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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 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* efavirenz/emtricitabine/tenofovir amlodipine-olmesartan buprenorphine-naloxone sublingual CORLANOR efavirenz/lamivudine/tenofovir amlodipine-telmisartan bupropion CORTIFOAM eletriptan amlodipine-valsartan bupropion ER (except bupropion COSENTYX [INJ]* ELIGARD [INJ]* amlodipine-valsartan-HCTZ ER tablet 450 mg) CREON ELIQUIS amoxicillin BYSTOLIC CRINONE EMGALITY [INJ] amoxicillin-clavulanate cromolyn sodium EMVERM amphetamine-dextroamphetamine C cyclobenzaprine (except ENBREL [INJ]* mixed salts CABOMETYX* cyclobenzaprine tablet 7.5 mg) ENDOMETRIN amphetamine-dextroamphetamine calcipotriene ointment, solution entacapone mixed salts ER calcitonin-salmon D entecavir ANDRODERM calciumacetate DALIRESP ENTRESTO ANNOVERA candesartan darifenacin ER EPCLUSA* ANORO ELLIPTA candesartan-HCTZ DESCOVY EPIDUO aprepitant carbamazepine desonide epinephrine auto-injector [INJ] ARANESP [INJ]* carbamazepine ER desoximetasone EPIPEN [INJ] aripiprazole carbidopa-levodopa desvenlafaxine ER EPIPEN JR [INJ] armodafinil carbidopa-levodopa ER dexamethasone EPISIL ARNUITY ELLIPTA carbidopa-levodopa-entacapone DEXCOM CONTINUOUS GLUCOSE ERIVEDGE * atazanavir carvedilol MONITORING SYSTEM ERLEADA* atenolol carvedilol phosphate ER DEXILANT erythromycin atomoxetine cefdinir diazepam erythromycin solution atorvastatin cefprozil diazepam rectal gel erythromycin-benzoyl peroxide AUBAGIO* cefuroxime axetil diclofenac erythromycins AUSTEDO* celecoxib diclofenac sodium ESBRIET* azelaic acid gel cephalexin diclofenac sodium gel 1% escitalopram azelastine CERDELGA* diclofenac sodium solution esomeprazole azithromycin CEREZYME [INJ]* diclofenac sodium-misoprostol estradiol AZOPT CETROTIDE [INJ]* dicloxacillin estradiol-norethindrone cholestyramine dicyclomine eszopiclone ciclopirox DIFICID ethinyl estradiol- drospirenone ethinyl estradiol-drospirenone-levomefolate [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 2021 SELECT EX FORMULARY Continued 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
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