Prescription Drug Formulary

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Cleveland Clinic Employee Health Plan Prescription Drug Formulary

July 2021 Cleveland Clinic Health Benefit Program Drug Formulary July 2021

Prescription Drug Coverage The listing of a drug in the Formulary does not guarantee coverage if your contract does not cover that category of drugs (e.g., oral contraceptives, infertility agents). Refer to the Benefits and Coverage Clarification section (page13) in the Handbook to determine specific coverage. Approved Medications — Only FDA-approved medications are eligible for coverage. Non-Covered Medications — These drugs are determined by the terms of the member’s group health plan. The following are examples of, but not limited to, drug categories that plans exclude from coverage: drugs used for cosmetic purposes, weight control, promotion of fertility, and sexual dysfunction. Preferred Generic Medications (Non-Specialty; Tier 1) — The Cleveland Clinic Health Benefit Program supports and encourages the use of FDA-approved generic drugs that are both chemically and therapeutically equivalent to manufacturers’ brand name products. Generically equivalent products are safe and effective treatments that offer savings as alternatives to brand name products. This Formulary lists both a generic and a brand name for the purpose of drug recognition. Preferred Brands (Non-Specialty; Tier 2) — An FDA-approved drug of proven therapeutic efficacy and safety and approved by the P&T Committee for inclusion in the Formulary. This Formulary lists both a generic and a brand name for the purpose of drug recognition. Non-Preferred /Non-Formulary Brands and Generics (Tier 3) — Any FDA-approved medication which has been reviewed by the P&T Committee and not added to the Formulary or is new and has not yet been reviewed by the P&T Committee is considered a Non-Preferred/Non-Formulary drug. A higher co-insurance is charged for Non-Preferred/Non-Formulary medications. Specialty Brand/Generic Drugs (Tier 4) — An FDA-approved drug of proven therapeutic efficacy and safety and approved by the P&T Committee for inclusion in the Formulary as a specialty medication due to its complex nature, administration, handling, and/or treatment of a complex disease state. Compounded Prescriptions — A customized medication prepared by a pharmacist according to a doctor’s specifications. Compounded prescriptions are considered Non-Preferred and have a charge of 45% at any Cleveland Clinic Pharmacy or 50% at all other locations. Prior authorization is required for coverage of compounded medications with a total gross cost of $100 or more. Investigational/Experimental Drug Use — A medication pending FDA approval or a FDA-approved medication not generally recognized by the medical community as effective or appropriate for a particular diagnosis. Charges for experimental or investigational drugs are not a covered benefit.

1 Important Points About the HBP Prescription Drug Formulary • The HBP Prescription Drug Formulary lists medications that are included in Tier 1, Tier 2 and Tier 4 of the HBP Prescription Drug Benefit (Tier 3 are Non-Preferred/Non-Formulary brand and generic drugs). All of the medications listed in this HBP Prescription Drug Formulary are considered formulary medications. This HBP Prescription Drug Formulary is designed to assist members and physicians to enhance cost savings by using Preferred Generic Medications (Non-Specialty; Tier 1), Preferred Brands (Non-Specialty; Tier 2) and Specialty Brand/Generic Drugs (Tier 4), thereby making all drugs in these Tiers the preferred drug(s) of choice. This HBP Prescription Drug Formulary is designed to assist members and physicians to enhance cost savings by using Preferred Generics (Non-Specialty; Tier 1), Preferred Brands (Non-Specialty; Tier 2) and Specialty Brand/Generic Drugs (Tier 4), thereby making all drugs in these Tiers the preferred drug(s) of choice. • Coverage of certain Formulary medications may also be subject to restrictions established by the Pharmacy and Therapeutics (P&T) Committee. • Brand names are listed in the HBP Prescription Drug Formulary only as a reference to help you identify the Preferred drug and do not indicate coverage of a particular brand. Brand names are capitalized (e.g., Amoxil) and generic names are in lower case (e.g., amoxicillin). • The inclusion of a drug on this list does not mean that all strengths or dosage forms for a given drug are covered under your prescription drug benefit. Medication strengths or dosage forms that are excluded from the formulary can be found in the Non-Covered Medications section starting on page 16. • Designated symbols/letters follow certain drugs listed in the HBP Prescription Drug Formulary and indicate criteria related to the drugs as follows: (*) indicates availability of a generic equivalent; (**) indicates availability of a generic equivalent but the brand product is still covered as a “Preferred Brands (Non-Specialty; Tier 2); (PA) indicates that prior authorization is required for use (physician must submit a Prior Authorization, Formulary Exception and Appeal Form); (SP) indicates a specialty brand or generic drug (a higher co-insurance may be charged and medications only available through Cleveland Clinic Pharmacies, Cleveland Clinic Specialty Pharmacy, or the CVS/caremark Specialty Drug Program); (QL) indicates the drug has a quantity limit. (ST) indicates the drug is part of the Step Therapy Program.

Notice The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2021. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with Cleveland Clinic or CVS/caremark. When viewing the HBP Prescription Drug Formulary via the Internet, please be advised that the HBP Prescription Drug Formulary is updated periodically and changes may appear prior to their effective date to allow for client notification.

2 Drug Formulary Medications by Category ALLERGY/COUGH & COLD/ ALLERGY/COUGH & COLD/ ANALGESICS RESPIRATORY RESPIRATORY (cont.) Arthritis Anticholinergic, Inhaled Nasal Cough/Cold Actemra (tocilizumab) (CC) (PA (QL) (SP) Atrovent (ipratropium)* Tessalon (benzonatate)* (only 100 mg & 200 mg) Arava (leflunomide)* (SP) Astagraf XL (tacrolimus ext-rel) (PA) Anticholinergic, Inhaled Oral Leukotriene Modulator Azulfidine (sulfasalazine)* Atrovent (ipratropium) inhalation solution* Accolate (zafirlukast)* Cimzia (certolizumab) (CC) (PA) (QL) (SP) (excluded Atrovent HFA (ipratropium) inhaler Singulair (montelukast)* for Psoriasis) Incruse Ellipta (umeclidinium bromide) (QL) Miscellaneous Agents Enbrel (etanercept) (CC) (PA) (QL) (SP) (excluded Lonhala Magnair (glycopyrrolate) (PA) (QL) Berinert (C1 inhibitor) (CC) (PA) (SP) for Psoriasis) Spiriva Respimat (tiotropium) (2.5 mcg/ Bethkis (tobramycin for inhalation) (PA) (SP) Gengraf (cyclosporine)* (SP) actuation only) Bronchitol (mannitol) (PA) (QL) (SP) Humira (adalimumab) (CC) (PA) (SP) Tudorza Pressair (aclidinium) Cayston (aztreonam) inhalation solution (CC) (SP) Imuran (azathioprine)* Yupelri (revefenacin inhalation solution) (PA) (QL) Cinqair (reslizumab) (CC) (PA) (SP) Kevzara (sarilumab) (CC) (PA) (QL) (SP) Anticholinergic/Beta Agonist, Inhaled Oral Cinryze (C1 inhibitor) (PA) (SP) Kineret (anakinra) (CC) (PA) (SP) Bevespi Aerosphere (glycopyrrolate/ formoterol) Cuvposa (glycopyrrolate) (PA) Neoral (cyclosporine) capsules*, oral solution* (SP) (QL) Daliresp (roflumilast) (PA) Olumiant (baricitinib) (CC) (PA) (QL) (SP) Combivent Respimat (ipratropium/albuterol) Elixophyllin (theophylline) elixir Orencia (abatacept) (CC) (PA) (SP) inhaler Epipen (epinephrine)* (generic only) (QL) Otezla (apremilast) (CC) (PA) (QL) (SP) Duoneb (ipratropium/albuterol)* Epipen Jr. (epinephrine)* (generic only) (QL) Otrexup (methotrexate injection) (PA) (QL) (SP) Plaquenil (hydroxychloroquine)* (QL) Antihistamines, Oral Esbriet (pirfenidone) (CC) (PA) (QL) (SP) Rasuvo (methotrexate injection) (PA) (QL) (SP) Atarax (hydroxyzine HCl)* Fasenra (benralizumab) pens, prefilled syringes Rinvoq (upadacitinib) (PA) (QL) (SP) Cyproheptadine tablets*, syrup* (PA) (QL) (SP) Rheumatrex (methotrexate)* Phenergan (promethazine)* Firazyr (icatibant) (PA) (SP) Sandimmune (cyclosporine) capsules*, Vistaril (hydroxyzine pamoate)* Grastek (timothy grass pollen allergen extract) (PA) (QL) solution (SP) Anti-Inflammatory, Inhaled Oral Haegarda (C1 inhibitor) (PA) (SP) Simponi (golimumab) (PA) (SP) Arnuity Ellipta (fluticasone) (QL) Intal (cromolyn sodium) inhalation solution* Xeljanz (tofacitinib) (CC) (PA) (QL) (SP) Asmanex (mometasone) inhaler Kalbitor (ecallantide) (PA) (QL) (SP) Xeljanz XR (tofacitinib) (CC) (PA) (QL) (SP) Flovent HFA (fluticasone) inhaler Kalydeco (ivacaftor) (CC) (PA) (QL) (SP) Gout Pulmicort (budesonide) inhaler Kitabis Pak (tobramycin) inhalation solution* (PA) (SP) Benemid (probenecid)* Pulmicort Respules (budesonide)* Lysteda (tranexamic acid)* (QL) Colcrys (colchicine) Qvar (beclomethasone) inhaler Nucala (mepolizumab) (CC) (PA) (QL) (SP) Zyloprim (allopurinol)* Anti-Inflammatory, Inhaled Oral/Long Odactra (house dust mite allergen extract) (PA) (QL) Migraine Acting Beta Agonist Combination Ofev (nintedanib) (CC) (PA) (QL) (SP) Aimovig (erenumab-aooe) (CC) (PA) (QL) (SP) Advair Diskus (fluticasone/salmeterol)* Oralair (grass mixed pollen allergen extract) (PA) (QL) Ajovy (fremanezumab-vfrm) (CC) (PA) (QL) (SP) AirDuo (fluticasone/salmeterol)* (generic only; Orkambi (lumacaftor/ivacaftor) (CC) (PA) (QL) (SP) Amerge (naratriptan)* (QL) $0 copay) Palforzia [peanut (arachis hypogaea) allergen Cafergot (ergotamine/caffeine)* Breo Ellipta (fluticasone/vilanterol) (QL) powder-dnfp] (PA) (QL) (SP) D.H.E. (dihydroergotamine)* (PA) (QL) Symbicort (budesonide/formoterol)* Pulmozyme (dornase alfa) inhalation solution (CC) (SP) Ragwitek (ragweed pollen allergen extract) (PA) (QL) Emgality (galcanezumab-gnlm) (CC) (PA) (QL) (SP) Beta Agonists, Inhaled Oral Ruconest (recombinant C1 inhibitor) (PA) (QL) (SP) Imitrex (sumatriptan) injection*, nasal spray*, Accuneb (albuterol) inhalation solution* Symdeko (tezacaftor/ivacaftor) (PA) (QL) (SP) tablet* (QL) Arcapta (indacaterol ) Neohaler Takhzyro (lanadelumab-flyo) (PA) (QL) (SP) Maxalt/Maxalt-MLT (rizatriptan)* (QL) Proventil (albuterol) inhalation solution* Theo-Dur (theophylline)* Migranal (dihydroergotamine)* (PA) (QL) Proventil HFA (albuterol) inhaler* TOBI (tobramycin) inhalation solution* (PA) (SP) Nurtec ODT (rimegepant) (CC) (PA) (QL) (SP) ProAir HFA (albuterol) inhaler* TOBI (tobramycin) Podhaler (PA) (SP) Relpax (eletriptan)* (QL) Serevent Diskus (salmeterol) Trelegy Ellipta (fluticasone/umeclidinium/vilanterol) (PA) Reyvow (lasmiditan) (CC) (PA) (QL) (SP) Ventolin HFA (albuterol) inhaler* Trikafta (elexacaftor/tezacaftor/ivacaftor) (CC) (PA) Ubrelvy (ubrogepant) (CC) (PA) (QL) (SP) Xopenex (levalbuterol)* (QL) (SP) Zomig (zolmitriptan)* (QL) Beta Agonists, Oral Xolair (omalizumab) (prefilled syringes only) Muscle Relaxants Alupent (metaproterenol) syrup*, tablet* (CC) (PA) (QL) (SP) Equanil (meprobamate)* Brethine (terbutaline) tablet* Flexeril (cyclobenzaprine)* (except 7.5 mg tablets) Proventil (albuterol) tablet*, syrup* Lioresal (baclofen)* (except 5 mg tablets) Vospire ER (albuterol extended release) tablet* Norflex (orphenadrine)*

ANALGESICS (cont.) ANALGESICS (cont.) ANTI-INFECTIVES (cont.) Muscle Relaxants (cont.) Salicylates (Antibiotics/Antifungals/Antivirals) Norgesic (orphenadrine/aspirin/caffeine)* Dolobid (diflunisal)* Antivirals, Oral (cont.) Norgesic Forte (orphenadrine/aspirin/ caffeine)* Easprin (aspirin)* Epivir (lamivudine)* (SP) Parafon Forte DSC (chlorzoxazone)* (500 mg Trilisate (choline magnesium trisalicylate)* Epivir HBV (lamivudine)* (SP) tablets only) Systemic Lupus Erythematosus Epzicom (abacavir/lamivudine) (SP) Robaxin (methocarbamol)* Benlysta (belimumab) (CC) (SP) (PA) Famvir (famciclovir)* (QL) Skelaxin (metaxalone)* Genvoya (elvitegravir/cobicistat/emtricitabine/ Soma (carisoprodol)* Miscellaneous Analgesics tenofovir alafenamide) (CC) (QL) (SP) Zanaflex (tizanidine)* Lidoderm (lidocaine) patch* (PA) Harvoni (ledipasvir/sofosbuvir)* (CC) (PA) (QL) (SP) Stadol NS (butorphanol)* (generic only) Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Talwin NX (pentazocine/naloxone)* Ansaid (flurbiprofen)* Hepsera (adefovir)* (SP) Arthrotec (diclofenac sodium delayed release/ ANTI-INFECTIVES Incivek (telaprevir) (SP) misoprostol)* Intelence (etravirine) (CC) (SP) (Antibiotics/Antifungals/Antivirals) Cataflam (diclofenac)* Invirase (saquinavir) (SP) Clinoril (sulindac)* Antifungals, Oral Isentress (raltegravir) (CC) (SP) Feldene (piroxicam)* Diflucan (fluconazole) tablet*, suspension* Kaletra (lopinavir/ritonavir)* solution (SP) Flector (diclofenac epolamine)* (PA) (QL) Mycelex Troche (clotrimazole)* (QL) Lexiva (fosamprenavir) (SP) Indocin (indomethacin)* Mycostatin (nystatin) tablet*, suspension* Mavyret (glecaprevir/pibrentasvir) (PA) (QL) (SP) Lodine immediate-release (etodolac)* (only 200 mg Nizoral (ketoconazole)* Norvir (ritonavir) (CC) (SP) capsules, 400 mg tablets, 500 mg tablets) Noxafil (posaconazole) (PA) (SP) tablets* Odefsey (emtricitabine/rilpivirine/tenofovir) (CC) Mobic (meloxicam)* Vfend (voriconazole)* (SP) (QL) (SP) Olysio (simeprevir) (PA) (QL) (SP) Motrin (ibuprofen) tablets*, suspension* Antifungals, Topical Prevymis (letermovir) (PA) (QL) (SP) Naprosyn (naproxen)* Lotrisone (clotrimazole/betamethasone) cream* Prezista (darunavir) (CC) (SP) Orudis (ketoprofen)* Mycolog II (nystatin/triamcinolone)* Rebetol (ribavirin)* (SP) Pennsaid (diclofenac sodium solution)* (PA) Mycostatin (nystatin) cream*, ointment*, Rescriptor (delavirdine) (SP) (only 1.5% solution) powder* (QL) Retrovir (zidovudine)* (SP) Relafen (nabumetone)* Naftin (naftifine) cream*, 1% gel* Solaraze (diclofenac gel)* (PA) Nizoral (ketoconazole) cream* (QL) Reyataz (atazanavir) (SP) Tolectin (tolmetin)* Selsun Rx (selenium sulfide) shampoo* Rukobia (fostemsavir) (PA) (QL) (SP) Toradol (ketorolac)* (QL) Selzentry (maraviroc) (SP) Antivirals, Injectable Voltaren (diclofenac)* Sovaldi (sofosbuvir) (CC) (PA) (QL) (SP) Fuzeon (enfuvirtide) (SP) Stribild (elvitegravir, cobicistat, emtricitabine, Opioid Analgesics Intron A (interferon alfa-2b) (SP) tenofovir) (CC) (SP) Avinza (morphine extended release) Pegasys (peginterferon alfa-2a) (PA) (SP) Sustiva (efavirenz)* (CC) (SP) (generic only) Codeine (codeine sulfate) 30 mg tablets* Pegintron (peginterferon alfa-2b) (PA) (SP) Symmetrel (amantadine)* Demerol (meperidine)* Prevymis (letermovir) (PA) (QL) (SP) Tamiflu (oseltamivir) capsules*, suspension* (QL) Dilaudid (hydromorphone)* Sylatron (peginterferon alfa-2b) (SP) ($0 copay) Dolophine (methadone)* Antivirals, Oral Technivie (ombitasvir/paritaprevir/ritonavir) (PA) Duragesic (fentanyl)* Aptivus (tipranavir) (SP) (QL) (SP) Lortab (hydrocodone/acetaminophen) elixir*, Atripla* (efavirenz/emtricitabine/tenofovir) (CC) (SP) Tivicay (Dolutegravir) (CC) (SP) tablets* (QL) Baraclude (entecavir) (SP) Trizivir (abacavir/lamivudine/zidovudine)* (SP) MS Contin (morphine extended release)* Biktarvy (bictegravir/emtricitabine/tenofovir Truvada (emtricitabine/tenofovir)* (CC) (QL) (SP) MS IR (morphine) tablets*, solution* alafenamide) (CC) (QL) (SP) Tyzeka (telbivudine) (SP) Norco (hydrocodone/acetaminophen)* (QL) Combivir (zidovudine/lamivudine)* (SP) Valcyte (valganciclovir) (SP)* (generic only) Oxycontin (oxycodone extended release) Complera (emtricitabine/rilpivirine/ tenofovir) Valtrex (valacyclovir)* (QL) Percocet (oxycodone/acetaminophen)* (QL) (CC) (SP) Vemlidy (tenofovir alafenamide) (PA) (QL) (SP) Percodan (oxycodone/aspirin)* Copegus (ribavirin)* (SP) Videx (didanosine) (SP) Tylenol with Codeine (acetaminophen/ codeine)* (QL) Crixivan (indinavir) (SP) Videx EC (didanosine)* (SP) Ultracet (tramadol/acetaminophen)* (QL) Cytovene (ganciclovir) (SP) Viekira (ombitasvir/paritaprevir/ritonavir/ Ultram (tramadol)* Daklinza (daclatasvir) (PA) (QL) (SP) dasabuvir) (CC) (PA) (QL) (SP) Ultram ER (tramadol extended release)* Descovy (emtricitabine/tenofovir) (CC) (PA) (QL) (SP) Viracept (nelfinavir) (SP) Opioid Antagonist Dovato (dolutegravir/lamivudine) (QL) (SP) Viramune (nevirapine)*(SP) ReVia (naltrexone)* Edurant (rilpivirine) (SP) Viread (tenofovir) (SP) Emtriva (emtricitabine) (SP) Vitekta (elvitegravir) (SP) Epclusa (sofosbuvir/velpatasvir) (CC) (PA) (QL) (SP) (generic only)*

ANTI-INFECTIVES (cont.) ANTI-INFECTIVES (cont.) CARDIOVASCULAR (Antibiotics/Antifungals/Antivirals) (Antibiotics/Antifungals/Antivirals) (Blood Pressure/Heart/Cholesterol) Antivirals, Oral (cont.) Miscellaneous ACE Inhibitors Viramune XR (nevirapine)*(SP) Aemcolo (rifamycin delayed-release) (PA) (QL) Accupril (quinapril)* Vosevi (sofosbuvir/velpatasvir/voxilaprevir) (CC) Albenza (albendazole) (PA) (QL) Accuretic (quinapril/hydrochlorothiazide)* (PA) (QL) (SP) Alinia (nitazoxanide)* (tablets only) Altace (ramipril)* Capoten (captopril)* Zepatier (elbasvir/grazoprevir) (PA) (SP) Biltricide (praziquantel)* Capozide (captopril/hydrochlorothiazide)* Zerit (stavudine)* (SP) Campral (acamprosate calcium)* Lotensin (benazepril)* Ziagen (abacavir)* (SP) Cleocin (clindamycin)* Lotensin HCT (benazepril/ hydrochlorothiazide)* Zovirax (acyclovir) capsule*, tablet* Dapsone (dapsone)* Mavik (trandolapril)* Antivirals, Topical Emverm (mebendazole) (PA) (QL) Monopril (fosinopril)* Aldara (imiquimod)* (QL) Flagyl (metronidazole)* Monopril-HCT (fosinopril/ hydrochlorothiazide)* Humatin (paromomycin)* Prinivil (lisinopril)* Condylox (podofilox) topical gel Prinzide (lisinopril/hydrochlorothiazide)* Condylox (podofilox) topical solution* Impavido (miltefosine) (PA) (QL) (SP) Lampit (nifurtimox) (PA) (QL) (SP) Univasc (moexipril)* Antibiotics, Oral Neomycin (neomycin)* Vaseretic (enalapril/hydrochlorothiazide)* Vasotec (enalapril)* Cephalosporins Sivextro (tedizolid) (CC) (PA) (QL) (SP) Ceclor (cefaclor)* Zestoretic (lisinopril/hydrochlorothiazide)* Tindamax (tinidazole)* Zestril (lisinopril)* Ceftin (cefuroxime)* Vancocin (vancomycin)* Duricef (cefadroxil) capsule* Xifaxan (rifaximin) (PA) (SP) Angiotensin II Receptor Blockers Keflex (cephalexin)* Zyvox (linezolid)* (QL) (generic only; oral suspension Avapro (irbesartan)* (ST) Omnicef (cefdinir)* for members 0-11 years of age) Cozaar (losartan)* Suprax (cefixime) capsules*, oral suspension* Diovan (valsartan)* (except for 320 mg tablets) (ST) Antibiotics, Topical Diovan HCT (valsartan/hydrochlorothiazide)* (ST) Erythromycins/Macrolides Bactroban (mupirocin) cream* (PA) (QL), Entresto (sacubitril/valsartan) (PA) (QL) Biaxin (clarithromycin)* (extended-release ointment* (QL) Hyzaar (losartan/hydrochlorothiazide)* tablets excluded) Garamycin (gentamicin)* Micardis (telmisartan)* (ST) Dificid (fidaxomicin) (ST) Peridex (chlorhexidine gluconate)* E.E.S. (erythromycin ethylsuccinate)* Silvadene (silver sulfadiazine)* Antiarrhythmic Agents Betapace (sotalol)* EryPed (erythromycin ethylsuccinate)* Antimalarials Cordarone (amiodarone)* Ery-Tab (erythromycin)* Aralen (chloroquine phosphate)* (QL) Mexitil (mexiletine)* Zithromax (azithromycin)* Lariam (mefloquine)* Multaq (dronedarone) (restricted to Cardiology) Amoxil (amoxicillin)* Plaquenil (hydroxychloroquine)* (QL) Augmentin (amoxicillin/clavulanate)* Norpace (disopyramide)* Augmentin XR (amoxicillin/clavulanate XR)* Antimycobacterials Norpace CR (disopyramide) Nydrazid (isoniazid)* Rythmol (propafenone)* Penicillins Priftin (rifapentine) Rythmol SR (propafenone extended release)* Dynapen (dicloxacillin)* Pyrazinamide (pyrazinamide)* Tambocor (flecainide)* Pen-Vee K (penicillin VK)* Rifadin (rifampin)* Tikosyn (dofetilide)* Principen (ampicillin)* Urinary Tract Agents Beta Blockers Quinolones Macrobid (nitrofurantoin)* Blocadren (timolol)* Avelox (moxifloxacin)* Macrodantin (nitrofurantoin)* Coreg (carvedilol)* Cipro (ciprofloxacin)* Proloprim (trimethoprim)* Inderal (propranolol)* Cipro XR (ciprofloxacin extended release)* Vaccines Lopressor (metoprolol)* Levaquin (levofloxacin)* (Only covered at Cleveland Clinic Pharmacies) Sectral (acebutolol)* Sulfas Adacel (diphtheria/tetanus toxoids/acellular Tenoretic (atenolol/chlorthalidone)* Bactrim (sulfamethoxazole/trimethoprim)* pertussis) ($0 copay; for members ≥7 years Tenormin (atenolol)* Bactrim DS (sulfamethoxazole/trimethoprim)* of age) Toprol XL (metoprolol extended-release)* Tetracyclines Pneumovax-23 (pneumococcal polysaccharide) Trandate (labetalol)* Minocin (minocycline) capsule* ($0 copay; for members ≥ 2 years of age) Visken (pindolol)* Monodox (doxycycline monohydrate)* Prevnar-13 (pneumococcal conjugate) ($0 copay) Zebeta (bisoprolol)* (except 75 mg, 150 mg) Shingrix (zoster vaccine recombinant, adjuvanted) Ziac (bisoprolol/hydrochlorothiazide)* Nuzyra (omadacycline) (PA) (QL) (SP) ($0 copay; for members ≥ 50 years of age) Sumycin (tetracycline)* Vaginal Agents Vibramycin (doxycycline hyclate)* (generic 50 mg, MetroGel Vaginal (metronidazole)* 100 mg capsules only)

CARDIOVASCULAR (cont.) CARDIOVASCULAR (cont.) CARDIOVASCULAR (cont.) (Blood Pressure/Heart/Cholesterol) (Blood Pressure/Heart/Cholesterol) (Blood Pressure/Heart/Cholesterol) Calcium Channel Blockers Coagulation Therapy (cont.) Miscellaneous Agents Adalat CC (nifedipine extended release)* Coumadin (warfarin)** Aldomet (methyldopa)* Calan (verapamil)* Eliquis (apixaban) (QL) Aldoril (methyldopa/hydrochlorothiazide)* Calan SR (verapamil extended release)* Lovenox (enoxaparin)* Apresoline (hydralazine)* Cardizem (diltiazem)* Persantine (dipyridamole)* Cardura (doxazosin)* Cardizem CD (diltiazem extended release)* Plavix (clopidogrel)* Catapres (clonidine) tablet* Cardizem SR (diltiazem extended release)* Pletal (cilostazol)* Catapres-TTS (clonidine) patch* Lotrel (amlodipine/benazepril)* Ticlid (ticlopidine)* Corlanor (ivabradine) (PA) (QL) Nimodipine capsules* (PA) (QL) Trental (pentoxifylline)* Corzide (nadolol/bendroflumethiazide)* Norvasc (amlodipine)* Xarelto (rivaroxaban) (QL) Hytrin (terazosin)* Nymalize (nimodipine) oral solution (PA) (QL) (SP) Diuretics Lanoxin (digoxin) tablet** Plendil (felodipine extended release)* Aldactazide (spironolactone/ hydrochlorothiazide)* Loniten (minoxidil) tablet* Procardia XL (nifedipine extended release)* Aldactone (spironolactone)* Minipress (prazosin)* Sular (nisoldipine extended release)* Bumex (bumetanide)* Ranexa (ranolazine)* (PA) (QL) Verelan PM (verapamil extended release)* Demadex (torsemide)* Serpasil (reserpine)* Cholesterol-Lowering Agents Diuril (chlorothiazide)* Tenex (guanfacine)* Antara (fenofibrate capsules) Dyazide (triamterene/hydrochlorothiazide)* Verquvo (vericiguat) (PA) (QL) (SP) Colestid (colestipol)* HydroDIURIL (hydrochlorothiazide)* Vyndamax (tafamidis) (PA) (QL) (SP) Crestor (rosuvastatin)* (QL) Hygroton (chlorthalidone)* Vyndaqel (tafamidis meglumine) (PA) (QL) (SP) Epanova (omega-3 carboxylic acids) Inspra (eplerenone)* (restricted to Cardiology) (QL) Lasix (furosemide)* CENTRAL NERVOUS SYSTEM Juxtapid (lomitapide) (PA) (SP) Lozol (indapamide)* Lescol (fluvastatin immediate release)* (ST) Maxzide (triamterene/hydrochlorothiazide)* Alzheimer’s Lescol XL (fluvastatin extended release)* (ST) Midamor (amiloride)* Aricept (donepezil)* Lipitor (atorvastatin)* (QL) Moduretic (amiloride/hydrochlorothiazide)* Exelon (rivastigmine)* Lopid (gemfibrozil)* Zaroxolyn (metolazone)* Namenda (memantine)* Lipofen (fenofibrate)* Namenda XR (memantine)* (PA) Nitrates Razadyne (galantamine)* Lovaza (omega-3-acid ethyl esters)* (restricted to Imdur (isosorbide mononitrate)* Cardiology) (QL) Isordil (isosorbide dinitrate)* (except 40 mg Anticonvulsants Mevacor (lovastatin)* tablets) Aptiom (eslicarbazepine) (PA) (QL) Nexletol (bempedoic acid) (PA) (QL) (SP) Minitran (nitroglycerin) patches* Banzel (rufinamide) tablets, oral suspension* (CC) Nexlizet (bempedoic acid/ezetimibe) (PA) (QL) (SP) Nitro-Bid (nitroglycerin) ointment (PA) (SP) Niaspan (niacin extended release)* Nitro-Dur (nitroglycerin) patches* Briviact (brivaracetam) (PA) (QL) Praluent (alirocumab) (CC) (PA) (QL) (SP) (only Nitrolingual (nitroglycerin) spray* Carbatrol (carbamazepine extended release)* NDCs: 72733-5901-02, 72733-5902-02) Nitrostat (nitroglycerin) SL tablets Celontin (methsuximide) Pravachol (pravastatin)* Depakene (valproic acid)* Questran (cholestyramine)* Orthostatic Hypotension Depakote (divalproex)* Questran Light (cholestyramine)* Florinef (fludrocortisone)* Diastat (diazepam rectal gel)* Repatha (evolocumab) (CC) (PA) (QL) (SP) Northera (droxidopa) (PA) (QL) (SP) Dilantin (phenytoin)** Tricor (fenofibrate)* Proamatine (midodrine)* Epidiolex (cannabidiol) (PA) (SP) Trilipix (fenofibric acid delayed release)* Pulmonary Arterial Hypertension Felbatol (felbamate)* Vascepa (icosapent ethyl) (restricted to Adcirca (tadalafil)* (CC) (PA) (QL) (SP) Fycompa (perampanel) (CC) (PA) (QL) (SP) Cardiology) 1 gm capsules* (QL) Adempas (riociguat) (PA) (QL) (SP) Gabitril (tiagabine)* Welchol (colesevelam)* Alyq (tadalafil)* (PA) (QL) (SP) Keppra (levetiracetam)* Zetia (ezetimibe)* (QL) Flolan (epoprostenol)* (SP) Keppra XR (levetiracetam)* Zocor (simvastatin)* Letairis (ambrisentan)* (PA) (QL) (SP) Klonopin (clonazepam)* Coagulation Therapy Opsumit (macitentan)* (PA) (QL) (SP) Lamictal (lamotrigine)* Advate (antihemophilic factor ) (CC) (SP) Orenitram (treprostinil) (CC) (PA) (QL) (SP) Lamictal ODT (lamotrigine orally Aggrenox (dipyridamole extended release/ Remodulin (treprostinil)* (PA) (SP) (generic only) disintegrating tablets)* aspirin)* (generic only) Revatio (sildenafil)* (CC) (PA) (SP) (generic only) Lamictal XR (lamotrigine extended release)* Agrylin (anagrelide)* Tracleer (bosentan)* (CC) (PA) (QL) (SP) Lyrica (pregabalin)* Arixtra (fondaparinux)* Tyvaso (treprostinil) (CC) (PA) (SP) Mysoline (primidone)* Cablivi (caplacizumab) (PA) (QL) (SP) Uptravi (selexipag) (CC) (PA) (SP) Nayzilam (midazolam) (PA) (QL) (SP) Ventavis (iloprost) (SP) Neurontin (gabapentin)*

CENTRAL NERVOUS SYSTEM (cont.) CENTRAL NERVOUS SYSTEM (cont.) CENTRAL NERVOUS SYSTEM (cont.) Anticonvulsants (cont.) Antiparkinson’s (cont.) Mood Stabilizers (cont.) Onfi (clobazam)* (CC) (PA) (SP) (generic only) Mirapex (pramipexole)* Haldol (haloperidol)* Oxtellar XR (oxcarbazepine) (CC) (PA) (QL) (SP) Mirapex ER (pramipexole extended release)* Invega (paliperidone extended release) Phenobarbital (phenobarbital)* Nourianz (istradefylline) (CC) (PA) (QL) (SP) Latuda (lurasidone) (PA) (QL) Sabril (vigabatrin)* (PA) (SP) Nuplazid (pimavanserin) (PA) (QL) (SP) Lithobid (lithium carbonate extended release)* Spritam (levetiracetam) (CC) (PA) (QL) (SP) Parcopa (carbidopa/levodopa orally Lithotabs (lithium carbonate)* Tegretol (carbamazepine)* disintegrating tablets)* Loxitane (loxapine)* Tegretol-XR (carbamazepine extended release)* Parlodel (bromocriptine)* (2.5 mg tablets only) Mellaril (thioridazine)* Topamax (topiramate)* Requip (ropinirole)* Navane (thiothixene)* Trileptal (oxcarbazepine) tablets*, suspension* Requip XL (ropinirole extended release)* Prolixin (fluphenazine)* Valium (diazepam)* Sinemet (carbidopa/levodopa)* Risperdal (risperidone)* Valtoco (diazepam) (PA) (QL) (SP) Sinemet CR (carbidopa/levodopa extended release)* Saphris (asenapine) (PA) (QL) Vimpat (lacosamide) Stalevo (carbidopa/entacapone/levodopa)* Secuado (asenapine) (PA) (QL) Xcopri (cenobamate) (PA) (QL) (SP) Symmetrel (amantadine)* Seroquel (quetiapine)* Zarontin (ethosuximide)* Xadago (safinamide) (PA) (QL) Seroquel XR (quetiapine extended-release)* (QL) Zonegran (zonisamide)* Stelazine (trifluoperazine)* Anxiolytics/Sedatives/Hypnotics Thorazine (chlorpromazine)* Antidepressants Ambien (zolpidem)* (QL) Trilafon (perphenazine)* Selective Serotonin Reuptake Inhibitors Ambien CR (zolpidem continuous-release)* (QL) Zyprexa (olanzapine)* Celexa (citalopram)* Ativan (lorazepam)* Lexapro (escitalopram)* (QL) Buspar (buspirone)* Multiple Sclerosis Agents Luvox (fluvoxamine immediate-release) tablets* Halcion (triazolam)* Ampyra (dalfampridine) (CC) (PA) (SP)(QL)* (Mylan Paxil (paroxetine)* Klonopin (clonazepam)* generic version excluded) Prozac (fluoxetine)* Librium (chlordiazepoxide)* Aubagio (teriflunomide) (CC) (PA) (SP) Zoloft (sertraline)* Lunesta (eszopiclone)* (QL) Avonex (interferon beta-1a)* (CC) (PA) (SP) Restoril (temazepam)* (PA except 15 mg and 30 mg Bafiertam (monomethyl fumarate) (PA) (QL) (SP) Tricyclics Betaseron (interferon beta-1b) (CC) (PA) (SP) Anafranil (clomipramine)* strengths) (QL) Serax (oxazepam)* Copaxone (glatiramer acetate)* (CC) (PA) (QL) (SP) Elavil (amitriptyline)* Extavia (interferon beta-1b) (PA) (SP) Norpramin (desipramine)* Sonata (zaleplon)* (QL) Tranxene (clorazepate)* Gilenya (fingolimod) (CC) (PA) (SP) Pamelor (nortriptyline)* Glatopa* (CC) (PA) (QL) (SP) Valium (diazepam)* Sinequan (doxepin)* Kesimpta (ofatumumab) (PA) (QL) (SP) Versed (midazolam)* Tofranil (imipramine)* Mavenclad (cladribine) (PA) (QL) (SP) Xanax (alprazolam)* Tofranil-PM (imipramine pamoate)* Mayzent (siponimod) (CC) (PA) (QL) (SP) Miscellaneous Antidepressants Attention Deficit Disorder/Narcolepsy Plegridy (peginterferon beta-1a) (PA) (SP) Desyrel (trazodone)* Adderall (dextroamphetamine racemic salts)* Rebif (interferon beta-1a) (CC) (PA) (SP) Effexor (venlafaxine)* Dexedrine (dextroamphetamine)* Tecfidera (dimethyl fumarate)* (generic only; Effexor XR (venlafaxine extended-release) Focalin (dexmethylphenidate)* $0 copay) (PA) (QL) (SP) capsules*, tablets* (PA) (QL) Intuniv (guanfacine extended release) Vumerity (diroximel fumarate) (PA) (QL) (SP) Emsam (selegiline transdermal) (PA) Metadate CD (methylphenidate extended release)* Zeposia (ozanimod) (CC) (PA) (QL) (SP) Ludiomil (maprotiline)* Nuvigil (armodafinil) (ST) Miscellaneous Parnate (tranylcypromine)* Provigil (modafinil)* Antabuse (disulfiram)* Remeron (mirtazapine)* Ritalin (methylphenidate)* Austedo (deutetrabenazine) (PA) (QL) (SP) Spravato (esketamine) (PA) (QL) (SP) Ritalin LA (methylphenidate extended release)* Evrysdi (risdiplam) (PA) (QL) (SP) Wellbutrin (bupropion)* Ritalin-SR (methylphenidate extended release)* Firdapse (amifampridine) (PA) (QL) (SP) Wellbutrin SR (bupropion extended release)* Sunosi (solriamfetol) (PA) (QL) (SP) Hetlioz (tasimelteon) (PA) (QL) (SP) Wellbutrin XL (bupropion extended release)* (QL) Mood Stabilizers Ingrezza (valbenazine) (PA) (QL) (SP) Lucemyra (lofexidine) (PA) (QL) Antiparkinson’s Abilify (aripiprazole) tablets* (QL) Mestinon Timespan (pyridostigmine extended-release)* Artane (trihexyphenidyl)* Abilify Maintena (aripiprazole) (PA) Mestinon (pyridostigmine)* Azilect (rasagiline)* Aristada (aripiprazole) (PA) (SP) Caplyta (lumateperone) (PA) (QL) Nuedexta (dextromethorphan/quinidine) (PA) (SP) Benadryl (diphenhydramine)* (50 mg only) Probuphine (buprenorphine) (PA) (SP) Cogentin (benztropine)* Clozaril (clozapine)* Eskalith (lithium carbonate)* ReVia (naltrexone)* Comtan (entacapone)* Rilutek (riluzole)* (SP) Eldepryl (selegiline) capsules* Fanapt (iloperidone) (PA) (QL) Geodon (ziprasidone)*

CENTRAL NERVOUS SYSTEM (cont.) DERMATOLOGICAL (cont.) Human Growth Hormone Receptor Antagonist Somavert (pegvisomant) injection (CC) (PA) (SP) Miscellaneous (cont.) Topical Corticosteroids (cont.) Ruzurgi (amifampridine) (PA) (QL) (SP) Hytone (hydrocortisone) cream*, lotion*, ENDOCRINE/DIABETES (cont.) Suboxone (buprenorphine/naloxone sublingual ointment* (QL) Human Growth Hormone tablets)* (PA) (QL) Kenalog (triamcinolone) lotion* Genotropin (somatropin) (PA) (SP) (ST) Subutex (buprenorphine)* (PA) Lidex (fluocinonide) 0.05% cream*, solution* (QL) Humatrope (somatropin) (CC) (PA) (SP) Tiglutik (riluzole) (PA) (QL) (SP) Temovate (clobetasol) cream*, gel*, ointment*, Increlex (mecasermin) (PA) (SP) Wakix (pitolisant) (PA) (QL) (SP) solution* Norditropin (somatropin) (CC) (PA) (SP) Xenazine (tetrabenazine)* (SP) Temovate-E (clobetasol emollient) cream* Nutropin AQ (somatropin) (PA) (SP) (ST) Xyrem (sodium oxybate) (CC) (PA) (QL) (SP) Ultravate (halobetasol) cream*, ointment* Omnitrope (somatropin) (PA) (SP) (ST) Xywav (calcium, magnesium, potassium, and Westcort (hydrocortisone valerate) ointment* Saizen (somatropin) (PA) (SP) (ST) sodium oxybates) (PA) (QL) (SP) Miscellaneous Serostim (somatropin) (PA) (SP) (ST) Carac (fluorouracil)* (QL) Tev-Tropin (somatropin) (PA) (SP) (ST) DERMATOLOGICAL Drysol (aluminum chloride hexahydrate)* Zomacton (somatropin) (PA) (SP) (ST) Acne Therapy Drysol Dab-O (aluminum chloride hexahydrate)* Zorbtive (somatropin) (PA) (SP) (ST) Claravis (isotretinoin)* Dupixent (dupilumab) (CC) (PA) (QL) (SP) Hypoglycemic Agents Cleocin T (clindamycin) lotion*, pads*, Efudex (fluorouracil)* (QL) Actos (pioglitazone)* (QL) solution* (QL) Elimite (permethrin) cream* Actoplus Met (pioglitazone/metformin) tablets* Differin (adapalene) cream*, gel* (PA) Klisyri (tirbanibulin) (PA) (QL) (SP) Adlyxin (lixisenatide) (PA) (QL) Erycette (erythromycin) pads* (QL) Kwell (lindane) lotion*, shampoo* Amaryl (glimepiride)* Eryderm (erythromycin) topical solution* (QL) Panretin (alitretinoin) (SP) (QL) Bydureon BCise (exenatide) (PA) (QL) Erygel (erythromycin) topical gel* (QL) Qbrexza (glycopyrronium) (PA) (QL) (SP) Byetta (exenatide) (PA) (QL) Erythromycin 5 mg/g ointment* Sulfamylon (mafenide) cream, lotion (SP) Diabeta (glyburide)* Klaron (sulfacetamide)* Xylocaine (lidocaine) 2% gel* Duetact (pioglitazone/glimepiride) tablets* Retin-A (tretinoin) gel* (QL) Farxiga (dapagliflozin) (PA) (QL) Antipsoriatic/Antiseborrheic ENDOCRINE/DIABETES Glucophage (metformin)* Cosentyx (secukinumab) (CC) (PA) (QL) (SP) Glucophage XR (metformin extended release)* Adrenal Hormones (excluded for Psoriasis) Glucotrol (glipizide)* Acthar (corticotropin) (CC) (PA) (QL) (SP) Dovonex (calcipotriene)* (QL) Glucotrol XL (glipizide extended release)* Cortef (hydrocortisone)* Ilumya (tildrakizumab) (PA) (QL) (SP) Glucovance (glyburide/metformin)* Cortone Acetate (cortisone)* Oxsoralen-Ultra (methoxsalen) (PA) (SP) Glyxambi (empagliflozin/linagliptin) (QL) (ST) Decadron (dexamethasone)* Skyrizi (risankizumab-rzaa) (PA) (QL) (SP) (Farxiga preferred) Deltasone (prednisone)* Soriatane (acitretin)* (CC) (SP) Glynase (glyburide)* Florinef (fludrocortisone)* Stelara (ustekinumab) (CC) (PA) (SP) Invokana (canagliflozin) (PA) (QL) (Farxiga Medrol (methylprednisolone)* Taltz (ixekizumab) (PA) (QL) (SP) preferred) Orapred (prednisolone)* Invokamet (canagliflozin/metformin) (PA) (QL) Immunomodulator Prelone (prednisolone) syrup* (Farxiga preferred) Elidel (pimecrolimus)* (PA) Antiandrogens Invokamet XR (canagliflozin/metformin (PA) (QL) Protopic (tacrolimus)* (QL) Casodex (bicalutamide)* (Farxiga preferred) Rosacea Eulexin (flutamide)* Janumet (sitagliptin/metformin) (QL) (ST) Finacea (azelaic acid) gel* Nilandron (nilutamide) (Alogliptin preferred) Metrocream (metronidazole)* Janumet XR (sitagliptin/metformin) (QL) (ST) Antithyroid MetroGel (metronidazole)* (PA except 0.75% (Alogliptin preferred) Propylthiouracil (propylthiouracil)* strength) Januvia (sitagliptin) (QL) (ST) (Alogliptin preferred) Tapazole (methimazole)* Metrolotion (metronidazole)* (PA) Jardiance (empagliflozin) (PA) (QL) (Farxiga Carnitine preferred) Topical Corticosteroids Carnitor (levocarnitine)* Jentadueto (linagliptin/metformin) (QL) (ST) Aristocort (triamcinolone) cream*, ointment* (QL) (Alogliptin preferred) Cutivate (fluticasone) cream*, lotion*, ointment* Glucose Elevating Agents Jentadueto XR (linagliptin/metformin) (QL) (ST) Diprolene (augmented betamethasone Baqsimi (glucagon) (Alogliptin preferred) dipropionate) cream*, gel*, ointment* GlucaGen (glucagon) Kazano (alogliptin/metformin)* (QL) (ST) Diprolene AF (augmented betamethasone Glucagon Emergency Kit (glucagon)* Kombiglyze XR (saxagliptin/metformin) (QL) (ST) dipropionate) cream* Growth Hormone Releasing Factor (Alogliptin preferred) Diprosone (betamethasone dipropionate) cream* Egrifta (tesamorelin) (PA) (SP) Micronase (glyburide)* Elocon (mometasone) cream*, lotion*, ointment* Nesina (alogliptin)* (QL) (ST)

ENDOCRINE/DIABETES (cont.) ENDOCRINE/DIABETES (cont.) GASTROINTESTINAL (cont.) Hypoglycemic Agents (cont.) Insulin Therapy (cont.) Antiemetic/Antivertigo Onglyza (saxagliptin) (Alogliptin preferred) (ST) NovoLog (insulin human aspart) (PA) (Humalog Antiemetic/Antivertigo Oseni (alogliptin/pioglitazone)* (QL) (ST) 100 units/mL preferred) Akynzeo (netupitant/palonosetron) (PA) (QL) Ozempic (semaglutide) (PA) (QL) NovoLog Mix 70/30 (insulin human aspart Antivert (meclizine)* Prandin (repaglinide)* NPL/aspart) (PA) (Humalog Mix preferred) Anzemet (dolasetron) (QL) Precose (acarbose)* Toujeo (insulin human glargine) (PA) (Lantus Compazine (prochlorperazine) suppository*, Qtern (dapagliflozin/saxagliptin) (PA) (QL) preferred) tablet* Rybelsus (semaglutide) (PA) (QL) Tresiba (insulin human degludec) (PA) (Lantus Emend (aprepitant) capsules, oral suspension Segluromet (ertugliflozin/metformin) (PA) (QL) preferred) (PA) (QL) (Farxiga preferred) Metabolic Bone Disorders Kytril (granisetron)* (QL) Soliqua (insulin human glargine/lixisenatide) Actonel (risedronate)* (QL) Marinol (dronabinol)* (PA) (PA) (QL) Evenity (romosozumab) (CC) (PA) (QL) (SP) Phenergan (promethazine)* Steglatro (ertugliflozin) (PA) (QL) (Farxiga preferred) Forteo (teriparatide) (CC) (PA) (QL) (SP) Reglan (metoclopramide)* Steglujan (ertugliflozin/sitagliptin) (PA) (QL) Fosamax (alendronate)* (QL) Tigan (trimethobenzamide)* (Farxiga preferred) Prolia (denosumab) (CC) (PA) (SP) Varubi (rolapitant) (PA) (QL) SymlinPen (pramlintide) Tymlos (abaloparatide) (CC) (PA) (QL) (SP) Zofran (ondansetron)* (QL) Synjardy (empagliflozin/metformin) (PA) (QL) Xgeva (denosumab) (CC) (PA) (SP) Anti-Spasmodic Agents (Farxiga preferred) Thyroid Supplement Bentyl (dicyclomine) capsule*, tablet* Synjardy XR (empagliflozin/metformin) (PA) (QL) Levbid (hyoscyamine)* (Farxiga preferred) Levothroid (levothyroxine)** Synthroid (levothyroxine)** Levsin (hyoscyamine)* Tradjenta (linagliptin) (Alogliptin preferred) (ST) Pro-Banthine (propantheline)* Trijardy XR (empagliflozin/linagliptin/metformin) Miscellaneous (PA) (QL) (Farxiga preferred) Arcalyst (rilonacept) (PA) (SP) Heartburn/Ulcer Therapies Trulicity (dulaglutide) (PA) (QL) Buphenyl (sodium phenylbutyrate)* (SP) Carafate (sucralfate) tablet* Victoza (liraglutide) (PA) (QL) Danocrine (danazol)* Cytotec (misoprostol)* Xigduo XR (dapagliflozin/metformin) (PA) (QL) DDAVP (desmopressin acetate)* First-Lansoprazole suspension (for members < 1 Dibenzyline (phenoxybenzamine) year of age only) Insulin Therapy First-Omeprazole suspension (for members < 1 Admelog (insulin human lispro) (PA) (Humalog Dostinex (cabergoline)* Fortical (calcitonin)* year of age only) 100 units/mL preferred) Pamine (methscopolamine)* Afrezza (insulin human) (PA) (Humalog 100 units/ Isturisa (osilodrostat) (PA) (QL) (SP) Jynarque (tolvaptan) (PA) (QL) (SP) Pepcid (Famotidine) 40 mg/5 mL suspension* mL preferred) (for members < 1 year of age only) Apidra (insulin human glulisine) (PA) (Humalog Korlym (mifepristone) (PA) (SP) Mycapssa (octreotide) (PA) (QL) (SP) Prevpac (lansoprazole, amoxicillin, and 100 units/mL preferred) clarithromycin)* Basaglar (insulin human glargine) (PA) (Lantus Natpara (parathyroid hormone) (PA) (SP) Orfadin (nitisinone)* (SP) (only 2 mg, 5 mg, 10 mg Zantac (Ranitidine) 75mg/5 mL syrup* (for preferred) members < 1 year of age only) Fiasp (insulin human aspart) (PA) (Humalog 100 capsules available generically) units/mL preferred) Regranex (becaplermin) (SP) (QL) Pancreatic Enzyme Humalog (insulin human lispro) Renagel (sevelamer)* Creon (amylase/lipase/protease) Humalog Mix 50/50 (insulin human lispro Renvela (sevelamer) tablets*, powder Pertzye (amylase/lipase/protease) NPL/lispro) Samsca (tolvaptan) (PA) (QL) (SP) Saliva Stimulant Humalog Mix 75/25 (insulin human lispro Sensipar (cinacalcet)* (PA) (SP) (generic only) Evoxac (cevimeline)* NPL/lispro) Sermorelin Acetate (PA) (SP) Humulin 70/30 (insulin human NPH/R) Stimate (desmopressin) (SP) Miscellaneous Humulin N (insulin human NPH) Sucraid (sacrosidase) (SP) Amitiza (lubiprostone)* (QL) Humulin R (insulin human regular) Synarel (nafarelin) (PA) (SP) Anusol-HC (hydrocortisone) cream* Humulin R U-500 (insulin human regular) (PA) Zavesca (miglustat) (SP) Apriso (mesalamine)* (Humalog 100 units/mL preferred) Asacol HD (mesalamine)* (QL) Lantus (insulin human glargine) GASTROINTESTINAL Azulfidine (sulfasalazine)* Levemir (insulin human detemir) (PA) (Lantus Canasa (mesalamine)* Antidiarrheals Cerezyme (imiglucerase) (PA) (SP) preferred) Imodium (loperamide)* Novolin 70/30 (insulin human NPH/R) Chronulac (lactulose)* Lomotil (diphenoxylate/atropine)* Colazal (balsalazide)* Novolin N (insulin human NPH) Paregoric (paregoric)* Novolin R (insulin human regular) Colyte (polyethylene glycol/potassium/sodium)*

GASTROINTESTINAL (cont.) IMMUNOSUPPRESSANT/ IMMUNOSUPPRESSANT/ Miscellaneous (cont.) ANTINEOPLASTIC ANTINEOPLASTIC (cont.) Cortenema (hydrocortisone)* Adjunctive Agents Immunosuppressant Therapies (cont.) Delzicol (mesalamine)* (ST) Actimmune (interferon gamma-1b) (SP) Neoral (cyclosporine) capsules*, oral Entocort (budesonide extended release)* (PA) (QL) Aranesp (darbepoetin alfa) (SP) solution* (SP) Gattex (teduglutide) (PA) (QL) (SP) Doptelet (avatrombopag) (CC) (PA) (QL) (SP) Prograf (tacrolimus)* (SP) GoLYTELY (polyethylene glycol-electrolyte solution)* Epogen (epoetin alfa) (SP) Rapamune (sirolimus)* (SP) Kuvan (sapropterin) (PA) (SP) Fulphila (pegfilgrastim-jmdb) (CC) (SP) Sandimmune (cyclosporine) capsules*, Librax (chlordiazepoxide/clidinium)*(QL) (only Granix (filgrastim) (SP) solution (SP) generic NDC: 51293-0607-01) Leucovorin (leucovorin)* Tegsedi (inotersen) (PA) (QL) (SP) Lokelma (sodium zirconium cyclosilicate) (PA) (QL) (SP) Leukine (sargramostim) (SP) Tavalisse (fostamatinib) (CC) (PA) (QL) (SP) Lotronex (alosetron)* (PA) Mircera (methoxy peg-epoetin beta) (SP) Zortress (everolimus) (CC) (SP)* MoviPrep (polyethylene glycol) Mulpleta (lusutrombopag) (PA) (QL) (SP) Ocaliva (obeticholic acid) (PA) (QL) (SP) Miscellaneous Antineoplastics Neulasta (pegfilgrastim) (CC) (SP) Adcetris (brentuximab vedotin) (PA) SP) Rowasa (mesalamine)* Neumega (oprelvekin) (SP) Strensiq (asfotase alfa) (PA) (SP) Afinitor (everolimus) (CC) (QL) (SP)* (generic only; Neupogen (filgrastim) (SP) 10 mg tablets excluded) Symproic (naldemedine) (PA) (QL) Procrit (epoetin alfa) (SP) Syprine (trientine) (PA) (SP) Alecensa (alectinib) (PA) (QL) (SP) Promacta (eltrombopag) (CC) (PA) (SP) Alunbrig (brigatinib) (CC) (PA) (QL) (SP) Uceris (budesonide extended release)* (PA) (QL) Udenyca (pegfilgrastim-cbqv) (CC) (SP) Urso (ursodiol)* Arimidex (anastrozole)* (SP) Zarxio (filgrastim) (CC) (SP) Aromasin (exemestane)* (SP) Veltassa (patiromer) (PA) (QL) (SP) Ziextenzo (pegfilgrastim-bmez) (CC) (SP) Ayvakit (avapritinib) (PA) (QL) (SP) Alkylating Agents Balversa (erdafitinib) (PA) (QL) (SP) GENITOURINARY Bosulif (bosutinib) (PA) (QL) (SP) BPH Alkeran (melphalan) (SP) Braftovi (encorafenib) (PA) (QL) (SP) Avodart (dutasteride)* Cyclophosphamide (SP) Gleostine (lomustine) (SP) Brukinsa (zanubrutinib) (CC) (PA) (QL) (SP) Cardura (doxazosin)* Cabometyx (cabozantinib) (CC) (PA) (QL) (SP) Flomax (tamsulosin)* Leukeran (chlorambucil) (SP) Matulane (procarbazine) (SP) Caprelsa (vandetanib) (PA) (SP) Hytrin (terazosin)* Cometriq (cabozantinib) capsules (PA) (QL) (SP) Proscar (finasteride)* Myleran (busulfan) (SP) Temodar (temozolomide)* (SP) Copiktra (duvelisib) (PA) (QL) (SP) Rapaflo (silodosin)* Cotellic (cobimetinib) (PA) (QL) (SP) Uroxatral (alfuzosin)* Antiandrogens (glasdegib) (PA) (QL) (SP) Urinary Anesthetic Erleada (apalutamide) (PA) (QL) (SP) Daurismo (glasdegib) (CC) (PA) (QL) (SP) Elmiron (pentosan polysulfate sodium) (PA) (QL) Nubeqa (darolutamide) (CC) (PA) (QL) (SP) Eligard (leuprolide) (PA) (SP) Zytiga (abiraterone acetate)* (generic only; $0 Emcyt (estramustine) (SP) Urinary Antispasmodics copay) (CC) (PA) (QL) (SP) Erivedge (vismodegib) (PA) (SP) Detrol (tolterodine)* Farydak (panobinostat) (PA) (QL) (SP) Detrol LA (tolterodine)* (QL) (ST) (only 2 mg capsules) Antiestrogens Fareston (toremifene)* (SP) Femara (letrozole)* (SP) Ditropan (oxybutynin)* Gilotrif (afatinib) (PA) (SP) Ditropan XL (oxybutynin extended release)* Faslodex (fulvestrant)* Nolvadex (tamoxifen)* Gleevec (imatinib)* (CC) (PA) (QL) (SP) (generic only) Enablex (darifenacin)* Gavreto (pralsetinib) (PA) (QL) (SP) Myrbetriq (mirabegron) (PA) (QL) Antimetabolites Hycamtin (topotecan) (PA) (QL) (SP) Sanctura (trospium)* Hydrea (hydroxyurea)* Ibrance (palbociclib) (CC) (PA) (QL) (SP) Sanctura XR (trospium extended release)* Purinethol (mercaptopurine)** (SP) Iclusig (ponatinib) tablets (PA) (SP) VESIcare (solifenacin)* Purixan (mercaptopurine) (SP) Imbruvica (ibrutinib) capsules, tablets 420 mg, Rheumatrex (methotrexate)* tablets 560 mg (CC) (PA) (QL) (SP) HEMATOLOGIC Tabloid (thioguanine) (QL) (SP) Inlyta (axitinib) (CC) (PA) (QL) (SP) Iron Chelator Xeloda (capecitabine)* (PA) (SP) Inqovi (decitabine/cedazuridine) (PA) (QL) (SP) Exjade (deferasirox)* (CC) (PA) (SP) Immunosuppressant Therapies Inrebic (fedratinib) (CC) (PA) (QL) (SP) Ferriprox (deferiprone) (PA) (SP) Cellcept (mycophenolate)* (SP) Iressa (gefitinib) (CC) (PA) (QL) (SP) Jadenu (deferasirox)*** (CC) (PA) (SP) Enspryng (satralizumab) (PA) (QL) (SP) Jakafi (ruxolitinib) (CC) (PA) (SP) Kisqali (ribociclib) (CC) (PA) (QL) (SP) Miscellenous Gengraf (cyclosporine)* (SP) Ilaris (canakinumab) (CC) (PA) (SP) Kisqali Femara (ribociclib/letrozole) (PA) (QL) (SP) Cuprimine (penicillamine)* (SP) Koselugo (selumetinib) (CC) (PA) (QL) (SP) Oxbryta (voxelotor) (CC) (PA) (QL) (SP) Imuran (azathioprine)* Lupkynis (voclosporin) (PA) (QL) (SP) Kyprolis (carfilzomib) (PA) (SP) Myfortic (mycophenolic acid)* (SP) Lenvima (lenvatinib) (CC) (PA) (QL) (SP) Lonsurf (trifluridine/tipiracil) (PA) (QL) (SP)

IMMUNOSUPPRESSANT/ OBSTETRICS/GYNECOLOGY (cont.) OBSTETRICS/GYNECOLOGY (cont.) ANTINEOPLASTIC (cont.) Contraceptives (cont.) Estrogens/Progestins (cont.) Miscellaneous Antineoplastics (cont.) Depo-Provera (medroxyprogesterone)* Provera (medroxyprogesterone)* Lorbrena (lorlatinib) (CC) (PA) (QL) (SP) Estrostep Fe (ethinyl estradiol/norethindrone/ Vagifem (estradiol vaginal inserts)* (QL) Lupron (leuprolide) (CC) (PA) (SP) ferrous fumarate)* Vivelle-Dot (estradiol)* patch Lynparza (olaparib) (CC) (PA) (QL) (SP) Levora (ethinyl estradiol/levonorgestrel)* Infertility (Consult SPD for Coverage) Lysodren (mitotane) (SP) Lessina (ethinyl estradiol/levonorgestrel)* Clomid (clomiphene)* (females only) Megace (megestrol) (except 625 mg/5 mL solution)* Lo/Ovral (ethinyl estradiol/norgestrel)* Mekinist (trametinib) (CC) (PA) (QL) (SP) Loestrin (ethinyl estradiol/norethindrone)* Miscellaneous Mektovi (binimetinib) (PA) (QL) (SP) Loestrin 24 Fe (ethinyl estradiol/norethindrone/ Evista (raloxifene)* Nexavar (sorafenib) (QL) (SP) ferrous fumarate)* Methergine (methylergonovine)* Ninlaro (ixazomib) (CC) (PA) (QL) (SP) Loestrin Fe (ethinyl estradiol/norethindrone/ Orilissa (elagolix) (CC) (PA) (QL) (SP) Odomzo (sonidegib) (CC) (PA) (QL) (SP) ferrous fumarate)* Pemazyre (pemigatinib) (CC) (PA) (QL) (SP) Micronor (norethindrone)* OPHTHALMIC Piqray (alpelisib) (PA) (QL) (SP) Mircette (ethinyl estradiol/desogestrel)* Anti-Infectives Modicon (ethinyl estradiol/norethindrone)* Pomalyst (pomalidomide) (CC) (PA) (QL) (SP) Bacitracin (bacitracin)* NuvaRing (ethinyl estradiol/etonogestrel)* Qinlock (ripretinib) (PA) (QL) (SP) Bleph-10 (sulfacetamide) solution* (only generic EluRyng) Retevmo (selpercatinib) (PA) (QL) (SP) Ciloxan (ciprofloxacin)* Ogestrel (ethinyl estradiol/norgestrel)* Revlimid (lenalidomide) (CC) (PA) (QL) (SP) Garamycin (gentamicin)* Ortho Tri-Cyclen (ethinyl estradiol/ norgestimate)* Rozlytrek (entrectinib) (CC) (PA) (QL) (SP) Ilotycin (erythromycin)* Ortho-Cept (ethinyl estradiol/desogestrel)* Rubraca (rucaparib) (CC) (PA) (QL) (SP) Neosporin (bacitracin/neomycin/ polymixin B) Ortho-Cyclen (ethinyl estradiol/norgestimate)* Rydapt (midostaurin) (CC) (PA) (QL) (SP) ointment* Sandostatin (octreotide)* (CC) (SP) Ortho-Novum 1/35 (ethinyl estradiol/ norethindrone)* Ortho-Novum 1/50 (mestranol & norethindrone)* Neosporin (gramicidin/neomycin/ polymixin B) Sprycel (dasatinib) (CC) (QL) (SP) solution* Stivarga (regorafenib) (CC) (PA) (SP) Ortho-Novum 7/7/7 (ethinyl estradiol/ norethindrone)* Ortho Tri-Cyclen Lo (ethinyl estradiol/norgestimate)* Ocuflox (ofloxacin)* Sutent (sunitinib) (CC) (QL) (SP) Polysporin (bacitracin/polymyxin B)* Tafinlar (dabrafenib) (CC) (PA) (QL) (SP) Seasonale (ethinyl estradiol/levonorgestrel)* Trivora (ethinyl estradiol/levonorgestrel)* Polytrim (trimethoprim/polymyxin B)* Tagrisso (osimertinib) (CC) (PA) (QL) (SP) Tobrex (tobramycin) solution* Talzenna (talazoparib) (CC) (PA) (QL) (SP) Xulane (ethinyl estradiol/norelgestromin)* (QL) Tarceva (erlotinib)** (PA) (QL) (SP) Yasmin (ethinyl estradiol/drospirenone)* Anti-Infective/Steroidal Combinations Targretin (bexarotene)* (PA) (QL) (SP) Zovia (ethinyl estradiol/ethynodiol diacetate)* Cortisporin (bacitracin/hydrocortisone Tasigna (nilotinib) (CC) (QL) (SP) Emergency Contraceptives neomycin/polymyxin B) ointment* Tazverik (tazemetostat) (PA) (QL) (SP) Plan B One Step (levonorgestrel)* Maxitrol (dexamethasone/neomycin/ Thalomid (thalidomide) (SP) Ella (ulipristal) polymixin B)* Tibsovo (ivosidenib) (PA) (QL) (SP) Next Choice (levonorgestrel)* TobraDex (tobramycin/dexamethasone) Tukysa (tucatinib) (PA) (QL) (SP) suspension*, ointment Turalio (pexidartinib) (PA) (QL) (SP) Estrogens/Progestins Vasocidin (sodium sulfacetamide/ Tykerb (lapatinib) (CC) (SP) Angeliq (estradiol/drospirenone) (PA) (QL) prednisolone)* Aygestin (norethindrone acetate)* Venclexta (venetoclax) (CC) (PA) (QL) (SP) Anti-Inflammatory, Non-Steroidal VePesid (etoposide)* Bijuva (estradiol/progesterone) (PA) (QL) Acular (ketorolac)* Vesanoid (tretinoin)* (SP) (only generic NDC: Climara (estradiol)* Ocufen (flurbiprofen)* 00555-0808-02) ClimaraPro (estradiol/levonorgestrel) (PA) (QL) Voltaren (diclofenac) solution* Vitrakvi (larotrectinib) (CC) (PA) (QL) (SP) CombiPatch (estradiol/norethindrone) (PA) (QL) Votrient (pazopanib) (CC) (QL) (SP) Duavee (conjugated estrogens/bazedoxifene) (PA) (QL) Anti-Inflammatory, Steroidal Xalkori (crizotinib) (CC) (PA) (SP) Estrace (estradiol)* Alrex (loteprednol) Xtandi (enzalutamide) (CC) (PA) (SP) Estrace (estradiol) vaginal cream Decadron (dexamethasone) solution* Zejula (niraparib) (CC) (PA) (QL) (SP) FemHRT (ethinyl estradiol/norethindrone)* FML (fluorometholone) 0.1% solution* Zelboraf (vemurafenib) (CC) (PA) (QL) (SP) Minivelle (estradiol)* Iluvien (fluocinolone) (PA) (SP) Zokinvy (lonafarnib) (PA) (QL) (SP) Ogen (estropipate)* Lotemax (loteprednol)* Zolinza (vorinostat) (QL) (SP) Prefest (estradiol/norgestimate) (PA) (QL) Pred Forte (prednisolone acetate)* Zykadia (ceritinib) (CC) (PA) (QL) (SP) Premarin (conjugated estrogens) tablets, vaginal cream Beta-Blockers OBSTETRICS/GYNECOLOGY Premphase (conjugated estrogens/ Betagan (levobunolol)* medroxyprogesterone) (PA) (QL) Betimol (timolol) Contraceptives Prempro (conjugated estrogens/ Betoptic S (betaxolol) Aviane (ethinyl estradiol/levonorgestrel)* medroxyprogesterone) (PA) (QL) Ocupress (carteolol)* Brevicon (ethinyl estradiol/norethindrone)* Prometrium (progesterone)* (QL) Timoptic (timolol)* Cyclessa (ethinyl estradiol/desogestrel)* Timoptic-XE (timolol)*

Brand names are listed only as a reference and do not indicate coverage of a particular brand. *Indicates that a generic is available. The brand name form will be covered only when the generic form is not available on the Formulary (see Generic Medication Policy on page 8 of the Cleveland Clinic Employee Health Plan Prescription Drug Benefit Handbook). **Indicates both the brand and generic product are on the Formulary. *** Indicates a generic is available but it is non-preferred. (PA)—Indicates the drug requires prior authorization. (CC)—Copay Card (SP)—Indicates the drug is a specialty product. 11 (QL)—Indicates the drug is a quantity limit product. (ST)—Indicates the drug is part of the step therapy program. Drug Formulary Medications by Category (continued) Carbonic Anhydrase Inhibitors VITAMINS/ELECTROLYTES Azopt (brinzolamide)* Trusopt (dorzolamide)* Electrolytes K-Dur (potassium chloride)* OPHTHALMIC (cont.) Klor-Con (potassium chloride)* K-Lyte (potassium bicarbonate/citrate)* Cycloplegic Mydriatics PhosLo (calcium acetate)* Cyclogyl (cyclopentolate)* Isopto Atropine (atropine)* Miscellaneous Vitamins Mydriacyl (tropicamide)* Drisdol (ergocalciferol)* Folic Acid* Prostaglandin Agonists Luride (sodium fluoride) chewable tablets* Travatan Z (travoprost) Mephyton (phytonadione) Travoprost* Poly-Vi-Flor Xalatan (latanoprost)* Poly-Vi-Flor with Iron Sympathomimetics Rocaltrol (calcitriol)* Alphagan P (brimonidine)* Tri-Vi-Flor* Miscellaneous Ophthalmics Prenatal Vitamins Cosopt (dorzolamide/timolol)* Prenatal Plus* Crolom (cromolyn)* Oxervate (cenegermin) (PA) (QL) (SP) Pilocar (pilocarpine)* Restasis (cyclosporine) (single-use vials only) (CC) (PA) (QL) (SP) Rhopressa (netarsudil) (PA) (QL) Upneeq (oxymetazoline) (PA) (QL) (SP) Viroptic (trifluridine)* Xiidra (lifitegrast) (CC) (PA) (QL) (SP) OTIC Otic Agents Auralgan (antipyrine/benzocaine)* Cortisporin Otic (hydrocortisone/neomycin/ polymixin B)* Domeboro Otic (aluminum acetate/acetic acid)* Floxin Otic (ofloxacin)* Vosol (acetic acid)* Vosol HC (acetic acid/hydrocortisone)*

A A (cont.) B (cont.) Abilify (aripiprazole) tablets* (QL) Ansaid (flurbiprofen)* Banzel (rufinamide) tablets, oral suspension* Abilify Maintena (aripiprazole) (PA) Antabuse (disulfiram)* (CC) (PA ) (SP) Accolate (zafirlukast)* Antara (fenofibrate capsules) Baraclude (entecavir) (SP) Accuneb (albuterol) inhalation solution* Antivert (meclizine)* Basaglar (insulin human glargine) (PA) (Lantus Accupril (quinapril)* Anusol-HC (hydrocortisone) cream* preferred) Accuretic (quinapril/hydrochlorothiazide)* Anzemet (dolasetron) (QL) Baqsimi (glucagon) Actemra (tocilizumab) (CC) (PA (QL) (SP) Apidra (insulin human glulisine) (PA) (Humalog Benadryl (diphenhydramine)* (50 mg only) Acthar (corticotropin) (CC) (PA) (QL) (SP) 100 units/mL preferred) Benemid (probenecid)* Actimmune (interferon gamma-1b) (SP) Apresoline (hydralazine)* Benlysta (belimumab) (CC) (SP) (PA) Actonel (risedronate) (QL) Apriso (mesalamine)* Bentyl (dicyclomine) capsule*, tablet* Actoplus Met (pioglitazone/metformin) tablets* Aptiom (eslicarbazepine) (PA) (QL) Berinert (C1 inhibitor) (CC) (PA) (SP) Actos (pioglitazone)* (QL) Aptivus (tipranavir) (SP) Betagan (levobunolol)* Acular (ketorolac)* Aralen (chloroquine phosphate)* (QL) Betapace (sotalol)* Adacel (diphtheria/tetanus toxoids/acellular Aranesp (darbepoetin alfa) (SP) Betaseron (interferon beta-1b) (CC) (PA) (SP) pertussis) ($0 copay; for members ≥ 7 years of age) Arava (leflunomide)* (SP) Bethkis (tobramycin for inhalation) (PA) (SP) Adalat CC (nifedipine extended release)* AArcalyst (rilonacept) (PA) (SP) Betimol (timolol) Adcetris (brentuximab vedotin) (PA) (SP) Arcapta (indacaterol ) Neohaler Betoptic S (betaxolol) Adcirca (tadalafil)* (CC) (PA) (QL) (SP) Aricept (donepezil)* Bevespi Aerosphere (glycopyrrolate/formoterol) (QL) Adderall (dextroamphetamine racemic salts)* Arimidex (anastrozole)* (SP) Biaxin (clarithromycin)* (extended-release Adempas (riociguat) (PA ) (QL) (SP) Aristada (aripiprazole) (PA) (SP) tablets excluded) Adlyxin (lixisenatide) (PA) (QL) Aristocort (triamcinolone) cream*, ointment* (QL) Bijuva (estradiol/progesterone) (PA) (QL) Admelog (insulin human lispro) (PA) (Humalog Arixtra (fondaparinux)* Biktarvy (bictegravir/emtricitabine/tenofovir 100 units/mL preferred) Arnuity Ellipta (fluticasone) (QL) alafenamide) (CC) (QL) (SP) Advair Diskus (fluticasone/salmeterol)* Aromasin (exemestane)* (SP) Biltricide (praziquantel)* Advate (antihemophilic factor ) (CC) (SP) Artane (trihexyphenidyl)* Bleph-10 (sulfacetamide) solution* Aemcolo (rifamycin delayed-release) (PA) (QL) Arthrotec (diclofenac sodium delayed release/ Blocadren (timolol)* Afinitor (everolimus) (CC) (QL) (SP)* (generic only; misoprostol)* Bosulif (bosutinib) (PA) (QL) (SP) 10 mg tablets excluded) Asacol HD (mesalamine)* (QL) Braftovi (encorafenib) (PA) (QL) (SP) Afrezza (insulin human) (PA) (Humalog 100 units/ Asmanex (mometasone) inhaler Breo Ellipta (fluticasone/vilanterol) (QL) mL preferred) Astagraf XL (tacrolimus ext-rel) (PA) Brethine (terbutaline) tablet* Aggrenox (dipyridamole extended release/ Atarax (hydroxyzine HCl)* Brevicon (ethinyl estradiol/norethindrone)* aspirin)* (generic only) Ativan (lorazepam)* Briviact (brivaracetam) (PA) (QL) Agrylin (anagrelide)* Atripla* (efavirenz/emtricitabine/tenofovir) (CC) (SP) Bronchitol (mannitol) (PA) (QL) (SP) Aimovig (erenumab-aooe) (CC) (PA) (QL) (SP) Atrovent (ipratropium) inhalation solution* Brukinsa (zanubrutinib) (CC) (PA) (QL) (SP) AirDuo (fluticasone/salmeterol)* (generic only; Atrovent (ipratropium)* Bumex (bumetanide)* $0 copay) Atrovent HFA (ipratropium) inhaler Buphenyl (sodium phenylbutyrate)* (SP) Ajovy (fremanezumab-vfrm) (CC) (PA) (QL) (SP) Aubagio (teriflunomide) (CC) (PA) (SP) Buspar (buspirone)* Akynzeo (netupitant/palonosetron) (PA) (QL) Augmentin (amoxicillin/clavulanate)* Bydureon BCise (exenatide) (PA) (QL) Aldactazide (spironolactone/hydrochlorothiazide)* Augmentin XR (amoxicillin/clavulanate XR)* Byetta (exenatide) (PA) (QL) Aldactone (spironolactone)* Auralgan (antipyrine/benzocaine)* Aldara (imiquimod)* (QL) Austedo (deutetrabenazine) (PA) (QL) (SP) C Aldomet (methyldopa)* Avalide (irbesartan/hydrochlorothiazide)* (ST) Cablivi (caplacizumab) (PA) (QL) (SP) Aldoril (methyldopa/hydrochlorothiazide)* Avapro (irbesartan)* (ST) Cabometyx (cabozantinib) (CC) (PA) (QL) (SP) Alecensa (alectinib) (PA) (QL) (SP) Avelox (moxifloxacin)* Cafergot (ergotamine/caffeine)* Alinia (nitazoxanide)* (tablets only) Aviane (ethinyl estradiol/levonorgestrel)* Calan (verapamil)* Alkeran (melphalan) (SP) Avinza (morphine extended release) Calan SR (verapamil extended release)* Alphagan P (brimonidine)* Avodart (dutasteride)* Campral (acamprosate calcium)* Alrex (loteprednol) Avonex (interferon beta-1a) (CC) (PA) (SP) Caplyta (lumateperone) (PA) (QL) Altace (ramipril)* Aygestin (norethindrone acetate)* Capoten (captopril)* Alunbrig (brigatinib) (CC) (PA) (QL) (SP) Ayvakit (avapritinib) (PA) (QL) (SP) Capozide (captopril/hydrochlorothiazide)* Alupent (metaproterenol) syrup*, tablet* Azilect (rasagiline)* Caprelsa (vandetanib) (PA) (SP) Alyq (tadalafil)* (PA) (QL) (SP) Azopt (brinzolamide)* Canasa (mesalamine)* Amaryl (glimepiride)* Azulfidine (sulfasalazine)* Carac (fluorouracil)* (QL) Ambien (zolpidem)* (QL) Carafate (sucralfate) tablet* Ambien CR (zolpidem continuous-release)* (QL) B Carbatrol (carbamazepine extended release)* Amerge (naratriptan)* (QL) Bacitracin (bacitracin)* Cardizem (diltiazem)* Amitiza (lubiprostone)* (QL) Bactrim (sulfamethoxazole/trimethoprim)* Cardizem CD (diltiazem extended release)* Amoxil (amoxicillin)* Bactrim DS (sulfamethoxazole/trimethoprim)* Cardizem SR (diltiazem extended release)* Ampyra (dalfampridine) (CC) (PA) (SP)(QL)* (Mylan Bactroban (mupirocin) cream* (PA) (QL), Cardura (doxazosin)* generic version excluded) ointment* (QL) Carnitor (levocarnitine)* Anafranil (clomipramine)* Bafiertam (monomethyl fumarate) (PA) (QL) (SP) Casodex (bicalutamide)* Angeliq (estradiol/drospirenone) (PA) (QL) Balversa (erdafitinib) (PA) (QL) (SP) Cataflam (diclofenac)* Catapres (clonidine) tablet* Brand names are listed only as a reference and do not indicate coverage of a particular brand. *Indicates that a generic is available. The brand name form will be covered only when the generic form is not available on the Formulary (see Generic Medication Policy on page 8 of the Cleveland Clinic Employee Health Plan Prescription Drug Benefit Handbook). **Indicates both the brand and generic product are on the Formulary. *** Indicates a generic is available but it is non-preferred. (PA)—Indicates the drug requires prior authorization. (CC)—Copay Card (SP)—Indicates the drug is a specialty product. 13 (QL)—Indicates the drug is a quantity limit product. (ST)—Indicates the drug is part of the step therapy program. Drug Formulary Medications Alphabetically (continued)

C (cont.) C (cont.) D (cont.) Catapres-TTS (clonidine) patch* Crolom (cromolyn)* Duetact (pioglitazone/glimepiride) tablets* Cayston (aztreonam) inhalation solution (CC) (SP) Cuprimine (penicillamine)* (SP) Duoneb (ipratropium/albuterol)* Ceclor (cefaclor)* Cutivate (fluticasone) cream*, lotion*, ointment* Duragesic (fentanyl)* Ceftin (cefuroxime)* Cuvposa (glycopyrrolate) (PA) Duricef (cefadroxil) capsule* Celexa (citalopram)* Cyclessa (ethinyl estradiol/desogestrel)* Dupixent (dupilumab) (CC) (PA) (QL) (SP) Cellcept (mycophenolate)*(SP) Cyclogyl (cyclopentolate)* Dyazide (triamterene/hydrochlorothiazide)* Celontin (methsuximide) Cyclophosphamide (SP) Dynapen (dicloxacillin)* Cerezyme (imiglucerase) (PA) (SP) Cyproheptadine tablets*, syrup* Chronulac (lactulose)* Cytotec (misoprostol)* E Ciloxan (ciprofloxacin)* Cytovene (ganciclovir) (SP) E.E.S. (erythromycin ethylsuccinate)* Cimzia (certolizumab) (CC) (PA) (QL) (SP) (excluded Easprin (aspirin)* for Psoriasis) D Edurant (rilpivirine) (SP) Cinqair (reslizumab) (CC) (PA) (SP) D.H.E. (dihydroergotamine)* (PA) (QL) Effexor (venlafaxine)* Cinryze (C1 inhibitor) (PA) (SP) Daliresp (roflumilast) (PA) Effexor XR (venlafaxine extended-release) Cipro (ciprofloxacin)* Daklinza (daclatasvir) (PA) (QL) (SP) capsules*, tablets* (PA) (QL) Cipro XR (ciprofloxacin extended release)* Danocrine (danazol)* Efudex (fluorouracil)* (QL) Claravis (isotretinoin)* Dapsone (dapsone)* Egrifta (tesamorelin) (PA) (SP) Cleocin (clindamycin)* (glasdegib) (PA) (QL) (SP) Elavil (amitriptyline)* Cleocin T (clindamycin) lotion*, pads*, Daurismo (glasdegib) (CC) (PA) (QL) (SP) Eldepryl (selegiline) capsules* solution* (QL) DDAVP (desmopressin acetate)* Elidel (pimecrolimus)* (PA) Climara (estradiol)* Decadron (dexamethasone)* Eligard (leuprolide) (PA) (SP) ClimaraPro (estradiol/levonorgestrel) (PA) (QL) Decadron (dexamethasone) solution* Elimite (permethrin) cream* Clinoril (sulindac)* Deltasone (prednisone)* Eliquis (apixaban) (QL) Clomid (clomiphene)* (females only) Delzicol (mesalamine)* (ST) Elixophyllin (theophylline) elixir Clozaril (clozapine)* Demadex (torsemide)* Ella (ulipristal) Codeine (codeine sulfate) 30 mg tablets* Demerol (meperidine)* Elocon (mometasone) cream*, lotion*, ointment* Cogentin (benztropine)* Depakene (valproic acid)* Elmiron (pentosan polysulfate sodium) (PA) (QL) Colazal (balsalazide)* Depakote (divalproex)* Emcyt (estramustine) (SP) Colcrys (colchicine) Depo-Provera (medroxyprogesterone)* Emend (aprepitant) capsules, oral suspension (PA) (QL) Colestid (colestipol)* Descovy (emtricitabine/tenofovir) (CC) (PA) (QL) (SP) Emgality (galcanezumab-gnlm) (CC) (PA) (QL) (SP) Colyte (polyethylene glycol/potassium/sodium)* Desyrel (trazodone)* Emsam (selegiline transdermal) (PA) CombiPatch (estradiol/norethindrone) (PA) (QL) Detrol (tolterodine)* Emtriva (emtricitabine) (SP) Combivent Respimat (ipratropium/albuterol) inhaler Detrol LA (tolterodine)* (QL) (ST) (only 2 mg capsules) Enablex (darifenacin)* Combivir (zidovudine/lamivudine)* (SP) Dexedrine (dextroamphetamine)* Enbrel (etanercept) (CC) (PA) (QL) (SP) (excluded Cometriq (cabozantinib) capsules (PA) (QL) (SP) Diabeta (glyburide)* for Psoriasis) Compazine (prochlorperazine) suppository*, tablet* Diastat (diazepam rectal gel)* Enspryng (satralizumab) (PA) (QL) (SP) Complera (emtricitabine/rilpivirine/tenofovir) (CC) (SP) Dibenzyline (phenoxybenzamine) Entresto (sacubitril/valsartan) (PA) (QL) Comtan (entacapone)* Differin (adapalene) cream*, gel* (PA) Epipen (epinephrine)* (generic only) (QL) Condylox (podofilox) topical gel Dificid (fidaxomicin) (ST) Epipen Jr. (epinephrine)* (generic only) (QL) Condylox (podofilox) topical solution* Diflucan (fluconazole) tablet*, suspension* Epivir (lamivudine)* (SP) Copaxone (glatiramer acetate)* (CC) (PA) (QL) (SP) Dilantin (phenytoin)** Epivir HBV (lamivudine)* (SP) Copegus (ribavirin)* (SP) Dilaudid (hydromorphone)* Epanova (omega-3 carboxylic acids) Copiktra (duvelisib) (PA) (QL) (SP) Diovan (valsartan)* (except 320 mg tablets) (ST) (restricted to Cardiology) (QL) Cordarone (amiodarone)* Diovan HCT (valsartan/hydrochlorothiazide)* (ST) Epclusa (sofosbuvir/velpatasvir)* (CC) (PA) (QL) (SP) Coreg (carvedilol)* Diprolene (augmented betamethasone (generic only) Corlanor (ivabradine) (PA) (QL) dipropionate) cream*, gel*, ointment* Epidiolex (cannabidiol) (PA) (SP) Cortef (hydrocortisone)* Diprolene AF (augmented betamethasone Epogen (epoetin alfa) (SP) Cortenema (hydrocortisone)* dipropionate) cream* Epzicom (abacavir/lamivudine) (SP) Cortisporin (bacitracin/hydrocortisone Diprosone (betamethasone dipropionate) cream* Equanil (meprobamate)* neomycin/polymyxin B) ointment* Ditropan (oxybutynin)* Erivedge (vismodegib) (PA) (SP) Cortisporin Otic (hydrocortisone/neomycin/ Ditropan XL (oxybutynin extended release)* Erleada (apalutamide) (PA) (QL) (SP) polymixin B)* Diuril (chlorothiazide)* Erycette (erythromycin) pads* (QL) Cortone Acetate (cortisone)* Dolobid (diflunisal)* Eryderm (erythromycin) topical solution* (QL) Corzide (nadolol/bendroflumethiazide)* Dolophine (methadone)* Erygel (erythromycin) topical gel* (QL) Cosentyx (secukinumab) (CC) (PA) (QL) (SP) Domeboro Otic (aluminum acetate/acetic acid)* EryPed (erythromycin ethylsuccinate)* (excluded for Psoriasis) Doptelet (avatrombopag) (CC) (PA) (QL) (SP) Ery-Tab (erythromycin)* Cosopt (dorzolamide/timolol)* Dostinex (cabergoline)* Erythromycin 5 mg/g ointment* Cotellic (cobimetinib) (CC) (PA) (QL) (SP) Dovato (dolutegravir/lamivudine) (QL) (SP) Esbriet (pirfenidone) (CC) (PA) (QL) (SP) Coumadin (warfarin)** Dovonex (calcipotriene)* (QL) Eskalith (lithium carbonate)* Cozaar (losartan)* Drisdol (ergocalciferol)* Estrace (estradiol)* Creon (amylase/lipase/protease) Drysol (aluminum chloride hexahydrate)* Estrace (estradiol) vaginal cream Crestor (rosuvastatin)* (QL) Drysol Dab-O (aluminum chloride hexahydrate)* Estrostep Fe (ethinyl estradiol/norethindrone/ Crixivan (indinavir) (SP) Duavee (conjugated estrogens/bazedoxifene) (PA) (QL) ferrous fumarate)* Brand names are listed only as a reference and do not indicate coverage of a particular brand. *Indicates that a generic is available. The brand name form will be covered only when the generic form is not available on the Formulary (see Generic Medication Policy on page 8 of the Cleveland Clinic Employee Health Plan Prescription Drug Benefit Handbook). **Indicates both the brand and generic product are on the Formulary. *** Indicates a generic is available but it is non-preferred. (PA)—Indicates the drug requires prior authorization. (CC)—Copay Card (SP)—Indicates the drug is a specialty product. (QL)—Indicates the drug is a quantity limit product. (ST)—Indicates the drug is part of the step therapy program. 14 Drug Formulary Medications Alphabetically (continued)

E (cont.) G (cont.) I (cont.) Eulexin (flutamide)* Gilotrif (afatinib) (PA) (SP) Increlex (mecasermin) (PA) (SP) Evenity (romosozumab) (CC) (PA) (QL) (SP) Glatopa* (CC) (PA) (QL) (SP) Incruse Ellipta (umeclidinium bromide) (QL) Evista (raloxifene)* Gleevec (imatinib)* (CC) (PA) (QL) (SP) (generic only) Inderal (propranolol)* Evoxac (cevimeline)* Gleostine (lomustine) (SP) Indocin (indomethacin)* Evrysdi (risdiplam) (PA) (QL) (SP) GlucaGen (glucagon) Ingrezza (valbenazine) (PA) (QL) (SP) Exelon (rivastigmine)* Glucagon Emergency Kit (glucagon)* Inlyta (axitinib) (CC) (PA) (QL) (SP) Exforge (amlodipine/valsartan)* Glucophage (metformin)* Inqovi (decitabine/cedazuridine) (PA) (QL) (SP) Exjade (deferasirox)* (CC) (PA) (SP) Glucophage XR (metformin extended release)* Inrebic (fedratinib) (CC) (PA) (QL) (SP) Extavia (interferon beta-1b) (PA) (SP) Glucotrol (glipizide)* Inspra (eplerenone)* Glucotrol XL (glipizide extended release)* Intal (cromolyn sodium) inhalation solution* F Glucovance (glyburide/metformin)* Intelence (etravirine) (CC) (SP) Famvir (famciclovir)* (QL) Glynase (glyburide)* Intron A (interferon alfa-2b) (SP) Fanapt (iloperidone) (PA) (QL) Glyxambi (empagliflozin/linagliptin) (QL) (ST) Intuniv (guanfacine extended release) Fareston (toremifene)* (SP) (Farxiga preferred) Invega (paliperidone extended release) Farxiga (dapagliflozin) (PA) (QL) GoLYTELY (polyethylene glycol-electrolyte solution)* Invirase (saquinavir) (SP) Farydak (panobinostat) (PA) (QL) (SP) Granix (filgrastim) (SP) Invokamet (canagliflozin/metformin) (PA) (QL) Fasenra (benralizumab) pens, prefilled syringes Grastek (timothy grass pollen allergen extract) (PA) (QL) (Farxiga preferred) (PA) (QL) (SP) Invokamet XR (canagliflozin/metformin (PA) (QL) Faslodex (fulvestrant)* H (Farxiga preferred) Felbatol (felbamate)* Haegarda (C1 inhibitor) (PA) (SP) Invokana (canagliflozin) (PA) (QL) (Farxiga Feldene (piroxicam)* Halcion (triazolam)* preferred) Femara (letrozole)* (SP) Haldol (haloperidol)* Iressa (gefitinib) (CC) (PA) (QL) (SP) FemHRT (ethinyl estradiol/norethindrone)* Harvoni (ledipasvir/sofosbuvir)* (CC) (PA) (QL) (SP) Isentress (raltegravir) (CC) (SP) Ferriprox (deferiprone) (PA) (SP) (generic only) Isordil (isosorbide dinitrate)* (except 40 mg tablets) Fiasp (insulin human aspart) (PA) (Humalog 100 Hepsera (adefovir)* (SP) Isturisa (osilodrostat) (PA) (QL) (SP) units/mL preferred) Hetlioz (tasimelteon) (PA) (QL) (SP) Finacea (azelaic acid) gel* Humalog (insulin human lispro) J Firazyr (icatibant) (PA) (SP) Humalog Mix 50/50 (insulin human lispro NPL/lispro) Jadenu (deferasirox)*** (CC) (PA) (SP) Firdapse (amifampridine) (PA) (QL) (SP) Humalog Mix 75/25 (insulin human lispro NPL/lispro) Jakafi (ruxolitinib) (CC) (PA) (SP) First-Lansoprazole suspension (for members Humatin (paromomycin)* Janumet (sitagliptin/metformin) (QL) (ST) < 1 year of age only) Humatrope (somatropin) (CC) (PA) (SP) (Alogliptin preferred) First-Omeprazole suspension (for members Humira (adalimumab) (CC) (PA) (SP) Janumet XR (sitagliptin/metformin) (QL) (ST) < 1 year of age only) Humulin 70/30 (insulin human NPH/R) (Alogliptin preferred) Flagyl (metronidazole)* Humulin N (insulin human NPH) Januvia (sitagliptin) (QL) (ST) (Alogliptin preferred) Flector (diclofenac epolamine)* (PA) (QL) Humulin R (insulin human regular) Jardiance (empagliflozin) (PA) (QL) (Farxiga Flexeril (cyclobenzaprine)* (except 7.5 mg tablets) Humulin R U-500 (insulin human regular) (PA) preferred) Flolan (epoprostenol)* (SP) (Humalog 100 units/mL preferred) Jentadueto (linagliptin/metformin) (QL) (ST) Flomax (tamsulosin)* Hycamtin (topotecan) (PA) (QL) (SP) (Alogliptin preferred) Florinef (fludrocortisone)* Hydrea (hydroxyurea)* Jentadueto XR (linagliptin/metformin) (QL) (ST) Florinef (fludrocortisone)* HydroDIURIL (hydrochlorothiazide)* (Alogliptin preferred) Flovent HFA (fluticasone) inhaler Hygroton (chlorthalidone)* Juxtapid (lomitapide) (PA) (SP) Floxin Otic (ofloxacin)* Hytone (hydrocortisone) cream*, lotion*, Jynarque (tolvaptan) (PA) (QL) (SP) FML (fluorometholone) 0.1% solution* ointment* (QL) Focalin (dexmethylphenidate)* Hytrin (terazosin)* K Folic Acid* Hyzaar (losartan/hydrochlorothiazide)* Kalbitor (ecallantide) (PA) (SP) Forteo (teriparatide) (CC) (PA) (QL) (SP) Kaletra (lopinavir/ritonavir)* solution (SP) Fortical (calcitonin)* I K-Dur (potassium chloride)* Fosamax (alendronate)* (QL) Ibrance (palbociclib) (CC) (PA) (QL) (SP) Kalydeco (ivacaftor) (CC) (PA) (QL) (SP) Fulphila (pegfilgrastim-jmdb) (CC) (SP) Iclusig (ponatinib) tablets (PA) (SP) Kazano (alogliptin/metformin)* (QL) (ST) Fuzeon (enfuvirtide) (SP) Ilaris (canakinumab) (CC) (PA) (SP) Keflex (cephalexin)* Fycompa (perampanel) (CC) (PA) (QL) (SP) Ilumya (tildrakizumab) (PA) (QL) (SP) Kenalog (triamcinolone) lotion* Ilotycin (erythromycin)* Keppra (levetiracetam)* G Iluvien (fluocinolone) (CC) (PA) (SP) Keppra XR (levetiracetam)* Gabitril (tiagabine)* Imbruvica (ibrutinib) capsules, tablets 420 mg, Kevzara (sarilumab) (CC) (PA) (QL) (SP) Garamycin (gentamicin)* tablets 560 mg (CC) (PA) (QL) (SP) Kesimpta (ofatumumab) (PA) (QL) (SP) Gattex (teduglutide) (PA) (QL) (SP) Imdur (isosorbide mononitrate)* Kineret (anakinra) (CC) (PA) (SP) Gavreto (pralsetinib) (PA) (QL) (SP) Imitrex (sumatriptan) injection*, nasal spray*, Kisqali (ribociclib) (CC) (PA) (QL) (SP) Gengraf (cyclosporine)* (SP) tablet* (CC) (QL) Kisqali Femara (ribociclib/letrozole) (PA) (QL) (SP) Genotropin (somatropin) (PA) (SP) (ST) Imodium (loperamide)* Kitabis Pak (tobramycin) inhalation solution* (PA) (SP) Genvoya (elvitegravir/cobicistat/emtricitabine/ Impavido (miltefosine) (PA) (QL) (SP) Klaron (sulfacetamide)* tenofovir alafenamide) (CC) (QL) (SP) Imuran (azathioprine)* Klisyri (tirbanibulin) (PA) (QL) (SP) Geodon (ziprasidone)* Imuran (azathioprine)* Klonopin (clonazepam)* Gilenya (fingolimod) (CC) (PA) (SP) Incivek (telaprevir) (SP) Klor-Con (potassium chloride)*

K (cont.) L (cont.) M (cont.) K-Lyte (potassium bicarbonate/citrate)* Lorbrena (lorlatinib) (CC) (PA) (QL) (SP) Minivelle (estradiol)* Kombiglyze XR (saxagliptin/metformin) (QL) (ST) Lortab (hydrocodone/acetaminophen) elixir*, Minocin (minocycline) capsule* (Alogliptin preferred) tablets* (QL) Mirapex (pramipexole)* Korlym (mifepristone) (PA) (SP) Lotemax (loteprednol)* Mirapex ER (pramipexole extended release)* Koselugo (selumetinib) (CC) (PA) (QL) (SP) Lotensin (benazepril)* Mircera (methoxy peg-epoetin beta) (SP) Kuvan (sapropterin) (PA) (SP) Lotensin HCT (benazepril/hydrochlorothiazide)* Mircette (ethinyl estradiol/desogestrel)* Kwell (lindane) lotion*, shampoo* Lotrel (amlodipine/benazepril)* Mobic (meloxicam)* Kyprolis (carfilzomib) (PA) (SP) Lotrisone (clotrimazole/betamethasone) cream* Modicon (ethinyl estradiol/norethindrone)* Kytril (granisetron)* (QL) Lotronex (alosetron)* (PA) Moduretic (amiloride/hydrochlorothiazide)* Lovaza (omega-3-acid ethyl esters)* (restricted to Monodox (doxycycline monohydrate)* L Cardiology) (QL) (except 75 mg, 150 mg) Lamictal (lamotrigine)* Lovenox (enoxaparin)* Monopril (fosinopril)* Lamictal ODT (lamotrigine orally disintegrating Loxitane (loxapine)* Monopril-HCT (fosinopril/hydrochlorothiazide)* tablets)* Lozol (indapamide)* Motrin (ibuprofen) tablets*, suspension* Lamictal XR (lamotrigine extended release)* Lucemyra (lofexidine) (PA) (QL) MoviPrep (polyethylene glycol) Lampit (nifurtimox) (PA) (QL) (SP) Ludiomil (maprotiline)* MS Contin (morphine extended release)* Lanoxin (digoxin) tablet** Lunesta (eszopiclone)* (QL) MS IR (morphine) tablets*, solution* Lantus (insulin human glargine) Lupkynis (voclosporin) (PA) (QL) (SP) Multaq (dronedarone) (restricted to Cardiology) Lariam (mefloquine)* Lupron (leuprolide) (CC) (PA) (SP) Mulpleta (lusutrombopag) (PA) (QL) (SP) Lasix (furosemide)* Luride (sodium fluoride) chewable tablets* Mycapssa (octreotide) (PA) (QL) (SP) Latuda (lurasidone) (PA) (QL) Luvox (fluvoxamine immediate-release) tablets* Mycelex Troche (clotrimazole)* (QL) Lenvima (lenvatinib) (CC) (PA) (QL) (SP) Lynparza (olaparib) (CC) (PA) (QL) (SP) Mycolog II (nystatin/triamcinolone)* Lescol (fluvastatin immediate release)* (ST) Lyrica (pregabalin)* Mycostatin (nystatin) cream*, ointment*, Lescol XL (fluvastatin extended release)* (ST) Lysodren (mitotane) (SP) powder* (QL) Lessina (ethinyl estradiol/levonorgestrel)* Lysteda (tranexamic acid)* (QL) Mycostatin (nystatin) tablet*, suspension* Letairis (ambrisentan)* (PA) (QL) (SP) Mydriacyl (tropicamide)* Leucovorin (leucovorin)* M Myfortic (mycophenolic acid)* (SP) Leukeran (chlorambucil) (SP) Macrobid (nitrofurantoin)* Myleran (busulfan) (SP) Leukine (sargramostim) (SP) Macrodantin (nitrofurantoin)* Myrbetriq (mirabegron) (PA) (QL) Levaquin (levofloxacin)* Marinol (dronabinol)* (PA) Mysoline (primidone)* Levbid (hyoscyamine)* Matulane (procarbazine) (SP) Levemir (insulin human detemir) (PA) (Lantus Mavenclad (cladribine) (PA) (QL) (SP) N preferred) Mavik (trandolapril)* Naftin (naftifine) cream*, 1% gel* Levora (ethinyl estradiol/levonorgestrel)* Mavyret (glecaprevir/pibrentasvir) (PA) (QL) (SP) Namenda (memantine)* Levothroid (levothyroxine)** Maxalt/Maxalt-MLT (rizatriptan)* (QL) Namenda XR (memantine)* (PA) Levsin (hyoscyamine)* Maxitrol (dexamethasone/neomycin/polymixin B)* Naprosyn (naproxen)* Lexapro (escitalopram)* (QL) Maxzide (triamterene/hydrochlorothiazide)* Natpara (parathyroid hormone) (PA) (SP) Librax (chlordiazepoxide/clidinium)*(QL) (only Mayzent (siponimod) (CC) (PA) (QL) (SP) Navane (thiothixene)* generic NDC: 51293-0607-01) Medrol (methylprednisolone)* Nayzilam (midazolam) (PA) (QL) (SP) Librium (chlordiazepoxide)* Megace (megestrol) (except 625 mg/5 mL solution)* Neomycin (neomycin)* Lidex (fluocinonide) 0.05% cream*, solution* (QL) Mekinist (trametinib) (CC) (PA) (QL) (SP) Neoral (cyclosporine) capsules*, oral solution* (SP) Lidoderm (lidocaine) patch* (PA) Mektovi (binimetinib) (PA) (QL) (SP) Neosporin (bacitracin/neomycin/polymixin B) Lioresal (baclofen)* (except 5 mg tablets) Mellaril (thioridazine)* ointment* Lipitor (atorvastatin)* (QL) Mephyton (phytonadione) Neosporin (gramicidin/neomycin/ (mandatory tablet splitting) Metadate CD (methylphenidate extended release)* polymixin B) solution* Lipofen (fenofibrate)* Methergine (methylergonovine)* Nerlynx (neratinib) (PA) (QL) (SP) Lithobid (lithium carbonate extended release)* Metrocream (metronidazole)* Nesina (alogliptin)* (QL) (ST) Lithotabs (lithium carbonate)* MetroGel (metronidazole)* (PA except 0.75% strength) Neulasta (pegfilgrastim) (CC) (SP) Lo/Ovral (ethinyl estradiol/norgestrel)* MetroGel Vaginal (metronidazole)* Neumega (oprelvekin) (SP) Lodine immediate-release (etodolac)* (only 200 mg Metrolotion (metronidazole)* (PA) Neupogen (filgrastim) (SP) capsules, 400 mg tablets, 500 mg tablets) Mestinon Timespan (pyridostigmine extended- Neurontin (gabapentin)* Loestrin (ethinyl estradiol/norethindrone)* release)* Nexavar (sorafenib) (QL) (SP) Loestrin 24 Fe (ethinyl estradiol/norethindrone/ Mestinon (pyridostigmine)* Nexletol (bempedoic acid) (PA) (QL) (SP) ferrous fumarate)* Mevacor (lovastatin)* Nexlizet (bempedoic acid/ezetimibe) (PA) (QL) (SP) Loestrin Fe (ethinyl estradiol/norethindrone/ Mexitil (mexiletine)* Next Choice (levonorgestrel)* ferrous fumarate)* Micardis (telmisartan)* (ST) Niaspan (niacin extended release)* Lokelma (sodium zirconium cyclosilicate) (PA) (QL) (SP) Micardis HCT (telmisartan/hydrochlorothiazide)* (ST) Nilandron (nilutamide) Lomotil (diphenoxylate/atropine)* Micronase (glyburide)* Nimodipine capsules* (PA) (QL) Lonhala Magnair (glycopyrrolate) (PA) (QL) Micronor (norethindrone)* Ninlaro (ixazomib) (CC) (PA) (QL) (SP) Loniten (minoxidil) tablet* Midamor (amiloride)* Nitro-Bid (nitroglycerin) ointment Lonsurf (trifluridine/tipiracil) (PA) (QL) (SP) Migranal (dihydroergotamine)* (PA) (QL) Nitro-Dur (nitroglycerin) patches* Lopid (gemfibrozil)* Minipress (prazosin)* Nitrolingual (nitroglycerin) spray* Lopressor (metoprolol)* Minitran (nitroglycerin) patches* Nitrostat (nitroglycerin) SL tablets Brand names are listed only as a reference and do not indicate coverage of a particular brand. *Indicates that a generic is available. The brand name form will be covered only when the generic form is not available on the Formulary (see Generic Medication Policy on page 8 of the Cleveland Clinic Employee Health Plan Prescription Drug Benefit Handbook). **Indicates both the brand and generic product are on the Formulary. *** Indicates a generic is available but it is non-preferred. (PA)—Indicates the drug requires prior authorization. (CC)—Copay Card (SP)—Indicates the drug is a specialty product. (QL)—Indicates the drug is a quantity limit product. (ST)—Indicates the drug is part of the step therapy program. 16 Drug Formulary Medications Alphabetically (continued)

N (cont.) O (cont.) P (cont.) Nizoral (ketoconazole)* Orkambi (lumacaftor/ivacaftor) (CC) (PA) (QL) (SP) Polytrim (trimethoprim/polymyxin B)* Nizoral (ketoconazole) cream* (QL) Ortho Tri-Cyclen (ethinyl estradiol/norgestimate)* Pomalyst (pomalidomide) (CC) (PA) (QL) (SP) Nolvadex (tamoxifen)* Ortho-Cept (ethinyl estradiol/desogestrel)* Praluent (alirocumab) (CC) (PA) (QL) (SP) (only Norco (hydrocodone/acetaminophen)* (QL) Ortho-Cyclen (ethinyl estradiol/norgestimate)* NDCs: 72733-5901-02, 72733-5902-02) Norditropin (somatropin) (CC) (PA) (SP) Ortho-Novum 1/35 (ethinyl estradiol/norethindrone)* Prandin (repaglinide)* Norflex (orphenadrine)* Ortho-Novum 1/50 (mestranol & norethindrone)* Pravachol (pravastatin)* Norgesic (orphenadrine/aspirin/caffeine)* Ortho-Novum 7/7/7 (ethinyl estradiol/norethindrone)* Precose (acarbose)* Norgesic Forte (orphenadrine/aspirin/caffeine)* Ortho Tri-Cyclen Lo (ethinyl estradiol/norgestimate)* Pred Forte (prednisolone acetate)* Norpace (disopyramide)* Orudis (ketoprofen)* Prefest (estradiol/norgestimate) (PA) (QL) Norpace CR (disopyramide) Oseni (alogliptin/pioglitazone)* (QL) (ST) Prelone (prednisolone) syrup* Norpramin (desipramine)* Otezla (apremilast) (CC) (PA) (QL) (SP) Premarin (conjugated estrogens) tablets, Northera (droxidopa) (PA) (QL) (SP) Otrexup (methotrexate injection) (PA) (QL)(SP) vaginal cream Norvasc (amlodipine)* Oxbryta (voxelotor) (CC) (PA) (QL) (SP) Premphase (conjugated estrogens/ Norvir (ritonavir) (CC) (SP) Oxervate (cenegermin) (PA) (QL) (SP) medroxyprogesterone) (PA) (QL) Nourianz (istradefylline) (CC) (PA) (QL) (SP) Oxsoralen-Ultra (methoxsalen) (PA) (SP) Prempro (conjugated estrogens/ Novolin 70/30 (insulin human NPH/R) Oxtellar XR (oxcarbazepine) (CC) (PA) (QL) (SP) medroxyprogesterone) (PA) (QL) Novolin N (insulin human NPH) Oxycontin (oxycodone extended release) Prenatal Plus* Novolin R (insulin human regular) Ozempic (semaglutide) (PA) (QL) Prevnar-13 (pneumococcal conjugate) ($0 copay) NovoLog (insulin human aspart) (PA) (Humalog Prevpac (lansoprazole, amoxicillin, and 100 units/mL preferred) P clarithromycin)* NovoLog Mix 70/30 (insulin human aspart NPL/ Palforzia [peanut (arachis hypogaea) allergen Prevymis (letermovir) (PA)(QL) (SP) aspart) (PA) (Humalog Mix preferred) powder-dnfp] (PA) (QL) (SP) Prezista (darunavir) (CC) (SP) Noxafil (posaconazole) (PA) (SP) tablets* Pamelor (nortriptyline)* Priftin (rifapentine) Nubeqa (darolutamide) (CC) (PA) (QL) (SP) Pamine (methscopolamine)* Principen (ampicillin)* Nucala (mepolizumab) (CC) (PA) (QL) (SP) Panretin (alitretinoin) (SP) (QL) Prinivil (lisinopril)* Nuedexta (dextromethorphan/quinidine) (PA) (SP) Parcopa (carbidopa/levodopa orally disintegrating Prinzide (lisinopril/hydrochlorothiazide)* Nuplazid (pimavanserin) (PA) (QL) (SP) tablets)* Pro-Banthine (propantheline)* Nurtec ODT (rimegepant) (CC) (PA) (QL) (SP) Parafon Forte DSC (chlorzoxazone)* (500 mg ProAir HFA (albuterol) inhaler* Nutropin AQ (somatropin) (PA) (SP) (ST) tablets only) Proamatine (midodrine)* NuvaRing (ethinyl estradiol/etonogestrel)* Paregoric (paregoric)* Pravachol (pravastatin)* (only generic EluRyng) Parlodel (bromocriptine)* (2.5 mg tablets only) Precose (acarbose)* Nuvigil (armodafinil) (ST) Parnate (tranylcypromine)* Procardia XL (nifedipine extended release)* Nuzyra (omadacycline) (PA) (QL) (SP) Paxil (paroxetine)* Procrit (epoetin alfa) (SP) Nydrazid (isoniazid)* Pegasys (peginterferon alfa-2a) (PA) (SP) Prograf (tacrolimus)* (SP) Nymalize (nimodipine) oral solution (PA) (QL) (SP) Pegintron (peginterferon alfa-2b) (PA) (SP) Prolia (denosumab) (CC) (PA) (SP) Pemazyre (pemigatinib) (CC) (PA) (QL) (SP) Prolixin (fluphenazine)* O Pen-Vee K (penicillin VK)* Proloprim (trimethoprim)* Ocaliva (obeticholic acid) (PA) (QL) (SP) Pennsaid (diclofenac sodium solution)* (PA) Promacta (eltrombopag) (CC) (PA) (SP) Ocufen (flurbiprofen)* (only 1.5% solution) Propylthiouracil (propylthiouracil)* Ocuflox (ofloxacin)* Pepcid (Famotidine) 40 mg/5 mL suspension* Proscar (finasteride)* Ocupress (carteolol)* (for members < 1 year of age only) Protopic (tacrolimus)* (QL) Odactra (house dust mite allergen extract) (PA) (QL) Percocet (oxycodone/acetaminophen)* (QL) Proventil (albuterol) inhalation solution* Odefsey (emtricitabine//rilpivirine/tenofovir) Percodan (oxycodone/aspirin)* Proventil (albuterol) tablet*, syrup* (CC) (QL) (SP) Peridex (chlorhexidine gluconate)* Proventil HFA (albuterol) inhaler* Odomzo (sonidegib) (CC) (PA) (QL) (SP) Persantine (dipyridamole)* Provera (medroxyprogesterone)* Ofev (nintedanib) (CC) (PA) (QL) (SP) Pertzye (amylase/lipase/protease) Provigil (modafinil)* Ogen (estropipate)* Phenergan (promethazine)* Prozac (fluoxetine)* Ogestrel (ethinyl estradiol/norgestrel)* (CC) Phenobarbital (phenobarbital)* Pulmicort (budesonide) inhaler Olumiant (baricitinib) (CC) (PA) (QL) (SP) PhosLo (calcium acetate)* Pulmicort Respules (budesonide)* Olysio (simeprevir) (PA) (QL) (SP) Pilocar (pilocarpine)* Pulmozyme (dornase alfa) inhalation solution(CC) (SP) Omnicef (cefdinir)* Piqray (alpelisib) (PA) (QL) (SP) Purinethol (mercaptopurine)** (SP) Omnitrope (somatropin) (PA) (SP) (ST) Plan B One Step (levonorgestrel)* Purixan (mercaptopurine) (SP) Onfi (clobazam)* (CC) (PA) (SP) (generic only) Plaquenil (hydroxychloroquine)* (QL) Pyrazinamide (pyrazinamide)* Onglyza (saxagliptin) (Alogliptin preferred) (ST) Plavix (clopidogrel)* Opsumit (macitentan)* (PA) (QL) (SP) Plegridy (peginterferon beta-1a) (PA ) (SP) Q Oralair (grass mixed pollen allergen extract) (PA) (QL) Plendil (felodipine extended release)* Qbrexza (glycopyrronium) (PA) (QL) (SP) Orapred (prednisolone)* Pletal (cilostazol)* Qinlock (ripretinib) (PA) (QL) (SP) Orencia (abatacept) (CC) (PA) (SP) Pneumovax-23 (pneumococcal polysaccharide) Questran (cholestyramine)* Orenitram (treprostinil) (CC) (PA) (QL) (SP) ($0 copay; for members ≥ 2 years of age) Questran Light (cholestyramine)* Orfadin (nitisinone)* (SP) (only 2 mg, 5 mg, 10 mg Poly-Vi-Flor Qvar (beclomethasone) inhaler capsules available generically) Poly-Vi-Flor with Iron Orilissa (elagolix) (CC) (PA) (QL) (SP) Polysporin (bacitracin/polymyxin B)*

R S (cont.) S (cont.) Ragwitek (ragweed pollen allergen extract) (PA) (QL) Saphris (asenapine) (PA) (QL) Sutent (sunitinib) (CC) (QL) (SP) Ranexa (ranolazine)* (PA) (QL) Seasonale (ethinyl estradiol/levonorgestrel)* Sylatron (peginterferon alfa-2b) (SP) Rapaflo (silodosin)* Sectral (acebutolol)* Symbicort (budesonide/formoterol)* Rapamune (sirolimus)* (SP) Secuado (asenapine) (PA) (QL) Symdeko (tezacaftor/ivacaftor) (PA) (QL) (SP) Rasuvo (methotrexate injection) (PA) (QL) (SP) Segluromet (ertugliflozin/metformin) (PA) (QL) SymlinPen (pramlintide) Razadyne (galantamine)* (Farxiga preferred) Symmetrel (amantadine)* Rebetol (ribavirin)* (SP) Selsun Rx (selenium sulfide) shampoo* Symproic (naldemedine) (PA) (QL) Rebif (interferon beta-1a) (CC) (PA) (SP) Selzentry (maraviroc) (SP) Synarel (nafarelin) (PA) (SP) Reglan (metoclopramide)* Sensipar (cinacalcet)* (PA) (SP) (generic only) Synjardy (empagliflozin/metformin) (PA) (QL) Regranex (becaplermin) (SP) (QL) Serax (oxazepam)* (Farxiga preferred) Relafen (nabumetone)* Serevent Diskus (salmeterol) Synjardy XR (empagliflozin/metformin) (PA) (QL) Relpax (eletriptan)* (QL) Sermorelin Acetate (PA) (SP) (Farxiga preferred) Remeron (mirtazapine)* Seroquel (quetiapine)* Synthroid (levothyroxine)** Remodulin (treprostinil)* (PA) (SP) (generic only) Seroquel XR (quetiapine extended-release)* (QL) Syprine (trientine) (PA) (SP) Renagel (sevelamer)* Serostim (somatropin) (PA) (SP) (ST) Renvela (sevelamer) tablets*, powder Serpasil (reserpine)* T Repatha (evolocumab) (CC) (PA ) (QL) (SP) Shingrix (zoster vaccine recombinant, adjuvanted) Tabloid (thioguanine) (QL) (SP) Requip (ropinirole)* ($0 copay; for members ≥ 50 years of age) Tafinlar (dabrafenib) (CC) (PA) (QL) (SP) Requip XL (ropinirole extended release)* Silvadene (silver sulfadiazine)* Tagrisso (osimertinib) (CC) (PA) (QL) (SP) Rescriptor (delavirdine) (SP) Simponi (golimumab) (PA) (SP) Takhzyro (lanadelumab-flyo) (PA) (QL) (SP) Restasis (cyclosporine) (single-use vials only) Sinemet (carbidopa/levodopa)* Taltz (ixekizumab) (PA) (QL) (SP) (CC) (PA) (QL) (SP) Sinemet CR (carbidopa/levodopa extended release)* Talwin NX (pentazocine/naloxone)* Restoril (temazepam)* (PA except 15 mg and 30 mg Sinequan (doxepin)* Talzenna (talazoparib) (CC) (PA) (QL) (SP) strengths) (QL) Singulair (montelukast)* Tambocor (flecainide)* Retevmo (selpercatinib) (PA) (QL) (SP) Sivextro (tedizolid) (CC) (PA) (QL) (SP) Tamiflu (oseltamivir) capsules*, suspension* (QL) Retin-A (tretinoin) gel* (QL) Skelaxin (metaxalone) ($0 copay) Retrovir (zidovudine)* (SP) Skyrizi (risankizumab-rzaa) (PA) (QL) (SP) Tapazole (methimazole)* Revatio (sildenafil)* (CC) (PA) (SP) (generic only) Solaraze (diclofenac gel)* (PA) Tarceva (erlotinib)** (PA) (QL) (SP) ReVia (naltrexone)* Soliqua (insulin human glargine/lixisenatide) (PA) (QL) Targretin (bexarotene)* (PA) (QL) (SP) Revlimid (lenalidomide) (CC) (PA) (QL) (SP) Soma (carisoprodol)* Tasigna (nilotinib) (CC) (QL) (SP) Reyataz (atazanavir) (SP) Somavert (pegvisomant) injection (CC) (PA) (SP) Tavalisse (fostamatinib) (CC) (PA) (QL) (SP) Reyvow (lasmiditan) (CC) (PA) (QL) (SP) Sonata (zaleplon)* (QL) Tazverik (tazemetostat) (PA) (QL) (SP) Rheumatrex (methotrexate) Soriatane (acitretin)* (SP) Tecfidera (dimethyl fumarate)* (generic only; Rifadin (rifampin)* Sovaldi (sofosbuvir) (CC) (PA) (QL) (SP) $0 copay) (PA) (QL) (SP) Rilutek (riluzole)* (SP) Spiriva Respimat (tiotropium) (2.5 mcg/ Tegretol (carbamazepine)* Rinvoq (upadacitinib) (PA) (QL) (SP) actuation only) Tegretol-XR (carbamazepine extended release)* Risperdal (risperidone)* Spritam (levetiracetam) (CC) (PA) (QL) (SP) Tegsedi (inotersen) (PA) (QL) (SP) Ritalin (methylphenidate)* Spravato (esketamine) (PA) (QL) (SP) Temodar (temozolomide)* (SP) Ritalin LA (methylphenidate extended release)* Sprycel (dasatinib) (CC) (QL) (SP) Temovate (clobetasol) cream*, gel*, ointment* Ritalin-SR (methylphenidate extended release)* Stadol NS (butorphanol)* Temovate-E (clobetasol emollient) cream* Robaxin (methocarbamol)* Stalevo (carbidopa/entacapone/levodopa)* Tenex (guanfacine)* Rocaltrol (calcitriol)* Steglatro (ertugliflozin) (PA) (QL) Tenoretic (atenolol/chlorthalidone)* Rowasa (mesalamine)* (Farxiga preferred) Tenormin (atenolol)* Rozlytrek (entrectinib) (CC) (PA) (QL) (SP) Steglujan (ertugliflozin/sitagliptin) (PA) (QL) Tessalon (benzonatate)* (only 100 mg & 200 mg) Rubraca (rucaparib) (CC) (PA) (QL) (SP) (Farxiga preferred) Tev-Tropin (somatropin) (PA) (SP) (ST) Ruconest (recombinant C1 inhibitor) (PA) (QL) (SP) Stelara (ustekinumab) (CC) (PA) (SP) Thalomid (thalidomide) (SP) Rukobia (fostemsavir) (PA) (QL) (SP) Stelazine (trifluoperazine)* Theo-Dur (theophylline)* Ruzurgi (amifampridine) (PA) (QL) (SP) Stimate (desmopressin) (SP) Thorazine (chlorpromazine)* Rybelsus (semaglutide) (PA) (QL) Stivarga (regorafenib) (CC) (PA) (SP) Tibsovo (ivosidenib) (PA) (QL) (SP) Rydapt (midostaurin) (CC) (PA) (QL) (SP) Strensiq (asfotase alfa) (PA) (SP) Ticlid (ticlopidine)* Rythmol (propafenone)* Stribild (elvitegravir, cobicistat, emtricitabine, Tigan (trimethobenzamide)* Rythmol SR (propafenone extended release)* tenofovir) (CC) (SP) Tiglutik (riluzole) (PA) QL) (SP) Suboxone (buprenorphine/naloxone Tikosyn (dofetilide)* S sublingual tablets)* (PA) (QL) Timoptic (timolol)* Sabril (vigabatrin)* (PA) (SP) Subutex (buprenorphine)* (PA) Timoptic-XE (timolol)* Saizen (somatropin) (PA) (SP) (ST) Sucraid (sacrosidase) (SP) Tindamax (tinidazole)* Samsca (tolvaptan) (PA) (QL) (SP) Sular (nisoldipine extended release)* Tivicay (Dolutegravir) (CC) (SP) Sanctura (trospium)* Sulfamylon (mafenide) cream, lotion (SP) TOBI (tobramycin) inhalation solution* (PA) (SP) Sanctura XR (trospium extended release)* Sumycin (tetracycline)* TOBI (tobramycin) Podhaler (PA) (SP) Sandimmune (cyclosporine) capsules*, Sunosi (solriamfetol) (PA) (QL) (SP) TobraDex (tobramycin/dexamethasone) solution (SP) Suprax (cefixime) capsules*, oral suspension* suspension*, ointment Sandostatin (octreotide)* (CC) (SP) Sustiva (efavirenz)* (CC) (SP) (generic only) Tobrex (tobramycin) solution*

T (cont.) V (cont.) X (cont.) Tofranil (imipramine)* Valtoco (diazepam) (PA) (QL) (SP) Xarelto (rivaroxaban) (QL) Tofranil-PM (imipramine pamoate)* Valtrex (valacyclovir)* (QL) Xcopri (cenobamate) (PA) (QL) (SP) Tolectin (tolmetin)* Vancocin (vancomycin)* Xeljanz (tofacitinib) (CC) (PA) (QL) (SP) Topamax (topiramate)* Varubi (rolapitant) (PA) (QL) Xeljanz XR (tofacitinib) (CC) (PA) (QL) (SP) Toprol XL (metoprolol extended-release)* Vascepa (icosapent ethyl) (restricted to Xeloda (capecitabine)* (PA) (SP) Toradol (ketorolac)* (QL) Cardiology) 1 gm capsules* (QL) Xenazine (tetrabenazine)* (SP) Toujeo (insulin human glargine) (PA) (Lantus Vaseretic (enalapril/hydrochlorothiazide)* Xgeva (denosumab) (CC) (PA) (SP) preferred) Vasocidin (sodium sulfacetamide/prednisolone)* Xifaxan (rifaximin) (PA) (SP) Tracleer (bosentan)* (CC) (PA) (QL) (SP) Vasotec (enalapril)* Xiidra (lifitegrast) (CC) (PA) (QL) (SP) Tradjenta (linagliptin) (Alogliptin preferred) (ST) Veltassa (patiromer) (PA) (QL) (SP) Xolair (omalizumab) (prefilled syringes only) Trandate (labetalol)* (CC) Vemlidy (tenofovir alafenamide) (PA) (QL) (SP) (CC) (QL) (PA) (SP) Tranxene (clorazepate)* Venclexta (venetoclax) (CC) (PA) (QL) (SP) Xopenex (levalbuterol)* Travatan Z (travoprost) Ventavis (iloprost) (SP) Xtandi (enzalutamide) (CC) (PA) (SP) Travoprost* Ventolin HFA (albuterol) inhaler* Xulane (ethinyl estradiol/norelgestromin)* (QL) Trelegy Ellipta (fluticasone/umeclidinium/ VePesid (etoposide)* Xylocaine (lidocaine) 2% gel* vilanterol) (PA) Verelan PM (verapamil extended release)* Xyrem (sodium oxybate) (CC) (PA) (QL) (SP) Trental (pentoxifylline)* Verquvo (vericiguat) (PA) (QL) (SP) Xywav (calcium, magnesium, potassium, and Tresiba (insulin human degludec) (PA) (Lantus Versed (midazolam)* sodium oxybates) (PA) (QL) (SP) preferred) Vesanoid (tretinoin)* (SP) (only generic NDC: Tri-Vi-Flor* 00555-0808-02) Y Tricor (fenofibrate)* VESIcare (solifenacin)* Yasmin (ethinyl estradiol/drospirenone)* Trijardy XR (empagliflozin/linagliptin/metformin) Vfend (voriconazole)* (SP) Yupelri (revefenacin inhalation solution) (PA) (QL) (PA) (QL) Vibramycin (doxycycline hyclate)* (generic 50 mg, Z Trikafta (elexacaftor/tezacaftor/ivacaftor) (CC) (PA) 100 mg capsules only) Zanaflex (tizanidine)* (QL) (SP) Victoza (liraglutide) (PA) (QL) Zantac (Ranitidine) 75mg/5 mL syrup* Trilafon (perphenazine)* Videx (didanosine) (SP) (for members < 1 year of age only) Trileptal (oxcarbazepine) tablets*, suspension* Videx EC (didanosine)* (SP) Zarontin (ethosuximide)* Trilipix (fenofibric acid delayed release)* Viekira (ombitasvir/paritaprevir/ritonavir/ Zaroxolyn (metolazone)* Trilisate (choline magnesium trisalicylate)* dasabuvir) (CC) (PA) (QL) (SP) Zarxio (filgrastim) (CC) (SP) Trivora (ethinyl estradiol/levonorgestrel)* Vimpat (lacosamide) Zavesca (miglustat) (SP) Trizivir (abacavir/lamivudine/zidovudine)* (SP) Viramune (nevirapine)* (SP) Zebeta (bisoprolol)* Trulicity (dulaglutide) (PA) (QL) Viramune XR (nevirapine)* (SP) Zejula (niraparib) (CC) (PA) (QL) (SP) Trusopt (dorzolamide)* Viread (tenofovir) (SP) Zelboraf (vemurafenib) (CC) (PA) (QL) (SP) Truvada (emtricitabine/tenofovir)* (CC) (QL) (SP) Viroptic (trifluridine)* Zepatier (elbasvir/grazoprevir) (PA) (SP) Trijardy XR (empagliflozin/linagliptin/metformin) Visken (pindolol)* Zeposia (ozanimod) (CC) (PA) (QL) (SP) (PA) (QL) (Farxiga preferred) Vistaril (hydroxyzine pamoate)* Zerit (stavudine)* (SP) Turalio (pexidartinib) (PA) (QL) (SP) Vitekta (elvitegravir) (SP) Zestoretic (lisinopril/hydrochlorothiazide)* Tudorza Pressair (aclidinium) Vitrakvi (larotrectinib) (CC) (PA) (QL) (SP) Zestril (lisinopril)* Tukysa (tucatinib) (PA) (QL) (SP) Voltaren (diclofenac)* Zetia (ezetimibe)* (QL) Tykerb (lapatinib) (CC) (SP) Voltaren (diclofenac) solution* Ziac (bisoprolol/hydrochlorothiazide)* Tylenol with Codeine (acetaminophen/codeine)* (QL) Vosevi (sofosbuvir/velpatasvir/voxilaprevir) (CC) Ziagen (abacavir)* (SP) Tymlos (abaloparatide) (CC) (PA) (QL) (SP) (PA) (QL) (SP) Ziextenzo (pegfilgrastim-bmez) (CC) (SP) Tyvaso (treprostinil) (CC) (PA) (SP) Vosol (acetic acid)* Zithromax (azithromycin)* Tyzeka (telbivudine) (SP) Vosol HC (acetic acid/hydrocortisone)* Zocor (simvastatin)* Vospire ER (albuterol extended release) tablet* U Zofran (ondansetron)* (QL) Votrient (pazopanib) (CC) (QL) (SP) Zokinvy (lonafarnib) (PA) (QL) (SP) Ubrelvy (ubrogepant) (CC) (PA) (QL) (SP) Vumerity (diroximel fumarate) (PA) (QL) (SP) Udenyca (pegfilgrastim-cbqv) (CC) (SP) Zolinza (vorinostat) (QL) (SP) Vyndamax (tafamidis) (PA) (QL) (SP) Zoloft (sertraline)* Uceris (budesonide extended release) (PA) (QL) Vyndaqel (tafamidis meglumine) (PA) (QL) (SP) Ultracet (tramadol/acetaminophen)* (QL) Zomacton (somatropin) (PA) (SP) (ST) Ultram (tramadol)* W Zomig (zolmitriptan)* (QL) Ultram ER (tramadol extended release)* Wakix (pitolisant) (PA) (QL) (SP) Zonegran (zonisamide)* Ultravate (halobetasol) cream*, ointment* Welchol (colesevelam) Zorbtive (somatropin) (PA) (SP) (ST) Univasc (moexipril)* Wellbutrin (bupropion)* Zortress (everolimus) (CC) (SP)* Upneeq (oxymetazoline) (PA) (QL) (SP) Wellbutrin SR (bupropion extended release)* Zovia (ethinyl estradiol/ethynodiol diacetate)* Uptravi (selexipag) (CC) (PA) (SP) Wellbutrin XL (bupropion extended release)* (QL) Zovirax (acyclovir) capsule*, tablet* Uroxatral (alfuzosin)* Westcort (hydrocortisone valerate) ointment* Zykadia (ceritinib) (CC) (PA) (QL) (SP) Urso (ursodiol)* Zyloprim (allopurinol)* X Zyprexa (olanzapine)* V Xadago (safinamide) (PA) (QL) Zytiga (abiraterone acetate)* (generic only; Vagifem (estradiol vaginal inserts)* (QL) Xalatan (latanoprost)* $0 copay) (CC) (PA) (QL) (SP) Valcyte (valganciclovir) (SP)* (generic only) Xalkori (crizotinib) (CC) (PA) (SP) Zyvox (linezolid)* (QL) (generic only; oral suspension Valium (diazepam)* Xanax (alprazolam)* for members 0-11 years of age)