PA INSULIN COMBINATIONS AND KITS metolazone zolpidem ext-rel QL, PA SOLIQUA ST, PA BD INSULIN SYRINGES AND spironolactone-hydrochlorothiazide NEEDLES torsemide § TRICYCLICS INSULINS DEXCOM CONTINUOUS GLUCOSE triamterene-hydrochlorothiazide doxepin BASAGLAR MONITORING SYSTEM QL

FIASP ONETOUCH ULTRA STRIPS AND HEART FAILURE MIGRAINE 1 HUMULIN R U-500 KITS CORLANOR MONOCLONAL ANTIBODIES LEVEMIR ONETOUCH VERIO STRIPS AND ENTRESTO AIMOVIG ST, PA, QL KITS 1 NOVOLIN § NITRATES EMGALITY ST, PA, QL NOVOLOG V-GO INSULIN INFUSION PUMP QL isosorbide dinitrate 5 mg, 10 mg, 20 NOVOLOG MIX § SELECTIVE SEROTONIN CALCIUM REGULATORS mg, 30 mg AGONISTS § INSULIN SENSITIZERS § BISPHOSPHONATES isosorbide mononitrate naratriptan QL, PA pioglitazone alendronate isosorbide mononitrate ext-rel rizatriptan QL, PA ibandronate nitroglycerin sublingual § INSULIN SENSITIZER / BIGUANIDE rizatriptan orally disintegrating tabs risedronate nitroglycerin transdermal QL, PA COMBINATIONS PARATHYROID HORMONES § MISCELLANEOUS sumatriptan QL, PA pioglitazone-metformin zolmitriptan orally disintegrating tabs FORTEO PA, SP, QL hydralazine § INSULIN SENSITIZER / QL, PA TYMLOS PA, SP, QL methyldopa zolmitriptan tabs QL, PA SULFONYLUREA COMBINATIONS midodrine pioglitazone-glimepiride CONTRACEPTIVES ranolazine ext-rel § MULTIPLE SCLEROSIS AGENTS MONOPHASIC dimethyl fumarate delayed-rel PA, SODIUM-GLUCOSE CENTRAL NERVOUS SYSTEM § 20 mcg Estrogen SP, QL CO-TRANSPORTER 2 (SGLT2) ethinyl estradiol-drospirenone ANTIANXIETY glatiramer PA, SP, QL INHIBITORS ethinyl estradiol-levonorgestrel AUBAGIO PA, SP, QL FARXIGA ST, PA § BENZODIAZEPINES ethinyl estradiol-norethindrone BETASERON PA, SP, QL JARDIANCE ST, PA alprazolam QL acetate COPAXONE PA, SP, QL alprazolam orally disintegrating tablet ethinyl estradiol-norethindrone GILENYA PA, SP, QL QL acetate and iron KESIMPTA PA, SP, QL clorazepate QL MAYZENT PA, SP, QL diazepam QL REBIF PA, SP, QL lorazepam QL

§ 25 mcg Estrogen VAGIFEM dipyridamole SPIRIVA QL ethinyl estradiol-norethindrone dipyridamole ext-rel/aspirin YUPELRI QL § PHOSPHATE BINDER AGENTS acetate and iron prasugrel ANTICHOLINERGIC / BETA calcium acetate BRILINTA § 30 mcg Estrogen sevelamer carbonate AGONIST COMBINATIONS ethinyl estradiol-desogestrel IMMUNOLOGIC AGENTS § SHORT ACTING PROGESTINS ethinyl estradiol-drospirenone ipratropium-albuterol inhalation § ORAL AUTOIMMUNE AGENTS (SELF- ethinyl estradiol-levonorgestrel ADMINISTERED) solution QL ethinyl estradiol-norethindrone medroxyprogesterone ANKYLOSING SPONDYLITIS LONG ACTING acetate norethindrone acetate ethinyl estradiol-norethindrone progesterone, micronized COSENTYX PA, SP, QL ANORO ELLIPTA QL

acetate and iron ENBREL PA, SP, QL BEVESPI AEROSPHERE QL VAGINAL ethinyl estradiol-norgestrel HUMIRA PA, SP, QL ENDOMETRIN BETA AGONISTS, INHALANTS § 35 mcg Estrogen CROHN'S DISEASE § SHORT ACTING § SELECTIVE ESTROGEN HUMIRA PA, SP, QL ethinyl estradiol-ethynodiol diacetate albuterol inhalation solution QL RECEPTOR MODULATORS STELARA SUBCUTANEOUS #, PA, ethinyl estradiol-norethindrone albuterol sulfate, CFC-free aerosol QL ethinyl estradiol-norgestimate raloxifene SP, QL levalbuterol nebulizer solution

concentrate QL § 50 mcg Estrogen § THYROID SUPPLEMENTS # After failure of HUMIRA PSORIASIS ethinyl estradiol-ethynodiol diacetate levothyroxine LONG ACTING HUMIRA PA, SP, QL liothyronine Hand-held Active Inhalation § BIPHASIC OTEZLA PA, SP, QL GASTROINTESTINAL SKYRIZI PA, SP, QL STRIVERDI RESPIMAT QL ethinyl estradiol-desogestrel STELARA SUBCUTANEOUS PA, § H2 RECEPTOR ANTAGONISTS Nebulized Passive Inhalation § TRIPHASIC SP, QL PERFOROMIST QL cimetidine ethinyl estradiol-desogestrel TALTZ PA, SP, QL famotidine ethinyl estradiol-levonorgestrel TREMFYA PA, SP, QL § LEUKOTRIENE MODULATORS ethinyl estradiol-norethindrone § PROTON PUMP INHIBITORS PSORIATIC ARTHRITIS montelukast ethinyl estradiol-norgestimate lansoprazole delayed-rel QL, PA COSENTYX PA, SP, QL § NASAL STEROIDS § EXTENDED CYCLE lansoprazole delayed-rel orally ENBREL PA, SP, QL flunisolide disintegrating tabs QL, PA HUMIRA PA, SP, QL ethinyl estradiol-levonorgestrel fluticasone omeprazole delayed-rel QL, PA OTEZLA PA, SP, QL § PROGESTIN ONLY pantoprazole delayed-rel tabs QL, PA STEROID / BETA AGONIST RHEUMATOID ARTHRITIS norethindrone COMBINATIONS GENITOURINARY ENBREL PA, SP, QL ADVAIR QL EMERGENCY CONTRACEPTION HUMIRA PA, SP, QL § BENIGN PROSTATIC ADVAIR HFA 2, QL ELLA KEVZARA PA, SP, QL HYPERPLASIA BREO ELLIPTA 2, QL ORENCIA CLICKJECT PA, SP, QL § INJECTABLE alfuzosin ext-rel SYMBICORT QL ORENCIA SUBCUTANEOUS PA, doxazosin medroxyprogesterone acetate 150 SP, QL § STEROID INHALANTS finasteride mg/mL RINVOQ PA, SP, QL tamsulosin budesonide inhalation XELJANZ PA, SP, QL § TRANSDERMAL terazosin suspension QL, PA XELJANZ XR PA, SP, QL ARNUITY ELLIPTA QL norelgestromin/ethinyl estradiol - § URINARY ANTISPASMODICS FLOVENT DISKUS QL Xulane ULCERATIVE COLITIS oxybutynin FLOVENT HFA QL HUMIRA PA, SP, QL § VAGINAL oxybutynin ext-rel QVAR REDIHALER QL STELARA SUBCUTANEOUS #, PA, tolterodine etonogestrel/ethinyl estradiol SP, QL trospium TOPICAL ANNOVERA XELJANZ #, PA, SP, QL

XELJANZ XR #, PA, SP, QL DERMATOLOGY HUMAN GROWTH HORMONES § VAGINAL ANTI-INFECTIVES § ACNE NORDITROPIN PA, SP clindamycin cream # After failure of HUMIRA metronidazole ALL OTHER CONDITIONS benzoyl peroxide cream, lotion clindamycin gel, lotion, MENOPAUSAL SYMPTOM AGENTS terconazole ENBREL PA, SP, QL solution QL, PA § ORAL HUMIRA PA, SP, QL HEMATOLOGIC erythromycin gel 2% QL, PA estradiol erythromycin solution QL, PA estradiol-norethindrone ANTICOAGULANTS RESPIRATORY erythromycin-benzoyl peroxide ethinyl estradiol-norethindrone § INJECTABLE § ANAPHYLAXIS TREATMENT sulfacetamide lotion 10% acetate AGENTS enoxaparin tretinoin PA

§ TRANSDERMAL epinephrine auto-injector QL, PA § ORAL EPIPEN QL, PA OPHTHALMIC estradiol warfarin EPIPEN JR QL, PA BETA-BLOCKERS CLIMARA PRO XARELTO SYMJEPI QL, PA § Nonselective § VAGINAL § PLATELET AGGREGATION § ANTICHOLINERGICS timolol maleate estradiol vaginal crm INHIBITORS ipratropium inhalation solution QL IMVEXXY clopidogrel

§ Selective § CARBONIC ANHYDRASE § PROSTAGLANDINS § SYMPATHOMIMETICS betaxolol solution INHIBITOR / BETA-BLOCKER latanoprost brimonidine 0.15%, 0.2% COMBINATIONS § CARBONIC ANHYDRASE dorzolamide-timolol maleate INHIBITORS dorzolamide

FOR YOUR INFORMATION: This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. In most instances, a brand-name drug for which a generic product becomes available will require prior authorization or will no longer be covered upon release of the generic product to the market. Unless specifically indicated, drug list products will include all oral dosage forms, except for orally disintegrating formulations. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. 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 www.carefirst.com/myaccount to check coverage.

An exception process may exist for specific clinical or regulatory circumstances that require coverage of a removed medication. § Generics are available in this class and should be considered the first line of prescribing. * For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 1 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. 2 Listing does not include certain NDCs. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

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.

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