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List of Formulary Drug Removals

List of Formulary Drug Removals

July 2021 Formulary Removals

Below is a list of by that have been removed from your plan’s formulary. If you continue using one of the listed below and identified as a Formulary Drug Removal, you may be required to pay the full cost.

If you are currently using one of the formulary drug removals, ask your doctor to choose one of the generic or brand formulary options listed below.

Category Formulary Drug Formulary Options Drug Class Removals

Acromegaly SANDOSTATIN LAR SOMATULINE DEPOT SIGNIFOR LAR SOMAVERT

Allergies Diphen RyClora 6 MG

Allergies BECONASE AQ spray, spray, spray, DYMISTA Nasal / Combinations OMNARIS QNASL ZETONNA

Anticonvulsants ext-rel , carbamazepine ext-rel, , divalproex , (generics for QUDEXY XR only) divalproex sodium ext-rel, , , lamotrigine ext-rel, , levetiracetam ext-rel, , , , phenytoin sodium extended, , , , topiramate, valproic , , FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

BANZEL clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR ONFI

SABRIL

ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

Anti-infectives, Antibacterials E.E.S. GRANULES Erythromycins / ERYPED Anti-infectives, Antibacterials hyclate delayed-rel tablet 50 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, , doxycycline hyclate delayed-rel tablet 200 mg doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only) doxycycline hyclate tablet 75 mg doxycycline hyclate tablet 150 mg doxycycline monohydrate capsule 75 mg doxycycline monohydrate capsule 150 mg minocycline ext-rel CoreMino Mondoxyne NL capsule 75 mg ACTICLATE DORYX DORYX MPC MINOCIN TARGADOX

Anti-infectives, Antibacterials nitrofurantoin (NDC^ 70408023932 only) nitrofurantoin (except NDC^ 70408023932) Miscellaneous MACRODANTIN

Category Formulary Drug Formulary Options Drug Class Removals

Anti-infectives, capsule 500 mg delayed-rel tablet fluconazole, NOXAFIL

CRESEMBA itraconazole

Anti-infectives, APTIVUS Consult doctor Antiretroviral Agents INVIRASE , EVOTAZ, PREZCOBIX, PREZISTA Protease Inhibitors LEXIVA VIRACEPT

Anti-infectives, Antivirals VALCYTE valganciclovir Cytomegalovirus *

Anti-infectives, Antivirals BARACLUDE TABLET entecavir, lamivudine, VEMLIDY B * Anti-infectives, Antivirals MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 1 Hepatitis C * VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) ZEPATIER

Anti-infectives, Antivirals acyclovir acyclovir capsule, acyclovir tablet, valacyclovir Herpes * VALTREX Anti-infectives DARAPRIM pyrimethamine Miscellaneous

Antiobesity CONTRAVE QSYMIA, SAXENDA XENICAL

Anxiety * ATIVAN , , , , XANAX XANAX XR * PROAIR HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol Beta , Short-Acting PROAIR RESPICLICK PROVENTIL HFA VENTOLIN HFA XOPENEX HFA

Asthma * ext-rel , Modulators SINGULAIR

Asthma * ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, ASMANEX PULMICORT FLEXHALER, QVAR REDIHALER ASMANEX HFA

Asthma * or Chronic Obstructive DULERA ADVAIR DISKUS, ADVAIR HFA †, BREO ELLIPTA †, SYMBICORT Pulmonary (COPD) * Steroid / Beta Combinations

Attention Deficit Hyperactivity - mixed salts, Disorder * EVEKEO ADZENYS ER amphetamine-dextroamphetamine mixed salts ext-rel †, ext-rel, ADZENYS XR-ODT methylphenidate ext-rel †, MYDAYIS, VYVANSE APTENSIO XR DAYTRANA FOCALIN XR

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel †, , dexmethylphenidate ext-rel, ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE

Category Formulary Drug Formulary Options Drug Class Removals

Autoimmune Agents ACTEMRA INTRAVENOUS REMICADE, SIMPONI ARIA -Administered Agents ORENCIA INTRAVENOUS AVSOLA REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS CIMZIA LYOPHILIZED INFLECTRA RENFLEXIS ENTYVIO (For Crohn's Disease Only) REMICADE, STELARA INTRAVENOUS

ILUMYA REMICADE

Autoimmune Agents ACTEMRA ACTPEN ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR Self-Administered Agents ACTEMRA SUBCUTANEOUS KINERET

CIMZIA PREFILLED COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR

ORENCIA CLICKJECT COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, ORENCIA SUBCUTANEOUS XELJANZ, XELJANZ XR SIMPONI

TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR

Cancer RIABNI RUXIENCE Biosimilars TRUXIMA GLEEVEC mesylate, BOSULIF, SPRYCEL Chronic Myelogenous Leukemia * TASIGNA Cancer ALIQOPA COPIKTRA Follicular Lymphoma * ZYDELIG PI3K Inhibitors Cancer AVASTIN ZIRABEV Monoclonal Antibodies HERCEPTIN KANJINTI, TRAZIMERA HERCEPTIN HYLECTA

RITUXAN RUXIENCE

Cancer BORTEZOMIB NINLARO, VELCADE Multiple Myeloma * KYPROLIS Proteasome Inhibitors Cancer NILANDRON abiraterone, , XTANDI, YONSA * ZYTIGA Cancer LUPRON DEPOT ELIGARD, FIRMAGON Prostate * TRELSTAR MIXJECT ZOLADEX Luteinizing -Releasing Hormone (LHRH) Agonists Cardiovascular BETAPACE Antiarrhythmics BETAPACE AF NORPACE

Cardiovascular ZETIA ezetimibe Antilipemics Absorption Inhibitors

Category Formulary Drug Formulary Options Drug Class Removals

Cardiovascular capsule 50 mg fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), Antilipemics fenofibrate capsule 130 mg fenofibric acid delayed-rel fenofibrate tablet 40 mg fenofibrate tablet 120 mg FENOGLIDE TABLET 120 MG TRICOR

Cardiovascular ALTOPREV , ezetimibe-, fluvastatin, , pravastatin, Antilipemics CRESTOR , simvastatin LESCOL XL HMG-CoA Reductase Inhibitors LIPITOR (HMGs or ) / Combinations 2 LIVALO

Cardiovascular tablet 500 mg niacin ext-rel Antilipemics Niacor

Niacins

Cardiovascular icosapent ethyl omega-3 acid ethyl , VASCEPA Antilipemics Omega-3 Fatty Cardiovascular REPATHA PRALUENT Antilipemics PCSK9 Inhibitors

Cardiovascular LANOXIN TABLET Digitalis (125 MCG and 250 MCG only)

Cardiovascular DYRENIUM , Cardiovascular 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), Cardiovascular LETAIRIS , , OPSUMIT Pulmonary Arterial TRACLEER Antagonists

Cardiovascular REMODULIN Pulmonary Arterial Hypertension Vasodilators

Carnitine Deficiency CARNITOR levocarnitine CARNITOR SF

Central LUPRON DEPOT-PED SUPPRELIN LA, TRIPTODUR

Chronic Obstructive Pulmonary INCRUSE ELLIPTA SPIRIVA, YUPELRI Disease (COPD) * TUDORZA

Chronic Obstructive Pulmonary BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO Disease (COPD) * / Beta Agonist Combinations Long Acting

Contraceptives BEYAZ ethinyl -, ethinyl estradiol-drospirenone-levomefolate, Monophasic MINASTRIN 24 FE ethinyl estradiol-norethindrone , ethinyl estradiol-norethindrone acetate-iron TAYTULLA YASMIN YAZ

Category Formulary Drug Formulary Options Drug Class Removals

Contraceptives NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, Four Phase ethinyl estradiol-, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-, LO LOESTRIN FE

Contraceptives SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, Extended Cycle ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Contraceptives NUVARING ethinyl estradiol-, ANNOVERA Vaginal

Cystic Fibrosis * TOBI , BETHKIS Inhaled TOBI PODHALER

Dental PREVIDENT Consult doctor Cavity/Caries Prevention * tablet 60 mg , , fluoxetine (except fluoxetine tablet 60 mg, , Selective LEXAPRO fluoxetine tablet [generics for SARAFEM]), HCl, paroxetine HCl ext-rel, PAXIL , TRINTELLIX Inhibitors PAXIL CR (SSRIs) PEXEVA PROZAC VIIBRYD ZOLOFT

Depression * ext-rel tablet (except 225 mg) ext-rel, , venlafaxine, venlafaxine ext-rel capsule Antidepressants, Serotonin CYMBALTA EFFEXOR XR Reuptake Inhibitors PRISTIQ (SNRIs) Depression * ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) Antidepressants, OLEPTRO Miscellaneous Agents Depression and/or * ABILIFY , , , , quetiapine ext-rel, , , Atypicals FANAPT , LATUDA, VRAYLAR SEROQUEL XR (NDC^ 68682046275 only) , , clindamycin gel (except NDC^ 68682046275), * Vanoxide-HC clindamycin solution, clindamycin-benzoyl peroxide, solution, ACANYA erythromycin-benzoyl peroxide, , EPIDUO, ONEXTON AZELEX BENZACLIN DIFFERIN FABIOR TAZORAC VELTIN ZIANA

Dermatology fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA * CARAC Dermatology NEO-SYNALAR or WITH Anti-infective / Anti-inflammatory Dermatology cream gentamicin, mupirocin ointment Antibiotics

Category Formulary Drug Formulary Options Drug Class Removals

Dermatology calcipotriene cream calcipotriene ointment, calcipotriene solution Antipsoriatics ointment SORILUX TAZORAC VECTICAL

calcipotriene- calcipotriene ointment or calcipotriene solution WITH (except desoximetasone ointment 0.05%), (except fluocinonide cream 0.1%) or BRYHALI

Dermatology cream desonide, hydrocortisone, , , EUCRISA Atopic * ELIDEL pimecrolimus, tacrolimus, EUCRISA

Dermatology doxycycline monohydrate delayed-rel capsule ORACEA * FINACEA GEL gel, , FINACEA FOAM, SOOLANTRA MIRVASO NORITATE

Dermatology BEAU RX Consult doctor Scars CICATRACE POLYTOZA RECEDO SCARSILK PAD SIL-K PAD SILIVEX SILTREX Dermatology foam 2% ketoconazole 2%, sulfide lotion 2.5% Seborrheic Dermatitis * Ketodan XOLEGEL , ketoconazole cream 2%

Dermatology spray clobetasol foam and * CLOBEX SPRAY OLUX-E fluocinonide cream 0.1% clobetasol cream

flurandrenolide cream desonide, hydrocortisone flurandrenolide lotion Nolix

cream cream, hydrocortisone butyrate ointment, desoximetasone ointment 0.05% hydrocortisone butyrate solution, mometasone, cream, flurandrenolide ointment triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate lotion triamcinolone aerosol 0.2% triamcinolone ointment 0.05% Trianex CORDRAN OINTMENT

cream desoximetasone (except desoximetasone ointment 0.05%), diflorasone ointment fluocinonide (except fluocinonide cream 0.1%), BRYHALI cream APEXICON E PSORCON

Dermatology VEREGEN imiquimod

Dermatology ALEVICYN GEL desonide, hydrocortisone Wound Care Products ALEVICYN SG ALEVICYN SOLUTION

Category Formulary Drug Formulary Options Drug Class Removals

Dermatology ALCORTIN A desonide, hydrocortisone Miscellaneous Skin Conditions ATOPADERM BENSAL HP EPICERAM KAMDOY NOVACORT SYNERDERM

ciclopirox, , , ketoconazole cream 2%, NAFTIN (NDCs^ 00168035830, 51672135902 only)

Diabetes * ext-rel (generics for FORTAMET and metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) Biguanides GLUMETZA only) FORTAMET GLUMETZA RIOMET

Diabetes * NESINA JANUVIA Dipeptidyl Peptidase-4 ONGLYZA TRADJENTA (DPP-4) Inhibitors Diabetes * JENTADUETO JANUMET, JANUMET XR Dipeptidyl Peptidase-4 JENTADUETO XR KAZANO (DPP-4) Inhibitor Combinations KOMBIGLYZE XR

OSENI JANUMET, JANUMET XR; JANUVIA WITH

Diabetes * BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA Injectable Mimetics BYETTA

Diabetes * APIDRA FIASP, NOVOLOG HUMALOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 3 NOVOLIN 70/30 3

HUMULIN N 3 NOVOLIN N 3

HUMULIN R 3 NOVOLIN R 3

NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered.

Diabetes * LANTUS BASAGLAR, LEVEMIR Long Acting Insulins 4 Diabetes * ACTOS pioglitazone Sensitizers

Diabetes * INVOKANA FARXIGA, JARDIANCE Sodium- Co-transporter 2 (SGLT2) Inhibitors Diabetes * INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR Sodium-Glucose INVOKAMET XR Co-transporter 2 (SGLT2) Inhibitor / Biguanide Combinations

Category Formulary Drug Formulary Options Drug Class Removals

Diabetes * QTERN GLYXAMBI Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor / Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

Diabetes * NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES Supplies, Needles 5 OWEN MUMFORD NEEDLES PERRIGO NEEDLES ULTIMED NEEDLES All other insulin needles that are not BD ULTRAFINE brand Diabetes * ALLISON MEDICAL INSULIN BD ULTRAFINE INSULIN SYRINGES Supplies, Syringes 5 TRIVIDIA INSULIN SYRINGES ULTIMED INSULIN SYRINGES All other insulin syringes that are not BD ULTRAFINE brand

Diabetes * BREEZE 2 STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, Supplies, Test Strips and Kits 6, 7 CONTOUR NEXT STRIPS AND KITS ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, CONTOUR STRIPS AND KITS ACCU-CHEK GUIDE STRIPS AND KITS 6, FREESTYLE STRIPS AND KITS ACCU-CHEK SMARTVIEW STRIPS AND KITS 6, All other test strips that are not ONETOUCH ULTRA STRIPS AND KITS 6, ACCU-CHEK or ONETOUCH brand ONETOUCH VERIO STRIPS AND KITS 6

ENLITE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM GLUCOSE MONITORING SYSTEM EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING SYSTEM GUARDIAN CONNECT CONTINUOUS GLUCOSE MONITORING SYSTEM GUARDIAN REAL-TIME CONTINUOUS GLUCOSE MONITORING SYSTEM All other continuous glucose monitoring systems that are not DEXCOM brand

Dietary Supplements FOSTEUM alendronate, ibandronate, risedronate FOSTEUM PLUS

Activite folic acid Dexifol Folvite-D Genicin Vita-S HylaVite Lorid TronVite Vitasure Xvite FERIVA 21/7 FOLIC-K NICADAN NICAPRIN NICAZEL NICAZEL FORTE NICOMIDE OMNIVEX ORTHO D ORTHO DF RHEUMATE RIBOZEL TALIVA XYZBAC ZYVIT

MultiPro Consult doctor PRODIGEN VASCULERA

Category Formulary Drug Formulary Options Drug Class Removals

Endocrine and Metabolic PROMETRIUM ; , micronized Progestins

Endometriosis * LUPRON DEPOT ORILISSA ZOLADEX

Erectile Dysfunction * CIALIS , Inhibitors STENDRA VIAGRA

Fertility Regulators FOLLISTIM AQ GONAL-F Follicle-Stimulating Gastrointestinal -clidinium dicyclomine Anticholinergics (NDCs^ 11534019701, 42494040901, 51293069601, 51293069610 only) sulfate ext-rel Oscimin SR Symax-SR GLYCOPYRROLATE TABLET 1.5 MG LIBRAX

Gastrointestinal ENTERAGAM , VIBERZI, XIFAXAN 550 MG Antidiarrheals MYTESI -, Gastrointestinal TRANSDERM SCOP , ZUPLENZ , , SANCUSO

Gastrointestinal AMITIZA LINZESS, MOVANTIK, SYMPROIC Irritable Bowel Syndrome Gastrointestinal LACTULOSE PAK lactulose solution Laxatives GOLYTELY peg 3350-, CLENPIQ MOVIPREP OSMOPREP SUPREP

Gastrointestinal Lactojen Consult doctor Probiotics PROVAD ZELAC

Gastrointestinal - delayed-rel, delayed-rel, omeprazole delayed-rel, Proton Pump Inhibitors (PPIs) pantoprazole delayed-rel suspension pantoprazole delayed-rel tablet, DEXILANT ACIPHEX ACIPHEX SPRINKLE NEXIUM PREVACID PRILOSEC PROTONIX ZEGERID

Gastrointestinal suspension sucralfate tablet Ulcer Treatment CARAFATE Gaucher Disease ELELYSO CERDELGA, CEREZYME

Genitourinary ELMIRON Consult doctor Interstitial Cystitis RIMSO-50

Genitourinary LITHOSTAT Consult doctor Miscellaneous THIOLA THIOLA EC

Gout * capsule colchicine tablet, MITIGARE COLCRYS

ULORIC

Category Formulary Drug Formulary Options Drug Class Removals

Growth Hormones HUMATROPE GENOTROPIN, NORDITROPIN NUTROPIN AQ OMNITROPE

Hematologic PRADAXA , ELIQUIS, XARELTO (oral)

Hematologic CUPRIMINE penicillamine capsule Chelating Agents DESFERAL deferasirox, deferiprone, deferoxamine EXJADE FERRIPROX JADENU

SYPRINE trientine

Hematologic EPOGEN ARANESP, RETACRIT Erythropoiesis-Stimulating Agents PROCRIT Hematologic ALPROLIX Consult doctor Hemophilia B Hematologic FULPHILA ZIEXTENZO Neutropenia Colony Stimulating NEULASTA NEULASTA ONPRO Factors UDENYCA

GRANIX NIVESTYM NEUPOGEN ZARXIO

Hematologic PLAVIX clopidogrel, prasugrel, BRILINTA Platelet Aggregation Inhibitors ZONTIVITY Consult doctor

High Pressure * ZESTORETIC -, -hydrochlorothiazide, ACE Inhibitor / -hydrochlorothiazide Combinations

High * ATACAND , , , , , II Receptor BENICAR COZAAR Antagonists DIOVAN EDARBI MICARDIS

High Blood Pressure * ATACAND HCT candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, Angiotensin II Receptor BENICAR HCT losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, DIOVAN HCT telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide Antagonist / Diuretic Combinations EDARBYCLOR HYZAAR MICARDIS HCT

High Blood Pressure * AZOR -olmesartan, amlodipine-telmisartan, amlodipine-valsartan Angiotensin II Receptor EXFORGE Antagonist / Combinations

High Blood Pressure * EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide Angiotensin II / Blocker / Diuretic Combinations High Blood Pressure * COREG CR , , carvedilol phosphate ext-rel, succinate ext-rel, Beta-blockers INDERAL LA metoprolol tartrate, , , , propranolol ext-rel, BYSTOLIC INDERAL XL INNOPRAN XL TOPROL-XL

Category Formulary Drug Formulary Options Drug Class Removals

High Blood Pressure * DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide Beta-blocker Combinations

High Blood Pressure * NORVASC amlodipine Calcium Channel Blockers ext-rel diltiazem ext-rel (except generics for CARDIZEM LA) (generics for CARDIZEM LA only) Matzim LA CARDIZEM CARDIZEM CD CARDIZEM LA

High Blood Pressure * CONSENSI amlodipine WITH / Anti-inflammatory Drugs (NSAIDs) Combinations Huntington's Disease XENAZINE , AUSTEDO

Immunology BERINERT , RUCONEST Hereditary

Immunology ZORTRESS Rapamycin Derivatives

Inflammatory Bowel Disease (IBD) mesalamine delayed-rel tablet 800 mg balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), Ulcerative Colitis * COLAZAL mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, DELZICOL PENTASA Aminosalicylates LIALDA

Kidney Disease * , sevelamer carbonate, PHOSLYRA, VELPHORO Phosphate Binders FOSRENOL

Menopausal Symptom Agents paroxetine mesylate capsule 7.5 mg paroxetine HCl Oral MENEST estradiol OSPHENA PREMARIN

Menopausal Symptom Agents MINIVELLE estradiol, DIVIGEL, EVAMIST Transdermal VIVELLE-DOT

Menopausal Symptom Agents estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM Vaginal Yuvafem ESTRING FEMRING INTRAROSA PREMARIN CREAM

Multiple Sclerosis AVONEX delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, EXTAVIA GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, PLEGRIDY ZEPOSIA TECFIDERA

Category Formulary Drug Formulary Options Drug Class Removals

Musculoskeletal 250 mg (except cyclobenzaprine tablet 7.5 mg) 375 mg chlorzoxazone 500 mg (NDC^ 73007001303 only) chlorzoxazone 750 mg cyclobenzaprine ext-rel capsule cyclobenzaprine tablet 7.5 mg 400 mg 500 mg (NDC^ 69036091010 only) methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only) -- Fexmid Lorzone Orphengesic Forte AMRIX CHLORZOXAZONE 250 MG NORGESIC FORTE

Narcolepsy NUVIGIL , , SUNOSI Wakefulness Promoters PROVIGIL Ophthalmic ALREX , cromolyn sodium, Allergies BEPREVE LASTACAFT ZERVIATE

Ophthalmic AZASITE , erythromycin, gentamicin, , moxifloxacin, , Anti-infectives CILOXAN , tobramycin, BESIVANCE Ophthalmic TOBRADEX ST -polymyxin B-bacitracin-hydrocortisone, Anti-infective / Anti-inflammatory ZYLET neomycin-polymyxin B-, tobramycin-dexamethasone, TOBRADEX OINTMENT

Ophthalmic ACUVAIL , , , ILEVRO, PROLENSA Anti-inflammatory, Nonsteroidal BROMSITE NEVANAC

Ophthalmic FLAREX dexamethasone, , acetate 1%, DUREZOL Anti-inflammatory, Steroidal FML FORTE FML LIQUIFILM FML S.O.P. INVELTYS LOTEMAX LOTEMAX SM MAXIDEX PRED FORTE PRED MILD

Ophthalmic ZIRGAN trifluridine Antivirals Ophthalmic LACRISERT RESTASIS, XIIDRA Artificial Tears

Ophthalmic solution 0.03% , , LUMIGAN, ZIOPTAN TRAVATAN Z BETIMOL maleate solution, BETOPTIC S TIMOPTIC OCUDOSE

Ophthalmic AVENOVA Consult doctor Miscellaneous Dependency SUBOXONE - sublingual, ZUBSOLV

Category Formulary Drug Formulary Options Drug Class Removals

Osteoarthritis * GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX Viscosupplements HYALGAN MONOVISC ORTHOVISC SYNVISC SYNVISC-ONE VISCO-3

Osteoporosis * MIACALCIN alendronate, -salmon, ibandronate, risedronate, FORTEO, PROLIA, Calcium Regulators TYMLOS MIACALCIN calcitonin-salmon

Otic CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic Anti-infective / Anti-inflammatory CIPRODEX Overactive Bladder / Incontinence * DETROL LA ext-rel, ext-rel, , , tolterodine ext-rel, Urinary ENABLEX trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ OXYTROL

Pain -acetaminophen tablet 50-300 mg diclofenac sodium, , (except naproxen CR or naproxen suspension) * butalbital-acetaminophen-caffeine capsule Bupap BUTALBITAL-ACETAMINOPHEN (NDC^ 69499034230 only) CAMBIA FIORICET CAPSULE

spray , , , , , NURTEC ODT, -caffeine ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, Migergot ZOMIG NASAL SPRAY CAFERGOT MAXALT MAXALT-MLT

sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR or TREXIMET naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY

Pain LYRICA duloxetine, *

Pain BUTRANS buprenorphine transdermal, BELBUCA Opioid LAZANDA transmucosal lozenge, SUBSYS

fentanyl transdermal, ext-rel, ext-rel, , ext-rel ext-rel, NUCYNTA ER, XTAMPZA ER HYSINGLA ER OXYCONTIN ZOHYDRO ER

PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, -acetaminophen, NUCYNTA

(NDC^ 52817019610 only) tramadol (except NDC^ 52817019610), tramadol ext-rel tablet tramadol ext-rel capsule

Pain - CREAM lidocaine- Topical Local (NDC^ 71800063115 only) LIDOTREX

Pain and Inflammation * MILLIPRED dexamethasone, hydrocortisone, , prednisolone solution, Corticosteroids RAYOS

Category Formulary Drug Formulary Options Drug Class Removals

Pain and Inflammation * ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, or naproxen (except naproxen CR or Nonsteroidal Anti-inflammatory naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or DEXILANT Drugs (NSAIDs) / Combinations CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, Diclosaicin meloxicam, naproxen (except naproxen CR or naproxen suspension) Inflammacin NuDiclo SoluPak NuDiclo TabPak PENNSAID

diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or indomethacin capsule 20 mg naproxen suspension) capsule 25 mg ketoprofen ext-rel capsule (NDC^ 69336012830 only) naproxen CR naproxen suspension FENOPROFEN CAPSULE INDOCIN NAPRELAN SPRIX ZORVOLEX

naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or DEXILANT

Parkinson's Disease APOKYN INBRIJA, KYNMOBI NOURIANZ , , , pramipexole ext-rel, , , ropinirole ext-rel, , NEUPRO

RYTARY -levodopa, carbidopa-levodopa ext-rel

Phenylketonuria KUVAN sapropterin

Postherpetic HORIZANT gabapentin, GRALISE Premenstrual Dysphoric Disorder fluoxetine tablet (generics for SARAFEM only) fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), (PMDD) paroxetine HCl ext-rel, sertraline

Prenatal Vitamins 8 AZESCO prenatal vitamins, CITRANATAL PRENATAL PLUS TRINAZ VITAFOL-ONE ZALVIT All other brand prenatal vitamins that are not CITRANATAL

Prostate Condition JALYN -; dutasteride or WITH ext-rel, Benign Prostatic Hyperplasia * , , tamsulosin or RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin UROXATRAL

Respiratory ARALAST NP PROLASTIN-C Alpha-1 Antitrypsin Deficiency GLASSIA ZEMAIRA

Respiratory benzonatate (except NDCs^ 69336012615, 69499032915) (NDCs^ 69336012615, 69499032915 only)

Respiratory THEO-24 ipratropium inhalation solution, PERFOROMIST, SEREVENT, SPIRIVA, STRIVERDI RESPIMAT, YUPELRI

Category Formulary Drug Formulary Options Drug Class Removals

Sleep Disorder doxepin, , , , zolpidem ext-rel, BELSOMRA , Non-benzodiazepines zolpidem sublingual LUNESTA ROZEREM SILENOR ZOLPIMIST

Testosterone Replacement * gel 1% (authorized generics for testosterone gel (except authorized generics for TESTIM and VOGELXO), TESTIM and VOGELXO only) testosterone solution, ANDRODERM, NATESTO ANDROGEL FORTESTA TESTIM VOGELXO

Thyroid Supplements CYTOMEL , , SYNTHROID NATURE-THROID WESTHROID WP

TIROSINT levothyroxine, SYNTHROID Uterine Fibroids * LUPRON DEPOT ORIAHNN

Category Other Considerations Drug Class All Drugs On a quarterly basis, new and existing products - including limited source generics, products with significant cost inflation, and specialty and non-specialty products - may be re-evaluated to determine appropriate formulary placement. These evaluations will assess whether clinically appropriate and cost-effective options remain available on the formulary and may result in removal, addition or deletion of a product.

Autoimmune and Hepatitis C * For some clients, an Indication-Based Formulary will be utilized for products in these classes and may result in additional removals for certain conditions only.

Drugs for Infusion Into Spaces A drug that must be infused into a space other than the blood will generally not be covered under the benefit. Other Than the Blood

New-to-Market Agents 9 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.

The listed formulary options are subject to change.

List of Formulary Drug Removals ABILIFY ALTOPREV AZELEX ACANYA ALVESCO AZESCO ACIPHEX AMITIZA AZOR ACIPHEX SPRINKLE AMRIX BANZEL SUSPENSION ACTEMRA ACTPEN ANDROGEL BARACLUDE TABLET ACTEMRA INTRAVENOUS APEXICON E BEAU RX ACTEMRA SUBCUTANEOUS APIDRA BECONASE AQ ACTICLATE APOKYN BENICAR Activite APTENSIO XR BENICAR HCT ACTOS APTIVUS BENSAL HP ACUVAIL ARALAST NP BENZACLIN acyclovir cream ARTHROTEC benzonatate (NDCs^ 69336012615, 69499032915 only) ADDERALL ASMANEX BEPREVE ADZENYS ER ASMANEX HFA BERINERT ADZENYS XR-ODT ATACAND BETAPACE ALCORTIN A ATACAND HCT BETAPACE AF ALEVICYN GEL ATIVAN BETIMOL ALEVICYN SG ATOPADERM BEVESPI AEROSPHERE ALEVICYN SOLUTION AVASTIN BEYAZ ALIQOPA AVENOVA bimatoprost solution 0.03% ALLISON MEDICAL INSULIN SYRINGES 5 AVONEX BORTEZOMIB ALPROLIX AVSOLA BREEZE 2 STRIPS AND KITS 7 ALREX AZASITE BROMSITE

Bupap DORYX MPC FULPHILA bupropion ext-rel tablet 450 mg doxepin cream GEL-ONE butalbital-acetaminophen tablet 50-300 mg doxycycline hyclate delayed-rel tablet 50 mg Genicin Vita-S BUTALBITAL-ACETAMINOPHEN doxycycline hyclate delayed-rel tablet 200 mg GLASSIA (NDC^ 69499034230 only) doxycycline hyclate tablet 50 mg GLEEVEC butalbital-acetaminophen-caffeine capsule (NDC^ 72143021160 only) GLUMETZA BUTRANS doxycycline hyclate tablet 75 mg GLYCOPYRROLATE TABLET 1.5 MG BYDUREON doxycycline hyclate tablet 150 mg GOLYTELY BYETTA doxycycline monohydrate capsule 75 mg GRANIX CAFERGOT doxycycline monohydrate capsule 150 mg GUARDIAN CONNECT CONTINUOUS calcipotriene cream doxycycline monohydrate delayed-rel capsule GLUCOSE MONITORING SYSTEM calcipotriene-betamethasone DULERA GUARDIAN REAL-TIME CONTINUOUS calcitriol ointment DUTOPROL GLUCOSE MONITORING SYSTEM CAMBIA DYRENIUM halcinonide cream CARAC EDARBI HERCEPTIN CARAFATE EDARBYCLOR HERCEPTIN HYLECTA CARBINOXAMINE TABLET 6 MG E.E.S. GRANULES HORIZANT CARDIZEM EFFEXOR XR HUMALOG CARDIZEM CD ELELYSO HUMALOG MIX 50/50 CARDIZEM LA ELIDEL HUMALOG MIX 75/25 carisoprodol 250 mg ELMIRON HUMATROPE CARNITOR ENABLEX HUMULIN 70/30 3 CARNITOR SF ENLITE CONTINUOUS GLUCOSE HUMULIN N 3 CELEBREX MONITORING SYSTEM HUMULIN R 3 chlordiazepoxide-clidinium (NDCs^ 11534019701, ENTERAGAM HYALGAN 42494040901, 51293069601, 51293069610 only) ENTYVIO (For Crohn's Disease Only) hydrocortisone butyrate lipophilic cream 0.1% CHLORZOXAZONE 250 MG EPICERAM hydrocortisone butyrate lotion chlorzoxazone 375 mg EPOGEN HylaVite chlorzoxazone 500 mg (NDC^ 73007001303 only) ergotamine-caffeine hyoscyamine sulfate ext-rel chlorzoxazone 750 mg ERYPED HYSINGLA ER CIALIS estradiol vaginal tablet HYZAAR CICATRACE ESTRING icosapent ethyl CILOXAN EVEKEO ILUMYA CIMZIA LYOPHILIZED POWDER EVERSENSE CONTINUOUS INCRUSE ELLIPTA CIMZIA PREFILLED SYRINGE GLUCOSE MONITORING SYSTEM INDERAL LA CIPRO HC EXFORGE INDERAL XL CIPRODEX EXFORGE HCT INDOCIN clindamycin gel (NDC^ 68682046275 only) EXJADE indomethacin capsule 20 mg clobetasol spray EXTAVIA Inflammacin CLOBEX SPRAY FABIOR INFLECTRA clocortolone cream FANAPT INNOPRAN XL COLAZAL FEMRING INTRAROSA colchicine capsule fenofibrate capsule 50 mg INTUNIV COLCRYS fenofibrate capsule 130 mg INVELTYS CONSENSI fenofibrate tablet 40 mg INVIRASE CONTOUR NEXT STRIPS AND KITS 7 fenofibrate tablet 120 mg INVOKAMET CONTOUR STRIPS AND KITS 7 FENOGLIDE TABLET 120 MG INVOKAMET XR CONTRAVE fenoprofen INVOKANA CORDRAN OINTMENT FENOPROFEN CAPSULE isosorbide dinitrate 40 mg COREG CR FERIVA 21/7 JADENU CoreMino FERRIPROX JALYN COZAAR Fexmid JENTADUETO CRESEMBA FINACEA GEL JENTADUETO XR CRESTOR FIORICET CAPSULE KAMDOY CUPRIMINE FLAREX KAZANO cyclobenzaprine ext-rel capsule flucytosine capsule 500 mg ketoconazole foam 2% cyclobenzaprine tablet 7.5 mg fluocinonide cream 0.1% Ketodan CYMBALTA fluorouracil cream 0.5% ketoprofen capsule 25 mg CYTOMEL fluoxetine tablet (generics for SARAFEM only) ketoprofen ext-rel capsule DARAPRIM fluoxetine tablet 60 mg KINERET DAYTRANA flurandrenolide cream KOMBIGLYZE XR DELZICOL flurandrenolide lotion KUVAN DESFERAL flurandrenolide ointment KYPROLIS desoximetasone ointment 0.05% FML FORTE LACRISERT DETROL LA FML LIQUIFILM Lactojen dexchlorpheniramine FML S.O.P. LACTULOSE PAK Dexifol FOCALIN XR LANOXIN TABLET (125 MCG and 250 MCG only) Diclofex DC (NDC^ 51021037201 only) FOLIC-K Diclosaicin FOLLISTIM AQ LANTUS DIFFERIN LOTION Folvite-D LASTACAFT diflorasone cream FORTAMET LAZANDA diflorasone ointment FORTESTA LESCOL XL dihydroergotamine spray FOSRENOL LETAIRIS diltiazem ext-rel (generics for CARDIZEM LA only) FOSTEUM levorphanol DIOVAN FOSTEUM PLUS LEXAPRO DIOVAN HCT FREESTYLE LIBRE CONTINUOUS LEXIVA Diphen Elixir GLUCOSE MONITORING SYSTEM LIALDA DORYX FREESTYLE STRIPS AND KITS 7 LIBRAX

LIDOCAINE-TETRACAINE CREAM NuDiclo SoluPak ROZEREM (NDC^ 71800063115 only) NuDiclo TabPak RyClora LIDOTREX NUTROPIN AQ RYTARY LIPITOR NUVARING SABRIL LITHOSTAT NUVIGIL SAIZEN LIVALO OLEPTRO SANDOSTATIN LAR Lorid OLUX-E SCARSILK PAD Lorzone omeprazole-sodium bicarbonate SEASONIQUE LOTEMAX OMNARIS SEROQUEL XR LOTEMAX SM OMNITROPE SIGNIFOR LAR luliconazole OMNIVEX SIL-K PAD LUNESTA ONFI SILENOR LUPRON DEPOT ONGLYZA SILIVEX LUPRON DEPOT-PED ORENCIA CLICKJECT SILTREX LYRICA ORENCIA INTRAVENOUS SIMPONI MACRODANTIN ORENCIA SUBCUTANEOUS SINGULAIR Matzim LA orphenadrine-aspirin-caffeine SOMAVERT MAVYRET Orphengesic Forte SORILUX MAXALT ORTHO D SPRIX MAXALT-MLT ORTHO DF STENDRA MAXIDEX ORTHOVISC SUBOXONE mefenamic acid (NDC^ 69336012830 only) Oscimin SR sucralfate suspension MENEST OSENI sumatriptan-naproxen mesalamine delayed-rel tablet 800 mg OSMOPREP SUPREP metaxalone 400 mg OSPHENA Symax-SR metformin ext-rel OWEN MUMFORD NEEDLES 5 SYNERDERM (generics for FORTAMET and GLUMETZA only) oxiconazole (NDCs^ 00168035830, 51672135902 only) SYNVISC methocarbamol 500 mg (NDC^ 69036091010 only) OXYCONTIN SYNVISC-ONE methocarbamol 750 mg oxymorphone ext-rel SYPRINE (NDCs^ 69036093090, 70868090190 only) OXYTROL TALIVA MIACALCIN INJECTION pantoprazole delayed-rel suspension TALTZ MIACALCIN NASAL SPRAY paroxetine mesylate capsule 7.5 mg TARGADOX MICARDIS PAXIL TASIGNA MICARDIS HCT PAXIL CR TAYTULLA Migergot PENNSAID TAZORAC MILLIPRED PERCOCET TECFIDERA MINASTRIN 24 FE PERRIGO NEEDLES 5 TESTIM MINIVELLE PEXEVA testosterone gel 1% MINOCIN PLAVIX (authorized generics for TESTIM and VOGELXO only) minocycline ext-rel PLEGRIDY THEO-24 MIRVASO POLYTOZA THIOLA Mondoxyne NL capsule 75 mg posaconazole delayed-rel tablet THIOLA EC MONOVISC PRADAXA TIMOPTIC OCUDOSE MOVIPREP PRED FORTE TIROSINT MultiPro PRED MILD TOBI mupirocin cream PREMARIN TOBI PODHALER MYTESI PREMARIN CREAM TOBRADEX ST NAPRELAN PRENATAL PLUS topiramate ext-rel capsule (generics for QUDEXY XR only) naproxen-esomeprazole PREVACID TOPROL-XL naproxen CR PREVIDENT TRACLEER naproxen suspension PRILOSEC TRADJENTA NATAZIA PRISTIQ tramadol (NDC^ 52817019610 only) NATURE-THROID PROAIR HFA tramadol ext-rel capsule NEO-SYNALAR PROAIR RESPICLICK TRANSDERM SCOP NESINA PROCRIT TRAVATAN Z NEULASTA PRODIGEN TRELSTAR MIXJECT NEULASTA ONPRO PROMETRIUM TREXIMET NEUPOGEN PROTONIX triamcinolone aerosol 0.2% NEVANAC PROVAD triamcinolone ointment 0.05% NEXIUM PROVENTIL HFA Trianex niacin tablet 500 mg PROVIGIL TRICOR Niacor PROZAC TRINAZ NICADAN PSORCON TRIVIDIA INSULIN SYRINGES 5 NICAPRIN QNASL TronVite NICAZEL QTERN TRUXIMA NICAZEL FORTE quazepam TUDORZA NICOMIDE RAPAFLO UDENYCA NILANDRON RAYOS ULORIC nitrofurantoin (NDC^ 70408023932 only) RECEDO ULTIMED INSULIN SYRINGES 5 Nolix REMODULIN ULTIMED NEEDLES 5 NORGESIC FORTE RENFLEXIS UROXATRAL NORITATE REPATHA VALCYTE NORPACE RHEUMATE VALTREX NORVASC RIABNI Vanoxide-HC NOURIANZ RIBOZEL VASCULERA NOVACORT RIMSO-50 VECTICAL NOVO NORDISK NEEDLES 5 RIOMET VELTIN NOXAFIL RITUXAN venlafaxine ext-rel tablet (except 225 mg)

VENTOLIN HFA XOLEGEL ZIANA VEREGEN XOPENEX HFA zileuton ext-rel VIAGRA Xvite ZIRGAN VIEKIRA PAK XYZBAC ZOHYDRO ER VIIBRYD YASMIN ZOLADEX VIRACEPT YAZ ZOLOFT VISCO-3 Yuvafem zolpidem sublingual VITAFOL-ONE ZALVIT ZOLPIMIST Vitasure ZARXIO ZONEGRAN VIVELLE-DOT ZEGERID ZONTIVITY VOGELXO ZELAC ZORTRESS WESTHROID ZEMAIRA ZORVOLEX WP THYROID ZEPATIER ZUPLENZ XANAX ZERVIATE ZYDELIG XANAX XR ZESTORETIC ZYLET XENAZINE ZETIA ZYTIGA XENICAL ZETONNA ZYVIT

This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available drug options. Log in to Caremark.com to check coverage and copay information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CVS Caremark assumes no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.

Subject to applicable laws and regulations.

* This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. † Listing does not include certain NDCs^. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, , formulation and package size. 1 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). 2 If approved for coverage and prescribed for primary prevention of , may be covered without cost sharing through an exceptions process. 3 Rebranded or private label formulations are not covered (i.e., RELION). 4 Long Acting Insulins - First Generation. 5 BD ULTRAFINE syringes and needles are the only preferred options. 6 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. 7 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 8 Generic prenatal vitamins and CITRANATAL are the only preferred options. 9 An exception process may exist for specific clinical or regulatory circumstances that require coverage of a non-covered .

This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.

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