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EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

EHIM Cares Custom Formulary is a well-designed, evidenced- currently available and less costly therapies. This listing is based formulary that optimizes patient outcomes by ensuring revised periodically as new medications and new prescribing that patients receive the most effective and safe therapy. All information becomes available. If you are utilizing an Excluded medications are reviewed by EHIM Pharmacy & Therapeutics or Non-Preferred medication, you may want to speak with Committee for clinical efficacy, safety and cost savings for your physician to determine if there is an alternative therapy formulary consideration. that provides the same therapeutic efficacy, but is available at a lower cost to you. This document may be shared with your This list of medications is a guide which includes preferred physician to evaluate potential preferred therapy options. medications within select therapeutic classes that demonstrate the greatest value to you and your Employer. For additional benefit coverage information, please check Medications are excluded from formulary coverage if they your benefit plan documents or feel free to contact the EHIM fail to demonstrate a clinical or safety advantage over Pharmacy Call Center at 800-311-3446.

Frequently Asked Questions About Generic Medications

What is a generic drug? Are generics really the same as the brand name? A generic drug is a lower cost version of a brand-name Yes. Generic drugs have the same medicine as the brand- medication. They are just as safe and effective as the brand name, and the FDA will not approve them unless they are name, but they are more affordable. just as safe and effective as the brand-name drug. There are a few special medical conditions where a generic drug might How are generic drugs different from brand name drugs? have a small difference in how it works, but that is very rare. The biggest difference between a generic and brand name Do generic drugs cause more side effects than brand-name drug is the price. Most generics cost 70-90% less than the drugs? brand name version. Generic drugs may also have a different No. Brand-name drugs and a generic drug have the same shape, color or package. But these differences only affect rates of side effects. Each medication can affect each person how the medicine looks, not how it works. in a different way. If your medicine has side effects that you are worried about, call your doctor.

• All MULTISOURCE medications (DAW) (brand name • Some medications may require an approved Prior medications that have an EXACT generic equivalent) are Authorization before being covered subject to the Non-Preferred copay (Not All MULTISOURCE medications are listed on this Formulary or may be covered) • Some medications may be applicable to a Quantity Limitation • All forms (oral, liquid, topical…) and dosages (DR, ER, LA, XR….) of the medications listed are classified as Non- • Not all medications on this formulary may be covered by Preferred your plan

• This formulary is subject to change at any time without notice

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

derreferP-noN derreferP Excluded derreferP-noN derreferP Excluded yapoC yapoC yapoC yapoC Alzheimer’s/Dementia Analgesics/Narcotics Con’t Namenda XR donepezil Ryzolt (tramadol) tramadol/APAP (memantine) (Ultracet) Namzaric (donepezil/ memantine Synalgos memantine) (dihydrocodeine, APAP, Analgesics/Narcotics caffeine) Aleveer (capsaicin) Abstral (fentanyl) buprenorphine/naloxone Trezix (dihydrocodeine, SL (Suboxone) caffeine, APAP) Allzital (butalbital/ Embeda (morphine buprenorphine patch Troxyca ER acetaminophen) naltrexone) (Butrans) (oxycodone, Avinza (morphine) Fentora (fentanyl codeine naltrexone) buccal) Ultram ER (tramadol) Belbuca Hysingla ER codeine/APAP (buprenorphine) (hydrocodone) Xartemis XR Bunavail Lazanda (fentanyl) fentanyl patch (oxycodone/ (buprenorphine/ (Duragesic) acetaminophen) naloxone) Zydone (hydrocodone, Butrans Nucynta, Nucynta ER hydrocodone/APAP APAP) (buprenorphine) (tapentadol) (Lortab, Norco, Vicodin, Zubsolv etc) (buprenorphine/ Cassipa Obredon hydrocodone/ibuprofen naloxone) (buprenorphine/ (hydrocodone, (Vicoprofen) Androgens/Hypogonadism naloxone) guaifenesin) Xyosted (testosterone Androderm testosterone cypionate inj Conzip (tramadol) Onsolis (fentanyl hydromorphone enanthate) Injection (testosterone) buccal) (Dilaudid) Androgel Elenza (capsaicin) Opana ER hydromorphone XR (testosterone) (oxymorphone) (Exalgo) Android Flowtuss (hydrocodone, Oxycontin (oxycodone) levorphenol (Levo (methyltestosterone) guaifenesin) Dromoran) Androxy Hycofenix Subsys (fentanyl) methadone (fluoxymesterone) (hydrocodone, pse, Aveed (testosterone guaifenesin) undecanote) Hydrocodone Targiniq ER morphine Axiron (testosterone) Bitartrate, Guaifenesin (oxycodone/naloxone) Tablets Danocrine (danazol) Morphabond Viberzi (eluxadoline) morphine ER (MS Contin, Delatestryl (morphine sulfate) Oramorph) (testosterone Oxaydo (oxycodone) Vicodin (hydrocodone/ oxycodone (OxyIR) enanthate) Inj acetaminophen) Depo-Testosterone Oxecta (oxycodone IR) Zohydro ER oxycodone/APAP (testosterone cyp) Inj (hydrocodone) (Percocet) Halotestin Qroxin (capsaicin) oxycodone/ibuprofen (fluoxymesterone) (Combunox) Methitest Renovo (capsaicin) oxymorphone IR (Opana) (methyltestosterone) Roxybond (oxycodone) tramadol (Ultram) Methyltestosterone Oral Tablets (Testred) Rybix ODT (tramadol)

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

derreferP-noN derreferP derreferP-noN derreferP Excluded yapoC yapoC Excluded yapoC yapoC Androgens/Hypogonadism Con’t Anticoagulants Natesto (testosterone) Eliquis (apixaban) warfarin Nasal Pradaxa (dabigatran) Oxandrin Savaysa (edoxaban) (oxandrolone) Xarelto (rivaroxaban) Striant XR Anticonvulsants/Seizures (testosterone) Elepsia XR Aptiom carbamazepine Testim (testosterone) (levetiracetam) (eslicarbazepine) (Tegretol) Testoprel Gralise (gabapentin) Briviact (brivacetam) carbamazepine XR (testosterone) (Tegretol XR) Testred Horizant (gabapentin) Carbatrol clonazepam (Klonopin) (methyltestosterone) (carbamazepine) Virilon Keppra XR Diastat Rectal Delivery divalproex (Depakote) (methyltestosterone) (levetiracetam) System (diazepam) Vogelxo (testosterone) Lamictal XR Dilantin (phenytoin)* divalproex ER (Depakote Anti Arthritics (lamotrigine) ER) Cambia (diclofenac) Flector Patch celecoxib (Celebrex) Lyrica CR (pregabalin) Equetro ethosuximide (Zarontin) Packets (diclofenac) (carbamazepine) Consensi (amlodipine, Indocin (indomethacin) diclofenac (Cataflam, Onfi (clobazam) Felbatol (felbamate) felbamate (Felbatol) celecoxib) supp Voltaren, Voltaren XR) Oxtellar XR Fycompa (perampanel) gabapentin (Neurontin) Duexis (ibuprofen, Siprix Nasal Spray diclofenac/misoprostol (oxcarbazepine) famotidine) (ketorolac) (Arthrotec) Qudexy XR Gabitril (tiagabine) lacosamide (Vimpat) Durlaza (aspirin) diclofenac 1% topical (topiramate) (Voltaren Gel) Spritam Lyrica (pregabalin) lamotrigine (Lamictal) Licart (diclofenac) diclofenac 1.5% topical (levetiracetam) (Pennsaid) Stavzor (valproic acid) Mebaral lamotrigine XR (Lamictal Nalfon (fenoprofen) etodolac (Lodine, Lodine (mephobarbital) XR) XL) Tegretol XR Nayzilam Nasal levetiracetam (Keppra) Naprelan (naproxen) ibuprofen (Motrin) (carbamazepine) (midazolam) Nexcede (ketoprofen) indomethacin (Indocin) Trokendi XR Peganone (ethotoin) oxcarbazepine (Trileptal) Film (topiramate) Pennsaid Topical ketoprofen (Orudis, Phenytek (phenytoin)* phenobarbital Solution (diclofenac) Oruvail) Potiga (ezogabine) phenytoin (Dilantin) Prevacid NapraPac lidocaine topical primidone (Mysoline) (naproxen, (Lidoderm) rufinamide (Banzel) lansoprazole) tiagabine (Gabitril) Tivorbex meloxicam (Mobic) (indomethacin) topiramate (Topamax) Vimovo (naproxen nabumetone (Relafen) valproate, valproic acid esomeprazole) zonisamide (Zonegran) Vivlodex (meloxicam) naproxen (Naproxen) Zipsor (diclofenac) naproxen DS (Anaprox DS) Zorvolex (diclofenac) oxaprozin (Daypro) piroxicam (Feldene) sulindac (Clinoril)

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

derreferP-noN derreferP Excluded derreferP-noN derreferP Excluded yapoC yapoC yapoC yapoC Antidiabetics Antihypertensives/Angiotension Receptor Blockers Actoplus Met XR metformin & Renin Inhibitors (pioglitazone, Benicar, Benicar HCT Amturnide (aliskerin, aliskerin (Tekturna) metformin) (olmesartan) amlodipine, HCTZ) Avandryl (glimepiride, Byvalson (, Entresto (sacubitril, candesartan (Atacand) rosiglitazone) valsartan) valsartan) Fortamet (metformin) Edarbi (azilsartan) Prestalia (perindopril, candesartan/HCTZ Glumetza (metformin) amlodipine) (Atacand-HCT) Glucophage Edarbychlor (azilsartan, Tekamlo (aliskerin, irbesartan (Avapro) (metformin) chlorthalidone) amlodipine) Glucophage XR Epaned (enalapril) Tekturna-HCT irbesartan/HCTZ (metformin XR) (aliskerin) (Avalide) Metformin XR 1000 mg Prexxartan (valsartan) Tevetan, Tevetan HCT losartan (Cozaar) (eprosartan) Riomet (metformin) Qbrelis (lisinopril) losartan/HCTZ (Hyzaar) Antihistamines olmesartan (Benicar) Allerx Clarinex azelastine nasal (chlorpheneramine) (desloratadine) olmesartan/amlodipine (Azor) Astepro (azelastine) Clarinex D (Zyrtec) olmesartan/HCTZ (desloratadine/pse) (Benicar-HCT) Bonjesta (doxylamine, Zutripro cetirizine / telmisartan (Micardis) pyridoxine) (chlorpheneramine, hydrocodone, pse) (Zyrtec-D) telmisartan/amlodipine (Twynsta) Karbinal ER (Zebeta) (carbinoxamine) telmisartan/HCTZ (Micardis-HCT) Polmon chlorpheniramine, (dexchlorpheneramine) hydrocodone (Vituz) valsartan (Diovan) Ryvent desloratadine (Clarinex) valsartan/amlodipine (carbinoxamine) (Exforge) Semprex D doxylamine/pyridoxine valsartan/HCTZ (acrivastine/pse) (Diclegis) (Diovan-HCT) fexofenadine (Allegra) Antihypertensives/Beta-Blockers fexofenadine / pse Byvalson (nebivolol, Bystolic (nebivolol) (Sectral) (Allegra-D) valsartan) levocetirizine (Xyzal) Coreg CR () (Tenormin) loratadine (Claritin) Dutoprol (, (Kerlone) HCTZ) loratidine / pseudoephedrine D 24 Hemangeol bisoprolol (Zebeta) hour (Claritin-D) () olopatadine (Patanase)

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

derreferP-noN derreferP derreferP-noN derreferP Excluded yapoC yapoC Excluded yapoC yapoC Antihypertensives/Beta-Blockers Con’t CNS Stimulants carvedilol (Coreg) Adezenys XR Belviq (lorcaserin) amphetamine sulfate carvedilol CR (Coreg CR) (amphetamine) (Evekeo) (Trandate) Adhansia XR Concerta armodafinil (Nuvigil) metoprolol (Lopressor) (methylphenidate XR) (methylphenidate CR) metoprolol XL (Toprol Aptensio XR Daytrana Patch atomoxetine (Straterra) XL) (methylphenidate) (methylphenidate) (Visken) Belviq XR (lorcaserin) Qsymia (phentermine, XL (Kapvay) topiramate) propranolol (Inderal) Cotempla XR Sunosi (solriamfetol) dexmethylphenidate propranolol ER (Inderal (methylphenidate) (Focalin) LA) Dynavel XR Vyvanse dexmethylphenidate XR (Blocadren) (amphetamine) (lisdexamfetamine) (Focalin XR) Antispasmodic Evekeo (amphetamine Wakix (pitolisant) dextroamphetamine Donnatol ( chlordiazepoxide sulfate) (Dexedrine) Hyoscyamine clindium Evekeo ODT XR (Intuniv) Scopolamine) (amphetamine sulfate) Librax dicyclomine Jornay PM methamphetamine (chlordiazepoxide (methylphenidate) XR (Desoxyn) clindium) Mydayis (mixed methylphenidate (Ritalin) hyoscyamine amphetamine salts) ER Antiulcer—Proton Pump Inhibitors Nuvigil (armodafinil) methylphenidate ER Aciphex Sprinkles Esomeprazole esomeprazole (Nexium) (Ritalin LA, Metadate CD) (rabeprazole) Strontium Quillichew XR methylphenidate SR Dexilant lansoprazole (Prevacid, (methylphenidate) (Ritalin SR) (dexlansoprazole) Prevacid SoluTab) Quillivant XR methylphenidate XR Dexilant Solutab Nexium OTC (methylphenidate) (Concerta) (dexlansoprazole) Suprenza mixed amphetamine salts omeprazole/sodium omeprazole (Prilosec) (phentermine) (Adderall) bicarbonate (Zegerid) Straterra mixed amphetamine salts Zegerid (omeprazole pantoprazole (Protonix) (atomoxetine) ER (Adderall XR) sodium bicarbonate) Zenzedi modafinil (Provigil) Prevacid OTC (dextroamphetamine) Prilosec OTC Dermatological/Oral rabeprazole Absorica (isotretinoin) doxycycline Zegerid OTC Accutane (isotretinoin) minocycline Bisphosphonates/Bone Health Acitretin (isotretinoin) Binosto (alendronate) Forteo (teriparatide) alendronate (Fosamax) Acticlate (doxycycline) Fosamax + D Fortical (calcitonin) ibandronate (Boniva) Adoxa (doxycycline) (alendronate w Amnesteem Vitamin D) (isotretinoin) Tymlos (abaloparatide) Miacalcin (calcitonin) raloxifene (Evista) Claravis (isotretinoin) Subcutaneous Injection Doryx (doxycycline) risendronate (Actonel, Doxteric (doxycycline) Atelvia) Lymepak (doxycycline) Minolira (minocycline) Oral Capsules

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

Excluded derreferP-noN derreferP Excluded derreferP-noN derreferP yapoC yapoC yapoC yapoC Dermatological/Oral Con’t Dermatological/Anti-Inflammatory & Minocin (minocycline) Anti-Pruritics/Topical Products Con’t Monodox (doxycycline) hydrocortisone 0.5, 1, 2.5% Myorisan (isotretinoin) (Cortaid, Hytone) Oracea (doxycycline) hydrocort/pramox 2.5-1%, 1-1% (Analpram HC) Seysara (sarecycline) hydrocortisone butyrate Solodyn (minocycline) (Locoid) Soriatane (isotretinoin) hydrocortisone valerate Sotret (isotretinoin) (Westcort) Targadox (doxycycline) mometasone (Elocon) Tetracycline prednicarbate (Dermatop) Ximino (minocycline) triamcinolone (Kenalog) Xyrosa (doxycycline) U-Cort (hydrocortisone, Oral Tablet urea) Zenatane (isotretinoin) Dermatological/Topical Products/Acne & Skin Diseases Dermatological/Anti-Inflammatory & Acanya (clindamycin/ Avage (tazarotene) adapalene 0.1% cream, gel Anti-Pruritics/Topical Products benz. perox) (Differin) Capex Shampoo Aczone (dapsone) aclometasone (Aclovate) Akne-Mycin Differin (adapalene) adapalene, benzoyl (fluocinolone) (erythromycin) Peroxide 1-2.5% gel (Epiduo) Clobex Lotion, Alcortin A (iodoquinol, amcinonide (Cyclocort) Shampoo, Spray hydrocortisone) Altabax (retapamulin) Duobrii (halobetasol azelaic acid gel (Finacea) (clobetasol) propionate, tazarotene) Cloderm (clocortolone) Cortifoam Aerosol betamethasone Altreno (tretinoin) Fabior (tazarotene) benzoyl peroxide 2.5% gel, wash (hydrocortisone) dipoprionate (Diprolene) Avita (tretinoin) Mirvaso () benzoyl peroxide 3%, 6% Cordran Epifoam betamethasone valerate pads (flurandrenolide) (hydrocortisone, (Valisone) pramoxine) Azelex (azelaic acid) Rhofade benzoyl peroxide 5% gel, () lotion, wash Halog (halcinonide) Eucrisa (crisaborole) calcipotriene, betamethasone Bactroban Nasal Tazorac (tazarotene) benzoyl peroxide 10% (Taclonex) (mupirocin) cream, gel, lotion, wash Impoyz (clobetasol Pramosone, Pramosone clobetasol (Clobex, Benzamycin Pak Xepi (ozenoxacin) benzoyl peroxide 4% kit proprionate) E (hydrocort, Embeline, Olux, (benzoyl peroxide (Brevoxyl) pramoxine) Temovate) erythromycin) Locoid Lotion (hydcort Prudoxin () clotrimazole, Carac (fluorouracil) clindamycin 1% gel, butyrate) cream betamethasone (Lotrisone) lotion, solution, pledgets Olux E (clobetasol) Vytone (iodoquinol, desonide (DesOwen) Clindagel (clindamycin) clindamycin/benz.perox. hydrocortisone) (Duac) Pandel (hydrocortisone Zonalon (doxepin) desoximetasone (Topicort) Clindesse (clindamycin) clindamycin 1% buteprate) Cream cream benz.perox. 5% gel Rectiv (nitroglycerin) diflorasone (Psorcon) (Benzaclin) Condylox Gel clindamycin 1.2% Sernivo (betamethasone) fluocinolone (Synalar) (podofilox) benz.perox. 2.5% gel Topicort Spray fluocinonide (Lidex) (Acanya) (desoximetasone) Denavir (penciclovir) clindamycin 1.2%/ Ultravate (halobetasol) flurandrenolide (Cordran) tretinoin 0.025% (Ziana) Verdeso Foam fluticasone (Cutivate) Ecoza (econazole erythromycin 2% gel, (desonide) nitrate) solution (Erygel) halobetasol (Ultravate)

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

derreferP-noN derreferP derreferP-noN derreferP Excluded yapoC yapoC Excluded yapoC yapoC Dermatological/Topical Products/Acne & Skin Diseases Con’t Dermatological/Topical Products/Acne & Skin Diseases Con’t Epiduo Forte erythromycin 3%/ Vusion (miconazole) (adapalene/benz. benz.perox. 5% gel Xerese (acyclovir, perox) (Benzamycin) hydrocortisone) Ertaczo (sertaconazole) naftifine 1% cream Xolegel () (Naftin) Zovirax Cream Estilar (betamethasone, naftifine 1.5% gel (acyclovir) calcipotriene) (Naftin) Lipotropics Eurax (crotamiton) naftifine 2% cream Advicor (lovastatin/ Vascepa (icosapent) atorvastatin (Lipitor) (Naftin) niacin) Exelderm (sulconazole) oxiconazole 1% (Oxistat) Altoprev (lovastatin cholestyramine Finacea (azelaic acid) tretinoin 0.01% gel XL) (Questran, Questran Lite) (Retin-A) Antara (fenofibrate) colestipol (Colestid) Fluoroplex tretinoin 0.025% cream, Epanova (omega-3- colesevelam (Welchol) (fluorouracil) gel (Retin-A) carboxylic acids) Fungoid Solution tretinoin 0.05% cream Ezallor (rosuvastatin) ezetimibe (Zetia) (clotrimazole) (Retin-A) Fenoglide (fenofibrate) fenofibrate Fungoid Tincture tretinoin 0.1% cream (miconazole) (Retin-A) Fibricor (fenofibric fenofibric acid (Fibricor) acid) Jublia (efinaconazole) tretinoin 0.1% gel (Retin-A Micro) Juxtapid (lomitapide) Fish Oil OTC Kerydin (tavaborole) Kynamro fluvastatin (Lescol, Lescol (mipomersen) XL) Kuric (ketoconazole) Lipofen (fenofibrate) gemfibrozil (Lopid) Luzu (luliconazole) Liptruzet (atorvastatin, lovastatin (Mevacor) Naftin (naftifine) ezetimibe) Noritate Livalo (pitavastatin) Niacin OTC (metronidazole) Lovaza (omega-3-acid omega-3-acid ethyl esters Nuvessa ethyl esters) (Lovaza) (metronidazole) Omtryg (omega-3-acid pitavastatin (Livalo) Onexton (benzoyl ethyl esters A peroxide, clindamycin) Niaspan (niacin XR) pravastatin (Pravachol) Oxistat (oxiconazole) Nikita (pitavastatin) rosuvastatin (Crestor) Pliaglis (lidocaine, tetracaine) Simcor (simvastatin/ simvastatin (Zocor) niacin) Refissa (emollient tretinoin) Tricor (fenofibrate) simvastatin/ezetimibe Renova (emollient (Vytorin) tretinoin) Triglide (fenofibrate) Retin-A Micro Trilipix (fenofibric acid) (tretinoin) Vytorin (simvastatin/ Sorilux (calciptriene) ezetimibe) Soolantra (ivermectin) Zetia (ezetimibe) cream Zypitamag Taclonex (pitavastatin) (betamethasone, calcipotriene) Tolak (fluorouracil) Veltin (clindamycin, tretinoin)

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

Excluded derreferP-noN derreferP Excluded derreferP-noN derreferP yapoC yapoC yapoC yapoC Migraine/Triptans Nasal Steroids Con’t Alsuma (sumatriptan) Migranal almotriptan (Axert) Rhinacort AQ triamcinolone acetonide () (budesonide) (Nasacort) Naproxen/Sumatriptan eletriptan (Relpax) Veramyst (fluticasone) (GEQ Treximet) Xhance (fluticasone Onzetra Xsail frovatriptan (Frova) propionate) (sumatriptan) Nasal Zetonna (ciclesonide) Relpax (eletriptan) naratriptan (Amerge) Ophthalmic Agents-Anti-Infectives Sumavel DosePro rizatriptan (Maxalt, Besivance (Ciloxan) (sumatriptan Maxalt MLT) (besifloxacin) needleless) Zymar (gatifloxacin) levofloxacin (Quixin) Tosymra (sumatriptan) sumatriptan (Imitrex) moxifloxacin (Vigamox) Treximet (naproxen sumatriptan injection Ophthalmic Agents sumatriptan) vials (Imitrex Inj) Alamast (pemirolast) Pazeo (olopatadine) atropine solution Zecuity (sumatriptan) sumatriptan nasal (Imitrex Nasal) Alocril (nedocromil) Pilopine () azelastine ophthalmic (Optivar) Zembrace Symtouch zolmitriptan (Zomig, (sumatriptan) Zomig ZMT) Alomide (lodoxamide) Rhopressa () bepotastine (Bepreve) Zomig Nasal Spray Alphagan 0.1%, 0.15% Rocklatan (netarsudil, betaxolol 0.5% (Betoptic) (zolmitriptan) (brimonidine) ) Muscle Relaxants Alrex (lotepredenol) 0.03% (Lumigan) Amrix baclofen (Lioresal) () Azopt () brimonidine 0.2% Fexmid carisoprodol (Soma) (Alphagan) (cyclobenzaprine) Bepreve (bepotastine) 1% (Ocupress) Flexeril SR chlorzoxazone (Parafon Betimol (timolol cromolyn ophthalmic (cyclobenzaprine) Forte) hemihydrate) (Crolom, Opticrom) Tiglutik (riluzole) cyclobenzaprine (Flexeril) Betoptic-S (betaxolol) cyclopentolate 0.5% Suspension (Cyclogel) dantrolene (Dantrium) Combigan cyclopentolate 1% metaxalone (Skelaxin) (brimonidine/timolol) (Cyclogel) methocarbamol Cosopt PF (timolol, solution (Robaxin) dorzolamide) (Trusopt) orphenadrine (Norflex) Dapiprazole (Rev-Eyes) gatifloxacin 0.5% (Zanaflex) ophthalmic (Zymaxid) Nasal Steroids Elestat (epinastine) Isopto- solution Beconase budesonide nasal Emadine (emedastine) Isopto-homatropine (beclomethasone) (Rhinacort) solution Dymista (fluticasone, Flonase Allergy OTC Istalol (timolol) ketotifen ophthalmic azelastine) (Zaditor) Nasacort AQ flunisolide (Nasarel) Izba () ketorolac ophthalmic (Acular) (triamcinolone) Lastacaft (aclaftadine) latanoprost (Xalatan) Nasacort HFA fluticasone propionate (triamcinolone) (Flonase) Lumify (brimonidine) (Betagan) Nasonex mometasone (Nasonex) Lumigan (bimatoprost) olopatadine 0.1% (mometasone) (Patanol) Omnaris (ciclesonide) Nasacort AQ OTC Pataday (olopatadine) olopatadine 0.2% (Pataday) QNasl Rhinocort OTC (beclomethasone) Patanol (olopatadine) pilocarpine (Isopto Carpine)

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

derreferP-noN derreferP Excluded derreferP-noN derreferP Excluded yapoC yapoC yapoC yapoC Ophthalmic Agents Con’t Overactive Bladder Simbrinza timolol (Timoptic, Istalol) Oxytrol (oxybutynin) Elmiron (pentosan) darifenacin (Enablex) (brimonidine, Gelnique (oxybutynin) fesoterodine (Toviaz) brinzolamide) Myrbetriq oxybutynin (Ditropan) Travatan, Travatan Z timolol GFS (Timoptic (travoprost) XE) () Xelpros (latanoprost) timolol/dorzolamide oxybutynin ER (Ditropan Emulsion (Cosopt) XL) Zerviate (cetirizine) travoprost 0.004% solifenacin (Vesicare) Ophthalmic Solution (Travatan-Z) tolterodine (Detrol) Zioptan () tolterodine SR (Detrol Ophthalmic Agents/Anti-Inflammatory LA) Steroidal Steroidal Steroidal trospium (Sanctura) Alrex (loteprednol) dexamethasone sodium trospium XR (Sanctura phosphate (Decadron) XR) Durezol (difluprednate) fluorometholone (FML) Prostate Agents Flarex prednisolone acetate (Uroxatrol) (fluorometholone) (Econopred, Pred Forte) (Cardura) FML, FML Forte prednisolone sodium dutasteride (Avodart) (fluorometholone) phosphate (Inflamase dutasteride/tamulosin Forte) (Jalyn Inveltys (loteprednol) finasteride (Proscar) Lotemax (loteprednol) (Minipress) Pred Mild (prednisolone acetate) sildosin (Rapaflo) Maxidex tamulosin (Flomax) (dexamethasone) (Hytrin) Vexol (rimexolone) Non-Steroidal Non-Steroidal Non-Steroidal Acuvail (ketorolac) Restasis (cyclosporine) bromfenac (Xibrom) Bromsite (bromfenac) Xiidra (lifitegrast) diclofenac (Voltaren) Cequa (cyclosporine) Ilevro 0.3% (nepafenac) flurbiprofen (Ocufen) Nevanac (nepafenac) ketorolac (Acular, Acular LS) Prolensa (bromfenac) Restasis Bulk (cyclosporine) Xibrom (bromfenac)

ehimrx.com EHIM Cares Custom Me Too Closed Formulary

26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com

Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan.

derreferP-noN derreferP Excluded derreferP-noN derreferP Excluded yapoC yapoC yapoC yapoC Psychostimulants/ Psychostimulants/Antipsychotics Aplenzin (bupropion) Contrave (bupropion, bupropion HCL Abilify Maintenna Fanapt () (Abilify) naltrexone) (Wellbutrin) (aripiprazole) Inj Brisdelle (paroxetine) Desvenlafaxine bupropion HCL SR Abilify Mycite Invega Sustenna Fumarate (Wellbutrin SR, Zyban) (aripiprazole) PO () Inj (Thorazine) Fetizma Emsam (selegiline) bupropion HCL XL Aristada (aripiprazole) Latuda () (Clozaril) (levomilnacipran) (Wellbutrin XL) Inj Forfivo XL (bupropion) Khedezla citalopram (Celexa) (desvenalfaxine) Invega Trinza Nuplazid (Haldol) (paliperidone) Inj (pimavanserin) Oleptro (trazadone ER) Pristiq (desvenlafaxine) desvenlafaxine succinate (Pristiq) Rexulti () inj Pexeva (paroxetine) Prozac Weekly duloxetine (Cymbalta) (Haldol) (fluoxetine) Risperdal Consta fluoxetine/ Sarafem (fluoxetine) Trintellix () fluoxetine (Prozac) ( inj) (Symbyax) Selfemra (fluoxetine) Saphris () (Prolixin) fluvoxamine (Luvox) Seroquel XR fluphenazine decanoate fluvoxamine CR (Luvox () inj (Prolixin) CR) Vraylar (cariprazine) olanzepine (Zyprexa, levomilnacipran Zyprexa Zydis) (Fetzima) Zyprexa Relprev olanzepine/fluoxetine (olanzapine) Inj (Symbyax) mirtazepine, mirtazepine ODT (Remeron) paliperidone (Invega) (Serzone) quetiapine (Seroquel) paroxetine HCL (Paxil) (Trilafon) paroxetine HCL CR (Paxil risperidone (Risperdal) CR) (Mellaril) sertraline (Zoloft) trazadone (Desyrel) (Stelazine) venlafaxine HCL (Effexor) (Geodon) venlafaxine HCL ER/XR Sedative/Non-Barbituates (Effexor XR) Edluar (zolpidem) Belsomra (suvorexant) doxepin (Silenor) (Viibryd) Zolpimist (zolpidem) Doral (quazepam) eszopiclone (Lunesta) Oral Spray Hetlioz (tasimelteon) flurazepam (Dalmane) ramelteon (Rozerem) temazepam (Restoril) triazolam (Halcion) zaleplon (Sonata) zolpidem (Ambien) zolpidem CR (Ambien CR) zolpidem SL (Edluar, Intermezzo)

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