3Q2021 Precision Formulary Exclusion List

Therapeutic Category Excluded Medications Preferred Alternatives ALLERGIC REACTIONS Anaphylaxis Treatment Auvi-Q, Epipen Jr 2-Pak 0.15 mg Epipen, epinephrine ANALGESICS celecoxib, diflunisal, flurbiprofen, Cambia, Zipsor, Zorvolex ibuprofen, indomethacin, ketorolac, meloxicam, piroxicam, sulindac Non-Steroidal Anti-Inflammatory Agents (Oral) Relafen, Relafen DS nabumetone

Qmiiz ODT meloxicam

Non-Steroidal Anti-Inflammatory Pennsaid, Voltaren gel diclofenac solution, diclofenac gel (Topical) Flector, Licart diclofenac patch Non-Steroidal Anti-Inflammatory Ketorolac Nasal Spray, Sprix Nasal diclofenac, ibuprofen, meloxicam (Other) Spray Skeletal Muscle Relaxant Norgesic Forte, Orphengesic Forte orphenadrine tab, aspirin Combinations Ozobax baclofen Kadian ER, Nucynta ER, Zohydro ER, Arymo ER, Hysingla ER, hydromorphone HCl ER, morphine sulfate Oxycontin, Embeda, Exalgo ER, MS Oral Long-Acting ER, oxymorphone HCl ER, Xtampza ER Contin, oxycodone ER, oxycodone Opioid Analgesics powder Conzip, tramadol ER 100mg, tramadol ER tablets 200mg and 300mg capsules codeine sulfate, hydromorphone hcl, Oral Short-Acting Opioid Analgesics Nucynta, Oxaydo, Qdolo morphine sulfate, oxycodone hcl, oxymorphone hcl, tramadol

Abstral, Fentora, Lazanda, Subsys, Transmucosal Fentanyl Analgesics fentanyl citrate lozenge fentanyl citrate buccal tab

Apadaz, hydrocodone/acetaminophen, Opioid Combinations benzhydrocodone/acetaminophen oxycodone/acetaminophen ANTICONVULSANTS Oxtellar XR oxcarbazepine IR Seizure Disorders Lamictal ODT kit lamotrigine ODT, lamotrigine XR ANTIDEPRESSANTS

Antidepressants bupropion 450mg XL, Forfivo XL bupropion XL

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Therapeutic Category Excluded Medications Preferred Alternatives ANTIPSYCHOTICS aripiprazole, olanzapine, quetiapine, Schizophrenia Secuado, Saphris quetiapine ER, risperidone, asenapine ANTIBACTERIALS, ORAL Doryx, doxycycline hyclate DR Oral Antibiotics doxycycline, minocycline 80mg, Minolira ANTIFUNGALS, ORAL

Oral Antifungals Tolsura itraconazole cap

AUTONOMIC & CENTRAL NERVOUS SYSTEM

Attention Deficit Disorder Adhansia XR Vyvanse, methylphenidate ER

CARDIOVASCULAR atorvastatin, fluvastatin, lovastatin, Statins Zypitamag, Livalo pravastatin, rosuvastatin, simvastatin

Inderal XL, Innopran XL propranolol ER

Hypertension Kapspargo metoprolol ER Conjupri, Katerzia amlodipine

Hypertension with Osteoarthritis Consensi amlodipine/celecoxib

CONTRACEPTIVES

Lo Loestrin junel FE, larin FE, microgestin FE, tarina FE Oral Camila,Incassia, Nora-Be, norethindrone, Slynd Norlyda, Norlyroc etonogestrel-ethinyl estradiol vaginal Vaginal Ring Annovera ring, Nuvaring Talk to your doctor about clinically Gel Phexxi appropriate options. Xulane, Zafemy, levonorgestrel/ethinyl Patch Twirla estradiol combined generic oral contraceptive CORTICOSTEROIDS

Hemady dexamethasone Oral Anti-Inflammatory Agents Rayos DR prednisone

ENDOCRINE

Nocturia Noctiva desmopressin, Nocdurna

Testosterone Replacement Aveed, Jatenzo, Natesto, Testopel testosterone, Androderm

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Therapeutic Category Excluded Medications Preferred Alternatives DERMATOLOGICAL AGENTS Acanya, Aczone 5%, Aktipak, Onexton, Epiduo Forte, adapalene, Benzaclin, Benzaclin Pump, adapalene/benzoyl peroxide, clindamycin Clindagel, clindamycin phosphate gel/lotion/solution, clindamycin/benzoyl 1% gel, Benzamycin, Duac, Epiduo, peroxide, erythromycin/benzoyl peroxide, Veltin, Ziana, Aklief, dapsone 7.5% tretinoin cream Topical Acne Treatment adapalene lotion, Differin lotion adapalene

Avita tretinoin cream/gel Arazlo, Fabior, Tazorac tazarotene cream

Topical Anesthetics Ztlido lidocaine patch

Topical Antifungals Jublia terbinafine, Kerydin ALA Scalp lotion, Micort-HC cream hydrocortisone Topical Corticosteroids Apexicon E cream fluocinonide, betamethasone Capex shampoo Derma-Smoothe/FS, fluocinolone acetonide scalp oil Cordran tape flurandrenolide

Pandel cream flurandrenolide, hydrocortisone valerate, triamcinolone acetonide Halobetasol foam(M), Lexette betamethasone, clobetasol, halobetasol cream/ointment Topical Corticosteroids Halog ointment betamethasone, mometasone, triamcinolone Impoyz cream clobetasol

Psorcon cream, Verdeso foam betamethasone, fluocinolone

Trianex hydrocortisone valerate, triamcinolone acetonide clobetasol proprionate, fluocinonide, Ultravate lotion halobetasol proprionate

imiquimod cream pump 3.75% Topical Immune Response Modifier Zyclara, Zyclara Pump imiquimod 5% cream

Duobrii Lotion clobetasol, fluocinonide, halobetasol, tazarotene, Enstilar Topical Plaque Psoriasis Calcipotriene Foam 0.005% (M), calcipotriene Sorilux

metronidazole cream/gel/lotion, Finacea Rosacea Treatment Noritate, Metrogel foam, Soolantra

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Therapeutic Category Excluded Medications Preferred Alternatives DIABETES All other blood glucose meters and strips. Examples: Abbott (FreeStyle, Precision), Arkray Ascensia Diabetes Care (Contour/Contour Blood Glucose Meters & Strips (Glucocard), Bayer (Breeze), Nipro Next) (TRUEtest, TRUEtrack), Roche (Accu-Chek), Lifescan (One Touch) Continuous Glucose Monitoring FreeStyle Libre, FreeStyle Libre 2 Dexcom (CGM) alogliptin, alogliptin/metformin, Dipeptidyl Peptidase-4 (DPP4) alogliptin/pioglitazone, Kazano, Janumet, Janumet XR, Januvia, Inhibitors & Combinations Kombiglyze XR, Nesina, Onglyza, Jentadueto, Jentadueto XR, Tradjenta Oseni Invokamet, Invokamet XR, Sodium-glucose co-transporter Farxiga, Xigduo XR, Jardiance, Synjardy, Invokana, Steglatro, Segluromet, (SGLT2) Inhibitors & Combinations Synjardy XR, Glyxambi, Trijardy XR Steglujan, Qtern Bydureon, Bydureon Bcise, Byetta, Glucagon-Like Peptide-1 Agonists Adlyxin, Tanzeum Trulicity, Victoza, Ozempic, Rybelsus Insulins Novolin Humulin Admelog, Apidra, Fiasp, insulin Rapid-acting insulin Humalog, Lyumjev lispro, insulin aspart, Novolog Basaglar, Levemir, Tresiba, Basal insulin Lantus, Toujeo Semglee Glumetza, Fortamet, Riomet suspension, metformin HCl 24hr metformin ER (Glucophage generic), Biguanides ER osmotic release, metformin HCl metformin IR 24hr ER modified release GASTROINTESTINAL

Anti-Diarrheal Agents Motofen diphenoxylate/atropine, loperamide

granisetron solution/tablet, ondansetron Antiemetics Sancuso patch ODT

Duexis, Vimovo, famotidine PLUS ibuprofen, omeprazole Anti-Inflammatory/Anti-Ulcer Agents naproxen/esomeprazole PLUS naproxen

Pancreatic Enzymes Pancreaze, Pertzye, Viokace Creon, Zenpep

Asacol HD, Delzicol, Dipentum, Inflammatory Bowel Disease Apriso, mesalamine Lialda, mesalamine DR 800 mg Chronic Idiopathic Constipation, Trulance, Amitiza, lubiprostone, Irritable bowel syndrome with Linzess Zelnorm constipation Opioid-Induced Constipation Movantik, Amitiza, Relistor Symproic

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Therapeutic Category Excluded Medications Preferred Alternatives omeppi, omeprazole with sodium bicarbonate (cap, powder pak), lansoprazole, omeprazole, pantoprazole, Proton Pump Inhibitors rabeprazole sprinkle cap, Aciphex Sprinkle caps, Dexilant esomeprazole mag DR capsules Golytely packets Gavilyte-C, Gavilyte-H, PEG 3350 Laxatives Moviprep, Plenvu, Osmoprep Clenpiq, Prepopik, Suprep IMMUNOMODULATORS Cimzia, Humira, Inflectra, Actemra, Autoimmune Agents3 Cosentyx, Olumiant, Ilumya, Orencia, Otezla, Avsola, Rinvoq ER, Remicade, Renflexis Simponi, Simponi Aria, Skyrizi, Stelara, Taltz, Tremfya, Xeljanz/XR MUSCULOSKELETAL

Muscle Relaxants Amrix cyclobenzaprine

ANTIMIGRAINES Ajovy Aimovig, Emgality CGRP Antagonists Reyvow Nurtec ODT, Ubrelvy

Onzetra XSAIL, Zembrace sumatriptan injection, sumatriptan, Serotonin Receptor Agonists Symtouch, Imitrex, Maxalt/MLT, rizatriptan, eletriptan, zolmitriptan Relpax, Zomig, Treximet, Tosymra,

OPHTHALMIC latanoprost ophthalmic solution, Vyzulta, Zioptan, Xalatan travoprost ophthalmic solution, Lumigan, Antiglaucoma Drugs Rhopressa, Rocklatan, Xelpros Timoptic Ocudose timolol ophthalmic solution

Prolensa, diclofenac, ketorolac, Anti-Inflammatory Bromsite, Ilevro, Nevanac flurbiprofen

azelastine ophthalmic solution, Antihistamines Bepreve, Lastacaft, Pazeo, Zerviate olopatadine ophthalmic solution

Dry Eye Disease Cequa Restasis, Xiidra

RESPIRATORY

Anticholinergic/Long-Acting Beta Bevespi, Utibron, Duaklir Pressair Anoro Ellipta, Stiolto Respimat Agonist Combination Inhalers

AirDuo Respiclick, Airduo Advair Diskus, Advair HFA, Breo Ellipta, Anti-Inflammatory/ Long-Acting Beta Digihaler, Dulera, Symbicort, fluticasone/salmeterol, Wixela Agonist Combination Inhalers budesonide/formoterol Inhub

Therapeutic Category Excluded Medications Preferred Alternatives levalbuterol HFA, Proventil HFA, Xopenex HFA, Proair Digihaler, Short-Acting Beta-2 Adrenergic albuterol HFA (Perrigo, Teva, Par, Cipla, Proair HFA, Proair Respiclick, Inhalers Lupin, Sandoz) albuterol HFA (Prasco), Ventolin HFA

Alvesco, Armonair Respiclick, Pulmonary Anti-Inflammatory Arnuity Ellipta, Flovent Diskus, Flovent Armonair Digihaler, Asmanex, Inhalers HFA, Pulmicort Flexhaler Asmanex HFA, QVAR Redihaler

Chronic Obstructive Pulmonary Tudorza, Seebri, Incruse Ellipta Spiriva Disease (inhaled anticholinergics)

UROLOGICAL Erectile Dysfunction Oral Agents Stendra sildenafil

Interstitial Cystitis Elmiron amitriptyline, hydroxyzine OTHER Colcrys, Mitigare, Gloperba, Antigout Agents colchicine tablet colchicine capsule Clarinex Syrup desloratadine Antihistamine Carinex-D desloratadine with pseudoephedrine

Corticosteroid nasal sprays Xhance mometasone furoate Corvita 150, Corvite 150, Corvite Fe, Dermacinrx Vitrexate/Fe, Dermacinrx Vitranol/Fe, Dermacinrx Foltrexyl, Dermacinrx Venexa, Dexifol, Folic-K, Folika-T, Multivitamins, Dietary Supplements, Folika-V, Genicin Vita-Q, Genicin Any preferred multivitamin Iron Replacements Vita-S, Hylavite, Hylazinc, Lorid, Multi Pro, Nicadan, Nicazel/Forte, Nicomide, Quflora Fe, Remedient, Tronvite, Vitasure, Vitrexyl, Vitrexyl plus iron, Xvite, Zyvana Azesco, Citranatal, Dermacinrx Prenatrix, Dermacinrx Prenatryl, Duet DHA, Natachew, Nestabs (DHA, One), OB Complete (One, Petite, Premier), PNV Tabs, Prenatal Vitamins Any preferred prenatal vitamin Pregenna, Prenate, Primacare, Select-OB, Trinaz, Tristart DHA, Vitafol (Fe Plus, -OB caplet, gummies), VitamedMD, Vitatrue, Vitapearl, Zalvit Tirosint, Thyquidity, levothyroxine Thyroid Agents levothyroxine tablets capsules

Therapeutic Category Excluded Medications Preferred Alternatives Obesity Contrave Qsymia, Saxenda

Opioid Reversal Agents naloxone auto-injector (M), Evzio Narcan

Platelet-Modifying Agent aspirin/omeprazole, Yosprala aspirin with omeprazole

Required Prior Authorization2 Therapeutic Class Non-Preferred Medications Preferred Medications All other products non-preferred with Erythropoiesis-Stimulating Agents Aranesp, Retacrit prior authorization All other products non-preferred with Growth Hormones Norditropin prior authorization Epclusa, Harvoni, Sovaldi, Mavyret, All other products non-preferred with Hepatitis C1 Vosevi, ledipasvir/sofosbuvir, sofosbuvir/ prior authorization velpatasvir Avonex, Betaseron, Copaxone, dimethyl All other products non-preferred with Multiple Sclerosis fumarate, Gilenya, glatiramer, Kesimpta, prior authorization Mayzent, Plegridy, Vumerity

Excluded medications with generic alternatives The medications listed below are excluded on the formulary. These medications have been identified as having available generic alternatives covered on the formulary.

ABILIFY CARAFATE DIFFERIN IMPEKLO ACANYA CARBATROL DILANTIN INDERAL LA ACIPHEX DR TABLET CARDIZEM LA DILAUDID INTUNIV ACTICLATE CARNITOR DIOVAN KADIAN ACZONE 5% CARNITOR SF DIOVAN HCT KENALOG SPRAY ADDERALL CATAPRES-TTS PATCH DORYX KENALOG-40 ADDERALL XR CELEBREX DUAC KEPPRA ADIPEX-P CELEXA DURAGESIC KEPPRA XR ALKINDI SPRINKLE CIALIS DYAZIDE KLONOPIN ALPHAGAN P CIPRODEX EFFEXOR XR K-TAB ER ALTACE CLARINEX ELIDEL LAMICTAL AMBIEN CLIMARA EPIDUO LAMICTAL ODT AMBIEN CR CLOBEX ESTRACE LAMICTAL STARTER KIT AMRIX CLODERM EVEKEO LAMICTAL XR ANDROGEL COLESTID EXALGO LASIX ARIMIDEX CONCERTA EXFORGE LATISSE ARTHROTEC COREG EXFORGE HCT LESCOL XL ASACOL HD COREG CR FIORICET LEVITRA ATACAND CORTEF FIORICET WITH CODEINE LEXAPRO ATIVAN COSOPT FLOMAX LIALDA AVAPRO COSOPT PF FOCALIN LIDODERM AVODART COZAAR FOCALIN XR LIPITOR AXIRON CRESTOR FORTAMET LOESTRIN 21 AZESCHEW CHEW CYMBALTA FORTESTA LOESTRIN FE AZOR CYTOMEL GENERESS FE LOTEMAX SUSPENSION BENICAR DELESTROGEN GLUCOPHAGE LOTREL BENICAR HCT DELZICOL GLUCOPHAGE XR LOVAZA BENZACLIN DEPAKOTE SPRINKLE GLUMETZA LUNESTA BENZAMYCIN DEPAKOTE GOCOVRI LYRICA BEYAZ DEPAKOTE ER GOLYTELY MAXALT BRISDELLE DEPO-TESTOSTERONE HALOG MAXALT MLT BUTRANS DESONATE GEL HYZAAR MICARDIS CANASA DICLOFENAC 35 MG CAP IMITREX MICARDIS HCT

MINASTRIN PRED FORTE SOMA VECTICAL MOBIC PREVACID STAXYN VESICARE MS CONTIN PRINIVIL STRATTERA VIAGRA NALFON PRISTIQ SUBOXONE VIGAMOX NASONEX PROMETRIUM SYNTHROID VIMOVO NATROBA PROPECIA TACLONEX OINTMENT VIVELLE-DOT NEEVODHA PROTONIX TABLET TAMIFLU VOGELXO NEURONTIN PROVIGIL TARGADOX VOLTAREN NEXIUM CAPSULE PROZAC TEGRETOL VYTORIN NIASPAN ER PULMICORT RESPULE TEGRETOL XR WELCHOL NITROSTAT QUDEXY XR TENORMIN WELLBUTRIN SR NORCO QUESTRAN LIGHT TESTIM GEL WELLBUTRIN XL NORVASC QUESTRAN TIKOSYN XALATAN NULYTELY WITH FLAVOR RANEXA TIMOPTIC XANAX NULYTELY SOLUTION RELPAX TIMOPTIC-XE XANAX XR NUVIGIL RENAGEL TOBRADEX SUSPENSION YASMIN 28 OMNIPRED RESTORIL TOPAMAX TABLET YAZ ONFI RETIN-A TOPAMAX SPRINKLE CAP ZANAFLEX ORACEA RETIN-A MICRO GEL TOPICORT SPRAY ZEGERID ORTHO MICRONOR RETIN-A MICRO PUMP TOPROL XL ZESTRIL ORTHO TRI-CYCLEN RISPERDAL TAB, SOLUTION TREXIMET ZETIA ORTHO-TRI-CYCLEN LO RITALIN TRIBENZOR ZIANA ORTHO-CYCLEN RITALIN LA TRICOR ZOCOR ORTHO-NOVUM ROXICODONE TRILEPTAL ZOHYDRO ER ORTIKOS ER SAFYRAL TYLENOL-CODEINE NO.3 ZOLOFT PATADAY SEASONIQUE TYLENOL-CODEINE NO.4 ZOMIG PATANOL SENSIPAR UCERIS ZOMIG ZMT PAXIL SEROQUEL ULTRACET ZONEGRAN PAXIL CR SEROQUEL XR ULTRAM ZOVIRAX PERCOCET SILVADENE VAGIFEM ZYPREXA PLAQUENIL SINGULAIR VALIUM PLAVIX SKELAXIN VALTREX PRAVACHOL SOLODYN VANADOM

(M) Co-branded product

** This list is not inclusive of all formulary strategies. Please check the formulary listing for specific drug coverage. All therapeutic classes do not allow grandfathering, unless specifically mentioned.

1 Grandfathering allowed; no duration limit. All other therapeutic classes do not allow Grandfathering, no exceptions. 2 All medications require a Prior Authorization. Use of a non-preferred medication requires clinical failure or intolerance of one or more preferred medications prior to beginning therapy. The number and type of preferred alternative(s) will depend on the indication 3 Grandfathering varies depending on which formulary the plan is enrolled in. The number and type of preferred alternative(s) will depend on the indication