2021 EMPIRE PLAN FLEXIBLE FORMULARY DRUG LIST Administered by CVS Caremark®

April 2021

The Empire Plan Flexible Formulary is a guide within select therapeutic categories for enrollees 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 drug to treat a condition. These preferred brand-name drugs are listed to help identify products that are clinically appropriate and cost-effective. This is not an all-inclusive list. This formulary includes a list of commonly prescribed covered drugs by therapeutic class, a Quick Reference Drug List with commonly prescribed covered drugs in alphabetic order, a listing of commonly prescribed non-preferred (Level 3) covered drugs and covered preferred drug alternatives, and a listing of excluded drugs along with covered alternatives. This list represents brand-name drugs in CAPS and generic drugs in lowercase italics.

Generally generics are subject to a Level 1 copayment, or the lowest copayment; preferred brand drugs are subject to a Level 2 copayment, and non-preferred brand drugs are subject to a Level 3 copayment, or the highest copayment. Refer to your plan materials for specific information regarding copayment amounts.

ENROLLEE 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 generic or a authorize generic substitution whenever possible. If you believe a preferred brand-name drug from this list. Take this list along when brand-name drug is necessary, consider prescribing a brand-name you or a covered family member sees a doctor. drug on this list.

Please note: Please note: • You will be responsible for the full cost of non-formulary products • Generics should be considered the first line of prescribing. that are excluded from coverage unless a request for a • This drug list represents a summary of prescription coverage. medical exception is approved. New prescription drug products It is not all-inclusive and does not guarantee coverage. may be subject to exclusion upon release to the market. • The enrollee's prescription benefit plan may have a different • For specific information regarding your prescription benefit copay for specific products on the list. coverage and copay information, please visit • Unless specifically indicated, drug list products will include all https://www.empireplanrxprogram.com or dosage forms. call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 • Log in to https://www.empireplanrxprogram.com to check for the Empire Plan Prescription Drug Program. coverage and copay information for a specific medicine. • Any brand-name drug for which a generic drug becomes available will be designated as a non-preferred drug. When a generic version is available, mandatory generic substitution will apply. In this case, use of a non-preferred product will result in the member paying the applicable non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug (Ancillary Charge).

ANALGESICS § NSAIDs, TOPICAL § OPIOID ANALGESICS hydromorphone ext-rel § NON-OPIOID ANALGESICS diclofenac sodium gel 1% buprenorphine transdermal QL/PA butalbital-acetaminophen- § NSAIDs (generic VOLTAREN GEL) (generic BUTRANS) methadone QL/PA caffeine diclofenac sodium QL/PA morphine QL/PA butalbital-aspirin-caffeine § COX-2 INHIBITORS diflunisal codeine-acetaminophen QL morphine ext-rel QL/PA etodolac celecoxib (generic fentanyl citrate (generic morphine suppository QL/PA VISCOSUPPLEMENTS ibuprofen CELEBREX) FENTORA) PA/QL oxycodone QL/PA DUROLANE meloxicam fentanyl transdermal QL/PA oxycodone-acetaminophen GELSYN-3 § GOUT nabumetone fentanyl transmucosal QL/PA HYALGAN naproxen (except naproxen CR or allopurinol lozenge PA/QL tramadol QL/PA SUPARTZ FX naproxen suspension) colchicine tablet (generic hydrocodone ext-rel (generic tramadol ext-rel QL/PA naproxen sodium COLCRYS) ZOHYDRO ER) QL/PA BELBUCA QL/PA ANTI-INFECTIVES oxaprozin febuxostat (generic ULORIC) HYSINGLA ER QL/PA hydrocodone-acetaminophen ANTIBACTERIALS sulindac probenecid (except hydrocodone-acetaminophen NUCYNTA QL/PA § CEPHALOSPORINS COLCRYS tablet 7.5-300 mg or hydrocodone- NUCYNTA ER QL/PA § NSAIDs, COMBINATIONS cefadroxil acetaminophen tablet 10-300 mg) OXYCONTIN QL/PA diclofenac sodium- cefdinir QL/PA SUBSYS PA/QL misoprostol cefixime (generic SUPRAX) XTAMPZA ER QL/PA hydromorphone QL/PA

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 1

cefprozil emtricitabine-tenofovir nitazoxanide (generic MISCELLANEOUS § ANGIOTENSIN II cefuroxime axetil disoproxil fumarate ALINIA) ERIVEDGE SGM RECEPTOR ANTAGONIST / cephalexin (generic TRUVADA) nitrofurantoin LYNPARZA SGM CALCIUM CHANNEL SUPRAX SUSPENSION 500 BIKTARVY nitrofurantoin ext-rel RUBRACA SGM BLOCKER COMBINATIONS MG/5 ML, TABLET CIMDUO pentamidine (generic ZEJULA SGM amlodipine-olmesartan

DESCOVY NEBUPENT) (generic AZOR) § ERYTHROMYCINS / DOVATO praziquantel (generic CARDIOVASCULAR MACROLIDES EVOTAZ BILTRICIDE) QL/PA § ANGIOTENSIN II § ACE INHIBITORS azithromycin GENVOYA sulfamethoxazole- RECEPTOR ANTAGONIST / clarithromycin ODEFSEY trimethoprim benazepril CALCIUM CHANNEL clarithromycin ext-rel SYMTUZA tinidazole captopril BLOCKER / DIURETIC erythromycin delayed-rel TRIUMEQ trimethoprim enalapril COMBINATIONS erythromycin ethylsuccinate TRUVADA vancomycin fosinopril olmesartan-amlodipine- erythromycin stearate ALINIA SUSPENSION lisinopril hydrochlorothiazide § ANTITUBERCULAR DIFICID EMVERM perindopril (generic TRIBENZOR) AGENTS SIVEXTRO quinapril § FLUOROQUINOLONES ethambutol XIFAXAN 550 MG ramipril § ANTIARRHYTHMICS ciprofloxacin isoniazid trandolapril amiodarone levofloxacin pyrazinamide ANTINEOPLASTIC disopyramide § ACE INHIBITOR / CALCIUM moxifloxacin rifampin AGENTS dofetilide (generic TIKOSYN) CHANNEL BLOCKER PRIFTIN SGM § PENICILLINS Generally, single-source brand COMBINATIONS TRECATOR drugs (products for which a flecainide amoxicillin generic is not available) and amlodipine-benazepril propafenone amoxicillin-clavulanate ANTIVIRALS generic drugs indicated for the trandolapril-verapamil ext-rel propafenone ext-rel treatment of cancer are amoxicillin-clavulanate ext-rel § CYTOMEGALOVIRUS (generic TARKA) formulary. sotalol ampicillin AGENTS § ACE INHIBITOR / MULTAQ dicloxacillin valganciclovir (generic HORMONAL penicillin VK DIURETIC COMBINATIONS ANTILIPEMICS VALCYTE) ANTINEOPLASTIC AGENTS benazepril- § ANTIANDROGENS § BILE ACID RESINS § TETRACYCLINES HEPATITIS AGENTS hydrochlorothiazide cholestyramine doxycycline hyclate abiraterone (generic captopril-hydrochlorothiazide Generally, single-source brand colesevelam (generic minocycline drugs (products for which a ZYTIGA) SGM enalapril-hydrochlorothiazide generic is not available) and WELCHOL) tetracycline ERLEADA SGM fosinopril-hydrochlorothiazide generic drugs indicated for the colestipol XTANDI SGM VIBRAMYCIN SYRUP treatment of Hepatitis B and lisinopril-hydrochlorothiazide

Hepatitis C are formulary. YONSA SGM quinapril-hydrochlorothiazide § CHOLESTEROL

§ ANTIFUNGALS § LUTEINIZING HORMONE- ABSORPTION INHIBITORS clotrimazole troches § HEPATITIS B AGENTS § ADRENOLYTICS, RELEASING HORMONE CENTRAL ezetimibe (generic ZETIA) fluconazole entecavir tablet (LHRH) AGONISTS griseofulvin ultramicrosize lamivudine tablet clonidine § FIBRATES itraconazole PA ELIGARD SGM clonidine transdermal BARACLUDE SOLUTION fenofibrate (except fenofibrate tablet LUPRON DEPOT SGM nystatin EPIVIR-HBV SOLUTION guanfacine 120 mg) terbinafine tablet PA VEMLIDY § KINASE INHIBITORS fenofibric acid delayed-rel voriconazole § ALDOSTERONE gemfibrozil imatinib mesylate SGM RECEPTOR ANTAGONISTS NOXAFIL INJECTION, § HEPATITIS C AGENTS ALECENSA SGM SUSPENSION ribavirin SGM eplerenone § HMG-CoA REDUCTASE ALUNBRIG SGM EPCLUSA SGM spironolactone INHIBITORS / § ANTIMALARIALS BOSULIF SGM HARVONI SGM COMBINATIONS atovaquone-proguanil CABOMETYX SGM § ANGIOTENSIN II SOVALDI SGM atorvastatin chloroquine ◊ IBRANCE SGM RECEPTOR ANTAGONISTS / VOSEVI , SGM ezetimibe-simvastatin mefloquine ICLUSIG SGM DIURETIC COMBINATIONS (generic VYTORIN) pyrimethamine (generic § HERPES AGENTS IRESSA SGM candesartan fluvastatin DARAPRIM) KISQALI SGM candesartan- acyclovir lovastatin COARTEM KISQALI FEMARA CO- hydrochlorothiazide famciclovir pravastatin PACK SGM irbesartan valacyclovir rosuvastatin (generic ANTIRETROVIRAL AGENTS RYDAPT SGM irbesartan- CRESTOR) Generally, single-source brand § INFLUENZA AGENTS SPRYCEL SGM hydrochlorothiazide drugs (products for which a simvastatin generic is not available) and oseltamivir (generic TASIGNA SGM losartan generic drugs indicated for the TAMIFLU) QL/PA VERZENIO SGM losartan-hydrochlorothiazide § NIACINS treatment of HIV and its VITRAKVI SGM olmesartan (generic RELENZA QL/PA niacin ext-rel opportunistic infections are BENICAR) formulary. § MISCELLANEOUS MULTIPLE MYELOMA olmesartan- § OMEGA-3 FATTY ACIDS § ANTIRETROVIRAL albendazole (generic IMMUNOMODULATORS hydrochlorothiazide COMBINATIONS icosapent ethyl (generic ALBENZA) QL/PA REVLIMID SGM (generic BENICAR HCT) VASCEPA) efavirenz-lamivudine- atovaquone telmisartan omega-3 acid ethyl esters tenofovir disoproxil PROTEASOME INHIBITORS clindamycin telmisartan- VASCEPA fumarate (generic SYMFI, dapsone NINLARO SGM hydrochlorothiazide SYMFI LO) ivermectin (generic VELCADE SGM valsartan PCSK9 INHIBITORS

STROMECTOL) valsartan-hydrochlorothiazide PRALUENT PA

metronidazole REPATHA PA

§ BETA-BLOCKERS § SUBLINGUAL / divalproex sodium ext-rel desipramine § ATTENTION DEFICIT atenolol TRANSLINGUAL ethosuximide doxepin (generic HYPERACTIVITY DISORDER bisoprolol nitroglycerin lingual spray gabapentin SINEQUAN) amphetamine- carvedilol nitroglycerin sublingual tablet lamotrigine imipramine HCl dextroamphetamine mixed labetalol (generic NITROSTAT) lamotrigine ext-rel nortriptyline salts metoprolol succinate ext-rel lamotrigine orally atomoxetine (generic § TRANSDERMAL § MISCELLANEOUS metoprolol tartrate disintegrating tablet STRATTERA) AGENTS nadolol nitroglycerin transdermal (generic LAMICTAL ODT) dexmethylphenidate bupropion pindolol levetiracetam dexmethylphenidate ext-rel PULMONARY ARTERIAL bupropion ext-rel (except propranolol levetiracetam ext-rel (generic FOCALIN XR) HYPERTENSION propranolol ext-rel oxcarbazepine bupropion ext-rel tablet 450 mg) dextroamphetamine mirtazapine BYSTOLIC * § ENDOTHELIN RECEPTOR phenobarbital dextroamphetamine ext-rel ANTAGONISTS phenytoin trazodone guanfacine ext-rel (generic

§ BETA-BLOCKER / phenytoin sodium extended ambrisentan (generic § ANTIPARKINSONIAN INTUNIV) DIURETIC COMBINATIONS primidone LETAIRIS) SGM AGENTS methylphenidate atenolol-chlorthalidone bosentan (generic tiagabine methylphenidate ext-rel amantadine bisoprolol- TRACLEER) SGM topiramate ADDERALL XR B4G benztropine hydrochlorothiazide OPSUMIT SGM valproic acid CONCERTA B4G bromocriptine metoprolol- zonisamide MYDAYIS § PHOSPHODIESTERASE carbidopa-levodopa hydrochlorothiazide DILANTIN 30 MG VYVANSE INHIBITORS FYCOMPA carbidopa-levodopa ext-rel § CALCIUM CHANNEL sildenafil 20 mg SGM OXTELLAR XR carbidopa-levodopa- § FIBROMYALGIA

BLOCKERS QUDEXY XR entacapone pregabalin (generic LYRICA) PROSTACYCLIN RECEPTOR entacapone amlodipine TROKENDI XR SAVELLA AGONISTS diltiazem ext-rel VIMPAT pramipexole felodipine ext-rel UPTRAVI SGM pramipexole ext-rel (generic § HUNTINGTON'S DISEASE nifedipine ext-rel § ANTIDEMENTIA MIRAPEX ER) AGENTS § PROSTAGLANDIN verapamil ext-rel donepezil rasagiline (generic AZILECT) tetrabenazine (generic VASODILATORS galantamine ropinirole XENAZINE) § DIGITALIS GLYCOSIDES treprostinil (generic galantamine ext-rel selegiline digoxin REMODULIN) SGM memantine (generic trihexyphenidyl HYPNOTICS digoxin pediatric elixir TYVASO SGM NAMENDA) APOKYN SGM § BENZODIAZEPINES

VELETRI SGM rivastigmine NEUPRO temazepam DIRECT RENIN INHIBITORS / VENTAVIS SGM rivastigmine transdermal PARLODEL 5 MG DIURETIC COMBINATIONS (generic EXELON PATCH) RYTARY § NONBENZODIAZEPINES SOLUBLE GUANYLATE aliskiren (generic NAMZARIC ZELAPAR eszopiclone CYCLASE STIMULATORS TEKTURNA) zolpidem ANTIPSYCHOTICS TEKTURNA HCT ADEMPAS SGM ANTIDEPRESSANTS zolpidem ext-rel

§ MONOAMINE OXIDASE § ATYPICALS BELSOMRA § DIURETICS § MISCELLANEOUS INHIBITORS (MAOIs) aripiprazole (generic acetazolamide hydralazine § TRICYCLICS phenelzine ABILIFY) acetazolamide ext-rel methyldopa tranylcypromine clozapine doxepin (generic SILENOR) amiloride midodrine MARPLAN olanzapine phenoxybenzamine (generic MIGRAINE amiloride-hydrochlorothiazide quetiapine bumetanide DIBENZYLINE) § SELECTIVE SEROTONIN quetiapine ext-rel (generic ACUTE MIGRAINE AGENTS ranolazine ext-rel (generic chlorthalidone REUPTAKE INHIBITORS SEROQUEL XR) § Ergotamine Derivatives RANEXA) furosemide (SSRIs) risperidone dihydroergotamine injection hydrochlorothiazide citalopram ziprasidone CENTRAL NERVOUS indapamide escitalopram ABILIFY MAINTENA § Triptans SYSTEM methazolamide fluoxetine (except fluoxetine tablet 60 ARISTADA eletriptan (generic RELPAX) metolazone ANTIANXIETY mg, fluoxetine tablet [generics for ARISTADA INITIO QL/PA spironolactone- § BENZODIAZEPINES SARAFEM]) INVEGA SUSTENNA naratriptan QL/PA

hydrochlorothiazide paroxetine HCl INVEGA TRINZA rizatriptan QL

alprazolam torsemide paroxetine HCl ext-rel LATUDA sumatriptan injection QL/PA

clonazepam tablet triamterene sertraline RISPERDAL CONSTA sumatriptan nasal spray diazepam triamterene- TRINTELLIX VRAYLAR QL/PA

lorazepam hydrochlorothiazide VIIBRYD sumatriptan tablet QL/PA

oxazepam § MISCELLANEOUS zolmitriptan QL/PA HEART FAILURE § SEROTONIN § MISCELLANEOUS chlorpromazine ZEMBRACE SYMTOUCH BIDIL NOREPINEPHRINE fluphenazine buspirone ZOMIG NASAL SPRAY CORLANOR REUPTAKE INHIBITORS haloperidol clomipramine QL/PA ENTRESTO (SNRIs) perphenazine fluvoxamine Miscellaneous NITRATES duloxetine pimozide § ANTICONVULSANTS venlafaxine thiothixene NURTEC ODT § ORAL carbamazepine venlafaxine ext-rel trifluoperazine isosorbide dinitrate PREVENTIVE MIGRAINE carbamazepine ext-rel isosorbide mononitrate § TRICYCLIC AGENTS diazepam rectal gel isosorbide mononitrate ext- ANTIDEPRESSANTS (TCAs) Monoclonal Antibodies divalproex sodium

rel amitriptyline AIMOVIG

AJOVY § PARTIAL OPIOID AGONIST / RYBELSUS ORAL PROGESTIN INTRAUTERINE EMGALITY OPIOID ANTAGONIST TRULICITY CONTRAVE PA DEVICE

COMBINATIONS VICTOZA KYLEENA § MOOD STABILIZERS CALCIUM RECEPTOR buprenorphine-naloxone MIRENA lithium carbonate INCRETIN MIMETIC AGENT / ANTAGONISTS sublingual tablet SKYLA lithium carbonate ext-rel INSULIN COMBINATIONS ZUBSOLV cinacalcet (generic

SOLIQUA SENSIPAR) SGM § TRANSDERMAL MOVEMENT DISORDERS PSEUDOBULBAR AFFECT XULTOPHY ethinyl estradiol- AUSTEDO SGM CALCIUM REGULATORS AGENTS norelgestromin INGREZZA SGM INSULINS NUEDEXTA § BISPHOSPHONATES

FIASP § VAGINAL § MULTIPLE SCLEROSIS alendronate § SMOKING DETERRENTS HUMULIN R U-500 ethinyl estradiol-etonogestrel AGENTS ibandronate LANTUS bupropion ext-rel risedronate (generic NUVARING) dalfampridine ext-rel (generic CHANTIX * LEVEMIR AMPYRA) SGM § ENDOMETRIOSIS NICOTROL NOVOLIN 70/30 § CALCITONINS dimethyl fumarate (generic NICOTROL NS NOVOLIN N calcitonin-salmon danazol TECFIDERA) SGM NOVOLIN R ORILISSA glatiramer (generic § VASOMOTOR SYMPTOM NOVOLOG PARATHYROID HORMONES SYNAREL

COPAXONE) SGM AGENTS NOVOLOG MIX 70/30 FORTEO SGM FERTILITY REGULATORS AUBAGIO SGM paroxetine mesylate (generic TOUJEO TYMLOS SGM BETASERON SGM BRISDELLE) TRESIBA GNRH / LHRH COPAXONE SGM CONTRACEPTIVES ANTAGONISTS § INSULIN SENSITIZERS GILENYA SGM ENDOCRINE AND § MONOPHASIC ganirelix acetate (generic

MAYZENT METABOLIC pioglitazone ethinyl estradiol-desogestrel GANIRELIX) SGM REBIF SGM ACROMEGALY ethinyl estradiol- CETROTIDE SGM § INSULIN SENSITIZER / TYSABRI SGM drospirenone SANDOSTATIN LAR SGM BIGUANIDE COMBINATIONS VUMERITY SGM ethinyl estradiol- § OVULATION STIMULANTS, SIGNIFOR LAR SGM pioglitazone-metformin drospirenone-levomefolate GONADOTROPINS § MUSCULOSKELETAL SOMATULINE DEPOT SGM (generic BEYAZ, chorionic gonadotropin - THERAPY AGENTS SOMAVERT SGM § INSULIN SENSITIZER / novarel SGM SULFONYLUREA SAFYRAL) baclofen § ANDROGENS COMBINATIONS ethinyl estradiol-ethynodiol GONAL-F SGM carisoprodol 350 mg diacetate GONAL-F RFF SGM testosterone cypionate pioglitazone-glimepiride chlorzoxazone 375 mg ethinyl estradiol- OVIDREL SGM cyclobenzaprine (except testosterone enanthate levonorgestrel testosterone solution § MEGLITINIDES § OVULATION STIMULANTS, cyclobenzaprine tablet 7.5 mg) ethinyl estradiol- dantrolene ANDRODERM nateglinide SYNTHETIC repaglinide norethindrone acetate metaxalone clomiphene ANTIDIABETICS ethinyl estradiol- methocarbamol § ALPHA-GLUCOSIDASE SODIUM-GLUCOSE norethindrone acetate orphenadrine-aspirin-caffeine GAUCHER DISEASE INHIBITORS CO-TRANSPORTER 2 (generic MINASTRIN 24 tizanidine tablet CERDELGA SGM (SGLT2) INHIBITORS FE) acarbose CEREZYME SGM § MYASTHENIA GRAVIS INVOKANA ethinyl estradiol-norgestimate pyridostigmine (generic AMYLIN ANALOGS JARDIANCE ethinyl estradiol-norgestrel § GLUCOCORTICOIDS

MESTINON) SYMLINPEN dexamethasone SODIUM-GLUCOSE § BIPHASIC pyridostigmine ext-rel fludrocortisone § BIGUANIDES CO-TRANSPORTER 2 ethinyl estradiol-desogestrel (generic MESTINON hydrocortisone metformin (SGLT2) INHIBITOR / LO LOESTRIN FE TIMESPAN) BIGUANIDE COMBINATIONS methylprednisolone metformin ext-rel (generic § TRIPHASIC prednisolone sodium INVOKAMET § NARCOLEPSY GLUCOPHAGE XR) phosphate INVOKAMET XR ethinyl estradiol-desogestrel armodafinil (generic prednisolone syrup § BIGUANIDE / SYNJARDY ethinyl estradiol- NUVIGIL) PA prednisone SULFONYLUREA SYNJARDY XR levonorgestrel modafinil PA RAYOS COMBINATIONS ethinyl estradiol- SUNOSI SODIUM-GLUCOSE glipizide-metformin norethindrone § GLUCOSE ELEVATING POSTHERPETIC CO-TRANSPORTER 2 ethinyl estradiol-norgestimate AGENTS NEURALGIA DIPEPTIDYL PEPTIDASE-4 (SGLT2) INHIBITOR / (DPP-4) INHIBITORS DIPEPTIDYL PEPTIDASE-4 FOUR PHASE diazoxide (generic GRALISE PROGLYCEM) JANUVIA (DPP-4) INHIBITOR NATAZIA GLUCAGEN HYPOKIT PSYCHOTHERAPEUTIC - TRADJENTA COMBINATIONS § EXTENDED CYCLE GLUCAGON EMERGENCY MISCELLANEOUS GLYXAMBI DIPEPTIDYL PEPTIDASE-4 ethinyl estradiol- KIT § ALCOHOL DETERRENTS QTERN levonorgestrel (DPP-4) INHIBITOR / HUMAN GROWTH disulfiram BIGUANIDE COMBINATIONS § SULFONYLUREAS VIVITROL SGM § PROGESTIN ONLY HORMONES JANUMET glimepiride norethindrone GENOTROPIN SGM JANUMET XR glipizide § OPIOID ANTAGONISTS HUMATROPE SGM JENTADUETO glipizide ext-rel naloxone injection § INJECTABLE SEROSTIM SGM JENTADUETO XR naltrexone ANTIOBESITY medroxyprogesterone ZORBTIVE SGM

NARCAN NASAL SPRAY INCRETIN MIMETIC AGENTS acetate 150 mg/mL INJECTABLE DEPO-SUBQ PROVERA

OZEMPIC SAXENDA PA

§ HYPERPARATHYROID THYROID AGENTS mesalamine ext-rel (generic dutasteride-tamsulosin HEMOPHILIA A AGENTS TREATMENT, VITAMIN D § ANTITHYROID AGENTS APRISO) (generic JALYN) ADYNOVATE ANALOGS sulfasalazine finasteride methimazole JIVI sulfasalazine delayed-rel silodosin (generic RAPAFLO) calcitriol (1,25-D3) propylthiouracil KOGENATE FS paricalcitol (generic PENTASA tamsulosin KOVALTRY

ZEMPLAR) § THYROID SUPPLEMENTS terazosin NOVOEIGHT § RECTAL AGENTS levothyroxine NUWIQ MENOPAUSAL SYMPTOM hydrocortisone enema ERECTILE DYSFUNCTION liothyronine AGENTS mesalamine suppository ALPROSTADIL AGENTS HEMOPHILIA B AGENTS § ORAL § VASOPRESSINS (generic CANASA) MUSE QL REBINYN mesalamine suspension estradiol desmopressin spray, tablet CORTIFOAM § PHOSPHODIESTERASE IDIOPATHIC estradiol-norethindrone § VASOPRESSIN INHIBITORS THROMBOCYTOPENIC ethinyl estradiol- § IRRITABLE BOWEL RECEPTOR ANTAGONISTS sildenafil (generic VIAGRA) PURPURA AGENTS norethindrone acetate SYNDROME QL PROMACTA SGM DUAVEE tolvaptan (generic SAMSCA)

SGM alosetron (generic tadalafil (generic CIALIS) PREFEST PAROXYSMAL NOCTURNAL LOTRONEX) QL/PA PREMARIN § MISCELLANEOUS AMITIZA HEMOGLOBINURIA (PNH) PREMPHASE cabergoline LINZESS § URINARY AGENTS PREMPRO ANTISPASMODICS levocarnitine VIBERZI SOLIRIS SGM

§ TRANSDERMAL H.P. ACTHAR SGM oxybutynin § LAXATIVES § PLATELET AGGREGATION oxybutynin ext-rel estradiol GASTROINTESTINAL lactulose solution solifenacin (generic INHIBITORS CLIMARA PRO peg 3350-electrolytes VESICARE) clopidogrel COMBIPATCH § ANTIDIARRHEALS polyethylene glycol 3350 dipyridamole tolterodine DIVIGEL diphenoxylate-atropine SUPREP dipyridamole ext-rel-aspirin tolterodine ext-rel EVAMIST loperamide trospium prasugrel (generic EFFIENT) OPIOID-INDUCED § VAGINAL trospium ext-rel BRILINTA § ANTIEMETICS CONSTIPATION estradiol vaginal cream MYRBETRIQ doxylamine-pyridoxine MOVANTIK § PLATELET SYNTHESIS TOVIAZ (generic ESTRACE) delayed-rel (generic INHIBITORS estradiol vaginal tablet PANCREATIC ENZYMES DICLEGIS) § VAGINAL anagrelide (generic VAGIFEM) dronabinol CREON ANTI-INFECTIVES ESTRING granisetron VIOKACE STEM CELL MOBILIZERS clindamycin PREMARIN CREAM meclizine ZENPEP metronidazole MOZOBIL SGM metoclopramide § PHENYLKETONURIA terconazole ondansetron § PROSTAGLANDINS THROMBOCYTOPENIA TREATMENT AGENTS CLEOCIN SUPPOSITORY prochlorperazine misoprostol AGENTS sapropterin (generic KUVAN) promethazine § MISCELLANEOUS MULPLETA SGM § PROTON PUMP trimethobenzamide INHIBITORS bethanechol § MISCELLANEOUS § PHOSPHATE BINDER SANCUSO phenazopyridine lansoprazole delayed-rel cilostazol AGENTS VARUBI potassium citrate ext-rel omeprazole delayed-rel deferasirox (generic calcium acetate ELMIRON § ANTISPASMODICS pantoprazole delayed-rel EXJADE) SGM sevelamer carbonate chlordiazepoxide-clidinium DEXILANT HEMATOLOGIC CHEMET (generic RENVELA) dicyclomine PHOSLYRA § SALIVA STIMULANTS hyoscyamine sulfate ANTICOAGULANTS IMMUNOLOGIC VELPHORO cevimeline AGENTS hyoscyamine sulfate ext-rel § INJECTABLE pilocarpine tablet hyoscyamine sulfate orally POTASSIUM-REMOVING enoxaparin AUTOIMMUNE AGENTS disintegrating tablet FRAGMIN AGENTS STEROIDS, RECTAL COSENTYX SGM LOKELMA § CHOLELITHOLYTICS EPIFOAM § ORAL ENBREL SGM VELTASSA PROCTOFOAM-HC HUMIRA SGM ursodiol warfarin OTEZLA SGM PROGESTINS ELIQUIS § H2 RECEPTOR § ULCER THERAPY RINVOQ SGM § ORAL COMBINATIONS XARELTO ANTAGONISTS SKYRIZI SGM medroxyprogesterone cimetidine PYLERA § SYNTHETIC HEPARINOID- STELARA SGM norethindrone LIKE AGENTS TREMFYA SGM famotidine § MISCELLANEOUS progesterone, micronized XELJANZ SGM fondaparinux INFLAMMATORY BOWEL sucralfate tablet XELJANZ XR SGM VAGINAL DISEASE HEMATOPOIETIC GROWTH CRINONE § ORAL AGENTS GENITOURINARY FACTORS § DISEASE-MODIFYING ENDOMETRIN ANTIRHEUMATIC DRUGS balsalazide § BENIGN PROSTATIC ARANESP SGM (DMARDs) § SELECTIVE ESTROGEN budesonide delayed-rel HYPERPLASIA EPOGEN SGM hydroxychloroquine RECEPTOR MODULATORS capsule alfuzosin ext-rel NEULASTA SGM leflunomide budesonide ext-rel tabs doxazosin NIVESTYM SGM raloxifene methotrexate (generic UCERIS) dutasteride (generic RETACRIT SGM OSPHENA OTREXUP SGM mesalamine delayed-rel AVODART) UDENYCA SGM RASUVO SGM

(generic LIALDA)

HEREDITARY ANGIOEDEMA ANTICHOLINERGIC / BETA CAYSTON SGM § Topical hydrocortisone butyrate RUCONEST SGM AGONIST / STEROID PULMOZYME SGM adapalene (except adapalene pads or cream, lotion, ointment,

INHALANT COMBINATIONS adapalene solution) PA solution IMMUNOMODULATORS § LEUKOTRIENE TRELEGY ELLIPTA benzoyl peroxide hydrocortisone valerate MODULATORS INTERFERONS clindamycin gel, solution mometasone § ANTIHISTAMINES, LOW montelukast INTRON A SGM clindamycin-benzoyl triamcinolone cream, lotion, SEDATING zafirlukast PEGASYS SGM peroxide (generic ointment

levocetirizine ACANYA, BENZACLIN) § MAST CELL STABILIZERS § High Potency MISCELLANEOUS erythromycin solution § ANTIHISTAMINES, cromolyn inhalation solution betamethasone dipropionate ILARIS SGM erythromycin-benzoyl SEDATING desoximetasone § NASAL ANTIHISTAMINES peroxide § IMMUNOSUPPRESSANTS diflorasone cream clemastine 2.68 mg sulfacetamide lotion 10% azelastine Generally, single-source brand cyproheptadine fluocinonide (except fluocinonide tazarotene (generic drugs (products for which a hydroxyzine HCl § NASAL STEROIDS TAZORAC) PA cream 0.1%) generic is not available) and generic drugs indicated for the flunisolide tretinoin PA prevention of transplant rejection § ANTITUSSIVES § Very High Potency fluticasone tretinoin gel microsphere PA are formulary. benzonatate betamethasone dipropionate mometasone (generic § ACTINIC KERATOSIS augmented NUTRITIONAL / ANTITUSSIVE NASONEX) clobetasol, except shampoo fluorouracil SUPPLEMENTS COMBINATIONS triamcinolone diflorasone ointment imiquimod § OPIOID halobetasol PICATO VITAMINS AND MINERALS PHOSPHODIESTERASE-4 codeine-chlorpheniramine- § FOLIC ACID / INHIBITORS § EMOLLIENTS pseudoephedrine § ANTIBIOTICS COMBINATIONS DALIRESP ammonium lactate 12% codeine-guaifenesin liquid gentamicin folic acid codeine-guaifenesin- PULMONARY FIBROSIS mupirocin folic acid-vitamin B6-vitamin § LOCAL ANESTHETICS pseudoephedrine AGENTS silver sulfadiazine lidocaine-prilocaine QL/PA B12 codeine-promethazine ESBRIET SGM FOLTX codeine-promethazine- § ANTIFUNGALS OFEV SGM § ROSACEA phenylephrine ciclopirox § PRENATAL VITAMINS azelaic acid (generic hydrocodone-homatropine SEVERE ASTHMA clotrimazole prenatal vitamins FINACEA GEL) DUPIXENT SGM econazole doxycycline monohydrate CITRANATAL § NON-OPIOID ketoconazole (except ketoconazole FASENRA SGM (generic ORACEA) dextromethorphan- foam) § MISCELLANEOUS NUCALA SGM metronidazole brompheniramine- luliconazole (generic LUZU) phytonadione (generic XOLAIR SGM FINACEA FOAM pseudoephedrine naftifine cream 2%, gel 1% MEPHYTON) MIRVASO dextromethorphan- § STEROID / BETA AGONIST (generic NAFTIN) NASCOBAL SOOLANTRA promethazine COMBINATIONS nystatin

budesonide-formoterol JUBLIA PA RESPIRATORY BETA AGONISTS, § SCABICIDES AND (generic SYMBICORT) NAFTIN GEL 2% PEDICULICIDES ALPHA-1 ANTITRYPSIN INHALANTS ADVAIR DISKUS B4G crotamiton DEFICIENCY AGENTS § SHORT ACTING † ANTIPSORIATICS ADVAIR HFA malathion albuterol inhalation solution † § Oral ARALAST NP SGM BREO ELLIPTA permethrin 5% PROLASTIN-C SGM albuterol sulfate CFC-free DULERA acitretin aerosol (generic PROAIR methoxsalen § MISCELLANEOUS SKIN § ANAPHYLAXIS HFA) § STEROID INHALANTS AND MUCOUS MEMBRANE TREATMENT AGENTS § Topical levalbuterol inhalation budesonide inhalation podofilox calcipotriene ointment, epinephrine auto-injector solution suspension CONDYLOX GEL solution EPIPEN PROAIR HFA ARNUITY ELLIPTA DENAVIR SORILUX EPIPEN JR PROAIR RESPICLICK ASMANEX REGRANEX

FLOVENT DISKUS LONG ACTING § ATOPIC DERMATITIS § ANTICHOLINERGICS FLOVENT HFA MOUTH / THROAT / DENTAL ipratropium inhalation Hand-held Active Inhalation PULMICORT FLEXHALER pimecrolimus (generic AGENTS solution ARCAPTA QVAR REDIHALER ELIDEL) § ANESTHETICS - TOPICAL

SPIRIVA SEREVENT tacrolimus (generic ORAL § XANTHINES STRIVERDI RESPIMAT PROTOPIC) ANTICHOLINERGIC / BETA lidocaine viscous theophylline ext-rel tablet EUCRISA AGONIST COMBINATIONS Nebulized Passive Inhalation ELIXOPHYLLIN PROTECTANTS CORTICOSTEROIDS § SHORT ACTING THEO-24 PERFOROMIST * MUGARD ipratropium-albuterol § Low Potency § BETA AGONISTS, ORAL MISCELLANEOUS inhalation solution alclometasone § STEROIDS - MOUTH / BEVESPI AEROSPHERE albuterol ipratropium spray desonide THROAT

COMBIVENT RESPIMAT albuterol ext-rel fluocinolone triamcinolone paste TOPICAL STIOLTO RESPIMAT terbutaline hydrocortisone

CAPEX SHAMPOO OPHTHALMIC § CYSTIC FIBROSIS DERMATOLOGY LONG ACTING TEXACORT SOLUTION § ANTIALLERGICS tobramycin inhalation ACNE ANORO ELLIPTA azelastine solution (generic KITABIS, § Oral § Medium Potency cromolyn sodium TOBI) SGM isotretinoin betamethasone valerate olopatadine BETHKIS B4G, SGM fluticasone

LASTACAFT neomycin-polymyxin B- BETA-BLOCKERS § PROSTAGLANDINS ofloxacin otic

PAZEO hydrocortisone § Nonselective latanoprost § ANTI-INFECTIVE / sulfacetamide-prednisolone travoprost (generic § ANTI-INFECTIVES levobunolol ANTI-INFLAMMATORY phosphate 10%/0.25% timolol maleate solution TRAVATAN Z) bacitracin tobramycin-dexamethasone COMBINATIONS BETIMOL ciprofloxacin suspension 0.3%/0.1% RETINAL DISORDERS ciprofloxacin-dexamethasone erythromycin ZYLET Selective EYLEA (generic CIPRODEX) gentamicin neomycin-polymyxin B- BETOPTIC S LUCENTIS levofloxacin ANTI-INFLAMMATORIES hydrocortisone moxifloxacin (generic § Nonsteroidal § CARBONIC ANHYDRASE RHO KINASE INHIBITORS MOXEZA, VIGAMOX) bromfenac INHIBITORS RHOPRESSA neomycin-polymyxin B- diclofenac dorzolamide RHO KINASE INHIBITOR / gramicidin ketorolac AZOPT PROSTAGLANDIN ofloxacin ACUVAIL COMBINATIONS polymyxin B-bacitracin ILEVRO § CARBONIC ANHYDRASE polymyxin B-trimethoprim INHIBITOR / BETA- ROCKLATAN sulfacetamide ointment, § Steroidal BLOCKER COMBINATIONS § SYMPATHOMIMETICS solution 10% dexamethasone dorzolamide-timolol tobramycin fluorometholone brimonidine 0.15%, 0.2% BESIVANCE loteprednol (generic CARBONIC ANHYDRASE ALPHAGAN P 0.1%

LOTEMAX) INHIBITOR / § ANTI-INFECTIVE / SYMPATHOMIMETIC / BETA- prednisolone acetate 1% SYMPATHOMIMETIC ANTI-INFLAMMATORY BLOCKER COMBINATIONS FML FORTE COMBINATIONS COMBINATIONS COMBIGAN SIMBRINZA FML S.O.P. neomycin-polymyxin B- PRED MILD OTIC bacitracin-hydrocortisone DRY EYE DISEASE § ANTI-INFECTIVES neomycin-polymyxin B- § ANTIVIRALS RESTASIS dexamethasone trifluridine XIIDRA acetic acid

QUICK REFERENCE DRUG LIST

A alosetron (generic armodafinil (generic betamethasone valerate bupropion ext-rel (except LOTRONEX) NUVIGIL) PA BETASERON SGM bupropion ext-rel tablet 450 mg) ABILIFY MAINTENA abiraterone (generic ALPHAGAN P 0.1% ARNUITY ELLIPTA bethanechol buspirone alprazolam ASMANEX BETHKIS B4G, SGM butalbital-acetaminophen- ZYTIGA) SGM ALUNBRIG SGM atenolol BETIMOL caffeine acarbose amantadine atenolol-chlorthalidone BETOPTIC S butalbital-aspirin-caffeine acetazolamide ambrisentan (generic atomoxetine (generic BEVESPI AEROSPHERE BYSTOLIC * acetazolamide ext-rel LETAIRIS) SGM STRATTERA) BIDIL acetic acid amiloride atorvastatin BIKTARVY C acitretin amiloride-hydrochlorothiazide atovaquone bisoprolol cabergoline ACUVAIL amiodarone atovaquone-proguanil bisoprolol- CABOMETYX SGM acyclovir AMITIZA AUBAGIO SGM hydrochlorothiazide calcipotriene ointment, adapalene (except adapalene pads or amitriptyline AUSTEDO SGM bosentan (generic solution adapalene solution) PA amlodipine azelaic acid (generic TRACLEER) SGM calcitonin-salmon ADDERALL XR B4G amlodipine-benazepril FINACEA GEL) BOSULIF SGM calcitriol (1,25-D3) ADEMPAS SGM † amlodipine-olmesartan azelastine BREO ELLIPTA calcium acetate ADVAIR DISKUS B4G (generic AZOR) azithromycin BRILINTA candesartan ADVAIR HFA † ammonium lactate 12% AZOPT brimonidine 0.15%, 0.2% candesartan- ADYNOVATE amoxicillin bromfenac hydrochlorothiazide AIMOVIG amoxicillin-clavulanate B bromocriptine CAPEX SHAMPOO AJOVY albendazole (generic amoxicillin-clavulanate ext-rel bacitracin budesonide delayed-rel captopril amphetamine- baclofen capsule captopril-hydrochlorothiazide ALBENZA) QL/PA dextroamphetamine mixed balsalazide budesonide ext-rel tabs carbamazepine albuterol salts BARACLUDE SOLUTION (generic UCERIS) carbamazepine ext-rel albuterol ext-rel ampicillin BELBUCA QL/PA budesonide inhalation carbidopa-levodopa albuterol inhalation solution anagrelide suspension albuterol sulfate CFC-free BELSOMRA carbidopa-levodopa ext-rel ANDRODERM budesonide-formoterol aerosol (generic PROAIR benazepril carbidopa-levodopa- ANORO ELLIPTA benazepril- (generic SYMBICORT) entacapone HFA) APOKYN SGM hydrochlorothiazide bumetanide carisoprodol 350 mg alclometasone ARALAST NP SGM benzonatate buprenorphine transdermal carvedilol ALECENSA SGM ARANESP SGM benzoyl peroxide (generic BUTRANS) CAYSTON SGM alendronate ARCAPTA benztropine QL/PA cefadroxil alfuzosin ext-rel aripiprazole (generic BESIVANCE buprenorphine-naloxone cefdinir ALINIA SUSPENSION ABILIFY) sublingual tablet aliskiren (generic betamethasone dipropionate cefixime (generic SUPRAX) ARISTADA betamethasone dipropionate bupropion cefprozil TEKTURNA) ARISTADA INITIO augmented bupropion ext-rel cefuroxime axetil allopurinol

celecoxib (generic CONDYLOX GEL dipyridamole ERLEADA SGM FIASP CELEBREX) CONTRAVE PA dipyridamole ext-rel-aspirin erythromycin FINACEA FOAM cephalexin COPAXONE SGM disopyramide erythromycin delayed-rel finasteride CERDELGA SGM CORLANOR disulfiram erythromycin ethylsuccinate flecainide CEREZYME SGM CORTIFOAM divalproex sodium erythromycin solution FLOVENT DISKUS CETROTIDE SGM COSENTYX SGM divalproex sodium ext-rel erythromycin stearate FLOVENT HFA cevimeline CREON DIVIGEL erythromycin-benzoyl fluconazole CHANTIX * CRINONE dofetilide (generic TIKOSYN) peroxide fludrocortisone CHEMET cromolyn inhalation solution SGM ESBRIET SGM flunisolide chlordiazepoxide-clidinium cromolyn sodium donepezil escitalopram fluocinolone chloroquine crotamiton dorzolamide estradiol fluocinonide (except fluocinonide chlorpromazine cyclobenzaprine (except dorzolamide-timolol estradiol vaginal cream cream 0.1%) chlorthalidone cyclobenzaprine tablet 7.5 mg) DOVATO (generic ESTRACE) fluorometholone chlorzoxazone 375 mg cyproheptadine doxazosin estradiol vaginal tablet fluorouracil cholestyramine doxepin (generic SILENOR) (generic VAGIFEM) fluoxetine (except fluoxetine tablet 60 chorionic gonadotropin - D doxepin (generic estradiol-norethindrone mg, fluoxetine tablet [generics for novarel SGM dalfampridine ext-rel (generic SINEQUAN) ESTRING SARAFEM]) ciclopirox AMPYRA) SGM doxycycline hyclate eszopiclone fluphenazine cilostazol DALIRESP doxycycline monohydrate ethambutol fluticasone CIMDUO danazol (generic ORACEA) ethinyl estradiol-desogestrel fluvastatin cimetidine dantrolene doxylamine-pyridoxine ethinyl estradiol- fluvoxamine cinacalcet (generic dapsone delayed-rel (generic drospirenone FML FORTE SENSIPAR) SGM deferasirox (generic DICLEGIS) ethinyl estradiol- FML S.O.P. ciprofloxacin EXJADE) SGM dronabinol drospirenone-levomefolate folic acid ciprofloxacin-dexamethasone DENAVIR DUAVEE (generic BEYAZ, folic acid-vitamin B6-vitamin (generic CIPRODEX) DEPO-SUBQ PROVERA DULERA SAFYRAL) B12 citalopram DESCOVY duloxetine ethinyl estradiol-ethynodiol FOLTX CITRANATAL desipramine DUPIXENT SGM diacetate fondaparinux clarithromycin desmopressin spray, tablet DUROLANE ethinyl estradiol-etonogestrel FORTEO SGM clarithromycin ext-rel desonide dutasteride (generic (generic NUVARING) fosinopril clemastine 2.68 mg desoximetasone AVODART) ethinyl estradiol- fosinopril-hydrochlorothiazide CLEOCIN SUPPOSITORY dexamethasone dutasteride-tamsulosin levonorgestrel FRAGMIN CLIMARA PRO DEXILANT (generic JALYN) ethinyl estradiol- furosemide clindamycin dexmethylphenidate norelgestromin FYCOMPA clindamycin gel, solution dexmethylphenidate ext-rel E ethinyl estradiol- clindamycin-benzoyl dexmethylphenidate ext-rel econazole norethindrone G peroxide (generic (generic FOCALIN XR) efavirenz-lamivudine- ethinyl estradiol- gabapentin ACANYA, BENZACLIN) dextroamphetamine tenofovir disoproxil norethindrone acetate galantamine clobetasol, except shampoo dextroamphetamine ext-rel fumarate (generic SYMFI, ethinyl estradiol- galantamine ext-rel clomiphene dextromethorphan- SYMFI LO) norethindrone acetate ganirelix acetate (generic clomipramine brompheniramine- eletriptan (generic RELPAX) (generic MINASTRIN 24 GANIRELIX) SGM clonazepam tablet pseudoephedrine QL/PA FE) GELSYN-3 clonidine dextromethorphan- ELIGARD SGM ethinyl estradiol-norgestimate gemfibrozil clonidine transdermal promethazine ELIQUIS ethinyl estradiol-norgestrel GENOTROPIN SGM clopidogrel diazepam ELIXOPHYLLIN ethosuximide gentamicin clotrimazole diazepam rectal gel ELMIRON etodolac GENVOYA clotrimazole troches diazoxide (generic EMGALITY EUCRISA GILENYA SGM clozapine PROGLYCEM) emtricitabine-tenofovir EVAMIST glatiramer (generic COARTEM diclofenac disoproxil fumarate EVOTAZ COPAXONE) SGM codeine-acetaminophen QL diclofenac sodium (generic TRUVADA) EYLEA glimepiride codeine-chlorpheniramine- diclofenac sodium gel 1% EMVERM ezetimibe (generic ZETIA) glipizide pseudoephedrine (generic VOLTAREN GEL) enalapril ezetimibe-simvastatin glipizide ext-rel codeine-guaifenesin liquid diclofenac sodium- enalapril-hydrochlorothiazide (generic VYTORIN) glipizide-metformin codeine-guaifenesin- misoprostol ENBREL SGM GLUCAGEN HYPOKIT pseudoephedrine dicloxacillin ENDOMETRIN F GLUCAGON EMERGENCY codeine-promethazine dicyclomine enoxaparin famciclovir KIT codeine-promethazine- DIFICID entacapone famotidine GLYXAMBI phenylephrine diflorasone cream entecavir tablet FASENRA SGM GONAL-F SGM colchicine tablet (generic diflorasone ointment ENTRESTO febuxostat (generic ULORIC) GONAL-F RFF SGM COLCRYS) diflunisal EPCLUSA SGM felodipine ext-rel GRALISE COLCRYS digoxin EPIFOAM fenofibrate (except fenofibrate tablet granisetron colesevelam (generic digoxin pediatric elixir epinephrine auto-injector 120 mg) griseofulvin ultramicrosize WELCHOL) dihydroergotamine injection EPIPEN fenofibric acid delayed-rel guanfacine colestipol DILANTIN 30 MG EPIPEN JR fentanyl citrate (generic guanfacine ext-rel (generic COMBIGAN diltiazem ext-rel EPIVIR-HBV SOLUTION FENTORA) PA/QL INTUNIV) COMBIPATCH dimethyl fumarate (generic eplerenone fentanyl transdermal QL/PA COMBIVENT RESPIMAT TECFIDERA) SGM EPOGEN SGM fentanyl transmucosal H CONCERTA B4G diphenoxylate-atropine ERIVEDGE SGM lozenge PA/QL H.P. ACTHAR SGM

halobetasol isotretinoin LUCENTIS N hydrochlorothiazide haloperidol itraconazole PA luliconazole (generic LUZU) (generic TRIBENZOR) nabumetone HARVONI SGM ivermectin (generic LUPRON DEPOT SGM olmesartan- nadolol HUMATROPE SGM STROMECTOL) LYNPARZA SGM hydrochlorothiazide naftifine cream 2%, gel 1% HUMIRA SGM (generic BENICAR HCT) (generic NAFTIN) HUMULIN R U-500 J M olopatadine NAFTIN GEL 2% HYALGAN JANUMET malathion omega-3 acid ethyl esters naloxone injection hydralazine JANUMET XR MARPLAN omeprazole delayed-rel naltrexone hydrochlorothiazide JANUVIA MAYZENT ondansetron NAMZARIC hydrocodone ext-rel (generic JARDIANCE meclizine OPSUMIT SGM naproxen (except naproxen CR or ZOHYDRO ER) QL/PA JENTADUETO medroxyprogesterone ORILISSA naproxen suspension) hydrocodone-acetaminophen JENTADUETO XR medroxyprogesterone orphenadrine-aspirin-caffeine naproxen sodium (except hydrocodone-acetaminophen JIVI acetate 150 mg/mL oseltamivir (generic naratriptan QL/PA tablet 7.5-300 mg or hydrocodone- JUBLIA PA mefloquine TAMIFLU) QL/PA NARCAN NASAL SPRAY acetaminophen tablet 10-300 mg) meloxicam OSPHENA NASCOBAL QL/PA K memantine (generic OTEZLA SGM NATAZIA hydrocodone-homatropine NAMENDA) OTREXUP SGM ketoconazole (except ketoconazole nateglinide hydrocortisone OVIDREL SGM foam) mesalamine delayed-rel neomycin-polymyxin B- hydrocortisone butyrate (generic LIALDA) oxaprozin ketorolac bacitracin-hydrocortisone cream, lotion, ointment, oxazepam KISQALI SGM mesalamine ext-rel (generic neomycin-polymyxin B- solution APRISO) oxcarbazepine KISQALI FEMARA CO- dexamethasone hydrocortisone enema OXTELLAR XR PACK SGM mesalamine suppository neomycin-polymyxin B- hydrocortisone valerate (generic CANASA) oxybutynin KOGENATE FS gramicidin hydromorphone QL/PA oxybutynin ext-rel KOVALTRY mesalamine suspension neomycin-polymyxin B- hydromorphone ext-rel metaxalone oxycodone QL/PA KYLEENA hydrocortisone QL/PA metformin oxycodone-acetaminophen NEULASTA SGM hydroxychloroquine L metformin ext-rel (generic QL/PA NEUPRO hydroxyzine HCl GLUCOPHAGE XR) OXYCONTIN QL/PA labetalol niacin ext-rel hyoscyamine sulfate lactulose solution methadone QL/PA OZEMPIC NICOTROL hyoscyamine sulfate ext-rel methazolamide lamivudine tablet NICOTROL NS hyoscyamine sulfate orally methimazole P lamotrigine nifedipine ext-rel disintegrating tablet methocarbamol pantoprazole delayed-rel lamotrigine ext-rel NINLARO SGM HYSINGLA ER QL/PA lamotrigine orally methotrexate paricalcitol (generic nitazoxanide (generic methoxsalen ZEMPLAR) disintegrating tablet ALINIA) I methyldopa PARLODEL 5 MG (generic LAMICTAL ODT) nitrofurantoin ibandronate methylphenidate paroxetine HCl lansoprazole delayed-rel nitrofurantoin ext-rel IBRANCE SGM methylphenidate ext-rel paroxetine HCl ext-rel LANTUS nitroglycerin lingual spray ibuprofen LASTACAFT methylprednisolone nitroglycerin sublingual tablet paroxetine mesylate (generic ICLUSIG SGM metoclopramide BRISDELLE) latanoprost (generic NITROSTAT) icosapent ethyl (generic metolazone PAZEO LATUDA nitroglycerin transdermal VASCEPA) metoprolol succinate ext-rel peg 3350-electrolytes leflunomide NIVESTYM SGM ILARIS SGM metoprolol tartrate PEGASYS SGM levalbuterol inhalation norethindrone ILEVRO metoprolol- penicillin VK solution nortriptyline imatinib mesylate SGM hydrochlorothiazide pentamidine (generic LEVEMIR NOVOEIGHT imipramine HCl metronidazole NEBUPENT) levetiracetam NOVOLIN 70/30 imiquimod midodrine PENTASA levetiracetam ext-rel NOVOLIN N indapamide minocycline PERFOROMIST * levobunolol NOVOLIN R INGREZZA SGM MIRENA perindopril levocarnitine NOVOLOG INTRON A SGM mirtazapine permethrin 5% levocetirizine NOVOLOG MIX 70/30 INVEGA SUSTENNA levofloxacin MIRVASO NOXAFIL INJECTION, perphenazine INVEGA TRINZA misoprostol phenazopyridine levothyroxine SUSPENSION INVOKAMET modafinil PA phenelzine lidocaine viscous NUCALA SGM INVOKAMET XR mometasone phenobarbital lidocaine-prilocaine QL/PA NUCYNTA QL/PA INVOKANA montelukast phenoxybenzamine (generic LINZESS NUCYNTA ER QL/PA ipratropium inhalation morphine QL/PA DIBENZYLINE) liothyronine NUEDEXTA solution morphine ext-rel QL/PA phenytoin lisinopril NURTEC ODT ipratropium spray morphine suppository QL/PA phenytoin sodium extended lisinopril-hydrochlorothiazide NUWIQ ipratropium-albuterol MOVANTIK PHOSLYRA lithium carbonate nystatin inhalation solution lithium carbonate ext-rel moxifloxacin (generic phytonadione (generic irbesartan LO LOESTRIN FE MOXEZA, VIGAMOX) O MEPHYTON) irbesartan- MOZOBIL SGM PICATO LOKELMA ODEFSEY hydrochlorothiazide MUGARD pilocarpine tablet loperamide OFEV SGM IRESSA SGM MULPLETA pimecrolimus (generic lorazepam ofloxacin isoniazid MULTAQ ELIDEL) losartan ofloxacin otic isosorbide dinitrate mupirocin pimozide losartan-hydrochlorothiazide olanzapine isosorbide mononitrate loteprednol (generic MUSE QL olmesartan (generic pindolol isosorbide mononitrate ext- MYDAYIS pioglitazone LOTEMAX) BENICAR) rel lovastatin MYRBETRIQ pioglitazone-glimepiride olmesartan-amlodipine-

pioglitazone-metformin ramipril SORILUX timolol maleate solution valproic acid podofilox ranolazine ext-rel (generic sotalol tinidazole valsartan polyethylene glycol 3350 RANEXA) SOVALDI SGM tizanidine tablet valsartan-hydrochlorothiazide polymyxin B-bacitracin rasagiline (generic AZILECT) SPIRIVA tobramycin vancomycin polymyxin B-trimethoprim RASUVO SGM spironolactone tobramycin inhalation VARUBI potassium citrate ext-rel RAYOS spironolactone- solution (generic KITABIS, VASCEPA PRALUENT PA REBIF SGM hydrochlorothiazide TOBI) SGM VELCADE SGM pramipexole REBINYN SPRYCEL SGM tobramycin-dexamethasone VELETRI SGM pramipexole ext-rel (generic REGRANEX STELARA SGM suspension 0.3%/0.1% VELPHORO MIRAPEX ER) RELENZA QL/PA STIOLTO RESPIMAT tolterodine VELTASSA prasugrel (generic EFFIENT) repaglinide STRIVERDI RESPIMAT tolterodine ext-rel VEMLIDY pravastatin REPATHA PA SUBSYS PA/QL tolvaptan (generic SAMSCA) venlafaxine praziquantel (generic RESTASIS sucralfate tablet SGM venlafaxine ext-rel BILTRICIDE) QL/PA RETACRIT SGM sulfacetamide lotion 10% topiramate VENTAVIS SGM PRED MILD REVLIMID SGM sulfacetamide ointment, torsemide verapamil ext-rel prednisolone acetate 1% RHOPRESSA solution 10% TOUJEO VERZENIO SGM prednisolone sodium ribavirin SGM sulfacetamide-prednisolone TOVIAZ VIBERZI phosphate rifampin phosphate 10%/0.25% TRADJENTA VIBRAMYCIN SYRUP prednisolone syrup RINVOQ SGM sulfamethoxazole- tramadol QL/PA VICTOZA prednisone risedronate trimethoprim tramadol ext-rel QL/PA VIIBRYD PREFEST RISPERDAL CONSTA sulfasalazine trandolapril VIMPAT pregabalin (generic LYRICA) risperidone sulfasalazine delayed-rel trandolapril-verapamil ext-rel VIOKACE PREMARIN rivastigmine sulindac (generic TARKA) VITRAKVI SGM PREMARIN CREAM rivastigmine transdermal sumatriptan injection QL/PA tranylcypromine VIVITROL SGM PREMPHASE (generic EXELON PATCH) sumatriptan nasal spray travoprost (generic voriconazole ◊ PREMPRO rizatriptan QL QL/PA TRAVATAN Z) VOSEVI , SGM prenatal vitamins ROCKLATAN sumatriptan tablet QL/PA trazodone VRAYLAR PRIFTIN ropinirole SUNOSI TRECATOR VUMERITY SGM primidone rosuvastatin (generic SUPARTZ FX TRELEGY ELLIPTA VYVANSE PROAIR HFA CRESTOR) SUPRAX SUSPENSION 500 TREMFYA SGM PROAIR RESPICLICK RUBRACA SGM MG/5 ML, TABLET treprostinil (generic W probenecid RUCONEST SGM SUPREP REMODULIN) SGM warfarin prochlorperazine RYBELSUS SYMLINPEN TRESIBA PROCTOFOAM-HC RYDAPT SGM SYMTUZA tretinoin PA X progesterone, micronized RYTARY SYNAREL tretinoin gel microsphere PA XARELTO PROLASTIN-C SGM SYNJARDY triamcinolone XELJANZ SGM PROMACTA SGM S SYNJARDY XR triamcinolone cream, lotion, XELJANZ XR SGM promethazine ointment SANCUSO XIFAXAN 550 MG propafenone T triamcinolone paste SANDOSTATIN LAR SGM XIIDRA propafenone ext-rel triamterene sapropterin (generic KUVAN) tacrolimus (generic XOLAIR SGM propranolol triamterene- SGM PROTOPIC) XTAMPZA ER QL/PA propranolol ext-rel hydrochlorothiazide SAVELLA tadalafil (generic CIALIS) XTANDI SGM propylthiouracil trifluoperazine SAXENDA PA QL/PA XULTOPHY PULMICORT FLEXHALER selegiline tamsulosin trifluridine PULMOZYME SGM SEREVENT TASIGNA SGM trihexyphenidyl Y PYLERA SEROSTIM SGM tazarotene (generic trimethobenzamide YONSA SGM pyrazinamide sertraline TAZORAC) PA trimethoprim pyridostigmine (generic sevelamer carbonate TEKTURNA HCT TRINTELLIX Z MESTINON) (generic RENVELA) telmisartan TRIUMEQ zafirlukast pyridostigmine ext-rel SIGNIFOR LAR SGM telmisartan- TROKENDI XR ZEJULA SGM (generic MESTINON sildenafil 20 mg SGM hydrochlorothiazide trospium ZELAPAR TIMESPAN) sildenafil (generic VIAGRA) temazepam trospium ext-rel ZEMBRACE SYMTOUCH pyrimethamine (generic QL terazosin TRULICITY ZENPEP DARAPRIM) silodosin (generic RAPAFLO) terbinafine tablet PA TRUVADA ziprasidone silver sulfadiazine terbutaline TYMLOS SGM zolmitriptan QL/PA Q SIMBRINZA terconazole TYSABRI SGM zolpidem QTERN simvastatin testosterone cypionate TYVASO SGM zolpidem ext-rel QUDEXY XR SIVEXTRO testosterone enanthate ZOMIG NASAL SPRAY quetiapine SKYLA testosterone solution U QL/PA quetiapine ext-rel (generic SKYRIZI SGM tetrabenazine (generic UDENYCA SGM zonisamide SEROQUEL XR) solifenacin (generic XENAZINE) UPTRAVI SGM ZORBTIVE SGM quinapril VESICARE) tetracycline ursodiol ZUBSOLV quinapril-hydrochlorothiazide SOLIQUA TEXACORT SOLUTION V ZYLET QVAR REDIHALER SOLIRIS SGM THEO-24

SOMATULINE DEPOT SGM theophylline ext-rel tablet valacyclovir R SOMAVERT SGM thiothixene valganciclovir (generic raloxifene SOOLANTRA tiagabine VALCYTE)

LIST OF LEVEL 3 OR NON-PREFERRED DRUGS DRUG NAME(S) PREFERRED ALTERNATIVE(S) + DRUG NAME(S) PREFERRED ALTERNATIVE(S) + ADCIRCA SGM sildenafil 20 mg SGM KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR ALVESCO ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER LEVITRA QL sildenafil (generic VIAGRA) QL, tadalafil (generic CIALIS) QL/PA ALREX azelastine, cromolyn sodium, loteprednol (generic LOTEMAX), olopatadine, LASTACAFT, PAZEO LIVALO atorvastatin, ezetimibe-simvastatin (generic VYTORIN), fluvastatin, lovastatin, pravastatin, rosuvastatin (generic CRESTOR), ANTARA fenofibrate (except fenofibrate tablet 120 mg), simvastatin fenofibric acid delayed-rel MAVENCLAD dimethyl fumarate (generic TECFIDERA) SGM, glatiramer (generic AVONEX SGM dimethyl fumarate (generic TECFIDERA) SGM, glatiramer (generic COPAXONE) SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE) SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE SGM, GILENYA SGM, MAYZENT, REBIF SGM, COPAXONE SGM, GILENYA SGM, MAYZENT, REBIF SGM, TYSABRI SGM TYSABRI SGM MENTAX ciclopirox, clotrimazole, econazole, ketoconazole (except AZELEX adapalene (except adapalene pads or adapalene solution) PA, ketoconazole foam) benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), NESINA JANUVIA, TRADJENTA erythromycin solution, erythromycin-benzoyl peroxide, tazarotene OMNARIS flunisolide, fluticasone, mometasone (generic NASONEX), (generic TAZORAC) PA, tretinoin PA, tretinoin gel microsphere PA triamcinolone BECONASE AQ flunisolide, fluticasone, mometasone (generic NASONEX), ONGLYZA JANUVIA, TRADJENTA triamcinolone OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR BENZACLIN clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN) OXISTAT ciclopirox, clotrimazole, econazole, ketoconazole (except BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA ketoconazole foam), nystatin BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA PRADAXA ELIQUIS, XARELTO CARDIZEM LA diltiazem ext-rel PULMICORT budesonide inhalation suspension CARDURA XL alfuzosin ext-rel, doxazosin, silodosin (generic RAPAFLO), 1 MG/2 ML tamsulosin, terazosin INHALATION SUSPENSION CIALIS QL/PA sildenafil (generic VIAGRA) QL, tadalafil (generic CIALIS) QL/PA QNASL flunisolide, fluticasone, mometasone (generic NASONEX), DAYTRANA dexmethylphenidate ext-rel (generic FOCALIN XR), triamcinolone dextroamphetamine ext-rel, methylphenidate ext-rel, ADDERALL XR B4G, CONCERTA B4G, MYDAYIS, VYVANSE QSYMIA PA CONTRAVE PA, SAXENDA PA DIPENTUM balsalazide, mesalamine delayed-rel (generic LIALDA), RELISTOR MOVANTIK mesalamine ext-rel (generic APRISO), sulfasalazine, REYVOW eletriptan (generic RELPAX) QL/PA, naratriptan QL/PA, sulfasalazine delayed-rel, PENTASA rizatriptan QL, sumatriptan injection QL/PA, DUREZOL dexamethasone, fluorometholone, loteprednol (generic sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, LOTEMAX), prednisolone acetate 1%, FML FORTE, FML S.O.P., zolmitriptan QL/PA, NURTEC ODT, ZEMBRACE SYMTOUCH, PRED MILD ZOMIG NASAL SPRAY QL/PA EDARBI, candesartan, candesartan-hydrochlorothiazide, irbesartan, ROZEREM eszopiclone, zolpidem, zolpidem ext-rel EDARBYCLOR irbesartan-hydrochlorothiazide, losartan, losartan- SIMPONI SGM COSENTYX SGM, ENBREL SGM, HUMIRA SGM, OTEZLA SGM, hydrochlorothiazide, olmesartan (generic BENICAR), olmesartan- RINVOQ SGM, STELARA SGM, TREMFYA SGM, XELJANZ SGM, hydrochlorothiazide (generic BENICAR HCT), XELJANZ XR SGM telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan- hydrochlorothiazide STAXYN QL sildenafil (generic VIAGRA) QL, tadalafil (generic CIALIS) QL/PA EDEX QL MUSE QL TRANSDERM-SCOP meclizine ENABLEX oxybutynin ext-rel, solifenacin (generic VESICARE), tolterodine, TUDORZA PRESSAIR SPIRIVA tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ UBRELVY eletriptan (generic RELPAX) QL/PA, naratriptan QL/PA, rizatriptan QL, sumatriptan injection QL/PA, FARXIGA INVOKANA, JARDIANCE sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, zolmitriptan QL/PA, NURTEC ODT, ZEMBRACE SYMTOUCH, FOSRENOL calcium acetate, sevelamer carbonate (generic RENVELA), ZOMIG NASAL SPRAY QL/PA PHOSLYRA, VELPHORO VIEKIRA PAK SGM EPCLUSA SGM, HARVONI SGM FROVA QL eletriptan (generic RELPAX) QL/PA, naratriptan QL/PA, rizatriptan QL, sumatriptan nasal spray QL/PA, ZETONNA flunisolide, fluticasone, mometasone (generic NASONEX), sumatriptan tablet QL/PA, zolmitriptan QL/PA, triamcinolone ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY QL/PA

GELNIQUE oxybutynin ext-rel, solifenacin (generic VESICARE), tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ

LIST OF EXCLUDED DRUGS ++ DRUG NAME(S) PREFERRED ALTERNATIVE(S) + DRUG NAME(S) PREFERRED ALTERNATIVE(S) + ACTICLATE doxycycline hyclate CAFERGOT dihydroergotamine injection, eletriptan (generic RELPAX) QL/PA, naratriptan QL/PA, rizatriptan QL, sumatriptan injection QL/PA, acyclovir cream acyclovir oral, famciclovir, valacyclovir sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, adapalene pads, adapalene (except adapalene pads or adapalene solution) PA, zolmitriptan QL/PA, NURTEC ODT, ZEMBRACE SYMTOUCH, adapalene solution benzoyl peroxide, clindamycin gel, clindamycin solution, ZOMIG NASAL SPRAY QL/PA clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), calcipotriene cream calcipotriene ointment, calcipotriene solution erythromycin solution, erythromycin-benzoyl peroxide, sulfacetamide lotion 10%, tazarotene (generic TAZORAC) PA, CAMBIA diclofenac sodium, meloxicam, naproxen (except naproxen CR tretinoin PA, tretinoin gel microsphere PA or naproxen suspension) ADMELOG FIASP, NOVOLOG CARAC fluorouracil, imiquimod, PICATO ADRENACLICK epinephrine auto-injector, EPIPEN, EPIPEN JR CARAFATE sucralfate tablet AFREZZA FIASP, NOVOLIN R, NOVOLOG CARBINOXAMINE clemastine 2.68 mg, cyproheptadine, hydroxyzine HCl, TABLET 6 MG levocetirizine ALTOPREV atorvastatin, ezetimibe-simvastatin (generic VYTORIN), fluvastatin, lovastatin, pravastatin, rosuvastatin (generic CRESTOR), carisoprodol 250 mg carisoprodol 350 mg simvastatin CARNITOR, levocarnitine amlodipine-atorvastatin amlodipine WITH atorvastatin CARNITOR SF amphetamine- ADDERALL XR B4G CENTANY AT mupirocin dextroamphetamine mixed salts ext-rel chlorzoxazone (except carisoprodol 350 mg, cyclobenzaprine (except cyclobenzaprine chlorzoxazone 375 mg) tablet 7.5 mg), metaxalone, methocarbamol, AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) orphenadrine-aspirin-caffeine ANDROGEL testosterone solution, ANDRODERM CLINDACIN ETZ clindamycin gel, clindamycin solution, erythromycin solution APEXICON E betamethasone dipropionate, desoximetasone, fluocinonide CLINDACIN PAC clindamycin gel, clindamycin solution, erythromycin solution (except fluocinonide cream 0.1%) CLINDAGEL clindamycin gel, clindamycin solution, erythromycin solution APIDRA, APIDRA FIASP, NOVOLOG SOLOSTAR clobetasol shampoo clobetasol foam, clobetasol solution APLENZIN bupropion, bupropion ext-rel (except bupropion ext-rel tablet CLOBEX SHAMPOO clobetasol foam, clobetasol solution 450 mg) CLODAN KIT clobetasol foam, clobetasol solution ARAZLO adapalene (except adapalene pads or adapalene solution) PA, clodan shampoo clobetasol foam, clobetasol solution benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), COLAZAL balsalazide, mesalamine delayed-rel (generic LIALDA), erythromycin solution, erythromycin-benzoyl peroxide, mesalamine ext-rel (generic APRISO), sulfasalazine, sulfacetamide lotion 10%, tazarotene (generic TAZORAC) PA, sulfasalazine delayed-rel, PENTASA tretinoin PA, tretinoin gel microsphere PA CONSENSI amlodipine WITH celecoxib (generic CELEBREX) ARICEPT 23 MG donepezil, galantamine, galantamine ext-rel, memantine (generic NAMENDA), rivastigmine, NAMZARIC CONZIP tramadol QL/PA, tramadol ext-rel QL/PA ASACOL HD balsalazide, mesalamine delayed-rel (generic LIALDA), CORDRAN OINTMENT betamethasone valerate, fluticasone, mesalamine ext-rel (generic APRISO), sulfasalazine, hydrocortisone butyrate cream, hydrocortisone butyrate lotion, sulfasalazine delayed-rel, PENTASA hydrocortisone butyrate ointment, hydrocortisone butyrate solution, hydrocortisone valerate, mometasone, triamcinolone cream, ATELVIA alendronate, ibandronate, risedronate triamcinolone lotion, triamcinolone ointment AUVI-Q epinephrine auto-injector, EPIPEN, EPIPEN JR COREG CR atenolol, bisoprolol, carvedilol, labetalol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, AVIDOXY DK doxycycline hyclate propranolol, propranolol ext-rel, BYSTOLIC * BASAGLAR LANTUS, LEVEMIR, TOUJEO, TRESIBA coremino doxycycline hyclate, minocycline, tetracycline, BETAPACE, sotalol VIBRAMYCIN SYRUP BETAPACE AF COSOPT PF dorzolamide-timolol, latanoprost, travoprost (generic BINOSTO alendronate, ibandronate, risedronate TRAVATAN Z) BRAVELLE GONAL-F SGM, GONAL-F RFF SGM cyclobenzaprine ext-rel, carisoprodol 350 mg, cyclobenzaprine (except cyclobenzaprine cyclobenzaprine tablet tablet 7.5 mg), metaxalone, methocarbamol, BUNAVAIL buprenorphine-naloxone sublingual tablet, ZUBSOLV 7.5 mg orphenadrine-aspirin-caffeine buprenorphine- buprenorphine-naloxone sublingual tablet, ZUBSOLV DELZICOL balsalazide, mesalamine delayed-rel (generic LIALDA), naloxone sublingual mesalamine ext-rel (generic APRISO), sulfasalazine, film sulfasalazine delayed-rel, PENTASA bupropion ext-rel bupropion, bupropion ext-rel (except bupropion ext-rel tablet DESVENLAFAXINE ER duloxetine, venlafaxine, venlafaxine ext-rel tablet 450 mg 450 mg) dihydroergotamine dihydroergotamine injection, eletriptan (generic RELPAX) QL/PA, CADUET amlodipine WITH atorvastatin spray naratriptan QL/PA, rizatriptan QL, sumatriptan injection QL/PA, sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, zolmitriptan QL/PA, NURTEC ODT, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY QL/PA

DRUG NAME(S) PREFERRED ALTERNATIVE(S) + DRUG NAME(S) PREFERRED ALTERNATIVE(S) + DIOVAN HCT candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, fenoprofen tablet diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide 600 mg, nabumetone, naproxen (except naproxen CR or naproxen (generic BENICAR HCT), telmisartan-hydrochlorothiazide, FENOPROFEN suspension), naproxen sodium, oxaprozin, sulindac valsartan-hydrochlorothiazide CAPSULE DORYX doxycycline hyclate fexmid carisoprodol 350 mg, cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxalone, methocarbamol, dorzolamide-timolol pf dorzolamide-timolol, latanoprost, travoprost (generic orphenadrine-aspirin-caffeine TRAVATAN Z) FLECTOR diclofenac sodium, diclofenac sodium gel 1% (generic doxycycline hyclate ext- doxycycline hyclate VOLTAREN GEL), meloxicam, naproxen (except naproxen CR rel tablet or naproxen suspension) doxycycline doxycycline hyclate flucytosine capsule fluconazole, voriconazole monohydrate 150 mg 500 mg capsule fluocinonide cream betamethasone dipropionate augmented, DUEXIS celecoxib (generic CELEBREX); diclofenac sodium, meloxicam or 0.1% clobetasol (except clobetasol shampoo), halobetasol naproxen (except naproxen CR or naproxen suspension) WITH lansoprazole delayed-rel, omeprazole delayed-rel, FLUOROPLEX fluorouracil, imiquimod, PICATO pantoprazole delayed-rel or DEXILANT fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide (generics for [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline SARAFEM only) DYMISTA flunisolide, fluticasone, mometasone (generic NASONEX) or triamcinolone WITH azelastine fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, DYRENIUM amiloride, triamterene paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD EDLUAR eszopiclone, zolpidem, zolpidem ext-rel flurandrenolide lotion alclometasone, desonide, fluocinolone, E.E.S. GRANULES erythromycin delayed-rel, erythromycin ethylsuccinate, hydrocortisone topical, TEXACORT SOLUTION erythromycin stearate flurandrenolide betamethasone valerate, fluticasone, EPIDUO, adapalene (except adapalene pads or adapalene solution) PA, ointment hydrocortisone butyrate cream, hydrocortisone butyrate lotion, EPIDUO FORTE benzoyl peroxide, clindamycin gel, clindamycin solution, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), hydrocortisone valerate, mometasone, triamcinolone cream, erythromycin solution, erythromycin-benzoyl peroxide, triamcinolone lotion, triamcinolone ointment tazarotene (generic TAZORAC) PA, tretinoin PA, fluticasone-salmeterol ADVAIR DISKUS B4G tretinoin gel microsphere PA FML LIQUIFILM dexamethasone, fluorometholone, loteprednol (generic ergotamine-caffeine dihydroergotamine injection, eletriptan (generic RELPAX) QL/PA, LOTEMAX), prednisolone acetate 1%, FML FORTE, FML S.O.P., naratriptan QL/PA, rizatriptan QL, sumatriptan injection QL/PA, PRED MILD sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, zolmitriptan QL/PA, NURTEC ODT, ZEMBRACE SYMTOUCH, FOLIC-K folic acid, folic acid-vitamin B6-vitamin B12, FOLTX ZOMIG NASAL SPRAY QL/PA FOLLISTIM AQ GONAL-F SGM, GONAL-F RFF SGM ERYPED erythromycin delayed-rel, erythromycin ethylsuccinate, erythromycin stearate FORTAMET metformin, metformin ext-rel (generic GLUCOPHAGE XR) esomeprazole lansoprazole delayed-rel, omeprazole delayed-rel, FORTESTA testosterone solution, ANDRODERM delayed-rel pantoprazole delayed-rel, DEXILANT FOSAMAX PLUS D alendronate, ibandronate, risedronate EUFLEXXA GELSYN-3, SUPARTZ FX FULPHILA NEULASTA SGM, UDENYCA SGM EVOCLIN clindamycin gel, clindamycin solution, erythromycin solution GEL-ONE DUROLANE EXFORGE amlodipine-olmesartan (generic AZOR) GLEEVEC imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM, EXFORGE HCT amlodipine-olmesartan-hydrochlorothiazide (generic TRIBENZOR) TASIGNA SGM EXTAVIA dimethyl fumarate (generic TECFIDERA) SGM, glatiramer (generic GLUMETZA metformin, metformin ext-rel (generic GLUCOPHAGE XR) COPAXONE) SGM, AUBAGIO SGM, BETASERON SGM, GLYCOPYRROLATE dicyclomine COPAXONE SGM, GILENYA SGM, MAYZENT, REBIF SGM, TABLET 1.5 MG TYSABRI SGM HELIXATE FS KOGENATE FS FABIOR adapalene (except adapalene pads or adapalene solution) PA, benzoyl peroxide, clindamycin gel, clindamycin solution, HORIZANT gabapentin, GRALISE clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), erythromycin solution, erythromycin-benzoyl peroxide, HUMALOG FIASP, NOVOLOG tazarotene (generic TAZORAC) PA, tretinoin PA, HUMALOG MIX 50/50 NOVOLOG MIX 70/30 tretinoin gel microsphere PA HUMALOG MIX 75/25 NOVOLOG MIX 70/30 fenofibrate tablet fenofibrate (except fenofibrate tablet 120 mg), 120 mg fenofibric acid delayed-rel HUMULIN NOVOLIN FENOGLIDE fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel

DRUG NAME(S) PREFERRED ALTERNATIVE(S) + DRUG NAME(S) PREFERRED ALTERNATIVE(S) + hydrocodone- hydrocodone-acetaminophen (except hydrocodone-acetaminophen LIPITOR atorvastatin, ezetimibe-simvastatin (generic VYTORIN), fluvastatin, acetaminophen solution tablet 7.5-300 mg or hydrocodone-acetaminophen tablet 10- lovastatin, pravastatin, rosuvastatin (generic CRESTOR), 10-325 mg/15 mL, 300 mg) QL/PA simvastatin hydrocodone- acetaminophen tablet LORTAB ELIXIR hydrocodone-acetaminophen (except hydrocodone-acetaminophen 7.5-300 mg, tablet 7.5-300 mg or hydrocodone-acetaminophen tablet 10- hydrocodone- 300 mg) QL/PA acetaminophen tablet lorzone carisoprodol 350 mg, cyclobenzaprine (except cyclobenzaprine 10-300 mg tablet 7.5 mg), metaxalone, methocarbamol, hydrocortisone butyrate betamethasone valerate, fluticasone, orphenadrine-aspirin-caffeine lipophilic cream 0.1% hydrocortisone butyrate cream, hydrocortisone butyrate lotion, LUMIGAN latanoprost, travoprost (generic TRAVATAN Z) hydrocortisone butyrate ointment, hydrocortisone butyrate solution, hydrocortisone valerate, mometasone, triamcinolone cream, LUNESTA eszopiclone, zolpidem, zolpidem ext-rel triamcinolone lotion, triamcinolone ointment LYUMJEV FIASP, NOVOLOG HYMOVIS GELSYN-3, SUPARTZ FX MACRODANTIN nitrofurantoin, nitrofurantoin ext-rel INDOCIN diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, nabumetone, naproxen (except naproxen CR or naproxen metformin ext-rel metformin, metformin ext-rel (generic GLUCOPHAGE XR) suspension), naproxen sodium, oxaprozin, sulindac (generic FORTAMET) indomethacin capsule diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, metformin ext-rel metformin, metformin ext-rel (generic GLUCOPHAGE XR) 20 mg nabumetone, naproxen (except naproxen CR or naproxen (generic GLUMETZA) suspension), naproxen sodium, oxaprozin, sulindac methylphenidate ext-rel CONCERTA B4G INNOPRAN XL atenolol, bisoprolol, carvedilol, labetalol, MIACALCIN alendronate, calcitonin-salmon, ibandronate, risedronate, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, INJECTION FORTEO SGM, TYMLOS SGM propranolol, propranolol ext-rel, BYSTOLIC * MIACALCIN NASAL calcitonin-salmon INSULIN ASPART FIASP, NOVOLOG SPRAY INSULIN ASPART MIX NOVOLOG MIX migergot dihydroergotamine injection, eletriptan (generic RELPAX) QL/PA, INSULIN LISPRO, FIASP, NOVOLOG naratriptan QL/PA, rizatriptan QL, sumatriptan injection QL/PA, INSULIN LISPRO sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, KWIKPEN zolmitriptan QL/PA, NURTEC ODT, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY QL/PA INSULIN LISPRO NOVOLOG MIX 70/30 PROTAMINE AND MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, INSULIN LISPRO MIX prednisolone sodium phosphate, prednisolone syrup, prednisone, 75/25 KWIKPEN RAYOS INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel MINOCIN doxycycline hyclate, minocycline, tetracycline, VIBRAMYCIN SYRUP JALYN dutasteride-tamsulosin (generic JALYN), dutasteride (generic AVODART) or finasteride WITH alfuzosin ext-rel, doxazosin, minocycline ext-rel doxycycline hyclate, minocycline, tetracycline, silodosin (generic RAPAFLO), tamsulosin or terazosin tablet VIBRAMYCIN SYRUP ketoconazole foam ciclopirox shampoo, ketoconazole shampoo MONOVISC DUROLANE ketodan ciclopirox shampoo, ketoconazole shampoo MORGIDOX KIT doxycycline hyclate ketoprofen capsule diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, naproxen CR diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, 25 mg, ketoprofen nabumetone, naproxen (except naproxen CR or naproxen nabumetone, naproxen (except naproxen CR or naproxen ext-rel suspension), naproxen sodium, oxaprozin, sulindac suspension), naproxen sodium, oxaprozin, sulindac LACTULOSE PAK lactulose solution naproxen suspension diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, nabumetone, naproxen (except naproxen CR or naproxen LANOXIN TABLET digoxin, digoxin pediatric elixir suspension), naproxen sodium, oxaprozin, sulindac (125 MCG and 250 MCG only) NATESTO testosterone solution, ANDRODERM lanthanum carbonate calcium acetate, sevelamer carbonate (generic NEUPOGEN NIVESTYM SGM RENVELA), PHOSLYRA, VELPHORO NEXIUM lansoprazole delayed-rel, omeprazole delayed-rel, LAZANDA fentanyl citrate (generic FENTORA) PA/QL, pantoprazole delayed-rel, DEXILANT fentanyl transmucosal lozenge PA/QL, SUBSYS PA/QL niacin tablet 500 mg niacin ext-rel LESCOL XL atorvastatin, ezetimibe-simvastatin (generic VYTORIN), fluvastatin, niacor niacin ext-rel lovastatin, pravastatin, rosuvastatin (generic CRESTOR), simvastatin NILANDRON abiraterone (generic ZYTIGA) SGM, ERLEADA SGM, XTANDI SGM, YONSA SGM LIDOCAINE CREAM lidocaine-prilocaine QL/PA 4.12% NORDITROPIN GENOTROPIN SGM, HUMATROPE SGM

LIDOCAINE- lidocaine-prilocaine QL/PA NORGESIC FORTE carisoprodol 350 mg, cyclobenzaprine (except cyclobenzaprine TETRACAINE tablet 7.5 mg), metaxalone, methocarbamol, orphenadrine-aspirin-caffeine LIDOTREX lidocaine-prilocaine QL/PA

DRUG NAME(S) PREFERRED ALTERNATIVE(S) + DRUG NAME(S) PREFERRED ALTERNATIVE(S) + NORITATE azelaic acid (generic FINACEA GEL), doxycycline monohydrate PROLENSA bromfenac, diclofenac, ketorolac, ACUVAIL, ILEVRO (generic ORACEA), metronidazole, FINACEA FOAM, SOOLANTRA PROTONIX lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel, DEXILANT NORPACE CR disopyramide PROVENTIL HFA albuterol sulfate CFC-free aerosol (generic PROAIR HFA), NUTROPIN AQ, GENOTROPIN SGM, HUMATROPE SGM PROAIR HFA, PROAIR RESPICLICK NUTROPIN AQ NUSPIN PROVIGIL armodafinil (generic NUVIGIL) PA, modafinil PA okebo doxycycline hyclate 20 mg, doxycycline hyclate capsule, PSORCON betamethasone dipropionate augmented, minocycline, tetracycline clobetasol (except clobetasol shampoo), halobetasol omeprazole-sodium lansoprazole delayed-rel, omeprazole delayed-rel, quazepam tablet 15 mg doxepin (generic SILENOR), eszopiclone, temazepam, bicarbonate capsule, pantoprazole delayed-rel, DEXILANT zolpidem, zolpidem ext-rel, BELSOMRA omeprazole-sodium RELION INSULIN NOVOLIN INSULIN bicarbonate packet RETIN-A MICRO adapalene (except adapalene pads or adapalene solution) PA, OMNITROPE GENOTROPIN SGM, HUMATROPE SGM benzoyl peroxide, clindamycin gel, clindamycin solution, ONEXTON adapalene (except adapalene pads or adapalene solution) PA, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), benzoyl peroxide, clindamycin gel, clindamycin solution, erythromycin solution, erythromycin-benzoyl peroxide, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), tazarotene (generic TAZORAC) PA, tretinoin PA, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin gel microsphere PA tazarotene (generic TAZORAC) PA, tretinoin PA, RHEUMATE folic acid, folic acid-vitamin B6-vitamin B12, FOLTX tretinoin gel microsphere PA ropinirole ext-rel pramipexole, ropinirole ONZETRA XSAIL eletriptan (generic RELPAX) QL/PA, naratriptan QL/PA, rizatriptan QL, sumatriptan nasal spray QL/PA, ryclora clemastine 2.68 mg, cyproheptadine, hydroxyzine HCl, sumatriptan tablet QL/PA, zolmitriptan QL/PA, levocetirizine ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY QL/PA SAIZEN GENOTROPIN SGM, HUMATROPE SGM orphengesic forte carisoprodol 350 mg, cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxalone, methocarbamol, SEMGLEE LANTUS, LEVEMIR, TOUJEO, TRESIBA orphenadrine-aspirin-caffeine SITAVIG valacyclovir ORTHOVISC GELSYN-3, SUPARTZ FX SOLODYN doxycycline hyclate, minocycline OXYTROL oxybutynin ext-rel, solifenacin (generic VESICARE), tolterodine, SOMA 250 MG carisoprodol 350 mg tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ SPRIX diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen PENNSAID diclofenac sodium, diclofenac sodium gel 1% (generic suspension), naproxen sodium VOLTAREN GEL), meloxicam, naproxen (except naproxen CR or naproxen suspension) SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV PERCOCET oxycodone-acetaminophen QL/PA sucralfate suspension sucralfate tablet PLAVIX clopidogrel, prasugrel (generic EFFIENT), BRILINTA sumatriptan-naproxen diclofenac sodium, diflunisal, etodolac, ibuprofen, naproxen (except naproxen CR or naproxen suspension) or posaconazole delayed- fluconazole, itraconazole PA, voriconazole, NOXAFIL INJECTION, naproxen sodium WITH dihydroergotamine injection, eletriptan rel tablet NOXAFIL SUSPENSION (generic RELPAX) QL/PA, naratriptan QL/PA, rizatriptan QL, PRED FORTE dexamethasone, fluorometholone, loteprednol (generic sumatriptan injection QL/PA, sumatriptan nasal spray QL/PA, LOTEMAX), prednisolone acetate 1%, FML FORTE, FML S.O.P., sumatriptan tablet QL/PA, zolmitriptan QL/PA, PRED MILD ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY QL/PA; NURTEC ODT PRENATE CHEWABLE prenatal vitamins, CITRANATAL SUMAXIN CP azelaic acid (generic FINACEA GEL), doxycycline monohydrate PRENATE DHA prenatal vitamins, CITRANATAL (generic ORACEA), metronidazole, FINACEA FOAM, SOOLANTRA PRENATE ELITE prenatal vitamins, CITRANATAL SYNALAR TS alclometasone, desonide, fluocinolone, hydrocortisone topical, PRENATE ENHANCE prenatal vitamins, CITRANATAL TEXACORT SOLUTION PRENATE ESSENTIAL prenatal vitamins, CITRANATAL SYNVISC GELSYN-3, SUPARTZ FX PRENATE MINI prenatal vitamins, CITRANATAL SYNVISC-ONE DUROLANE PRENATE PIXIE prenatal vitamins, CITRANATAL TESTIM testosterone solution, ANDRODERM PRENATE RESTORE prenatal vitamins, CITRANATAL testosterone gel testosterone solution, ANDRODERM PREVACID SOLUTAB lansoprazole delayed-rel, omeprazole delayed-rel, TIVORBEX diclofenac sodium, meloxicam, naproxen (except naproxen CR pantoprazole delayed-rel, DEXILANT or naproxen suspension) PRIMLEV oxycodone-acetaminophen QL/PA TOBI tobramycin inhalation solution (generic KITABIS, TOBI), SGM, PROCORT CORTIFOAM BETHKIS B4G, SGM PROCRIT EPOGEN SGM, RETACRIT SGM TOBI PODHALER tobramycin inhalation solution (generic KITABIS, TOBI) SGM, BETHKIS B4G, SGM PROLATE oxycodone-acetaminophen QL/PA TOBRADEX neomycin-polymyxin B-hydrocortisone,

DRUG NAME(S) PREFERRED ALTERNATIVE(S) + DRUG NAME(S) PREFERRED ALTERNATIVE(S) + OINTMENT neomycin-polymyxin B-bacitracin-hydrocortisone, VIMOVO celecoxib (generic CELEBREX); diclofenac sodium, meloxicam or neomycin-polymyxin B-dexamethasone, naproxen (except naproxen CR or naproxen suspension) WITH sulfacetamide-prednisolone 10%/0.25%, lansoprazole delayed-rel, omeprazole delayed-rel, tobramycin-dexamethasone suspension 0.3%/0.1%, ZYLET pantoprazole delayed-rel or DEXILANT TOBRADEX ST neomycin-polymyxin B-hydrocortisone, VIVLODEX diclofenac sodium, meloxicam, naproxen (except naproxen CR neomycin-polymyxin B-bacitracin-hydrocortisone, or naproxen suspension) neomycin-polymyxin B-dexamethasone, sulfacetamide-prednisolone 10%/0.25%, VOGELXO testosterone solution, ANDRODERM tobramycin-dexamethasone suspension 0.3%/0.1%, ZYLET XERESE acyclovir oral, famciclovir, valacyclovir tobramycin inhalation tobramycin inhalation solution (generic KITABIS, TOBI) SGM, XOLEGEL GEL 2% ciclopirox shampoo, ketoconazole shampoo solution (generic BETHKIS B4G, SGM BETHKIS) XOPENEX HFA albuterol sulfate CFC-free aerosol (generic PROAIR HFA), PROAIR HFA, PROAIR RESPICLICK TREXIMET diclofenac sodium, diflunisal, etodolac, ibuprofen, naproxen (except naproxen CR or naproxen suspension) or ZARXIO NIVESTYM SGM naproxen sodium WITH dihydroergotamine injection, eletriptan (generic RELPAX) QL/PA, naratriptan QL/PA, rizatriptan QL, ZEGERID CAPSULE lansoprazole delayed-rel, omeprazole delayed-rel, sumatriptan injection QL/PA, sumatriptan nasal spray QL/PA, pantoprazole delayed-rel, DEXILANT sumatriptan tablet QL/PA, zolmitriptan QL/PA, ZEGERID POWDER lansoprazole delayed-rel, omeprazole delayed-rel, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY QL/PA; FOR ORAL pantoprazole delayed-rel, DEXILANT NURTEC ODT SUSPENSION triamcinolone acetonide betamethasone valerate, fluticasone, ZIANA adapalene (except adapalene pads or adapalene solution) PA, aerosol 0.2% hydrocortisone butyrate cream, hydrocortisone butyrate lotion, benzoyl peroxide, clindamycin gel, clindamycin solution, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), hydrocortisone valerate, mometasone, triamcinolone cream, erythromycin solution, erythromycin-benzoyl peroxide, triamcinolone lotion, triamcinolone ointment tazarotene (generic TAZORAC) PA, tretinoin PA, TRIBENZOR amlodipine-olmesartan-hydrochlorothiazide (generic TRIBENZOR) tretinoin gel microsphere PA TRIGLIDE fenofibrate (except fenofibrate tablet 120 mg), ZIPSOR diclofenac sodium, meloxicam, naproxen (except naproxen CR fenofibric acid delayed-rel or naproxen suspension) TRILURON GELSYN-3, SUPARTZ FX ZOLPIMIST doxepin (generic SILENOR), eszopiclone, temazepam, zolpidem, zolpidem ext-rel, BELSOMRA UROXATRAL alfuzosin ext-rel, doxazosin, silodosin (generic RAPAFLO), tamsulosin, terazosin ZOMACTON GENOTROPIN SGM, HUMATROPE SGM VANOS betamethasone dipropionate augmented, ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, clobetasol (except clobetasol shampoo), halobetasol divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext- rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, vanoxide-hc adapalene (except adapalene pads or adapalene solution) PA, phenobarbital, phenytoin, phenytoin sodium extended, primidone, benzoyl peroxide, clindamycin gel, clindamycin solution, tiagabine, topiramate, valproic acid, zonisamide, DILANTIN 30 MG, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), FYCOMPA, OXTELLAR XR, QUDEXY XR, TROKENDI XR, erythromycin solution, erythromycin- VIMPAT benzoyl peroxide, tazarotene (generic TAZORAC) PA, tretinoin PA, tretinoin gel microsphere PA ZORVOLEX diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam, nabumetone, naproxen (except naproxen CR or naproxen VECTICAL calcipotriene ointment, calcipotriene solution suspension), naproxen sodium, oxaprozin, sulindac VELTIN adapalene (except adapalene pads or adapalene solution) PA, ZUPLENZ granisetron, ondansetron benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), ZYCLARA fluorouracil, imiquimod, PICATO erythromycin solution, erythromycin-benzoyl peroxide, tazarotene (generic TAZORAC) PA, tretinoin PA, tretinoin gel microsphere PA

VENTOLIN HFA albuterol sulfate CFC-free aerosol (generic PROAIR HFA), PROAIR HFA, PROAIR RESPICLICK

Also excluded from coverage: Drugs that are only FDA approved for cosmetic indications are excluded from the plan and are not eligible for a medical exception. Examples include, but are not limited to: Botox Cosmetic, hydroquinone-containing products, Latisse, Propecia, Renova and Vaniqa.

KEY Generic drugs are listed in lowercase italics. Brand-name drugs are listed in CAPS.

Symbol Meaning § 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^. B4G Brand for Generic medication (see note below). Brand-name product is dispensed at the generic copayment. ◊ 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). * This drug may be available as a generic in 2020 or 2021. When a generic is available, mandatory generic substitution will apply, unless the brand-name drug has been placed on Level 1. + The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. ++ You will be responsible for the full cost of non-formulary products that are excluded from coverage unless a request for a medical exception is approved. Information on the medical exception process can be found below in the For Your Information section. PA A Prior authorization is required for coverage. PA/QL A Prior Authorization is required for coverage and a quantity limit applies to the drug. QL A Quantity limit applies to the drug. QL/PA Initial Quantity limit is applied to the drug. Additional quantities may be authorized through a Prior authorization. SGM Specialty Guideline Management applies to the drug.

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. Any brand-name drug for which a generic drug becomes available may be designated as a non-preferred drug. 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 drugs on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand-name drugs in CAPS and generic drugs in lowercase italics. Listed drugs 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 https://www.empireplanrxprogram.com to check coverage and copay information for a specific medicine.

The Flexible Formulary has an additional feature called Brand for Generic (B4G) which saves you money on certain Brand-Name drugs that have a new generic available. When advantageous to the Plan, this feature allows a Brand-Name drug to be placed on Level 1, the lowest copayment level, and the new generic equivalent to be placed on Level 3, the highest copayment level or excluded. These placements are for a limited time, typically six months, and may be revised mid-year when such changes are advantageous to The Empire Plan. You will be notified when B4G savings are available. We will also notify your pharmacist so that the lowest cost option will always be dispensed. Please refer to the Empire Plan Prescription Drug Program website at https://www.empireplanrxprogram.com for the most current information regarding the B4G feature.

The Empire Plan has implemented a medical exception process for prescription drugs that are excluded from the Flexible Formulary. Enrollees and their physicians must first evaluate whether covered drugs on the Flexible Formulary are appropriate alternatives. After an appropriate trial of formulary alternatives, an enrollee's physician may submit a letter of medical necessity to CVS Caremark which details the enrollee's formulary alternative trials and any other clinical documentation supporting medical necessity. The physician can fax the exception request to 1- 888-487-9257. If an exception is approved, the Level 1 copay will apply for generic drugs and the Level 3 copay (and ancillary charge, if applicable) will apply for brand-name drugs.

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.