STATE OF FLORIDA STATE EMPLOYEES’ PRESCRIPTION DRUG PLAN CVS CAREMARK® MAINTENANCE DRUG LIST EFFECTIVE AS OF 06/02/2021 Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long- term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

For the PPO Plan only: You may fill maintenance medications at a participating 30-day retail pharmacy three times. After the third fill, you must use the CVS Caremark Mail Service Pharmacy™ or a participating 90-Day Maintenance at Retail pharmacy for the maintenance medications to be covered by the PPO Plan. You will be responsible for the entire cost of maintenance medications after the third fill at a 30-day retail pharmacy.

Please note: This list (1) does not include all maintenance medications, (2) is subject to change,(3) may include medications not covered by your health plan, (4) may include medications that are subject to additional coverage rules as determined by your health plan, and (5) includes the generic name where a generic is available. If no generic is available, then the brand name appears. This list represents brand-name products in CAPS and generic products in lowercase italics. All drugs are subject to the appropriate member cost share (i.e., copayment or coinsurance*).

If you have questions about the State of Florida Employees’ Prescription Drug Plan, please sign in to your account at Caremark.com or call Customer Care 24/7 at 1-888-766-5490. Allergies dipyridamole Depression desloratidine pentoxifylline bupropion levocetirizine prasugrel citalopram ticlopidine desvenlafaxine Alzheimer’s Disease ZONTIVITY duloxetine donepezil escitalopram galantamine Cancer fluoxetine memantine anastrozole fluvoxamine rivastigmine exemestane mirtazapine NAMZARIC letrozole nefazodone tamoxifen paroxetine Antipsychotics toremifene sertraline trazodone Aripiprazole venlafaxine brexipiprazole Contraceptives APLENZIN loxapine ethinyl estradiol-desogestrel FETZIMA olanzapine ethinyl estradiol-drospirenone TRINTELLIX paliperidone ethinyl estradiol-ethynodiol VIIBRYD quetiapine IR/ER ethinyl estradiol- etonogestrel risperidone ethinyl estradiol-levonorgestrel thiothixene ethinyl estradiol-norelgestromin Diabetes ethinyl estradiol-norethindrone acarbose -Combinations ethinyl estradiol-norgestimate chlorpropamide Olanzapine/fluoxetine ethinyl estradiol-norgestrel glimepiride ethinyl estradiol-drospirenone- glipizide levomefo glyburide Attention LO LOESTRIN metformin Deficit/Hyperactivity NATAZIA miglitol Disorder (ADHD) NEXTSTELLIS nateglinide atomoxetine pioglitazone clonidine er Hormone Replacement repaglinidine guanfacine er estradiol tolazamide QELBREE estradiol gel tolbutamide estradiol transdermal CYCLOSET Blood Modifiers ESTRING SYMLIN Anagrelide EVAMIST aspirin-dipyridamole IMVEXXY -Combinations cilostazol MENEST alogliptin/pioglitazone clopidogrel PREMARIN glipizide/metformin

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. ©2021 CVS Caremark. All rights reserved. 106-32234A 060321 1 of 3 glyburide/metformin COMBIGAN isradipine pioglitazone/glimepiride nicardipine pioglitazone/metformin Gout nifedipine nisoldipine allopurinol verapamil -Test Strips/Lancets/Meters probenecid/colchicine glucose meter glucose test strip Heart Disease & High Blood -Combinations insulin pump amlodipine/atorvastatin insulin syringes and needles Pressure amlodipine/hctz ALBUSTIX -Angiotensin-Converting-Enzyme amlodipine/olmesartan CHEMSTRIPS (ACE) Inhibitors amlodipine/valsartan NOVA MAX PLUS KETONE benazepril amlodipine/olmesartan/hctz captopril amlodipine/valsartan/hctz Digestive Enzymes enalapril atenolol/chlorthalidone CREON fosinopril benazepril/hctz PANCREAZE lisinopril bisoprolol/hctz ZENPEP moexipril candesartan/hctz perindopril clonidine/chlorthalidone Diuretics quinapril captopril/hctz ramipril enalapril/hctz acetazolamide trandolapril fosinopril/hctz amiloride irbesartan/hctz chlorthalidone lisinopril/hctz dyrenium -Angiotensin II Receptor losartan/hctz hydrochlorothiazide (hctz) Antagonists methyldopa/hctz methazolamide candesartan metoprolol/hctz spironolactone eprosartan irbesartan moexipril/hctz losartan nadolol/bendroflumethiazide -Combinations telmisartan olmesartan/hctz hctz/spironolactone valsartan propranolol/hctz hctz/triamterene EDARBI quinapril/hctz telmisartan/amlodipine Enlarged Prostate -Antiarrhythmics telmisartan/hctz Alfuzosin amiodarone trandolapril/verapamil doxazosin disopyramide valsartan/hctz dutasteride flecainide EDARBYCLOR dutasteride/tamsulosin mexiletine PRESTALIA finasteride propafenone TEKTURNA HCT silodosin quinidine gluconate tamsulosin quinidine sulfate -Miscellaneous Cardiovascular terazosin MULTAQ aliskiren CARDURA XL clonidine -Beta Blockers guanfacine Glaucoma acebutolol hydralazine betaxolol atenolol isoxsuprine bimatoprost betaxolol methyldopa brimonidine bisoprolol minoxidil brinzolamide carvedilol prazosin carbachol labetalol ranolazine carteolol levatol reserpine dorzolamide metoprolol BIDIL latanoprost nadolol levobunolol pindolol High Cholesterol methazolamide propranolol atorvastatin metipranolol sotalol cholestyramine phospholine timolol colesevelam timolol BYSTOLIC colestipo travoprost ezetimibe ZIOPTAN -Calcium Channel Blockers ezetimibe/simvastatin amlodipine fenofibrate micronized -Combinations diltiazem fluvastatin dorzolamide/timolol felodipine gemfibrozil This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. ©2021 CVS Caremark. All rights reserved. 106-32234A 060321 2 of 3 icosapent ethyl Parkinson’s Disease Rheumatoid Arthritis lovastatin benztropine leflunomide omega-3-acid ethyl ester (fda bromocriptine RIDAURA approved) carbidopa niacin cr carbidopa/levodopa Seizure Disorders pravastatin carbidopa/levodopa/entacapone carbamazepine rosuvastatin entacapone divalproex simvastatin pramipexole ethosuximide LIVALO ropinirole felbamate ROSZET tolcapone lamotrigine trihexyphenidyl levetiracetam Immune Disorders NEUPRO oxcarbazepine azathioprine ONGENTYS primidone RYTARY tiagabine XADAGO Inflammatory Bowel Disease topiramate sulfasalazine topiramate er DIPENTUM Respiratory Agents valproic acid aminophylline zonisamide Gastrointestinal Agents budesonide APTIOM budesonide/formoterol lubiprostone CELONTIN cromolyn PEGANONE dyphylline TROKENDI XR Kidney Disease fluticasone/salmeterol calcitriol formoterol Thyroid calcium acetate ipratropium levothyroxine lanthanum carbonate ipratropium/albuterol liothyronine sevelamer hcl metaproterenol thyroid sevelamer carbonate montelukast AURYXIA terbutaline VELPHORO theophylline Ulcer/Gastroesophageal zafirlukast Reflux Disease (GERD) Miscellaneous ADVAIR HFA cimetidine cevimeline ALVESCO esomeprazole magnesium ergoloid mesylate ANORO ELLIPTA famotidine tab pilocarpine ARCAPTA lansoprazole ursodiol ARNUITY ELLIPTA nizatidine CUVPOSA ASMANEX omeprazole NASCOBAL BEVESPI omeprazole/sodium bicarbonate BREO ELLIPTA pantoprazole Osteoporosis BREZTRI AEROSPHERE rabeprazole alendronate BROVANA ranitidine calcitonin DULERA sucralfate ibandronate FLOVENT DEXILANT raloxifene INCRUSE ELLIPTA ESOMEPRAZOLE STRONTIUM risedronate QVAR REDIHALER BINOSTO SEEBRI NEOHALER FOSAMAX D SEREVENT SPIRIVA Overactive Bladder STIOLTO RESPIMAT STRIVERDI darifenacin TRELEGY ELLIPTA flavoxate TUDORZA oxybutynin ZYFLO solifenacin tolterodine trospium TOVIAZ

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. ©2021 CVS Caremark. All rights reserved. 106-18393A 060321 3 of 3