2021 SELECT EX FORMULARY the Following Is a List of the Most Commonly Prescribed Brand and Generic Medications

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2021 SELECT EX FORMULARY The following is a list of the most commonly prescribed brand and generic medications. It represents an abbreviated version of the formulary list that is at the core of your prescription drug benefit plan. The list is not all-inclusive and does not guarantee coverage. Some preferred medications overlap with other clinical programs and may not be covered. In addition to drugs on this list, the majority of generic medications are covered under your plan and you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. Search complete formulary drug information at elixirsolutions.com. PLEASE NOTE: Preferred brand drugs may move to non-preferred status if a generic version becomes available during the year. Any medication approved to enter the market will not be covered until reviewed by Elixir. Not all drugs listed are covered by all prescription drug benefit programs. For specific questions about your coverage, please visit elixirsolutions.com.

A B CILOXAN OINTMENT digoxin abacavir tablet balsalazide CIMDUO diltiazem ER (except generics for abacavir-lamivudine BAQSIMI cinacalcet CARDIZEM LA) ABILIFY MAINTENA [INJ] BASAGLAR [INJ] ciprofloxacin dimethyl fumarate DR* abiraterone* BD ULTRAFINE INSULIN SYRINGES ciprofloxacin-dexamethasone diphenoxylate-atropine acetic acid & NEEDLES citalopram dipyridamole ER-aspirin acitretin BELBUCA CITRANATAL divalproex sodium ACUVAIL BELSOMRA clarithromycin divalproex sodium ER acyclovir capsule, tablet benzonatate (except NDCs: clarithromycin ER DIVIGEL adapalene 69336012615, 69499032915) CLENPIQ donepezil ADEMPAS * benzoyl peroxide CLIMARA PRO DOPTELET* ADVAIR HFA BESIVANCE clindamycin dorzolamide ADYNOVATE* BETASERON [INJ]* clindamycin gel (except NDC: dorzolamide-timolol AFINITOR* BETHKIS* 68682046275) DOVATO AIMOVIG [INJ] BETIMOL clindamycin solution doxazosin AJOVY [INJ] BETOPTIC S clindamycin-benzoyl peroxide doxepin albuterol inhalation solution bicalutamide clobazam doxycycline hyclate 20 mg albuterol sulfate CFC-free aerosol BIDIL clobetasol cream, foam, gel, lotion, doxycycline hyclate capsule ALECENSA* BIKTARVY ointment, shampoo dronabinol alendronate bosentan* clonazepam DUAVEE alfuzosin ER BOSULIF* clopidogrel duloxetine aliskiren BREO ELLIPTA clotrimazole DUPIXENT [INJ]* allopurinol BREZTRI AEROSPHERE clozapine DUREZOL alosetron BRILINTA codeine-acetaminophen DUROLANE [INJ]* ALPHAGAN P brimonidine colchicine tablet dutasteride alprazolam bromfenac colesevelam dutasteride-tamsulosin ALUNBRIG* BRYHALI COMBIGAN DYMISTA ambrisentan budesonide capsule COMBIPATCH amiloride budesonide ER COMPLERA E amlodipine budesonide inhalation suspension COPAXONE [INJ]* econazole amlodipine-atorvastatin buprenorphine transdermal COPIKTRA* eletriptan amlodipine-olmesartan buprenorphine-naloxone sublingual CORLANOR ELIGARD [INJ]* amlodipine-telmisartan bupropion CORTIFOAM ELIQUIS amlodipine-valsartan bupropion ER (except bupropion COSENTYX [INJ]* EMGALITY [INJ] amlodipine-valsartan-HCTZ ER tablet 450 mg) CREON CRINONE EMVERM amoxicillin BYSTOLIC cromolyn sodium ENBREL [INJ]* amoxicillin-clavulanate cyclobenzaprine (except ENDOMETRIN amphetamine-dextroamphetamine C cyclobenzaprine tablet 7.5 mg) entacapone mixed salts CABOMETYX* entecavir amphetamine-dextroamphetamine calcipotriene ointment, solution D ENTRESTO mixed salts ER calcitonin-salmon DALIRESP EPCLUSA* ANDRODERM calciumacetate darifenacin ER EPIDUO ANNOVERA candesartan DESCOVY epinephrine auto-injector [INJ] ANORO ELLIPTA candesartan-HCTZ desonide EPIPEN [INJ] aprepitant carbamazepine desoximetasone EPIPEN JR [INJ] ARANESP [INJ]* carbamazepine ER desvenlafaxine ER EPISIL aripiprazole carbidopa-levodopa dexamethasone ERIVEDGE * armodafinil carbidopa-levodopa ER DEXCOM CONTINUOUS GLUCOSE ERLEADA* ARNUITY ELLIPTA carbidopa-levodopa-entacapone MONITORING SYSTEM erythromycin atazanavir carvedilol DEXILANT erythromycin solution atenolol carvedilol phosphate ER diazepam erythromycin-benzoyl peroxide atomoxetine cefdinir diazepam rectal gel erythromycins atorvastatin cefprozil diclofenac ESBRIET* ATRIPLA cefuroxime axetil diclofenac sodium escitalopram AUBAGIO* celecoxib diclofenac sodium gel 1% esomeprazole AUSTEDO* cephalexin diclofenac sodium solution estradiol azelaic acid gel CERDELGA* diclofenac sodium-misoprostol estradiol-norethindrone azelastine CEREZYME [INJ]* dicloxacillin eszopiclone azithromycin CETROTIDE [INJ]* dicyclomine ethinyl estradiol- drospirenone AZOPT cholestyramine DIFICID ethinyl estradiol-drospirenone-levomefolate ciclopirox ethinyl estradiol-etonogestrel

[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 1

2021 SELECT EX FORMULARY Continued ethinyl estradiol-levonorgestrel H linezolid neomycin-polymyx in B-bacitracin- ethinyl estradiol-norelgestromin HARVONI* LINZESS hydrocortisone ethinyl estradiol-norethindrone acetate HUMIRA [INJ]* liothyronine neomycin-polymyx in B-dexamethasone ethinyl estradiol-norethindrone acetate-iron HUMULIN R U-500 [INJ] lisinopril neomycin-polymyx in B-hydrocortisone ethinyl estradiol-norgestimate hydrochlorothiazide lisinopril-HCTZ NEUPRO ethosuximide hydrocodone ER LO LOESTRIN FE NEVANAC EUCRISA hydrocodone-acetaminophen LOKELMA NEXLETOL EUFLEXXA [INJ]* hydrocortisone loperamide NEXLIZET EVAMIST hydrocortisone butyrate cream, lotion, lorazepam niacin ER everolimus* ointment, solution losartan nifedipine ER EVOTAZ hydrocortisone enema losartan-HCTZ NINLARO* ezetimibe hydromorphone loteprednol nitrofurantoin ezetimibe-simvastatin hydromorphone ER lovastatin nitroglycerin sublingual spray luliconazole nitroglycerin sublingual F I LUMIGAN NIVESTYM [INJ]* famotidine ibandronate LUPRON DEPOT [INJ]* NORDITROPIN [INJ]* FARXIGA IBRANCE* LYNPARZA* NORVIR FASENRA [INJ]* ibuprofen NOVOEIGHT* fenofibrate (except fenofibrate tablet ILEVRO M NOVOLIN 70/30 [INJ] 120 mg) imatinib mesylate* MAXIDEX NOVOLIN N [INJ] fenofibric acid DR imiquimod MAYZENT* NOVOLIN R [INJ] fentanyl transdermal IMVEXXY meclizine NOVOLOG [INJ] fentanyl transmucosal lozenge INBRIJA medroxyprogesterone NOVOLOG MIX 70/30 [INJ] FIASP [INJ] INGREZZA* megestrol acetate NUBEQA* FINACEA FOAM ipratropiuminhalation solution meloxicam NUCALA [INJ]* finasteride ipratropium-albuterol inhalation solution memantine NUCYNTA FIRAZYR [INJ]* irbesartan mesalamine DR NUCYNTA ER FLOVENT DISKUS irbesartan-HCTZ mesalamine ER NUEDEXTA FLOVENT HFA IRESSA* mesalamine suppository NURTEC ODT fluconazole ISENTRESS mesalamine suspension NUWIQ* fludrocortisone isosorbide dinitrate (except isosorbide metformin nystatin flunisolide dinitrate 40 mg) metformin ER (except generics for fluocinonide (except fluocinonide isosorbide mononitrate FORTAMET and GLUMETZA) O cream 0.1%) itraconazole methadone OCREVUS [INJ]* fluorouracil cream 5% ivermectin methoxsalen ODEFSEY fluorouracil solution methylphenidate ODOMZO* fluoxetine (except fluoxetine tablet 60 mg, J methylphenidate ER OFEV* fluoxetine tablet [generics for SARAFEM]) JANUMET methylprednisolone ofloxacin fluticasone JANUMET XR metoclopramide ofloxacin otic fluticasone/salmeterol JANUVIA metolazone olanzapine fluvastatin JARDIANCE metoprolol succinate ER olmesartan FML FORTE JIVI* metoprolol tartrate olmesartan-amlodipine-HCTZ FML S.O.P. metronidazole olmesartan-HCTZ folic acid K minocycline olopatadine FORTEO [INJ]* KESIMPTA [INJ]* MIRENA omega-3 acid ethyl esters fosinopril ketoconazole cream 2% mirtazapine omeprazole fosinopril-HCTZ ketoconazole shampoo 2% mometasone OMNIPOD DASH INSULIN INFUSION furosemide ketorolac montelukast PUMP KISQALI* morphine OMNIPOD INSULIN INFUSION PUMP G KISQALI FEMARA CO-PACK* morphine ER ondansetron gabapentin KOGENATE FS* morphine suppository ONETOUCH ULTRA STRIPS AND KITS galantamine KOVALTRY* MOVANTIK ONETOUCH VERIO STRIPS AND KITS galantamine ER KYLEENA moxifloxacin ONEXTON GELSYN-3 [INJ]* MULPLETA* ONZETRA XSAIL GENOTROPIN [INJ]* L MULTAQ OPSUMIT * gentamicin lactulose solution mupirocin ointment ORACEA GENVOYA lamivudine MUSE ORALAIR GILENYA* lamotrigine MYDAYIS ORENITRAM* Glatiramer [INJ]* glimepiride lamotrigine ER MYRBETRIQ ORFADIN* glipizide ER lansoprazole ORILISSA glipizide-metformin LASTACAFT N oseltamivir GLUCAGEN HYPOKIT [INJ] latanoprost nadolol OTEZLA* GLUCAGON EMERGENCY KIT [INJ] LATUDA NAFTIN OVIDREL [INJ]* GLYXAMBI levalbuterol tartrate CFC-free aerosol naloxone injection [INJ] oxazepam GONAL-F [INJ]* LEVEMIR [INJ] NAMZARIC oxcarbazepine GRALISE levetiracetam naproxen (except naproxen CR or OXTELLAR XR granisetron levetiracetam ER naproxen suspension) oxybutynin GRASTEK levocarnitine naratriptan oxybutynin ER guanfacine ER levocetirizine NARCAN NASAL SPRAY oxycodone GVOKE [INJ] levofloxacin nateglinide oxycodone-acetaminophen levothyroxine NAYZILAM OZEMPIC [INJ] lidocaine-prilocaine

[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 2

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P REYVOW telmisartan VIOKACE pantoprazole RHOPRESSA telmisartan-HCTZ VISTOGARD paroxetine HCl ribavirin TEMIXYS VOSEVI* paroxetine HCl ER RINVOQ* terazosin VRAYLAR paroxetine mesylate risedronate terbinafine tablet VUMERITY* PAZEO risperidone testosterone gel (except authorized VYVANSE peg 3350-electrolytes rivastigmine generics for TESTIM and penicillin VK rivastigmine transdermal VOGELXO) testosterone solution W PENTASA rizatriptan tetrabenazine warfarin PERFOROMIST ROCKLATAN tetracycline wixela inhub PERSERIS [INJ] ropinirole tiagabine phenobarbital ropinirole ER timolol maleate solution X phenytoin rosuvastatin TIVICAY XARELTO phenytoin sodium ER RUBRACA* TOBRADEX OINTMENT XCOPRI PHOSLYRA RUCONEST* TOBRADEX ST XELJANZ * PICATO RYBELSUS tobramycin XELJANZ XR* pimecrolimus RYDAPT tobramycin inhalation solution XIFAXAN 550 MG pindolol tobramycin-dexamethasone XIGDUO XR pioglitazone S TOLAK XIIDRA pioglitazone-glimepiride SANCUSO tolterodine XOLAIR [INJ]* pioglitazone-metformin SAXENDA tolterodine ER XOSPATA* potassiumchloride liquid scopolamine transdermal topiramate XTAMPZA ER PRALUENT [INJ] selegiline seleniumsulfide lotion 2.5% torsemide XTANDI * pramipex ole SEREVENT TOUJEO [INJ] XULTOPHY [INJ] pramipex ole ER sertraline TOVIAZ prasugrel sevelamer carbonate tramadol (except NDC: 52817019610) Y pravastatin sildenafil tramadol ER YONSA * PRED MILD silodosin travoprost YUPELRI prednisolone acetate 1% SIMBRINZA trazodone prednisolone solution simvastatin TRELEGY ELLIPTA Z prednisone SKYLA TREMFYA [INJ]* zafirlukast pregabalin SKYRIZI [INJ]* TRESIBA [INJ] ZEJULA* PREMPHASE solifenacin tretinoin ZEMBRACE SYMTOUCH PREMPRO SOLIQUA [INJ] triamcinolone cream, lotion, ointment ZENPEP prenatal vitamins SOMATULINE DEPOT [INJ]* triamterene triamterene-HCTZ ZEPOSIA* PREZCOBIX SOOLANTRA trifluridine ZIEXTENZO PREZISTA sotalol TRIJARDY XR [INJ]* primidone SPIRIVA trimethobenzamide zileuton ER probenecid spironolactone- HCTZ TRINTELLIX ZIOPTAN prochlorperazine SPRYCEL * TRIUMEQ ziprasidone PROCTOFOAM-HC STELARA SC [INJ]* TROKENDI XR zolmitriptan progesterone, micronized STIOLTO RESPIMAT trospium zolpidem PROLASTIN-C [INJ]* STRIBILD trospium ER zolpidem ER PROLIA [INJ]* STRIVERDI RESPIMAT TRULICITY [INJ] zolpidem sublingual promethazine SUBSYS TRUVADA ZOMIG NASAL SPRAY propranolol sucralfate tablet TYMLOS [INJ]* zonisamide propranolol ER sulfacetamide TYSABRI [INJ]* ZUBSOLV PULMICORT FLEXHALER sulfamethox azole-trimethoprim ZYCLARA PYLERA sulfasalazine U pyrimethamine sulfasalazine DR UBRELVY sumatriptan UPTRAVI* Q SUNOSI quetiapine SUPARTZ FX [INJ]* V quetiapine ER SUPRAX valacyclovir quinapril SYMBICORT valganciclovir quinapril-HCTZ SYMFI valproic acid QVAR REDIHALER SYMFI LO valsartan SYMJEPI [INJ] valsartan-HCTZ R SYMLINPEN [INJ] VALTOCO RAGWITEK SYMPROIC vancomycin capsule raloxifene SYMTUZA VASCEPA ramelteon SYNJARDY VELPHORO ramipril SYNJARDY XR VELTASSA ranolazine ER SYNTHROID VEMLIDY rasagiline venlafaxine RASUVO [INJ] T venlafaxine ER capsule REBIF [INJ]* tacrolimus verapamil ER REBINYN* tadalafil V-GO INSULIN INFUSION PUMP RELENZA TAKHZYRO [INJ]* VIBERZI repaglinide tamsulosin VICTOZA [INJ] RESTASIS TEGSEDI [INJ]* Vigabatrin RETACRIT [INJ]* TEKTURNA HCT VIMPAT

[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 3

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THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION

ANTIBIOTICS Antiprotozoals Metronidazole SOLOSEC ANTIHISTAMINE Non-sedating diphenhydramine injection QUZYTTIR AUTONOMIC & CENTRAL NERVOUS SYSTEM Anticonvulsants Carbamazepine/ER, divalproex sodium/ER, APTIOM, BRIVIACT, ZONEGRAN FYCOMPA, lamotrigine/ER, levetiracetam/ER, oxcarbazepine, tiagabine, topiramate, valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI Anti-Migraine Therapy eletriptan, naratriptan, rizatriptan, sumatriptan, CAFERGOT, FROVA, MIGERGOT zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY

Antiparkinson Agents INBRIJA APOKYN Antiparkinson Agents-COMT Inhibitors Entacapone ONGENTYS Antipsychotics aripiprazole, clozapine, olanzapine, quetiapine, CAPLYTA, FANAPT quetiapine ER, risperidone, ziprasidone, LATUDA, VRAYLAR

Antipsychotics (Injectables) ABILIFY MAINTENA, PERSERIS INVEGA SUSTENNA Attention Deficit Hyperactivity Disorder amphetamine dextroamphetamine mixed salts ER, ADZENYS ER, ADZENYS XR-ODT, APTENSIO XR, methylphenidate ER, MYDAYIS, VYVANSE DAYTRANA

Multiple Sclerosis dimethyl fumarate DR, glatiramer, AUBAGIO, AVONEX, EXTAVIA, PLEGRIDY, TECFIDERA BETASERON, COPAXONE, GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA

Narcolepsy Armodafinil, SUNOSI NUVIGIL, WAKIX Narcotic Analgesics & Combinations fentanyl transdermal, hydrocodone ER, hydromorphone HYSINGLA ER, OXYCONTIN, oxymorphone ER, methadone, morphine ER, NUCYNTA ER, ER, ZOHYDRO ER XTAMPZA ER

fentanyl transmucosal lozenge, SUBSYS LAZANDA Narcotic Antagonists naloxone injection, NARCAN NASAL SPRAY EVZIO Opioid Oral Analgesics hydrocodone-acetaminophen, hydromorphone, PERCOCET, PRIMLEV morphine, oxycodone-acetaminophen, NUCYNTA Partial Opioid Agonist/Opioid buprenorphine-naloxone sublingual, ZUBSOLV SUBOXONE Antagonist Combinations Sedative-Hypnotic Agents doxepin, eszopiclone, ramelteon, zolpidem, zolpidem DORAL, EDLUAR, INTERMEZZO, LUNESTA, ER, zolpidem sublingual, BELSOMRA quazepam, ROZEREM, ZOLPIMIST

Selective Serotonin Reuptake Inhibitor paroxetine HCl/ER, TRINTELLIX PEXEVA, PROZAC, VIIBRYD Tardive Dyskinesia Therapy tetrabenazine, AUSTEDO XENAZINE CARDIOVASCULAR Anticoagulants ELIQUIS, XARELTO PRADAXA Beta Blocker Combination metoprolol succinate ER WITH hydrochlorothiazide DUTOPROL Calcium Channel Blockers & Combinations amlodipine WITH celecoxib CONSENSI

[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 4

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THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION

HMG & Cholesterol Inhibitor Combinations atorvastatin, lovastatin, pravastatin, rosuvastatin, ALTOPREV, LIVALO simvastatin Pulmonary Arterial ambrisentan, bosentan, OPSUMIT LETAIRIS, TRACLEER Hypertension/Endothelin Receptor Antagonists

DERMATOLOGICAL Oral Agents for Acne doxycycline hyclate 20 mg, doxycycline hyclate ACTICLATE, CoreMino, DORYX, DORYX MPC, capsule, minocycline, tetracycline MINOCIN, TARGADOX Topical Agents for Atopic Dermatitis pimecrolimus, tacrolimus, EUCRISA PROTOPIC Topical Agents for Actinic Keratosis fluorouracil cream 5%, fluorouracil solution, CARAC, fluorouracil cream 0.5% imiquimod, PICATO, TOLAK, ZYCLARA Topical Acne Combinations adapalene, benzoyl peroxide, clindamycin gel ACANYA, clindamycin gel (NDC^ 68682046275 (except NDC^ 68682046275), clindamycin solution, only ), FABIOR, DIFFERIN LOTION, AZELEX, clindamycin- benzoyl peroxide, erythromycin solution, BENZAC AC, BENZACLIN, BENZIQ, VELTIN, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ZIANA, TAZORAC ONEXTON

Topical Agents for Rosacea azelaic acid gel, metronidazole, FINACEA FOAM, FINACEA GEL, MIRVASO, NORITATE SOOLANTRA Topical Antifungals ciclopirox , clotrimazole, econazole, ketoconazole XOLEGEL cream 2%, luliconazole clobetasol foam CLOBEX SPRAY, OLUX-E desonide, hydrocortisone ALCORTIN A, ALEVICYN GEL, ALEVICYN SG, ALEVICYN SOLUTION, ATOPADERM, BENSAL HP, EPICERAM, KAMDOY, NOVACORT, SYNERDERM

desoximetasone, fluocinonide (except fluocinonide APEXICON E, PSORCON cream 0.1%), BRYHALI hydrocortisone butyrate cream/lotion/ointment/ CORDRAN OINTMENT solution, mometasone, triamcinolone cream/lotion/ointment Vitamin D Analogs (Topical) calcipotriene ointment or calcipotriene solution SORILUX, VECTICAL WITH desoximetasone, fluocinonide (except fluocinonide cream 0.1%) or BRYHALI DIABETES Biguanides metformin, metformin ER (except generics for FORTAMET, GLUMETZA, RIOMET FORTAMET and GLUMETZA) Blood Glucose Meters & Test Strips DEXCOM CONTINUOUS GLUCOSE ENLITE, EVERSENSE, GUARDIAN MONITORING SYSTEM CONNECT ONETOUCH ULTRA STRIPS AND KITS ACCU-CHEK, ASCENSIA, BREEZE, CONTOUR NEXT, FREESTYLE, PRECISION XTRA, SURE- TEST, TRUETEST, TRUETRACK

Dipeptidyl Peptidase-4 Inhibitors JANUMET, JANUMET XR JENTADUETO, JENTADUETO XR, KAZANO, & Combinations KOMBIGLYZE XR JANUMET, JANUMET XR; JANUVIA WITH OSENI pioglitazone JANUVIA NESINA, ONGLYZA, TRADJENTA Glucagon-Like Peptide-1 Agonists OZEMPIC, RYBELSUS, TRULICITY, VICTOZA BYDUREON, BYETTA Insulins BASAGLAR, LEVEMIR LANTUS

[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 5

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THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION

Insulins FIASP, NOVOLOG APIDRA, HUMALOG, LYUMJEV

NOVOLIN HUMULIN Sodium-Glucose Cotransporter-2 Inhibitors FARXIGA, JARDIANCE INVOKANA & Combinations GLYXAMBI QTERN Sodium-Glucose Cotransporter-2 Inhibitors SYNJARDY, SYNJARDY XR, XIGDUO XR INVOKAMET, INVOKAMET XR & Combinations (Continued)

EAR/NOSE Nasal Steroids & Combinations flunisolide, fluticasone, mometasone, DYMISTA BECONASE AQ, OMNARIS, QNASL, ZETONNA ENDOCRINE Contraceptives ethinyl estradiol-drospirenone, ethinyl estradiol- BEYAZ, MINASTRIN 24 FE, NATAZIA, TAYTULLA, drospirenone-levomefolate, ethinyl estradiol- YAZ levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE

Estrogen and Estrogen Modifiers estradiol-norethindrone, PREMPHASE, PREMPRO ANGELIQ, PREFEST for Vaginal Symptoms estradiol MENEST, MENOSTAR, OSPHENA, estradiol, DIVIGEL, EVAMIST ALORA, MINIVELLE, VIVELLE-DOT estradiol, IMVEXXY FEMRING, INTRAROSA Growth Hormones GENOTROPIN, NORDITROPIN HUMATROPE, NUTROPIN AQ, OMNITROPE, SAIZEN, ZOMACTON ENDOCRINE (OTHER) Somatostatin Analogs SOMATULINE DEPOT SANDOSTATIN LAR, SIGNIFOR LAR, SOMAVERT, Testosterone Products testosterone gel (except authorized generics for ANDROGEL 1%, FORTESTA, NATESTO, TESTIM, TESTIM and VOGELXO), testosterone solution, testosterone gel 1% (authorized generics for TESTIM ANDRODERM and VOGELXO only ), VOGELXO GASTROINTESTINAL Antiemetics granisetron, ondansetron, SANCUSO ZUPLENZ Bowel Evacuants peg 3350-electrolytes, CLENPIQ GOLYTELY, MOVIPREP, OSMOPREP, SUPREP Irritable Bowel Disease - Constipation LINZESS, MOVANTIK, SYMPROIC TRULANCE, AMITIZA, ZELNORM Irritable Bowel Disease – Diarrhea alosetron, VIBERZI, XIFAXAN 550 MG ENTERAGAM Pancreatic Enzymes CREON, VIOKACE, ZENPEP PANCREAZE, PERTZYE Miscellaneous Gastrointestinal Agents sucralfate tablet CARAFATE HEMATOLOGICAL Erythropoiesis-Stimulating Agents ARANESP, RETACRIT EPOGEN, PROCRIT Granulocyte Colony Stimulating Factors NIVESTYM GRANIX, NEUPOGEN, ZARXIO Hematopoietic Agents ZIEXTENZO NEULASTA, NEULASTA ONPRO, UDENYCA, Hemophilia A Agents ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, ELOCTATE NOVOEIGHT, NUWIQ HEPATITIS Hepatitis C Agents EPCLUSA, HARVONI MAVYRET, VIEKIRA PAK, ZEPATIER MISCELLANEOUS AGENTS

[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 6

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THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION

Hereditary Angioedema FIRAZYR, RUCONEST BERINERT Miscellaneous Antidepressants bupropion, bupropion ER (except bupropion APLENZIN ER tablet 450 mg) Multivitamins folic acid Activite, DaVite, Dexifol, FERIVA 21/7, FOLIC-K, Folvik-D, Folvite-D, Genicin Vita-S, HylaVite, Lorid, NICADAN, NICAPRIN, NICAZEL, NICAZEL FORTE, NICOMIDE, OMNIVEX, ORTHO D, ORTHO DF, RHEUMATE, RIBOZEL, TALIVA, TronVite, vitasure, xvite, XYZBAC, ZYVIT

Oral Corticosteroids dexamethasone, hydrocortisone, MILLIPRED, RAYOS methylprednisolone, prednisolone, prednisone Prenatal Vitamins CITRANATAL (except CITRANATAL ESSENCE), AZESCO, CITRANATAL ESSENCE, PRENATABS RX, PRENATAL 19 CHEW PRENATAL, VITAFOL-ONE, ZALVIT

MUSCULOSKELETAL & RHEUMATOLOGY Muscle Relaxers cyclobenzaprine AMRIX, CHLORZOXAZONE 250 MG, FEXMID, NORGESIC FORTE

OBSTETRICAL & GYNECOLOGICAL Ovulatory Stimulants (Follitropins) GONAL-F FOLLISTIM AQ ONCOLOGY Hormonal Antineoplastic Agents abiraterone, bicalutamide, XTANDI, YONSA NILANDRON, ZYTIGA Proteasome Inhibitor NINLARO, VELCADE KYPROLIS, BORTEZOMIB Tyrosine Kinase Inhibitor Imatinib mesylate, BOSULIF, SPRYCEL GLEEVEC, TASIGNA OPHTHALMIC Antiglaucoma Drug timolol maleate solution, BETIMOL, BETOPTIC S ISTALOL, TIMOPTIC OCUDOSE Antiglaucoma Drugs (Ophthalmic latanoprost, travoprost, LUMIGAN, ZIOPTAN XELPROS Prostaglandins) Dry Eye Disease RESTASIS, XIIDRA LACRISERT, CEQUA Ophthalmic Anti-Allergic azelastine, cromolyn sodium, olopatadine, ALREX, BEPREVE LASTACAFT, PAZEO Ophthalmic Anti-Inflammatory dexamethasone, loteprednol, prednisolone FML LIQUIFILM, LOTEMAX, LOTEMAX SM, acetate 1%, DUREZOL, FML FORTE, FML S.O.P., PRED FORTE MAXIDEX, PRED MILD

Ophthalmic Antibiotics & Combinations neomycin-polymyxin B-bacitracin-hydrocortisone, ZYLET neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST

Ophthalmic Antiviral trifluridine ZIRGAN Ophthalmic Non-Steroidal Anti- bromfenac, diclofenac, ketorolac, ACUVAIL, PROLENSA Inflammatory Drugs (NSAIDs) ILEVRO, NEVANAC OSTEOARTHRITIS Hyaluronic Acid Derivatives DUROLANE, EUFLEXXA, GELSYN-3, GEL-ONE, GENVISC, HYALGAN, MONOVISC, SUPARTZ FX ORTHOVISC, SYNVISC, SYNVISC-ONE, TRIVISC, VISCO-3, SODIUM HYALURONATE 20MG/2ML

OSTEOPOROSIS Bone Modifiers alendronate, calcitonin-salmon, ibandronate, MIACALCIN INJECTION risedronate, FORTEO, PROLIA, TYMLOS

[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 7

2021 SELECT EX FORMULARY Continued

THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION

Bone Modifiers alendronate, ibandronate, risedronate FOSAMAX PLUS D, FOSTEUM, FOSTEUM PLUS RENAL DISEASE Phosphate Binders calcium acetate, sevelamer carbonate, FOSRENOL PHOSLYRA, VELPHORO RESPIRATORY Alpha-1 Antitrypsin Deficiency Agents PROLASTIN-C ARALAST NP, GLASSIA, ZEMAIRA Long-Acting Muscarinic Antagonist Agents SPIRIVA, YUPELRI INCRUSE ELLIPTA, TUDORZA, LONHALA Long-Acting Muscarinic ANORO ELLIPTA, STIOLTO RESPIMAT BEVESPI AEROSPHERE Antagonist/Long- Acting Beta-Agonist Combination Inhalers Muscarinic Antagonist Inhalers ipratropium inhalation solution, SPIRIVA, YUPELRI ATROVENT HFA Pulmonary Anti-Inflammatory /Long- ADVAIR HFA, BREO ELLIPTA, DULERA, Acting Beta-Agonist Combination fluticasone/salmeterol, SYMBICORT, wixela inhub Inhalers

Pulmonary Anti-Inflammatory Inhalers ARNUITY ELLIPTA, FLOVENT DISKUS, ALVESCO, ASMANEX, ASMANEX HFA FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER

Short Acting Beta Agonist/Rescue Inhalers albuterol sulfate HFA, lev albuterol tartrate HFA PROAIR HFA, PROAIR RESPICLICK, PROVENTIL HFA, VENTOLIN HFA, XOPENEX HFA URINARY AGENTS Benign Prostatic Hyperplasia alfuzosin ER, doxazosin, silodosin, tamsulosin, UROXATRAL terazosin WEIGHT LOSS Weight Loss Agents SAXENDA CONTRAVE, QSYMIA

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[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 Select EX Formulary | 8