Quick viewing(Text Mode)

2019 National Preferred Formulary List for BJC Healthcare

2019 National Preferred Formulary List for BJC Healthcare

2019 Express Scripts National Preferred Formulary List For BJC HealthCare

The 2019 National Preferred Formulary drug list for BJC HealthCare is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY For the member: FDA-approved generic meet strict standards and [INJ] – Injectable Drug contain the same active ingredients as their corresponding brand-name medications, [OTC] – Over-the-counter Product although they may have a different appearance. [SP] – Specialty Drug For the physician: Please prescribe preferred products and allow generic Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA substitutions when medically appropriate. Generic drugs are listed in lower-case letters. Example:

A ADCETRIS [INJ] [SP] ALPROLIX [INJ] [SP] ampicillin sodium/sulbactam [INJ] ADDAMEL N [INJ] alprostadil [INJ] AMYTAL [INJ] abacavir [SP] adefovir ALREX anagrelide abacavir/lamivudine [SP] ADEMPAS [SP] altavera anastrozole abacavir/lamivudine/zidovudine [SP] adenosine [INJ] alyacen ANDRODERM ABELCET [INJ] ADVAIR DISKUS amabelz ANORO ELLIPTA ABILIFY MAINTENA [INJ] ADVAIR HFA anthralin ABRAXANE [INJ] [SP] ADVATE [INJ] [SP] AMBISOME [INJ] APLISOL [INJ] ABSORICA ADYNOVATE [INJ] [SP] amcinonide APOKYN [INJ] [SP] acamprosate delayed-release AFINITOR [SP] amethia apraclonidine eye solution ACANYA AFINITOR DISPERZ [SP] amethia lo acarbose AFLURIA [INJ] amethyst apri ACCU-CHEK FASTCLIX LANCETS [OTC] AFLURIA QUAD [INJ] AMICAR APRISO ACCU-CHEK MULTICLIX LANCET KIT [OTC] AFSTYLA [INJ] [SP] amifostine [INJ] APTIVUS [SP] ACCU-CHEK MULTICLIX LANCETS [OTC] AIMOVIG [INJ] amikacin [INJ] AQUASOL A [INJ] ACCU-CHEK SOFTCLIX LANCET KIT [OTC] AKYNZEO amiloride ARALAST NP [INJ] [SP] ACCU-CHEK SOFTCLIX LANCETS [OTC] albendazole amiloride/hydrochlorothiazide aranelle acebutolol albumin human [INJ] aminocaproic acid [INJ] ARCAPTA NEOHALER acetaminophen/ albuterol aminophylline [INJ] acetazolamide albuterol ext-release AMINOSYN [INJ] aripiprazole orally disintegrating tablets acetazolamide ext-release albuterol nebulization solution amiodarone ARISTADA [INJ] acetazolamide sodium [INJ] alclometasone amiodarone [INJ] ARISTOSPAN [INJ] acetic acid ear solution ALDURAZYME [INJ] [SP] AMITIZA armodafinil acetic acid irrigation solution ALECENSA [SP] ARMONAIR RESPICLICK acetic acid/hydrocortisone ear solution alendronate amitriptyline/chlordiazepoxide ARMOUR THYROID acetic acid/oxyquinoline vaginal [INJ] amlodipine ARNUITY ELLIPTA acetylcysteine [INJ] ALFERON N [INJ] amlodipine/atorvastatin ARRANON [INJ] [SP] acetylcysteine inhalation solution alfuzosin ext-release amlodipine/benazepril ARZERRA [INJ] [SP] acitretin ALIMTA [INJ] amlodipine/olmesartan ascorbic acid [INJ] ACTEMRA [INJ] [SP] ALINIA amlodipine/valsartan ashlyna ACTHIB [INJ] ALIQOPA [INJ] [SP] amlodipine/valsartan/hydrochlorothiazide ASMANEX HFA ACTHREL [INJ] allopurinol ammonium lactate 12% topical ASMANEX TWISTHALER ACTIMMUNE [INJ] [SP] allopurinol sodium [INJ] /dipyridamole ext-release ACTIVASE [INJ] amoxicillin atazanavir [SP] acyclovir amoxicillin/potassium clavulanate atenolol acyclovir ointment ALPHAGAN P 0.1% amoxicillin/potassium clavulanate atenolol/chlorthalidone acyclovir sodium [INJ] ALPHANATE [INJ] [SP] ext-release ATGAM [INJ] ADACEL [INJ] ALPHANINE SD [INJ] [SP] sulfate atomoxetine ADAGEN [INJ] [SP] alprazolam amphotericin [INJ] atorvastatin adapalene alprazolam ext-release ampicillin atovaquone adapalene/benzoyl peroxide alprazolam orally disintegrating tablets ampicillin sodium [INJ] atovaquone/proguanil (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 1 COMPBJCANP-19 (11/15/18) [INJ] BEXSERO [INJ] calcitriol ointment CETROTIDE [INJ] [SP] atropine sulfate eye ointment bicalutamide calcium acetate atropine sulfate eye solution BICILLIN C-R [INJ] calcium chloride [INJ] CHANTIX ATROVENT HFA BICILLIN L-A [INJ] CALCIUM DISODIUM VERSENATE [INJ] chateal aubra BIKTARVY [SP] calcium gluconate [INJ] chateal eq aubra eq bimatoprost eye solution calcium-pnv 28-1-250 prenatal vitamins CHEMET AUGMENTIN 125-31.25 MG/5 ML biolon [INJ] CALDOLOR [INJ] CHENODAL [SP] AVASTIN [INJ] [SP] BIOTHRAX [INJ] camila chloramphenicol [INJ] aviane bisoprolol camrese chlorcyclizine/codeine avo cream bisoprolol/hydrochlorothiazide camrese lo chlorcyclizine/pseudoephedrine/codeine AVONEX [INJ] [SP] bivalirudin [INJ] CANASA chlordiazepoxide AVYCAZ [INJ] blanche candesartan chlordiazepoxide/clidinium azacitidine [INJ] [SP] bleomycin [INJ] candesartan/hydrochlorothiazide chlorhexidine gluconate AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] BLINCYTO [INJ] [SP] CAPASTAT SULFATE [INJ] chloroprocaine hcl [INJ] AZASITE blisovi 24 fe capecitabine [SP] chloroquine azathioprine [SP] blisovi fe CAPRELSA [SP] chlorothiazide azathioprine sodium [INJ] [SP] BOOSTRIX [INJ] captopril chlorothiazide sodium [INJ] AZEDRA [INJ] [SP] BOSULIF [SP] captopril/hydrochlorothiazide chlorpheniramine/phenylephrine/ eye solution BOTOX [INJ] [SP] CARAC azelastine nasal spray BREO ELLIPTA CARAFATE SUSPENSION azithromycin BREVITAL [INJ] [INJ] chlorpromazine [INJ] azithromycin [INJ] briellyn CARBAGLU [SP] chlorthalidone aztreonam [INJ] BRILINTA azurette brimonidine eye solution carbamazepine ext-release CHOLBAM [SP] BRINEURA [INJ] [SP] carbidopa cholestyramine B eye solution carbidopa/levodopa cholestyramine light carbidopa/levodopa ext-release salicylate/ bacitracin [INJ] /pseudoephedrine/ carbidopa/levodopa orally chromium chloride [INJ] bacitracin eye ointment codeine disintegrating tablets ciclopirox bacitracin/polymyxin eye ointment brompheniramine/pseudoephedrine/ carbidopa/levodopa/entacapone ciclopirox shampoo baclofen dextromethorphan cidofovir [INJ] BAL IN OIL [INJ] budesonide ext-release carboplatin [INJ] cilostazol balanced salt eye irrigation solution budesonide nebulization suspension carmustine [INJ] CIMDUO [SP] bal-care dha prenatal vitamins bumetanide eye solution balsalazide bumetanide [INJ] carvedilol CINRYZE [INJ] [SP] balziva bupivacaine [INJ] carvedilol phosphate ext-release BANZEL bupivacaine/dextrose [INJ] caspofungin [INJ] ciprofloxacin ear solution BARACLUDE SOLUTION bupivacaine/epinephrine [INJ] CATHFLO ACTIVASE [INJ] ciprofloxacin ext-release BAVENCIO [INJ] [SP] CAVERJECT [INJ] ciprofloxacin eye solution b-complex [INJ] buprenorphine [INJ] CAYSTON [SP] ciprofloxacin lactate/dextrose [INJ] BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine/naloxone caziant cisplatin [INJ] BD ULTRAFINE INSULIN SYRINGES [OTC] cefaclor citalopram BD ULTRAFINE PEN NEEDLES [OTC] bupropion ext-release cefaclor ext-release cladribine [INJ] BEBULIN [INJ] [SP] bupropion ext-release (smoking deterrent) cefadroxil clarithromycin bekyree cefazolin [INJ] clarithromycin ext-release BELBUCA busulfan [INJ] cefdinir benazepril butalbital/acetaminophen cefditoren CLENPIQ benazepril/hydrochlorothiazide butalbital/acetaminophen/caffeine cefepime [INJ] clindamycin hcl BENDEKA [INJ] [SP] butalbital/acetaminophen/caffeine/ cefepime/dextrose [INJ] clindamycin palmitate BENEFIX [INJ] [SP] codeine cefixime clindamycin phosphate [INJ] BENLYSTA [INJ] [SP] butalbital/aspirin/caffeine cefotaxime [INJ] clindamycin phosphate topical benoxinate/fluorescein eye solution butalbital/aspirin/caffeine/codeine cefotetan [INJ] clindamycin phosphate vaginal BENZNIDAZOLE [INJ] cefoxitin [INJ] clindamycin phosphate/benzoyl peroxide benzonatate butorphanol nasal cefoxitin/dextrose [INJ] clindamycin phosphate/dextrose [INJ] benzoyl peroxide BYDUREON [INJ] cefpodoxime clindamycin phosphate/tretinoin benztropine BYETTA [INJ] cefprozil CLINIMIX [INJ] benztropine [INJ] BYSTOLIC ceftazidime [INJ] CLINIMIX E [INJ] BEPREVE BYVALSON CEFTAZIDIME/DEXTROSE [INJ] clobetasol propionate BESPONSA [INJ] [SP] ceftibuten clobetasol propionate shampoo betamethasone acetate/betamethasone C ceftriaxone [INJ] clobetasol propionate/emollient sodium phosphate [INJ] ceftriaxone/dextrose [INJ] clofarabine [INJ] betamethasone dipropionate cefuroxime axetil clomiphene citrate betamethasone dipropionate augmented CABOMETYX [SP] cefuroxime sodium [INJ] betamethasone valerate caffeine citrated celacyn clonazepam BETASERON [INJ] [SP] caffeine citrated [INJ] clonazepam orally disintegrating tablets betaxolol caffeine/sodium benzoate [INJ] CELONTIN betaxolol eye solution calcipotriene cephalexin clonidine [INJ] calcipotriene/betamethasone dipropionate CEPROTIN [INJ] [SP] clonidine ext-release BETHKIS [SP] calcitonin salmon nasal CERDELGA [SP] clonidine patches BEVESPI AEROSPHERE calcitriol CEREZYME [INJ] [SP] clonidine/chlorthalidone bexarotene [SP] calcitriol [INJ] syrup clopidogrel (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 2 COMPBJCANP-19 (11/15/18) clorazepate dantrolene [INJ] digoxin [INJ] ELIDEL clotrimazole topical dapsone /acetaminophen/caffeine ELIGARD [INJ] [SP] clotrimazole troche DAPTACEL [INJ] [INJ] elinest clotrimazole/betamethasone dipropionate daptomycin [INJ] dihydroergotamine nasal eliphos DARAPRIM [SP] DILANTIN 30 MG CAPSULES ELIQUIS clozapine orally disintegrating tablets ext-release DILATRATE-SR ELITEK [INJ] c-nate dha prenatal vitamins DARZALEX [INJ] [SP] diltiazem elite-ob prenatal vitamins COAGADEX [INJ] [SP] dasetta diltiazem [INJ] ELMIRON COARTEM daunorubicin [INJ] diltiazem ext-release EMCYT topical solution daysee [INJ] EMGALITY [INJ] codeine sulfate DAYTRANA emoquette colchicine/probenecid deblitane diphenhydramine [INJ] EMTRIVA [SP] COLCRYS decitabine [INJ] [SP] diphenoxylate/atropine emulsion sb colesevelam hcl deferoxamine [INJ] DIPHTHERIA-TETANUS TOXOIDS-PED [INJ] EMVERM colestipol delflex with dextrose [INJ] dipyridamole enalapril colistimethate [INJ] delyla dipyridamole [INJ] enalapril/hydrochlorothiazide COMBIGAN demeclocycline disulfiram enalaprilat [INJ] COMBIPATCH DEMSER divalproex delayed-release ENBREL [INJ] [SP] COMBIVENT RESPIMAT DEPEN divalproex ext-release ENGERIX-B [INJ] COMPLERA [SP] DEPO-ESTRADIOL [INJ] DIVIGEL enoxaparin [INJ] [SP] complete natal dha prenatal vitamins DEPO-PROVERA 400 MG/ML [INJ] dobutamine [INJ] enpresse completenate prenatal vitamins DESCOVY [SP] dobutamine/dextrose [INJ] enskyce constulose DOCEFREZ [INJ] ENSTILAR COPAXONE 40 MG [INJ] [SP] docetaxel [INJ] entacapone copper chloride [INJ] desloratadine orally disintegrating tablets DOCETAXEL 200 MG/10 ML [INJ] entecavir CORIFACT [INJ] [SP] desmopressin acetate dofetilide ENTRESTO CORLANOR desmopressin acetate [INJ] [SP] donepezil ENTYVIO [INJ] [SP] cortisone acetate desmopressin nasal donepezil orally disintegrating tablets EOVIST [INJ] COSENTYX [INJ] [SP] desogestrel-ethinyl estradiol [INJ] EPCLUSA [SP] cosyntropin [INJ] desonide dopamine/dextrose [INJ] ephedrine [INJ] COTELLIC [SP] desoximetasone DOPTELET [SP] EPIDIOLEX CREON desvenlafaxine succinate ext-release dorzolamide eye solution EPIDUO FORTE CRESEMBA dorzolamide/timolol eye solution eye solution CRESEMBA [INJ] dexamethasone sodium phosphate [INJ] dothelle dha prenatal vitamins EPINEPHRINE AUTO-INJECTOR CRINONE 4% dexamethasone sodium phosphate doxazosin (by Mylan) [INJ] CRINONE 8% [SP] eye solution epinephrine vial, ampule, syringe [INJ] CRIXIVAN [SP] DEXCOM G4 doxepin cream epinephrine-dextrose [INJ] CROFAB [INJ] DEXCOM G5 doxercalciferol epinephrine-nacl [INJ] cromolyn sodium eye solution DEXCOM G6 doxercalciferol [INJ] EPIPEN [INJ] cromolyn sodium nebulization solution dexmedetomidine [INJ] doxorubicin [INJ] EPIPEN JR. [INJ] cromolyn sodium oral solution dexmethylphenidate doxorubicin/liposomal [INJ] epirubicin [INJ] crotamiton dexmethylphenidate ext-release doxycycline hyclate EPIVIR HBV SOLUTION cryselle dexrazoxane [INJ] doxycycline hyclate [INJ] eplerenone CRYSVITA [INJ] [SP] dextran/dextrose [INJ] doxycycline hyclate delayed-release epoprostenol [INJ] [SP] cyanocobalamin [INJ] dextran/normal saline [INJ] doxycycline monohydrate epoprostenol diluent [INJ] [SP] cyclafem dextroamphetamine eprosartan dextroamphetamine ext-release [INJ] eptifibatide [INJ] eye solution dextroamphetamine/amphetamine drospirenone-ethinyl estradiol ERAXIS [INJ] cyclophosphamide [INJ] dextroamphetamine/amphetamine drospirenone-ethinyl ERBITUX [INJ] [SP] CYCLOPHOSPHAMIDE CAPSULES ext-release estradiol-levomefolate ergocalciferol cyclosporine [INJ] [SP] dextrose/lactated ringers [INJ] DROXIA ergoloid mesylates cyclosporine [SP] dextrose/sodium chloride [INJ] DUAVEE tartrate/caffeine cyclosporine modified [SP] dextrose/water [INJ] DULERA ergotamine tartrate/caffeine diazepam duloxetine delayed-release suppositories CYRAMZA [INJ] [SP] diazepam [INJ] DUPIXENT [INJ] [SP] ERIVEDGE [SP] cyred diazepam rectal gel dutasteride ERLEADA [SP] CYSTADANE [SP] eye solution dutasteride/tamsulosin ext-release errin CYSTAGON [SP] diclofenac potassium DYMISTA ertapenem [INJ] CYSTARAN [SP] diclofenac sodium delayed-release ERYTHROCIN [INJ] cytarabine [INJ] diclofenac sodium ext-release E erythromycin CYTOGAM [INJ] [SP] diclofenac sodium gel erythromycin delayed-release diclofenac sodium topical solution econazole erythromycin ethylsuccinate D diclofenac sodium/misoprostol ext-release EDARBI erythromycin eye ointment dicloxacillin EDARBYCLOR erythromycin stearate dacarbazine [INJ] dicyclomine EDURANT [SP] erythromycin topical dactinomycin [INJ] dicyclomine [INJ] [SP] erythromycin/benzoyl peroxide dalfampridine ext-release [SP] didanosine delayed-release [SP] EGRIFTA [INJ] [SP] ESBRIET [SP] DALIRESP diflorasone ELAPRASE [INJ] [SP] escitalopram DALVANCE [INJ] diflorasone/emollient electrolyte-48 solution/dextrose [INJ] esmolol [INJ] danazol eletone esmolol-nacl [INJ] dantrolene digoxin (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 3 COMPBJCANP-19 (11/15/18) esomeprazole magnesium delayed-release FIRST-LANSOPRAZOLE furosemide [INJ] guanidine esomeprazole sodium [INJ] FIRST-MOUTHWASH BLM FUZEON [INJ] [SP] estarylla FIRST-OMEPRAZOLE fyavolv H estazolam FYCOMPA esterified estrogens/methyltestosterone flecainide HALAVEN [INJ] [SP] estradiol FLECTOR G halobetasol estradiol cream FLOLAN [INJ] [SP] estradiol patches FLOLAN DILUENT [INJ] [SP] [INJ] estradiol vaginal FLOVENT DISKUS GABLOFEN [INJ] haloperidol lactate estradiol valerate [INJ] FLOVENT HFA haloperidol lactate [INJ] estradiol/norethindrone acetate floxuridine [INJ] galantamine ext-release HARVONI [SP] ESTRING FLUAD [INJ] GAMASTAN [INJ] [SP] HAVRIX [INJ] estropipate FLUARIX QUAD [INJ] GAMASTAN S-D [INJ] [SP] heather eszopiclone FLUBLOK QUAD [INJ] GAMMAGARD LIQUID [INJ] [SP] HELIXATE FS [INJ] [SP] ethacrynate [INJ] FLUCELVAX QUAD [INJ] GAMMAGARD S-D [INJ] [SP] HEMABATE [INJ] ethacrynic acid fluconazole GAMUNEX-C [INJ] [SP] hemenatal ob + dha prenatal vitamins ethambutol fluconazole/dextrose [INJ] ganciclovir [INJ] hemenatal ob prenatal vitamins ETHAMOLIN [INJ] fluconazole/normal saline [INJ] GARDASIL 9 [INJ] HEMLIBRA [INJ] [SP] ethosuximide flucytosine gatifloxacin eye solution HEMOFIL-M [INJ] [SP] ethyl [INJ] fludarabine [INJ] gavilyte-c HEPAGAM B [INJ] ethyl chloride spray fludrocortisone acetate gavilyte-g heparin lock flush [INJ] ethynodiol-ethinyl estradiol FLULAVAL QUAD [INJ] gavilyte-n heparin sodium [INJ] etidronate flumazenil [INJ] GAZYVA [INJ] [SP] heparin sodium/dextrose [INJ] flunisolide nasal spray GELNIQUE heparin sodium/nacl [INJ] etodolac ext-release fluocinolone gemcitabine [INJ] HEPATAMINE [INJ] etomidate [INJ] fluocinolone acetonide oil ear solution gemfibrozil HERCEPTIN [INJ] [SP] ETOPOPHOS [INJ] fluocinonide GENOTROPIN [INJ] [SP] hetastarch/normal saline [INJ] etoposide fluocinonide/emollient gentamicin [INJ] HEXALEN etoposide [INJ] fluorescein [INJ] gentamicin eye ointment HEXTEND LACTATED ELECTROLYTE [INJ] EUFLEXXA [INJ] [SP] fluorescein eye strips gentamicin eye solution HIBERIX [INJ] exemestane fluorometholone eye suspension gentamicin topical HIZENTRA [INJ] [SP] EXJADE [SP] fluorouracil gentamicin/normal saline [INJ] eye solution EXTRANEAL ICODEXTRIN DIALYSIS fluorouracil [INJ] GENTAMICIN/NORMAL SALINE hpr emollient foam SOLUTION [INJ] 100 MG/50 ML [INJ] hpr plus EYLEA [INJ] [SP] fluoxetine delayed-release GENVOYA [SP] hpr plus hydrogel ezetimibe decanoate [INJ] gianvi HUMALOG [INJ] ezetimibe/simvastatin fluphenazine hcl gildagia HUMATE-P [INJ] [SP] fluphenazine hcl [INJ] GILENYA [SP] HUMIRA [INJ] [SP] F flurandrenolide GILOTRIF [SP] HUMULIN [INJ] flurazepam glatiramer [INJ] [SP] HUMULIN R 500 UNITS [INJ] FABRAZYME [INJ] [SP] glatopa [INJ] [SP] HYCAMTIN CAPSULES [SP] falmina flurbiprofen sodium eye solution GLEOSTINE hydralazine famciclovir flutamide glimepiride hydralazine [INJ] fluticasone nasal spray glipizide hydrochlorothiazide famotidine [INJ] fluticasone topical glipizide ext-release /acetaminophen famotidine/nacl [INJ] FLUTICASONE/SALMETEROL glipizide/metformin hydrocodone/chlorpheniramine polistirex FARESTON fluvastatin GLUCAGEN [INJ] ext-release FARXIGA fluvastatin ext-release GLUCAGON [INJ] hydrocodone/chlorpheniramine/ FASENRA [INJ] [SP] fluvoxamine glyburide pseudoephedrine FASLODEX [INJ] fluvoxamine ext-release glyburide micronized hydrocodone/homatropine fayosim FLUZONE HIGH-DOSE [INJ] glyburide/metformin hydrocodone/ibuprofen FEIBA NF [INJ] [SP] FLUZONE QUAD [INJ] glycine irrigation solution hydrocortisone felbamate folic acid glycolax hydrocortisone acetate suppositories felodipine ext-release folic acid [INJ] GLYCOPHOS [INJ] hydrocortisone butyrate femynor folivane-ob prenatal vitamins glycopyrrolate hydrocortisone butyrate/emollient fenofibrate FOLOTYN [INJ] [SP] glycopyrrolate [INJ] hydrocortisone enema fenofibrate micronized fomepizole [INJ] glycopyrrolate-water [INJ] hydrocortisone sodium succinate [INJ] fenofibric acid fondaparinux [INJ] [SP] GLYXAMBI hydrocortisone topical fenofibric acid delayed-release FORTAZ-ISO-OSMOTIC DEXTROSE [INJ] GONAL-F [INJ] [SP] hydrocortisone valerate FORTEO [INJ] [SP] GONAL-F RFF [INJ] [SP] hydrocortisone/iodoquinol citrate [INJ] fosamprenavir [SP] GONAL-F RFF REDI-JECT [INJ] [SP] hydrocortisone/iodoquinol/aloe fentanyl citrate lozenges foscarnet [INJ] hydrocortisone/ fentanyl citrate/nacl [INJ] fosinopril granisetron [INJ] hydrocortisone/pramoxine fentanyl patches fosinopril/hydrochlorothiazide GRANIX [INJ] [SP] FERAHEME [INJ] fosphenytoin [INJ] GRASTEK hydromorphone [INJ] FERRIPROX [SP] FRAGMIN [INJ] [SP] griseofulvin microsize hydromorphone ext-release FETZIMA FREAMINE HBC [INJ] griseofulvin ultramicrosize hydromorphone suppositories FINACEA freamine iii [INJ] guaifenesin/codeine hydromorphone/nacl [INJ] finasteride guaifenesin/phenylephrine hydroquinone FIRAZYR [INJ] [SP] FULPHILA [INJ] [SP] guanfacine hydroquinone microspheres FIRMAGON [INJ] [SP] furosemide guanfacine ext-release hydroxocobalamin [INJ] (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 4 COMPBJCANP-19 (11/15/18) hydroxychloroquine ipratropium/albuterol sulfate nebulization eye solution levothyroxine sodium hydroxyprogesterone [INJ] solution KEYTRUDA [INJ] [SP] levothyroxine sodium [INJ] hydroxyprogesterone [INJ] [SP] irbesartan kimidess LEVOTHYROXINE SODIUM 100 MCG [INJ] hydroxyurea irbesartan/hydrochlorothiazide KINEVAC [INJ] LEVSIN [INJ] hcl IRESSA [SP] KITABIS PAK [SP] LEXISCAN [INJ] hydroxyzine hcl [INJ] irinotecan [INJ] KOGENATE FS [INJ] [SP] LEXIVA SUSPENSION [SP] hydroxyzine pamoate ISENTRESS [SP] KOVALTRY [INJ] [SP] lidocaine [INJ] hyophen isibloom K-PHOS ORIGINAL lidocaine hcl/glycerin ISOLYTE [INJ] KRYSTEXXA [INJ] [SP] lidocaine jelly hyoscyamine ext-release isometheptene/caffeine/acetaminophen kurvelo lidocaine patches hyoscyamine orally disintegrating tablets isometheptene/dichloralphenazone/ KUVAN [SP] lidocaine topical HYPERHEP B S-D [INJ] acetaminophen KYLEENA [SP] lidocaine viscous HYPERRAB [INJ] isoniazid KYMRIAH [INJ] [SP] lidocaine/dextrose [INJ] HYPERRAB S-D [INJ] isoniazid [INJ] KYPROLIS [INJ] [SP] lidocaine/epinephrine [INJ] HYPERRHO S-D [INJ] isoproterenol [INJ] lidocaine/glycerin HYPERTET S-D [INJ] isosorbide dinitrate L lidocaine/hydrocortisone hypochlorous acid/sodium chloride isosorbide dinitrate ext-release lidocaine/prilocaine HYSINGLA ER isosorbide mononitrate labetalol lillow isosorbide mononitrate ext-release labetalol [INJ] lincomycin [INJ] I isotretinoin lactulose lindane shampoo isoxsuprine lamivudine [SP] linezolid ibandronate isradipine lamivudine hbv linezolid [INJ] ibandronate [INJ] [SP] ISTODAX [INJ] [SP] lamivudine/zidovudine [SP] linezolid/nacl [INJ] IBRANCE [SP] lamotrigine LINZESS ibuprofen lamotrigine ext-release LIORESAL [INJ] ibuprofen [INJ] IXEMPRA [INJ] [SP] lamotrigine orally disintegrating tablets liothyronine ibutilide [INJ] IXIARO [INJ] LANOXIN PEDIATRIC [INJ] liothyronine [INJ] ICLUSIG [SP] IXINITY [INJ] [SP] lansoprazole delayed-release LIPOFEN idarubicin [INJ] lansoprazole delayed-release lisinopril IDHIFA [SP] J +amoxicillin+clarithromycin lisinopril/hydrochlorothiazide ifosfamide [INJ] lansoprazole orally disintegrating tablets lithium carbonate ifosfamide/mesna [INJ] JADENU [SP] lanthanum lithium carbonate ext-release ILARIS [INJ] [SP] JAKAFI [SP] LANTUS [INJ] lithium citrate ILEVRO JANUMET larin LIVALO [SP] JANUMET XR larin fe LO LOESTRIN FE IMBRUVICA [SP] JANUVIA larissia LOKELMA IMFINZI [INJ] [SP] JARDIANCE LARTRUVO [INJ] [SP] LONSURF [SP] imipenem/cilastatin [INJ] jencycla latanoprost eye solution loperamide hcl JENTADUETO LATUDA lopinavir/ritonavir [SP] imipramine pamoate JENTADUETO XR layolis fe lopreeza imiquimod JETREA [INJ] [SP] l-cysteine [INJ] IMOGAM RABIES-HT [INJ] jevantique lo leena lorazepam [INJ] IMOVAX RABIES VACCINE [INJ] JEVTANA [INJ] [SP] leflunomide loryna IMPAVIDO jinteli LENVIMA [SP] losartan incassia JIVI [INJ] [SP] lessina losartan/hydrochlorothiazide INCRELEX [INJ] [SP] jolessa LETAIRIS [SP] LOTEMAX INCRUSE ELLIPTA jolivette letrozole lovastatin indapamide juleber leucovorin low-ogestrel indomethacin junel leucovorin [INJ] indomethacin ext-release junel fe LEUKERAN LUMIZYME [INJ] [SP] indomethacin sodium [INJ] JUXTAPID [SP] LEUKINE [INJ] [SP] LUPRON DEPOT 3.75 MG, 11.25 MG INFANRIX [INJ] leuprolide [INJ] [SP] [INJ] [SP] infed [INJ] K levalbuterol nebulization solution LUTATHERA [INJ] [SP] INFUMORPH [INJ] LEVEMIR [INJ] lutera INFUVITE [INJ] KADCYLA [INJ] [SP] levetiracetam luxamend INLYTA [SP] kaitlib fe levetiracetam [INJ] LUXTURNA [INJ] [SP] INTELENCE [SP] KALETRA TABLETS [SP] levetiracetam ext-release LYNPARZA [SP] intralipid 20% [INJ] KALYDECO [SP] levetiracetam-nacl [INJ] LYRICA INTRON A [INJ] [SP] KANUMA [INJ] [SP] levobunolol eye solution LYSODREN introvale kariva levocarnitine lyza INVANZ ADD-VANTAGE [INJ] kelnor INVIRASE [SP] KEPIVANCE [INJ] [SP] levofloxacin M INVOKAMET [INJ] levofloxacin [INJ] INVOKAMET XR ketamine-nacl [INJ] levofloxacin eye solution m.v.i. adult [INJ] INVOKANA levofloxacin/dextrose [INJ] M.V.I. PEDIATRIC [INJ] iodine/potassium iodide ketoconazole shampoo LEVOLEUCOVORIN [INJ] M.V.I.-12 [INJ] IODOPEN [INJ] ketoconazole topical levomefolate dha mafenide IONOSOL/DEXTROSE [INJ] levonest magnesium chloride [INJ] IPOL [INJ] ketoprofen ext-release levonorgestrel-ethinyl estradiol magnesium sulfate [INJ] nasal spray ketorolac levora MAGNESIUM/DEXTROSE ipratropium bromide nebulization solution ketorolac [INJ] 1 GM/100 ML [INJ] (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 5 COMPBJCANP-19 (11/15/18) malathion orally mupirocin newgen prenatal vitamins manganese chloride [INJ] disintegrating tablets MUSE NEXAVAR [SP] manganese sulfate [INJ] metolazone MUSTARGEN [INJ] NEXIUM PACKETS mannitol [INJ] metoprolol succinate ext-release MYALEPT [INJ] [SP] NEXPLANON [INJ] [SP] metoprolol tartrate MYCAMINE [INJ] NEXTERONE [INJ] marlissa metoprolol tartrate [INJ] mycophenolate mofetil [SP] niacin ext-release MARQIBO [INJ] [SP] metoprolol/hydrochlorothiazide mycophenolate mofetil hcl [INJ] [SP] nicardipine MATULANE [SP] metronidazole mycophenolic acid delayed-release [SP] nicardipine [INJ] mb hydrogel metronidazole topical MYDAYIS nifedipine ext-release metronidazole vaginal MYLERAN nikki meclofenamate metronidazole/nacl [INJ] MYLOTARG [INJ] [SP] nilutamide medroxyprogesterone mynatal advance prenatal vitamins nimodipine medroxyprogesterone (contraceptive) [INJ] MIACALCIN [INJ] mynatal plus prenatal vitamins NINLARO [SP] mibelas 24 fe mynatal prenatal vitamins nisoldipine ext-release mefloquine miconazole vaginal mynatal ultracaplet prenatal vitamins nitrofurantoin megestrol microgestin mynatal-z prenatal vitamins nitrofurantoin macrocrystal MEKINIST [SP] microgestin fe mynate 90 plus prenatal vitamins nitrofurantoin monohydrate/macrocrystal melodetta 24 fe MYOBLOC [INJ] [SP] nitroglycerin [INJ] midazolam [INJ] MYRBETRIQ nitroglycerin ext-release melphalan midazolam/nacl [INJ] myzilra nitroglycerin ointment melphalan [INJ] midodrine nitroglycerin patches miglitol N nitroglycerin spray memantine ext-release miglustat [SP] nitroglycerin/dextrose [INJ] MENACTRA [INJ] mili nitroprusside sodium [INJ] MENOPUR [INJ] [SP] milrinone [INJ] nadolol NITYR [SP] mepivacaine [INJ] milrinone/dextrose [INJ] nadolol/bendroflumethiazide nivatopic plus MEPSEVII [INJ] [SP] mimvey nafcillin [INJ] mercaptopurine mimvey lo nafcillin/dextrose [INJ] nora-be meropenem [INJ] MINIMED INFUSION SET naftifine NORDITROPIN [INJ] [SP] MEROPENEM/NACL [INJ] MINIMED RESERVOIR NAGLAZYME [INJ] [SP] norepinephrine [INJ] mesalamine delayed-release MINIVELLE [INJ] norepinephrine/dextrose [INJ] mesalamine enema MINOCIN [INJ] naloxone [INJ] norepinephrine/nacl [INJ] mesalamine kit minocycline naltrexone norethindrone mesna [INJ] minocycline ext-release norethindrone acetate MESNEX TABLETS minoxidil naproxen delayed-release norethindrone acetate-ethinyl estradiol MESTINON SYRUP MIRENA [SP] naproxen sodium norethindrone acetate-ethinyl estradiol metaproterenol naproxen sodium ext-release + iron metaxalone mirtazapine orally disintegrating tablets norgestimate-ethinyl estradiol metformin MIRVASO NARCAN NASAL SPRAY norlyda metformin ext-release misoprostol NASCOBAL norlyroc MITIGARE NATACYN NORMOSOL-M AND DEXTROSE [INJ] methadone [INJ] mitomycin [INJ] nateglinide NORMOSOL-R AND DEXTROSE [INJ] methamphetamine mitoxantrone [INJ] [SP] NATPARA [INJ] [SP] NORMOSOL-R PH 7.4 [INJ] methazolamide M-M-R II [INJ] NATRECOR [INJ] nortrel methenamine hippurate modafinil NEBUPENT methenamine mandelate moderiba [SP] necon NORVIR CAPSULES [SP] methenamine/sodium phosphate/ moexipril neomycin NORVIR PACKETS [SP] methylene blue/hyoscyamine moexipril/hydrochlorothiazide neomycin/bacitracin/polymyxin NORVIR SOLUTION [SP] methimazole mometasone eye ointment NOVAREL [INJ] [SP] METHITEST mometasone nasal spray neomycin/bacitracin/polymyxin/ NOVOEIGHT [INJ] [SP] MONOCLATE-P [INJ] [SP] hydrocortisone eye ointment NOVOFINE AUTOSHIELD NEEDLES [OTC] methocarbamol [INJ] mono-linyah neomycin/polymyxin irrigation solution NOVOFINE NEEDLES [OTC] methotrexate mononessa neomycin/polymyxin/dexamethasone NOVOSEVEN RT [INJ] [SP] methotrexate [INJ] MONONINE [INJ] [SP] eye ointment NOVOTWIST NEEDLES [OTC] methoxsalen MONOVISC [INJ] [SP] neomycin/polymyxin/dexamethasone NOXAFIL methyclothiazide montelukast eye suspension NOXAFIL [INJ] methyldopa sulfate neomycin/polymyxin/gramicidin NPLATE [INJ] [SP] methyldopa/hydrochlorothiazide morphine sulfate [INJ] eye solution NUCALA [INJ] [SP] methyldopate [INJ] morphine sulfate ext-release neomycin/polymyxin/hydrocortisone NUCYNTA methylergonovine morphine sulfate suppositories ear solution NUCYNTA ER methylergonovine [INJ] morphine sulfate/nacl [INJ] neomycin/polymyxin/hydrocortisone NUEDEXTA methylphenidate MOVANTIK ear suspension NULOJIX [INJ] [SP] methylphenidate ext-release MOXEZA neomycin/polymyxin/hydrocortisone nutrilyte [INJ] methylprednisolone moxifloxacin eye suspension NUVARING methylprednisolone acetate [INJ] MOXIFLOXACIN [INJ] neostigmine [INJ] NUWIQ [INJ] [SP] methylprednisolone sodium moxifloxacin eye solution NEPHRAMINE [INJ] nystatin succinate [INJ] MOZOBIL [INJ] [SP] NERLYNX [SP] nystatin topical methyltestosterone MULPLETA [SP] NEULASTA [INJ] [SP] nystatin/triamcinolone metipranolol eye solution MULTI-LANCET DEVICE [OTC] NEUT [INJ] metoclopramide MULTITRACE-4 [INJ] nevirapine [SP] metoclopramide [INJ] MULTITRACE-5 [INJ] nevirapine ext-release [SP] (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 6 COMPBJCANP-19 (11/15/18) O ext-release phenylephrine/dextrose [INJ] pramipexole phenylephrine/nacl [INJ] pramipexole ext-release OBIZUR [INJ] [SP] oxycodone/acetaminophen phenytoin prasugrel obstetrix dha prenatal vitamins oxycodone/aspirin phenytoin sodium [INJ] pravastatin OCALIVA [SP] oxycodone/ibuprofen phenytoin sodium extended praziquantel ocella OXYCONTIN philith prazosin OCREVUS [INJ] [SP] PHOSLYRA PRECISION XTRA B-KETONE STRIPS [OTC] octreotide [INJ] [SP] oxymorphone ext-release phosphasal PRECISION XTRA MONITOR [OTC] ODACTRA oxytocin [INJ] PHOSPHOLINE IODIDE prednicarbate ODEFSEY [SP] OZEMPIC [INJ] PHOTOFRIN [INJ] prednisolone OFEV [SP] OZURDEX [INJ] [SP] physostigmine [INJ] prednisolone acetate eye suspension OFIRMEV [INJ] phytonadione prednisolone sodium phosphate ofloxacin P phytonadione [INJ] prednisolone sodium phosphate ofloxacin ear solution PHYTONADIONE 1 MG/0.5 ML disintegrating tablets ofloxacin eye solution paclitaxel [INJ] SYRINGE [INJ] prednisolone sodium phosphate ogestrel ext-release PICATO eye solution [INJ] prednisone olanzapine [INJ] PALYNZIQ [INJ] [SP] pilocarpine eye solution PREMARIN [INJ] olanzapine orally disintegrating tablets pamidronate [INJ] PREMARIN CREAM olanzapine/fluoxetine pantoprazole [INJ] pimtrea PREMARIN TABLETS olmesartan pantoprazole delayed-release premasol [INJ] olmesartan/amlodipine/ papaverine [INJ] pioglitazone PREMASOL 6% [INJ] hydrochlorothiazide PARADIGM INFUSION SETS pioglitazone/glimepiride PREMPHASE olmesartan/hydrochlorothiazide PARADIGM RESERVOIRS pioglitazone/metformin PREMPRO eye solution PARADIGM SILHOUETTE SETS piperacillin/tazobactam [INJ] prena1 chew prenatal vitamins olopatadine nasal spray pirmella prena1 pearl prenatal vitamins omega-3 ethyl esters paricalcitol prena1 true prenatal vitamins omeprazole delayed-release paricalcitol [INJ] PLASMA-LYTE [INJ] prenaissance plus prenatal vitamins omeprazole/sodium bicarbonate paromomycin plasmanate [INJ] prenaissance prenatal vitamins OMNIPAQUE [INJ] hcl PLEGRIDY [INJ] [SP] prenatabs fa prenatal vitamins OMNIPOD paroxetine hcl ext-release plenamine [INJ] prenatabs rx prenatal vitamins ONCASPAR [INJ] paroxetine mesylate PNEUMOVAX 23 [INJ] prenatal low iron prenatal vitamins PAZEO pnv 29-1 prenatal vitamins prenatal plus iron prenatal vitamins ondansetron [INJ] PEDIARIX [INJ] pnv ob+dha prenatal vitamins prenatal plus prenatal vitamins ondansetron orally disintegrating tablets PEDITRACE [INJ] pnv-dha + docusate prenatal vitamins prenatal-u prenatal vitamins ONETOUCH DELICA LANCETS [OTC] PEDVAXHIB [INJ] pnv-dha prenatal vitamins preplus prenatal vitamins ONETOUCH ULTRA 2 SYSTEM [OTC] peg 3350/electrolytes powder for 4000 ml pnv-ferrous fumarate-docu-fa PREPOPIK ONETOUCH ULTRA TEST STRIPS [OTC] solution prenatal vitamins pretab 29-1 prenatal vitamins ONETOUCH ULTRAMINI METER [OTC] PEGANONE pnv-omega prenatal vitamins previfem ONETOUCH ULTRASOFT LANCETS [OTC] PEGASYS [INJ] [SP] pnv-select prenatal vitamins PREVNAR 13 [INJ] ONETOUCH VERIO FLEX [OTC] peg-prep kit pnv-vp-u prenatal vitamins PREVYMIS ONETOUCH VERIO IQ METER [OTC] penicillin g potassium [INJ] podofilox PREVYMIS [INJ] ONETOUCH VERIO METER SYSTEM [OTC] penicillin g procaine [INJ] POLOCAINE [INJ] PREZISTA [SP] ONETOUCH VERIO TEST STRIPS [OTC] penicillin g sodium [INJ] polyethylene glycol 3350 PRIALT [INJ] [SP] ONEXTON PENICILLIN GK/DEXTROSE [INJ] POLYFIN QR INFUSION SET PRIFTIN ONFI penicillin v potassium polymyxin [INJ] PRIMAQUINE ONIVYDE [INJ] [SP] PENTACEL [INJ] polymyxin/trimethoprim eye solution primidone OPDIVO [INJ] [SP] PENTACEL ACTHIB COMPONENT [INJ] POMALYST [SP] PRIVIGEN [INJ] [SP] tincture PENTASA portia PROAIR HFA opium/belladonna alkaloids suppositories [INJ] potassium acetate [INJ] PROAIR RESPICLICK OPSUMIT [SP] pentoxifylline ext-release potassium bicarbonate/citric acid probenecid ORACEA PERFOROMIST effervescent tablets procainamide [INJ] ORBACTIV [INJ] perindopril potassium chloride [INJ] PROCALAMINE [INJ] ORFADIN [SP] PERJETA [INJ] [SP] potassium chloride ext-release edisylate [INJ] ORKAMBI [SP] permethrin potassium chloride oral solution prochlorperazine maleate [INJ] potassium chloride powder packets for prochlorperazine maleate suppositories orphenadrine ext-release perphenazine/amitriptyline solution PROCRIT [INJ] [SP] orsythia potassium chloride/dextrose [INJ] PROFILNINE SD [INJ] [SP] ORTHOVISC [INJ] [SP] phendimetrazine potassium chloride/dextrose/nacl [INJ] in oil [INJ] [SP] oseltamivir phendimetrazine ext-release potassium chloride/lactated ringers/ progesterone micronized OTEZLA [SP] phenelzine dextrose [INJ] PROGLYCEM OTREXUP [INJ] phenobarbital potassium chloride/nacl [INJ] PROGRAF [INJ] [SP] OVIDREL [INJ] [SP] phenobarbital sodium [INJ] potassium citrate ext-release PROLASTIN C [INJ] [SP] oxacillin [INJ] phenobarbital/hyoscyamine/atropine/ potassium iodide/iodine solution PROLENSA oxacillin/dextrose [INJ] potassium phosphate [INJ] PROLEUKIN [INJ] [SP] oxaliplatin [INJ] POTELIGEO [INJ] [SP] PROMACTA [SP] oxandrolone phentolamine [INJ] pr natal 400 ec prenatal vitamins phenylbutyrate pr natal 400 prenatal vitamins promethazine [INJ] oxcarbazepine phenylephrine [INJ] pr natal 430 ec prenatal vitamins promethazine suppositories oxiconazole phenylephrine eye solution pr natal 430 prenatal vitamins promethazine/codeine oxybutynin phenylephrine/chlorpheniramine PRALUENT [INJ] [SP] (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 7 COMPBJCANP-19 (11/15/18) promethazine/dextromethorphan rasagiline SAVELLA SPIRIVA RESPIMAT promethazine/phenylephrine RASUVO [INJ] scopolamine patches spironolactone promethazine/phenylephrine/codeine RAVICTI [SP] secobarbital spironolactone/hydrochlorothiazide propafenone REBIF [INJ] [SP] SEGLUROMET sprintec propafenone ext-release reclipsen selegiline SPRYCEL [SP] proparacaine eye solution RECOMBIVAX HB [INJ] selenium [INJ] sronyx proparacaine/fluorescein eye solution RECTIV selenium sulfide STAMARIL [INJ] [INJ] REGRANEX selenium sulfide shampoo stavudine [SP] RELENZA SELZENTRY [SP] STEGLATRO propranolol [INJ] RELISTOR [INJ] se-natal 19 prenatal vitamins STELARA SC [INJ] [SP] propranolol ext-release REMICADE [INJ] [SP] SENSIPAR STIMATE [SP] propranolol/hydrochlorothiazide [INJ] SENSORCAINE-EPI 0.75%-0.0005% [INJ] STIOLTO RESPIMAT propylthiouracil REMODULIN [INJ] [SP] SEREVENT DISKUS STIVARGA [SP] PROQUAD [INJ] RENACIDIN SEROSTIM [INJ] [SP] STRENSIQ [INJ] [SP] PROSOL [INJ] REOPRO [INJ] sertraline STREPTOMYCIN SULFATE [INJ] protamine [INJ] repaglinide setlakin STRIBILD [SP] PROTOPAM [INJ] repaglinide/metformin hcl sevelamer carbonate STRIVERDI RESPIMAT RESCRIPTOR [SP] sharobel SUBLOCADE [INJ] [SP] PROVENGE [INJ] [SP] RESECTISOL SHINGRIX [INJ] SUBOXONE SL FILM pruclair RESTASIS SIGNIFOR [INJ] [SP] succinylcholine chloride [INJ] prumyx RETROVIR [INJ] [SP] SUCRAID [SP] prutect REVLIMID [SP] sildenafil [INJ] [SP] sucralfate pseudoephedrine/chlorpheniramine/ REYATAZ PACKETS [SP] sildenafil [SP] [INJ] methscopolamine ext-release R-GENE 10 [INJ] SILHOUETTE INFUSION SETS sulfacetamide eye ointment pseudoephedrine/codeine/guaifenesin RHOPRESSA silver nitrate sulfacetamide eye solution PULMICORT FLEXHALER RIASTAP [INJ] [SP] silver sulfadiazine sulfacetamide sodium shampoo PULMOZYME [SP] ribavirin [SP] SIMPONI 100 MG (for ulcerative sulfacetamide sodium topical PURIXAN [SP] ribavirin nebulization solution colitis only) [INJ] [SP] sulfacetamide sodium/sulfur PYLERA RIDAURA SIMULECT [INJ] [SP] sulfacetamide sodium/sulfur/urea pyrazinamide rifabutin simvastatin sulfacetamide/prednisolone eye solution pyridostigmine rifampin sirolimus [SP] sulfadiazine pyridostigmine [INJ] rifampin [INJ] SIRTURO sulfamethoxazole/trimethoprim pyridostigmine ext-release riluzole SKYLA [SP] sulfamethoxazole/trimethoprim [INJ] pyridoxine [INJ] rimantadine sodium acetate [INJ] SULFAMYLON CREAM ringers irrigation solution sodium benzoate/ sulfasalazine Q ringers lactated irrigation solution sodium phenylacetate [INJ] sulfasalazine delayed-release ringers solution [INJ] sodium bicarbonate [INJ] QBREXZA ringers solution lactated [INJ] sodium chloride [INJ] QUADRACEL DTAP-IPV [INJ] risedronate sodium chloride 0.45 % [INJ] sumatriptan [INJ] quasense risedronate delayed-release sodium chloride 0.9 % [INJ] sumatriptan nasal quazepam RISPERDAL CONSTA [INJ] sodium chloride 3 % [INJ] sumatriptan/naproxen sodium QUDEXY XR sodium chloride 5 % [INJ] SUPREP risperidone orally disintegrating tablets sodium chloride irrigation solution SURE-T INFUSION SET quetiapine ext-release ritonavir [SP] sodium chloride nebulization solution SUTENT [SP] QUICK RELEASE TEFLON CANNULA RITUXAN [INJ] [SP] sodium chloride, bacteriostatic [INJ] syeda QUILLICHEW ER RITUXAN HYCELA [INJ] [SP] sodium ferric gluconate complex [INJ] SYLATRON [INJ] [SP] QUILLIVANT XR rivastigmine sodium fluoride dental cream, gel SYLVANT [INJ] [SP] quinapril rivastigmine patches sodium lactate [INJ] SYMBICORT quinapril/hydrochlorothiazide rivelsa sodium phosphate [INJ] SYMDEKO [SP] gluconate [INJ] sodium polystyrene sulfonate SYMFI [SP] quinidine gluconate ext-release rizatriptan orally disintegrating tablets sodium polystyrene sulfonate rectal SYMFI LO [SP] quinidine sulfate ropinirole sodium thiosulfate [INJ] SYMLINPEN [INJ] quinine sulfate ropinirole ext-release SOF-SET MICRO INFUSION SET SYMPROIC QVAR ropivacaine/nacl [INJ] SOF-SET ULTIMATE QR SET SYNAGIS [INJ] [SP] QVAR REDIHALER rosuvastatin SOFT TOUCH LANCETS [OTC] SYNAREL ROTATEQ SOLIQUA [INJ] SYNERCID [INJ] R ROZEREM SOLIRIS [INJ] [SP] SYNJARDY RUBRACA [SP] SOLODYN SYNJARDY XR RABAVERT [INJ] RUCONEST [INJ] [SP] SOLU-CORTEF [INJ] SYNRIBO [INJ] [SP] rabeprazole delayed-release RYDAPT [SP] SOMATULINE DEPOT [INJ] [SP] RADICAVA [INJ] [SP] SOMAVERT [INJ] [SP] T RAGWITEK S sonafine rajani SOOLANTRA TABLOID raloxifene SABRIL [SP] sotalol TACLONEX SUSPENSION ramipril shampoo SOTALOL [INJ] tacrolimus [SP] RANEXA salicylic acid topical SOTRADECOL [INJ] tacrolimus topical SOTYLIZE ranitidine [INJ] SAMSCA [SP] sp antipruritic tadalafil [SP] RAPAFLO SANCUSO sp scar TAFINLAR [SP] RAPAMUNE SOLUTION [SP] SANDIMMUNE SOLUTION [SP] spinosad TAGRISSO [SP] RAPIVAB [INJ] SANTYL SPINRAZA [INJ] [SP] tamoxifen (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 8 COMPBJCANP-19 (11/15/18) tamsulosin ext-release tolazamide eye solution VENCLEXTA [SP] TARCEVA [SP] tolbutamide trospium venlafaxine TARGRETIN GEL [SP] tolcapone trospium ext-release venlafaxine ext-release tarina fe TRULANCE VENOFER [INJ] taron-c dha prenatal vitamins TRULICITY [INJ] VENTOLIN HFA taron-prex dha prenatal vitamins tolterodine ext-release TRUMENBA [INJ] verapamil TASIGNA [SP] topiramate trust natal dha prenatal vitamins verapamil [INJ] TAYTULLA topotecan [INJ] [SP] TRUVADA [SP] verapamil ext-release tazarotene TORISEL [INJ] [SP] TUBERSOL [INJ] veripred TAZORAC 0.05% CREAM torsemide TUDORZA PRESSAIR VERZENIO [SP] TAZORAC GEL TOUJEO [INJ] tulana VESICARE TECENTRIQ [INJ] [SP] TOVIAZ TWINRIX [INJ] vestura TECFIDERA [SP] TPN ELECTROLYTES [INJ] tydemy VGO TECHLITE BLOOD LANCETS [OTC] TRACE ELEMENTS-4 [INJ] TYKERB [SP] VIBATIV [INJ] TEFLARO [INJ] TRACLEER [SP] TYMLOS [INJ] [SP] VIBERZI TEKTURNA TRADJENTA TYPHIM VI [INJ] VIDEX SOLUTION [SP] TEKTURNA HCT TYSABRI [INJ] [SP] vienva telmisartan tramadol ext-release TYVASO [SP] vigabatrin [SP] telmisartan/amlodipine tramadol/acetaminophen VIIBRYD telmisartan/hydrochlorothiazide trandolapril U vilamit mb TEMODAR [INJ] [SP] trandolapril/verapamil ext-release vilevev mb temozolomide [SP] tranexamic acid UCERIS FOAM VIMIZIM [INJ] [SP] temsirolimus [INJ] [SP] tranexamic acid [INJ] ULORIC VIMPAT TENIPOSIDE [INJ] tranylcypromine ultimatecare one nf prenatal vitamins VIMPAT [INJ] tenofovir disoproxil fumarate [SP] travasol [INJ] ultimatecare one prenatal vitamins vinate care prenatal vitamins terazosin UNITUXIN [INJ] [SP] vinate ii prenatal vitamins terbinafine TREANDA [INJ] [SP] UPTRAVI [SP] vinate one prenatal vitamins terbutaline TRELEGY ELLIPTA ur n-c vinate-m prenatal vitamins terbutaline [INJ] TREMFYA [INJ] [SP] urea vinblastine [INJ] terconazole vaginal TRESIBA [INJ] uretron d-s vincristine [INJ] testosterone tretinoin urimar-t vinorelbine [INJ] testosterone cypionate [INJ] tretinoin microspheres urin d.s. VIOKACE testosterone enanthate [INJ] tretinoin topical uro-458 viorele TETANUS DIPHTHERIA TOXOIDS [INJ] tretinoin/emollient urogesic VIRACEPT [SP] tetrabenazine [SP] TRETTEN [INJ] [SP] uro-mp VIREAD 150 MG, 200 MG, 250 MG tetracaine [INJ] tri femynor ursodiol TABLETS [SP] tetracaine eye solution triamcinolone [INJ] uryl VIREAD POWDER [SP] tetracycline triamcinolone dental paste ustell virt nate prenatal vitamins THALOMID [SP] triamcinolone topical utira-c virt-advance prenatal vitamins theophylline triamterene/hydrochlorothiazide UVADEX [INJ] virt-c dha prenatal vitamins theophylline ext-release triazolam virt-nate dha prenatal vitamins theophylline/dextrose [INJ] trientine V virt-pn dha prenatal vitamins THERACYS [INJ] tri-estarylla virt-pn plus prenatal vitamins thiamine [INJ] valacyclovir virt-pn prenatal vitamins trifluridine eye solution VALCHLOR [SP] virt-select prenatal vitamins thiotepa [INJ] valganciclovir virt-vite gt prenatal vitamins thiothixene tri-legest fe valproate sodium [INJ] VISTOGARD [SP] THROMBATE III [INJ] tri-linyah valproic acid VISUDYNE [INJ] [SP] THYMOGLOBULIN [INJ] [SP] tri-lo-estarylla valsartan VIVITROL [INJ] [SP] THYROGEN [INJ] [SP] tri-lo-marzia valsartan/hydrochlorothiazide VIVOTIF thyroid tri-lo-sprintec VALSTAR [SP] VOLUVEN [INJ] tiagabine trilyte with flavor packets vancomycin VONVENDI [INJ] [SP] TIBSOVO [SP] vancomycin [INJ] VORAXAZE [INJ] TICE BCG [INJ] trimethoprim VANCOMYCIN/DEXTROSE [INJ] voriconazole tigecycline [INJ] tri-mili VANCOMYCIN-NS [INJ] voriconazole [INJ] tilia fe VANTAS [SP] VOSEVI [SP] timolol maleate TRIMO-SAN VARIVAX [INJ] VOTRIENT [SP] timolol maleate eye solution trinatal rx 1 prenatal vitamins VARIZIG [INJ] vp-ch plus prenatal vitamins tinidazole trinate prenatal vitamins VARUBI vp-ch-pnv prenatal vitamins TIVICAY [SP] trinessa VARUBI [INJ] vp-ggr-b6 prenatal vitamins tizanidine trinessa lo VASCEPA vyfemla tl g-fol os tri-previfem vasopressin [INJ] vylibra TOBI PODHALER [SP] TRIPTODUR [INJ] [SP] vasopressin/nacl [INJ] VYVANSE TOBRADEX OINTMENT TRISENOX [INJ] VAXCHORA VACCINE VYXEOS LIPOSOME [INJ] [SP] TOBRADEX ST tri-sprintec VECTIBIX [INJ] [SP] tobramycin [INJ] TRIUMEQ [SP] VELCADE [INJ] [SP] W tobramycin eye solution triveen-duo dha prenatal vitamins velivet tobramycin nebulization solution [SP] trivora VELPHORO warfarin tobramycin/dexamethasone tri-vylibra VELTASSA water for injection, bacteriostatic [INJ] eye suspension TROGARZO [INJ] [SP] vemavite-prx 2 prenatal vitamins water for injection, sterile [INJ] tobramycin/nacl [INJ] TROPHAMINE [INJ] VEMLIDY water for irrigation; sterile (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 9 COMPBJCANP-19 (11/15/18) wera XULTOPHY [INJ] ZARXIO [INJ] [SP] ZOLINZA [SP] WILATE [INJ] [SP] XURIDEN [SP] zatean-pn dha prenatal vitamins wymzya fe XYREM [SP] zatean-pn plus prenatal vitamins zolmitriptan orally disintegrating tablets ZEJULA [SP] zolpidem X Y ZELBORAF [SP] zolpidem ext-release ZEMAIRA [INJ] [SP] ZOMETA 4 MG/100 ML [INJ] [SP] XALKORI [SP] YERVOY [INJ] [SP] zenchent zonisamide XARELTO YESCARTA [INJ] [SP] ZENPEP ZONTIVITY XELJANZ [SP] YF-VAX [INJ] ZEPATIER [SP] ZORTRESS [SP] XELJANZ XR [SP] YONDELIS [INJ] [SP] ZERBAXA [INJ] ZOSYN GALAXY BAGS [INJ] XERMELO [SP] YONSA [SP] ZEVALIN [INJ] zovia XGEVA [INJ] [SP] yuvafem zidovudine [SP] ZOVIRAX CREAM XIAFLEX [INJ] [SP] zileuton ext-release ZTLIDO XIFAXAN Z zinc chloride [INJ] ZUBSOLV XIGDUO XR zinc sulfate [INJ] ZYDELIG [SP] XIIDRA zafirlukast zingiber prenatal vitamins ZYKADIA [SP] XOFIGO [INJ] [SP] zaleplon ZYLET XOLAIR [INJ] [SP] ZALTRAP [INJ] [SP] ZOLADEX [INJ] [SP] ZYTIGA [SP] XTANDI [SP] ZANOSAR [INJ] zoledronic acid [INJ] [SP] xulane patches zarah zoledronic acid/mannitol [INJ] [SP]

Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2018 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 10 COMPBJCANP-19 (11/15/18) 2019 BJC HealthCare Preferred Drug List Exclusions The excluded medications shown below are not covered on the BJC HealthCare drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. Drug Class Excluded Medications Preferred Alternatives

AUTONOMIC & CENTRAL NERVOUS SYSTEM LUCEMYRA clonidine Alpha-2 Adrenergic (for Withdrawal)

Anti-Migraine Therapy SUMAVEL DOSEPRO sumatriptan injection

amantadine capsules, amantadine tablets, GOCOVRI ER, OSMOLEX ER Antiparkinsonism Agents amantadine oral solution XADAGO rasagiline, selegiline

AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, Beta Interferons for Multiple Sclerosis EXTAVIA PLEGRIDY, REBIF, REBIF REBIDOSE

Calcitonin Gene-Related Peptide Antagonists AJOVY AIMOVIG, EMGALITY

EMFLAZA prednisone solution, prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51 No alternatives recommended

hydromorphone ER, morphine sulfate ER, oxymorphone ER, Long-Acting Opioid Oral EMBEDA, OXYCODONE ER HYSINGLA ER, NUCYNTA ER, OXYCONTIN

Narcotic Analgesics BUTRANS BELBUCA

Narcotic Antagonists EVZIO naloxone syringes, NARCAN NASAL SPRAY

Neuropathic Agents LYRICA CR gabapentin, LYRICA

Transmucosal Fentanyl Analgesics ABSTRAL, FENTORA, LAZANDA fentanyl citrate lozenges

CARDIOVASCULAR PRADAXA, SAVAYSA ELIQUIS, XARELTO Anticoagulants

Beta Blockers KAPSPARGO SPRINKLE metoprolol succinate

HMG & Cholesterol Inhibitor Combinations ALTOPREV, ZYPITAMAG atorvastatin, lovastatin, rosuvastatin, simvastatin, LIVALO

PCSK9 Inhibitors REPATHA PRALUENT

DERMATOLOGICAL MINOCYCLINE ER 55 MG TABLETS, MINOLIRA minocycline ER Oral Agents for Acne

Oral Agents for Rosacea DOXYCYCLINE 40 MG CAPSULES ORACEA

Topical Acne PLIXDA adapalene

clindamycin/benzoyl peroxide, clindamycin/tretinoin, Topical Acne/Antibiotic Combinations AKTIPAK, VELTIN erythromycin/benzoyl peroxide, ACANYA, ONEXTON

diclofenac 3% gel, fluorouracil 2% solution, FLUOROURACIL 0.5% CREAM, Topical Agents for Actinic Keratosis fluorouracil 5% cream, imiquimod 5% cream, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA CARAC, PICATO

Topical Antifungals LULICONAZOLE ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

acyclovir capsules, acyclovir tablets, famciclovir tablets, Topical Antiviral Agents XERESE CREAM valacyclovir tablets, ZOVIRAX CREAM

desonide 0.05% cream/lotion/ointment, Topical Corticosteroids TOPICORT SPRAY, VERDESO FOAM desoximetasone 0.25% cream/ointment

Miscellaneous Topical Dermatological Agents ALCORTIN A hydrocortisone, mupirocin

Continued

© 2018 Express Scripts. All Rights Reserved. 2884 All trademarks are the property of their respective owners. Page 11 DL44109Q-BJC-19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

ABBOTT (FREESTYLE, PRECISION), BAYER (BREEZE, CONTOUR), NATIONAL MEDICAL (ADVOCATE), OMNIS DIABETES HEALTH (EMBRACE, VICTORY), ROCHE (ACCU-CHEK), LIFESCAN (ONETOUCH) Blood Glucose Meters & Test Strips TRIVIDIA (TRUETEST, TRUETRACK), UNISTRIP ALL OTHER METERS & STRIPS THAT ARE NOT LIFESCAN BRAND

ALOGLIPTIN, NESINA, ONGLYZA JANUVIA, TRADJENTA Dipeptidyl Peptidase-4 Inhibitors & Combinations ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

Glucagon-Like Peptide-1 Agonists ADLYXIN, TANZEUM, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY

NOVOLIN HUMULIN Insulins ADMELOG, APIDRA, FIASP, NOVOLOG HUMALOG

EAR/NOSE BECONASE AQ, OMNARIS, ZETONNA budesonide, flunisolide, fluticasone, mometasone Nasal Steroids

Otic Fluoroquinolone Antibiotics CETRAXAL ciprofloxacin ear solution, ofloxacin ear solution

ENDOCRINE (OTHER) CLIMARA PRO COMBIPATCH Combination Patches

estradiol patches, estradiol tablets, yuvafem, Estrogen and Estrogen Modifiers for Vaginal Symptoms FEMRING ESTRING, PREMARIN CREAM, PREMARIN TABLETS

Gonadotropin Releasing Hormone (GnRH) Agonists LUPRON DEPOT-PED TRIPTODUR (for Central Precocious Puberty)

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, Growth Hormones GENOTROPIN, NORDITROPIN FLEXPRO SAIZEN, SAIZENPREP, ZOMACTON

Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT

Topical Estrogen Gels ESTROGEL DIVIGEL

GASTROINTESTINAL CORTIFOAM hydrocortisone enema, UCERIS FOAM Corticosteroids (Rectal Formulations)

balsalazide disodium, mesalamine 1.2 gm delayed release, Inflammatory Bowel Agents DELZICOL, DIPENTUM sulfasalazine, APRISO, PENTASA

Pancreatic Enzymes PANCREAZE, PERTZYE CREON, ZENPEP

ACIPHEX SPRINKLE, PRILOSEC SUSPENSION, esomeprazole, lansoprazole, omeprazole, pantoprazole, Proton Pump Inhibitors PROTONIX SUSPENSION rabeprazole, NEXIUM PACKETS

HEMATOLOGICAL ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT Erythropoiesis-Stimulating Agents

ADVATE, ADYNOVATE, AFSTYLA, HELIXATE FS, JIVI, Factor VIII Recombinant Products ELOCTATE, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ

Granulocyte Colony Stimulating Factors NEUPOGEN, NIVESTYM GRANIX, ZARXIO

HEPATITIS DAKLINZA, LEDIPASVIR/SOFOSBUVIR, MAVYRET, OLYSIO, EPCLUSA, HARVONI, VOSEVI, ZEPATIER SOFOSBUVIR/VELPATASVIR, SOVALDI

BIKTARVY, GENVOYA, ODEFSEY, STRIBILD, SYMFI, SYMFI LO, ATRIPLA, DELSTRIGO, SYMTUZA HIV TRIUMEQ Antiretrovirals PIFELTRO efavirenz, nevirapine ER, EDURANT, INTELENCE, RESCRIPTOR

MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE COLCRYS, MITIGARE Gout Therapy DUZALLO, ZURAMPIC allopurinol, probenecid

fenoprofen calcium tablets, diclofenac, ibuprofen, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES indomethacin, meloxicam, nabumetone, naproxen

OBSTETRICAL & GYNECOLOGICAL Gonadotropin-Releasing Hormone (GnRH) GANIRELIX ACETATE CETROTIDE Antagonists (for Infertility)

Continued

© 2018 Express Scripts. All Rights Reserved. 2884 All trademarks are the property of their respective owners. Page 12 DL44109Q-BJC-19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

OBSTETRICAL & GYNECOLOGICAL (continued) Gonadotropin-Releasing Hormone (GnRH) ORILISSA LUPRON DEPOT, SYNAREL, ZOLADEX Receptor Antagonists (for Endometriosis)

Human Chorionic Gonadotropin CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL

Ovulatory Stimulants (Follitropins) BRAVELLE, FOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT

Vaginal ENDOMETRIN CRINONE 8% GEL

OPHTHALMIC betaxolol drops, levobunolol drops, timolol drops, TIMOPTIC OCUDOSE Antiglaucoma Drugs (Beta-Adrenergic Blockers) ALPHAGAN P 0.1%, COMBIGAN

Antiglaucoma Drugs (Ophthalmic Prostaglandins) ZIOPTAN bimatoprost drops, latanoprost drops

azelastine drops, cromolyn drops, olopatadine drops, Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, EMADINE ALREX, BEPREVE, PAZEO

dexamethasone drops, fluorometholone drops, Ophthalmic Anti-Inflammatory FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD prednisolone drops, LOTEMAX

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs bromfenac drops, diclofenac drops, ketorolac drops, ACUVAIL, NEVANAC (NSAIDs) ILEVRO, PROLENSA

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, OSTEOARTHRITIS HYMOVIS, SUPARTZ FX, SYNVISC, SYNVISC-ONE, TRIVISC, EUFLEXXA, MONOVISC, ORTHOVISC Hyaluronic Acid Derivatives VISCO-3

RENAL DISEASE FOSRENOL POWDER PACKETS, RENAGEL lanthanum, sevelamer carbonate, PHOSLYRA, VELPHORO Phosphate Binders

RESPIRATORY AUVI-Q, EPINEPHRINE AUTO-INJECTOR EPINEPHRINE AUTO-INJECTOR (BY MYLAN), Epinephrine Auto-Injector Systems (BY A-S , IMPAX & LINEAGE) EPIPEN, EPIPEN JR

Long-Acting Beta Nebulized BROVANA PERFOROMIST

ARMONAIR RESPICLICK, ARNUITY ELLIPTA, Pulmonary Anti-Inflammatory Inhalers ALVESCO ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR

Short-Acting Beta 2-Agonist Inhalers LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA HYDROXYPROGESTERONE 1,250 MG/5 ML hydroxyprogesterone caproate 250 mg/ml (single dose vial)

MISCELLANEOUS AGENTS SIKLOS DROXIA

NOCTIVA desmopressin tablets

Hereditary Angioedema BERINERT RUCONEST

Polyneuropathy of Hereditary ONPATTRO No alternatives recommended Transthyretin-Mediated Amyloidosis

Indication Based Management Drug Class Nonpreferred Medications Preferred Alternatives

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted ACTEMRA, COSENTYX, ENBREL, HUMIRA, following a coverage review. A trial of one or more Preferred INFLECTRA, OTEZLA, REMICADE, RENFLEXIS, INFLAMMATORY CONDITIONS‡ medications is required prior to initiating therapy with a SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY), Nonpreferred medication. A formulary exception may be STELARA SC, TREMFYA*, XELJANZ, XELJANZ XR granted for patients already established on therapy with a Nonpreferred medication.

‡ Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches. * This medication may be subject to step therapy.

Continued

© 2018 Express Scripts. All Rights Reserved. 2884 All trademarks are the property of their respective owners. Page 13 DL44109Q-BJC-19 (12/05/2018) Excluded Medications/Products at a Glance

ABBOTT (FREESTYLE, PRECISION) FIASP PIFELTRO ABILIFY^ FLAREX PLAQUENIL^ ABSTRAL FLUOROURACIL 0.5% CREAM PLAVIX^ ACIPHEX^ FML FORTE, FML S.O.P. PLIXDA ACIPHEX SPRINKLE FOLLISTIM AQ PRADAXA ACUVAIL FOSRENOL CHEWABLE TABLETS^ PRED MILD ADCIRCA^ FOSRENOL POWDER PACKETS PREGNYL ADDERALL^ GANIRELIX ACETATE PREVACID^, PREVACID SOLUTAB^ ADLYXIN GEL-ONE PRILOSEC SUSPENSION ADMELOG GELSYN-3 PRISTIQ^ AJOVY GENVISC 850 PROTONIX^ AKTIPAK GLEEVEC^ PROTONIX SUSPENSION ALCORTIN A GLUCOPHAGE^, GLUCOPHAGE XR^ PROVENTIL HFA ALOCRIL GLUMETZA^ PROVIGIL^ ALOGLIPTIN GOCOVRI ER PROZAC^ ALOGLIPTIN/METFORMIN HUMATROPE PULMICORT RESPULES^ ALOMIDE HYALGAN RECOMBINATE ALTOPREV HYDROXYPROGESTERONE 1,250 MG/5 ML RENAGEL ALVESCO HYMOVIS REPATHA ANDROGEL 1%^ IMIQUIMOD 3.75% CREAM PUMP ROCHE (ACCU-CHEK) ANUSOL-HC^ IMITREX^ SAIZEN, SAIZENPREP APIDRA INDERAL LA^ SANDOSTATIN LAR DEPOT ARANESP INTUNIV^ SAVAYSA ARIMIDEX^ ISTALOL^ SEROQUEL^, SEROQUEL XR^ ASACOL HD^ KAPSPARGO SPRINKLE SIGNIFOR LAR ATACAND^, ATACAND HCT^ KAZANO SIKLOS ATRIPLA KEPPRA^, KEPPRA XR^ SINGULAIR^ AUVI-Q KOMBIGLYZE XR SOFOSBUVIR/VELPATASVIR AVALIDE^, AVAPRO^ LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ SOVALDI AVODART^ LAZANDA STRATTERA^ AZOR^ LEDIPASVIR/SOFOSBUVIR SUMAVEL DOSEPRO BAYER (BREEZE, CONTOUR) LEVALBUTEROL HFA SUPARTZ FX BECONASE AQ LEXAPRO^ SYMTUZA BENICAR^, BENICAR HCT^ LIBRAX^ SYNVISC, SYNVISC-ONE BERINERT LIDODERM^ TANZEUM BRAVELLE LIPITOR^ TESTIM^ BRISDELLE^ LOESTRIN^, LOESTRIN FE^ TIKOSYN^ BROVANA LOTREL^ TIMOPTIC OCUDOSE BUPAP^ LOVENOX^ TOBI SOLUTION^ BUTRANS LUCEMYRA TOPAMAX^ CELEBREX^ LULICONAZOLE TOPICORT SPRAY CELEXA^ LUNESTA^ TRIBENZOR^ CETRAXAL LUPRON DEPOT-PED TRICOR^ CHORIONIC GONADOTROPIN LYRICA CR TRILEPTAL^ CLIMARA PRO MAVYRET TRIVIDIA (TRUETEST, TRUETRACK) COLCHICINE MAXALT^, MAXALT MLT^ TRIVISC COREG^ MAXIDEX UNISTRIP CORTIFOAM MICARDIS^, MICARDIS HCT^ UROXATRAL^ COSOPT^ MINASTRIN 24 FE^ VAGIFEM^ COZAAR^, HYZAAR^ MINOCYCLINE ER 55 MG TABLETS VALIUM^ CRESTOR^ MINOLIRA VALTREX^ CYMBALTA^ MIRCERA VELTIN CYTOMEL^ NALFON CAPSULES VERDESO FOAM DAKLINZA NAMENDA XR^ VIAGRA^ DELSTRIGO NASONEX^ VICTOZA DELZICOL NATIONAL MEDICAL (ADVOCATE) VISCO-3 DETROL^, DETROL LA^ NESINA VIVELLE-DOT^ DIOVAN^, DIOVAN HCT^ NEUPOGEN VYTORIN^ DIPENTUM NEURONTIN^ WELLBUTRIN SR^ DOXYCYCLINE 40 MG CAPSULES NEVANAC XADAGO DUROLANE NIVESTYM XALATAN^ DUZALLO NOCTIVA XANAX^, XANAX XR^ EFFEXOR XR^ NORCO^ XENAZINE^ ELOCTATE NORVASC^ XERESE CREAM EMADINE NOVOLIN XOPENEX HFA EMBEDA NOVOLOG XYNTHA, XYNTHA SOLOFUSE EMFLAZA NUTROPIN AQ NUSPIN YASMIN^ ENDOMETRIN NUVIGIL^ ZEGERID^ EPINEPHRINE AUTO-INJECTOR OLYSIO ZETIA^ (BY A-S MEDICATION, IMPAX & LINEAGE) OMNARIS ZETONNA EPOGEN OMNIS HEALTH (EMBRACE, VICTORY) ZIOPTAN ESTROGEL OMNITROPE ZOCOR^ EVZIO ONGLYZA ZOLOFT^ EXFORGE^, EXFORGE HCT^ ONPATTRO ZOMACTON EXONDYS 51 ORILISSA ZOMIG TABLETS^, ZOMIG ZMT^ EXTAVIA ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ ZONEGRAN^ FEMRING OSMOLEX ER ZURAMPIC FENOPROFEN CAPSULES OXYCODONE ER ZYCLARA FENORTHO PANCREAZE ZYFLO CR^ FENTORA PERTZYE ZYPITAMAG ^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.

© 2018 Express Scripts. All Rights Reserved. 2884 All trademarks are the property of their respective owners. Page 14 DL44109Q-BJC-19 (12/05/2018)

Top View