July 1, 2021 Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements

Therapeutic Category Excluded Medications Preferred Alternatives

ALLERGIC REACTIONS

epinephrine injection (0.15mg, Anaphylaxis Treatment Auvi-Q (0.15mg, 0.3mg) 0.3mg)

ANALGESICS

celecoxib, diflunisal, etodolac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, Cambia, Diclofenac Cap 35mg ketorolac, meclofenamate, (M), Zipsor, Zorvolex meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, Oral sulindac, tolmetin

Non-Steroidal Anti- Qmiiz ODT meloxicam Inflammatory Agents Relafen DS nabumetone

Ketorolac Nasal Spray (M), Sprix diclofenac, ibuprofen, Other Nasal Spray meloxicam

Diclofenac Patch (M), Flector, Topical diclofenac gel/solution Licart, Pennsaid, Voltaren gel

Opioid Apadaz, hydrocodone/acetaminophen, combinations Benzhydrocodone/acetaminophen oxycodone/acetaminophen

hydromorphone HCl ER, Arymo ER, Kadian ER 200 mg, morphine sulfate ER, Oral Long- Nucynta ER, Oxycodone ER (M) oxymorphone HCl ER, Hysingla Acting ER, OxyContin, Xtampza ER Pain Opioid Analgesics Conzip, Tramadol ER 100mg, tramadol ER 200mg, 300mg cap (M)

Oral Short- codeine sulfate, Acting hydromorphone HCl, morphine Nucynta Opioid sulfate, oxycodone HCl, Analgesics oxymorphone HCl

1 (M) Co-branded product

1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs. 2 Existing utilizers of these medications will be allowed to continue on therapy with the diagnosis of HIV only. Continuation of therapy will not be provided for any other excluded drugs.

Therapeutic Category Excluded Medications Preferred Alternatives ANALGESICS

Transmucosal Abstral, Fentora, Fentanyl Citrate Pain Fentanyl Buccal Tab (M), fentanyl citrate lozenge Analgesics Lazanda, Subsys

Norgesic Forte, Orphengesic Forte (M) orphenadrine tab, aspirin Skeletal Muscle Relaxants Ozobax baclofen

ANTIBACTERIALS, ORAL Doryx 80mg, Doryx MPC, Doxycycline Hyclate DR Oral Antibiotics doxycycline, minocycline 80mg, Minolira ANTICONVULSANTS

Lamictal ODT Kit lamotrigine ODT Seizure Disorders Oxtellar XR1 oxcarbazepine IR

ANTIDEPRESSANTS

Antidepressants Bupropion XL (M)1, Forfivo XL1 bupropion XL

ANTIFUNGALS, ORAL

Oral Antifungals Tolsura itraconazole cap

ANTIHEMOPHILIACS Adynovate, Afstyla, Eloctate, Hemophilia A Esperoct 1 Jivi ANTIMIGRAINES amitriptyline, atenolol, divalproex sodium, nadolol, Ajovy propranolol, timolol, topiramate, CGRP Antagonists venlafaxine, Aimovig, Emgality

Reyvow Nurtec ODT, Ubrelvy

rizatriptan ODT, sumatriptan Serotonin Receptor Onzetra Xsail, Tosymra, Zembrace Symtouch injection, sumatriptan nasal Agonists spray, zolmitriptan ODT ANTIPARKINSON AGENTS

Parkinson's Disease Gocovri, Osmolex ER amantadine

ANTIPSYCHOTICS aripiprazole, asenipine, Atypical/Second Secuado1 olanzapine, quetiapine, Generation Antipsychotics quetiapine ER, risperidone ANTIVIRALS Ledipasvir-Sofosbuvir (M), Epclusa, Harvoni, Mavyret, Hepatitis-C drugs Sofosbuvir-Velpatasvir (M) Vosevi

2 (M) Co-branded product

Therapeutic Category Excluded Medications Preferred Alternatives

ANTIVIRALS

Please talk with your doctor HIV drugs Descovy2, Temixys1 about clinically appropriate options. AUTONOMIC & CENTRAL NERVOUS SYSTEM

Attention Deficit Disorder Adhansia XR methylphenidate ER, Vyvanse

Interferon Beta Medications Extavia1, Plegridy1, Rebif 1, Avonex, Betaseron for Multiple Sclerosis Rebif Rebidose1

CARDIOVASCULAR atorvastatin, fluvastatin, Cholesterol-Lowering Livalo, Zypitamag lovastatin, pravastatin, Agents rosuvastatin, simvastatin

Inderal XL , Innopran XL propranolol ER

Hypertension Kapspargo metoprolol ER

Katerzia amlodipine

Hypertension with Consensi amlodipine, celecoxib Osteoarthritis CHEMOTHERAPY AGENTS

Alkylating Agents Belrapzo, Bendamustine, Treanda

Antiandrogens Erleada1, Yonsa1

HER-2 Inhibitors Herzuma, Ontruzant

1 Please talk to your doctor about Kinase Inhibitors Tabrecta clinically appropriate options.

Methyltransferase Tazverik 1 Inhibitors

Monoclonal Antibodies Ogivri, Truxima

Miscellaneous Darzalex Faspro

CONTRACEPTIVES Please talk to your doctor about Gel Phexxi clinically appropriate options.

junel FE, larin FE, microgestin Lo Loestrin Oral FE, tarina FE

3 (M) Co-branded product

Therapeutic Category Excluded Medications Preferred Alternatives

CONTRACEPTIVES

Camila, Incassia, Nora-Be, Oral Slynd norethindrone, Norlyda, Norlyroc

levonorgestrel/ethinyl estradiol Patch Twirla combined generic oral contraceptive, Xulane

etonogestrel-ethinyl estradiol Vaginal ring Annovera vaginal ring

CORTICOSTEROIDS

Hemady dexamethasone

Oral Steroids Rayos prednisone

DERMATOLOGICAL AGENTS adapalene, tretinoin cream/gel, Avita, Differin lotion Retin-A micro gel 0.06% and 0.08% adapalene, adapalene/benzoyl peroxide, clindamycin gel/lotion/solution, Aklief, Aktipak, Clindagel, Clindamycin phosphate clindamycin/benzoyl peroxide, Topical Acne Treatment 1% gel(M), Dapsone 7.5% (M), Veltin dapsone, erythromycin/benzoyl peroxide, tretinoin cream, Aczone 7.5%, Amzeeq, Epiduo Forte, Onexton

Arazlo, Fabior, Tazorac tazarotene cream

Topical anesthetics ZTlido lidocaine patch

ciclopirox, tavaborole, Topical Antifungals Jublia terbinafine, Kerydin

metronidazole cream/gel/lotion, Topical Antiinfectives Noritate cream Finacea, Soolantra

ALA Scalp lotion hydrocortisone

Apexicon E cream fluocinonide, betamethasone

Derma-Smoothe/FS, Capex shampoo Topical Corticosteroids flucinolone acetonide scalp oil

Cordran tape flurandrenolide

4 (M) Co-branded product

Therapeutic Category Excluded Medications Preferred Alternatives

DERMATOLOGICAL AGENTS

betamethasone, clobetasol, Halobetasol foam(M), Lexette halobetasol cream/ointment

betamethasone, mometasone, Halog ointment triamcinolone

Impoyz cream clobetasol

flurandrenolide, hydrocortisone Pandel cream valerate, triamcinolone Topical Corticosteroids acetonide

Psorcon cream, Verdeso foam betamethasone, fluocinolone

hydrocortisone valerate, Trianex oint 0.05% triamcinolone acetonide

clobetasol proprionate, Ultravate lotion fluocinonide, halobetasol proprionate Topical Immune Response Imiquimod cream pump 3.75% (M), Zyclara Pump imiquimod Modifier

Calcipotriene foam 0.005% (M), Sorilux calcipotriene

clobetasol, fluocinonide, Topical Plaque Psoriasis Duobrii lotion halobetasol, tazorotene, Enstilar DIABETES Blood Glucose Meters, Examples: Abbott (FreeStyle, Precision), Ascencia (Contour, Contour Test Strips and Control Arkray(Glucocard), Lifescan (Onetouch), Trividia, Next) Solutions (TRUEtest, TRUEtrack), Roche (Accu-Chek)

Continuous Glucose Freestyle Libre Dexcom Monitoring (CGM)

Blood Sugar Regulators metformin HCl 24hr ER osmotic release, metformin metformin ER Miscellaneous HCl 24hr ER modified release

Dipeptidyl Peptidase-4 Alogliptin(M), Alogliptin with metformin(M), Janumet, Janumet XR, Januvia, (DPP4) Inhibitors & Alogliptin with pioglitazone(M), Kazano, Jentadueto, Jentadueto XR, Combinations Kombiglyze XR, Nesina, Onglyza, Oseni Tradjenta

Basal insulins Basaglar, Levemir, Semglee, Tresiba Lantus, Toujeo

Bydureon, Bydureon BCise, Glucagon-Like Peptide- Adlyxin Byetta, Ozempic, Rybelsus, 1(GLP1) Agonists Trulicity, Victoza

Insulins Novolin Humulin

Admelog, Apidra, Fiasp, Insulin Aspart (M), Insulin Humalog, Lyumjev Rapid-acting insulins Lispro (M), Novolog

5 (M) Co-branded product

Therapeutic Category Excluded Medications Preferred Alternatives

DIABETES Sodium-glucose co- transporter (SGLT2) Invokana, Steglatro Farxiga, Jardiance Inhibitors - Single agent Sodium-glucose co- transporter (SGLT2) Synjardy, Synjardy XR, Xigduo Invokamet, Invokamet XR, Segluromet inhibitors - Combination XR agents SGLT2 and DPP4 QTERN, Steglujan Glyxambi, Trijardy XR Combinations ENDOCRINE (OTHER) Genotropin, Humatrope, Omnitrope, Saizen, Growth Hormones Norditropin, Nutropin Zomacton

Gonal-F, Gonal-F RFF Follistim AQ Infertility Cetrotide ganirelix (made by Organon)

Nocturia Noctiva desmopressin, Nocdurna

testosterone, Androderm, Testosterone Replacement Aveed, Jatenzo, Natesto, Testopel Xyosted

ENZYME DISORDERS Duchenne Muscular dexamethasone, Exondys 51, Vyondys 53 dystrophy (DMD) methylprednisolone, prednisone GASTROINTESTINAL

diphenoxylate/atropine, Motofen Anti-Diarrheal Agents loperamide

granisetron solution/tablet, Antiemetics Sancuso patch ondansetron ODT

Anti-Inflammatory, Anti- Duexis famotidine, ibuprofen Ulcer Agents

Irritable Bowel Syndrome with Constipation/ Chronic Amitiza, Lubiprostone (M), Trulance Linzess Idiopathic Constipation (IBS-C/CIC)

Opioid-Induced Amitiza, Lubiprostone (M), Movantik, Relistor Symproic Constipation (OIC)

balsalazide, mesalamine, Dipentum Apriso Inflammatory Bowel Disease Ortikos budesonide ER

Gavilyte-C, Gavilyte-H, PEG Laxatives Golytely packets 3350

6 (M) Co-branded product

Therapeutic Category Excluded Medications Preferred Alternatives

GASTROINTESTINAL

Clenpiq, Gavilyte, PEG 3350, Laxatives Osmoprep, Plenvu Prepopik, Suprep

Pancreatic Enzymes Pancreaze, Pertzye, Viokace Creon, Zenpep

esomeprazole magnesium omeprazole with sodium bicarbonate (cap, powder delayed release, lansoprazole, Proton pump inhibitors pak), Rabeprazole sprinkle cap (M) omeprazole, pantoprazole, Aciphex Sprinkle caps, Dexilant

HEMATOLOGICAL Erythropoiesis-Stimulating Epogen, Procrit Aranesp, Retacrit Agents

Immune globulin, Please talk to your doctor about Asceniv 1, Panzyga1 intravenous (IVIG) clinically appropriate options.

Immune globulin, Please talk to your doctor about Cutaquig1 subcutaneous (SCIG) clinically appropriate options.

Long-Acting Granulocyte- Colony Stimulating Factor Fulphila, Udenyca Neulasta, Ziextenzo (G-CSFs)

Short-Acting Granulocyte- Colony Stimulating Factor Granix, Neupogen Nivestym, Zarxio (G-CSFs)

IMMUNOMODULATORS Interleukin-17 (IL-17) Cosentyx 1 Taltz Inhibitor

JAK Inhibitor Olumiant1 Rinvoq, Xeljanz, Xeljanz XR

TNF inhibitor Remicade, Renflexis Avsola, Inflectra

IMMUNOTHERAPY

Please talk to your doctor about Oral Palforzia clinically appropriate options.

OPHTHALMIC latanoprost ophthalmic solution, Vyzulta, Zioptan travoprost ophthalmic solution, Lumigan Antiglaucoma Drugs

Timoptic Ocudose 0.25% timolol ophthalmic solution

azelastine ophthalmic solution, Antihistamines Bepreve, Lastacaft, Pazeo, Zerviate olopatadine ophthalmic solution

7 (M) Co-branded product

Therapeutic Category Excluded Medications Preferred Alternatives

OPHTHALMIC

Dry Eye Disease Cequa Restasis, Xiidra

bromfenac ophthalmic solution, diclofenac ophthalmic solution, Non-steroidal Anti- flurbiprofen sodium ophthalmic Bromsite, Ilevro, Nevanac Inflammatory Agents solution, ketorolac tromethamine ophthalmic solution, Prolensa

ophthalmic bevacizumab Wet Age-related Macular Beovu (compound), Eylea, Lucentis, Degeneration Macugen OTHER Colchicine capsule (M), Colcrys, Gloperba, Antigout Agents colchicine tablet Mitigare

Antihistamines and desloratadine, Clarinex-D combinations pseudoephedrine

mometasone furoate, Beconase Corticosteroid nasal sprays Xhance AQ

Cortisol Synthesis Isturisa ketoconazole tabs, Korlym Inhibitors

Diabetic Gastroparesis Gimoti metoclopramide

Lambert-Eaton Myasthenic Firdapse Ruzurgi Syndrome (LEMS)

Long-Chain Fatty Acid Please talk to your doctor about Oxidation Disorders (LC- Dojolvi clinically appropriate options. FAOD)

Examples: Folic-K, Genicin Vita-S, Hylavite, Lorid, Multivitamins Any preferred multivitamin Tronvite, Xvite

Obesity Contrave phentermine, Qsymia, Saxenda

Opioid Reversal Agents Naloxone auto-injector, Evzio Narcan

Gel-One, Genvisc, Hyalgan, Hymovis, Monovisc, Osteoarthritis/Hyaluronic Orthovisc, Sodium Hyaluronate, Supartz FX, Durolane, Euflexxa, Gelsyn-3 acid injections Synvisc, Synvisc-One, Triluron, Trivisc, Visco-3

Osteoporosis Forteo Teriparatide, Tymlos

8 (M) Co-branded product

Therapeutic Category Excluded Medications Preferred Alternatives

OTHER

Platelet-Modifying Agent Aspirin/Omeprazole (M), Yosprala aspirin, omeprazole

Examples: Azesco, Pregenna, Prenate, Trinaz, Prenatal vitamins Any preferred prenatal vitamin Vitafol FE, Vitathely, Zalvit

Sickle Cell Anemia Oxbryta hydroxyurea

Somatostatin Analog Bynfezia Pen, Mycapssa, Signifor (SQ) octreotide injection

Levothyroxine caps (M), Thyquidity, Thyroid Agents levothyroxine Tirosint caps, solution RESPIRATORY

COPD: Inhaled Incruse Ellipta, Seebri, Tudorza Spiriva Anticholinergics

COPD: Long-Acting Beta Agonist/Long-Acting Bevespi, Duaklir, Utibron Anoro Ellipta, Stiolto Respimat Muscarinic Agonist Combination inhalers

Cayston, Kitabis Pak, tobramycin nebulizer soln, Cystic Fibrosis Tobramycin Neb 300mg/5ml (M) TOBI podhaler

Arnuity Ellipta, Flovent Diskus, Pulmonary Anti- Alvesco, Asmanex, Asmanex HFA, QVAR Flovent HFA, Pulmicort Inflammatory Inhalers Redihaler Flexhaler

Pulmonary Anti- Inflammatory, Long-Acting Airduo Digihaler, AirDuo Respiclick, Armonair Advair Diskus, Advair HFA, Beta Agonist Combination Digihaler, Budesonide/Formoterol (M), Dulera Breo Ellipta, Symbicort Inhalers

Albuterol HFA (brand alternative for Ventolin HFA Any generic albuterol HFA Short-Acting Beta-2 made by Prasco) (M)), Levalbuterol Inhaler (M), inhaler (EXCEPTION: albuterol Adrenergic Inhalers Proair Digihaler, Proventil HFA, Xopenex HFA HFA made by Prasco)

UROLOGICAL Erectile Dysfunction Oral Stendra sildenafil Agents

Interstitial Cystitis Elmiron amitriptyline, hydroxyzine

9 (M) Co-branded product

Excluded brand-name medications with generic equivalents

The brand-name medications below are excluded on the formulary. These brand-name medications have been identified as having available generic equivalents covered at Tier 1 on the formulary. Speak with your pharmacist to have your excluded brand-name medication substituted with its generic equivalent.

A generic medication contains the same active ingredient(s) as a brand-name medication. An active ingredient is what makes the medication work. For example, Lipitor® and its generic both contain atorvastatin, which reduces the amount of bad cholesterol in the blood. Brand-name medications are often protected by a patent. When the patent ends, drug companies can apply to the U.S. Food and Drug Administration (FDA) to begin making generic versions of the medication.

Abilify Cosopt solution Kuvan Prevacid Timoptic Ocudose 0.5% Acanya Cosopt PF solution Lamictal chewable Prinivil Timoptic-XE Aciphex tablet Cozaar Lamictal starter kit Pristiq TOBI nebulizer solution Acticlate Crestor Lamictal ODT Prometrium Tobradex suspension Aczone 5% Cymbalta Lamictal tab Propecia Topamax Adcirca Cytomel Lamictal XR Protonix tab Topamax sprinkle cap Adderall Delestrogen injection Lasix Provigil Topicort spray Adderall XR 20mg/ml, 40mg/ml Latisse Prozac Toprol XL Adipex-P Delzicol Lescol XL Pulmicort inhalation Tracleer 62.5,125mg Afinitor 2.5,5,7.5mg Depakote Letairis suspension Treximet Alphagan P 0.15% Depakote ER Levitra Qudexy XR Tribenzor Altace Depakote sprinkle cap Lexapro Questran Tricor Ambien Depo-testosterone Lialda Questran Light Trileptal Ambien CR injection Lidoderm Ranexa Truvada2 Amrix Desonate gel Lipitor Relafen Tylenol/cod tab Androgel Differin cream, gel Loestrin 21 Relpax Uceris tab Arimidex Dilantin cap 100mg Loestrin FE Remodulin injection Ultracet Arthrotec Dilantin chewable Lotemax suspension Renagel Ultram Asacol HD Dilantin suspension Lotrel Restoril Vagifem Atacand Dilaudid Lovaza Retin-A Valium Ativan Diovan Lunesta Retin-A micro gel Valtrex Atripla1 Diovan HCT Lyrica 0.04%, 0.1% Vanadom Avapro Doryx tab 50, 200mg Maxalt Risperdal solution, Vectical Avodart Duragesic Maxalt-MLT tablet Vesicare Azor Dyazide Metrogel Ritalin Viagra Baraclude Effexor XR Micardis Ritalin LA Vigamox Benicar Elidel Micardis HCT Roxicodone Vimovo Benicar HCT Epiduo gel Minastrin Sabril Vivelle-Dot Benzaclin EpiPen Jr 0.15mg Mobic Safyral Volgelxo Benzamycin Estrace Moviprep Sandostatin injection Vytorin Bethkis Evekeo MS Contin Saphris Welchol Beyaz Exforge Nalfon Seasonique Wellbutrin SR Brisdelle Exforge HCT Nasonex Sensipar Wellbutrin XL Butrans Fioricet Natroba Seroquel Xalatan Canasa Fioricet w/ codeine Neurontin Seroquel XR Xanax Carafate Flomax Nexium capsule Silvadene Xanax XR Carbatrol Focalin Niaspan ER Singulair Yasmin 28 Cardizem LA Focalin XR Nitrostat Skelaxin Yaz 180,240,300, Fortamet Norco Solodyn Zanaflex 360, 420mg Fortesta Norvasc Soma Zegerid Carnitor solution, Generess FE Nulytely Staxyn Zestril tablet chewable Nuvigil Strattera Zetia Catapres-TTS patch Gleevec Onfi Suboxone Ziana Celebrex Glumetza Oracea Synthroid Zocor Celexa Golytely solution Ortho Micron Taclonex ointment Zohydro ER Cialis Halog cream Ortho-Tri-Cyclen Lo Tamiflu Zoloft Ciprodex Hyzaar Ortho-Novum Targadox Zomig tab Clarinex 5mg tab Imitrex Pataday Targretin Zomig ZMT Climara patch Inderal LA Patanol Tecfidera Zonegran Clobex Intuniv Paxil tab Tegretol Zovirax Cloderm Kenalog spray Paxil CR Tegretol-XR Zyclara cream 3.75% Colestid Kenalog-40 Injection Percocet Tenormin Zyprexa Concerta Keppra Plaquenil Testim gel Zytiga Coreg Keppra XR Plavix Tikosyn Coreg CR Klonopin Pravachol Timoptic Cortef K-tab Pred Forte

10 (M) Co-branded product

Required Prior Authorization +

Therapeutic Class Non-Preferred Medications Preferred Medications

All other brands non-preferred with prior Hepatitis C Epclusa, Harvoni, Mavyret, Vosevi authorization

dimethyl fumarate DR, glatopa, All other brands non-preferred with prior glatiramer, Avonex, Bafiertam, Multiple Sclerosis authorization Betaseron, Copaxone, Kesimpta, Vumerity

Avsola, Cimzia, Humira, Inflectra, All other brands non-preferred with prior Immunomodulators Otezla, Rinvoq, Simponi, Skyrizi, authorization Stelara, Tremfya, Xeljanz, Xeljanz XR

+ All of the products listed above are currently subject to prior authorization. Preferred medications are required prior to new requests for non-preferred medication(s). Existing utilizers of non-preferred medication(s) within the therapeutic categories of Hepatitis C, Immunomodulators and Multiple Sclerosis will be eligible to remain on current therapy if compliance and efficacy of therapy are demonstrated. Exceptions will be granted for specific indications where the preferred agents do not have FDA-approval for use.

About this document: Where differences exist between this formulary and your benefit plan documents, the benefit plan documents rule. This may not be a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or plan sponsor for full details.

© 2021 Optum, Inc. All rights reserved. OR100-7555 All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

11 (M) Co-branded product