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This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Not all of the drugs listed are covered by all prescription plans; check your benefit materials and formulary for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

For the member: FDA-approved generic medications meet strict standards and contain 2020 Home Delivery, CVS and Walgreens the same active ingredients as their corresponding brand-name medications, although 90-Day Supply List they may have a different appearance. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. A Aplenzin Binosto Carvedilol Cyred Apri Bisoprolol Fumarate Carvedilol ER Cyred EQ Acarbose Aranelle Bisoprolol-Hydrochlorothiazide Casodex Cytotec Accolate Arava Blisovi 24 Fe Catapres Accupril Arcapta Neohaler Blisovi Fe Catapres-TTS D Accuretic Aricept Boniva Tablets Caverject Acebutolol HCl Armonair Respiclick Breo Ellipta Caziant Daliresp Acetazolamide Armour Thyroid Brevicon Cequa ER Actigall Arnuity Ellipta Briellyn HCl Dasetta Active OB Aromasin Brilinta Chateal Daysee Activella Ashlyna Brimonidine Tartrate Eye Drops Chateal EQ Deblitane Actonel Asmanex Bromocriptine Mesylate Chlorothiazide Delyla Actoplus Met Asmanex HFA Budesonide Chlorpropamide Demadex Actoplus Met XR Aspirin-Dipyridamole ER Bumetanide Chlorthalidone Denta 5000 Plus Actos Atelvia Buphenyl Cholestyramine Dentagel Adalat CC Atenolol Bupropion HCl Cholestyramine Light Depen Advair Diskus Atenolol-Chlorthalidone Bupropion HCl ER Cilostazol Depo-Provera 150 mg Advair HFA Atomoxetine HCl Bupropion HCl SR Cimetidine Depo-Subq Provera 104 Aerospan Atorvastatin Calcium Bupropion XL Cinacalcet HCl Desmopressin Acetate Afeditab CR Atrovent Buspirone HCl Citalopram HBr Tablets and Nasal Spray Afirmelle Atrovent HFA Bydureon Citranatal 90 DHA Desogen Afrezza Aubra Bydureon Bcise Citranatal Assure Desvenlafaxine ER Aggrenox Aubra EQ Byetta Citranatal B-Calm Desvenlafaxine Fumarate ER Agrylin Aurovela Bystolic Citranatal DHA Desvenlafaxine Succinate ER Airduo Respiclick Aurovela 24 Fe Byvalson Citranatal Harmony Dexilant Albuterol Sulfate Aurovela Fe Citranatal Rx Diamox Sequels Tablets and Syrup Avandamet C Climara Digox Aldactazide Avandia Clinpro 5000 Digoxin Aldactone Aviane Cabergoline Clonidine Dilatrate-SR Alendronate Sodium Aygestin Cadeau DHA Clonidine HCl Diltiazem 12 HR ER Alfuzosin HCl ER Ayuna Caduet Clonidine HCl ER Diltiazem 24 HR CD Aliskiren Azilect Calan Clonidine Patch Diltiazem 24 HR ER Allopurinol Azopt Calan SR Clopidogrel Diltiazem 24 HR LA Alora Azulfidine Calcitonin-Salmon C-Nate DHA Diltiazem 24 HR XR Alphagan P Azurette Calcitriol Oral Colesevelam HCl Diltiazem HCl Altace Calcium PNV Colestid Diltiazem HCl ER Altavera B Calcium-Folic Acid Plus D Colestipol HCl Dilt-XR Alyacen Camila Combigan Dipyridamole Amabelz Bal-Care DHA Camrese Combipatch Disopyramide Phosphate Amaryl Bal-Care DHA Essential Camrese Lo Combivent Respimat Ditropan XL Amethia Balcoltra Candesartan Cilexetil Complete Natal DHA Diuril Amethia Lo Balziva Candesartan-Hydrochlorothiazide Completenate Divigel Amethyst Basaglar Kwikpen Captopril Comtan Donepezil HCl Amiloride HCl Bekyree Captopril-Hydrochlorothiazide Concept DHA Donepezil HCl ODT Amiloride-Hydrochlorothiazide Benazepril HCl Carafate Concept OB Dorzolamide HCl Amiodarone HCl Benazepril-Hydrochlorothiazide Carbidopa Contrave ER Dorzolamide-Timolol Amitiza Betagan Carbidopa-Levodopa Cordarone Dothelle DHA Amlodipine Besylate Betapace Carbidopa-Levodopa ER Coreg Dotti Amlodipine Besylate-Benazepril Betapace AF Carbidopa-Levodopa-Entacapone Coreg ER Doxazosin Mesylate Amlodipine-Atorvastatin Betaxolol HCl Cardizem Corgard Doxercalciferol Amlodipine-Olmesartan Betimol Cardizem CD Corlanor Drisdol Amlodipine-Valsartan Betoptic S Cardizem LA Cromolyn Sodium Drospirenone-E.Estradiol- Amlodipine-Valsartan-HCTZ Bevespi Aerosphere Cardura Oral Concentrate Levomefol Anagrelide HCl Beyaz Cardura XL Cryselle Drospirenone-Ethinyl Estradiol Anastrozole Bicalutamide Carnitor Cyanocobalamin Injection Duavee Angeliq Bidil Carnitor SF Cyclafem Duet DHA 400 Anoro Ellipta Bijuva Carteolol HCl Cyclessa Duet DHA Balanced Antara Bimatoprost Cartia XT Cycloset Duetact (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2019 Express Scripts. All Rights Reserved. Page 1 DL466313-KEY CRP1910_001131.1 (10/01/19) All trademarks are the property of their respective owners. Dulera Femhrt Glycate Jevantique Lo Lo Loestrin Fe Duloxetine HCl Femynor Glycopyrrolate Jinteli Lodosyn Dutasteride Fenofibrate Glynase Jolessa Lomedia 24 Fe Dutasteride-Tamsulosin Fenofibric Acid Glyset Jolivette Lonhala Magnair Refill Dyazide Fenoglide Glyxambi Juleber Lopid Dyrenium Fetzima Grastek Junel Lopreeza Fibricor Guanfacine HCl Junel Fe Lopressor E Finasteride Guanfacine HCl ER Junel Fe 24 Lopressor HCT HCl Loryna Edarbi Flecainide Acetate H K Losartan Potassium Edarbyclor Flolipid Losartan-Hydrochlorothiazide Edecrin Flomax Hailey K Effervescent Loseasonique Edex Flovent Diskus Hailey 24 Fe Kaitlib Fe Lotensin Effer-K Flovent HFA Heather Kalliga Lotensin HCT Effient Fludrocortisone Acetate Hectorol Kapvay Lovastatin Elestrin Flunisolide Hemenatal OB Kariva Lovaza Elinest Fluoridex Hemenatal OB + DHA Katerzia Low-Ogestrel Eliquis Fluoridex Daily Defense Humalog Kelnor Lo-Zumandimine Elite-OB Fluoridex Sensitivity Relief Humalog Junior Kwikpen Khedezla Lumigan Elixophyllin Fluoxetine HCl Humalog Kwikpen Kimidess Lutera Emoquette Fluoxetine HCl DR Humalog Mix Klor-Con Lyza Enablex Flutamide Humalog Mix Kwikpen Klor-Con EF Enalapril Maleate Fluticasone Propionate Humulin N Klor-Con M M Enalapril-Hydrochlorothiazide Fluticasone-Salmeterol Humulin N Kwikpen Klor-Con Sprinkle Enbrace HR Fluvastatin Sodium Humulin R Kosher Prenatal Plus Iron Macnatal CN DHA Enjuvia Fluvastatin Sodium ER Humulin R Kwikpen K-Sol Marlissa Enpresse Fluvoxamine Maleate Hydralazine HCl K-Tab ER Marnatal-F Enskyce Fluvoxamine Maleate ER Hydrochlorothiazide Kurvelo Matzim LA Entacapone Focalgin 90 DHA Hydroxychloroquine Sulfate Maxinate Entresto Focalgin Ca L Maxzide Eplerenone Folet DHA I Medroxyprogesterone Acetate Eprosartan Mesylate Folet One Labetalol HCl Melodetta 24 Fe Ergoloid Mesylates Folic Acid 1 mg Ibandronate Sodium Lanoxin Memantine HCl Errin Folivane-OB Imvexxy Lansoprazole Memantine HCl ER Escitalopram Oxalate Foradil Incassia Lantus Menest Esomeprazole Magnesium Forfivo XL Incruse Ellipta Lantus Solostar Menostar Esomeprazole Strontium Fortamet Indapamide Larin Mesalamine DR Estarylla Fortical Innopran XL Larin 24 Fe Mestinon Estrace Fosamax Inspra Larin Fe Metaproterenol Sulfate Estradiol Fosamax Plus D Introvale Larissia Metformin HCl Estradiol Transdermal Patch Fosinopril Sodium Invokamet Lasix Metformin HCl ER Estradiol-Norethindrone Tablets Fosinopril-Hydrochlorothiazide Invokamet XR Latanoprost Methazolamide Estring Fulvestrant Invokana Layolis Fe Methimazole Estropipate Furosemide Leena Methyclothiazide Estrostep Fe Fyavolv Ipratropium-Albuterol Leflunomide Methyldopa Ethacrynic Acid Irbesartan Lescol Methyldopa-Hydrochlorothiazide Ethynodiol-Ethinyl Estradiol G Irbesartan-Hydrochlorothiazide Lescol XL Metipranolol Etidronate Disodium Isibloom Lessina Metolazone Euthyrox Galantamine HBr Isochron Letrozole Metoprolol Succinate Evamist Galantamine HBr ER Isopto Carpine Levemir Metoprolol Tartrate Evista Gastrocrom Isordil Levemir Flextouch Metoprolol-Hydrochlorothiazide Evoxac Gelnique Isordil Titradose Levitra Mexiletine HCl Exelon Gemfibrozil Isosorbide Dinitrate Levobunolol HCl Miacalcin Exemestane Generess Fe Isosorbide Dinitrate ER Levocarnitine Mibelas 24 Fe Extra-Virt Plus DHA Gianvi Isosorbide Mononitrate Levomefolate DHA Microgestin Ezetimibe Gildagia Isosorbide Mononitrate ER Levonest Microgestin 24 Fe Ezetimibe-Simvastatin Gildess Isoxsuprine HCl Levonorgestrel-E.Estradiol Microgestin Fe Gildess 24 Fe Isradipine Levonorgestrel-Ethinyl Estradiol Microzide F Gildess Fe Levora-28 Miglitol Glimepiride J Levo-T Mili Falmina Glipizide Levothyroxine Sodium Mimvey Famotidine Glipizide ER Jalyn Levoxyl Mimvey Lo Fareston Glipizide XL Janumet Lialda Minipress Farxiga Glipizide-Metformin Janumet XR Lillow Minitran Faslodex Glucotrol Januvia Linzess Minivelle Fayosim Glucotrol XL Jardiance Liothyronine Sodium Minoxidil Febuxostat Glucovance Jasmiel Lipofen Mirapex Felodipine ER Glyburide Jencycla Lisinopril Mirapex ER Femara Glyburide Micronized Jentadueto Lisinopril-Hydrochlorothiazide Mircette Femcon Fe Glyburide-Metformin HCl Jentadueto XR Livalo (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2019 Express Scripts. All Rights Reserved. Page 2 DL466313-KEY CRP1910_001131.1 (10/01/19) All trademarks are the property of their respective owners. M-Natal Plus Norlyroc Pioglitazone-Metformin Procardia Robinul Forte Modicon Norpace Pirmella Procardia XL Rocaltrol Moexipril HCl Norpace CR PNV 29-1 Proglycem Rocklatan Moexipril-Hydrochlorothiazide Nor-Q-D PNV OB+DHA Propafenone HCl Ropinirole HCl Mometasone Furoate Nortrel PNV-DHA Propafenone HCl ER Ropinirole HCl ER Mono-Linyah NP Thyroid PNV-DHA + Docusate Propecia Rosuvastatin Calcium Mononessa Nuvaring PNV-Iron-Docusate-Folic Acid Propranolol HCl Rulavite DHA Montelukast Sodium PNV-Omega Propranolol HCl ER Rytary Motegrity O PNV-Select Propranolol-Hydrochlorothiazide Rythmol Multaq PNV-Total Propylthiouracil Rythmol SR Muse OB Complete PNV-VP-U Proscar Mynatal OB Complete Gold Portia Provera S Mynatal Advance OB Complete One Potaba Provida DHA Mynatal Plus OB Complete Petite Potassium Bicarbonate Provida OB Safyral Mynatal-Z OB Complete Premier Potassium Chloride Pulmicort Flexhaler Salagen Mynate 90 Plus OB Complete With DHA Potassium Citrate ER Purefe OB Plus Sarafem Myrbetriq Obstetrix DHA PR Natal Pyridostigmine Bromide Savella Myzilra Obstetrix EC Dihydrochloride Pyridostigmine Bromide ER Saxenda Obstetrix One Pramipexole Dihydrochloride ER Seasonique N Obtrex DHA Prandin Q Sectral O-Cal Prenatal Prasugrel HCl Seebri Neohaler Nadolol Ocella Pravastatin Sodium Qnasl Segluromet Nadolol-Bendroflumethiazide Odactra Prazosin HCl Qnasl Children Select-OB Namenda Ogestrel Precose Qtern Select-OB + DHA Namzaric Olmesartan Medoxomil Prefera OB Quartette Selegiline HCl Nascobal Olmesartan-Amlodipine-HCTZ Prefera-OB One Quasense Se-Natal 19 Natachew Olmesartan-Hydrochlorothiazide Prefera-OB Plus DHA Questran Sensipar Natazia Omega-3 Acid Ethyl Esters Prefest Questran Light Serevent Diskus Nateglinide Omeppi Premarin Quinapril HCl Sertraline HCl Natelle One Omeprazole Premphase Quinapril-Hydrochlorothiazide Setlakin Nature-Throid Omeprazole-Sodium Bicarbonate Prempro Gluconate Sharobel Necon Orilissa 150 mg Prena1 Chew Quinidine Sulfate Sildenafil Citrate Neevodha Orsythia Prena1 Pearl Qvar Silodosin Nefazodone HCl Ortho Micronor Prena1 True Qvar Redihaler Simbrinza Nestabs Ortho-Cyclen Prenaissance Simliya Nestabs ABC Ortho-Novum Prenaissance Next R Simpesse Nestabs DHA Oseni Prenaissance Plus Simvastatin Nestabs One Osphena Prenata Rabeprazole Sodium Sinemet Neupro Otrexup Prenatabs FA Ragwitek Sinemet CR Newgen Ovcon-35 Prenatabs Rx Rajani Slynd Nexa Plus Chloride Prenatal 19 Raloxifene HCl Sodium Fluoride (SF) 5000 Plus Nexium Oxybutynin Chloride ER Prenatal Low Iron Ramipril Sodium Fluoride (SF) Gel Niacin Oxytrol Prenatal Plus Ranexa Sodium Phenylbutyrate Niacin ER Ozempic Prenatal Plus-DHA Ranitidine HCl Succinate Niacor Prenatal Vitamin Plus Low Iron Ranolazine ER Soliqua Niaspan P Prenatal-U Rasagiline Mesylate Soltamox Nicardipine HCl Prenate AM Rasuvo Sorine Nifedical XL Pacerone Prenate Chewable Rayaldee Sotalol Nifedipine Pantoprazole Sodium Prenate DHA Razadyne Sotalol AF Nifedipine ER Paricalcitol Prenate Elite Razadyne ER Sotylize Nikki Parlodel Prenate Enhance Reclipsen Spironolactone Nilandron HCl Prenate Essential Relnate DHA Spironolactone-HCTZ Nilutamide Paroxetine HCl CR Prenate Mini Remeron Sprintec Nisoldipine Paroxetine HCl ER Prenate Pixie Repaglinide Sronyx Nitro-Bid Paroxetine Mesylate Prenate Restore Repaglinide-Metformin HCl Stalevo Nitro-Dur Paxil Prenate Star Requip Starlix Nitroglycerin Capsules Paxil CR Preplus Requip XL Staxyn Nitroglycerin Patch Pentasa Preque 10 Restasis Steglatro Nitro-Time Pentoxifylline Prestalia Restasis Multidose Steglujan Nizatidine Pepcid Pretab Rhopressa Stendra Nocdurna Perforomist Prevalite Ridaura Sucralfate Nora-Be Perindopril Erbumine Prevident Rilutek Sular Norethindrone Pexeva Prevident 5000 Riluzole Sulfasalazine Norethindrone Acetate Philith Prevident 5000 Enamel Protect Riomet Sulfasalazine DR Norethindrone-Ethinyl Estradiol Phospholine Iodide Prevident 5000 Plus Risedronate Sodium Sulfazine Norethindrone-E.Estradiol-Iron HCl Prevident 5000 Sensitive Risedronate Sodium DR Syeda Norgestimate-Ethinyl Estradiol Pimtrea Previfem Rivastigmine Symbicort Norgestrel-Ethinyl Estradiol Pindolol Primacare Rivelsa Symlinpen Norinyl Pioglitazone HCl Prinivil R-Natal OB Synjardy Norlyda Pioglitazone-Glimepiride Probenecid Robinul Synjardy XR (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2019 Express Scripts. All Rights Reserved. Page 3 DL466313-KEY CRP1910_001131.1 (10/01/19) All trademarks are the property of their respective owners. Synthroid Toprol XL Tri-Vylibra Lo Viibryd Wera Toremifene Citrate Trospium Chloride Vinate Care Westhroid T Torsemide Trospium Chloride ER Vinate DHA RF Wixela Inhub Toujeo Max Solostar Trulance Vinate II WP Thyroid Tadalafil (Generic Cialis) Toujeo Solostar Trulicity Vinate One Wymzya Fe Tamoxifen Citrate Toviaz Trusopt Vinate-M Tamsulosin HCl Tradjenta Trust Natal DHA Viorele X Tapazole Trandolapril Tulana Virt Nate Tarina Fe Trandolapril-Verapamil ER Twynsta Virt-Advance Xarelto Tarka Travatan Z Tydemy Virt-C DHA Xenical Taron-C DHA Travoprost Virt-Nate Xhance Taron-Prex Prenatal Trazodone HCl U Virt-Nate DHA Xifaxan 550 mg Tasmar Trelegy Ellipta Virt-PN Xigduo XR Taytulla Tresiba Uloric Virt-PN DHA Xiidra Taztia XT Tresiba Flextouch Ultimatecare One Virt-PN Plus Xulane Tekturna Tri Femynor Ultimatecare One NF Virtprex Xultophy Tekturna HCT Triamterene-HCTZ Unithroid Virt-Select Telmisartan Tricare Urocit-K Virt-Vite GT Y Telmisartan-Amlodipine Tricare Prenatal Urso Vitafol Fe+ Telmisartan-Hydrochlorothiazide Tricare Prenatal DHA One Urso Forte Vitafol Gummies Yaz Tenex Tricare Prenatal With DHA Ursodiol Vitafol Nano Yupelri Tenoretic Tri-Estarylla Utibron Neohaler Vitafol Nano Tablets Yuvafem Tenormin Triglide Vitafol Ultra Terazosin HCl Triklo V Vitafol-OB Z Terbutaline Sulfate Tablets Tri-Legest Fe Vitafol-OB+DHA Theo-24 Tri-Linyah Valsartan Vitafol-One Zafirlukast Theochron Trilipix Valsartan-Hydrochlorothiazide Vitamedmd One Rx Zantac Theophylline Tri-Lo-Estarylla Vardenafil HCl Vitamedmd Plus Rx Zarah Theophylline Anhydrous Tri-Lo-Marzia Vascepa Vitamedmd Redichew Rx Zatean-CH Thrivite Rx Tri-Lo-Mili Vaseretic Vitamin D2 (Prescription) Zatean-PN DHA Thyroid Tri-Lo-Sprintec Vasotec Vitapearl Zatean-PN Plus Thyrolar Tri-Mili Velivet Vitatrue Zebeta Tiazac Trinatal GT VemaVite-Prx 2 Vivelle-Dot Zelapar Ticlopidine HCl Trinatal Rx 1 Venlafaxine HCl VP-CH Plus Zemplar Tiglutik Trinate Venlafaxine HCl ER VP-CH-PNV Zenchent Tilia Fe Trinessa Veramyst VP-GGR-B6 Zenchent Fe Timolol Maleate Trinessa Lo Verapamil ER VP-PNV-DHA Zestoretic Timoptic Tri-Norinyl Verapamil ER PM Vyfemla Zestril Timoptic-XE Trintellix Verapamil HCl Vylibra Ziac Tirosint Tri-Previfem Verapamil SR Vyzulta Zingiber Tolazamide Tri-Sprintec Verelan Zontivity Tolbutamide Tristart DHA Verelan PM W Zovia Tolcapone Triveen-Duo DHA Vesicare Zumandimine Tartrate Trivora-28 Vestura Welchol Zyloprim Tolterodine Tartrate ER Tri-Vylibra Vienva Wellbutrin XL

This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2019 Express Scripts. All Rights Reserved. Page 4 DL466313-KEY CRP1910_001131.1 (10/01/19) All trademarks are the property of their respective owners.