BC BA HA Standard with Step Drug List July 2021

July 2021 A Iii\ Arkansas +• BlueAdvantage T. ~ BlueCross BlueShield • 9. Administrators of Arkansas MhlependentlicenseeoiftheBlueCroaandBlueSl'.idAsaocialion Nl~~tt1.-.11... a..N-..»..~

Arkansas Blue Cross and Blue Shield Standard with Step Drug List

The Arkansas Blue Cross and Blue Shield Standard with Step Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by Arkansas Blue Cross and Blue Shield. Ask your administered by Arkansas Blue Cross and Blue Shield. As a way to doctor to consider prescribing, when medically appropriate, a help manage health care costs, authorize generic substitution preferred medicine from this list. Take this list along when you or a whenever possible. If you believe a brand-name product is covered family member sees a doctor. necessary, consider prescribing a brand name on this list. Please note: Please note:

• Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. • The member's prescription benefit plan design may alter Food and Drug Administration (FDA) may not be covered coverage of certain products or vary copay amounts based on upon release to the market. the condition being treated. This drug list represents a summary of prescription coverage. • Your prescription benefit plan design may alter coverage of • certain products or vary copay1 amounts based on the It is not all-inclusive and does not guarantee coverage. The condition being treated. member's specific prescription benefit plan design may not cover certain products or categories, regardless of their • You may be responsible for the full cost of non-formulary appearance in this document. Products recently approved by products that are removed from coverage. the FDA may not be covered upon release to the market. • For specific information regarding your prescription benefit • The member's prescription benefit plan may have a different coverage and copay information, please visit copay for specific products on the list. www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care • Unless specifically indicated, drug list products will include all representative at 1-800-863-5561. dosage forms. • Log in to www.arkansasbluecross.com to check coverage • Arkansas Blue Cross and Blue Shield may contact your doctor after receiving your prescription to request consideration of a and copay information for a specific medicine. drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.

• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non- preferred option upon release of the generic product to the market.

ANALGESICS naproxen (except naproxen CR or § NSAIDs, TOPICAL § OPIOID ANALGESICS § GOUT naproxen suspension) diclofenac sodium gel 1% PA buprenorphine transdermal § NSAIDs allopurinol diclofenac sodium solution QL § NSAIDs, COMBINATIONS colchicine tablet diclofenac sodium codeine-acetaminophen QL diclofenac sodium- § COX-2 INHIBITORS probenecid ibuprofen fentanyl transdermal QL

meloxicam misoprostol celecoxib

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.

fentanyl transmucosal efavirenz-emtricitabine- nitrofurantoin (except NDC^ PROSTATE CANCER § ANTIARRHYTHMICS lozenge PA tenofovir disoproxil 70408023932) § LUTEINIZING HORMONE- disopyramide hydrocodone ext-rel QL fumarate QL pyrimethamine PA RELEASING HORMONE sotalol hydrocodone-acetaminophen efavirenz-lamivudine- sulfamethoxazole- (LHRH) AGONISTS MULTAQ QL tenofovir disoproxil trimethoprim ELIGARD SGM hydromorphone QL fumarate QL vancomycin capsule QL ANTILIPEMICS hydromorphone ext-rel QL BIKTARVY QL EMVERM LUTEINIZING HORMONE- ACL INHIBITORS / methadone QL CIMDUO QL XIFAXAN 550 MG PA RELEASING HORMONE COMBINATIONS

morphine QL COMPLERA QL (LHRH) ANTAGONISTS NEXLETOL PA ANTINEOPLASTIC morphine ext-rel QL DESCOVY QL FIRMAGON † NEXLIZET PA morphine suppository QL DOVATO QL AGENTS § MISCELLANEOUS § BILE ACID RESINS oxycodone QL EVOTAZ QL ANTIMETABOLITES oxycodone-acetaminophen GENVOYA QL ERIVEDGE SGM cholestyramine LONSURF SGM

QL ODEFSEY QL LYNPARZA SGM colesevelam tramadol (except NDC^ PREZCOBIX QL BIOSIMILARS ODOMZO SGM § CHOLESTEROL 52817019610) QL STRIBILD QL RUBRACA SGM KANJINTI † ABSORPTION INHIBITORS SYMTUZA QL ZEJULA SGM tramadol ext-rel tablet QL RUXIENCE †

BELBUCA QL TEMIXYS QL ezetimibe TRAZIMERA † NUCYNTA QL TRIUMEQ QL CARDIOVASCULAR ZIRABEV † § FIBRATES TRUVADA QL NUCYNTA ER QL § ACE INHIBITORS fenofibrate (except fenofibrate capsule SUBSYS PA HORMONAL INTEGRASE INHIBITORS fosinopril 50 mg, 130 mg; fenofibrate tablet 40 mg, XTAMPZA ER QL ANTINEOPLASTIC AGENTS ISENTRESS QL lisinopril 120 mg) § ANTIANDROGENS ANTI -INFECTIVES TIVICAY QL quinapril fenofibric acid delayed-rel abiraterone SGM ramipril ANTIBACTERIALS § NUCLEOSIDE REVERSE bicalutamide § HMG-CoA REDUCTASE § ACE INHIBITOR / § CEPHALOSPORINS TRANSCRIPTASE ERLEADA SGM INHIBITORS / INHIBITORS NUBEQA SGM DIURETIC COMBINATIONS COMBINATIONS cefdinir XTANDI SGM fosinopril-hydrochlorothiazide cefprozil abacavir tablet QL atorvastatin lamivudine QL YONSA SGM lisinopril-hydrochlorothiazide ezetimibe-simvastatin cefuroxime axetil quinapril-hydrochlorothiazide fluvastatin cephalexin § KINASE INHIBITORS § PROTEASE INHIBITORS SUPRAX lovastatin imatinib mesylate SGM § ANGIOTENSIN II § ERYTHROMYCINS / atazanavir QL pravastatin AFINITOR SGM RECEPTOR ANTAGONISTS / MACROLIDES NORVIR QL rosuvastatin ALECENSA SGM DIURETIC COMBINATIONS PREZISTA QL simvastatin azithromycin ALUNBRIG SGM candesartan / candesartan- clarithromycin ANTIVIRALS BOSULIF SGM hydrochlorothiazide § NIACINS clarithromycin ext-rel § CYTOMEGALOVIRUS CABOMETYX SGM irbesartan / irbesartan- niacin ext-rel erythromycins AGENTS COPIKTRA SGM hydrochlorothiazide § OMEGA-3 FATTY ACIDS DIFICID ST, QL IBRANCE SGM losartan / losartan- valganciclovir omega-3 acid ethyl esters PA IRESSA SGM hydrochlorothiazide § FLUOROQUINOLONES VASCEPA PA § HEPATITIS B AGENTS KISQALI SGM olmesartan / olmesartan- ciprofloxacin entecavir KISQALI FEMARA CO- hydrochlorothiazide PCSK9 INHIBITORS levofloxacin lamivudine PACK SGM telmisartan / telmisartan- PRALUENT PA moxifloxacin RYDAPT SGM hydrochlorothiazide VEMLIDY § BETA-BLOCKERS § PENICILLINS SPRYCEL SGM valsartan / valsartan- § HEPATITIS C AGENTS STIVARGA SGM hydrochlorothiazide atenolol amoxicillin ribavirin SGM XOSPATA SGM carvedilol amoxicillin-clavulanate § ANGIOTENSIN II EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) carvedilol phosphate ext-rel dicloxacillin MONOCLONAL ANTIBODIES RECEPTOR ANTAGONIST / SGM metoprolol succinate ext-rel penicillin VK CALCIUM CHANNEL HARVONI (genotypes 1, 4, 5, 6) PERJETA † metoprolol tartrate BLOCKER COMBINATIONS § TETRACYCLINES SGM PHESGO SGM nadolol 2 VOSEVI SGM amlodipine-olmesartan pindolol doxycycline hyclate 20 mg MULTIPLE MYELOMA amlodipine-telmisartan propranolol doxycycline hyclate capsule § HERPES AGENTS IMMUNOMODULATORS amlodipine-valsartan propranolol ext-rel minocycline acyclovir capsule, tablet POMALYST SGM tetracycline BYSTOLIC § ANGIOTENSIN II valacyclovir REVLIMID SGM RECEPTOR ANTAGONIST / § ANTIFUNGALS THALOMID SGM § CALCIUM CHANNEL § INFLUENZA AGENTS CALCIUM CHANNEL BLOCKERS fluconazole PROTEASOME INHIBITORS BLOCKER / DIURETIC oseltamivir QL amlodipine itraconazole PA COMBINATIONS RELENZA QL NINLARO SGM diltiazem ext-rel (except generics terbinafine tablet VELCADE † amlodipine-valsartan- for CARDIZEM LA) § MISCELLANEOUS ANTIRETROVIRAL AGENTS hydrochlorothiazide nifedipine ext-rel clindamycin § ANTIRETROVIRAL olmesartan-amlodipine- verapamil ext-rel ivermectin COMBINATIONS hydrochlorothiazide linezolid PA abacavir-lamivudine QL metronidazole

§ CALCIUM CHANNEL CENTRAL NERVOUS REUPTAKE INHIBITORS HYPNOTICS POSTHERPETIC BLOCKER / ANTILIPEMIC SYSTEM (SNRIs) § NONBENZODIAZEPINES NEURALGIA (PHN) COMBINATIONS desvenlafaxine ext-rel eszopiclone GRALISE ST ANTIANXIETY amlodipine-atorvastatin duloxetine ramelteon § BENZODIAZEPINES PSYCHOTHERAPEUTIC - venlafaxine zolpidem § DIGITALIS GLYCOSIDES MISCELLANEOUS alprazolam venlafaxine ext-rel capsule zolpidem ext-rel digoxin § OPIOID ANTAGONISTS clonazepam BELSOMRA ST § MISCELLANEOUS diazepam naloxone injection § DIRECT RENIN AGENTS lorazepam § TRICYCLICS NARCAN NASAL SPRAY INHIBITORS / DIURETIC oxazepam bupropion doxepin COMBINATIONS bupropion ext-rel (except § PARTIAL OPIOID AGONIST aliskiren § ANTICONVULSANTS bupropion ext-rel tablet 450 mg) MIGRAINE / OPIOID ANTAGONIST TEKTURNA HCT ST carbamazepine mirtazapine ACUTE MIGRAINE AGENTS COMBINATIONS

carbamazepine ext-rel trazodone § Triptans buprenorphine-naloxone § DIURETICS clobazam sublingual QL amiloride § ANTIPARKINSONIAN eletriptan QL diazepam rectal gel ZUBSOLV QL naratriptan QL furosemide divalproex sodium AGENTS rizatriptan QL hydrochlorothiazide divalproex sodium ext-rel amantadine PSEUDOBULBAR AFFECT sumatriptan QL metolazone ethosuximide carbidopa-levodopa AGENTS zolmitriptan QL spironolactone- gabapentin carbidopa-levodopa ext-rel NUEDEXTA PA ONZETRA XSAIL ST hydrochlorothiazide lamotrigine carbidopa-levodopa- ZEMBRACE SYMTOUCH ST torsemide lamotrigine ext-rel entacapone ENDOCRINE AND ZOMIG NASAL SPRAY QL triamterene METABOLIC levetiracetam entacapone triamterene- pramipexole levetiracetam ext-rel Miscellaneous ACROMEGALY hydrochlorothiazide oxcarbazepine pramipexole ext-rel NURTEC ODT ST SOMATULINE DEPOT SGM phenobarbital rasagiline HEART FAILURE REYVOW ST phenytoin ropinirole § ANDROGENS BIDIL UBRELVY ST phenytoin sodium extended ropinirole ext-rel CORLANOR testosterone gel (except authorized primidone selegiline PREVENTIVE MIGRAINE ENTRESTO generics for TESTIM and VOGELXO) rufinamide INBRIJA SGM AGENTS PA tiagabine KYNMOBI SGM § NITRATES Monoclonal Antibodies testosterone solution PA topiramate NEUPRO isosorbide dinitrate (except AIMOVIG ST ANDRODERM PA valproic acid isosorbide dinitrate 40 mg) ANTIPSYCHOTICS AJOVY ST NATESTO PA vigabatrin SGM isosorbide mononitrate § ATYPICALS EMGALITY ST zonisamide ANTIDIABETICS nitroglycerin lingual spray FYCOMPA aripiprazole § MOVEMENT DISORDERS nitroglycerin sublingual AMYLIN ANALOGS NAYZILAM clozapine tetrabenazine SGM SYMLINPEN

PULMONARY ARTERIAL OXTELLAR XR olanzapine AUSTEDO SGM

HYPERTENSION VALTOCO quetiapine INGREZZA SGM § BIGUANIDES VIMPAT quetiapine ext-rel § ENDOTHELIN RECEPTOR metformin XCOPRI risperidone § MULTIPLE SCLEROSIS ANTAGONISTS metformin ext-rel (except generics ziprasidone AGENTS ambrisentan SGM § ANTIDEMENTIA for FORTAMET and GLUMETZA) ABILIFY MAINTENA dimethyl fumarate delayed- bosentan SGM donepezil LATUDA rel SGM § BIGUANIDE / OPSUMIT SGM galantamine PERSERIS glatiramer SGM SULFONYLUREA galantamine ext-rel § PHOSPHODIESTERASE VRAYLAR ST AUBAGIO SGM COMBINATIONS memantine INHIBITORS BETASERON SGM glipizide-metformin rivastigmine § ATTENTION DEFICIT sildenafil SGM COPAXONE SGM HYPERACTIVITY DISORDER rivastigmine transdermal GILENYA SGM DIPEPTIDYL PEPTIDASE-4

PROSTACYCLIN RECEPTOR NAMZARIC amphetamine- KESIMPTA SGM (DPP-4) INHIBITORS

dextroamphetamine mixed JANUVIA AGONISTS ANTIDEPRESSANTS MAYZENT SGM salts QL UPTRAVI SGM OCREVUS † § SELECTIVE SEROTONIN DIPEPTIDYL PEPTIDASE-4 amphetamine- REBIF SGM REUPTAKE INHIBITORS (DPP-4) INHIBITOR / § PROSTAGLANDIN dextroamphetamine mixed TYSABRI † (SSRIs) BIGUANIDE COMBINATIONS VASODILATORS salts ext-rel QL VUMERITY SGM

treprostinil SGM citalopram atomoxetine QL ZEPOSIA SGM JANUMET

ORENITRAM SGM escitalopram dexmethylphenidate ext-rel JANUMET XR fluoxetine (except fluoxetine tablet 60 QL § MUSCULOSKELETAL SOLUBLE GUANYLATE mg, fluoxetine tablet [generics for guanfacine ext-rel QL THERAPY AGENTS INCRETIN MIMETIC AGENTS CYCLASE STIMULATORS SARAFEM]) methylphenidate QL cyclobenzaprine (except OZEMPIC ADEMPAS SGM paroxetine HCl methylphenidate ext-rel QL cyclobenzaprine tablet 7.5 mg) RYBELSUS paroxetine HCl ext-rel MYDAYIS QL TRULICITY § MISCELLANEOUS sertraline VYVANSE QL § NARCOLEPSY VICTOZA

ranolazine ext-rel TRINTELLIX ST armodafinil PA FIBROMYALGIA modafinil PA § SEROTONIN pregabalin ST, QL SUNOSI PA NOREPINEPHRINE

INCRETIN MIMETIC AGENT / glipizide PREMPRO promethazine § EXTENDED CYCLE INSULIN COMBINATIONS glipizide ext-rel scopolamine transdermal ethinyl estradiol- § TRANSDERMAL SOLIQUA trimethobenzamide SUPPLIES levonorgestrel estradiol XULTOPHY SANCUSO PA, QL

ACCU-CHEK AVIVA PLUS CLIMARA PRO PROGESTIN INTRAUTERINE INSULINS STRIPS AND KITS 3 OTC COMBIPATCH § ANTISPASMODICS DEVICES BASAGLAR ACCU-CHEK COMPACT DIVIGEL dicyclomine 3 KYLEENA † FIASP PLUS STRIPS AND KITS EVAMIST MIRENA † § H2 RECEPTOR HUMULIN R U-500 OTC SKYLA † § VAGINAL ANTAGONISTS LEVEMIR ACCU-CHEK GUIDE

STRIPS AND KITS 3 OTC estradiol vaginal cream famotidine NOVOLIN 70/30 OTC § TRANSDERMAL IMVEXXY NOVOLIN N OTC ACCU-CHEK SMARTVIEW 3 ethinyl estradiol- INFLAMMATORY BOWEL NOVOLIN R OTC STRIPS AND KITS OTC norelgestromin § PHENYLKETONURIA DISEASE NOVOLOG BD ULTRAFINE INSULIN TREATMENT AGENTS § ORAL AGENTS NOVOLOG MIX 70/30 SYRINGES AND § VAGINAL sapropterin SGM TOUJEO NEEDLES OTC balsalazide ethinyl estradiol-etonogestrel TRESIBA DEXCOM CONTINUOUS budesonide capsule ANNOVERA § PHOSPHATE BINDER GLUCOSE MONITORING budesonide ext-rel AGENTS § INSULIN SENSITIZERS SYSTEM PA ENDOMETRIOSIS mesalamine delayed-rel calcium acetate pioglitazone OMNIPOD DASH QL (except mesalamine delayed-rel tablet

ORILISSA PA sevelamer carbonate ONETOUCH ULTRA 800 mg) § INSULIN SENSITIZER / 3 PHOSLYRA STRIPS AND KITS OTC FERTILITY REGULATORS mesalamine ext-rel VELPHORO ST BIGUANIDE COMBINATIONS sulfasalazine ONETOUCH VERIO STRIPS GNRH / LHRH 3 pioglitazone-metformin AND KITS OTC ANTAGONISTS POLYNEUROPATHY sulfasalazine delayed-rel PENTASA § INSULIN SENSITIZER / § CALCIUM RECEPTOR CETROTIDE TEGSEDI SGM SULFONYLUREA ANTAGONISTS § RECTAL AGENTS POTASSIUM-REMOVING COMBINATIONS OVULATION STIMULANTS, cinacalcet SGM GONADOTROPINS AGENTS hydrocortisone enema pioglitazone-glimepiride mesalamine suppository GONAL-F PA LOKELMA CALCIUM REGULATORS mesalamine suspension OVIDREL VELTASSA § MEGLITINIDES § BISPHOSPHONATES CORTIFOAM

nateglinide alendronate PROGESTINS GAUCHER DISEASE § IRRITABLE BOWEL repaglinide ibandronate CERDELGA SGM § ORAL SYNDROME

risedronate CEREZYME † SODIUM-GLUCOSE medroxyprogesterone alosetron CO-TRANSPORTER 2 megestrol acetate § CALCITONINS § GLUCOCORTICOIDS LINZESS (SGLT2) INHIBITORS progesterone, micronized VIBERZI calcitonin-salmon dexamethasone FARXIGA fludrocortisone VAGINAL JARDIANCE PARATHYROID HORMONES § LAXATIVES hydrocortisone tablet CRINONE PA FORTEO SGM lactulose solution SODIUM-GLUCOSE methylprednisolone ENDOMETRIN PA TYMLOS SGM peg 3350-electrolytes CO-TRANSPORTER 2 prednisolone solution § SELECTIVE ESTROGEN CLENPIQ (SGLT2) INHIBITOR / MISCELLANEOUS prednisone BIGUANIDE COMBINATIONS RECEPTOR MODULATORS OPIOID-INDUCED PROLIA † GLUCOSE ELEVATING SYNJARDY raloxifene CONSTIPATION AGENTS SYNJARDY XR § CARNITINE DEFICIENCY MOVANTIK BAQSIMI § THYROID SUPPLEMENTS XIGDUO XR AGENTS SYMPROIC GLUCAGEN HYPOKIT levothyroxine levocarnitine SODIUM-GLUCOSE GLUCAGON EMERGENCY liothyronine PANCREATIC ENZYMES CO-TRANSPORTER 2 CENTRAL PRECOCIOUS KIT SYNTHROID CREON

(SGLT2) INHIBITOR / PUBERTY GVOKE VIOKACE UTERINE FIBROIDS DIPEPTIDYL PEPTIDASE-4 SUPPRELIN LA † ZENPEP HEREDITARY TYROSINEMIA ORIAHNN PA (DPP-4) INHIBITOR TRIPTODUR † TYPE 1 AGENTS COMBINATIONS § PROTON PUMP ORFADIN SGM GASTROINTESTINAL CONTRACEPTIVES INHIBITORS GLYXAMBI

§ MONOPHASIC HUMAN GROWTH § ANTIDIARRHEALS esomeprazole delayed-rel SODIUM-GLUCOSE ethinyl estradiol- diphenoxylate-atropine lansoprazole delayed-rel CO-TRANSPORTER 2 HORMONES drospirenone omeprazole delayed-rel GENOTROPIN SGM loperamide (SGLT2) INHIBITOR / ethinyl estradiol- pantoprazole delayed-rel DIPEPTIDYL PEPTIDASE-4 NORDITROPIN SGM drospirenone-levomefolate § ANTIEMETICS tablet (DPP-4) ethinyl estradiol- MENOPAUSAL SYMPTOM aprepitant QL DEXILANT ST INHIBITOR/BIGUANIDE norethindrone acetate AGENTS dronabinol PA, QL COMBINATIONS § STEROIDS, RECTAL ethinyl estradiol- § ORAL granisetron QL PROCTOFOAM-HC TRIJARDY XR norethindrone acetate-iron meclizine estradiol metoclopramide § SULFONYLUREAS estradiol-norethindrone § MISCELLANEOUS § TRIPHASIC ondansetron QL DUAVEE sucralfate tablet glimepiride ethinyl estradiol-norgestimate prochlorperazine PREMPHASE

GENITOURINARY BRILINTA RESPIRATORY § LEUKOTRIENE ONEXTON MODULATORS § BENIGN PROSTATIC THROMBOCYTOPENIA ALPHA-1 ANTITRYPSIN § ACTINIC KERATOSIS montelukast HYPERPLASIA AGENTS DEFICIENCY AGENTS fluorouracil cream 5% zafirlukast alfuzosin ext-rel DOPTELET SGM PROLASTIN-C † fluorouracil solution doxazosin MULPLETA SGM § NASAL ANTIHISTAMINES imiquimod § ANAPHYLAXIS dutasteride azelastine spray QL PICATO IMMUNOLOGIC TREATMENT AGENTS dutasteride-tamsulosin olopatadine spray QL TOLAK finasteride AGENTS epinephrine auto-injector ZYCLARA

silodosin EPIPEN § NASAL STEROIDS / ALLERGENIC EXTRACTS § ANTIBIOTICS tamsulosin EPIPEN JR COMBINATIONS GRASTEK PA terazosin SYMJEPI flunisolide QL gentamicin QL ORALAIR PA fluticasone QL mupirocin ointment § URINARY RAGWITEK PA § ANTICHOLINERGICS mometasone nasal spray QL ANTISPASMODICS ipratropium inhalation § ANTIFUNGALS AUTOIMMUNE AGENTS DYMISTA ST, QL solution QL ciclopirox PA darifenacin ext-rel (PHYSICIAN- SPIRIVA QL PHOSPHODIESTERASE-4 clotrimazole oxybutynin ADMINISTERED) YUPELRI QL INHIBITORS econazole QL oxybutynin ext-rel † REMICADE solifenacin DALIRESP ketoconazole cream 2% QL SIMPONI ARIA † ANTICHOLINERGIC / BETA tolterodine nystatin QL STELARA INTRAVENOUS † AGONIST COMBINATIONS PULMONARY FIBROSIS tolterodine ext-rel NAFTIN AGENTS trospium § SHORT ACTING AUTOIMMUNE AGENTS § ANTIPSORIATICS trospium ext-rel (SELF-ADMINISTERED) 4 ipratropium-albuterol ESBRIET SGM acitretin PA MYRBETRIQ ST inhalation solution QL OFEV SGM COSENTYX SGM calcipotriene ointment, TOVIAZ ST

ENBREL SGM LONG ACTING SEVERE ASTHMA AGENTS solution QL HUMIRA SGM HEMATOLOGIC ANORO ELLIPTA QL DUPIXENT SGM methoxsalen OTEZLA SGM STIOLTO RESPIMAT QL FASENRA AUTOINJECTOR § ANTICOAGULANTS RINVOQ SGM § ANTISEBORRHEICS SGM SKYRIZI SGM warfarin ANTICHOLINERGIC / BETA NUCALA AUTOINJECTOR ketoconazole shampoo 2% STELARA ELIQUIS AGONIST / STEROID SGM selenium sulfide lotion 2.5% SUBCUTANEOUS SGM XARELTO INHALANT COMBINATIONS XOLAIR † ATOPIC DERMATITIS TREMFYA SGM BREZTRI AEROSPHERE § CHELATING AGENTS XELJANZ SGM QL STEROID / BETA AGONIST Injectable deferasirox SGM XELJANZ XR SGM TRELEGY ELLIPTA QL COMBINATIONS DUPIXENT SGM

deferiprone SGM ADVAIR DISKUS QL § DISEASE-MODIFYING § Topical deferoxamine † § ANTIHISTAMINES, LOW ADVAIR HFA ‡, QL ANTIRHEUMATIC DRUGS penicillamine capsule ST SEDATING BREO ELLIPTA ‡, QL pimecrolimus PA (DMARDs) trientine ST levocetirizine SYMBICORT QL tacrolimus PA RASUVO SGM EUCRISA ST HEMATOPOIETIC GROWTH § ANTITUSSIVES § STEROID INHALANTS CORTICOSTEROIDS FACTORS § HEREDITARY benzonatate (except NDCs^ budesonide inhalation ANGIOEDEMA § Low Potency ARANESP SGM 69336012615, 69499032915) suspension QL icatibant SGM desonide QL NIVESTYM SGM ARNUITY ELLIPTA QL hydrocortisone QL RETACRIT SGM BETA AGONISTS, IMMUNOMODULATORS FLOVENT DISKUS QL ZIEXTENZO SGM INHALANTS FLOVENT HFA QL § Medium Potency IMMUNE GLOBULINS § SHORT ACTING PULMICORT FLEXHALER hydrocortisone butyrate HEMOPHILIA A AGENTS CUTAQUIG SGM QL † albuterol inhalation solution cream, ointment, solution ADVATE QVAR REDIHALER QL IMMUNOSUPPRESSANTS QL QL ADYNOVATE † albuterol sulfate CFC-free mometasone QL AFSTYLA † § RAPAMYCIN DERIVATIVES TOPICAL † aerosol QL triamcinolone cream, lotion, ELOCTATE everolimus SGM levalbuterol tartrate CFC-free DERMATOLOGY ointment (except triamcinolone ESPEROCT † aerosol QL † NUTRITIONAL / ACNE ointment 0.05%) QL JIVI KOGENATE FS † SUPPLEMENTS LONG ACTING § Topical § High Potency KOVALTRY † Hand-held Active Inhalation adapalene PA desoximetasone QL † § ELECTROLYTES NOVOEIGHT benzoyl peroxide potassium chloride liquid SEREVENT QL fluocinonide (except fluocinonide NUWIQ † clindamycin gel (except NDC^ cream 0.1%) QL STRIVERDI RESPIMAT QL HEMOPHILIA B AGENTS VITAMINS AND MINERALS 68682046275) BRYHALI PA § FOLIC ACID / Nebulized Passive Inhalation clindamycin solution QL REBINYN † § Very High Potency COMBINATIONS PERFOROMIST QL clindamycin-benzoyl § PLATELET AGGREGATION peroxide clobetasol cream, foam, gel, folic acid § CYSTIC FIBROSIS INHIBITORS erythromycin solution lotion, ointment, shampoo § PRENATAL VITAMINS tobramycin inhalation erythromycin-benzoyl QL clopidogrel solution SGM peroxide dipyridamole ext-rel-aspirin prenatal vitamins § LOCAL ANALGESICS BETHKIS SGM tretinoin PA, ** CITRANATAL prasugrel EPIDUO lidocaine patch PA

sulfacetamide loteprednol CARBONIC ANHYDRASE RHO KINASE INHIBITOR / § LOCAL ANESTHETICS tobramycin prednisolone acetate 1% INHIBITOR / PROSTAGLANDIN lidocaine-prilocaine BESIVANCE DUREZOL SYMPATHOMIMETIC COMBINATIONS

COMBINATIONS ROCKLATAN ST § ROSACEA § ANTI-INFECTIVE / § ANTIVIRALS SIMBRINZA azelaic acid gel PA ANTI-INFLAMMATORY trifluridine § SYMPATHOMIMETICS metronidazole COMBINATIONS DRY EYE DISEASE brimonidine FINACEA FOAM PA BETA-BLOCKERS neomycin-polymyxin B- RESTASIS ALPHAGAN P ORACEA PA § Nonselective bacitracin-hydrocortisone XIIDRA SOOLANTRA PA neomycin-polymyxin B- timolol maleate solution SYMPATHOMIMETIC / BETA-

dexamethasone § PROSTAGLANDINS BLOCKER COMBINATIONS OPHTHALMIC Selective tobramycin-dexamethasone latanoprost COMBIGAN § ANTIALLERGICS TOBRADEX OINTMENT BETOPTIC S travoprost OTIC azelastine LUMIGAN ST ANTI-INFLAMMATORIES § CARBONIC ANHYDRASE cromolyn sodium ZIOPTAN ST § ANTI-INFECTIVES INHIBITORS olopatadine § Nonsteroidal acetic acid dorzolamide RETINAL DISORDERS bromfenac ofloxacin otic § ANTI-INFECTIVES † diclofenac AZOPT EYLEA

ciprofloxacin LUCENTIS † § ANTI-INFECTIVE / ketorolac QL § CARBONIC ANHYDRASE erythromycin ANTI-INFLAMMATORY ILEVRO INHIBITOR / BETA- gentamicin QL RHO KINASE INHIBITORS COMBINATIONS PROLENSA BLOCKER COMBINATIONS levofloxacin RHOPRESSA ciprofloxacin-dexamethasone moxifloxacin § Steroidal dorzolamide-timolol neomycin-polymyxin B-

ofloxacin dexamethasone hydrocortisone

QUICK REFERENCE DRUG LIST

A alprazolam AZOPT bupropion clarithromycin

ALUNBRIG SGM bupropion ext-rel (except clarithromycin ext-rel abacavir tablet QL amantadine B bupropion ext-rel tablet 450 mg) CLENPIQ abacavir-lamivudine QL ambrisentan SGM balsalazide BYSTOLIC CLIMARA PRO ABILIFY MAINTENA amiloride BAQSIMI clindamycin abiraterone SGM C ACCU-CHEK AVIVA PLUS amlodipine BASAGLAR clindamycin gel (except NDC^ amlodipine-atorvastatin BD ULTRAFINE INSULIN CABOMETYX SGM 68682046275) STRIPS AND KITS 3 OTC ACCU-CHEK COMPACT amlodipine-olmesartan SYRINGES AND calcipotriene ointment, clindamycin gel, solution QL PLUS STRIPS AND KITS 3 amlodipine-telmisartan NEEDLES OTC solution QL clindamycin-benzoyl amlodipine-valsartan BELBUCA QL calcitonin-salmon peroxide OTC ACCU-CHEK GUIDE amlodipine-valsartan- BELSOMRA ST calcium acetate clobazam hydrochlorothiazide candesartan clobetasol cream, foam, gel, STRIPS AND KITS 3 OTC benzonatate (except NDCs^ amoxicillin lotion, ointment, shampoo ACCU-CHEK SMARTVIEW 69336012615, 69499032915) candesartan- amoxicillin-clavulanate hydrochlorothiazide QL STRIPS AND KITS 3 OTC benzoyl peroxide amphetamine- carbamazepine clonazepam acetic acid BESIVANCE dextroamphetamine mixed carbamazepine ext-rel clopidogrel acitretin PA BETASERON SGM salts QL carbidopa-levodopa clotrimazole acyclovir capsule, tablet BETHKIS SGM amphetamine- carbidopa-levodopa ext-rel clozapine adapalene PA BETOPTIC S dextroamphetamine mixed carbidopa-levodopa- codeine-acetaminophen QL ADEMPAS SGM bicalutamide salts ext-rel QL entacapone colchicine tablet ADVAIR DISKUS QL BIDIL ANDRODERM PA carvedilol colesevelam ADVAIR HFA ‡, QL BIKTARVY QL ANNOVERA carvedilol phosphate ext-rel COMBIGAN ADVATE † bosentan SGM ANORO ELLIPTA QL cefdinir COMBIPATCH ADYNOVATE † BOSULIF SGM aprepitant QL ‡ cefprozil COMPLERA QL AFINITOR SGM BREO ELLIPTA , QL ARANESP SGM cefuroxime axetil COPAXONE SGM AFSTYLA † BREZTRI AEROSPHERE aripiprazole celecoxib COPIKTRA SGM AIMOVIG ST QL armodafinil PA cephalexin CORLANOR AJOVY ST BRILINTA ARNUITY ELLIPTA QL CORTIFOAM albuterol inhalation solution brimonidine CERDELGA SGM atazanavir QL CEREZYME † COSENTYX SGM QL bromfenac atenolol CREON albuterol sulfate CFC-free BRYHALI PA CETROTIDE atomoxetine QL cholestyramine CRINONE PA aerosol QL budesonide capsule atorvastatin ciclopirox PA cromolyn sodium ALECENSA SGM budesonide ext-rel AUBAGIO SGM CIMDUO QL CUTAQUIG SGM alendronate budesonide inhalation AUSTEDO SGM cinacalcet SGM cyclobenzaprine (except alfuzosin ext-rel suspension QL azelaic acid gel PA ciprofloxacin cyclobenzaprine tablet 7.5 mg) aliskiren buprenorphine transdermal azelastine ciprofloxacin-dexamethasone allopurinol QL azelastine spray QL citalopram D alosetron buprenorphine-naloxone azithromycin CITRANATAL DALIRESP ALPHAGAN P sublingual QL

darifenacin ext-rel ELIQUIS finasteride IBRANCE SGM liothyronine deferasirox SGM ELOCTATE † FIRMAGON † ibuprofen lisinopril deferiprone SGM EMGALITY ST FLOVENT DISKUS QL icatibant SGM lisinopril-hydrochlorothiazide deferoxamine † EMVERM FLOVENT HFA QL ILEVRO LOKELMA DESCOVY QL ENBREL SGM fluconazole imatinib mesylate SGM LONSURF SGM desonide QL ENDOMETRIN PA fludrocortisone imiquimod loperamide desoximetasone QL entacapone flunisolide QL IMVEXXY lorazepam desvenlafaxine ext-rel entecavir fluocinonide (except fluocinonide INBRIJA SGM losartan dexamethasone ENTRESTO cream 0.1%) QL INGREZZA SGM losartan-hydrochlorothiazide DEXCOM CONTINUOUS EPCLUSA SGM fluorouracil cream 5% ipratropium inhalation loteprednol GLUCOSE MONITORING EPIDUO fluorouracil solution solution QL lovastatin SYSTEM PA epinephrine auto-injector fluoxetine (except fluoxetine tablet 60 ipratropium-albuterol LUCENTIS † DEXILANT ST EPIPEN mg, fluoxetine tablet [generics for inhalation solution QL LUMIGAN ST dexmethylphenidate ext-rel EPIPEN JR SARAFEM]) irbesartan LYNPARZA SGM QL ERIVEDGE SGM fluticasone QL irbesartan- diazepam ERLEADA SGM fluvastatin hydrochlorothiazide M diazepam rectal gel erythromycin folic acid IRESSA SGM MAYZENT SGM diclofenac erythromycin solution FORTEO SGM ISENTRESS QL meclizine diclofenac sodium erythromycin-benzoyl fosinopril isosorbide dinitrate (except medroxyprogesterone diclofenac sodium gel 1% peroxide fosinopril-hydrochlorothiazide isosorbide dinitrate 40 mg) megestrol acetate PA erythromycins furosemide isosorbide mononitrate meloxicam diclofenac sodium solution ESBRIET SGM FYCOMPA itraconazole PA memantine diclofenac sodium- escitalopram ivermectin mesalamine delayed-rel

misoprostol esomeprazole delayed-rel G (except mesalamine delayed-rel tablet † dicloxacillin ESPEROCT gabapentin J 800 mg) dicyclomine estradiol galantamine JANUMET mesalamine ext-rel DIFICID ST, QL estradiol vaginal cream galantamine ext-rel JANUMET XR mesalamine suppository digoxin estradiol-norethindrone GENOTROPIN SGM JANUVIA mesalamine suspension diltiazem ext-rel (except generics eszopiclone gentamicin QL JARDIANCE metformin for CARDIZEM LA) ethinyl estradiol- GENVOYA QL JIVI † metformin ext-rel (except generics

dimethyl fumarate delayed- drospirenone GILENYA SGM for FORTAMET and GLUMETZA) rel SGM ethinyl estradiol- glatiramer SGM K methadone QL diphenoxylate-atropine drospirenone-levomefolate glimepiride KANJINTI † methoxsalen dipyridamole ext-rel-aspirin ethinyl estradiol-etonogestrel glipizide KESIMPTA SGM methylphenidate QL disopyramide ethinyl estradiol- glipizide ext-rel ketoconazole cream 2% QL methylphenidate ext-rel QL divalproex sodium levonorgestrel glipizide-metformin ketoconazole shampoo 2% methylprednisolone divalproex sodium ext-rel ethinyl estradiol- GLUCAGEN HYPOKIT ketorolac QL metoclopramide DIVIGEL norelgestromin GLUCAGON EMERGENCY KISQALI SGM metolazone donepezil ethinyl estradiol- KIT KISQALI FEMARA CO- metoprolol succinate ext-rel DOPTELET SGM norethindrone acetate GLYXAMBI PACK SGM metoprolol tartrate dorzolamide ethinyl estradiol- GONAL-F PA KOGENATE FS † metronidazole dorzolamide-timolol norethindrone acetate-iron GRALISE ST KOVALTRY † minocycline † DOVATO QL ethinyl estradiol-norgestimate granisetron QL KYLEENA † MIRENA doxazosin ethosuximide GRASTEK PA KYNMOBI SGM mirtazapine doxepin EUCRISA ST guanfacine ext-rel QL modafinil PA doxycycline hyclate 20 mg EVAMIST GVOKE L mometasone QL

doxycycline hyclate capsule everolimus SGM lactulose solution mometasone nasal spray QL H dronabinol PA, QL EVOTAZ QL lamivudine QL montelukast † DUAVEE EYLEA HARVONI SGM lamotrigine morphine QL

duloxetine ezetimibe HUMIRA SGM lamotrigine ext-rel morphine ext-rel QL

DUPIXENT SGM ezetimibe-simvastatin HUMULIN R U-500 lansoprazole delayed-rel morphine suppository QL

DUREZOL hydrochlorothiazide latanoprost MOVANTIK F dutasteride hydrocodone ext-rel QL LATUDA moxifloxacin dutasteride-tamsulosin famotidine hydrocodone-acetaminophen levalbuterol tartrate CFC-free MULPLETA SGM DYMISTA ST, QL FARXIGA QL aerosol QL MULTAQ

FASENRA AUTOINJECTOR hydrocortisone QL LEVEMIR mupirocin ointment E SGM hydrocortisone butyrate levetiracetam MYDAYIS QL econazole QL fenofibrate (except fenofibrate capsule cream, ointment, solution levetiracetam ext-rel MYRBETRIQ ST

efavirenz-emtricitabine- 50 mg, 130 mg; fenofibrate tablet 40 mg, QL levocarnitine N tenofovir disoproxil 120 mg) hydrocortisone enema levocetirizine fumarate QL fenofibric acid delayed-rel hydrocortisone tablet levofloxacin nadolol efavirenz-lamivudine- fentanyl transdermal QL hydromorphone QL levothyroxine NAFTIN tenofovir disoproxil fentanyl transmucosal hydromorphone ext-rel QL lidocaine patch PA naloxone injection

fumarate QL lozenge PA lidocaine-prilocaine NAMZARIC eletriptan QL FIASP I linezolid PA naproxen (except naproxen CR or ELIGARD SGM FINACEA FOAM PA ibandronate LINZESS naproxen suspension)

naratriptan QL OPSUMIT SGM PROLIA † solifenacin torsemide NARCAN NASAL SPRAY ORACEA PA promethazine SOLIQUA TOUJEO nateglinide ORALAIR PA propranolol SOMATULINE DEPOT SGM TOVIAZ ST NATESTO PA ORENITRAM SGM propranolol ext-rel SOOLANTRA PA tramadol (except NDC^ NAYZILAM ORFADIN SGM PULMICORT FLEXHALER sotalol 52817019610) QL neomycin-polymyxin B- ORIAHNN PA QL SPIRIVA QL tramadol ext-rel tablet QL bacitracin-hydrocortisone ORILISSA PA pyrimethamine PA spironolactone- travoprost

neomycin-polymyxin B- oseltamivir QL hydrochlorothiazide TRAZIMERA † Q dexamethasone OTEZLA SGM SPRYCEL SGM trazodone † neomycin-polymyxin B- OVIDREL quetiapine STELARA INTRAVENOUS TRELEGY ELLIPTA QL hydrocortisone oxazepam quetiapine ext-rel STELARA TREMFYA SGM NEUPRO oxcarbazepine quinapril SUBCUTANEOUS SGM treprostinil SGM NEXLETOL PA OXTELLAR XR quinapril-hydrochlorothiazide STIOLTO RESPIMAT QL TRESIBA NEXLIZET PA oxybutynin QVAR REDIHALER QL STIVARGA SGM tretinoin PA, ** niacin ext-rel oxybutynin ext-rel STRIBILD QL triamcinolone cream, lotion, R nifedipine ext-rel oxycodone QL STRIVERDI RESPIMAT QL ointment (except triamcinolone NINLARO SGM oxycodone-acetaminophen RAGWITEK PA SUBSYS PA ointment 0.05%) QL nitrofurantoin (except NDC^ QL raloxifene sucralfate tablet triamterene 70408023932) OZEMPIC ramelteon sulfacetamide triamterene-

nitroglycerin lingual spray ramipril sulfamethoxazole- hydrochlorothiazide P nitroglycerin sublingual ranolazine ext-rel trimethoprim trientine ST NIVESTYM SGM pantoprazole delayed-rel rasagiline sulfasalazine trifluridine NORDITROPIN SGM tablet RASUVO SGM sulfasalazine delayed-rel TRIJARDY XR NORVIR QL paroxetine HCl REBIF SGM sumatriptan QL trimethobenzamide † NOVOEIGHT paroxetine HCl ext-rel REBINYN † SUNOSI PA TRINTELLIX ST NOVOLIN 70/30 OTC peg 3350-electrolytes RELENZA QL SUPPRELIN LA † TRIPTODUR † NOVOLIN N OTC penicillamine capsule ST REMICADE † SUPRAX TRIUMEQ QL NOVOLIN R OTC penicillin VK repaglinide SYMBICORT QL trospium NOVOLOG PENTASA RESTASIS SYMJEPI trospium ext-rel NOVOLOG MIX 70/30 PERFOROMIST QL RETACRIT SGM SYMLINPEN TRULICITY NUBEQA SGM PERJETA † REVLIMID SGM SYMPROIC TRUVADA QL NUCALA AUTOINJECTOR PERSERIS REYVOW ST SYMTUZA QL TYMLOS SGM SGM phenobarbital RHOPRESSA SYNJARDY TYSABRI † NUCYNTA QL phenytoin ribavirin SGM SYNJARDY XR NUCYNTA ER QL phenytoin sodium extended RINVOQ SGM SYNTHROID U NUEDEXTA PA PHESGO SGM risedronate UBRELVY ST NURTEC ODT ST T PHOSLYRA risperidone UPTRAVI SGM † NUWIQ PICATO rivastigmine tacrolimus PA nystatin QL pimecrolimus PA rivastigmine transdermal tamsulosin V

pindolol TEGSEDI SGM rizatriptan QL valacyclovir O pioglitazone TEKTURNA HCT ST ROCKLATAN ST valganciclovir OCREVUS † pioglitazone-glimepiride telmisartan ropinirole valproic acid ODEFSEY QL pioglitazone-metformin telmisartan- ropinirole ext-rel valsartan ODOMZO SGM POMALYST SGM rosuvastatin hydrochlorothiazide valsartan-hydrochlorothiazide OFEV SGM potassium chloride liquid TEMIXYS QL RUBRACA SGM VALTOCO ofloxacin PRALUENT PA terazosin rufinamide vancomycin capsule QL ofloxacin otic pramipexole terbinafine tablet RUXIENCE † VASCEPA PA olanzapine pramipexole ext-rel testosterone gel (except authorized RYBELSUS VELCADE † olmesartan prasugrel generics for TESTIM and VOGELXO) RYDAPT SGM VELPHORO ST olmesartan-amlodipine- pravastatin PA VELTASSA hydrochlorothiazide prednisolone acetate 1% S testosterone solution PA VEMLIDY olmesartan- prednisolone solution tetrabenazine SGM SANCUSO PA, QL venlafaxine hydrochlorothiazide prednisone tetracycline sapropterin SGM venlafaxine ext-rel capsule olopatadine pregabalin ST, QL THALOMID SGM scopolamine transdermal verapamil ext-rel olopatadine spray QL PREMPHASE tiagabine selegiline VIBERZI omega-3 acid ethyl esters PREMPRO timolol maleate solution selenium sulfide lotion 2.5% VICTOZA PA prenatal vitamins TIVICAY QL SEREVENT QL vigabatrin SGM omeprazole delayed-rel PREZCOBIX QL TOBRADEX OINTMENT sertraline VIMPAT OMNIPOD DASH QL PREZISTA QL tobramycin sevelamer carbonate VIOKACE ondansetron QL primidone tobramycin inhalation sildenafil SGM VOSEVI 2 SGM ONETOUCH ULTRA probenecid solution SGM silodosin VRAYLAR ST STRIPS AND KITS 3 OTC prochlorperazine tobramycin-dexamethasone SIMBRINZA VUMERITY SGM ONETOUCH VERIO STRIPS PROCTOFOAM-HC † TOLAK SIMPONI ARIA VYVANSE QL 3 AND KITS OTC progesterone, micronized simvastatin tolterodine ONEXTON PROLASTIN-C † SKYLA † tolterodine ext-rel W ONZETRA XSAIL ST PROLENSA topiramate SKYRIZI SGM warfarin

XIGDUO XR Y ZEMBRACE SYMTOUCH ZIRABEV † X XIIDRA ST zolmitriptan QL YONSA SGM XARELTO XOLAIR † ZENPEP zolpidem YUPELRI QL XCOPRI XOSPATA SGM ZEPOSIA SGM zolpidem ext-rel XELJANZ SGM XTAMPZA ER QL Z ZIEXTENZO SGM XELJANZ XR SGM XTANDI SGM ZIOPTAN ST zafirlukast XIFAXAN 550 MG PA XULTOPHY ziprasidone ZEJULA SGM ZOMIG NASAL SPRAY QL zonisamide ZUBSOLV QL ZYCLARA

PREFERRED OPTIONS LIST NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, AMITIZA LINZESS, MOVANTIK, SYMPROIC quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR ST AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) ACANYA adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, clindamycin- ANDROGEL testosterone gel (except authorized generics for benzoyl peroxide, erythromycin solution, TESTIM and VOGELXO) PA, testosterone erythromycin-benzoyl peroxide, tretinoin PA, **, solution PA, ANDRODERM PA, NATESTO PA EPIDUO, ONEXTON ANGELIQ estradiol-norethindrone, PREMPHASE, ACIPHEX, ACIPHEX SPRINKLE esomeprazole delayed-rel, lansoprazole delayed- PREMPRO rel, omeprazole delayed-rel, pantoprazole ANTARA fenofibrate (except fenofibrate capsule 50 mg, delayed-rel tablet, DEXILANT ST 130 mg; fenofibrate tablet 40 mg, 120 mg), ACTEMRA ACTPEN, ACTEMRA ENBREL SGM, HUMIRA SGM, RINVOQ SGM, fenofibric acid delayed-rel SUBCUTANEOUS XELJANZ SGM, XELJANZ XR SGM APEXICON E desoximetasone (except desoximetasone ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate ointment 0.05%) QL, fluocinonide (except capsule, minocycline, tetracycline fluocinonide cream 0.1%) QL, BRYHALI PA Activite folic acid APIDRA FIASP, NOVOLOG ACTOS pioglitazone APOKYN INBRIJA SGM, KYNMOBI SGM ACUVAIL bromfenac, diclofenac, ketorolac QL, ILEVRO, APTENSIO XR amphetamine- PROLENSA dextroamphetamine mixed salts ext-rel QL, dexmethylphenidate ext-rel QL, methylphenidate acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir ext-rel QL, MYDAYIS QL, VYVANSE QL ADDERALL amphetamine-dextroamphetamine mixed salts APTIVUS Consult doctor QL, methylphenidate QL ADZENYS ER, ADZENYS XR-ODT amphetamine-dextroamphetamine mixed salts ARALAST NP PROLASTIN-C † ext-rel QL, dexmethylphenidate ext-rel QL, methylphenidate ext-rel QL, MYDAYIS QL, ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID VYVANSE QL ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, ALCORTIN A desonide QL, hydrocortisone QL meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole ALEVICYN GEL, ALEVICYN SG, desonide QL, hydrocortisone QL delayed-rel, lansoprazole delayed-rel, ALEVICYN SOLUTION omeprazole delayed-rel, pantoprazole delayed- rel tablet or DEXILANT ST ALIQOPA COPIKTRA SGM ASACOL HD balsalazide, mesalamine delayed- ALLISON MEDICAL INSULIN BD ULTRAFINE INSULIN SYRINGES OTC rel, mesalamine ext-rel, sulfasalazine, 5 SYRINGES sulfasalazine delayed-rel, PENTASA ALORA estradiol, DIVIGEL, EVAMIST ASCENSIA STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND 3 ALPROLIX Consult doctor KITS OTC, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE ALREX azelastine, cromolyn sodium, olopatadine STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, lovastatin, pravastatin, rosuvastatin, simvastatin ONETOUCH VERIO STRIPS AND KITS 3 OTC ALVESCO ARNUITY ELLIPTA QL, FLOVENT DISKUS QL, ASMANEX, ASMANEX HFA ARNUITY ELLIPTA QL, FLOVENT DISKUS QL, FLOVENT HFA QL, FLOVENT HFA QL, PULMICORT FLEXHALER QL, PULMICORT FLEXHALER QL, QVAR REDIHALER QL QVAR REDIHALER QL

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, BERINERT icatibant SGM irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, BETAPACE, BETAPACE AF sotalol olmesartan, olmesartan-hydrochlorothiazide, BETIMOL timolol maleate solution, BETOPTIC S telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide BEVESPI AEROSPHERE ANORO ELLIPTA QL, STIOLTO RESPIMAT QL ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol- drospirenone-levomefolate, ethinyl estradiol- ATOPADERM desonide QL, hydrocortisone QL norethindrone acetate, ethinyl estradiol- ATROVENT HFA ipratropium inhalation solution QL, SPIRIVA QL, norethindrone acetate-iron YUPELRI QL bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN ST † AVASTIN ZIRABEV BORTEZOMIB NINLARO SGM, VELCADE †

BREEZE 2 STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3 AVENOVA Consult doctor OTC, ACCU-CHEK COMPACT PLUS STRIPS 3 AVONEX dimethyl fumarate delayed-rel SGM, AND KITS OTC, ACCU-CHEK GUIDE STRIPS 3 glatiramer SGM, AUBAGIO SGM, BETASERON AND KITS OTC, ACCU-CHEK SMARTVIEW 3 SGM, COPAXONE SGM, GILENYA SGM, STRIPS AND KITS OTC, ONETOUCH ULTRA 3 KESIMPTA SGM, MAYZENT SGM, OCREVUS †, STRIPS AND KITS OTC, ONETOUCH VERIO REBIF SGM, TYSABRI †, ZEPOSIA SGM STRIPS AND KITS 3 OTC AZASITE ciprofloxacin, erythromycin, gentamicin QL, levofloxacin, moxifloxacin, ofloxacin, BROMSITE bromfenac, diclofenac, ketorolac QL, ILEVRO, sulfacetamide, tobramycin, BESIVANCE PROLENSA AZELEX adapalene PA, benzoyl peroxide, clindamycin gel Bupap diclofenac sodium, ibuprofen, naproxen (except (except NDC^ 68682046275) QL, naproxen CR or naproxen suspension) clindamycin solution QL, clindamycin- bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion benzoyl peroxide, erythromycin solution, ext-rel tablet 450 mg) erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON butalbital-acetaminophen tablet 50- diclofenac sodium, ibuprofen, naproxen (except 300 mg, BUTALBITAL- naproxen CR or naproxen suspension) AZESCO 7 prenatal vitamins, CITRANATAL ACETAMINOPHEN (NDC^ AZOR amlodipine-olmesartan, amlodipine-telmisartan, 69499034230 only) amlodipine-valsartan butalbital-acetaminophen-caffeine diclofenac sodium, ibuprofen, naproxen (except BANZEL SUSPENSION clobazam, lamotrigine, rufinamide, topiramate capsule naproxen CR or naproxen suspension) BARACLUDE TABLET entecavir, lamivudine, VEMLIDY BUTRANS buprenorphine transdermal QL, BELBUCA QL BEAU RX Consult doctor BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA BECONASE AQ flunisolide QL, fluticasone QL, BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA mometasone nasal spray QL, DYMISTA ST, QL CAFERGOT eletriptan QL, rizatriptan QL, sumatriptan QL, BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, zolmitriptan QL, NURTEC ODT ST, ONZETRA irbesartan, irbesartan-hydrochlorothiazide, XSAIL ST, REYVOW ST, UBRELVY ST, losartan, losartan-hydrochlorothiazide, ZEMBRACE SYMTOUCH ST, olmesartan, olmesartan-hydrochlorothiazide, ZOMIG NASAL SPRAY QL telmisartan, telmisartan-hydrochlorothiazide, calcipotriene cream calcipotriene ointment QL, calcipotriene valsartan, valsartan-hydrochlorothiazide solution QL BENSAL HP desonide QL, hydrocortisone QL calcipotriene-betamethasone calcipotriene ointment QL or calcipotriene BENZAC AC adapalene PA, benzoyl peroxide, clindamycin gel solution QL WITH desoximetasone (except (except NDC^ 68682046275) QL, desoximetasone ointment 0.05%) QL, clindamycin solution QL, clindamycin- fluocinonide (except fluocinonide cream 0.1%) benzoyl peroxide, erythromycin solution, QLor BRYHALI PA erythromycin-benzoyl peroxide, tretinoin PA, **, calcitriol ointment calcipotriene ointment QL, calcipotriene EPIDUO, ONEXTON solution QL BENZACLIN adapalene PA, benzoyl peroxide, clindamycin gel CAMBIA diclofenac sodium, ibuprofen, naproxen (except (except NDC^ 68682046275) QL, naproxen CR or naproxen suspension) clindamycin solution QL, clindamycin- benzoyl peroxide, erythromycin solution, CARAC fluorouracil cream 5%, fluorouracil solution, erythromycin-benzoyl peroxide, tretinoin PA, **, imiquimod, PICATO, TOLAK, ZYCLARA EPIDUO, ONEXTON CARAFATE sucralfate tablet benzonatate (NDCs^ 69336012615, benzonatate (except NDCs^ 69336012615, 69499032915 only) 69499032915) CARBINOXAMINE TABLET 6 MG levocetirizine BEPREVE azelastine, cromolyn sodium, olopatadine CARDIZEM, CARDIZEM CD, diltiazem ext-rel (except generics for CARDIZEM CARDIZEM LA LA)

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* CARNITOR, CARNITOR SF levocarnitine STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC carisoprodol 250 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) CORDRAN OINTMENT hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment CELEBREX celecoxib, diclofenac sodium, ibuprofen, QL,hydrocortisone butyrate solution QL, meloxicam, naproxen (except naproxen CR or mometasone QL, triamcinolone naproxen suspension) cream QL, triamcinolone lotion QL, triamcinolone chlordiazepoxide-clidinium (NDCs^ dicyclomine ointment (except triamcinolone ointment 0.05%) 11534019701, 42494040901, QL 51293069601, 51293069610 only) COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, chlorzoxazone 375 mg, cyclobenzaprine (except cyclobenzaprine tablet metoprolol succinate ext-rel, metoprolol tartrate, chlorzoxazone 500 mg (NDC^ 7.5 mg) nadolol, pindolol, propranolol, propranolol ext-rel, 73007001303 only), chlorzoxazone BYSTOLIC 750 mg, CHLORZOXAZONE 250 MG CoreMino doxycycline hyclate 20 mg, doxycycline hyclate CICATRACE Consult doctor capsule, minocycline, tetracycline CILOXAN ciprofloxacin, erythromycin, gentamicin QL, COZAAR candesartan, irbesartan, losartan, olmesartan, levofloxacin, moxifloxacin, ofloxacin, telmisartan, valsartan sulfacetamide, tobramycin, BESIVANCE CRESEMBA itraconazole PA CIMZIA PREFILLED SYRINGE COSENTYX SGM, ENBREL SGM, CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, HUMIRA SGM, OTEZLA SGM, RINVOQ SGM, lovastatin, pravastatin, rosuvastatin, simvastatin STELARA SUBCUTANEOUS SGM, TREMFYA SGM, XELJANZ SGM, CUPRIMINE penicillamine capsule ST XELJANZ XR SGM CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic cyclobenzaprine ext-rel capsule, cyclobenzaprine (except cyclobenzaprine tablet cyclobenzaprine tablet 7.5 mg 7.5 mg) CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, CLINDAGEL erythromycin solution venlafaxine ext-rel capsule clindamycin gel (NDC^ 68682046275 adapalene, benzoyl peroxide, clindamycin gel CYTOMEL levothyroxine, liothyronine, SYNTHROID only) (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, DARAPRIM pyrimethamine PA erythromycin solution, erythromycin-benzoyl peroxide, DAYTRANA amphetamine-dextroamphetamine mixed salts tretinoin PA, **, EPIDUO, ONEXTON ext-rel QL, dexmethylphenidate ext-rel QL, methylphenidate ext-rel QL, MYDAYIS QL, clobetasol spray clobetasol foam QL VYVANSE QL CLOBEX SPRAY clobetasol foam QL DELZICOL balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 clocortolone cream hydrocortisone butyrate cream QL, mg), mesalamine ext-rel, sulfasalazine, hydrocortisone butyrate ointment QL, sulfasalazine delayed-rel, PENTASA hydrocortisone butyrate solution QL, mometasone QL, triamcinolone cream QL, DESFERAL deferasirox SGM, deferiprone SGM, triamcinolone lotion QL, triamcinolone ointment deferoxamine † (except triamcinolone ointment 0.05%) QL desoximetasone ointment 0.05% hydrocortisone butyrate cream QL, COLAZAL balsalazide, mesalamine delayed-rel (except hydrocortisone butyrate ointment QL, mesalamine delayed-rel tablet 800 mg), hydrocortisone butyrate solution QL, mesalamine ext-rel, sulfasalazine, sulfasalazine mometasone QL, triamcinolone delayed-rel, PENTASA cream QL, triamcinolone lotion QL, triamcinolone ointment (except triamcinolone ointment 0.05%) colchicine capsule colchicine tablet QL COLCRYS colchicine tablet DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, CONSENSI amlodipine WITH celecoxib tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST CONTOUR NEXT STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6 KITS 3 OTC, ACCU-CHEK COMPACT PLUS dexchlorpheniramine levocetirizine 3 STRIPS AND KITS OTC, ACCU-CHEK GUIDE Dexifol folic acid STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, Diclofex DC (NDC^ 51021037201 diclofenac sodium, diclofenac sodium gel 1% PA, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, only) diclofenac sodium solution, ibuprofen, ONETOUCH VERIO STRIPS AND meloxicam, naproxen (except naproxen CR or KITS 3 OTC naproxen suspension) CONTOUR STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3 Diclosaicin diclofenac sodium, diclofenac sodium gel 1% PA, OTC, ACCU-CHEK COMPACT PLUS STRIPS diclofenac sodium solution, ibuprofen, AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS meloxicam, naproxen (except naproxen CR or AND KITS 3 OTC, ACCU-CHEK SMARTVIEW naproxen suspension) STRIPS AND KITS 3 OTC, ONETOUCH ULTRA

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* DIFFERIN LOTION adapalene PA, benzoyl peroxide, clindamycin gel EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, (except NDC^ 68682046275) QL, venlafaxine ext-rel capsule clindamycin solution QL, clindamycin- † benzoyl peroxide, erythromycin solution, ELELYSO CERDELGA SGM, CEREZYME erythromycin-benzoyl peroxide, tretinoin PA, **, ELIDEL pimecrolimus PA, tacrolimus PA, EUCRISA ST EPIDUO, ONEXTON ELMIRON Consult doctor diflorasone cream, diflorasone desoximetasone (except desoximetasone ointment ointment 0.05%) QL, fluocinonide (except fluocinonide cream 0.1%) QL, BRYHALI PA ENABLEX darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, dihydroergotamine spray eletriptan QL, naratriptan QL, rizatriptan QL, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE UBRELVY ST, ZEMBRACE SYMTOUCH ST, MONITORING MONITORING SYSTEM PA ZOMIG NASAL SPRAY QL ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG PA diltiazem ext-rel diltiazem ext-rel (generics for CARDIZEM LA only) (except generics for CARDIZEM LA) ENTYVIO HUMIRA SGM, STELARA SUBCUTANEOUS SGM, DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, XELJANZ SGM irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- EPICERAM desonide QL, hydrocortisone QL hydrochlorothiazide, olmesartan, olmesartan- EPOGEN ARANESP SGM, RETACRIT SGM hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan- ergotamine-caffeine eletriptan QL, naratriptan QL, rizatriptan QL, hydrochlorothiazide sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, Diphen Elixir levocetirizine UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL DORAL doxepin, eszopiclone, ramelteon, zolpidem, ERYPED erythromycins zolpidem ext-rel, BELSOMRA ST estradiol vaginal tablet estradiol vaginal cream, IMVEXXY DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline ESTRING estradiol vaginal cream, IMVEXXY doxepin cream desonide QL, pimecrolimus PA, EVEKEO amphetamine- hydrocortisone QL, tacrolimus PA, EUCRISA ST dextroamphetamine mixed salts QL, methylphenidate QL doxycycline hyclate delayed-rel tablet doxycycline hyclate 20 mg, doxycycline hyclate 50 mg, 200 mg capsule, minocycline, tetracycline EVERSENSE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE GLUCOSE MONITORING SYSTEM MONITORING SYSTEM PA doxycycline hyclate tablet 50 mg doxycycline hyclate 20 mg, doxycycline hyclate (NDC^ 72143021160 capsule, minocycline, tetracycline EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, only), doxycycline hyclate tablet 75 amlodipine-valsartan mg, doxycycline hyclate tablet 150 mg EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide doxycycline monohydrate capsule 75 doxycycline hyclate 20 mg, doxycycline hyclate mg, doxycycline monohydrate capsul capsule, minocycline, tetracycline EXJADE deferasirox SGM, deferiprone SGM, † e 150 mg deferoxamine doxycycline monohydrate delayed-rel ORACEA PA EXTAVIA dimethyl fumarate delayed-rel SGM, capsule glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE SGM, DULERA ADVAIR DISKUS QL, ADVAIR HFA ‡ QL, BREO GILENYA SGM, KESIMPTA SGM, ELLIPTA ‡ QL, SYMBICORT QL MAYZENT SGM, OCREVUS †, REBIF SGM, TYSABRI †, ZEPOSIA SGM DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide FABIOR adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, DYRENIUM amiloride, triamterene clindamycin solution QL, clindamycin- EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, benzoyl peroxide, erythromycin solution, irbesartan, irbesartan-hydrochlorothiazide, erythromycin-benzoyl peroxide, tretinoin PA, **, losartan, losartan- EPIDUO, ONEXTON hydrochlorothiazide, olmesartan, olmesartan- FANAPT aripiprazole, clozapine, olanzapine, quetiapine, hydrochlorothiazide, telmisartan, telmisartan- quetiapine ext-rel, risperidone, ziprasidone, hydrochlorothiazide, valsartan, valsartan- LATUDA, VRAYLAR ST hydrochlorothiazide FEMRING estradiol vaginal cream, IMVEXXY EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA ST fenofibrate capsule 50 mg, 130 mg; fenofibrate (except fenofibrate capsule 50 mg, fenofibrate tablet 40 mg, 120 mg 130 mg; fenofibrate tablet 40 mg, 120 mg), E.E.S. GRANULES erythromycins fenofibric acid delayed-rel

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate capsule 50 mg, FOSRENOL calcium acetate, sevelamer 130 mg; fenofibrate tablet 40 mg, 120 mg), carbonate, PHOSLYRA, VELPHORO ST fenofibric acid delayed-rel FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate fenoprofen, FENOPROFEN diclofenac sodium, ibuprofen, meloxicam, CAPSULE naproxen (except naproxen CR or naproxen FREESTYLE LIBRE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE suspension) GLUCOSE MONITORING SYSTEM PA 6 FERIVA 21/7 folic acid FREESTYLE STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK COMPACT PLUS FERRIPROX deferasirox SGM, deferiprone SGM, STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE deferoxamine † STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, venlafaxine ext-rel capsule ONETOUCH VERIO STRIPS AND KITS 3 OTC Fexmid cyclobenzaprine (except cyclobenzaprine tablet FROVA eletriptan QL, ergotamine-caffeine, 7.5 mg) naratriptan QL, rizatriptan QL, sumatriptan QL, FINACEA GEL azelaic acid gel PA, metronidazole, FINACEA zolmitriptan QL, NURTEC ODT ST, ONZETRA FOAM PA, SOOLANTRA PA XSAIL ST, REYVOW ST, UBRELVY ST, ZEMBRACE SYMTOUCH ST, FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except ZOMIG NASAL SPRAY QL naproxen CR or naproxen suspension) FULPHILA ZIEXTENZO SGM FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL Genicin Vita-S folic acid † flucytosine capsule 500 mg fluconazole GLASSIA PROLASTIN-C GLEEVEC imatinib mesylate SGM, BOSULIF SGM, fluocinonide cream 0.1% clobetasol cream QL SPRYCEL SGM fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, GLUMETZA metformin, metformin ext-rel (except generics imiquimod, PICATO, TOLAK, ZYCLARA for FORTAMET and GLUMETZA) fluoxetine tablet (generics for fluoxetine (except fluoxetine tablet 60 mg, GLYCOPYRROLATE TABLET 1.5 dicyclomine SARAFEM only) fluoxetine tablet [generics for SARAFEM]), MG paroxetine HCl ext-rel, sertraline GOLYTELY peg 3350-electrolytes, CLENPIQ fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except GRANIX NIVESTYM SGM fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, GUARDIAN CONNECT DEXCOM CONTINUOUS GLUCOSE paroxetine HCl ext-rel, sertraline, TRINTELLIX CONTINUOUS GLUCOSE MONITORING SYSTEM PA ST MONITORING SYSTEM flurandrenolide cream, desonide QL, hydrocortisone QL GUARDIAN REAL-TIME DEXCOM CONTINUOUS GLUCOSE flurandrenolide lotion CONTINUOUS GLUCOSE MONITORING SYSTEM PA MONITORING SYSTEM flurandrenolide ointment hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment QL, halcinonide cream desoximetasone (except desoximetasone hydrocortisone butyrate solution QL, ointment 0.05%) QL, fluocinonide (except mometasone QL, triamcinolone cream QL, fluocinonide cream 0.1%) QL, BRYHALI PA triamcinolone lotion QL, triamcinolone ointment (except triamcinolone ointment 0.05%) QL HORIZANT gabapentin, GRALISE ST FML FORTE, FML LIQUIFILM, dexamethasone, loteprednol, prednisolone acetat HUMALOG FIASP, NOVOLOG FML S.O.P. e 1%, DUREZOL HUMALOG MIX 50/50 NOVOLOG MIX 70/30 FOCALIN XR amphetamine-dextroamphetamine mixed salts HUMALOG MIX 75/25 NOVOLOG MIX 70/30 ext-rel QL, dexmethylphenidate ext-rel QL, methylphenidate ext-rel QL, MYDAYIS QL, HUMATROPE GENOTROPIN SGM, NORDITROPIN SGM VYVANSE QL HUMULIN 70/30 NOVOLIN 70/30 OTC FOLIC-K folic acid HUMULIN N NOVOLIN N OTC FOLLISTIM AQ GONAL-F PA HUMULIN R NOVOLIN R OTC Folvite-D folic acid hydrocortisone butyrate lipophilic hydrocortisone butyrate cream QL, FORTAMET metformin, metformin ext-rel (except generics cream 0.1% hydrocortisone butyrate ointment QL, for FORTAMET and GLUMETZA) hydrocortisone butyrate solution QL, mometasone QL, triamcinolone FORTESTA testosterone gel (except authorized generics for cream QL, triamcinolone lotion QL, triamcinolone TESTIM and VOGELXO) PA, testosterone ointment (except triamcinolone ointment 0.05%) solution PA, ANDRODERM PA, NATESTO PA QL FOSAMAX PLUS D alendronate, ibandronate, risedronate hydrocortisone butyrate lotion hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment QL,

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* hydrocortisone butyrate solution QL, KAMDOY desonide QL, hydrocortisone QL mometasone QL, triamcinolone cream QL, triamcinolone lotion QL, triamcinolone KAZANO JANUMET, JANUMET XR ointment (except triamcinolone ointment 0.05%) ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide QL lotion 2.5% HylaVite folic acid Ketodan ketoconazole shampoo 2%, selenium sulfide hyoscyamine sulfate ext-rel dicyclomine lotion 2.5% HYSINGLA ER fentanyl transdermal QL, hydrocodone ext-rel ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, QL, hydromorphone ext-rel QL, methadone QL, naproxen (except naproxen CR or naproxen morphine ext-rel QL, suspension) NUCYNTA ER QL, XTAMPZA ER QL ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, HYZAAR candesartan-hydrochlorothiazide, irbesartan- naproxen (except naproxen CR or naproxen hydrochlorothiazide, losartan- suspension) hydrochlorothiazide, olmesartan- KINERET ENBREL SGM, HUMIRA SGM, RINVOQ SGM, hydrochlorothiazide, telmisartan- XELJANZ SGM, XELJANZ XR SGM hydrochlorothiazide, valsartan- hydrochlorothiazide KOMBIGLYZE XR JANUMET, JANUMET XR INCRUSE ELLIPTA SPIRIVA QL, YUPELRI QL KUVAN sapropterin SGM

INDERAL LA, INDERAL XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, KYPROLIS NINLARO SGM, VELCADE † nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC LACRISERT RESTASIS, XIIDRA INDOCIN diclofenac sodium, ibuprofen, meloxicam, Lactojen Consult doctor naproxen (except naproxen CR or naproxen suspension) LACTULOSE PAK lactulose solution indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, LANOXIN TABLET (125 MCG and digoxin naproxen (except naproxen CR or naproxen 250 MCG only) suspension) lanthanum carbonate calcium acetate, sevelamer carbonate, Inflammacin diclofenac sodium, diclofenac sodium gel 1% PA, PHOSLYRA, VELPHORO ST diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or LANTUS 8 BASAGLAR, LEVEMIR naproxen suspension) LASTACAFT azelastine, cromolyn sodium, olopatadine INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, LAZANDA fentanyl transmucosal lozenge PA, SUBSYS PA BYSTOLIC LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, INTRAROSA estradiol vaginal cream, IMVEXXY lovastatin, pravastatin, rosuvastatin, simvastatin INTUNIV amphetamine-dextroamphetamine mixed salts LETAIRIS ambrisentan SGM, bosentan SGM, OPSUMIT ext-rel QL, atomoxetine QL, dexmethylphenidate SGM ext-rel QL, guanfacine ext-rel QL, levorphanol fentanyl transdermal QL, hydrocodone ext-rel methylphenidate ext-rel QL, MYDAYIS QL, QL, hydromorphone ext-rel QL, methadone QL, VYVANSE QL morphine ext-rel QL, INVELTYS dexamethasone, loteprednol, NUCYNTA ER QL, XTAMPZA ER QL prednisolone acetate 1%, DUREZOL LEXAPRO citalopram, escitalopram, fluoxetine (except INVIRASE atazanavir QL, EVOTAZ QL, PREZCOBIX QL, fluoxetine tablet 60 mg, fluoxetine tablet PREZISTA QL [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR TRINTELLIX ST INVOKANA FARXIGA, JARDIANCE LEXIVA atazanavir QL, EVOTAZ QL, PREZCOBIX QL, PREZISTA QL isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate LIALDA balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 ISTALOL timolol maleate solution, BETOPTIC S mg), mesalamine ext-rel, sulfasalazine, JADENU deferasirox SGM, deferiprone SGM, sulfasalazine delayed-rel, PENTASA deferoxamine † LIBRAX dicyclomine JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine tamsulosin or terazosin (NDC^ 71800063115 only) JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR LIDOTREX lidocaine-prilocaine

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, lovastatin, pravastatin, rosuvastatin, simvastatin irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- LITHOSTAT Consult doctor hydrochlorothiazide, olmesartan, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, hydrochlorothiazide, valsartan, valsartan- lovastatin, pravastatin, rosuvastatin, simvastatin hydrochlorothiazide LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone Migergot eletriptan QL, naratriptan QL, rizatriptan QL, acetate 1%, DUREZOL sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, Lorid folic acid UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) MINIVELLE estradiol, DIVIGEL, EVAMIST luliconazole ciclopirox PA, clotrimazole, econazole QL, MILLIPRED dexamethasone, hydrocortisone tablet, ketoconazole cream 2% QL, NAFTIN methylprednisolone, prednisolone solution, prednisone LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA ST MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol- drospirenone-levomefolate, ethinyl estradiol- † LUPRON DEPOT ELIGARD SGM, FIRMAGON , ORIAHNN PA, norethindrone acetate, ethinyl estradiol- ORILISSA PA norethindrone acetate-iron † † LUPRON DEPOT-PED SUPPRELIN LA , TRIPTODUR MINOCIN doxycycline hyclate 20 mg, doxycycline hyclate LYRICA duloxetine, pregabalin ST, QL capsule, minocycline, tetracycline MACRODANTIN nitrofurantoin (except NDC^ 70408023932) minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline Matzim LA diltiazem ext-rel (except generics for CARDIZEM LA) MIRVASO azelaic acid gel PA, metronidazole, FINACEA FOAM PA, SOOLANTRA PA MAXIDEX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM, MOVIPREP peg 3350-electrolytes, CLENPIQ 2 VOSEVI SGM MultiPro Consult doctor MAXALT, MAXALT-MLT eletriptan QL, naratriptan QL, rizatriptan QL, mupirocin cream gentamicin QL, mupirocin ointment sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, MYTESI diphenoxylate-atropine, loperamide UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen mefenamic acid (NDC^ 69336012830 diclofenac sodium, ibuprofen, meloxicam, suspension) only) naproxen (except naproxen CR or naproxen suspension) naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen MENEST estradiol suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed- MENOSTAR estradiol rel, pantoprazole delayed-rel tablet or DEXILANT mesalamine delayed-rel tablet 800 balsalazide, mesalamine delayed-rel (except ST mg mesalamine delayed-rel tablet 800 mg), naproxen CR diclofenac sodium, ibuprofen, meloxicam, mesalamine ext-rel, sulfasalazine, sulfasalazine naproxen (except naproxen CR or naproxen delayed-rel, PENTASA suspension) metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet naproxen suspension diclofenac sodium, ibuprofen, meloxicam, 7.5 mg) naproxen (except naproxen CR or naproxen metformin ext-rel metformin, metformin ext-rel (except generics suspension) (generics for FORTAMET and for FORTAMET and GLUMETZA) NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol- GLUMETZA only) drospirenone-levomefolate, ethinyl estradiol- methocarbamol 500 mg (NDC^ cyclobenzaprine (except cyclobenzaprine tablet levonorgestrel, ethinyl estradiol- 69036091010 only), 7.5 mg) norethindrone acetate, ethinyl estradiol- methocarbamol 750 mg (NDCs^ norethindrone acetate-iron, ethinyl estradiol- 69036093090, 70868090190 only) norgestimate MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, NATURE-THROID levothyroxine, liothyronine, SYNTHROID risedronate, FORTEO SGM, PROLIA †, TYMLOS SGM NEO-SYNALAR desonide QL or hydrocortisone WITH MIACALCIN NASAL SPRAY calcitonin-salmon gentamicin QL NESINA JANUVIA

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NEULASTA, NEULASTA ONPRO ZIEXTENZO SGM ONFI clobazam, lamotrigine, rufinamide, topiramate NEUPOGEN NIVESTYM SGM ONGLYZA JANUVIA NEVANAC bromfenac, diclofenac, ketorolac QL, ILEVRO, ORENCIA CLICKJECT, COSENTYX SGM, ENBREL SGM, PROLENSA ORENCIA SUBCUTANEOUS HUMIRA SGM, OTEZLA SGM, RINVOQ SGM, STELARA SUBCUTANEOUS SGM, NEXIUM esomeprazole delayed-rel, lansoprazole delayed- XELJANZ SGM, XELJANZ XR SGM rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) niacin tablet 500 mg niacin ext-rel Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet Niacor niacin ext-rel 7.5 mg) NICADAN folic acid ORTHO D folic acid NICAPRIN folic acid ORTHO DF folic acid NICAZEL, NICAZEL FORTE folic acid Oscimin SR dicyclomine NICOMIDE folic acid OSENI JANUMET, JANUMET XR; JANUVIA WITH NILANDRON abiraterone SGM, pioglitazone bicalutamide, XTANDI SGM, YONSA SGM, OSMOPREP peg 3350-electrolytes, CLENPIQ nitrofurantoin (NDC^ 70408023932 nitrofurantoin (except NDC^ 70408023932) OSPHENA estradiol only) OWEN MUMFORD NEEDLES 5 BD ULTRAFINE NEEDLES OTC NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual oxiconazole (NDCs^ 00168035830, ciclopirox PA, clotrimazole, econazole QL, 51672135902 only) ketoconazole cream 2% QL, NAFTIN Nolix desonide QL, hydrocortisone QL OXYCONTIN fentanyl transdermal QL, hydrocodone ext-rel QL, hydromorphone ext-rel QL, methadone QL, NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet morphine ext-rel QL, 7.5 mg) NUCYNTA ER QL, XTAMPZA ER QL NORITATE azelaic acid gel PA, metronidazole, oxymorphone ext-rel fentanyl transdermal QL, hydrocodone ext-rel FINACEA FOAM PA, SOOLANTRA PA QL, hydromorphone ext-rel QL, methadone QL, NORPACE disopyramide morphine ext-rel QL, NUCYNTA ER QL, XTAMPZA ER QL NORVASC amlodipine OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, NOURIANZ amantadine, entacapone, pramipexole, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST pramipexole ext-rel, rasagiline, ropinirole, ropinirole ext-rel, selegiline, NEUPRO PANCREAZE CREON, VIOKACE, ZENPEP NOVACORT desonide QL, hydrocortisone QL pantoprazole delayed-rel suspension esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, NOVO NORDISK NEEDLES 5 BD ULTRAFINE NEEDLES OTC pantoprazole delayed-rel tablet, DEXILANT ST NOXAFIL fluconazole, itraconazole PA paroxetine mesylate capsule 7.5 mg paroxetine HCl

PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1% PA, fluoxetine tablet 60 mg, fluoxetine tablet diclofenac sodium solution, ibuprofen, [generics for SARAFEM]), paroxetine HCl, meloxicam, naproxen (except naproxen CR or paroxetine HCl ext-rel, sertraline, TRINTELLIX naproxen suspension) ST NUTROPIN AQ GENOTROPIN SGM, NORDITROPIN SGM PENNSAID diclofenac sodium, diclofenac sodium gel 1% PA, diclofenac sodium solution, ibuprofen, meloxicam NUVARING ethinyl estradiol-etonogestrel, ANNOVERA , naproxen (except naproxen CR or naproxen NUVIGIL armodafinil PA, modafinil PA, SUNOSI PA suspension) OLEPTRO trazodone PERCOCET hydrocodone-acetaminophen QL, hydromorphone QL, morphine QL, oxycodone- OLUX-E clobetasol foam QL acetaminophen QL, NUCYNTA QL omeprazole-sodium bicarbonate esomeprazole delayed-rel, lansoprazole delayed- PERRIGO NEEDLES 5 BD ULTRAFINE NEEDLES OTC rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST PERTZYE CREON, VIOKACE, ZENPEP OMNARIS flunisolide QL, fluticasone QL, PEXEVA citalopram, escitalopram, fluoxetine (except mometasone nasal spray QL, DYMISTA ST, QL fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, OMNITROPE GENOTROPIN SGM, NORDITROPIN SGM paroxetine HCl ext-rel, sertraline, TRINTELLIX ST OMNIVEX folic acid

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* PLAVIX clopidogrel, prasugrel, BRILINTA QNASL flunisolide QL, fluticasone QL, mometasone nasal spray QL, DYMISTA ST, QL PLEGRIDY dimethyl fumarate delayed-rel SGM, glatiramer SGM, AUBAGIO SGM, BETASERON QTERN GLYXAMBI SGM, COPAXONE SGM, GILENYA SGM, KESIMPTA SGM, MAYZENT SGM, OCREVUS †, quazepam doxepin, eszopiclone, ramelteon, zolpidem, REBIF SGM, TYSABRI †, ZEPOSIA SGM zolpidem ext-rel, BELSOMRA ST POLYTOZA Consult doctor RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin posaconazole delayed-rel tablet fluconazole, itraconazole PA RAYOS dexamethasone, PRADAXA warfarin, ELIQUIS, XARELTO hydrocortisone tablet, methylprednisolone, predni solone solution, prednisone PRECISION XTRA STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6 KITS 3 OTC, ACCU-CHEK COMPACT PLUS RECEDO Consult doctor STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK RELION INSULIN NOVOLIN INSULIN OTC SMARTVIEW STRIPS AND KITS 3 OTC, REMODULIN treprostinil SGM ONETOUCH ULTRA STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC REPATHA PRALUENT PA PRED FORTE, PRED MILD dexamethasone, loteprednol, prednisolone acetat RHEUMATE folic acid e 1%, DUREZOL RIABNI RUXIENCE † PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO RIBOZEL folic acid PREMARIN estradiol RIMSO-50 Consult doctor PREMARIN CREAM estradiol vaginal cream, IMVEXXY RIOMET metformin, metformin ext-rel (except generics PRENATAL PLUS 7 prenatal vitamins, CITRANATAL for FORTAMET and GLUMETZA) PREVACID esomeprazole delayed-rel, lansoprazole RITUXAN RUXIENCE † delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, PREVIDENT Consult doctor zolpidem ext-rel, BELSOMRA ST PRILOSEC esomeprazole delayed-rel, lansoprazole RyClora levocetirizine delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST RYTARI carbidopa-levodopa, carbidopa-levodopa ext-rel

PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule SABRIL vigabatrin SGM PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol QL, SAIZEN GENOTROPIN SGM, NORDITROPIN SGM levalbuterol tartrate CFC-free aerosol QL SANDOSTATIN LAR SOMATULINE DEPOT SGM PROCRIT ARANESP SGM, RETACRIT SGM SCARSILK PAD Consult doctor PRODIGEN Consult doctor SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol- PROMETRIUM medroxyprogesterone; progesterone, micronized drospirenone-levomefolate, ethinyl estradiol- levonorgestrel, ethinyl estradiol- norethindrone acetate, ethinyl estradiol- PROTONIX esomeprazole delayed-rel, lansoprazole norethindrone acetate-iron delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, PROTOPIC pimecrolimus PA, tacrolimus PA, EUCRISA ST ziprasidone, LATUDA, VRAYLAR ST PROVAD Consult doctor SIGNIFOR LAR SOMATULINE DEPOT SGM PROVENTIL HFA albuterol sulfate CFC-free aerosol QL, SILENOR doxepin, eszopiclone, ramelteon, zolpidem, levalbuterol tartrate CFC-free aerosol QL zolpidem ext-rel, BELSOMRA ST PROVIGIL armodafinil PA, modafinil PA, SUNOSI PA SIL-K PAD Consult doctor

SILIVEX Consult doctor PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet SILTREX Consult doctor [generics for SARAFEM]), paroxetine HCl, SIMPONI COSENTYX SGM, ENBREL SGM, paroxetine HCl ext-rel, sertraline, HUMIRA SGM, OTEZLA SGM, RINVOQ SGM, TRINTELLIX ST STELARA SUBCUTANEOUS SGM, PSORCON desoximetasone (except desoximetasone XELJANZ SGM, XELJANZ XR SGM ointment 0.05%) QL, fluocinonide (except SINGULAIR montelukast, zafirlukast fluocinonide cream 0.1%) QL, BRYHALI PA SOMAVERT SOMATULINE DEPOT SGM

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* SORILUX calcipotriene ointment QL, calcipotriene THEO-24 ipratropium inhalation solution QL, solution QL PERFOROMIST QL, SEREVENT QL, SPIRIVA QL, STRIVERDI RESPIMAT QL, SPRIX diclofenac sodium, ibuprofen, meloxicam, YUPELRI QL naproxen (except naproxen CR or naproxen suspension) THIOLA, THIOLA EC Consult doctor

SUBOXONE buprenorphine-naloxone sublingual QL, ZUBSOLV QL TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S sucralfate suspension sucralfate tablet TIROSINT levothyroxine, SYNTHROID sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except TOBI, TOBI PODHALER tobramycin inhalation solution SGM, naproxen CR or naproxen suspension) BETHKIS SGM WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT ST, TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone, ONZETRA XSAIL ST, REYVOW ST, neomycin-polymyxin B-dexamethasone, UBRELVY ST, ZEMBRACE SYMTOUCH ST, tobramycin-dexamethasone, ZOMIG NASAL SPRAY QL TOBRADEX OINTMENT SUPREP peg 3350-electrolytes, CLENPIQ topiramate ext-rel capsule (generics carbamazepine, carbamazepine ext-rel, for QUDEXY XR only) clobazam, divalproex sodium, divalproex sodium SURE-TEST STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND ext-rel, gabapentin, lamotrigine, lamotrigine ext- KITS 3 OTC, ACCU-CHEK COMPACT PLUS rel, levetiracetam, levetiracetam ext-rel, STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE oxcarbazepine, phenobarbital, phenytoin, STRIPS AND KITS 3 OTC, ACCU-CHEK phenytoin sodium extended, primidone, SMARTVIEW STRIPS AND KITS 3 OTC, rufinamide, tiagabine, topiramate, valproic acid, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, zonisamide, FYCOMPA, OXTELLAR XR, ONETOUCH VERIO STRIPS AND KITS 3 OTC VIMPAT, XCOPRI Symax-SR dicyclomine TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext- rel, metoprolol succinate ext-rel, SYNERDERM desonide QL, hydrocortisone QL metoprolol tartrate, nadolol, pindolol, propranolol, SYPRINE trientine ST propranolol ext-rel, BYSTOLIC TRACLEER ambrisentan SGM, bosentan SGM, OPSUMIT TALIVA folic acid SGM TALTZ COSENTYX SGM, ENBREL SGM, TRADJENTA JANUVIA HUMIRA SGM, OTEZLA SGM, SKYRIZI SGM, tramadol (NDC^ 52817019610 only), tramadol (except NDC^ 52817019610) QL, STELARA SUBCUTANEOUS SGM, tramadol ext-rel capsule tramadol ext-rel tablet QL TREMFYA SGM, XELJANZ SGM, XELJANZ XR SGM TRANSDERM SCOP meclizine, scopolamine transdermal TARGADOX doxycycline hyclate 20 mg, doxycycline hyclate TRAVATAN Z latanoprost, travoprost, LUMIGAN, ZIOPTAN ST capsule, minocycline, tetracycline TRELSTAR MIXJECT ELIGARD SGM, FIRMAGON † TASIGNA imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM triamcinolone aerosol 0.2% hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment QL, TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol- hydrocortisone butyrate solution QL, drospirenone-levomefolate, ethinyl estradiol- mometasone QL, triamcinolone norethindrone acetate, ethinyl estradiol- cream QL, triamcinolone lotion QL, triamcinolone norethindrone acetate-iron ointment (except triamcinolone ointment 0.05%) QL TAZORAC adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, triamcinolone ointment 0.05% hydrocortisone butyrate cream QL, clindamycin solution QL, clindamycin- hydrocortisone butyrate ointment QL, benzoyl peroxide, erythromycin solution, hydrocortisone butyrate solution QL, erythromycin-benzoyl peroxide, tretinoin PA, **, mometasone QL, triamcinolone EPIDUO, ONEXTON; calcipotriene ointment QL, cream QL, triamcinolone lotion QL, triamcinolone calcipotriene solution QL ointment (except triamcinolone ointment 0.05%) QL TECFIDERA dimethyl fumarate delayed-rel SGM, glatiramer SGM, AUBAGIO SGM, Trianex hydrocortisone butyrate cream QL, BETASERON SGM, COPAXONE SGM, hydrocortisone butyrate ointment QL, GILENYA SGM, KESIMPTA SGM, MAYZENT hydrocortisone butyrate solution QL, SGM, OCREVUS †, REBIF SGM, TYSABRI †, mometasone QL, triamcinolone ZEPOSIA SGM cream QL, triamcinolone lotion QL, triamcinolone ointment (except triamcinolone ointment 0.05%) TESTIM testosterone gel (except authorized generics for QL TESTIM and VOGELXO) PA, testosterone solution PA, ANDRODERM PA, NATESTO PA TRICOR fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), testosterone gel 1% (authorized testosterone gel (except authorized generics for fenofibric acid delayed-rel generics for TESTIM and VOGELXO TESTIM and VOGELXO) PA, testosterone only) solution PA, ANDRODERM PA, NATESTO PA

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* TRILIPIX fenofibrate (except fenofibrate capsule 50 mg, VIRACEPT atazanavir QL, EVOTAZ QL, PREZCOBIX QL, 130 mg; fenofibrate tablet 40 mg, 120 mg), PREZISTA QL fenofibric acid delayed-rel VITAFOL-ONE 7 prenatal vitamins, CITRANATAL TRINAZ 7 prenatal vitamins, CITRANATAL Vitasure folic acid TRIVIDIA INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES OTC VIVELLE-DOT estradiol, DIVIGEL, EVAMIST TronVite folic acid VOGELXO testosterone gel (except authorized generics for TRUETEST STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND TESTIM and VOGELXO) PA, testosterone KITS 3 OTC, ACCU-CHEK COMPACT PLUS solution PA, ANDRODERM PA, NATESTO PA STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK WESTHROID levothyroxine, liothyronine, SYNTHROID SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, WP THYROID levothyroxine, liothyronine, SYNTHROID 3 ONETOUCH VERIO STRIPS AND KITS OTC TRUETRACK STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, 3 KITS OTC, ACCU-CHEK COMPACT PLUS oxazepam STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK XENAZINE tetrabenazine SGM, AUSTEDO SGM SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, XOLEGEL ciclopirox PA, ketoconazole cream 2% QL ONETOUCH VERIO STRIPS AND KITS 3 OTC XOPENEX HFA albuterol sulfate CFC-free aerosol QL, TRUXIMA RUXIENCE † levalbuterol tartrate CFC-free aerosol QL Xvite folic acid TUDORZA SPIRIVA QL, YUPELRI QL XYZBAC folic acid UDENYCA ZIEXTENZO SGM YASMIN ethinyl estradiol-drospirenone, ethinyl estradiol- ULORIC allopurinol drospirenone-levomefolate, ethinyl estradiol- norethindrone acetate, ethinyl estradiol- ULTIMED INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES OTC norethindrone acetate-iron ULTIMED NEEDLES 5 BD ULTRAFINE NEEDLES OTC YAZ ethinyl estradiol-drospirenone, ethinyl estradiol- drospirenone-levomefolate, ethinyl estradiol- UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, norethindrone acetate, ethinyl estradiol- tamsulosin, terazosin norethindrone acetate-iron VALCYTE valganciclovir Yuvafem estradiol vaginal cream, IMVEXXY VALTREX acyclovir capsule, acyclovir tablet, valacyclovir ZALVIT 7 prenatal vitamins, CITRANATAL Vanoxide-HC adapalene PA, benzoyl peroxide, clindamycin gel ZARXIO NIVESTYM SGM (except NDC^ 68682046275) QL, clindamycin solution QL, clindamycin-benzoyl peroxide, ZEGERID esomeprazole delayed-rel, lansoprazole delayed- erythromycin solution, erythromycin-benzoyl rel, omeprazole delayed-rel, pantoprazole peroxide, tretinoin PA, **, EPIDUO, ONEXTON delayed-rel tablet, DEXILANT ST VASCULERA Consult doctor ZELAC Consult doctor VECTICAL calcipotriene ointment QL, calcipotriene ZEMAIRA PROLASTIN-C † solution QL ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, VELTIN adapalene PA, benzoyl peroxide, clindamycin gel HARVONI (genotypes 1, 4, 5, 6) SGM (except NDC^ 68682046275) QL, clindamycin solution QL, clindamycin-benzoyl peroxide, ZERVIATE azelastine, cromolyn sodium, olopatadine erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril- venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, hydrochlorothiazide, quinapril- (except 225 mg) venlafaxine ext-rel capsule hydrochlorothiazide VENTOLIN HFA albuterol sulfate CFC-free aerosol QL, ZETIA ezetimibe levalbuterol tartrate CFC-free aerosol QL ZETONNA flunisolide QL, fluticasone QL, VEREGEN imiquimod mometasone nasal spray QL, DYMISTA ST, QL VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, ZIANA adapalene PA, benzoyl peroxide, clindamycin gel HARVONI (genotypes 1, 4, 5, 6) SGM (except NDC^ 68682046275) QL, clindamycin solution QL, clindamycin-benzoyl peroxide, VIIBRYD citalopram, escitalopram, fluoxetine (except erythromycin solution, erythromycin-benzoyl fluoxetine tablet 60 mg, fluoxetine tablet peroxide, tretinoin PA, **, EPIDUO, ONEXTON [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX zileuton ext-rel montelukast, zafirlukast ST ZIRGAN trifluridine

NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON -FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* ZOHYDRO ER fentanyl transdermal QL, hydrocodone ext-rel ZONTIVITY Consult doctor QL, hydromorphone ext-rel QL, methadone QL, morphine ext-rel QL, ZORTRESS everolimus SGM NUCYNTA ER QL, XTAMPZA ER QL ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, ZOLADEX ELIGARD SGM, FIRMAGON †, ORILISSA PA naproxen (except naproxen CR or naproxen suspension) ZOLOFT citalopram, escitalopram, fluoxetine (except ZUPLENZ granisetron QL, ondansetron QL, fluoxetine tablet 60 mg, fluoxetine tablet SANCUSO PA, QL [generics for SARAFEM]), paroxetine HCl, ZYDELIG COPIKTRA SGM paroxetine HCl ext-rel, sertraline, TRINTELLIX ST ZYFLO montelukast, zafirlukast zolpidem sublingual doxepin, eszopiclone, ramelteon, zolpidem, ZYLET neomycin-polymyxin B-bacitracin- zolpidem ext-rel, BELSOMRA ST hydrocortisone, neomycin-polymyxin B- dexamethasone, tobramycin-dexamethasone, ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, TOBRADEX OINTMENT zolpidem ext-rel, BELSOMRA ST ZYTIGA abiraterone SGM, bicalutamide, XTANDI SGM, ZONEGRAN carbamazepine, carbamazepine ext-rel, YONSA SGM divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, ZYVIT folic acid levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, VIMPAT, XCOPRI

You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to www.arkansasbluecross.com to check coverage and copay information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

§ 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. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. ** Prior Authorization applies for members age 35 and older. † Coverage determined under the Medical Benefit ‡ Listing does not include certain NDCs^.

OTC Over the Counter PA Prior Authorization QL Quantity Limit SGM Specialty Guideline Management ST Step Therapy 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 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). 3 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746 4 Coverage may be altered or copay amounts may vary based on the condition being treated (e.g., psoriasis). 5 BD ULTRAFINE syringes and needles are the only preferred options. 6 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options.

7 Generic prenatal vitamins and CITRANATAL are the only preferred options.

8 Long Acting Insulins - First Generation.

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

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