CVS Formulary Drug Listing

January 2021 Updated 11/01/2020

Performance Drug List - Standard Control

The CVS Caremark® Performance Drug List - Standard Control is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a doctor. on this list.

Please note: Please note: • Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in • The member's prescription benefit plan design may alter coverage this document. Products recently approved by the U.S. Food and of certain products or vary copay1 amounts based on the condition Drug Administration (FDA) may not be covered upon release being treated. to the market. • This drug list represents a summary of prescription coverage. It is • Your prescription benefit plan design may alter coverage of certain not all-inclusive and does not guarantee coverage. The member’s products or vary copay1 amounts based on the condition being specific prescription benefit plan design may not cover certain treated. products or categories, regardless of their appearance in this • You may be responsible for the full cost of non-formulary products document. Products recently approved by the FDA may not be that are removed from coverage. covered upon release to the market. • For specific information regarding your prescription benefit • The member's prescription benefit plan may have a different coverage and copay1 information, please visit Caremark.com copay1 for specific products on the list. or contact a CVS Caremark Customer Care representative. • Unless specifically indicated, drug list products will include all • CVS Caremark may contact your doctor after receiving your dosage forms. prescription to request consideration of a drug list product or • Log in to Caremark.com to check coverage and copay1 generic equivalent. This may result in your doctor prescribing, information for a specific medicine. when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.

ANALGESICS § OPIOID ANALGESICS VISCOSUPPLEMENTS § FLUOROQUINOLONES ANTIRETROVIRAL AGENTS buprenorphine transdermal DUROLANE ciprofloxacin § ANTIRETROVIRAL § NSAIDs codeine-acetaminophen EUFLEXXA levofloxacin COMBINATIONS diclofenac sodium fentanyl transdermal GELSYN-3 moxifloxacin abacavir-lamivudine ibuprofen fentanyl transmucosal SUPARTZ FX ATRIPLA meloxicam § PENICILLINS lozenge BIKTARVY naproxen (except naproxen CR or ANTI-INFECTIVES amoxicillin hydrocodone ext-rel CIMDUO naproxen suspension) hydrocodone-acetaminophen amoxicillin-clavulanate ANTIBACTERIALS COMPLERA dicloxacillin § NSAIDs, COMBINATIONS hydromorphone DESCOVY § CEPHALOSPORINS penicillin VK hydromorphone ext-rel DOVATO diclofenac sodium- cefdinir methadone EVOTAZ misoprostol § TETRACYCLINES cefprozil morphine GENVOYA cefuroxime axetil doxycycline hyclate 20 mg § NSAIDs, TOPICAL morphine ext-rel ODEFSEY morphine suppository cephalexin doxycycline hyclate capsule diclofenac sodium gel 1% PREZCOBIX SUPRAX minocycline oxycodone diclofenac sodium solution STRIBILD oxycodone-acetaminophen tetracycline § ERYTHROMYCINS / SYMFI tramadol (except NDC^ 52817019610) § COX-2 INHIBITORS MACROLIDES § ANTIFUNGALS SYMFI LO celecoxib tramadol ext-rel SYMTUZA azithromycin fluconazole BELBUCA TEMIXYS clarithromycin itraconazole § GOUT NUCYNTA TRIUMEQ terbinafine tablet clarithromycin ext-rel allopurinol NUCYNTA ER TRUVADA erythromycins colchicine tablet SUBSYS DIFICID XTAMPZA ER probenecid

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.

INTEGRASE INHIBITORS § KINASE INHIBITORS § ANGIOTENSIN II § CALCIUM CHANNEL § MISCELLANEOUS ISENTRESS imatinib mesylate RECEPTOR ANTAGONIST / BLOCKERS ranolazine ext-rel TIVICAY AFINITOR CALCIUM CHANNEL amlodipine

ALECENSA BLOCKER / DIURETIC diltiazem ext-rel (except generics CENTRAL NERVOUS § NUCLEOSIDE REVERSE ALUNBRIG COMBINATIONS for CARDIZEM LA) SYSTEM TRANSCRIPTASE BOSULIF amlodipine-valsartan- nifedipine ext-rel INHIBITORS ANTIANXIETY CABOMETYX hydrochlorothiazide verapamil ext-rel § BENZODIAZEPINES abacavir tablet COPIKTRA olmesartan-amlodipine- § CALCIUM CHANNEL lamivudine IBRANCE hydrochlorothiazide alprazolam BLOCKER / ANTILIPEMIC IRESSA clonazepam § PROTEASE INHIBITORS § ANTIARRHYTHMICS COMBINATIONS KISQALI diazepam atazanavir KISQALI FEMARA sotalol amlodipine-atorvastatin lorazepam

NORVIR CO-PACK MULTAQ oxazepam § DIGITALIS GLYCOSIDES PREZISTA RYDAPT ANTILIPEMICS § ANTICONVULSANTS SPRYCEL digoxin ANTIVIRALS ACL INHIBITORS / carbamazepine XOSPATA § DIRECT RENIN § CYTOMEGALOVIRUS COMBINATIONS carbamazepine ext-rel AGENTS INHIBITORS / DIURETIC MULTIPLE MYELOMA NEXLETOL clobazam COMBINATIONS valganciclovir PROTEASOME INHIBITORS NEXLIZET diazepam rectal gel aliskiren divalproex sodium NINLARO § HEPATITIS B AGENTS § BILE ACID RESINS TEKTURNA HCT divalproex sodium ext-rel VELCADE entecavir cholestyramine ethosuximide § DIURETICS lamivudine § MISCELLANEOUS colesevelam gabapentin amiloride VEMLIDY ERIVEDGE lamotrigine § CHOLESTEROL furosemide LYNPARZA lamotrigine ext-rel § HEPATITIS C AGENTS ABSORPTION INHIBITORS hydrochlorothiazide ODOMZO levetiracetam ribavirin metolazone PERJETA ezetimibe levetiracetam ext-rel EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) spironolactone- PHESGO oxcarbazepine HARVONI (genotypes 1, 4, 5, 6) § FIBRATES hydrochlorothiazide RUBRACA phenobarbital VOSEVI 2 fenofibrate (except fenofibrate torsemide phenytoin VISTOGARD tablet 120 mg) triamterene phenytoin sodium extended § HERPES AGENTS ZEJULA fenofibric acid delayed-rel triamterene- primidone acyclovir capsule, tablet CARDIOVASCULAR hydrochlorothiazide tiagabine § HMG-CoA REDUCTASE valacyclovir topiramate § ACE INHIBITORS INHIBITORS / HEART FAILURE valproic acid § INFLUENZA AGENTS COMBINATIONS BIDIL fosinopril vigabatrin oseltamivir CORLANOR lisinopril atorvastatin zonisamide RELENZA ENTRESTO quinapril ezetimibe-simvastatin FYCOMPA

ramipril fluvastatin NAYZILAM § MISCELLANEOUS § NITRATES lovastatin OXTELLAR XR clindamycin § ACE INHIBITOR / isosorbide dinitrate (except pravastatin TROKENDI XR ivermectin DIURETIC COMBINATIONS isosorbide dinitrate 40 mg) rosuvastatin VALTOCO linezolid isosorbide mononitrate fosinopril-hydrochlorothiazide simvastatin VIMPAT metronidazole nitroglycerin lingual spray lisinopril-hydrochlorothiazide XCOPRI § NIACINS nitrofurantoin quinapril-hydrochlorothiazide nitroglycerin sublingual pyrimethamine niacin ext-rel § ANTIDEMENTIA sulfamethoxazole- § ANGIOTENSIN II PULMONARY ARTERIAL donepezil trimethoprim RECEPTOR ANTAGONISTS / § OMEGA-3 FATTY ACIDS HYPERTENSION galantamine vancomycin capsule DIURETIC COMBINATIONS omega-3 acid ethyl esters § ENDOTHELIN RECEPTOR galantamine ext-rel EMVERM VASCEPA ANTAGONISTS candesartan / candesartan- memantine XIFAXAN 550 MG hydrochlorothiazide ambrisentan PCSK9 INHIBITORS rivastigmine irbesartan / irbesartan- bosentan rivastigmine transdermal ANTINEOPLASTIC hydrochlorothiazide PRALUENT OPSUMIT NAMZARIC AGENTS losartan / losartan- § BETA-BLOCKERS § PHOSPHODIESTERASE HORMONAL hydrochlorothiazide ANTIDEPRESSANTS atenolol INHIBITORS ANTINEOPLASTIC AGENTS olmesartan / olmesartan- § SELECTIVE SEROTONIN carvedilol hydrochlorothiazide sildenafil REUPTAKE INHIBITORS § ANTIANDROGENS carvedilol phosphate ext-rel telmisartan / telmisartan- (SSRIs) abiraterone metoprolol succinate ext-rel PROSTACYCLIN RECEPTOR

hydrochlorothiazide bicalutamide metoprolol tartrate AGONISTS citalopram valsartan / valsartan- ERLEADA nadolol escitalopram hydrochlorothiazide UPTRAVI fluoxetine (except fluoxetine tablet 60 mg, NUBEQA pindolol

XTANDI § ANGIOTENSIN II propranolol § PROSTAGLANDIN fluoxetine tablet [generics for SARAFEM]) paroxetine HCl YONSA RECEPTOR ANTAGONIST / propranolol ext-rel VASODILATORS CALCIUM CHANNEL BYSTOLIC ORENITRAM paroxetine HCl ext-rel § LUTEINIZING HORMONE- BLOCKER COMBINATIONS sertraline RELEASING HORMONE SOLUBLE GUANYLATE TRINTELLIX amlodipine-olmesartan (LHRH) AGONISTS CYCLASE STIMULATORS amlodipine-telmisartan ELIGARD ADEMPAS

amlodipine-valsartan LUPRON DEPOT

§ SEROTONIN ramelteon PSYCHOTHERAPEUTIC - INSULINS DEXCOM CONTINUOUS NOREPINEPHRINE zolpidem MISCELLANEOUS BASAGLAR GLUCOSE REUPTAKE INHIBITORS zolpidem ext-rel § OPIOID ANTAGONISTS FIASP MONITORING SYSTEM (SNRIs) zolpidem sublingual OMNIPOD DASH INSULIN naloxone injection HUMULIN R U-500 BELSOMRA INFUSION PUMP desvenlafaxine ext-rel LEVEMIR NARCAN NASAL SPRAY duloxetine NOVOLIN 70/30 OMNIPOD INSULIN § TRICYCLICS venlafaxine § PARTIAL OPIOID AGONIST / NOVOLIN N INFUSION PUMP doxepin venlafaxine ext-rel capsule OPIOID ANTAGONIST NOVOLIN R ONETOUCH ULTRA 3 COMBINATIONS NOVOLOG STRIPS AND KITS § MISCELLANEOUS MIGRAINE buprenorphine-naloxone NOVOLOG MIX 70/30 ONETOUCH VERIO AGENTS ACUTE MIGRAINE AGENTS 3 sublingual TOUJEO STRIPS AND KITS § Triptans bupropion ZUBSOLV TRESIBA V-GO INSULIN bupropion ext-rel (except eletriptan INFUSION PUMP

bupropion ext-rel tablet 450 mg) naratriptan PSEUDOBULBAR AFFECT § INSULIN SENSITIZERS ANTIOBESITY mirtazapine rizatriptan AGENTS pioglitazone trazodone sumatriptan NUEDEXTA SAXENDA § INSULIN SENSITIZER / zolmitriptan § ANTIPARKINSONIAN § VASOMOTOR SYMPTOM BIGUANIDE COMBINATIONS § CALCIUM RECEPTOR ONZETRA XSAIL AGENTS AGENTS ANTAGONISTS ZEMBRACE SYMTOUCH pioglitazone-metformin cinacalcet amantadine ZOMIG NASAL SPRAY paroxetine mesylate § INSULIN SENSITIZER / carbidopa-levodopa SULFONYLUREA CALCIUM REGULATORS carbidopa-levodopa ext-rel Miscellaneous ENDOCRINE AND COMBINATIONS § BISPHOSPHONATES carbidopa-levodopa- NURTEC ODT METABOLIC entacapone REYVOW pioglitazone-glimepiride alendronate ACROMEGALY entacapone UBRELVY ibandronate SOMATULINE DEPOT § MEGLITINIDES pramipexole risedronate pramipexole ext-rel PREVENTIVE MIGRAINE nateglinide § ANDROGENS § CALCITONINS rasagiline AGENTS repaglinide testosterone gel (except authorized ropinirole Monoclonal Antibodies calcitonin-salmon generics for TESTIM and VOGELXO) SODIUM-GLUCOSE ropinirole ext-rel AIMOVIG testosterone solution CO-TRANSPORTER 2 PARATHYROID HORMONES selegiline AJOVY ANDRODERM (SGLT2) INHIBITORS FORTEO INBRIJA EMGALITY FARXIGA TYMLOS

NEUPRO ANTIDIABETICS § MOVEMENT DISORDERS JARDIANCE AMYLIN ANALOGS MISCELLANEOUS ANTIPSYCHOTICS tetrabenazine SYMLINPEN SODIUM-GLUCOSE PROLIA § ATYPICALS AUSTEDO CO-TRANSPORTER 2 aripiprazole INGREZZA § BIGUANIDES (SGLT2) INHIBITOR / § CARNITINE DEFICIENCY clozapine AGENTS § MULTIPLE SCLEROSIS metformin BIGUANIDE COMBINATIONS olanzapine AGENTS metformin ext-rel (except generics SYNJARDY levocarnitine quetiapine for FORTAMET and GLUMETZA) SYNJARDY XR quetiapine ext-rel dimethyl fumarate CONTRACEPTIVES XIGDUO XR delayed-rel risperidone § BIGUANIDE / § MONOPHASIC glatiramer ziprasidone SULFONYLUREA SODIUM-GLUCOSE ethinyl estradiol- AUBAGIO ABILIFY MAINTENA COMBINATIONS CO-TRANSPORTER 2 drospirenone BETASERON LATUDA glipizide-metformin (SGLT2) INHIBITOR / ethinyl estradiol- COPAXONE PERSERIS DIPEPTIDYL PEPTIDASE-4 drospirenone-levomefolate GILENYA VRAYLAR DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR ethinyl estradiol- KESIMPTA (DPP-4) INHIBITORS COMBINATIONS norethindrone acetate § ATTENTION DEFICIT MAYZENT JANUVIA GLYXAMBI ethinyl estradiol- HYPERACTIVITY DISORDER OCREVUS norethindrone acetate-iron amphetamine- REBIF DIPEPTIDYL PEPTIDASE-4 SODIUM-GLUCOSE dextroamphetamine TYSABRI (DPP-4) INHIBITOR / CO-TRANSPORTER 2 BIPHASIC VUMERITY BIGUANIDE COMBINATIONS mixed salts (SGLT2) INHIBITOR / LO LOESTRIN FE amphetamine- ZEPOSIA JANUMET DIPEPTIDYL PEPTIDASE-4

dextroamphetamine JANUMET XR (DPP-4) INHIBITOR / § TRIPHASIC † § MUSCULOSKELETAL mixed salts ext-rel BIGUANIDE COMBINATIONS ethinyl estradiol-norgestimate THERAPY AGENTS INCRETIN MIMETIC AGENTS atomoxetine TRIJARDY XR guanfacine ext-rel cyclobenzaprine (except OZEMPIC § EXTENDED CYCLE methylphenidate cyclobenzaprine tablet 7.5 mg) RYBELSUS § SULFONYLUREAS ethinyl estradiol- † methylphenidate ext-rel TRULICITY glimepiride levonorgestrel § NARCOLEPSY MYDAYIS VICTOZA glipizide armodafinil PROGESTIN INTRAUTERINE VYVANSE glipizide ext-rel SUNOSI INCRETIN MIMETIC AGENT / DEVICES § FIBROMYALGIA INSULIN COMBINATIONS SUPPLIES POSTHERPETIC KYLEENA pregabalin SOLIQUA NEURALGIA (PHN) BD ULTRAFINE MIRENA XULTOPHY INSULIN SYRINGES SKYLA HYPNOTICS GRALISE AND NEEDLES § NONBENZODIAZEPINES eszopiclone

§ TRANSDERMAL § PHOSPHATE BINDER sulfasalazine § URINARY § DISEASE-MODIFYING ethinyl estradiol- AGENTS sulfasalazine delayed-rel ANTISPASMODICS ANTIRHEUMATIC DRUGS norelgestromin calcium acetate PENTASA darifenacin ext-rel (DMARDs)

sevelamer carbonate oxybutynin RASUVO § VAGINAL § RECTAL AGENTS PHOSLYRA oxybutynin ext-rel hydrocortisone enema HEREDITARY ANGIOEDEMA ethinyl estradiol-etonogestrel VELPHORO solifenacin mesalamine suppository ANNOVERA tolterodine FIRAZYR POLYNEUROPATHY mesalamine suspension tolterodine ext-rel RUCONEST ENDOMETRIOSIS CORTIFOAM TEGSEDI trospium TAKHZYRO

ORILISSA trospium ext-rel POTASSIUM-REMOVING § IRRITABLE BOWEL IMMUNOSUPPRESSANTS MYRBETRIQ FERTILITY REGULATORS AGENTS SYNDROME TOVIAZ § RAPAMYCIN DERIVATIVES GNRH / LHRH alosetron LOKELMA everolimus ANTAGONISTS VELTASSA LINZESS HEMATOLOGIC

CETROTIDE VIBERZI NUTRITIONAL / PROGESTINS § ANTICOAGULANTS SUPPLEMENTS § LAXATIVES OVULATION STIMULANTS, § ORAL warfarin GONADOTROPINS lactulose solution § ELECTROLYTES medroxyprogesterone ELIQUIS peg 3350-electrolytes GONAL-F megestrol acetate XARELTO potassium chloride liquid CLENPIQ OVIDREL progesterone, micronized HEMATOPOIETIC GROWTH VITAMINS AND MINERALS GAUCHER DISEASE VAGINAL OPIOID-INDUCED FACTORS § FOLIC ACID / CONSTIPATION CERDELGA CRINONE ARANESP COMBINATIONS MOVANTIK CEREZYME ENDOMETRIN NIVESTYM folic acid SYMPROIC RETACRIT

§ GLUCOCORTICOIDS § SELECTIVE ESTROGEN ZIEXTENZO § PRENATAL VITAMINS PANCREATIC ENZYMES dexamethasone RECEPTOR MODULATORS prenatal vitamins CREON HEMOPHILIA A AGENTS fludrocortisone raloxifene CITRANATAL hydrocortisone VIOKACE ADYNOVATE methylprednisolone § THYROID SUPPLEMENTS ZENPEP JIVI RESPIRATORY prednisolone solution levothyroxine KOGENATE FS § PROTON PUMP ALPHA-1 ANTITRYPSIN prednisone liothyronine KOVALTRY INHIBITORS DEFICIENCY AGENTS SYNTHROID NOVOEIGHT esomeprazole GLUCOSE ELEVATING NUWIQ PROLASTIN-C

AGENTS GASTROINTESTINAL lansoprazole § ANAPHYLAXIS BAQSIMI omeprazole HEMOPHILIA B AGENTS § ANTIDIARRHEALS TREATMENT AGENTS GLUCAGEN HYPOKIT pantoprazole REBINYN GLUCAGON diphenoxylate-atropine DEXILANT epinephrine auto-injector § PLATELET AGGREGATION EPIPEN EMERGENCY KIT loperamide § STEROIDS, RECTAL INHIBITORS EPIPEN JR GVOKE § ANTIEMETICS PROCTOFOAM-HC clopidogrel SYMJEPI

HEREDITARY TYROSINEMIA aprepitant dipyridamole ext-rel-aspirin § ULCER THERAPY § ANTICHOLINERGICS TYPE 1 AGENTS doxylamine-pyridoxine prasugrel COMBINATIONS ipratropium ORFADIN delayed-rel BRILINTA dronabinol PYLERA inhalation solution

HUMAN GROWTH granisetron THROMBOCYTOPENIA SPIRIVA § MISCELLANEOUS HORMONES meclizine AGENTS YUPELRI sucralfate tablet GENOTROPIN metoclopramide DOPTELET ANTICHOLINERGIC / BETA NORDITROPIN ondansetron MULPLETA GENITOURINARY AGONIST COMBINATIONS prochlorperazine MENOPAUSAL SYMPTOM promethazine § BENIGN PROSTATIC IMMUNOLOGIC § SHORT ACTING AGENTS scopolamine transdermal HYPERPLASIA AGENTS ipratropium-albuterol § ORAL trimethobenzamide inhalation solution alfuzosin ext-rel ALLERGENIC EXTRACTS SANCUSO estradiol doxazosin GRASTEK LONG ACTING estradiol-norethindrone dutasteride § ANTISPASMODICS ORALAIR ANORO ELLIPTA DUAVEE dutasteride-tamsulosin dicyclomine RAGWITEK STIOLTO RESPIMAT PREMPHASE finasteride PREMPRO 4 § H2 RECEPTOR silodosin AUTOIMMUNE AGENTS ANTICHOLINERGIC / BETA

tamsulosin § TRANSDERMAL ANTAGONISTS COSENTYX AGONIST / STEROID terazosin famotidine ENBREL INHALANT COMBINATIONS estradiol HUMIRA BREZTRI AEROSPHERE CLIMARA PRO ERECTILE DYSFUNCTION INFLAMMATORY BOWEL OTEZLA TRELEGY ELLIPTA COMBIPATCH ALPROSTADIL AGENTS DISEASE RINVOQ DIVIGEL § ORAL AGENTS MUSE SKYRIZI § ANTIHISTAMINES, LOW EVAMIST STELARA SEDATING balsalazide § PHOSPHODIESTERASE SUBCUTANEOUS levocetirizine § VAGINAL budesonide capsule INHIBITORS TREMFYA estradiol budesonide ext-rel sildenafil XELJANZ IMVEXXY mesalamine delayed-rel tadalafil XELJANZ XR mesalamine ext-rel

§ ANTITUSSIVES STEROID / BETA AGONIST calcipotriene ointment, cromolyn sodium § CARBONIC ANHYDRASE benzonatate (except NDCs^ COMBINATIONS solution olopatadine INHIBITORS methoxsalen LASTACAFT ADVAIR DISKUS dorzolamide 69336012615, 69499032915) ADVAIR HFA PAZEO AZOPT § ANTISEBORRHEICS BETA AGONISTS, BREO ELLIPTA ketoconazole shampoo 2% § ANTI-INFECTIVES § CARBONIC ANHYDRASE INHALANTS SYMBICORT § SHORT ACTING selenium sulfide lotion 2.5% ciprofloxacin INHIBITOR / BETA- § STEROID INHALANTS erythromycin BLOCKER COMBINATIONS albuterol inhalation solution ATOPIC DERMATITIS budesonide gentamicin dorzolamide-timolol albuterol sulfate Injectable inhalation suspension levofloxacin CFC-free aerosol CARBONIC ANHYDRASE ARNUITY ELLIPTA DUPIXENT moxifloxacin levalbuterol tartrate INHIBITOR / FLOVENT DISKUS ofloxacin CFC-free aerosol § Topical SYMPATHOMIMETIC FLOVENT HFA sulfacetamide pimecrolimus COMBINATIONS LONG ACTING PULMICORT FLEXHALER tobramycin tacrolimus BESIVANCE Hand-held Active Inhalation QVAR REDIHALER SIMBRINZA EUCRISA CILOXAN OINTMENT SEREVENT TOPICAL DRY EYE DISEASE CORTICOSTEROIDS STRIVERDI RESPIMAT § ANTI-INFECTIVE / RESTASIS DERMATOLOGY § Low Potency ANTI-INFLAMMATORY XIIDRA Nebulized Passive Inhalation ACNE desonide COMBINATIONS PERFOROMIST neomycin-polymyxin B- § PROSTAGLANDINS § Topical hydrocortisone bacitracin-hydrocortisone latanoprost § CYSTIC FIBROSIS adapalene § Medium Potency neomycin-polymyxin B- travoprost tobramycin benzoyl peroxide hydrocortisone butyrate dexamethasone LUMIGAN inhalation solution clindamycin gel (except NDC^ cream, lotion, ointment, ZIOPTAN 68682046275) tobramycin-dexamethasone BETHKIS solution TOBRADEX OINTMENT clindamycin solution RETINAL DISORDERS § LEUKOTRIENE clindamycin-benzoyl mometasone TOBRADEX ST triamcinolone cream, lotion, EYLEA MODULATORS peroxide ointment ANTI-INFLAMMATORIES LUCENTIS montelukast erythromycin solution § Nonsteroidal zafirlukast erythromycin-benzoyl § High Potency RHO KINASE INHIBITORS peroxide bromfenac zileuton ext-rel RHOPRESSA desoximetasone tretinoin diclofenac fluocinonide (except fluocinonide § NASAL ANTIHISTAMINES EPIDUO ketorolac RHO KINASE INHIBITOR / cream 0.1%) azelastine ONEXTON ACUVAIL PROSTAGLANDIN BRYHALI ILEVRO olopatadine COMBINATIONS § ACTINIC KERATOSIS NEVANAC § Very High Potency ROCKLATAN § NASAL STEROIDS / fluorouracil cream 5% clobetasol cream, foam, gel, § Steroidal COMBINATIONS fluorouracil solution § SYMPATHOMIMETICS lotion, ointment, shampoo dexamethasone flunisolide imiquimod brimonidine loteprednol fluticasone PICATO § LOCAL ANESTHETICS ALPHAGAN P mometasone TOLAK prednisolone acetate 1% lidocaine-prilocaine DUREZOL DYMISTA ZYCLARA SYMPATHOMIMETIC / BETA- § ROSACEA FML FORTE BLOCKER COMBINATIONS PHOSPHODIESTERASE-4 § ANTIBIOTICS FML S.O.P. azelaic acid gel COMBIGAN INHIBITORS gentamicin MAXIDEX metronidazole DALIRESP mupirocin ointment PRED MILD OTIC FINACEA FOAM § ANTI-INFECTIVES PULMONARY FIBROSIS § ANTIFUNGALS ORACEA § ANTIVIRALS SOOLANTRA acetic acid AGENTS trifluridine ciclopirox ofloxacin otic ESBRIET clotrimazole MOUTH / THROAT / BETA-BLOCKERS OFEV econazole DENTAL AGENTS § ANTI-INFECTIVE /

ketoconazole cream 2% § Nonselective ANTI-INFLAMMATORY SEVERE ASTHMA AGENTS PROTECTANTS luliconazole timolol maleate solution COMBINATIONS EPISIL DUPIXENT nystatin BETIMOL ciprofloxacin-dexamethasone MUGARD FASENRA NAFTIN neomycin-polymyxin B- NUCALA Selective OPHTHALMIC hydrocortisone XOLAIR § ANTIPSORIATICS BETOPTIC S § ANTIALLERGICS acitretin azelastine QUICK REFERENCE DRUG LIST

A acitretin ADYNOVATE ALECENSA alprazolam ACUVAIL AFINITOR alendronate ALUNBRIG abacavir tablet acyclovir capsule, tablet AIMOVIG alfuzosin ext-rel amantadine abacavir-lamivudine adapalene AJOVY aliskiren ambrisentan ABILIFY MAINTENA ADEMPAS albuterol inhalation solution allopurinol amiloride abiraterone ADVAIR DISKUS albuterol sulfate alosetron amlodipine acetic acid ADVAIR HFA CFC-free aerosol ALPHAGAN P amlodipine-atorvastatin

amlodipine-olmesartan bupropion CRINONE entacapone fluorouracil solution amlodipine-telmisartan bupropion ext-rel (except cromolyn sodium entecavir fluoxetine (except fluoxetine tablet 60 mg, amlodipine-valsartan bupropion ext-rel tablet 450 mg) cyclobenzaprine (except ENTRESTO fluoxetine tablet [generics for SARAFEM]) amlodipine-valsartan- BYSTOLIC cyclobenzaprine tablet 7.5 mg) EPCLUSA fluticasone hydrochlorothiazide EPIDUO fluvastatin amoxicillin C D epinephrine auto-injector FML FORTE amoxicillin-clavulanate CABOMETYX DALIRESP EPIPEN FML S.O.P. amphetamine- calcipotriene ointment, darifenacin ext-rel EPIPEN JR folic acid dextroamphetamine solution DESCOVY EPISIL FORTEO mixed salts calcitonin-salmon desonide ERIVEDGE fosinopril amphetamine- calcium acetate desoximetasone ERLEADA fosinopril-hydrochlorothiazide dextroamphetamine candesartan desvenlafaxine ext-rel erythromycin furosemide † mixed salts ext-rel candesartan- dexamethasone erythromycin solution FYCOMPA

ANDRODERM hydrochlorothiazide DEXCOM CONTINUOUS erythromycin-benzoyl ANNOVERA carbamazepine GLUCOSE peroxide G ANORO ELLIPTA carbamazepine ext-rel MONITORING SYSTEM erythromycins gabapentin aprepitant carbidopa-levodopa DEXILANT ESBRIET galantamine ARANESP carbidopa-levodopa ext-rel diazepam escitalopram galantamine ext-rel aripiprazole carbidopa-levodopa- diazepam rectal gel esomeprazole GELSYN-3 armodafinil entacapone diclofenac estradiol GENOTROPIN ARNUITY ELLIPTA carvedilol diclofenac sodium estradiol-norethindrone gentamicin atazanavir carvedilol phosphate ext-rel diclofenac sodium gel 1% eszopiclone GENVOYA atenolol cefdinir diclofenac sodium solution ethinyl estradiol- GILENYA atomoxetine cefprozil diclofenac sodium- drospirenone glatiramer atorvastatin cefuroxime axetil misoprostol ethinyl estradiol- glimepiride ATRIPLA celecoxib dicloxacillin drospirenone-levomefolate glipizide AUBAGIO cephalexin dicyclomine ethinyl estradiol-etonogestrel glipizide ext-rel AUSTEDO CERDELGA DIFICID ethinyl estradiol- glipizide-metformin azelaic acid gel CEREZYME digoxin levonorgestrel GLUCAGEN HYPOKIT azelastine CETROTIDE diltiazem ext-rel (except generics ethinyl estradiol- GLUCAGON azithromycin cholestyramine for CARDIZEM LA) norelgestromin EMERGENCY KIT AZOPT ciclopirox dimethyl fumarate ethinyl estradiol- GLYXAMBI

CILOXAN OINTMENT delayed-rel norethindrone acetate GONAL-F B CIMDUO diphenoxylate-atropine ethinyl estradiol- GRALISE balsalazide cinacalcet dipyridamole ext-rel-aspirin norethindrone acetate-iron granisetron BAQSIMI ciprofloxacin divalproex sodium ethinyl estradiol-norgestimate GRASTEK BASAGLAR ciprofloxacin-dexamethasone divalproex sodium ext-rel ethosuximide guanfacine ext-rel BD ULTRAFINE citalopram DIVIGEL EUCRISA GVOKE INSULIN SYRINGES CITRANATAL donepezil EUFLEXXA AND NEEDLES clarithromycin DOPTELET EVAMIST H BELBUCA clarithromycin ext-rel dorzolamide everolimus HARVONI BELSOMRA CLENPIQ dorzolamide-timolol EVOTAZ HUMIRA benzonatate (except NDCs^ CLIMARA PRO DOVATO EYLEA HUMULIN R U-500

69336012615, 69499032915) clindamycin doxazosin ezetimibe hydrochlorothiazide ezetimibe-simvastatin benzoyl peroxide clindamycin gel (except NDC^ doxepin hydrocodone ext-rel

BESIVANCE 68682046275) doxycycline hyclate 20 mg hydrocodone-acetaminophen F BETASERON clindamycin solution doxycycline hyclate capsule hydrocortisone BETHKIS clindamycin-benzoyl doxylamine-pyridoxine famotidine hydrocortisone butyrate BETIMOL peroxide delayed-rel FARXIGA cream, lotion, ointment, BETOPTIC S clobazam dronabinol FASENRA solution bicalutamide clobetasol cream, foam, gel, DUAVEE fenofibrate (except fenofibrate hydrocortisone enema BIDIL lotion, ointment, shampoo duloxetine tablet 120 mg) hydromorphone BIKTARVY clonazepam DUPIXENT fenofibric acid delayed-rel hydromorphone ext-rel bosentan clopidogrel DUREZOL fentanyl transdermal BOSULIF clotrimazole DUROLANE fentanyl transmucosal I BREO ELLIPTA clozapine dutasteride lozenge ibandronate BREZTRI AEROSPHERE codeine-acetaminophen dutasteride-tamsulosin FIASP IBRANCE BRILINTA colchicine tablet DYMISTA FINACEA FOAM ibuprofen brimonidine colesevelam finasteride ILEVRO E bromfenac COMBIGAN FIRAZYR imatinib mesylate BRYHALI COMBIPATCH econazole FLOVENT DISKUS imiquimod budesonide capsule COMPLERA eletriptan FLOVENT HFA IMVEXXY budesonide ext-rel COPAXONE ELIGARD fluconazole INBRIJA budesonide COPIKTRA ELIQUIS fludrocortisone INGREZZA inhalation suspension CORLANOR EMGALITY flunisolide ipratropium buprenorphine transdermal CORTIFOAM EMVERM fluocinonide (except fluocinonide inhalation solution buprenorphine-naloxone COSENTYX ENBREL cream 0.1%) ipratropium-albuterol sublingual CREON ENDOMETRIN fluorouracil cream 5% inhalation solution

irbesartan M nitroglycerin lingual spray paroxetine HCl ext-rel repaglinide irbesartan- nitroglycerin sublingual paroxetine mesylate RESTASIS MAXIDEX hydrochlorothiazide NIVESTYM PAZEO RETACRIT MAYZENT IRESSA NORDITROPIN peg 3350-electrolytes REYVOW meclizine ISENTRESS NORVIR penicillin VK RHOPRESSA medroxyprogesterone isosorbide dinitrate (except NOVOEIGHT PENTASA ribavirin megestrol acetate isosorbide dinitrate 40 mg) NOVOLIN 70/30 PERFOROMIST RINVOQ meloxicam isosorbide mononitrate NOVOLIN N PERJETA risedronate memantine itraconazole NOVOLIN R PERSERIS risperidone mesalamine delayed-rel ivermectin NOVOLOG phenobarbital rivastigmine mesalamine ext-rel NOVOLOG MIX 70/30 phenytoin rivastigmine transdermal mesalamine suppository J NUBEQA phenytoin sodium extended rizatriptan mesalamine suspension JANUMET NUCALA PHESGO ROCKLATAN metformin JANUMET XR NUCYNTA PHOSLYRA ropinirole metformin ext-rel (except generics JANUVIA NUCYNTA ER PICATO ropinirole ext-rel for FORTAMET and GLUMETZA) JARDIANCE NUEDEXTA pimecrolimus rosuvastatin methadone JIVI NURTEC ODT pindolol RUBRACA methoxsalen NUWIQ pioglitazone RUCONEST methylphenidate K nystatin pioglitazone-glimepiride RYBELSUS methylphenidate ext-rel † pioglitazone-metformin RYDAPT KESIMPTA methylprednisolone O potassium chloride liquid ketoconazole cream 2% metoclopramide OCREVUS PRALUENT S ketoconazole shampoo 2% metolazone ODEFSEY pramipexole SANCUSO ketorolac metoprolol succinate ext-rel ODOMZO pramipexole ext-rel SAXENDA KISQALI metoprolol tartrate OFEV prasugrel scopolamine transdermal KISQALI FEMARA metronidazole ofloxacin pravastatin selegiline CO-PACK minocycline ofloxacin otic PRED MILD selenium sulfide lotion 2.5% KOGENATE FS MIRENA olanzapine prednisolone acetate 1% SEREVENT KOVALTRY mirtazapine olmesartan prednisolone solution sertraline KYLEENA mometasone olmesartan-amlodipine- prednisone sevelamer carbonate montelukast L hydrochlorothiazide pregabalin sildenafil morphine olmesartan- PREMPHASE silodosin lactulose solution morphine ext-rel hydrochlorothiazide PREMPRO SIMBRINZA lamivudine morphine suppository olopatadine prenatal vitamins simvastatin lamotrigine MOVANTIK omega-3 acid ethyl esters PREZCOBIX SKYLA lamotrigine ext-rel moxifloxacin omeprazole PREZISTA SKYRIZI lansoprazole MUGARD OMNIPOD DASH INSULIN primidone solifenacin LASTACAFT MULPLETA INFUSION PUMP probenecid SOLIQUA latanoprost MULTAQ OMNIPOD INSULIN prochlorperazine SOMATULINE DEPOT LATUDA mupirocin ointment INFUSION PUMP PROCTOFOAM-HC SOOLANTRA levalbuterol tartrate MUSE ondansetron progesterone, micronized sotalol CFC-free aerosol MYDAYIS ONETOUCH ULTRA PROLASTIN-C SPIRIVA LEVEMIR MYRBETRIQ 3 levetiracetam STRIPS AND KITS PROLIA spironolactone- levetiracetam ext-rel N ONETOUCH VERIO promethazine hydrochlorothiazide STRIPS AND KITS 3 propranolol SPRYCEL levocarnitine nadolol ONEXTON propranolol ext-rel STELARA levocetirizine NAFTIN ONZETRA XSAIL PULMICORT FLEXHALER SUBCUTANEOUS levofloxacin naloxone injection OPSUMIT PYLERA STIOLTO RESPIMAT levothyroxine NAMZARIC lidocaine-prilocaine ORACEA pyrimethamine STRIBILD naproxen (except naproxen CR ORALAIR STRIVERDI RESPIMAT linezolid or naproxen suspension) ORENITRAM Q SUBSYS LINZESS naratriptan ORFADIN quetiapine sucralfate tablet liothyronine NARCAN NASAL SPRAY ORILISSA quetiapine ext-rel sulfacetamide lisinopril nateglinide oseltamivir quinapril sulfamethoxazole- lisinopril-hydrochlorothiazide NAYZILAM OTEZLA quinapril-hydrochlorothiazide trimethoprim LO LOESTRIN FE neomycin-polymyxin B- OVIDREL QVAR REDIHALER sulfasalazine LOKELMA bacitracin-hydrocortisone oxazepam sulfasalazine delayed-rel loperamide neomycin-polymyxin B- oxcarbazepine R sumatriptan lorazepam dexamethasone losartan neomycin-polymyxin B- OXTELLAR XR RAGWITEK SUNOSI oxybutynin raloxifene SUPARTZ FX losartan-hydrochlorothiazide hydrocortisone oxybutynin ext-rel ramelteon SUPRAX loteprednol NEUPRO oxycodone ramipril SYMBICORT lovastatin NEVANAC oxycodone-acetaminophen ranolazine ext-rel SYMFI LUCENTIS NEXLETOL luliconazole OZEMPIC rasagiline SYMFI LO NEXLIZET RASUVO SYMJEPI LUMIGAN niacin ext-rel P REBIF SYMLINPEN LUPRON DEPOT nifedipine ext-rel pantoprazole REBINYN SYMPROIC LYNPARZA NINLARO paroxetine HCl RELENZA SYMTUZA nitrofurantoin

SYNJARDY tobramycin TROKENDI XR V-GO INSULIN XTANDI SYNJARDY XR inhalation solution trospium INFUSION PUMP XULTOPHY SYNTHROID tobramycin-dexamethasone trospium ext-rel VIBERZI TOLAK TRULICITY VICTOZA Y T tolterodine TRUVADA vigabatrin YONSA tacrolimus tolterodine ext-rel TYMLOS VIMPAT YUPELRI tadalafil topiramate TYSABRI VIOKACE

TAKHZYRO torsemide VISTOGARD Z U 2 tamsulosin TOUJEO VOSEVI zafirlukast TEGSEDI TOVIAZ UBRELVY VRAYLAR ZEJULA TEKTURNA HCT tramadol (except NDC^ 52817019610) UPTRAVI VUMERITY ZEMBRACE SYMTOUCH telmisartan tramadol ext-rel VYVANSE ZENPEP telmisartan- travoprost V ZEPOSIA W hydrochlorothiazide trazodone valacyclovir ZIEXTENZO TEMIXYS TRELEGY ELLIPTA valganciclovir warfarin zileuton ext-rel terazosin TREMFYA valproic acid ZIOPTAN terbinafine tablet TRESIBA valsartan X ziprasidone testosterone gel (except authorized tretinoin valsartan-hydrochlorothiazide XARELTO zolmitriptan generics for TESTIM and VOGELXO) triamcinolone cream, lotion, VALTOCO XCOPRI zolpidem testosterone solution ointment vancomycin capsule XELJANZ zolpidem ext-rel tetrabenazine triamterene VASCEPA XELJANZ XR zolpidem sublingual tetracycline triamterene- VELCADE XIFAXAN 550 MG ZOMIG NASAL SPRAY tiagabine hydrochlorothiazide VELPHORO XIGDUO XR zonisamide timolol maleate solution trifluridine VELTASSA XIIDRA ZUBSOLV TIVICAY TRIJARDY XR VEMLIDY XOLAIR ZYCLARA TOBRADEX OINTMENT trimethobenzamide venlafaxine XOSPATA TOBRADEX ST TRINTELLIX venlafaxine ext-rel capsule XTAMPZA ER tobramycin TRIUMEQ verapamil ext-rel PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, ADZENYS ER, ADZENYS XR-ODT amphetamine- quetiapine, quetiapine ext-rel, risperidone, dextroamphetamine mixed salts ext-rel †, ziprasidone, LATUDA, VRAYLAR methylphenidate ext-rel †, MYDAYIS, VYVANSE ACANYA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), ALCORTIN A desonide, hydrocortisone clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, ALEVICYN GEL, ALEVICYN SG, desonide, hydrocortisone erythromycin-benzoyl peroxide, tretinoin, ALEVICYN SOLUTION EPIDUO, ONEXTON ALIQOPA COPIKTRA 5 3 ACCU-CHEK AVIVA PLUS STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS , ALLISON MEDICAL INSULIN SYRINGES 6 BD ULTRAFINE INSULIN SYRINGES ONETOUCH VERIO STRIPS AND KITS 3 ALORA estradiol, DIVIGEL, EVAMIST ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 ALPROLIX Consult doctor ACCU-CHEK GUIDE STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, ALREX azelastine, cromolyn sodium, olopatadine, ONETOUCH VERIO STRIPS AND KITS 3 LASTACAFT, PAZEO ACCU-CHEK SMARTVIEW STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, ALTOPREV atorvastatin, ezetimibe-simvastatin, ONETOUCH VERIO STRIPS AND KITS 3 fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin ACIPHEX, ACIPHEX SPRINKLE esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, ACTEMRA ENBREL, HUMIRA, RINVOQ, XELJANZ, QVAR REDIHALER XELJANZ XR AMITIZA LINZESS, MOVANTIK, SYMPROIC ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, AMRIX cyclobenzaprine tetracycline (except cyclobenzaprine tablet 7.5 mg) Activite folic acid ANDROGEL 1% testosterone gel (except authorized generics for TESTIM and VOGELXO), ACTOS pioglitazone testosterone solution, ANDRODERM acyclovir cream acyclovir capsule, acyclovir tablet, ANGELIQ estradiol-norethindrone, PREMPHASE, valacyclovir PREMPRO ANTARA fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* APEXICON E desoximetasone, BENZAC AC adapalene, benzoyl peroxide, fluocinonide (except fluocinonide cream 0.1%), clindamycin gel (except NDC^ 68682046275), BRYHALI clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, APIDRA FIASP, NOVOLOG erythromycin-benzoyl peroxide, tretinoin, APLENZIN bupropion, bupropion ext-rel EPIDUO, ONEXTON (except bupropion ext-rel tablet 450 mg) BENZACLIN adapalene, benzoyl peroxide, APOKYN INBRIJA clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- APTENSIO XR amphetamine- benzoyl peroxide, erythromycin solution, dextroamphetamine mixed salts ext-rel †, erythromycin-benzoyl peroxide, tretinoin, methylphenidate ext-rel †, MYDAYIS, EPIDUO, ONEXTON VYVANSE BENZIQ adapalene, benzoyl peroxide, ARALAST NP PROLASTIN-C clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID benzoyl peroxide, erythromycin solution, ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, erythromycin-benzoyl peroxide, tretinoin, meloxicam or naproxen (except naproxen CR EPIDUO, ONEXTON or naproxen suspension) WITH esomeprazole, benzonatate benzonatate lansoprazole, omeprazole, pantoprazole or (NDCs^ 69336012615, 69499032915 only) (except NDCs^ 69336012615, 69499032915) DEXILANT BEPREVE azelastine, cromolyn sodium, olopatadine, ASACOL HD balsalazide, mesalamine delayed-rel, LASTACAFT, PAZEO mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA BERINERT FIRAZYR, RUCONEST ASCENSIA STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, BETAPACE, BETAPACE AF sotalol ONETOUCH VERIO STRIPS AND KITS 3 BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT ASMANEX, ASMANEX HFA ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, BEYAZ ethinyl estradiol-drospirenone, QVAR REDIHALER ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, ethinyl estradiol-norethindrone acetate-iron irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN olmesartan, olmesartan-hydrochlorothiazide, BORTEZOMIB NINLARO, VELCADE telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide BREEZE 2 STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 ATOPADERM desonide, hydrocortisone Bupap diclofenac sodium, ibuprofen, ATROVENT HFA ipratropium inhalation solution, SPIRIVA, naproxen (except naproxen CR or YUPELRI naproxen suspension) AVENOVA Consult doctor bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel AVONEX dimethyl fumarate delayed-rel, glatiramer, (except bupropion ext-rel tablet 450 mg) AUBAGIO, BETASERON, COPAXONE, butalbital-acetaminophen tablet 50-300 mg, diclofenac sodium, ibuprofen, GILENYA, KESIMPTA, MAYZENT, BUTALBITAL-ACETAMINOPHEN naproxen (except naproxen CR or OCREVUS, REBIF, TYSABRI, VUMERITY, (NDC^ 69499034230 only) naproxen suspension) ZEPOSIA butalbital-acetaminophen-caffeine capsule diclofenac sodium, ibuprofen, AZELEX adapalene, benzoyl peroxide, naproxen (except naproxen CR or clindamycin gel (except NDC^ 68682046275), naproxen suspension) clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, BUTRANS buprenorphine transdermal, BELBUCA erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA AZESCO prenatal vitamins, CITRANATAL BYETTA OZEMPIC, RYBELSUS, TRULICITY, BARACLUDE TABLET entecavir, lamivudine, VEMLIDY VICTOZA BEAU RX Consult doctor CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, BECONASE AQ flunisolide, fluticasone, mometasone, ONZETRA XSAIL, REYVOW, UBRELVY, DYMISTA ZEMBRACE SYMTOUCH, BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, ZOMIG NASAL SPRAY irbesartan, irbesartan-hydrochlorothiazide, calcipotriene cream calcipotriene ointment, calcipotriene solution losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, calcipotriene-betamethasone calcipotriene ointment or calcipotriene telmisartan, telmisartan-hydrochlorothiazide, solution WITH desoximetasone, valsartan, valsartan-hydrochlorothiazide fluocinonide (except fluocinonide cream 0.1%) or BRYHALI BENSAL HP desonide, hydrocortisone calcitriol ointment calcipotriene ointment, calcipotriene solution

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* CAMBIA diclofenac sodium, ibuprofen, DARAPRIM pyrimethamine naproxen (except naproxen CR or naproxen suspension) DaVite folic acid CARAC fluorouracil cream 5%, fluorouracil solution, DAYTRANA amphetamine- † imiquimod, PICATO, TOLAK, ZYCLARA dextroamphetamine mixed salts ext-rel , methylphenidate ext-rel †, MYDAYIS, CARAFATE sucralfate tablet VYVANSE CARBINOXAMINE TABLET 6 MG levocetirizine DELZICOL balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, CARDIZEM, CARDIZEM CD, diltiazem ext-rel sulfasalazine delayed-rel, PENTASA CARDIZEM LA (except generics for CARDIZEM LA) DETROL LA darifenacin ext-rel, oxybutynin ext-rel, CARNITOR, CARNITOR SF levocarnitine solifenacin, tolterodine, tolterodine ext-rel, chlordiazepoxide-clidinium dicyclomine trospium, trospium ext-rel, MYRBETRIQ, (NDC^ 42494040901 only) TOVIAZ chlorzoxazone 375 mg, cyclobenzaprine dexchlorpheniramine levocetirizine chlorzoxazone 500 mg (NDC^ 73007001303 only), (except cyclobenzaprine tablet 7.5 mg) Dexifol folic acid chlorzoxazone 750 mg, CHLORZOXAZONE 250 MG Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, CIALIS sildenafil, tadalafil meloxicam, naproxen (except naproxen CR or CICATRACE Consult doctor naproxen suspension) CIMZIA COSENTYX, ENBREL, HUMIRA, OTEZLA, Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, RINVOQ, SKYRIZI, diclofenac sodium solution, ibuprofen, STELARA SUBCUTANEOUS, TREMFYA, meloxicam, naproxen (except naproxen CR or XELJANZ, XELJANZ XR naproxen suspension) CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic DIFFERIN LOTION adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin- CLINDAGEL erythromycin solution benzoyl peroxide, tretinoin, EPIDUO, clindamycin gel (NDC^ 68682046275 only) adapalene, benzoyl peroxide, ONEXTON clindamycin gel (except NDC^ 68682046275), diflorasone cream, diflorasone ointment desoximetasone, clindamycin solution, clindamycin- fluocinonide (except fluocinonide cream 0.1%), benzoyl peroxide, erythromycin solution, BRYHALI erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, clobetasol spray clobetasol foam ONZETRA XSAIL, REYVOW, UBRELVY, CLOBEX SPRAY clobetasol foam ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY COLAZAL balsalazide diltiazem ext-rel diltiazem ext-rel COLCRYS colchicine tablet (generics for CARDIZEM LA only) (except generics for CARDIZEM LA) CONSENSI amlodipine WITH celecoxib DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, 5 3 CONTOUR NEXT STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS , losartan, losartan-hydrochlorothiazide, 3 ONETOUCH VERIO STRIPS AND KITS olmesartan, olmesartan-hydrochlorothiazide, CONTOUR STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, telmisartan, telmisartan-hydrochlorothiazide, ONETOUCH VERIO STRIPS AND KITS 3 valsartan, valsartan-hydrochlorothiazide CONTRAVE SAXENDA Diphen Elixir levocetirizine CORDRAN OINTMENT hydrocortisone butyrate cream, DORAL doxepin, eszopiclone, ramelteon, zolpidem, hydrocortisone butyrate lotion, zolpidem ext-rel, zolpidem sublingual, hydrocortisone butyrate ointment, BELSOMRA hydrocortisone butyrate solution, DORYX, DORYX MPC doxycycline hyclate 20 mg, mometasone, triamcinolone cream, doxycycline hyclate capsule, minocycline, triamcinolone lotion, triamcinolone ointment tetracycline CoreMino doxycycline hyclate 20 mg, doxycycline doxepin cream desonide, hydrocortisone, pimecrolimus, hyclate capsule, minocycline, tetracycline tacrolimus, EUCRISA CRESTOR atorvastatin, ezetimibe-simvastatin, doxycycline hyclate delayed-rel tablet 200 mg doxycycline hyclate 20 mg, fluvastatin, lovastatin, pravastatin, doxycycline hyclate capsule, minocycline, rosuvastatin, simvastatin tetracycline cyclobenzaprine ext-rel capsule, cyclobenzaprine doxycycline hyclate tablet 50 mg doxycycline hyclate 20 mg, cyclobenzaprine tablet 7.5 mg (except cyclobenzaprine tablet 7.5 mg) (NDC^ 72143021160 only), doxycycline hyclate capsule, minocycline, CYMBALTA desvenlafaxine ext-rel, duloxetine, doxycycline hyclate tablet 75 mg, tetracycline venlafaxine, venlafaxine ext-rel capsule doxycycline hyclate tablet 150 mg

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* doxycycline monohydrate capsule 75 mg, doxycycline hyclate 20 mg, FABIOR adapalene, benzoyl peroxide, doxycycline monohydrate capsule 150 mg doxycycline hyclate capsule, minocycline, clindamycin gel (except NDC^ 68682046275), tetracycline clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, doxycycline monohydrate delayed-rel capsule ORACEA erythromycin-benzoyl peroxide, tretinoin, DULERA ADVAIR DISKUS, ADVAIR HFA, EPIDUO, ONEXTON BREO ELLIPTA, SYMBICORT FANAPT aripiprazole, clozapine, olanzapine, DUTOPROL metoprolol succinate ext-rel WITH quetiapine, quetiapine ext-rel, risperidone, hydrochlorothiazide ziprasidone, LATUDA, VRAYLAR DYRENIUM amiloride, triamterene FEMRING estradiol, IMVEXXY EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), irbesartan, irbesartan-hydrochlorothiazide, fenofibric acid delayed-rel losartan, losartan-hydrochlorothiazide, FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate tablet 120 mg), olmesartan, olmesartan-hydrochlorothiazide, fenofibric acid delayed-rel telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide fenoprofen, FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, naproxen suspension) zolpidem ext-rel, zolpidem sublingual, BELSOMRA FERIVA 21/7 folic acid E.E.S. GRANULES erythromycins FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule Fexmid cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) ELELYSO CERDELGA, CEREZYME FINACEA GEL azelaic acid gel, metronidazole, ELOCTATE ADYNOVATE, JIVI, KOGENATE FS, FINACEA FOAM, SOOLANTRA KOVALTRY, NOVOEIGHT, NUWIQ FIORICET CAPSULE diclofenac sodium, ibuprofen, ENABLEX darifenacin ext-rel, oxybutynin ext-rel, naproxen (except naproxen CR or solifenacin, tolterodine, tolterodine ext-rel, naproxen suspension) trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ flucytosine capsule 500 mg fluconazole ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE fluocinonide cream 0.1% clobetasol cream MONITORING SYSTEM MONITORING SYSTEM fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG imiquimod, PICATO, TOLAK, ZYCLARA ENTYVIO HUMIRA, STELARA SUBCUTANEOUS, fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, XELJANZ, XELJANZ XR (generics for SARAFEM only) fluoxetine tablet [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline EPICERAM desonide, hydrocortisone fluoxetine tablet 60 mg citalopram, escitalopram, EPOGEN ARANESP, RETACRIT fluoxetine (except fluoxetine tablet 60 mg, ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, fluoxetine tablet [generics for SARAFEM]), zolmitriptan, NURTEC ODT, paroxetine HCl, paroxetine HCl ext-rel, ONZETRA XSAIL, REYVOW, UBRELVY, sertraline, TRINTELLIX ZEMBRACE SYMTOUCH, flurandrenolide lotion desonide, hydrocortisone ZOMIG NASAL SPRAY (NDC^ 24470092112 only) ERYPED erythromycins flurandrenolide ointment hydrocortisone butyrate cream, ESTRING estradiol, IMVEXXY hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, EVEKEO amphetamine- hydrocortisone butyrate solution, dextroamphetamine mixed salts, mometasone, triamcinolone cream, methylphenidate triamcinolone lotion, triamcinolone ointment EVERSENSE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE FML LIQUIFILM dexamethasone, loteprednol, MONITORING SYSTEM MONITORING SYSTEM prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, EVZIO naloxone injection, NARCAN NASAL SPRAY PRED MILD EXFORGE amlodipine-olmesartan, amlodipine- FOLIC-K folic acid telmisartan, amlodipine-valsartan FOLLISTIM AQ GONAL-F EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide Folvik-D folic acid EXTAVIA dimethyl fumarate delayed-rel, glatiramer, Folvite-D folic acid AUBAGIO, BETASERON, COPAXONE, GILENYA, KESIMPTA, MAYZENT, FORTAMET metformin, metformin ext-rel (except generics OCREVUS, REBIF, TYSABRI, VUMERITY, for FORTAMET and GLUMETZA) ZEPOSIA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* FORTESTA testosterone gel (except authorized generics INDERAL LA, INDERAL XL atenolol, carvedilol, for TESTIM and VOGELXO), carvedilol phosphate ext-rel, testosterone solution, ANDRODERM metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, FOSAMAX PLUS D alendronate, ibandronate, risedronate propranolol, propranolol ext-rel, BYSTOLIC FOSRENOL calcium acetate, sevelamer carbonate, INDOCIN diclofenac sodium, ibuprofen, meloxicam, PHOSLYRA, VELPHORO naproxen (except naproxen CR or FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate naproxen suspension) FREESTYLE LIBRE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, GLUCOSE MONITORING SYSTEM MONITORING SYSTEM naproxen (except naproxen CR or naproxen suspension) FREESTYLE STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 Inflammacin diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, meloxicam, naproxen (except naproxen CR or zolmitriptan, NURTEC ODT, naproxen suspension) ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, INNOPRAN XL atenolol, carvedilol, ZOMIG NASAL SPRAY carvedilol phosphate ext-rel, metoprolol succinate ext-rel, FULPHILA ZIEXTENZO metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX INTERMEZZO doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Genicin Vita-S folic acid BELSOMRA GLASSIA PROLASTIN-C INTRAROSA estradiol, IMVEXXY GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL INTUNIV amphetamine- GLUMETZA metformin, metformin ext-rel (except generics dextroamphetamine mixed salts ext-rel †, for FORTAMET and GLUMETZA) atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, GLYCOPYRROLATE TABLET 1.5 MG dicyclomine VYVANSE GOLYTELY peg 3350-electrolytes, CLENPIQ INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR GRANIX NIVESTYM INVOKANA FARXIGA, JARDIANCE GUARDIAN CONNECT CONTINUOUS DEXCOM CONTINUOUS GLUCOSE isosorbide dinitrate 40 mg isosorbide dinitrate GLUCOSE MONITORING SYSTEM MONITORING SYSTEM (except isosorbide dinitrate 40 mg), isosorbide mononitrate HORIZANT gabapentin, GRALISE ISTALOL timolol maleate solution, BETIMOL, HUMALOG FIASP, NOVOLOG BETOPTIC S HUMALOG MIX 50/50 NOVOLOG MIX 70/30 JALYN dutasteride-tamsulosin; dutasteride or HUMALOG MIX 75/25 NOVOLOG MIX 70/30 finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin HUMATROPE GENOTROPIN, NORDITROPIN JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR HUMULIN 70/30 NOVOLIN 70/30 KAMDOY desonide, hydrocortisone HUMULIN N NOVOLIN N KAZANO JANUMET, JANUMET XR HUMULIN R NOVOLIN R ketoconazole foam 2% ketoconazole shampoo 2%, HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, selenium sulfide lotion 2.5% SUPARTZ FX Ketodan ketoconazole shampoo 2%, hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate cream, selenium sulfide lotion 2.5% hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, hydrocortisone butyrate solution, naproxen (except naproxen CR or mometasone, triamcinolone cream, naproxen suspension) triamcinolone lotion, triamcinolone ointment ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, HylaVite folic acid naproxen (except naproxen CR or naproxen suspension) HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, KINERET ENBREL, HUMIRA, RINVOQ, XELJANZ, morphine ext-rel, NUCYNTA ER, XELJANZ XR XTAMPZA ER KOMBIGLYZE XR JANUMET, JANUMET XR INCRUSE ELLIPTA SPIRIVA, YUPELRI KYPROLIS NINLARO, VELCADE LACRISERT RESTASIS, XIIDRA

LACTULOSE PAK lactulose solution

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* LANOXIN TABLET digoxin methocarbamol 500 mg cyclobenzaprine (125 MCG and 250 MCG only) (NDC^ 69036091010 only), (except cyclobenzaprine tablet 7.5 mg) methocarbamol 750 mg lanthanum carbonate calcium acetate, sevelamer carbonate, (NDCs^ 69036093090, 70868090190 only) PHOSLYRA, VELPHORO MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, 7 LANTUS BASAGLAR, LEVEMIR risedronate, FORTEO, PROLIA, TYMLOS LAZANDA fentanyl transmucosal lozenge, SUBSYS MIACALCIN NASAL SPRAY calcitonin-salmon LESCOL XL atorvastatin, ezetimibe-simvastatin, MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, fluvastatin, lovastatin, pravastatin, irbesartan, irbesartan-hydrochlorothiazide, rosuvastatin, simvastatin losartan, losartan-hydrochlorothiazide, LETAIRIS ambrisentan, bosentan, OPSUMIT olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, levorphanol fentanyl transdermal, hydrocodone ext-rel, valsartan, valsartan-hydrochlorothiazide hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, XTAMPZA ER zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, LEXAPRO citalopram, escitalopram, ZEMBRACE SYMTOUCH, fluoxetine (except fluoxetine tablet 60 mg, ZOMIG NASAL SPRAY fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, MILLIPRED dexamethasone, hydrocortisone, sertraline, TRINTELLIX methylprednisolone, prednisolone solution, prednisone LIALDA balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, MINASTRIN 24 FE ethinyl estradiol-drospirenone, sulfasalazine delayed-rel, PENTASA ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine ethinyl estradiol-norethindrone acetate-iron (NDC^ 71800063115 only) MINIVELLE estradiol, DIVIGEL, EVAMIST LIDOTREX lidocaine-prilocaine MINOCIN doxycycline hyclate 20 mg, LIPITOR atorvastatin, ezetimibe-simvastatin, doxycycline hyclate capsule, minocycline, fluvastatin, lovastatin, pravastatin, tetracycline rosuvastatin, simvastatin minocycline ext-rel doxycycline hyclate 20 mg, LIVALO atorvastatin, ezetimibe-simvastatin, doxycycline hyclate capsule, minocycline, fluvastatin, lovastatin, pravastatin, tetracycline rosuvastatin, simvastatin MIRVASO azelaic acid gel, metronidazole, Lorid folic acid FINACEA FOAM, SOOLANTRA Lorzone cyclobenzaprine Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, (except cyclobenzaprine tablet 7.5 mg) doxycycline hyclate capsule, minocycline, tetracycline LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, FML FORTE, FML S.O.P., MAXIDEX, SUPARTZ FX PRED MILD MOVIPREP peg 3350-electrolytes, CLENPIQ LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, MultiPro Consult doctor BELSOMRA mupirocin cream gentamicin, mupirocin ointment MACRODANTIN nitrofurantoin MYTESI diphenoxylate-atropine, loperamide Matzim LA diltiazem ext-rel NAPRELAN diclofenac sodium, ibuprofen, meloxicam, (except generics for CARDIZEM LA) naproxen (except naproxen CR or MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), naproxen suspension) 2 HARVONI (genotypes 1, 4, 5, 6), VOSEVI naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or mefenamic acid (NDC^ 69336012830 only) diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, naproxen suspension) lansoprazole, omeprazole, pantoprazole or DEXILANT MENEST estradiol naproxen CR diclofenac sodium, ibuprofen, meloxicam, MENOSTAR estradiol naproxen (except naproxen CR or naproxen suspension) metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or metformin ext-rel metformin, metformin ext-rel (except generics naproxen suspension) (generics for FORTAMET and GLUMETZA only) for FORTAMET and GLUMETZA)

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* NATAZIA ethinyl estradiol-drospirenone, Orphengesic Forte cyclobenzaprine ethinyl estradiol-drospirenone-levomefolate, (except cyclobenzaprine tablet 7.5 mg) ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ORTHO D folic acid ethinyl estradiol-norethindrone acetate-iron, ORTHO DF folic acid ethinyl estradiol-norgestimate, LO LOESTRIN FE ORTHOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX NATESTO testosterone gel (except authorized generics for TESTIM and VOGELXO), OSENI JANUMET, JANUMET XR; JANUVIA WITH testosterone solution, ANDRODERM pioglitazone NESINA JANUVIA OSMOPREP peg 3350-electrolytes, CLENPIQ NEULASTA, NEULASTA ONPRO ZIEXTENZO OSPHENA estradiol NEUPOGEN NIVESTYM OWEN MUMFORD NEEDLES 6 BD ULTRAFINE NEEDLES NEXIUM esomeprazole, lansoprazole, omeprazole, oxiconazole ciclopirox, clotrimazole, econazole, pantoprazole, DEXILANT (NDCs^ 00168035830, 51672135902 only) ketoconazole cream 2%, luliconazole niacin tablet 500 mg niacin ext-rel OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, Niacor niacin ext-rel morphine ext-rel, NUCYNTA ER, NICADAN folic acid XTAMPZA ER NICAPRIN folic acid oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, NICAZEL, NICAZEL FORTE folic acid morphine ext-rel, NUCYNTA ER, XTAMPZA ER NICOMIDE folic acid OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, NILANDRON abiraterone, bicalutamide, XTANDI, YONSA trospium, trospium ext-rel, MYRBETRIQ, NITROMIST nitroglycerin lingual spray, TOVIAZ nitroglycerin sublingual PANCREAZE CREON, VIOKACE, ZENPEP NORGESIC FORTE cyclobenzaprine PAXIL, PAXIL CR citalopram, escitalopram, (except cyclobenzaprine tablet 7.5 mg) fluoxetine (except fluoxetine tablet 60 mg, NORITATE azelaic acid gel, metronidazole, fluoxetine tablet [generics for SARAFEM]), FINACEA FOAM, SOOLANTRA paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX NORVASC amlodipine PENNSAID diclofenac sodium, diclofenac sodium gel 1%, NOVACORT desonide, hydrocortisone diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or 6 NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES naproxen suspension) NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1%, PERCOCET hydrocodone-acetaminophen, diclofenac sodium solution, ibuprofen, hydromorphone, morphine, meloxicam, naproxen (except naproxen CR or oxycodone-acetaminophen, NUCYNTA naproxen suspension) PERRIGO NEEDLES 6 BD ULTRAFINE NEEDLES NUTROPIN AQ GENOTROPIN, NORDITROPIN PERTZYE CREON, VIOKACE, ZENPEP NUVARING ethinyl estradiol-etonogestrel, ANNOVERA PEXEVA citalopram, escitalopram, NUVIGIL armodafinil, SUNOSI fluoxetine (except fluoxetine tablet 60 mg, OLEPTRO trazodone fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, OLUX-E clobetasol foam sertraline, TRINTELLIX omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole, PLAVIX clopidogrel, prasugrel, BRILINTA pantoprazole, DEXILANT PLEGRIDY dimethyl fumarate delayed-rel, glatiramer, OMNARIS flunisolide, fluticasone, mometasone, AUBAGIO, BETASERON, COPAXONE, DYMISTA GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, OMNITROPE GENOTROPIN, NORDITROPIN ZEPOSIA OMNIVEX folic acid POLYTOZA Consult doctor ONFI clobazam, lamotrigine, topiramate, posaconazole delayed-rel tablet fluconazole, itraconazole TROKENDI XR PRADAXA warfarin, ELIQUIS, XARELTO ONGLYZA JANUVIA PRECISION XTRA STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, ORENCIA CLICKJECT, COSENTYX, ENBREL, HUMIRA, OTEZLA, ONETOUCH VERIO STRIPS AND KITS 3 ORENCIA INTRAVENOUS, RINVOQ, STELARA SUBCUTANEOUS, ORENCIA SUBCUTANEOUS XELJANZ, XELJANZ XR orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* PRED FORTE dexamethasone, loteprednol, RIOMET metformin, metformin ext-rel (except generics prednisolone acetate 1%, DUREZOL, for FORTAMET and GLUMETZA) FML FORTE, FML S.O.P., MAXIDEX, PRED MILD ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, PREFEST estradiol-norethindrone, PREMPHASE, BELSOMRA PREMPRO RyClora levocetirizine PREMARIN estradiol SABRIL vigabatrin PREMARIN CREAM estradiol, IMVEXXY SAIZEN GENOTROPIN, NORDITROPIN PRENATAL PLUS prenatal vitamins, CITRANATAL SANDOSTATIN LAR SOMATULINE DEPOT PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT SCARSILK PAD Consult doctor PREVIDENT Consult doctor SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, PRIMLEV hydrocodone-acetaminophen, ziprasidone, LATUDA, VRAYLAR hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA SIGNIFOR LAR SOMATULINE DEPOT PRISTIQ desvenlafaxine ext-rel, duloxetine, SIL-K PAD Consult doctor venlafaxine, venlafaxine ext-rel capsule SILIVEX Consult doctor PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol, SILTREX Consult doctor levalbuterol tartrate CFC-free aerosol SIMPONI COSENTYX, ENBREL, HUMIRA, OTEZLA, PROCRIT ARANESP, RETACRIT RINVOQ, STELARA SUBCUTANEOUS, PRODIGEN Consult doctor XELJANZ, XELJANZ XR PROLENSA bromfenac, diclofenac, ketorolac, ACUVAIL, SINGULAIR montelukast, zafirlukast, zileuton ext-rel ILEVRO, NEVANAC SOMAVERT SOMATULINE DEPOT PROTONIX esomeprazole, lansoprazole, omeprazole, SORILUX calcipotriene ointment, calcipotriene solution pantoprazole, DEXILANT SPRIX diclofenac sodium, ibuprofen, meloxicam, PROTOPIC pimecrolimus, tacrolimus, EUCRISA naproxen (except naproxen CR or PROVAD Consult doctor naproxen suspension) PROVENTIL HFA albuterol sulfate CFC-free aerosol, STENDRA sildenafil, tadalafil levalbuterol tartrate CFC-free aerosol SUBOXONE buprenorphine-naloxone sublingual, PROZAC citalopram, escitalopram, ZUBSOLV fluoxetine (except fluoxetine tablet 60 mg, sucralfate suspension sucralfate tablet fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sumatriptan-naproxen diclofenac sodium, ibuprofen or sertraline, TRINTELLIX naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, PSORCON desoximetasone, naratriptan, rizatriptan, sumatriptan, fluocinonide (except fluocinonide cream 0.1%), zolmitriptan, NURTEC ODT, BRYHALI ONZETRA XSAIL, REYVOW, UBRELVY, QNASL flunisolide, fluticasone, mometasone, ZEMBRACE SYMTOUCH or DYMISTA ZOMIG NASAL SPRAY QSYMIA SAXENDA SUPREP peg 3350-electrolytes, CLENPIQ 5 3 QTERN GLYXAMBI SURE-TEST STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS , ONETOUCH VERIO STRIPS AND KITS 3 quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, SYNERDERM desonide, hydrocortisone BELSOMRA SYNVISC, SYNVISC-ONE DUROLANE, EUFLEXXA, GELSYN-3, RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, SUPARTZ FX tamsulosin, terazosin TALIVA folic acid RAYOS dexamethasone, hydrocortisone, TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, methylprednisolone, prednisolone solution, SKYRIZI, STELARA SUBCUTANEOUS, prednisone TREMFYA, XELJANZ, XELJANZ XR RECEDO Consult doctor TARGADOX doxycycline hyclate 20 mg, RELION INSULIN NOVOLIN INSULIN doxycycline hyclate capsule, minocycline, tetracycline REPATHA PRALUENT TASIGNA imatinib mesylate, BOSULIF, SPRYCEL RHEUMATE folic acid RIBOZEL folic acid RIMSO-50 Consult doctor

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* TAYTULLA ethinyl estradiol-drospirenone, TRUETRACK STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, ethinyl estradiol-drospirenone-levomefolate, ONETOUCH VERIO STRIPS AND KITS 3 ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron TRULANCE LINZESS TAZORAC adapalene, benzoyl peroxide, TUDORZA SPIRIVA, YUPELRI clindamycin gel (except NDC^ 68682046275), UDENYCA ZIEXTENZO clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, ULTIMED INSULIN SYRINGES 6 BD ULTRAFINE INSULIN SYRINGES erythromycin-benzoyl peroxide, tretinoin, 6 EPIDUO, ONEXTON; calcipotriene ointment, ULTIMED NEEDLES BD ULTRAFINE NEEDLES calcipotriene solution UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, TECFIDERA dimethyl fumarate delayed-rel, glatiramer, tamsulosin, terazosin AUBAGIO, BETASERON, COPAXONE, VALCYTE valganciclovir GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, VALTREX acyclovir capsule, acyclovir tablet, ZEPOSIA valacyclovir TESTIM testosterone gel (except authorized generics Vanatol LQ, Vanatol S diclofenac sodium, ibuprofen, for TESTIM and VOGELXO), naproxen (except naproxen CR or testosterone solution, ANDRODERM naproxen suspension) testosterone gel 1% testosterone gel (except authorized generics Vanoxide-HC adapalene, benzoyl peroxide, (authorized generics for TESTIM and for TESTIM and VOGELXO), clindamycin gel (except NDC^ 68682046275), VOGELXO only) testosterone solution, ANDRODERM clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, erythromycin-benzoyl peroxide, tretinoin, BETOPTIC S EPIDUO, ONEXTON TIROSINT levothyroxine, SYNTHROID VASCULERA Consult doctor TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS VECTICAL calcipotriene ointment, calcipotriene solution TOPROL-XL atenolol, carvedilol, VELTIN adapalene, benzoyl peroxide, carvedilol phosphate ext-rel, clindamycin gel (except NDC^ 68682046275), metoprolol succinate ext-rel, clindamycin solution, clindamycin- metoprolol tartrate, nadolol, pindolol, benzoyl peroxide, erythromycin solution, propranolol, propranolol ext-rel, BYSTOLIC erythromycin-benzoyl peroxide, tretinoin, TRACLEER ambrisentan, bosentan, OPSUMIT EPIDUO, ONEXTON TRADJENTA JANUVIA venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule tramadol (NDC^ 52817019610 only) tramadol (except NDC^ 52817019610), tramadol ext-rel VENTOLIN HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol TRANSDERM SCOP meclizine, scopolamine transdermal VEREGEN imiquimod TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR or VIAGRA sildenafil, tadalafil naproxen suspension) WITH eletriptan, VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), naratriptan, rizatriptan, sumatriptan, HARVONI (genotypes 1, 4, 5, 6) zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, VIIBRYD citalopram, escitalopram, ZEMBRACE SYMTOUCH or fluoxetine (except fluoxetine tablet 60 mg, ZOMIG NASAL SPRAY fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, triamcinolone acetonide aerosol 0.2% hydrocortisone butyrate cream, sertraline, TRINTELLIX hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, hydrocortisone butyrate solution, SUPARTZ FX mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment VITAFOL-ONE prenatal vitamins, CITRANATAL TRICOR fenofibrate (except fenofibrate tablet 120 mg), Vitasure folic acid fenofibric acid delayed-rel VIVELLE-DOT estradiol, DIVIGEL, EVAMIST TRIGLIDE fenofibrate (except fenofibrate tablet 120 mg), VOGELXO testosterone gel (except authorized generics fenofibric acid delayed-rel for TESTIM and VOGELXO), TRILIPIX fenofibrate (except fenofibrate tablet 120 mg), testosterone solution, ANDRODERM fenofibric acid delayed-rel XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam TRIVIDIA INSULIN SYRINGES 6 BD ULTRAFINE INSULIN SYRINGES TronVite folic acid XENAZINE tetrabenazine, AUSTEDO ciclopirox, ketoconazole cream 2% TRUETEST STRIPS AND KITS 5 ONETOUCH ULTRA STRIPS AND KITS 3, XOLEGEL ONETOUCH VERIO STRIPS AND KITS 3 XOPENEX HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* Xvite folic acid ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, XYZBAC folic acid BELSOMRA YAZ ethinyl estradiol-drospirenone, ZONEGRAN carbamazepine, carbamazepine ext-rel, ethinyl estradiol-drospirenone-levomefolate, divalproex sodium, divalproex sodium ext-rel, ethinyl estradiol-norethindrone acetate, gabapentin, lamotrigine, lamotrigine ext-rel, ethinyl estradiol-norethindrone acetate-iron levetiracetam, levetiracetam ext-rel, ZALVIT prenatal vitamins, CITRANATAL oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, ZARXIO NIVESTYM tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, ZEGERID esomeprazole, lansoprazole, omeprazole, TROKENDI XR, VIMPAT, XCOPRI pantoprazole, DEXILANT ZONTIVITY Consult doctor ZELAC Consult doctor ZORTRESS everolimus ZEMAIRA PROLASTIN-C ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), naproxen (except naproxen CR or HARVONI (genotypes 1, 4, 5, 6) naproxen suspension) ZETIA ezetimibe ZUPLENZ granisetron, ondansetron, SANCUSO ZETONNA flunisolide, fluticasone, mometasone, ZYDELIG COPIKTRA DYMISTA ZYFLO montelukast, zafirlukast, zileuton ext-rel ZIANA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, clindamycin solution, clindamycin- neomycin-polymyxin B-dexamethasone, benzoyl peroxide, erythromycin solution, tobramycin-dexamethasone, erythromycin-benzoyl peroxide, tretinoin, TOBRADEX OINTMENT, TOBRADEX ST EPIDUO, ONEXTON ZYTIGA abiraterone, bicalutamide, XTANDI, YONSA ZIRGAN trifluridine ZYVIT folic acid ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER

You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay1 information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. † Listing does not include certain NDCs^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 3 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 4 Coverage may be altered or copay1 amounts may vary based on the condition being treated (e.g. psoriasis). 5 ONETOUCH brand test strips are the only preferred options.

6 BD ULTRAFINE syringes and needles are the only preferred options. 7 Long Acting Insulins - First Generation.

CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.