Ebenefit Highlights the Drugs Listed Below Will Require Prior Authorization Through Your GE Prescription Drug Benefits

eBenefit Highlights The drugs listed below will require prior authorization through your GE Prescription Drug Benefits.

Acne/Rosacea 1 1 • Absorica (isotretinoin) • Epiduo (adapalene/benzoyl peroxide) 1 • Acanya (clindamycin/benzoyl peroxide) • Fabior (tazarotene) 1 • Aczone (dapsone) • Inova (benzoyl peroxide/tocopherols) 1 • Akne-mycin (erythromycin) • Noritate (metronidazole) 1 • Atralin (tretinoin) • Onexton (clindamycin/benzoyl peroxide) 1 • Azelex (azelaic acid) • Tretin-X (tretinoin) 1 • Clindacin ETZ (clindamycin phosphate) • Vanoxide-HC (benzoyl peroxide/hydrocortisone) 1 • Clindacin PAC (clindamycin phosphate) • Veltin (clindamycin/tretinoin) 1 • Clindagel (clindamycin phosphate) • Ziana (clindamycin/tretinoin) 1 2 ADHD/Amphetamines/Stimulants 2 • Aptensio XR (methylphenidate) • Evekeo (amphetamine) 2 • Dyanavel XR (amphetamine extended release) • Intuniv (guanfacine) 2 3 Allergic Asthma/Asthma/COPD 3 • Aerospan (flunisolide) • Proventil HFA (albuterol) 3 • Alvesco (ciclesonide) • Symbicort (budesonide/formoterol) 3 • Cinqair (reslizumab) • Ventolin HFA (albuterol) 3 • Flunisolide nasal (flunisolide nasal) • Xolair (omalizumab) 3 • Incruse Ellipta (umeclidinium) • Xopenex HFA (levalbuterol) 3 • Nucala (mepolizumab)

3 4 Allergies Ophthalmic 4 • Lastacaft (alcaftadine)

4 5 Allergy/ Antihistamines/Nasal Corticosteroids 5 • Adrenaclick (epinephrine) • Omnaris (ciclesonide) 5 • Beconase AQ (beclomethasone) • Oralair (grass mixed pollens extract) 5 • Clarinex, Desloratadine (desloratadine) • Qnasl (beclomethasone) 5 • Clarinex-D (desloratadine/pseudoephedrine) • Ragwitek (ragweed pollen extract) 5 • Dymista (azelastine/fluticasone) • Veramyst (fluticasone) 5 • Grastek (timothy grass pollen extract) • Xyzal, Levocetirizine (levocetirizine) 5 • Nasonex (mometasone) • Zetonna (ciclesonide) 5

7 8 Anticonvulsants 8 • Banzel (rufinamide) • Onfi (clobazam) 8 • Briviact (brivaracetam) • Oxtellar XR (oxcarbazepine ext-rel) 8 • Celontin (methsuximide) • Spritam (levetiracetam) 8 • Lamictal ODT (lamotrigine) • Trokendi XR (topiramate ext-rel) 8 • Lamictal XR (lamotrigine ext-rel)

8 9 Antifungal 9 • Jublia (efinaconazole) • Kerydin (tavaborole) 9 10 Anti-Inflammatory Agents (Nonsteroidal) 10 • Arthrotec (diclofenac/misoprostol) • Tivorbex (indomethacin) 10 • Cambia (diclofenac) • Vivlodex (meloxicam) 10 • Celebrex (celecoxib) • Voltaren Gel 1% (diclofenac topical gel) 10 • Nalfon (fenoprofen) • Zipsor (diclofenac) 10 • Naprelan (naproxen ext-rel) • Zorvolex (diclofenac) 10 • Pennsaid (diflofenac)

10 11 Antipsychotics 11 • Abilify (aripiprazole) • Rexulti (brexpiprazole) 11 • Equetro (carbamazepine) • Vraylar (cariprazine) 11 12 Antiviral Agents (CMV) 12 • Valcyte (valacylclovir)

12 13 Antiviral Agents (Herpes) 13 • Sitavig (acyclovir) • Valtrex (valacylclovir) 13

15 16 Benign Prostatic Hyperplasia 16 • Avodart (dutasteride) • Jalyn (dutasteride/tamsulosin) 16 • Cardura XL (doxazosin ext-rel) • Rapaflo (silodosin) 16 17 Botulinum Toxin 17 • Botox (botulinum toxin type A) • Myobloc (botulinum toxin type B) 17 • Dysport (abobotulinumtoxinA) • Xeomin (incobotulinumtoxina) 17 18 CNS Stimulants/Narcolepsy 18 • Nuvigil (armodafinil) • Provigil (modafinil) 18 19 Compounded Medications $300 and over 19 • Various (various)

19 20 Corticosteroids 20 • Rayos (prednisone delayed release)

20 21 Cystic Fibrosis 21 • Bethkis (tobramycin) • Orkambi (lumacaftor/ivacaftor) 21 • Cayston (aztreonam lysinate) • Pulmozyme (dornase alfa) 21 • Kalydeco (ivacaftor) • Tobi Podhaler (tobramycin) 21 • Kitabis Pak (tobramycin inhalation solution) • TOBI, Tobramycin (tobramycin/sodium chloride) 21 22 Dermatologicals, Miscellaneous 22 • Apexicon E (diflorasone) • Efudex (fluorouracil) 22 • Avita (tretinoin) • Fluorouracil cream 0.5% (fluorouracil) 22 • Carac (fluorouracil) • Olux-E (clobetasol) 22 • Clobetasol spray (clobetasol) • Retin-A (tretinoin) 22 • Clobex Spray (clobetasol) • Retin-A Micro (tretinoin gel, microsphere) 22

24 25 Erectile Dysfunction Agents 25 • Cialis (tadalafil) • Stendra (avanafil) 25 • Levitra (vardenafil) • Viagra (sildenafil) 25 • Staxyn (vardenafil)

25 26 Estrogen Combinations 26 • Angeliq (drospirenone/estradiol) • Prefest (estradiol/norgestimate) 26 • Climara Pro (estradiol/levonorgestrel)

26 27 Estrogens 27 • Alora (estradiol) • Menest (estrogens, esterified) 27 • Divigel (estradiol) • Menostar (estradiol) 27 • Elestrin (estradiol) • Minivelle (estradiol) 27 • Estrogel (estradiol)

27 28 Gastroinestinal Drugs, Miscellaneous 28 • Amitiza (lubiprostone) • Relistor (methylnaltrexone) 28 29 Glaucoma Agents 29 • Lumigan (bimatoprost) • Zioptan (tafluprost) 29 • Travatan Z (travoprost)

* Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 5 2016 04-20 Hemophilia, Von Willebrand Disease, and 34 Related Bleeding Disorders • Advate (antihemophilic factor, human, • Kogenate FS (antihemophilic factor, human, 34 recombinant) recombinant) 34 • Adynovate (pegylated recombinant factor VIII) • Kovaltry (octocog alfa) 34 • Alphanate (antihemophilic factor, human) • Monoclate-P (antihemophilic factor, human) 34 • Alphanine SD (factor IX) • Mononine (factor IX) 34 • Alprolix (recombinant factor IX) • NovoEight (turoctocog alfa) 34 • Bebulin VH (factor IX complex, human) • NovoSeven (factor VIIA, recombinant) 34 • Benefix (factor IX) • Nuwiq (antihemophilic factor [recombinant]) • Obizur (antihemophilic factor VIII [recombinant], • Coagadex (coagulation factor X [human]) 34 porcine sequence) 34 • Corifact (factor XIII concentrate, human) • Profilnine SD (factor IX complex, human) • Recombinate (antihemophilic factor, human, • Eloctate (recombinant factor VIII-Fc) 34 recombinant) 34 • Feiba VH (anti-inhibitor coagulant complement) • RiaSTAP (fibrinogen concentrate, human) • Helixate FS (antihemophilic factor, human, 34 recombinant) • Rixubis (recombinant factor IX) 34 • Hemofil-M (antihemophilic factor, human) • Stimate (desmopressin) 34 • Humate-P (antihemophilic factor, human) • Tretten (factor XIII A-subunit, recombinant) • Idelvion (Coagulation factor IX recomb albumin 34 fusion protein (RIX-FP)) • Vonvendi (vonicog alfa) 34 • Ixinity (coagulation factor IX [recombinant]) • Wilate (AHF/VWF) 34 • Koate-DVI (antihemophilic factor, human) • Xyntha (antihemophilic factor, FVIII) 34 35 Hepatitis C/ Interferon Alpha 35 • Alferon N (interferon alfa-n3) • Rebetol (ribavirin) 35 • Copegus (ribavirin) • Ribapak (ribavirin) 35 • Daklinza (daclatasvir) • Ribasphere (ribavirin) 35 • Harvoni (ledipasvir/sofosbuvir) • Ribavirin (ribavirin) 35 • Infergen (interferon alfacon-1) • Sovaldi (sofosbuvir) 35 • Intron A (interferon alfa-2b) • Tecnivie (ombitasvir/ paritaprevir/ ritonavir) 35 • Moderiba (ribavirin) • Victrelis (boceprevir) • Viekira Pak (ombitasvir, paritaprevir, ritonavir and • Olysio (simeprevir) 35 dasabuvir) 35 • Pegasys (interferon alfa-2a) • Zepatier (elbasvir/ grazoprevir) 35 • Peg-Intron (interferon alfa-2b)

35 36 Hereditary Angioedema 36 • Berinert (C1 esterase inhibitor [human]) • Kalbitor (ecallantide) • Ruconest (recombinant human C1 esterase • Cinryze (C1 Inhibitor) 36 inhibitor) 36 • Firazyr (icatibant)

37 38 HIV/Related Therapies 38 • Egrifta (tesamorelin) • Fuzeon (enfuvirtide) 38 • Fulyzaq (crofelemer/fulyzaq) • Serostim (somatropin) 38 39 Hormonal Therapies 39 • Eligard (leuprolide) • Lupron Depot-Ped (leuprolide) 39 • Firmagon (degarelix) • Supprelin LA (histrelin) 39 • Leuprolide (leuprolide) • Trelstar (triptorelin) 39 • Lupaneta (leuprolide/norethindrone) • Vantas (histrelin) 39 • Lupron (leuprolide) • Zoladex (goserelin) 39 • Lupron Depot (leuprolide)

39 40 Hypnotic Agents 40 • Belsomra (suvorexant) • Rozerem (ramelteon) 40 • Edluar (zolpidem) • Silenor (doxepin) 40 • Intermezzo (zolpidem) • Zolpimist (zolpidem) 40 • Lunesta (eszopiclone)

43 44 Kidney Disease, Phosphate Binder 44 • Fosrenol (lanthanum)

44 45 Lipid Lowering Agents 45 • Advicor (niacin ext-rel/lovastatin) • Livalo (pitavastatin) 45 • Altoprev (lovastatin ext-rel) • Simcor (niacin ext-rel/simvastatin) 45 • Crestor (rosuvastatin) • Tricor (fenofibrate micronized) 45 • Fenoglide (fenofibrate) • Triglide (fenofibrate) 45 • Lescol XL (fluvastatin) • Trilipix (choline fenofibrate) 45 • Lipitor (atorvastatin) • Vytorin (ezetimibe/simvastatin) 45 • Lipofen (fenofibrate) • Zetia (ezetimibe) 45 • Liptruzet (ezetimibe/atorvastatin)

47 48 Menopause 48 • Brisdelle (paroxetine)

48 49 Migraine Agents 49 • Alsuma (sumatriptan) • Sumavel DosePro (sumatriptan) 49 • Axert (almotriptan) • Treximet (sumatriptan/naproxen) 49 • Frova (frovatriptan) • Zecuity (sumatriptan) 49 • Relpax (eletriptan) • Zomig (zolmitriptan) 49 50 Multiple Sclerosis Drugs 50 • Ampyra (dalfampridine) • Lemtrada (alemtuzumab) 50 • Aubagio (teriflunamide) • Novantrone (mitoxantrone) 50 • Avonex (interferon beta-1a) • Plegridy (peginterferon beta-1a) 50 • Betaseron (interferon beta-1b) • Rebif (interferon beta-1a) 50 • Copaxone (glatiramer) • Tecfidera (dimethyl fumarate delayed release) 50 • Extavia (interferon beta-1b) • Tysabri (natalizumab) 50 • Gilenya (fingolimod)

* Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 9 2016 04-20 51 Oncology 51 • Adcetris (brentuximab) • Novantrone (mitoxantrone) 51 • Afinitor (everolimus) • Oncaspar (pegaspargase) 51 • Alecensa (alectinib) • Onivyde (irinotecan liposome) 51 • Arzerra (ofatumumab) • Opdivo (nivolumab) 51 • Avastin (bevacizumab) • Perjeta (pertuzumab) 51 • Azacitidine (azacitidine) • Pomalyst (pomalidomide) 51 • Beleodaq (belinostat) • Portrazza (necitumumab) 51 • Bendeka (bendamustine) • Proleukin (aldesleukin) 51 • Blincyto (blinatumomab) • Revlimid (lenalidomide) 51 • Bosulif (bosutinib) • Rituxan (rituximab) 51 • Caprelsa (vandetanib) • Sprycel (dasatinib) 51 • Coltellic (cobimetinib) • Stivarga (regorafenib) 51 • Cometriq (cabozantinib) • Sutent (sunitinib) 51 • Cyramza (ramucirumab) • Sylatron (peginterferon alfa-2b) 51 • Dacogen (decitabine) • Sylvant (siltuximab) 51 • Darzalex (daratumumab) • Synribo (omacetaxine) 51 • Empliciti (elotuzumab) • Tafinlar (debrafenib) 51 • Erbitux (cetuximab) • Tagrisso (osimertinib) 51 • Erivedge (vismodegib) • Tarceva (erlotinib) 51 • Erwinaze (asparaginase) • Targretin (bexarotene) 51 • Farydak (panobinostat) • Tasigna (nilotinib) 51 • Folotyn (pralatrexate) • Temodar (temozolamide) 51 • Fusilev (levoleucovorin) • Thalomid (thalidomide) 51 • Gazyva (obinutuzumab) • Torisel (temsirolimus) 51 • Gilotrif (afatinib) • Treanda (bendamustine) 51 • Gleevec (imatinib) • Tykerb (lapatinib) 51 • Halaven (eribulin) • Unituxin (dinutuximab) 51 • Herceptin (trastuzumab) • Valchlor (mechlorethamine) 51 • Hycamtin (topotecan) • Valstar (valrubicin) 51 • Ibrance (palbociclib) • Vectibix (panitumumab) 51 • Iclusig (ponatinib) • Velcade (bortezomib) 51 • Imbruvica (ibrutinib) • Venclexta (venetoclax) 51 • Imlygic (talimogene laherparepvec) • Vidaza (azacitidine) 51 • Inlyta (axitinib) • Votrient (pazopanib) 51 • Intron A (interferon alfa-2b) • Xalkori (crizotinib) 51 • Istodax (romidepsin) • Xeloda (capecitabine) 51 • Ixempra (ixabepilone) • Xgeva (denosumab) 51 • Jakafi (ruxolitinib) • Xtandi (enzalutamide) 51 • Jevtana (cabazitaxel) • Yervoy (ipilimumab) 51 • Kadcyla (ado-trastuzumab) • Yondelis (trabectedin) 51 • Keytruda (pembrolizumab) • Zaltrap (aflibercept)

51 52 Osteoarthritis 52 • Euflexxa (hyaluronate) • Orthovisc (hyaluronate) 52 • Gel-One (hyaluronate) • Supartz (hyaluronate) 52 • GenVisc (sodium hyaluronate) • Synvisc (hylan G-F 20) 52 • Hyalgan (hyaluronate) • Synvisc One (hylan G-F 20) 52 • Monovisc (hyaluronate)

52 53 Osteoporosis (Injectable) 53 • Forteo (teriparatide) • Reclast (zoledronic acid) 53 • Prolia (denosumab)

53 54 Osteoporosis Therapy (Oral) 54 • Actonel (risedronate) • Boniva (ibandronate) 54 • Atelvia (risedronate) • Fosamax Plus D (alendronate/vitamin D3) 54 • Binosto (alendronate effervescent) • Risedronate (risedronate) 54 55 Other Specialty Products • Natpara (recombinant human parathyroid hormone • Acthar Gel (corticotropin) 55 [1-84]) 55 • Actimmune (interferon gamma-1b) • Northera (droxidopa) 55 • Adagen (pegademase) • Nplate (romiplostim) 55 • Apokyn (apomorphine) • Octreotide (octreotide) 55 • Arcalyst (rilonacept) • Orfadin (nitisinone) 55 • Benlysta (belimumab) • Praluent (alirocumab) 55 • Buphenyl (sodium phenylbutyrate) • Prialt (ziconotide) 55 • Carbaglu (carglumic acid) • Promacta (eltrombopag) 55 • Ceprotin (protein C concentrate, human) • Ravicti (glycerol phenylbutyrate) 55 • Desferal (deferoxamine) • Sabril (vigabatrin) 55 • Exjade (deferasirox) • Samsca (tolvaptan) 55 • Ferriprox (deferiprone) • Sandostatin (octreotide) 55 • Gattex (teduglutide) • Sandostatin LAR (octreotide) 55 • H.P. Acthar Gel (corticotropin) • Signifor (pasireotide) 55 • Hetlioz (tasimelteon) • Signifor® LAR (pasireotide long-acting release) 55 • Ilaris (canakinumab) • Soliris (eculizumab) 55 • Jadenu (deferasirox) • Somatuline Depot (lanreotide)

55 Pain/ Narcotic 56 Analgesics/Neurological/Skeletal Muscle 56 • Abstral (fentanyl sublingual) • Hysingla ER (hydrocodone ext-rel) 56 • Actiq (fentanyl transmucosal) • Lazanda (fentanyl intranasal) 56 • Amrix (cyclobenzaprine) • Nucynta (tapentadol) 56 • Belbuca (buprenorphine) • Nucynta ER (tapentadol ext-rel) 56 • Butrans (buprenorphine) • Onsolis (fentanyl buccal soluble film) 56 • Conzip (tramadol extended-release) • OxyContin (oxycodone ext-rel) • Oxymorphone ext-rel, Opana ER (oxymorphone ext- • Embeda (morphine ext-rel/naltrexone) 56 rel) 56 • Exalgo (hydromorphone ext-rel) • Qutenza (capsaicin) 56 • Fentanyl (fentanyl transmucosal) • Subsys (fentanyl oral spray) 56 • Fentora (fentanyl buccal) • Zohydro ER (hydrocodone ext-rel) 56 • Gralise (gabapentin) • Zubsolv (buprenorphine/naloxone) 56 • Horizant (gabapentin)

56 57 Proton Pump Inhibitors 57 • Aciphex Sprinkles (rabeprazole) • Prevacid Solutab (lansoprazole) 57 • Aciphex tabs (rabeprazole) • Prilosec Packets (omeprazole) 57 • Dexilant (dexlansoprazole) • Protonix Packets (pantoprazole) 57 • Esomezol (esomeprazole strontiium) • Protonix tabs (pantoprazole) • Zegerid 40 mg Packets (omeprazole/sodium • Nexium packets (esomeprazole) 57 bicarbonate) 57 • Prevacid (all forms) (lansoprazole)

57 58 Psoriasis 58 • Cosentyx (secukinumab) • Remicade (infliximab) 58 • Enbrel (etanercept) • Stelara (ustekinumab) 58 • Humira (adalimumab) • Taltz (ixekizumab) 58 • Otezla (apremilast)

60 61 Pulmonary Disease 61 • Aralast (alpha-1 proteinase inhibitor) • Prolastin-C (Proteinase inhibitor, human) 61 • Glassia (alpha-1 proteinase inhibitor) • Zemaira (proteinase inhibitor, human) 61 62 Renal Disease 62 • Sensipar (cinacalcet)

62 63 Respiratory Syncytial Virus (RSV) 63 • Synagis (palivizumab)

63 64 Rheumatoid Arthritis 64 • Actemra (tocilizumab) • Rasuvo (methotrexate) 64 • Cimzia (certolizumab) • Remicade (infliximab) 64 • Enbrel (etanercept) • Rituxan (rituximab) 64 • Humira (adalimumab) • Simponi (golimumab) 64 • Kineret (anakinra) • Simponi Aria (golimumab) 64 • Orencia (abatacept) • Xeljanz (tofacitinib) 64 • Otezla (apremilast) • Xeljanz XR (tofacitinib) 64 • Otrexup (methotrexate)

64 65 Sympathomimetics 65 • Brovana (arformoterol)

66 67 Tetracyclines 67 • Adoxa (doxycycline monohydrate) • Ocudox (doxycycline hyclate w/ eyelid cleanser & spray) 67 • Arestin (minocycline HCl) • Solodyn (minocycline HCl) 67 • Doryx (doxycycline hyclate) • Vibramycin (doxycycline monohydrate) 67 68 Thyroid Hormones 68 • Armour Thyroid (thyroid) • Westhroid (thyroid) 68 • Nature-Throid (thyroid) • WP Thyroid (thyroid) 68 • Tirosint (levothyroxine)

68 69 Topical Antipsoriatics 69 • Drithocreme HP (anthralin) • Vectical (calcitriol) 69 • Enstilar (calcipotriene/ betamethasone) • Zithranol (anthralin) 69 70 Topical Corticosteroids 70 • Apexicon E (diflorasone diacetate/emollient) • Pediaderm TA (triamcinolone/emollient) 70 • Dermasorb TA (triamcinolone/emollient) • Pramosone E (pramoxine-hydrocortisone emollient base) 70 • Desonate (desonide) • Synalar (fluocinolone) 70 • Desowen (desonide) • Texacort (hydrocortisone) 70 • Epifoam (hydrocortisone/pramoxine) • Trianex (triamcinolone) 70 • Pandel (hydrocortisone probutate) • Ultravate X (halobetasol/lactic acid) 70 • Pediaderm HC (hydrocortisone & emollient) • Verdeso (desonide) 70 71 Transplant 71 • Hecoria (tacrolimus) • Prograf (tacrolimus) 71 72 Urinary Antispasmodics 72 • Detrol LA (tolterodine ext-rel) • Oxytrol (oxybutynin transdermal) 72 • Enablex (darifenacin) • Sanctura XR (trospium ext-rel) 72 • Gelnique (oxybutynin gel) • Toviaz (fesoterodine) 72 • Myrbetriq (mirabegron) • Vesicare (solifenacin)