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Drug Formulary List

Drug Formulary List

2021 Express Scripts National Preferred Formulary List For BJC HealthCare

The 2021 National Preferred Formulary drug list for BJC HealthCare is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY For the member: FDA-approved generic medications meet strict standards and [INJ] – Injectable Drug contain the same active ingredients as their corresponding brand-name medications, [OTC] – Over-the-counter Product although they may have a different appearance. [SP] – Specialty Drug For the physician: Please prescribe preferred products and allow generic Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA substitutions when medically appropriate. Generic drugs are listed in lower-case letters. Example: ibuprofen

A ADDAMEL N [INJ] alprazolam orally disintegrating tablets ampicillin sodium [INJ] adefovir ALPROLIX [INJ] [SP] ampicillin sodium/sulbactam [INJ] abacavir [SP] ADEMPAS [SP] alprostadil [INJ] AMYTAL [INJ] abacavir/lamivudine [SP] adenosine [INJ] altavera AMZEEQ abacavir/lamivudine/zidovudine [SP] ADVAIR HFA ALUNBRIG [SP] anagrelide ABELCET [INJ] ADVATE [INJ] [SP] alyacen anastrozole ABILIFY MAINTENA [INJ] ADYNOVATE [INJ] [SP] amabelz ANDRODERM abiraterone [SP] AFINITOR 10 MG TABLETS [SP] ANORO ELLIPTA ABRAXANE [INJ] [SP] AFINITOR DISPERZ [SP] AMBISOME [INJ] APLISOL [INJ] acamprosate delayed-release afirmelle ambrisentan [SP] APOKYN [INJ] [SP] acarbose AFLURIA QUAD [INJ] eye solution ACCU-CHEK FASTCLIX LANCETS [OTC] AFSTYLA [INJ] [SP] amethia aprepitant ACCU-CHEK MULTICLIX LANCET KIT [OTC] AIMOVIG [INJ] amethia lo apri ACCU-CHEK MULTICLIX LANCETS [OTC] AJOVY [INJ] amethyst APTIVUS [SP] ACCU-CHEK SOFTCLIX LANCET KIT [OTC] albendazole amifostine [INJ] AQUASOL A [INJ] ACCU-CHEK SOFTCLIX LANCETS [OTC] albumin human [INJ] amikacin [INJ] ARALAST NP [INJ] [SP] albuterol amiloride aranelle acetaminophen/codeine albuterol ext-release amiloride/ ARIKAYCE [SP] albuterol nebulization solution aminocaproic acid acetazolamide ext-release albuterol sulfate hfa (by Cipla, Lupin, aminocaproic acid [INJ] aripiprazole orally disintegrating tablets acetazolamide sodium [INJ] Par, Perrigo, Proficient Rx & Teva) aminophylline [INJ] ARISTADA [INJ] acetic acid ear solution AMINOSYN [INJ] ARISTOSPAN [INJ] acetic acid irrigation solution ALDURAZYME [INJ] [SP] amiodarone armodafinil acetic acid/ ear solution ALECENSA [SP] amiodarone [INJ] ARMOUR THYROID acetic acid/oxyquinoline vaginal alendronate ARNUITY ELLIPTA [INJ] alfentanil [INJ] amitriptyline/chlordiazepoxide ARRANON [INJ] [SP] acetylcysteine inhalation solution ALFERON N [INJ] amlodipine arsenic trioxide [INJ] acitretin ext-release amlodipine/atorvastatin ascorbic acid [INJ] ACTEMRA [INJ] [SP] ALIMTA [INJ] amlodipine/benazepril ashlyna ACTHIB [INJ] ALINIA amlodipine/olmesartan ASMANEX HFA ACTHREL [INJ] ALIQOPA [INJ] [SP] amlodipine/valsartan ASMANEX TWISTHALER ACTIMMUNE [INJ] [SP] aliskiren amlodipine/valsartan/hydrochlorothiazide aspirin/dipyridamole ext-release ACTIVASE [INJ] allopurinol ammonium lactate 12% topical atazanavir [SP] acyclovir allopurinol sodium [INJ] acyclovir ointment amoxicillin atenolol/chlorthalidone acyclovir sodium [INJ] amoxicillin/potassium clavulanate ATGAM [INJ] ADACEL [INJ] ALPHAGAN P 0.1% amoxicillin/potassium clavulanate ADAKVEO [INJ] [SP] ALPHANATE [INJ] [SP] ext-release atorvastatin adapalene ALPHANINE SD [INJ] [SP] sulfate atovaquone adapalene/benzoyl peroxide alprazolam amphotericin [INJ] atovaquone/proguanil ADCETRIS [INJ] [SP] alprazolam ext-release ampicillin [INJ] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 1 COMPBJCANP-21 (04/01/21) atropine sulfate eye ointment valerate CABLIVI [INJ] [SP] CEPROTIN [INJ] [SP] atropine sulfate eye solution BETASERON [INJ] [SP] CABOMETYX [SP] CERDELGA [SP] AUBAGIO [SP] caffeine citrated CEREZYME [INJ] [SP] aubra betaxolol eye solution caffeine citrated [INJ] cetirizine syrup aubra eq bethanechol caffeine/sodium benzoate [INJ] CETROTIDE [INJ] [SP] AUGMENTIN 125-31.25 MG/5 ML BEVESPI AEROSPHERE calcipotriene cevimeline aurovela bexarotene [SP] calcipotriene/betamethasone dipropionate CHANTIX aurovela 24 fe BEXSERO [INJ] calcitonin salmon nasal charlotte 24 fe aurovela fe calcitriol chateal AUSTEDO [SP] BICILLIN C-R [INJ] calcitriol [INJ] chateal eq aviane BICILLIN L-A [INJ] calcitriol ointment CHEMET AVONEX [INJ] [SP] BIKTARVY [SP] acetate CHENODAL [SP] AVYCAZ [INJ] eye solution calcium chloride [INJ] chloramphenicol [INJ] ayuna biolon [INJ] CALCIUM DISODIUM VERSENATE [INJ] chlordiazepoxide azacitidine [INJ] [SP] BIOTHRAX [INJ] calcium gluconate [INJ] chlordiazepoxide/clidinium AZASITE CALDOLOR VIALS [INJ] chlorhexidine gluconate azathioprine [SP] bisoprolol/hydrochlorothiazide camila chloroprocaine hcl [INJ] azathioprine sodium [INJ] [SP] bivalirudin [INJ] camrese chloroquine AZEDRA [INJ] [SP] blanche camrese lo chlorothiazide bleomycin [INJ] candesartan chlorothiazide sodium [INJ] azelastine eye solution BLINCYTO [INJ] [SP] candesartan/hydrochlorothiazide azelastine nasal spray blisovi 24 fe CAPASTAT SULFATE [INJ] chlorpromazine [INJ] azelastine/ blisovi fe capecitabine [SP] chlorthalidone azithromycin BOOSTRIX [INJ] CAPRELSA [SP] chlorzoxazone azithromycin [INJ] bosentan [SP] captopril CHOLBAM [SP] AZOPT BOSULIF [SP] captopril/hydrochlorothiazide cholestyramine aztreonam [INJ] BOTOX [INJ] [SP] [INJ] cholestyramine light azurette BREO ELLIPTA CARBAGLU [SP] choline salicylate/ salicylate bretylium tosylate [INJ] carbamazepine chromium chloride [INJ] B BREVITAL [INJ] carbamazepine ext-release ciclopirox BREZTRI AEROSPHERE carbidopa ciclopirox shampoo bacitracin [INJ] briellyn carbidopa/levodopa cidofovir [INJ] bacitracin eye ointment BRILINTA carbidopa/levodopa ext-release cilostazol bacitracin/polymyxin eye ointment eye solution carbidopa/levodopa orally CIMDUO [SP] baclofen BRINEURA [INJ] [SP] disintegrating tablets baclofen [INJ] bromfenac eye solution carbidopa/levodopa/entacapone cinacalcet BAFIERTAM [SP] carbinoxamine CINRYZE [INJ] [SP] BAL IN OIL [INJ] brompheniramine// carboplatin [INJ] CINVANTI [INJ] balanced salt eye irrigation solution codeine carmustine [INJ] ciprofloxacin bal-care dha prenatal vitamins brompheniramine/pseudoephedrine/ eye solution ciprofloxacin ear solution balsalazide ciprofloxacin eye solution BALVERSA [SP] ext-release carvedilol phosphate ext-release ciprofloxacin lactate/dextrose [INJ] balziva budesonide nebulization suspension caspofungin [INJ] ciprofloxacin/ BANZEL CATHFLO ACTIVASE [INJ] ear suspension BAQSIMI bumetanide [INJ] CAVERJECT [INJ] cisplatin [INJ] BARACLUDE SOLUTION bupivacaine [INJ] CAYSTON [SP] citalopram BAVENCIO [INJ] [SP] bupivacaine/dextrose [INJ] caziant cladribine [INJ] BAXDELA bupivacaine/epinephrine [INJ] cefaclor clarithromycin BAXDELA [INJ] buprenorphine cefaclor ext-release clarithromycin ext-release b-complex [INJ] buprenorphine [INJ] cefadroxil clemastine BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine patches cefazolin [INJ] clindamycin hcl BD NANO 2ND GEN PEN NEEDLES buprenorphine/naloxone cefdinir clindamycin palmitate BD ULTRAFINE INSULIN SYRINGES [OTC] cefditoren clindamycin phosphate [INJ] BD ULTRAFINE PEN NEEDLES [OTC] bupropion ext-release cefepime [INJ] clindamycin phosphate topical bekyree bupropion ext-release (smoking deterrent) cefepime/dextrose [INJ] clindamycin phosphate vaginal BELBUCA cefixime clindamycin phosphate/benzoyl peroxide benazepril busulfan [INJ] cefotaxime [INJ] clindamycin phosphate/dextrose [INJ] benazepril/hydrochlorothiazide butalbital/acetaminophen cefotetan [INJ] clindamycin phosphate/tretinoin BENDEKA [INJ] [SP] butalbital/acetaminophen/caffeine cefoxitin [INJ] CLINIMIX [INJ] BENEFIX [INJ] [SP] butalbital/acetaminophen/caffeine/ cefoxitin/dextrose [INJ] CLINIMIX E [INJ] BENLYSTA [INJ] [SP] codeine cefpodoxime clobazam BENZNIDAZOLE butalbital/aspirin/caffeine cefprozil propionate benzonatate butalbital/aspirin/caffeine/codeine ceftazidime [INJ] shampoo benzoyl peroxide butorphanol [INJ] CEFTAZIDIME/DEXTROSE [INJ] clobetasol propionate/emollient benztropine butorphanol nasal ceftriaxone [INJ] clofarabine [INJ] benztropine [INJ] BYDUREON [INJ] ceftriaxone/dextrose [INJ] clomiphene citrate BESPONSA [INJ] [SP] BYETTA [INJ] cefuroxime axetil /betamethasone cefuroxime sodium [INJ] clonazepam sodium phosphate [INJ] C celecoxib clonazepam orally disintegrating tablets betamethasone dipropionate CELONTIN betamethasone dipropionate augmented cephalexin clonidine [INJ] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 2 COMPBJCANP-21 (04/01/21) clonidine ext-release dantrolene /emtricitabine/ clonidine patches dantrolene [INJ] diflorasone/emollient tenofovir disoproxil fumarate [SP] clopidogrel dapsone diflunisal efavirenz/lamivudine/ clorazepate dapsone topical digoxin tenofovir disoproxil fumarate [SP] clotrimazole topical DAPTACEL [INJ] digoxin [INJ] EGRIFTA [INJ] [SP] clotrimazole troche daptomycin [INJ] dihydrocodeine/acetaminophen/caffeine EGRIFTA SV [INJ] [SP] clotrimazole/betamethasone dipropionate darifenacin ext-release [INJ] ELAPRASE [INJ] [SP] DARZALEX [INJ] [SP] dihydroergotamine nasal electrolyte-48 solution/dextrose [INJ] clozapine orally disintegrating tablets dasetta DILANTIN 30 MG CAPSULES c-nate dha prenatal vitamins daunorubicin [INJ] DILATRATE-SR ELIGARD [INJ] [SP] COAGADEX [INJ] [SP] daysee diltiazem elinest COARTEM DAYTRANA diltiazem [INJ] ELIQUIS codeine sulfate DDAVP RHINAL SOLUTION diltiazem ext-release ELITEK [INJ] colchicine tablets deblitane dimenhydrinate [INJ] elite-ob prenatal vitamins colchicine/probenecid decitabine [INJ] [SP] dimethyl fumarate [SP] ELMIRON colesevelam hcl deferasirox [SP] ELOCTATE [INJ] [SP] colestipol deferiprone [SP] diphenhydramine [INJ] eluryng vaginal ring colistimethate [INJ] deferoxamine [INJ] diphenoxylate/atropine ELZONRIS [INJ] [SP] COMBIGAN delflex with dextrose [INJ] DIPHTHERIA-TETANUS TOXOIDS-PED [INJ] EMCYT COMBIPATCH demeclocycline dipyridamole EMGALITY [INJ] COMBIVENT RESPIMAT DEPO- [INJ] dipyridamole [INJ] emoquette COMETRIQ [SP] DEPO-PROVERA 400 MG/ML [INJ] disulfiram emtricitabine [SP] complete natal dha prenatal vitamins DESCOVY [SP] divalproex delayed-release emtricitabine/ constulose divalproex ext-release tenofovir disoproxil fumarate [SP] copper chloride [INJ] desloratadine DIVIGEL EMTRIVA SOLUTION [SP] CORIFACT [INJ] [SP] desloratadine orally disintegrating tablets [INJ] EMVERM CORLANOR desmopressin acetate dobutamine/dextrose [INJ] enalapril acetate desmopressin acetate [INJ] [SP] DOCEFREZ [INJ] enalapril/hydrochlorothiazide cosyntropin [INJ] desmopressin nasal [INJ] enalaprilat [INJ] COTELLIC [SP] -ethinyl estradiol DOCETAXEL 200 MG/10 ML [INJ] ENBREL [INJ] [SP] CREON dofetilide ENDOMETRIN [SP] CRESEMBA donepezil ENGERIX-B [INJ] CRESEMBA [INJ] desvenlafaxine succinate ext-release donepezil orally disintegrating tablets enoxaparin [INJ] [SP] CRIXIVAN [SP] dexamethasone [INJ] enpresse CROFAB [INJ] dexamethasone sodium phosphate [INJ] dopamine/dextrose [INJ] enskyce cromolyn sodium eye solution dexamethasone sodium phosphate DOPTELET [SP] ENSPRYNG [INJ] [SP] cromolyn sodium nebulization solution eye solution eye solution ENSTILAR cromolyn sodium oral solution dexchlorpheniramine dorzolamide/ eye solution entacapone crotamiton DEXCOM RECEIVER, SENSOR, DOVATO [SP] entecavir cryselle TRANSMITTER ENTRESTO CRYSVITA [INJ] [SP] [INJ] ENTYVIO [INJ] [SP] cyanocobalamin [INJ] dexmedetomidine/nacl [INJ] doxepin cream EOVIST [INJ] cyclafem dexmethylphenidate doxercalciferol EPCLUSA [SP] dexmethylphenidate ext-release doxercalciferol [INJ] [INJ] cyclobenzaprine ext-release dexrazoxane [INJ] doxorubicin [INJ] EPIDIOLEX [SP] cyclopentolate eye solution dextran/dextrose [INJ] doxorubicin/liposomal [INJ] epinastine eye solution cyclopentolate/tropicamide/ dextran/normal saline [INJ] doxycycline hyclate epinephrine auto-injector eye solution dextroamphetamine doxycycline hyclate [INJ] (by Mylan, Teva) [INJ] cyclophosphamide [INJ] dextroamphetamine ext-release doxycycline hyclate delayed-release epinephrine vials, ampules, syringes [INJ] cyclophosphamide capsules dextroamphetamine/amphetamine doxycycline monohydrate epinephrine-dextrose [INJ] cyclosporine [INJ] [SP] dextroamphetamine/amphetamine doxylamine succinate/vit b6 epinephrine-nacl [INJ] cyclosporine [SP] ext-release D-PENAMINE EPIPEN, EPIPEN JR [INJ] cyclosporine modified [SP] dextrose/lactated ringers [INJ] dronabinol epirubicin [INJ] dextrose/sodium chloride [INJ] [INJ] EPIVIR HBV SOLUTION CYRAMZA [INJ] [SP] dextrose/water [INJ] -ethinyl estradiol eplerenone cyred DIACOMIT [SP] drospirenone-ethinyl epoprostenol [INJ] [SP] cyred eq diazepam estradiol-levomefolate epoprostenol diluent [INJ] [SP] CYSTADANE [SP] diazepam [INJ] DROXIA eprosartan CYSTAGON [SP] diazepam rectal gel DUAVEE eptifibatide [INJ] CYSTARAN [SP] DULERA ERAXIS [INJ] cytarabine [INJ] diclofenac eye solution duloxetine delayed-release ERBITUX [INJ] [SP] CYTOGAM [INJ] [SP] diclofenac potassium DUPIXENT [INJ] [SP] ergocalciferol diclofenac sodium delayed-release mesylates D diclofenac sodium ext-release dutasteride/ ext-release tartrate/caffeine diclofenac sodium gel DYANAVEL XR ergotamine tartrate/caffeine dacarbazine [INJ] diclofenac sodium topical solution suppositories dactinomycin [INJ] diclofenac sodium/misoprostol ext-release E ERIVEDGE [SP] dalfampridine ext-release [SP] dicloxacillin ERLEADA [SP] DALIRESP dicyclomine econazole erlotinib [SP] DALVANCE [INJ] dicyclomine [INJ] EDURANT [SP] errin didanosine delayed-release [SP] efavirenz [SP] ertapenem [INJ] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 3 COMPBJCANP-21 (04/01/21) ERYTHROCIN [INJ] fentanyl citrate [INJ] fosphenytoin [INJ] irrigation solution erythromycin fentanyl citrate lozenges FRAGMIN [INJ] [SP] GLYCOPHOS [INJ] erythromycin delayed-release fentanyl citrate/nacl [INJ] FREAMINE HBC [INJ] glycopyrrolate erythromycin ethylsuccinate fentanyl patches freamine iii [INJ] glycopyrrolate [INJ] erythromycin eye ointment FERAHEME [INJ] FREESTYLE FREEDOM KIT [OTC] glycopyrrolate-water [INJ] erythromycin stearate FERRIPROX 1,000 MG TABLETS, FREESTYLE FREEDOM LITE METER [OTC] GLYXAMBI erythromycin topical SOLUTION [SP] FREESTYLE INSULINX GLUCOSE GONAL-F, GONAL-F RFF, erythromycin/benzoyl peroxide FETZIMA SYSTEM [OTC] GONAL-F RFF REDI-JECT [INJ] [SP] ESBRIET [SP] FINACEA FOAM FREESTYLE INSULINX TEST STRIPS [OTC] escitalopram FREESTYLE LIBRE & LIBRE 2 READER, granisetron [INJ] esmolol [INJ] FIRMAGON [INJ] [SP] SENSOR GRASTEK esmolol-nacl [INJ] flavoxate FREESTYLE LITE METER [OTC] griseofulvin microsize esomeprazole magnesium delayed-release flecainide FREESTYLE LITE TEST STRIPS [OTC] griseofulvin ultramicrosize esomeprazole sodium [INJ] FLECTOR FREESTYLE TEST STRIPS [OTC] guaifenesin/codeine ESPEROCT [INJ] [SP] FLOLAN [INJ] [SP] guaifenesin/phenylephrine estarylla FLOVENT DISKUS FULPHILA [INJ] [SP] estazolam FLOVENT HFA [INJ] guanfacine ext-release esterified / floxuridine [INJ] guanidine estradiol FLUAD [INJ] furosemide [INJ] GVOKE [INJ] estradiol cream FLUAD QUAD [INJ] FUZEON [INJ] [SP] estradiol patches FLUARIX QUAD [INJ] fyavolv H estradiol vaginal FLUBLOK QUAD [INJ] FYCOMPA [INJ] FLUCELVAX QUAD [INJ] hailey estradiol/norethindrone acetate fluconazole G hailey 24 fe ESTRING fluconazole/normal saline [INJ] hailey fe eszopiclone flucytosine gabapentin HALAVEN [INJ] [SP] ethacrynate [INJ] fludarabine [INJ] GABLOFEN SYRINGES [INJ] ethacrynic acid acetate galantamine halobetasol ethambutol FLULAVAL QUAD [INJ] galantamine ext-release ETHAMOLIN [INJ] flumazenil [INJ] GAMASTAN [INJ] [SP] [INJ] ethosuximide nasal spray GAMASTAN S-D [INJ] [SP] haloperidol lactate ethyl [INJ] GAMIFANT [INJ] [SP] haloperidol lactate [INJ] ethynodiol-ethinyl estradiol oil ear solution GAMMACORE HARVONI [SP] etidronate GAMMAGARD LIQUID [INJ] [SP] HAVRIX [INJ] etodolac fluocinonide/emollient GAMMAGARD S-D [INJ] [SP] heather etodolac ext-release fluorescein [INJ] GAMUNEX-C [INJ] [SP] HEMABATE [INJ] etomidate [INJ] fluorescein eye strips ganciclovir [INJ] HEMLIBRA [INJ] [SP] -ee vaginal ring eye suspension ganirelix acetate [INJ] [SP] HEMOFIL-M [INJ] [SP] ETOPOPHOS [INJ] fluorouracil GARDASIL 9 [INJ] HEPAGAM B [INJ] etoposide fluorouracil [INJ] gatifloxacin eye solution heparin lock flush [INJ] etoposide [INJ] gavilyte-c heparin sodium [INJ] EUFLEXXA [INJ] [SP] fluoxetine delayed-release gavilyte-g heparin sodium/dextrose [INJ] everolimus [SP] decanoate [INJ] gavilyte-n heparin sodium/nacl [INJ] fluphenazine hcl GAZYVA [INJ] [SP] HEPATAMINE [INJ] EXTRANEAL ICODEXTRIN DIALYSIS fluphenazine hcl [INJ] GELNIQUE hetastarch/normal saline [INJ] SOLUTION [INJ] flurandrenolide gemcitabine [INJ] HEXTEND LACTATED ELECTROLYTE [INJ] EYLEA [INJ] [SP] flurazepam gemfibrozil HIBERIX [INJ] ezetimibe flurbiprofen GENOTROPIN [INJ] [SP] homatropine eye solution ezetimibe/simvastatin flurbiprofen sodium eye solution gentamicin [INJ] HUMALOG [INJ] gentamicin eye ointment HUMATE-P [INJ] [SP] F fluticasone nasal spray gentamicin eye solution HUMIRA [INJ] [SP] fluticasone topical gentamicin topical HUMULIN [INJ] FABRAZYME [INJ] [SP] fluticasone/ powder inhaler gentamicin/normal saline [INJ] HUMULIN R 500 UNITS [INJ] falmina fluvastatin GENTAMICIN/NORMAL SALINE HYCAMTIN CAPSULES [SP] famciclovir fluvastatin ext-release 100 MG/50 ML [INJ] hydralazine famotidine fluvoxamine GENVOYA [SP] hydralazine [INJ] famotidine [INJ] fluvoxamine ext-release gianvi hydrochlorothiazide famotidine/nacl [INJ] FLUZONE HIGH-DOSE [INJ] GILENYA [SP] hydrocodone ext-release FARXIGA FLUZONE HIGH-DOSE QUAD [INJ] GLASSIA [INJ] [SP] hydrocodone/acetaminophen FASENRA [INJ] [SP] FLUZONE QUAD [INJ] glatiramer [INJ] [SP] hydrocodone/chlorpheniramine polistirex fayosim folic acid glatopa [INJ] [SP] ext-release febuxostat folic acid [INJ] GLEOSTINE hydrocodone/homatropine FEIBA NF [INJ] [SP] folivane-ob prenatal vitamins glimepiride hydrocodone/ibuprofen FOLOTYN [INJ] [SP] glipizide hydrocortisone felodipine ext-release fomepizole [INJ] glipizide ext-release suppositories femynor fondaparinux [INJ] [SP] glipizide/metformin fenofibrate FORTEO [INJ] [SP] GLUCAGEN [INJ] hydrocortisone butyrate/emollient fenofibrate micronized fosamprenavir [SP] GLUCAGON [INJ] hydrocortisone enema fenofibric acid fosaprepitant [INJ] glyburide hydrocortisone sodium succinate [INJ] fenofibric acid delayed-release fosinopril glyburide micronized hydrocortisone topical fenoprofen fosinopril/hydrochlorothiazide glyburide/metformin (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 4 COMPBJCANP-21 (04/01/21) hydrocortisone/lidocaine INVOKAMET -nacl [INJ] levoleucovorin [INJ] hydrocortisone/pramoxine INVOKAMET XR levonest hydromorphone INVOKANA ketoconazole shampoo -ethinyl estradiol hydromorphone [INJ] iodine/potassium iodide ketoconazole topical levora hydromorphone ext-release iodine/sodium iodide ketoconazole/skin cleanser kit levothyroxine sodium hydromorphone suppositories IODOPEN [INJ] ketoprofen levothyroxine sodium [INJ] hydromorphone/nacl [INJ] IONOSOL/DEXTROSE [INJ] ketoprofen ext-release LEVSIN [INJ] hydroquinone IPOL [INJ] ketorolac LEXISCAN [INJ] hydroquinone microspheres ipratropium bromide nasal spray ketorolac [INJ] LEXIVA SUSPENSION [SP] hydroxocobalamin [INJ] ipratropium bromide nebulization solution ketorolac eye solution LIBTAYO [INJ] [SP] hydroxychloroquine ipratropium/albuterol sulfate nebulization KEYTRUDA [INJ] [SP] LICART hydroxyprogesterone [INJ] solution KINEVAC [INJ] lidocaine [INJ] hydroxyprogesterone [INJ] [SP] irbesartan KITABIS PAK [SP] lidocaine jelly hydroxyurea irbesartan/hydrochlorothiazide KOGENATE FS [INJ] [SP] lidocaine patches hcl IRESSA [SP] KOVALTRY [INJ] [SP] lidocaine topical hydroxyzine hcl [INJ] irinotecan [INJ] K-PHOS ORIGINAL lidocaine viscous hydroxyzine pamoate ISENTRESS [SP] KRYSTEXXA [INJ] [SP] lidocaine/dextrose [INJ] hyophen isibloom kurvelo lidocaine/epinephrine [INJ] hyoscyamine ISOLYTE [INJ] KYLEENA [SP] lidocaine/hydrocortisone hyoscyamine ext-release isoniazid KYMRIAH [INJ] [SP] lidocaine/prilocaine hyoscyamine orally disintegrating tablets isoniazid [INJ] KYNMOBI lillow HYPERHEP B S-D [INJ] isoproterenol [INJ] KYPROLIS [INJ] [SP] lincomycin [INJ] HYPERRAB [INJ] isosorbide dinitrate lindane shampoo HYPERRAB S-D [INJ] isosorbide dinitrate ext-release L linezolid HYPERRHO S-D [INJ] isosorbide mononitrate linezolid [INJ] HYPERTET S-D [INJ] isosorbide mononitrate ext-release linezolid/nacl [INJ] HYSINGLA ER isotretinoin labetalol [INJ] LINZESS lactulose LIORESAL [INJ] I isradipine lamivudine [SP] liothyronine ISTODAX [INJ] [SP] lamivudine hbv liothyronine [INJ] ibandronate itraconazole lamivudine/zidovudine [SP] LIPOFEN ibandronate [INJ] [SP] ivermectin lamotrigine lisinopril IBRANCE [SP] IXEMPRA [INJ] [SP] lamotrigine ext-release lisinopril/hydrochlorothiazide ibuprofen IXIARO [INJ] lamotrigine orally disintegrating tablets lithium carbonate ibuprofen [INJ] IXINITY [INJ] [SP] LANOXIN PEDIATRIC AMPULES [INJ] lithium carbonate ext-release ibutilide [INJ] lansoprazole delayed-release lithium citrate icatibant [INJ] [SP] J lansoprazole delayed-release LIVALO ICLUSIG [SP] +amoxicillin+clarithromycin lojaimiess idarubicin [INJ] jaimiess lansoprazole orally disintegrating tablets LOKELMA IDHIFA [SP] JAKAFI [SP] lanthanum LONSURF [SP] ifosfamide [INJ] JANUMET LANTUS [INJ] ILARIS [INJ] [SP] JANUMET XR lapatinib [SP] lopinavir/ritonavir [SP] imatinib [SP] JANUVIA larin lopreeza IMBRUVICA [SP] JARDIANCE larin fe lorazepam IMFINZI [INJ] [SP] jasmiel larissia lorazepam [INJ] imipenem/cilastatin [INJ] jencycla eye solution LORBRENA [SP] hcl JETREA [INJ] [SP] LATUDA loryna imipramine pamoate JEVTANA [INJ] [SP] layolis fe losartan imiquimod jinteli leena losartan/hydrochlorothiazide IMOGAM RABIES-HT [INJ] JIVI [INJ] [SP] leflunomide LOTEMAX GEL, OINTMENT IMOVAX RABIES VACCINE [INJ] jolessa LENVIMA [SP] LOTEMAX SM IMPAVIDO juleber lessina eye suspension INBRIJA [SP] JULUCA [SP] letrozole lovastatin incassia junel leucovorin low-ogestrel INCRELEX [INJ] [SP] junel fe leucovorin [INJ] INCRUSE ELLIPTA JUXTAPID [SP] LEUKERAN lo-zumandimine indapamide LEUKINE [INJ] [SP] LUMIZYME [INJ] [SP] indomethacin K leuprolide [INJ] [SP] LUPANETA PACK [INJ] [SP] indomethacin ext-release levalbuterol nebulization solution LUPRON DEPOT 3.75 MG, 11.25 MG indomethacin sodium [INJ] KADCYLA [INJ] [SP] LEVEMIR [INJ] [INJ] [SP] INFANRIX [INJ] kaitlib fe levetiracetam LUPRON DEPOT-PED [INJ] [SP] infed [INJ] KALETRA TABLETS [SP] levetiracetam [INJ] LUTATHERA [INJ] [SP] INFUMORPH [INJ] kalliga levetiracetam ext-release lutera INFUVITE [INJ] KALYDECO [SP] levetiracetam-nacl [INJ] LUXTURNA [INJ] [SP] INLYTA [SP] KANJINTI [INJ] [SP] eye solution LYNPARZA [SP] INTELENCE [SP] KANUMA [INJ] [SP] levocarnitine LYSODREN intralipid 20% [INJ] kariva levocetirizine LYUMJEV [INJ] INTRON A [INJ] [SP] kelnor levofloxacin lyza introvale KEPIVANCE [INJ] [SP] levofloxacin [INJ] INVELTYS KESIMPTA [INJ] [SP] levofloxacin eye solution INVIRASE [SP] ketamine [INJ] levofloxacin/dextrose [INJ] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 5 COMPBJCANP-21 (04/01/21) M methylphenidate moxifloxacin /polymyxin/hydrocortisone methylphenidate ext-release MOXIFLOXACIN [INJ] eye suspension m.v.i. adult [INJ] moxifloxacin eye solution [INJ] M.V.I. PEDIATRIC [INJ] methylprednisolone acetate [INJ] moxifloxacin-nacl [INJ] NEPHRAMINE [INJ] M.V.I.-12 [INJ] methylprednisolone sodium MOZOBIL [INJ] [SP] NERLYNX [SP] mafenide succinate [INJ] MULTI-LANCET DEVICE [OTC] nevirapine [SP] magnesium chloride [INJ] methyltestosterone MULTITRACE-4 [INJ] nevirapine ext-release [SP] magnesium sulfate [INJ] eye solution MULTITRACE-5 [INJ] newgen prenatal vitamins MAGNESIUM/DEXTROSE mupirocin NEXAVAR [SP] 1 GM/100 ML [INJ] metoclopramide [INJ] MUSE NEXLETOL malathion metoclopramide orally MVASI [INJ] [SP] NEXLIZET manganese chloride [INJ] disintegrating tablets MYALEPT [INJ] [SP] NEXPLANON [INJ] [SP] manganese sulfate [INJ] metolazone mycophenolate mofetil [SP] NEXTERONE [INJ] mannitol [INJ] succinate ext-release mycophenolate mofetil hcl [INJ] [SP] metoprolol tartrate mycophenolic acid delayed-release [SP] niacin ext-release marlissa metoprolol tartrate [INJ] MYDAYIS nicardipine MARQIBO [INJ] [SP] metoprolol/hydrochlorothiazide MYLERAN nicardipine [INJ] MATULANE [SP] metronidazole MYLOTARG [INJ] [SP] nifedipine ext-release MAYZENT [SP] metronidazole topical mynatal advance prenatal vitamins nikki meclizine metronidazole vaginal mynatal plus prenatal vitamins meclofenamate metronidazole/nacl [INJ] mynatal prenatal vitamins nimodipine medroxyprogesterone metyrosine mynatal ultracaplet prenatal vitamins NINLARO [SP] medroxyprogesterone (contraceptive) [INJ] mexiletine mynatal-z prenatal vitamins nisoldipine ext-release mefenamic acid MIACALCIN [INJ] mynate 90 plus prenatal vitamins nitisinone [SP] mefloquine mibelas 24 fe MYOBLOC [INJ] [SP] nitrofurantoin megestrol micafungin [INJ] MYRBETRIQ nitrofurantoin macrocrystal MEKINIST [SP] vaginal nitrofurantoin monohydrate/macrocrystal melodetta 24 fe microgestin N nitroglycerin [INJ] meloxicam microgestin fe nitroglycerin ext-release melphalan midazolam nabumetone nitroglycerin ointment melphalan [INJ] midazolam [INJ] nitroglycerin patches midazolam/nacl [INJ] nadolol/bendroflumethiazide nitroglycerin spray memantine ext-release nafcillin [INJ] nitroglycerin/dextrose [INJ] MENACTRA [INJ] nafcillin/dextrose [INJ] nitroprusside sodium [INJ] MENOPUR [INJ] [SP] miglitol naftifine NITYR [SP] mepivacaine [INJ] miglustat [SP] NAGLAZYME [INJ] [SP] NIVESTYM [INJ] [SP] MEPSEVII [INJ] [SP] mili nalbuphine [INJ] nizatidine mercaptopurine milrinone [INJ] naloxone [INJ] nora-be meropenem [INJ] milrinone/dextrose [INJ] naltrexone NORDITROPIN [INJ] [SP] MEROPENEM/NACL [INJ] mimvey naproxen [INJ] mesalamine delayed-release MINIMED INFUSION SETS naproxen delayed-release norepinephrine/dextrose [INJ] mesalamine enema MINIMED RESERVOIR naproxen sodium norepinephrine/nacl [INJ] mesalamine ext-release MINOCIN [INJ] naproxen sodium ext-release norethindrone mesalamine kit naproxen/esomeprazole magnesium norethindrone acetate mesalamine suppositories minocycline ext-release ext-release norethindrone acetate-ethinyl estradiol mesna [INJ] minoxidil norethindrone acetate-ethinyl estradiol MESNEX TABLETS MIRENA [SP] NARCAN NASAL SPRAY + iron metaproterenol NASCOBAL -ethinyl estradiol metaxalone mirtazapine orally disintegrating tablets NATACYN norlyda metformin MIRVASO nateglinide NORMOSOL-M AND DEXTROSE [INJ] metformin ext-release misoprostol NATESTO NORMOSOL-R AND DEXTROSE [INJ] MITIGARE NATPARA [INJ] [SP] NORMOSOL-R PH 7.4 [INJ] methadone [INJ] mitomycin [INJ] NAYZILAM nortrel methamphetamine mitoxantrone [INJ] [SP] necon M-M-R II [INJ] neomycin NORVIR PACKETS [SP] methenamine hippurate m-natal prenatal vitamins neomycin/bacitracin/polymyxin NORVIR SOLUTION [SP] methenamine mandelate modafinil eye ointment NOVAREL [INJ] [SP] methenamine/sodium phosphate/ moexipril neomycin/bacitracin/polymyxin/ NOVOEIGHT [INJ] [SP] /hyoscyamine molindone hydrocortisone eye ointment NOVOFINE AUTOSHIELD NEEDLES [OTC] methimazole neomycin/polymyxin irrigation solution NOVOFINE NEEDLES [OTC] METHITEST mometasone nasal spray neomycin/polymyxin/dexamethasone NOVOSEVEN RT [INJ] [SP] methocarbamol mono-linyah eye ointment NOVOTWIST NEEDLES [OTC] methocarbamol [INJ] MONONINE [INJ] [SP] neomycin/polymyxin/dexamethasone NOXAFIL [INJ] methotrexate MONOVISC [INJ] [SP] eye suspension NOXAFIL SUSPENSION methotrexate [INJ] montelukast neomycin/polymyxin/gramicidin NPLATE [INJ] [SP] methoxsalen morphine sulfate eye solution NUBEQA [SP] morphine sulfate [INJ] neomycin/polymyxin/hydrocortisone NUCALA [INJ] [SP] methyldopa/hydrochlorothiazide morphine sulfate ext-release ear solution NUEDEXTA methyldopate [INJ] morphine sulfate suppositories neomycin/polymyxin/hydrocortisone NULOJIX [INJ] [SP] methylergonovine morphine sulfate/nacl [INJ] ear suspension nutrilyte [INJ] methylergonovine [INJ] MOVANTIK nystatin (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 6 COMPBJCANP-21 (04/01/21) nystatin topical oxacillin/dextrose [INJ] phendimetrazine ext-release potassium citrate ext-release nystatin/ oxaliplatin [INJ] phenelzine potassium citrate/citric acid NYVEPRIA [INJ] [SP] potassium iodide/iodine solution oxaprozin phenobarbital sodium [INJ] potassium phosphate [INJ] O oxcarbazepine phenobarbital/hyoscyamine/atropine/ POTELIGEO [INJ] [SP] OXERVATE [SP] scopolamine pr natal 400 ec prenatal vitamins OBIZUR [INJ] [SP] oxiconazole pr natal 400 prenatal vitamins obstetrix dha prenatal vitamins oxybutynin [INJ] pr natal 430 ec prenatal vitamins OCALIVA [SP] oxybutynin ext-release phenylbutyrate pr natal 430 prenatal vitamins ocella oxycodone phenylephrine [INJ] pramipexole OCREVUS [INJ] [SP] oxycodone/acetaminophen phenylephrine eye solution pramipexole ext-release octreotide [INJ] [SP] oxycodone/aspirin phenylephrine/chlorpheniramine prasugrel ODACTRA oxycodone/ibuprofen phenylephrine/dextrose [INJ] pravastatin ODEFSEY [SP] OXYCONTIN phenylephrine/nacl [INJ] praziquantel ODOMZO [SP] oxymorphone OFEV [SP] oxymorphone ext-release phenytoin sodium [INJ] PRECISION XTRA B-KETONE STRIPS [OTC] OFIRMEV [INJ] oxytocin [INJ] phenytoin sodium extended PRECISION XTRA MONITOR [OTC] ofloxacin OZEMPIC [INJ] philith PRECISION XTRA TEST STRIPS [OTC] ofloxacin ear solution OZURDEX [INJ] [SP] PHOSLYRA ofloxacin eye solution phosphasal ogestrel P PHOSPHOLINE IODIDE eye suspension PHOTOFRIN [INJ] prednisolone sodium phosphate olanzapine [INJ] paclitaxel [INJ] [INJ] prednisolone sodium phosphate olanzapine orally disintegrating tablets ext-release phytonadione disintegrating tablets olanzapine/fluoxetine [INJ] phytonadione [INJ] prednisolone sodium phosphate olmesartan PALYNZIQ [INJ] [SP] PHYTONADIONE 1 MG/0.5 ML eye solution olmesartan/amlodipine/ pamidronate [INJ] SYRINGES [INJ] hydrochlorothiazide PANCREAZE pregabalin olmesartan/hydrochlorothiazide pantoprazole [INJ] pilocarpine eye solution PREMARIN [INJ] olopatadine eye solution pantoprazole delayed-release pimecrolimus PREMARIN CREAM olopatadine nasal spray pantoprazole suspension premasol [INJ] omega-3 ethyl esters papaverine [INJ] pimtrea PREMASOL 6% [INJ] omeprazole delayed-release PARADIGM INFUSION SETS prena1 chew prenatal vitamins omeprazole/sodium bicarbonate PARADIGM RESERVOIRS pioglitazone prena1 pearl prenatal vitamins OMNIPAQUE [INJ] PARADIGM SILHOUETTE SETS pioglitazone/glimepiride prena1 true prenatal vitamins OMNIPOD paregoric pioglitazone/metformin prenaissance plus prenatal vitamins OMNIPOD DASH paricalcitol piperacillin/tazobactam [INJ] prenaissance prenatal vitamins ONCASPAR [INJ] paricalcitol [INJ] pirmella prenatabs fa prenatal vitamins paromomycin piroxicam prenatabs rx prenatal vitamins ondansetron [INJ] paroxetine hcl PLASMA-LYTE [INJ] prenatal low iron prenatal vitamins ondansetron orally disintegrating tablets paroxetine hcl ext-release plasmanate [INJ] prenatal plus iron prenatal vitamins ONETOUCH DELICA LANCETS [OTC] paroxetine mesylate PLEGRIDY [INJ] [SP] prenatal plus prenatal vitamins ONETOUCH DELICA PLUS LANCETS [OTC] PEDIARIX [INJ] plenamine [INJ] prenatal-u prenatal vitamins ONETOUCH ULTRA 2 SYSTEM [OTC] PEDITRACE [INJ] PNEUMOVAX 23 [INJ] preplus prenatal vitamins ONETOUCH ULTRA TEST STRIPS [OTC] PEDVAXHIB [INJ] pnv 29-1 prenatal vitamins PREPOPIK ONETOUCH ULTRAMINI METER [OTC] peg 3350/electrolytes powder for 4000 ml pnv-dha + docusate prenatal vitamins pretab 29-1 prenatal vitamins ONETOUCH ULTRASOFT LANCETS [OTC] solution pnv-dha prenatal vitamins previfem ONETOUCH VERIO FLEX [OTC] PEGANONE pnv-omega prenatal vitamins PREVNAR 13 [INJ] ONETOUCH VERIO IQ METER [OTC] PEGASYS [INJ] [SP] pnv-select prenatal vitamins PREVYMIS ONETOUCH VERIO TEST STRIPS [OTC] peg-prep kit podofilox PREVYMIS [INJ] ONEXTON penicillamine POLOCAINE [INJ] PREZISTA [SP] ONIVYDE [INJ] [SP] penicillin g potassium [INJ] polyethylene glycol 3350 PRIALT [INJ] [SP] OPDIVO [INJ] [SP] penicillin g procaine [INJ] POLYFIN QR INFUSION SETS PRIFTIN opium tincture penicillin g sodium [INJ] polymyxin [INJ] PRIMAQUINE opium/belladonna alkaloids suppositories PENICILLIN GK/DEXTROSE [INJ] polymyxin/trimethoprim eye solution primaquine phosphate OPSUMIT [SP] penicillin v potassium portia primidone ORALAIR [SP] PENTACEL [INJ] posaconazole probenecid ORBACTIV [INJ] PENTACEL ACTHIB COMPONENT [INJ] potassium acetate [INJ] procainamide [INJ] ORIAHNN [INJ] potassium bicarbonate/citric acid PROCALAMINE [INJ] ORILISSA pentamidine inhalation effervescent tablets edisylate [INJ] ORKAMBI [SP] PENTASA potassium chloride [INJ] prochlorperazine maleate [INJ] [INJ] potassium chloride ext-release prochlorperazine maleate suppositories orphenadrine ext-release ext-release potassium chloride oral solution PROCRIT [INJ] [SP] orphenadrine/aspirin/caffeine PERFOROMIST potassium chloride powder packets for PROFILNINE SD [INJ] [SP] orsythia perindopril solution in oil [INJ] [SP] ORTHOVISC [INJ] [SP] PERJETA [INJ] [SP] potassium chloride/dextrose [INJ] progesterone micronized oseltamivir permethrin potassium chloride/dextrose/nacl [INJ] PROGRAF [INJ] [SP] OTEZLA [SP] potassium chloride/lactated ringers/ PROGRAF PACKETS [SP] OTOVEL perphenazine/amitriptyline dextrose [INJ] PROLASTIN C [INJ] [SP] OVIDREL [INJ] [SP] phenazopyridine potassium chloride/nacl [INJ] PROLEUKIN [INJ] [SP] oxacillin [INJ] phendimetrazine potassium chloride/water [INJ] PROMACTA [SP] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 7 COMPBJCANP-21 (04/01/21) RELISTOR TABLETS se-natal 19 prenatal vitamins STAMARIL [INJ] promethazine [INJ] REMICADE [INJ] [SP] SENSORCAINE-EPI 0.75%-0.0005% [INJ] stavudine [SP] promethazine suppositories remifentanil [INJ] SEREVENT DISKUS STEGLATRO promethazine/codeine RENACIDIN SEROSTIM [INJ] [SP] STEGLUJAN promethazine/dextromethorphan repaglinide sertraline STELARA SC [INJ] [SP] promethazine/phenylephrine repaglinide/metformin hcl setlakin STIMATE [SP] promethazine/phenylephrine/codeine REPATHA [INJ] sevelamer carbonate STIOLTO RESPIMAT RESCRIPTOR [SP] sevelamer hcl STIVARGA [SP] propafenone ext-release RESECTISOL SEVENFACT [INJ] [SP] STRENSIQ [INJ] [SP] proparacaine eye solution RESTASIS sharobel STREPTOMYCIN SULFATE [INJ] proparacaine/fluorescein eye solution RETACRIT [INJ] [SP] SHINGRIX [INJ] SUBLOCADE [INJ] [SP] propofol [INJ] RETROVIR [INJ] [SP] SIGNIFOR [INJ] [SP] SUCRAID [SP] REVCOVI [INJ] [SP] sildenafil sucralfate propranolol [INJ] REVLIMID [SP] sildenafil [INJ] [SP] sufentanil [INJ] propranolol ext-release REYATAZ PACKETS [SP] sildenafil [SP] sulfacetamide eye ointment propranolol/hydrochlorothiazide R-GENE 10 [INJ] SILHOUETTE INFUSION SETS sulfacetamide eye solution propylthiouracil RHOPRESSA sulfacetamide sodium shampoo PROQUAD [INJ] RIASTAP [INJ] [SP] silver sulfadiazine sulfacetamide sodium topical PROSOL [INJ] ribavirin [SP] simliya sulfacetamide sodium/sulfur protamine [INJ] ribavirin nebulization solution simpesse sulfacetamide/prednisolone eye solution PROTOPAM [INJ] RIDAURA SIMPONI 100 MG (for ulcerative sulfadiazine rifabutin colitis only) [INJ] [SP] sulfamethoxazole/trimethoprim PROVENGE [INJ] [SP] rifampin SIMULECT [INJ] [SP] sulfamethoxazole/trimethoprim [INJ] pseudoephedrine/chlorpheniramine/ rifampin [INJ] simvastatin SULFAMYLON CREAM methscopolamine ext-release riluzole sirolimus [SP] sulfasalazine pseudoephedrine/codeine/guaifenesin SIRTURO sulfasalazine delayed-release PULMICORT FLEXHALER ringers irrigation solution SKYLA [SP] sulindac PULMOZYME [SP] ringers lactated irrigation solution SKYRIZI [INJ] [SP] PURIXAN [SP] ringers solution [INJ] sodium acetate [INJ] sumatriptan [INJ] pyrazinamide ringers solution lactated [INJ] sodium benzoate/ sumatriptan nasal pyridostigmine RINVOQ ER [SP] sodium phenylacetate [INJ] sumatriptan/naproxen sodium pyridostigmine [INJ] risedronate sodium bicarbonate [INJ] SUNOSI pyridostigmine ext-release risedronate delayed-release sodium bicarbonate/dextrose [INJ] SURE-T INFUSION SETS pyridoxine [INJ] RISPERDAL CONSTA [INJ] sodium chloride [INJ] SUTENT [SP] pyrimethamine [SP] sodium chloride 0.45 % [INJ] syeda risperidone orally disintegrating tablets sodium chloride 0.9 % [INJ] SYLATRON [INJ] [SP] Q ritonavir [SP] sodium chloride 3 % [INJ] SYLVANT [INJ] [SP] rivastigmine sodium chloride 5 % [INJ] SYMBICORT QUADRACEL DTAP-IPV [INJ] rivastigmine patches sodium chloride irrigation solution SYMDEKO [SP] QUDEXY XR rivelsa sodium chloride nebulization solution SYMFI [SP] sodium chloride, bacteriostatic [INJ] SYMFI LO [SP] quetiapine ext-release rizatriptan orally disintegrating tablets sodium ferric gluconate complex [INJ] SYMJEPI [INJ] QUICK RELEASE TEFLON CANNULA ropinirole sodium fluoride dental cream, gel SYMLINPEN [INJ] QUILLIVANT XR ropinirole ext-release sodium phosphate [INJ] SYMPROIC quinapril ropivacaine/nacl [INJ] sodium polystyrene sulfonate SYMTUZA [SP] quinapril/hydrochlorothiazide rosuvastatin sodium polystyrene sulfonate rectal SYNAGIS [INJ] [SP] gluconate ext-release ROTATEQ sodium tetradecyl sulfate [INJ] SYNAREL quinidine sulfate ROZLYTREK [SP] sodium thiosulfate [INJ] SYNERCID [INJ] quinine sulfate RUBRACA [SP] SOF-SET MICRO INFUSION SETS SYNJARDY QVAR REDIHALER RUCONEST [INJ] [SP] SOF-SET ULTIMATE QR SETS SYNJARDY XR RUXIENCE [INJ] [SP] SOFT TOUCH LANCETS [OTC] SYNRIBO [INJ] [SP] R RUZURGI [SP] solifenacin RYBELSUS SOLIQUA [INJ] T RABAVERT [INJ] RYDAPT [SP] SOLIRIS [INJ] [SP] rabeprazole delayed-release SOLOSEC tacrolimus [SP] RADICAVA [INJ] [SP] S SOLU-CORTEF [INJ] tacrolimus topical RAGWITEK SOMATULINE DEPOT [INJ] [SP] tadalafil salsalate SOMAVERT [INJ] [SP] tadalafil [SP] ramelteon SAMSCA 15 MG TABLETS [SP] TAFINLAR [SP] ramipril SANDIMMUNE SOLUTION [SP] SOTALOL [INJ] TAGRISSO [SP] ranolazine ext-release SANTYL SOTRADECOL 1% [INJ] TAKHZYRO [INJ] [SP] RAPIVAB [INJ] sapropterin [SP] SOTYLIZE TALICIA rasagiline SAVELLA spinosad TALTZ [INJ] [SP] RASUVO [INJ] scopolamine patches SPINRAZA [INJ] [SP] TALZENNA [SP] RAVICTI [SP] secobarbital SPIRIVA HANDIHALER REBIF [INJ] [SP] SEGLUROMET SPIRIVA RESPIMAT tamsulosin ext-release reclipsen selegiline TARGRETIN GEL [SP] RECOMBIVAX HB [INJ] selenium [INJ] spironolactone/hydrochlorothiazide tarina fe RECTIV selenium sulfide sprintec taron-c dha prenatal vitamins REGRANEX selenium sulfide shampoo SPRYCEL [SP] taron-prex dha prenatal vitamins RELISTOR [INJ] SELZENTRY [SP] sronyx TASIGNA [SP] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 8 COMPBJCANP-21 (04/01/21) tazarotene TOUJEO [INJ] trust natal dha prenatal vitamins vienva TAZORAC 0.05% CREAM TOVIAZ TRUVADA 100 MG-150 MG, vigabatrin [SP] TAZORAC GEL TPN ELECTROLYTES [INJ] 133 MG-200 MG, 167 MG-250 MG vilamit mb TECENTRIQ [INJ] [SP] TRACE ELEMENTS-4 [INJ] TABLETS [SP] vilevev mb TECHLITE BLOOD LANCETS [OTC] TRACLEER SUSPENSION [SP] TUBERSOL [INJ] VIMIZIM [INJ] [SP] TEFLARO [INJ] tulana VIMPAT TEGSEDI [INJ] [SP] tramadol ext-release TWINRIX [INJ] VIMPAT [INJ] TEKTURNA HCT tramadol/acetaminophen tydemy vinblastine [INJ] telmisartan trandolapril TYMLOS [INJ] [SP] vincristine [INJ] telmisartan/amlodipine trandolapril/verapamil ext-release TYPHIM VI [INJ] vinorelbine [INJ] telmisartan/hydrochlorothiazide tranexamic acid TYSABRI [INJ] [SP] VIOKACE TEMIXYS [SP] tranexamic acid [INJ] TYVASO [SP] viorele TEMODAR [INJ] [SP] tranylcypromine VIRACEPT [SP] temozolomide [SP] travasol [INJ] U VIREAD 150 MG, 200 MG, 250 MG temsirolimus [INJ] [SP] eye solution TABLETS [SP] TENIPOSIDE [INJ] TRAZIMERA [INJ] [SP] UCERIS FOAM VIREAD POWDER [SP] tenofovir disoproxil fumarate [SP] UNITUXIN [INJ] [SP] virt-c dha prenatal vitamins TREANDA [INJ] [SP] UPTRAVI [SP] virt-nate dha prenatal vitamins terbinafine TRELEGY ELLIPTA uretron d-s virt-pn dha prenatal vitamins TREMFYA [INJ] [SP] urimar-t virt-pn plus prenatal vitamins terbutaline [INJ] treprostinil diluent [INJ] [SP] urin d.s. VISTOGARD [SP] terconazole vaginal treprostinil sodium [INJ] [SP] uro-458 VISUDYNE [INJ] [SP] TRESIBA [INJ] urogesic VITRAKVI [SP] [INJ] tretinoin uro-mp VIVITROL [INJ] [SP] [INJ] tretinoin microspheres ursodiol VIVOTIF TETANUS DIPHTHERIA TOXOIDS [INJ] tretinoin topical uryl VIZIMPRO [SP] tetrabenazine [SP] tretinoin/emollient ustell volnea tetracaine [INJ] TRETTEN [INJ] [SP] utira-c VOLUVEN [INJ] tetracaine eye solution tri femynor UVADEX [INJ] VONVENDI [INJ] [SP] tetracycline triamcinolone [INJ] VORAXAZE [INJ] theophylline triamcinolone dental paste V voriconazole theophylline ext-release triamcinolone topical voriconazole [INJ] theophylline/dextrose [INJ] triamterene valacyclovir VOSEVI [SP] THERACYS [INJ] triamterene/hydrochlorothiazide VALCHLOR [SP] VOTRIENT [SP] thiamine [INJ] triazolam valganciclovir vp-ch-pnv prenatal vitamins trientine sodium [INJ] VUMERITY [SP] thiotepa [INJ] tri-estarylla valproic acid vyfemla thiothixene valrubicin [SP] vylibra THROMBATE III [INJ] trifluridine eye solution valsartan VYNDAMAX [SP] THYMOGLOBULIN [INJ] [SP] trihexyphenidyl valsartan/hydrochlorothiazide VYNDAQEL [SP] THYROGEN [INJ] [SP] TRIJARDY XR vancomycin VYVANSE thyroid TRIKAFTA [SP] vancomycin [INJ] VYXEOS LIPOSOME [INJ] [SP] tiagabine tri-legest fe VANCOMYCIN/DEXTROSE [INJ] TIBSOVO [SP] tri-linyah VANCOMYCIN/NACL [INJ] W TICE BCG [INJ] tri-lo-estarylla VANTAS [SP] tigecycline [INJ] tri-lo-marzia vardenafil warfarin tilia fe tri-lo-mili vardenafil orally disintegrating tablets water for injection, bacteriostatic [INJ] timolol maleate tri-lo-sprintec VARIVAX [INJ] water for injection, sterile [INJ] timolol maleate eye solution trilyte with flavor packets VARIZIG [INJ] water for irrigation, sterile tinidazole trimethobenzamide VARUBI wera TIVICAY [SP] trimethoprim VASCEPA WILATE [INJ] [SP] TIVICAY PD [SP] tri-mili vasopressin/nacl [INJ] wixela inhub VAXCHORA VACCINE wymzya fe TOBI PODHALER [SP] TRIMO-SAN VECTIBIX [INJ] [SP] TOBRADEX OINTMENT trinatal rx 1 prenatal vitamins VELCADE [INJ] [SP] X TOBRADEX ST trinate prenatal vitamins velivet tobramycin [INJ] tri-previfem VELPHORO XALKORI [SP] tobramycin eye solution TRIPTODUR [INJ] [SP] VEMLIDY XARELTO tobramycin nebulization solution [SP] tri-sprintec VENCLEXTA [SP] XELJANZ [SP] tobramycin/dexamethasone TRIUMEQ [SP] venlafaxine XELJANZ XR [SP] eye suspension triveen-duo dha prenatal vitamins venlafaxine ext-release XEMBIFY [INJ] [SP] tobramycin/nacl [INJ] trivora VENOFER [INJ] XERMELO [SP] tolcapone tri-vylibra verapamil XGEVA [INJ] [SP] tolmetin TROGARZO [INJ] [SP] verapamil [INJ] XIAFLEX [INJ] [SP] tolterodine TROPHAMINE [INJ] verapamil ext-release XIFAXAN tolterodine ext-release tropicamide eye solution veripred XIGDUO XR tolvaptan [SP] trospium VERZENIO [SP] XIIDRA trospium ext-release VGO XOFIGO [INJ] [SP] topotecan [INJ] [SP] TRULANCE VIBATIV [INJ] XOLAIR [INJ] [SP] TRULICITY [INJ] VIBERZI XOSPATA [SP] torsemide TRUMENBA [INJ] VIDEX SOLUTION [SP] XTANDI [SP] (continued) Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 9 COMPBJCANP-21 (04/01/21) xulane patches Z ZERVIATE XULTOPHY [INJ] ZEVALIN [INJ] zolmitriptan orally disintegrating tablets XURIDEN [SP] zafirlukast zidovudine [SP] zolpidem XYREM [SP] zaleplon ZIEXTENZO [INJ] [SP] zolpidem ext-release XYWAV [SP] ZALTRAP [INJ] [SP] zileuton ext-release zonisamide ZANOSAR [INJ] chloride [INJ] ZORTRESS 1 MG TABLETS [SP] Y zarah zinc sulfate [INJ] ZOSYN GALAXY BAGS [INJ] ZARXIO [INJ] [SP] zingiber prenatal vitamins zovia YERVOY [INJ] [SP] zatean-pn dha prenatal vitamins ZIOPTAN ZUBSOLV YESCARTA [INJ] [SP] zatean-pn plus prenatal vitamins ZULRESSO [INJ] [SP] YF-VAX [INJ] ZEJULA [SP] ziprasidone mesylate [INJ] zumandimine YONDELIS [INJ] [SP] ZELBORAF [SP] ZIRABEV [INJ] [SP] ZYDELIG [SP] YONSA [SP] ZEMAIRA [INJ] [SP] ZOLADEX [INJ] [SP] ZYKADIA [SP] YUPELRI ZENPEP zoledronic acid [INJ] [SP] ZYLET yuvafem ZEPATIER [SP] zoledronic acid/mannitol [INJ] [SP] ZYTIGA 500 MG [SP] ZEPOSIA [SP] ZOLGENSMA [INJ] [SP] ZERBAXA [INJ] ZOLINZA [SP]

Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com .

© 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 10 COMPBJCANP-21 (04/01/21) 2021 BJC HealthCare Preferred Drug List Exclusions The excluded medications shown below are not covered on the BJC HealthCare drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. Excluded Medications Preferred Alternatives

ANTIINFECTIVES FIRVANQ vancomycin capsules, vancomycin oral solution Antibiotic Agents - Vancomycins (Oral) ACTICLATE doxycycline tablets Antibiotics DORYX MPC doxycycline hyclate dr capsules Antifungal Agents (Oral) TOLSURA itraconazole Antifungal Agents (Topical) JUBLIA, KERYDIN itraconazole, terbinafine Antivirals (Oral) SITAVIG acyclovir oral or cream, famciclovir, valacyclovir Chagas Disease Agents LAMPIT BENZNIDAZOLE

AUTONOMIC & CENTRAL NERVOUS SYSTEM LUCEMYRA clonidine Alpha-2 (for Opioid Withdrawal) carbamazepine, oxcarbazepine, pregabalin, topiramate, APTIOM Anticonvulsants VIMPAT FINTEPLA DIACOMIT, EPIDIOLEX VYEPTI AIMOVIG, AJOVY, EMGALITY Antimigraine Agents ZEMBRACE SYMTOUCH sumatriptran injection ZOLMITRIPTAN NASAL SPRAY sumatriptan nasal spray APOKYN~ KYNMOBI amantadine capsules, amantadine tablets, GOCOVRI ER amantadine oral solution Antiparkinsonism Agents ONGENTYS entacapone RYTARY carbidopa/levodopa XADAGO, ZELAPAR rasagiline, selegiline aripiprazole, , olanzapine, quetiapine er, Antipsychotics (Oral) CAPLYTA quetiapine fumarate, risperidone, ziprasidone, LATUDA Antispasmodic Agents OZOBAX baclofen, tizanidine APTENSIO XR methylphenidate er capsules Attention Disorders QUILLICHEW ER methylphenidate er

dexmethylphenidate er, dextroamphetamine er, dextroamphetamine/amphetamine er, methylphenidate cd, Central Nervous System Stimulants AMPHETAMINE ER SUSPENSION methylphenidate er, methylphenidate la, DYANAVEL XR, MYDAYIS, QUILLIVANT XR, VYVANSE

EMFLAZA prednisone solution, prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51, VILTEPSO, VYONDYS 53 No alternatives recommended Lambert-Eaton Myasthenic Syndrome Agents FIRDAPSE RUZURGI

AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, Multiple Sclerosis (Beta Interferons) EXTAVIA PLEGRIDY, REBIF, REBIF REBIDOSE

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APADAZ, BENZHYDROCODONE/ACETAMINOPHEN hydrocodone/acetaminophen MORPHABOND ER, NUCYNTA ER, OXYCODONE ER, hydromorphone er, morphine sulfate er, oxymorphone er, XTAMPZA ER HYSINGLA ER, OXYCONTIN AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) hydrocodone/acetaminophen, morphine sulfate, oxycodone, Narcotic Analgesics & Combinations NUCYNTA tramadol, tramadol/acetaminophen PRIMLEV oxycodone/acetaminophen QDOLO tramadol tablets BUNAVAIL buprenorphine/naloxone, ZUBSOLV Narcotic Antagonists EVZIO, NALOXONE AUTO-INJECTOR naloxone syringes, NARCAN NASAL SPRAY Narcotics TARTRATE generic opioids Neuropathic Agents GRALISE, LYRICA CR gabapentin, pregabalin -Hypnotic Agents DORAL, QUAZEPAM estazolam, lorazepam Selective Reuptake Inhibitors (SSRIs) citalopram, escitalopram, fluoxetine, fluvoxamine, PEXEVA, VIIBRYD paroxetine, sertraline Serotonin/Norepinephrine Reuptake Inhibitor DRIZALMA SPRINKLE desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA Antidepressants Tardive Dyskinesia Therapy INGREZZA AUSTEDO FENTANYL CITRATE BUCCAL TABLETS, FENTORA, Transmucosal Fentanyl Analgesics fentanyl citrate lozenges LAZANDA, SUBSYS APLENZIN bupropion er, bupropion sr

Miscellaneous Antidepressants olanzapine/fluoxetine, bupropion, desvenlafaxine er, SPRAVATO duloxetine, escitalopram, mirtazapine, sertraline

CARDIOVASCULAR EPANED enalapril ACE Inhibitors QBRELIS lisinopril candesartan, irbesartan, losartan, olmesartan, telmisartan, EDARBI valsartan

candesartan/hydrochlorothiazide, Angiotensin Receptor Blockers (ARBs) and Combinations irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, EDARBYCLOR olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, chlorthalidone plus valsartan

Anticoagulants PRADAXA, SAVAYSA ELIQUIS, XARELTO BYSTOLIC atenolol, carvedilol, metoprolol succinate metoprolol tartrate/hydrochlorothiazide, DUTOPROL Beta Blockers & Combinations metoprolol succinate er plus hydrochlorothiazide INDERAL XL, INNOPRAN XL propranolol er KAPSPARGO SPRINKLE metoprolol succinate CONJUPRI amlodipine, felodipine er, nifedipine er, nisoldipine Calcium Channel Blockers KATERZIA amlodipine Diuretics CAROSPIR spironolactone atorvastatin, fluvastatin er, lovastatin, pravastatin, HMG & Cholesterol Inhibitor Combinations ALTOPREV, EZALLOR SPRINKLE rosuvastatin, simvastatin tablets, LIVALO PCSK9 Inhibitors PRALUENT REPATHA

atenolol, bisoprolol, carvedilol, metoprolol succinate, Miscellaneous Cardiovascular Agents CORLANOR~ metoprolol tartrate, propranolol

DERMATOLOGICAL DRYSOL Over-the-Counter aluminum chloride containing products Agents for Hyperhidrosis

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ABSORICA isotretinoin DERMATOLOGICAL (continued) DORYX DR 80 MG, DOXYCYCLINE HYCLATE DR 80 MG doxycycline hyclate, doxycycline monohydrate Oral Agents for Acne MINOCYCLINE ER CAPSULES, XIMINO minocycline er tablets Rosacea Agents (Oral) DOXYCYCLINE 40 MG CAPSULES doxycycline hyclate, doxycycline monohydrate Rosacea Agents (Topical) NORITATE metronidazole 0.75% cream AVAR-E GREEN, PLEXION sulfacetamide sodium/sulfur 10-5% CLINDAGEL, clindamycin phosphate gel, erythromycin gel, AMZEEQ CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE) EPIDUO FORTE adapalene/benzoyl peroxide Topical Agents for Acne clindamycin/benzoyl peroxide, clindamycin/tretinoin, VELTIN erythromycin/benzoyl peroxide, ONEXTON clindamycin phosphate gel, clindamycin/tretinoin, WINLEVI erythromycin gel, tretinoin, AMZEEQ, ONEXTON CARAC, FLUOROURACIL 0.5% CREAM, diclofenac 3% gel, fluorouracil 2% solution, Topical Agents for Actinic Keratosis IMIQUIMOD 3.75% CREAM PUMP, KLISYRI, ZYCLARA fluorouracil 5% cream, imiquimod 5% cream

betamethasone dipropionate, calcipotriene, Topical Agents for Plaque Psoriasis WYNZORA calcipotriene/betamethasone dipropionate, clobetasol propionate, , ENSTILAR Topical Antifungals ECOZA, LULICONAZOLE, SULCONAZOLE, XOLEGEL ciclopirox, econazole, ketoconazole, naftifine, oxiconazole , fluocinolone acetonide, BRYHALI,

betamethasone dipropionate, clobetasol, desonide, Topical IMPEKLO desoximetasone, diflorasone, fluocinonide, halcinonide, halobetasol, mometasone, triamcinolone

desonide 0.05% cream/lotion/ointment, VERDESO FOAM desoximetasone 0.25% cream/ointment Vitamin D Analogs (Topical) CALCIPOTRIENE FOAM calcipotriene, calcitriol ALCORTIN A hydrocortisone, mupirocin Miscellaneous Topical Dermatological Agents LIDOCAINE/TETRACAINE, PLIAGLIS~ lidocaine cream, lidocaine/prilocaine cream

FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE ASCENSIA (CONTOUR) FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, ROCHE (ACCU-CHEK) DIABETES FREESTYLE LITE TRIVIDIA (TRUETEST, TRUETRACK) Blood Glucose Meters & Test Strips ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, ALL OTHER METERS & TEST STRIPS VERIO FLEX THAT ARE NOT LISTED AS PREFERRED ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS

ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA JANUVIA ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations JANUMET, JANUMET XR KAZANO, KOMBIGLYZE XR ALOGLIPTIN/PIOGLITAZONE pioglitazone plus JANUVIA Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose QTERN GLYXAMBI, STEGLUJAN Co-Transporter-2 (SGLT-2) Inhibitors Combinations Glucagon-Like Peptide-1 Agonists ADLYXIN, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY ADMELOG, AFREZZA, APIDRA, FIASP, INSULIN ASPART, HUMALOG, LYUMJEV INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG Insulins NOVOLIN, RELION NOVOLIN HUMULIN SEMGLEE LANTUS, LEVEMIR, TOUJEO, TRESIBA

EAR/NOSE BECONASE AQ, OMNARIS, QNASL~, ZETONNA flunisolide, fluticasone, mometasone Nasal

Otic Fluoroquinolone Antibiotics CIPROFLOXACIN/FLUOCINOLONE OTIC ciprofloxacin/dexamethasone otic, OTOVEL

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ENDOCRINE (OTHER) -Releasing (GnRH) Analogs FENSOLVI LUPRON DEPOT-PED, TRIPTODUR (for Central Precocious Puberty)

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, Growth GENOTROPIN, NORDITROPIN FLEXPRO SAIZEN, SAIZENPREP, ZOMACTON MYCAPSSA, SANDOSTATIN LAR DEPOT SOMATULINE DEPOT Somatostatin Analogs For Acromegaly: SOMATULINE DEPOT SIGNIFOR LAR For Cushing’s Disease: SIGNIFOR Testosterone Products AVEED testosterone cypionate, testosterone enanthate LEVOTHYROXINE CAPSULES, THYQUIDITY, Thyroid Replacement Therapy levothyroxine tablets TIROSINT~, TIROSINT-SOL~

Miscellaneous Endocrine Drugs KORLYM ketoconazole, LYSODREN, SIGNIFOR

GASTROINTESTINAL MYTESI diphenoxylate/atropine, loperamide Antidiarrheal Agents AKYNZEO CAPSULES granisetron, ondansetron, aprepitant, VARUBI TABLETS Antiemetics (Oral) BONJESTA, DICLEGIS doxylamine/vit b6, ondansetron, promethazine EMEND POWDER PACKETS aprepitant, VARUBI TABLETS DUEXIS famotidine plus ibuprofen Anti-Inflammatory/Anti-Ulcer Agents VIMOVO famotidine plus naproxen CLENPIQ, GOLYTELY PACKETS, OSMOPREP, PLENVU, Bowel Evacuants peg-electrolyte solution SUPREP, SUTAB Corticosteroids (Rectal Formulations) CORTIFOAM hydrocortisone enema, UCERIS FOAM Gallstone Dissolution Agents RELTONE ursodiol Gastroparesis Agents GIMOTI No alternatives recommended Helicobacter Pylori Agents HELIDAC, PYLERA lansoprazole/amoxicillin/clarithromycin, TALICIA Hemorrhoidal Preparations PROCTOFOAM-HC pramoxine/hydrocortisone balsalazide disodium, mesalamine dr, mesalamine er, Inflammatory Bowel Agents DIPENTUM sulfasalazine, PENTASA Irritable Bowel Syndrome & Chronic Constipation Agents AMITIZA, LUBIPROSTONE LINZESS, TRULANCE Pancreatic Enzymes PERTZYE CREON, PANCREAZE, ZENPEP

ACIPHEX SPRINKLE, DEXILANT, ESOMEPRAZOLE , esomeprazole magnesium, lansoprazole, omeprazole, Proton Pump Inhibitors NEXIUM PACKETS, PRILOSEC SUSPENSION, pantoprazole, rabeprazole RABEPRAZOLE DR SPRINKLE

HEMATOLOGICAL aspirin plus omeprazole, esomeprazole, lansoprazole, ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR Antiplatelet Agents pantoprazole or rabeprazole Erythropoiesis-Stimulating Agents ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT NOVOSEVEN RT~ SEVENFACT Factor Deficiency Agents & Related Products ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI, NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE KOGENATE FS, KOVALTRY, NOVOEIGHT GRANIX, NEUPOGEN NIVESTYM, ZARXIO Granulocyte Colony Stimulating Factors NEULASTA, UDENYCA FULPHILA, NYVEPRIA, ZIEXTENZO Iron Replacement Agents MONOFERRIC sodium ferric gluconate complex, VENOFER OXBRYTA hydroxyurea, ADAKVEO, DROXIA Sickle Cell Disease Agents SIKLOS DROXIA MULPLETA DOPTELET Thrombocytopenia Agents TAVALISSE DOPTELET, PROMACTA, NPLATE

HEPATITIS LEDIPASVIR/SOFOSBUVIR, MAVYRET, EPCLUSA, HARVONI, VOSEVI, ZEPATIER Hepatitis C SOFOSBUVIR/VELPATASVIR, SOVALDI

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COMPLERA ODEFSEY

efavirenz/emtricitabine/tenofovir disoproxil fumarate, efavirenz/lamivudine/tenofovir disoproxil fumarate, DELSTRIGO BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ HIV Antiretrovirals PIFELTRO efavirenz, EDURANT Note: Current patients established on therapy are allowed to continue therapy. PREZCOBIX atazanavir, ritonavir, KALETRA TABLETS, PREZISTA Coverage may be approved for the treatment of human RUKOBIA ER immunodeficiency virus-1 infection in heavily treatment- experienced patients with multidrug-resistant infection.

STRIBILD BIKTARVY, GENVOYA

MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE CAPSULES colchicine tablets, MITIGARE Gout Therapy

DICLOFENAC 35 MG CAPSULES, diclofenac, etodolac, ibuprofen, indomethacin, INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY, meloxicam, nabumetone, naproxen, piroxicam TIVORBEX, ZIPSOR, ZORVOLEX

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) fenoprofen calcium tablets, diclofenac, ibuprofen, FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES indomethacin, meloxicam, nabumetone, naproxen nabumetone, diclofenac, ibuprofen, indomethacin, RELAFEN DS meloxicam, naproxen, piroxicam Anti-Inflammatory RAYOS prednisone Topical Analgesics ZTLIDO lidocaine transdermal patches

diclofenac sodium topical, Topical Anti-Inflammatory Drugs (NSAIDs) DICLOFENAC EPOLAMINE PATCHES, PENNSAID FLECTOR PATCHES, LICART PATCHES

OBSTETRICAL & GYNECOLOGICAL CLIMARA PRO COMBIPATCH Combination Patches ANNOVERA, BALCOLTRA, LO LOESTRIN FE, NATAZIA, TWIRLA generic oral and ring contraceptives, xulane patches Barrier methods of contraception, such as condoms, Contraceptives PHEXXI diaphragms, spermicides or sponges. SLYND generic progestin-only oral contraceptives estradiol cream, estradiol vaginal tablets, yuvafem, ESTRING~, IMVEXXY~, INTRAROSA, OSPHENA PREMARIN CREAM & Estrogen Modifiers for Vaginal Symptoms estradiol cream, estradiol patches, estradiol tablets, FEMRING yuvafem, PREMARIN CREAM amabelz, estradiol/norethindrone acetate, fyavolv, jinteli, Estrogen/Progestin Combinations (Oral) BIJUVA~, PREMPHASE, PREMPRO mimvey, norethindrone/ethinyl estradiol Estrogens (Oral) MENEST~, PREMARIN TABLETS estradiol tablets Human Chorionic Gonadotropin CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL Ovulatory Stimulants (Follitropins) FOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT Prenatal Vitamins PREGENNA, TRINAZ generic prenatal vitamins Topical Estrogen Agents DIVIGEL~, ELESTRIN, ESTROGEL, EVAMIST~ estradiol patches CRINONE 4% medroxyprogesterone, megestrol, norethindrone, progesterone Vaginal CRINONE 8% ENDOMETRIN

ONCOLOGY ONUREG azacitidine, decitabine Acute Myeloid Leukemia (AML) Agents Bevacizumab-Containing Agents AVASTIN MVASI, ZIRABEV Agents KISQALI, KISQALI FEMARA CO-PACK, PIQRAY IBRANCE, VERZENIO Chronic Lymphocytic Leukemia (CLL) Agents CALQUENCE IMBRUVICA, VENCLEXTA

~ Medications will be excluded beginning 07/01/2021. Continued

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ONCOLOGY (continued) DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, BLENREP, XPOVIO Multiple Myeloma Agents THALOMID, VELCADE Myelodysplastic Syndrome Agents INQOVI decitabine Myelofibrosis Agents INREBIC JAKAFI Cancer Agents ORGOVYX, TRELSTAR ELIGARD, FIRMAGON Rituximab-Containing Agents RIABNI, RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, OGIVRI, KANJINTI, TRAZIMERA Trastuzumab-Containing Agents ONTRUZANT PHESGO PERJETA plus KANJINTI or TRAZIMERA

imatinib, NEXAVAR, SPRYCEL, STIVARGA, SUTENT, TASIGNA, Kinase Inhibitors QINLOCK VOTRIENT

OPHTHALMIC timolol drops, betaxolol drops, levobunolol drops, BETIMOL~ Antiglaucoma Agents (Beta-Adrenergic Blockers) ALPHAGAN P 0.1%, COMBIGAN

betaxolol drops, bimatoprost drops, Antiglaucoma Agents (Other) RHOPRESSA~, ROCKLATAN~ dorzolamide/timolol drops, latanoprost drops, levobunolol drops, timolol drops, travoprost drops

bimatoprost drops, latanoprost drops, travoprost drops, Antiglaucoma Drugs (Ophthalmic ) DURYSTA, XELPROS ZIOPTAN Blepharoptosis Agents UPNEEQ No alternatives recommended Ophthalmic Agents - Other CYSTADROPS CYSTARAN azelastine drops, cromolyn drops, epinastine drops, Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, LASTACAFT, PAZEO olopatadine drops, ZERVIATE

dexamethasone drops, fluorometholone drops, Ophthalmic Anti-Inflammatory FLAREX~, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD loteprednol drops, prednisolone drops, INVELTYS, LOTEMAX GEL/OINTMENT Ophthalmic Combinations TOBRADEX ST~, ZYLET~ tobramycin/dexamethasone drops, TOBRADEX OINTMENT Ophthalmic Non-Steroidal Anti-Inflammatory Drugs ACUVAIL, BROMSITE~, NEVANAC bromfenac drops, diclofenac drops, ketorolac drops (NSAIDs)

ciprofloxacin drops, gatifloxacin drops, levofloxacin drops, Ophthalmic Quinolone Antibiotics BESIVANCE~, CILOXAN OINTMENT moxifloxacin drops, ofloxacin drops

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, OSTEOARTHRITIS HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, EUFLEXXA, MONOVISC, ORTHOVISC Hyaluronic Acid Derivatives SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3

OSTEOPOROSIS alendronate, ibandronate, risedronate, zoledronic acid, EVENITY, PROLIA Bone Modifiers FORTEO, TYMLOS

RENAL DISEASE PROCYSBI CYSTAGON Nephropathic Cystinosis Medications

lanthanum, sevelamer carbonate, sevelamer hcl, Phosphate Binders FOSRENOL POWDER PACKETS PHOSLYRA, VELPHORO

RESPIRATORY epinephrine auto-injector (by Mylan, Teva), AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX) Epinephrine Auto-Injector Systems EPIPEN, EPIPEN JR Immunological Agents for Asthma CINQAIR DUPIXENT, FASENRA, NUCALA Long-Acting Beta Inhalers STRIVERDI RESPIMAT SEREVENT DISKUS Long-Acting Inhalers TUDORZA PRESSAIR INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT Long-Acting Muscarinic Antagonist/ DUAKLIR PRESSAIR ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT Long-Acting Beta-Agonist Combination Inhalers ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, Pulmonary Anti-Inflammatory Inhalers ARMONAIR DIGIHALER, PULMICORT FLEXHALER~ FLOVENT DISKUS, FLOVENT HFA, QVAR REDIHALER

AIRDUO DIGIHALER, AIRDUO RESPICLICK, Pulmonary Anti-Inflammatory/ fluticasone/salmeterol (by Prasco, Proficient Rx), BUDESONIDE/, Beta-Agonist Combination Inhalers ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT FLUTICASONE/SALMETEROL (BY A-S MEDICATION, TEVA)

~ Medications will be excluded beginning 07/01/2021. Continued

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fluticasone/salmeterol (by Prasco, Proficient Rx), ADVAIR HFA, ANORO ELLIPTA, ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, BEVESPI AEROSPHERE, RESPIRATORY (continued) DALIRESP~ BREO ELLIPTA, DULERA, FLOVENT DISKUS, FLOVENT HFA, Respiratory Agents - Other INCRUSE ELLIPTA, PERFOROMIST, QVAR REDIHALER, SEREVENT DISKUS, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, STIOLTO RESPIMAT, SYMBICORT

ALBUTEROL SULFATE HFA (BY A-S MEDICATION, PRASCO), albuterol sulfate hfa (by Cipla, Lupin, Par, Perrigo, Short-Acting Beta -Agonist Inhalers LEVALBUTEROL HFA, PROAIR DIGIHALER, PROAIR RESPICLICK, 2 Proficient Rx & Teva) VENTOLIN HFA, XOPENEX HFA

MISCELLANEOUS AGENTS PALFORZIA No alternatives recommended Allergen Immunotherapy and Cold Products TUSSICAPS generic tussionex Cushing’s Agents ISTURISA SIGNIFOR Gaucher Disease Agents ELELYSO CEREZYME ALKINDI SPRINKLE hydrocortisone tablets HEMADY dexamethasone tablets Hereditary Angioedema BERINERT CINRYZE, RUCONEST CUTAQUIG SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY IV: GAMMAGARD LIQUID, GAMMAGARD S-D, GAMUNEX-C Immune Globulins GAMMAKED SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY HIZENTRA SC: XEMBIFY OTREXUP RASUVO Immunosuppressant Agents XATMEP methotrexate Neuromyelitis Optica Spectrum Disorder Agents UPLIZNA ENSPRYNG Nocturnal Polyuria Agents NOCTIVA desmopressin tablets Overactive Bladder Agents VESICARE LS oxybutynin, oxybutynin er Polyneuropathy of Hereditary ONPATTRO TEGSEDI Transthyretin-Mediated Amyloidosis

Potassium Binders VELTASSA LOKELMA

Indication Based Management Drug Class Excluded Medications Preferred Alternatives

Spinal Conditions (nr-axSpA) COSENTYX TALTZ, CIMZIA

TALTZ, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SC, Inflammatory Conditions‡ where COSENTYX is indicated COSENTYX TREMFYA, XELJANZ, XELJANZ XR

Drug Class Nonpreferred Medications Preferred Alternatives

All other Brand Name medications for Inflammatory Preferred: ENBREL, HUMIRA, OTEZLA, RINVOQ ER, SKYRIZI, Conditions are Nonpreferred. Approval may be granted STELARA SC, TALTZ, TREMFYA, XELJANZ, XELJANZ XR following a coverage review. A trial of one or more Preferred Inflammatory Conditions‡ medications is required prior to initiating therapy with a Preferred after Step through HUMIRA: ACTEMRA Nonpreferred medication. A formulary exception may be granted for a patient already established on therapy with a ULCERATIVE COLITIS ONLY Preferred after Step through Nonpreferred medication. HUMIRA: SIMPONI 100 MG, XELJANZ, XELJANZ XR

‡ Please note that product placement for treatment of Inflammatory Conditions in the Inflammatory Conditions Care Value (ICCV) Program are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.

~ Medications will be excluded beginning 07/01/2021. Continued

© 2021 Express Scripts. All Rights Reserved. #2884 All trademarks are the property of their respective owners. Page 17 DL44109Q-BJC-21 (04/01/2021) Excluded Medications/Products at a Glance

ABILIFY^ COSOPT^ (currently excluded), IMIQUIMOD 3.75% CREAM PUMP OMNITROPE SUPREP ABSORICA COSOPT PF^~ IMITREX^ ONGENTYS SUTAB ACANYA^ COZAAR^, HYZAAR^ IMPEKLO ONGLYZA SYNVISC, SYNVISC-ONE ACIPHEX^ CRESTOR^ IMVEXXY~ ONPATTRO TARGRETIN CAPSULES^ ACIPHEX SPRINKLE CRINONE INDERAL LA^ ONTRUZANT TAVALISSE ACTICLATE CUPRIMINE^ INDERAL XL, INNOPRAN XL ONUREG TAYTULLA^ ACUVAIL CUTAQUIG INDOMETHACIN 20 MG CAPSULES ORGOVYX TAZORAC 0.1% CREAM^ ADCIRCA^ CYMBALTA^ INGREZZA OSMOPREP TEKTURNA^ ADDERALL^ CYSTADROPS INQOVI OSPHENA TESTIM^ ADLYXIN CYTOMEL^ INREBIC OTREXUP THYQUIDITY ADMELOG DALIRESP~ INSULIN ASPART, OXBRYTA TIKOSYN^ AFREZZA DELSTRIGO INSULIN ASPART PROTAMINE OXYCODONE ER TIMOPTIC OCUDOSE^ AGGRENOX^ DELZICOL^ INSULIN LISPRO OZOBAX TIROSINT~, TIROSINT-SOL~ AIRDUO DIGIHALER, AIRDUO RESPICLICK DETROL^, DETROL LA^ INTRAROSA PALFORZIA TIVORBEX AKYNZEO CAPSULES DEXILANT INTUNIV^ PATADAY^ TOBI SOLUTION^ ALBUTEROL SULFATE HFA DICLEGIS ISTALOL^ PAZEO TOBRADEX ST~ (BY A-S MEDICATION, PRASCO) DICLOFENAC 35 MG CAPSULES ISTURISA PENNSAID TOLSURA ALCORTIN A DICLOFENAC EPOLAMINE PATCHES JADENU^, JADENU SPRINKLE^ PERCOCET^ TOPAMAX^ ALKINDI SPRINKLE DIOVAN^, DIOVAN HCT^ JENTADUETO, JENTADUETO XR PERTZYE TOPICORT SPRAY^ ALOCRIL DIPENTUM JUBLIA PEXEVA TOPROL XL^ ALOGLIPTIN DIVIGEL~ KAPSPARGO SPRINKLE PHESGO TRADJENTA ALOGLIPTIN/METFORMIN DORAL KATERZIA PHEXXI TRANSDERM-SCOP^ ALOGLIPTIN/PIOGLITAZONE DORYX DR 80 MG, KAZANO PIFELTRO TRAVATAN Z^ ALOMIDE DOXYCYCLINE HYCLATE DR 80 MG KEPPRA^, KEPPRA XR^ PIQRAY TRELSTAR ALTOPREV DORYX MPC KERYDIN PLAQUENIL^ TREXIMET^ AMBIEN^, AMBIEN CR^ DOXYCYCLINE 40 MG CAPSULES KETOROLAC NASAL SPRAY PLAVIX^ TRIBENZOR^ AMITIZA DRIZALMA SPRINKLE KISQALI, KISQALI FEMARA CO-PACK PLENVU TRICOR^ AMPHETAMINE ER SUSPENSION DRYSOL KLISYRI PLEXION TRILEPTAL^ AMPYRA^ DUAKLIR PRESSAIR KOMBIGLYZE XR PLIAGLIS~ TRILURON AMRIX^ DUEXIS KORLYM PRADAXA TRINAZ ANDROGEL^ DURAGESIC^ LAMICTAL^, LAMICTAL ODT^, PRALUENT TRIVIDIA (TRUETEST, TRUETRACK) ANNOVERA DUROLANE LAMICTAL XR^ PRAVACHOL^ TRIVISC ANUSOL-HC^ DURYSTA LAMPIT PRED MILD TRUVADA^~ APADAZ DUTOPROL LASTACAFT PREGENNA TRUXIMA APIDRA ECOZA LAZANDA PREGNYL TUDORZA PRESSAIR APLENZIN EDARBI, EDARBYCLOR LEDIPASVIR/SOFOSBUVIR PREMARIN TABLETS, TUSSICAPS APOKYN~ EFFEXOR XR^ LETAIRIS^ PREMPHASE, PREMPRO TWIRLA APTENSIO XR ELELYSO LEVALBUTEROL HFA PREVACID^, PREVACID SOLUTAB^ UDENYCA APTIOM ELESTRIN LEVORPHANOL TARTRATE PREZCOBIX ULORIC^ ARANESP ELIDEL^ LEVOTHYROXINE CAPSULES PRILOSEC SUSPENSION UPLIZNA ARIMIDEX^ EMEND CAPSULES^, TRIFOLD PACK^ LEXAPRO^ PRIMLEV UPNEEQ ARMONAIR DIGIHALER EMEND POWDER PACKETS LIALDA^ PRISTIQ^ UROXATRAL^ ASACOL HD^ EMFLAZA LIBRAX^ PROAIR DIGIHALER, PROAIR RESPICLICK VAGIFEM^ ASCENSIA (CONTOUR) EPANED LIDOCAINE/TETRACAINE PROAIR HFA^ VALIUM^ ASPIRIN/OMEPRAZOLE DR EPIDUO^ LIDODERM^ PROCTOFOAM-HC VALTREX^ ATACAND^, ATACAND HCT^ EPIDUO FORTE LIPITOR^ PROCYSBI VANOS^ ATRALIN^ EPINEPHRINE AUTO-INJECTOR (BY IMPAX) LO LOESTRIN FE PROLIA VELTASSA ATRIPLA^ EPOGEN LOCOID^, LOCOID LIPOCREAM^ PROTONIX^ VELTIN AUVI-Q ESOMEPRAZOLE STRONTIUM LOESTRIN^, LOESTRIN FE^ PROVENTIL HFA^ VENTOLIN HFA AVALIDE^, AVAPRO^ ESTRACE CREAM^ LOTREL^ PROVIGIL^ VERDESO FOAM AVAR-E GREEN ESTRING~ LOTRONEX^ PROZAC^ VESICARE^ AVASTIN ESTROGEL LOVENOX^ PULMICORT FLEXHALER~ VESICARE LS AVEED ESTROSTEP FE^ LUBIPROSTONE PULMICORT RESPULES^ VIAGRA^ AVODART^ EVAMIST~ LUCEMYRA PYLERA VICTOZA AZOR^ EVENITY LULICONAZOLE QBRELIS VIIBRYD BALCOLTRA EVZIO LUNESTA^ QDOLO VILTEPSO BARACLUDE TABLETS^ EXFORGE^, EXFORGE HCT^ LYRICA^ QINLOCK VIMOVO BECONASE AQ EXJADE^ LYRICA CR QNASL~ VISCO-3 BENICAR^, BENICAR HCT^ EXONDYS 51 MAVYRET QTERN VIVELLE-DOT^ BENZHYDROCODONE/ACETAMINOPHEN EXTAVIA MAXALT^, MAXALT MLT^ QUARTETTE^ VIVLODEX^ BERINERT EZALLOR SPRINKLE MAXIDEX QUAZEPAM VYEPTI BESIVANCE~ FEMRING MENEST~ QUILLICHEW ER VYONDYS 53 BETIMOL~ FENOPROFEN CAPSULES MESTINON^ RABEPRAZOLE DR SPRINKLE VYTORIN^ BIJUVA~ FENORTHO MICARDIS^, MICARDIS HCT^ RANEXA^ WELCHOL PACKETS^ (currently excluded), BLENREP FENSOLVI MINASTRIN 24 FE^ RAPAFLO^ WELCHOL TABLETS^~ BONJESTA FENTANYL CITRATE BUCCAL TABLETS MINIVELLE^ RAYOS WELLBUTRIN SR^, WELLBUTRIN XL^ BRISDELLE^ FENTORA MINOCYCLINE ER CAPSULES RECOMBINATE WINLEVI BROMSITE~ FIASP MIRCERA RELAFEN DS WYNZORA BRYHALI FINTEPLA MIRCETTE^ RELTONE XADAGO BUDESONIDE/FORMOTEROL FIRAZYR^ MONOFERRIC RENAGEL^ XALATAN^ BUNAVAIL FIRDAPSE MORPHABOND ER RETIN-A MICRO 0.04% & 0.1%^ XANAX^, XANAX XR^ BUPAP^ FIRVANQ MOVIPREP^ RHOPRESSA~, ROCKLATAN~ XATMEP BUTRANS^ FLAREX~ MULPLETA RIABNI XELPROS BYSTOLIC FLUOROURACIL 0.5% CREAM MYCAPSSA RITUXAN, RITUXAN HYCELA XENAZINE^ CALCIPOTRIENE FOAM FLUTICASONE/SALMETEROL MYTESI ROCHE (ACCU-CHEK) XIMINO CALQUENCE (BY A-S MEDICATION, TEVA) NALFON CAPSULES ROZEREM^ XOLEGEL CANASA^~ FML FORTE, FML S.O.P. NALOXONE AUTO-INJECTOR RUKOBIA ER XOPENEX HFA CAPLYTA FOCALIN^, FOCALIN XR^ NAMENDA XR^ RYTARY XPOVIO CARAC FOLLISTIM AQ NASONEX^ SAFYRAL^ XTAMPZA ER CAROSPIR FOSRENOL CHEWABLE TABLETS^ NATAZIA SAIZEN, SAIZENPREP XYNTHA, XYNTHA SOLOFUSE CELEBREX^ FOSRENOL POWDER PACKETS NATROBA^ SANDOSTATIN LAR DEPOT YASMIN^ CELEXA^ GAMMAKED NESINA SAPHRIS^~ YOSPRALA DR CHORIONIC GONADOTROPIN GANIRELIX ACETATE^ NEULASTA SAVAYSA ZAVESCA^ CIALIS^ GEL-ONE NEUPOGEN SEASONIQUE^, LOSEASONIQUE^ ZEGERID^ CILOXAN OINTMENT GELSYN-3 NEURONTIN^ SEMGLEE ZELAPAR CINQAIR GENERESS FE^ NEVANAC SENSIPAR^ ZEMBRACE SYMTOUCH CIPROFLOXACIN/FLUOCINOLONE OTIC GENVISC 850 NEXIUM CAPSULES^ SEROQUEL^, SEROQUEL XR^ ZETIA^ CLENPIQ GIMOTI NEXIUM PACKETS SIGNIFOR LAR ZETONNA CLIMARA PRO GLEEVEC^ NOCTIVA SIKLOS ZIPSOR CLINDAGEL GLUCOPHAGE^, GLUCOPHAGE XR^ NORCO^ SINGULAIR^ ZOCOR^ CLINDAMYCIN PHOSPHATE 1% GEL GLUMETZA^ NORITATE SITAVIG ZOHYDRO ER^ (BY OCEANSIDE) GOCOVRI ER NORTHERA^~ SLYND ZOLMITRIPTAN NASAL SPRAY CLOCORTOLONE GOLYTELY PACKETS NORVASC^ SODIUM HYALURONATE ZOLOFT^ COLCHICINE CAPSULES GRALISE NOVOLIN, RELION NOVOLIN SOFOSBUVIR/VELPATASVIR ZOMACTON COLCRYS^~ GRANIX NOVOLOG SOVALDI ZOMIG TABLETS^, ZOMIG ZMT^ COMPLERA HELIDAC NOVOSEVEN RT~ SPRAVATO ZONEGRAN^ CONCERTA^ HEMADY NOXAFIL TABLETS^ STRATTERA^ ZORVOLEX CONJUPRI HERCEPTIN, HERCEPTIN HYLECTA NUCYNTA, NUCYNTA ER STRIBILD ZOVIRAX OINTMENT^ COREG^ HERZUMA NUTROPIN AQ NUSPIN STRIVERDI RESPIMAT ZTLIDO CORLANOR~ HIZENTRA NUVIGIL^ SUBOXONE^~ ZYCLARA CORTIFOAM HUMATROPE NUWIQ SUBSYS ZYLET~ COSENTYX HYALGAN OGIVRI SULCONAZOLE ZYTIGA 250 MG^ (currently excluded), HYMOVIS OMNARIS SUPARTZ FX ZYTIGA 500 MG^~ ^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded. ~ Medications will be excluded beginning 07/01/2021.

© 2021 Express Scripts. All Rights Reserved. #2884 All trademarks are the property of their respective owners. Page 18 DL44109Q-BJC-21 (04/01/2021)

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