Performance Drug List - Standard Control for Clients ® with Advanced Control Specialty Formulary

July 2021 Performance Drug List - Standard Control for Clients ® with Advanced Control Specialty Formulary

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

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

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

ANALGESICS § OPIOID ANALGESICS ANTI-INFECTIVES § PENICILLINS § INFLUENZA AGENTS buprenorphine transdermal amoxicillin oseltamivir § NSAIDs ANTIBACTERIALS codeine-acetaminophen amoxicillin-clavulanate RELENZA diclofenac sodium fentanyl transdermal § CEPHALOSPORINS dicloxacillin § MISCELLANEOUS ibuprofen fentanyl transmucosal cefdinir penicillin VK meloxicam lozenge cefprozil clindamycin § TETRACYCLINES naproxen (except naproxen CR or hydrocodone ext-rel cefuroxime axetil ivermectin naproxen suspension) hydrocodone-acetaminophen cephalexin doxycycline hyclate 20 mg linezolid

hydromorphone SUPRAX doxycycline hyclate capsule metronidazole § NSAIDs, COMBINATIONS hydromorphone ext-rel minocycline nitrofurantoin (except diclofenac sodium- § ERYTHROMYCINS / methadone tetracycline NDC^ 70408023932) misoprostol MACROLIDES pyrimethamine morphine azithromycin § ANTIFUNGALS § NSAIDs, TOPICAL morphine ext-rel sulfamethoxazole- morphine suppository clarithromycin fluconazole trimethoprim diclofenac sodium gel 1% oxycodone clarithromycin ext-rel itraconazole vancomycin capsule diclofenac sodium solution oxycodone-acetaminophen erythromycins terbinafine tablet EMVERM

§ COX-2 INHIBITORS tramadol (except NDC^ 52817019610) DIFICID XIFAXAN 550 MG ANTIVIRALS tramadol ext-rel tablet celecoxib § FLUOROQUINOLONES § CYTOMEGALOVIRUS BELBUCA ciprofloxacin AGENTS § GOUT NUCYNTA levofloxacin valganciclovir allopurinol NUCYNTA ER moxifloxacin SUBSYS colchicine tablet § HERPES AGENTS probenecid XTAMPZA ER acyclovir capsule, tablet MITIGARE valacyclovir

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

ANTINEOPLASTIC § BILE ACID RESINS metolazone memantine § ATTENTION DEFICIT AGENTS cholestyramine spironolactone- rivastigmine HYPERACTIVITY DISORDER colesevelam hydrochlorothiazide rivastigmine transdermal amphetamine- HORMONAL torsemide NAMZARIC dextroamphetamine ANTINEOPLASTIC AGENTS § CHOLESTEROL triamterene mixed salts ANTIDEPRESSANTS § ANTIANDROGENS ABSORPTION INHIBITORS triamterene- amphetamine- bicalutamide ezetimibe hydrochlorothiazide § SELECTIVE SEROTONIN dextroamphetamine REUPTAKE INHIBITORS mixed salts ext-rel † § MISCELLANEOUS § FIBRATES HEART FAILURE (SSRIs) atomoxetine BIDIL VISTOGARD fenofibrate (except citalopram dexmethylphenidate ext-rel CORLANOR fenofibrate capsule 50 mg, 130 mg; escitalopram guanfacine ext-rel CARDIOVASCULAR ENTRESTO fenofibrate tablet 40 mg, 120 mg) fluoxetine (except fluoxetine tablet 60 mg, methylphenidate

fenofibric acid delayed-rel fluoxetine tablet [generics for SARAFEM]) methylphenidate ext-rel † § ACE INHIBITORS § NITRATES paroxetine HCl MYDAYIS fosinopril § HMG-CoA REDUCTASE isosorbide dinitrate (except paroxetine HCl ext-rel VYVANSE lisinopril INHIBITORS / isosorbide dinitrate 40 mg) sertraline quinapril COMBINATIONS isosorbide mononitrate TRINTELLIX § FIBROMYALGIA ramipril atorvastatin nitroglycerin lingual spray pregabalin ezetimibe-simvastatin nitroglycerin sublingual § SEROTONIN § ACE INHIBITOR / fluvastatin NOREPINEPHRINE HYPNOTICS DIURETIC COMBINATIONS § MISCELLANEOUS lovastatin REUPTAKE INHIBITORS § NONBENZODIAZEPINES fosinopril-hydrochlorothiazide ranolazine ext-rel (SNRIs) pravastatin eszopiclone lisinopril-hydrochlorothiazide rosuvastatin desvenlafaxine ext-rel quinapril-hydrochlorothiazide CENTRAL NERVOUS ramelteon simvastatin duloxetine zolpidem SYSTEM venlafaxine § ANGIOTENSIN II § NIACINS zolpidem ext-rel RECEPTOR ANTAGONISTS / ANTIANXIETY venlafaxine ext-rel capsule BELSOMRA niacin ext-rel DIURETIC COMBINATIONS § BENZODIAZEPINES § MISCELLANEOUS § TRICYCLICS candesartan / candesartan- § OMEGA-3 FATTY ACIDS alprazolam AGENTS doxepin hydrochlorothiazide clonazepam omega-3 acid ethyl esters bupropion irbesartan / irbesartan- diazepam VASCEPA bupropion ext-rel (except MIGRAINE hydrochlorothiazide lorazepam bupropion ext-rel tablet 450 mg) ACUTE MIGRAINE AGENTS losartan / losartan- § BETA-BLOCKERS oxazepam mirtazapine § Triptans hydrochlorothiazide atenolol § ANTICONVULSANTS trazodone olmesartan / olmesartan- carvedilol eletriptan hydrochlorothiazide carvedilol phosphate ext-rel carbamazepine § ANTIPARKINSONIAN naratriptan telmisartan / telmisartan- metoprolol succinate ext-rel carbamazepine ext-rel AGENTS rizatriptan hydrochlorothiazide clobazam sumatriptan metoprolol tartrate amantadine valsartan / valsartan- diazepam rectal gel zolmitriptan nadolol carbidopa-levodopa hydrochlorothiazide divalproex sodium ONZETRA XSAIL pindolol carbidopa-levodopa ext-rel

propranolol divalproex sodium ext-rel carbidopa-levodopa- ZEMBRACE SYMTOUCH § ANGIOTENSIN II ethosuximide ZOMIG NASAL SPRAY propranolol ext-rel RECEPTOR ANTAGONIST / entacapone BYSTOLIC gabapentin entacapone Miscellaneous CALCIUM CHANNEL lamotrigine pramipexole BLOCKER COMBINATIONS § CALCIUM CHANNEL lamotrigine ext-rel NURTEC ODT pramipexole ext-rel amlodipine-olmesartan BLOCKERS levetiracetam REYVOW rasagiline amlodipine-telmisartan amlodipine levetiracetam ext-rel UBRELVY ropinirole amlodipine-valsartan diltiazem ext-rel (except oxcarbazepine ropinirole ext-rel PREVENTIVE MIGRAINE generics for CARDIZEM LA) phenobarbital § ANGIOTENSIN II selegiline AGENTS nifedipine ext-rel phenytoin RECEPTOR ANTAGONIST / NEUPRO verapamil ext-rel phenytoin sodium extended Monoclonal Antibodies CALCIUM CHANNEL primidone ANTIPSYCHOTICS AIMOVIG BLOCKER / DIURETIC § CALCIUM CHANNEL rufinamide AJOVY COMBINATIONS BLOCKER / ANTILIPEMIC § ATYPICALS tiagabine EMGALITY COMBINATIONS aripiprazole amlodipine-valsartan- topiramate clozapine § MUSCULOSKELETAL hydrochlorothiazide amlodipine-atorvastatin valproic acid olanzapine THERAPY AGENTS olmesartan-amlodipine- zonisamide § DIGITALIS GLYCOSIDES quetiapine hydrochlorothiazide FYCOMPA cyclobenzaprine (except quetiapine ext-rel digoxin NAYZILAM cyclobenzaprine tablet 7.5 mg) § ANTIARRHYTHMICS risperidone OXTELLAR XR disopyramide § DIRECT RENIN ziprasidone § NARCOLEPSY TROKENDI XR sotalol INHIBITORS / DIURETIC ABILIFY MAINTENA armodafinil VALTOCO MULTAQ COMBINATIONS LATUDA modafinil VIMPAT aliskiren PERSERIS SUNOSI XCOPRI ANTILIPEMICS TEKTURNA HCT VRAYLAR ACL INHIBITORS / POSTHERPETIC § ANTIDEMENTIA COMBINATIONS § DIURETICS NEURALGIA (PHN) donepezil amiloride GRALISE NEXLETOL galantamine furosemide NEXLIZET galantamine ext-rel hydrochlorothiazide

PSYCHOTHERAPEUTIC - NOVOLOG DEXCOM CONTINUOUS methylprednisolone GASTROINTESTINAL MISCELLANEOUS NOVOLOG MIX 70/30 GLUCOSE prednisolone solution § ANTIDIARRHEALS § OPIOID ANTAGONISTS TOUJEO MONITORING SYSTEM prednisone TRESIBA OMNIPOD DASH INSULIN diphenoxylate-atropine naloxone injection GLUCOSE ELEVATING INFUSION PUMP loperamide NARCAN NASAL SPRAY § INSULIN SENSITIZERS OMNIPOD INSULIN AGENTS § ANTIEMETICS § PARTIAL OPIOID AGONIST / pioglitazone INFUSION PUMP BAQSIMI OPIOID ANTAGONIST ONETOUCH ULTRA GLUCAGEN HYPOKIT aprepitant § INSULIN SENSITIZER / COMBINATIONS STRIPS AND KITS 2 GLUCAGON doxylamine-pyridoxine BIGUANIDE COMBINATIONS delayed-rel buprenorphine-naloxone ONETOUCH VERIO EMERGENCY KIT pioglitazone-metformin STRIPS AND KITS 2 GVOKE dronabinol sublingual V-GO INSULIN granisetron ZUBSOLV § INSULIN SENSITIZER / MENOPAUSAL SYMPTOM INFUSION PUMP meclizine SULFONYLUREA AGENTS PSEUDOBULBAR AFFECT metoclopramide COMBINATIONS AGENTS ANTIOBESITY § ORAL ondansetron pioglitazone-glimepiride INJECTABLE estradiol prochlorperazine NUEDEXTA promethazine § MEGLITINIDES SAXENDA estradiol-norethindrone ENDOCRINE AND DUAVEE scopolamine transdermal nateglinide METABOLIC ORAL PREMPHASE trimethobenzamide repaglinide SANCUSO QSYMIA PREMPRO § ANDROGENS SODIUM-GLUCOSE CALCIUM REGULATORS § TRANSDERMAL § ANTISPASMODICS testosterone gel (except authorized CO-TRANSPORTER 2 generics for TESTIM and VOGELXO) § BISPHOSPHONATES estradiol dicyclomine (SGLT2) INHIBITORS testosterone solution alendronate CLIMARA PRO FARXIGA § H2 RECEPTOR ANDRODERM ibandronate COMBIPATCH JARDIANCE ANTAGONISTS

NATESTO risedronate DIVIGEL

EVAMIST famotidine ANTIDIABETICS SODIUM-GLUCOSE CO-TRANSPORTER 2 § CALCITONINS AMYLIN ANALOGS § VAGINAL INFLAMMATORY BOWEL (SGLT2) INHIBITOR / calcitonin-salmon DISEASE SYMLINPEN BIGUANIDE COMBINATIONS estradiol vaginal cream § CARNITINE DEFICIENCY IMVEXXY § ORAL AGENTS SYNJARDY § BIGUANIDES AGENTS VAGIFEM balsalazide SYNJARDY XR metformin levocarnitine budesonide capsule XIGDUO XR § PHOSPHATE BINDER metformin ext-rel (except generics budesonide ext-rel CONTRACEPTIVES AGENTS for FORTAMET and GLUMETZA) SODIUM-GLUCOSE mesalamine delayed-rel (except CO-TRANSPORTER 2 § MONOPHASIC calcium acetate mesalamine delayed-rel tablet 800 mg) § BIGUANIDE / (SGLT2) INHIBITOR / ethinyl estradiol- sevelamer carbonate mesalamine ext-rel SULFONYLUREA DIPEPTIDYL PEPTIDASE-4 drospirenone PHOSLYRA sulfasalazine COMBINATIONS (DPP-4) INHIBITOR ethinyl estradiol- VELPHORO sulfasalazine delayed-rel glipizide-metformin COMBINATIONS drospirenone-levomefolate ASACOL HD POTASSIUM-REMOVING ethinyl estradiol- PENTASA DIPEPTIDYL PEPTIDASE-4 GLYXAMBI AGENTS norethindrone acetate (DPP-4) INHIBITORS § RECTAL AGENTS SODIUM-GLUCOSE ethinyl estradiol- LOKELMA JANUVIA VELTASSA CO-TRANSPORTER 2 hydrocortisone enema norethindrone acetate-iron mesalamine suppository DIPEPTIDYL PEPTIDASE-4 (SGLT2) INHIBITOR / PROGESTINS BIPHASIC mesalamine suspension (DPP-4) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 § ORAL CORTIFOAM BIGUANIDE COMBINATIONS (DPP-4) INHIBITOR / LO LOESTRIN FE medroxyprogesterone BIGUANIDE COMBINATIONS § IRRITABLE BOWEL JANUMET § TRIPHASIC megestrol acetate

JANUMET XR TRIJARDY XR SYNDROME ethinyl estradiol-norgestimate progesterone, micronized

alosetron INCRETIN MIMETIC AGENTS § SULFONYLUREAS § EXTENDED CYCLE VAGINAL LINZESS glimepiride OZEMPIC ethinyl estradiol- CRINONE VIBERZI glipizide RYBELSUS levonorgestrel ENDOMETRIN

TRULICITY glipizide ext-rel § LAXATIVES § SELECTIVE ESTROGEN VICTOZA SUPPLIES § TRANSDERMAL lactulose solution

ethinyl estradiol- RECEPTOR MODULATORS peg 3350-electrolytes INCRETIN MIMETIC AGENT / ACCU-CHEK AVIVA PLUS norelgestromin raloxifene CLENPIQ 2 INSULIN COMBINATIONS STRIPS AND KITS SOLIQUA ACCU-CHEK COMPACT § VAGINAL § THYROID SUPPLEMENTS OPIOID-INDUCED PLUS STRIPS AND KITS 2 XULTOPHY ethinyl estradiol-etonogestrel levothyroxine CONSTIPATION ACCU-CHEK GUIDE ANNOVERA liothyronine MOVANTIK INSULINS STRIPS AND KITS 2 SYNTHROID SYMPROIC BASAGLAR ACCU-CHEK SMARTVIEW ENDOMETRIOSIS 2 FIASP STRIPS AND KITS ORILISSA UTERINE FIBROIDS PANCREATIC ENZYMES HUMULIN R U-500 BD ULTRAFINE ORIAHNN CREON LEVEMIR INSULIN SYRINGES § GLUCOCORTICOIDS VIOKACE NOVOLIN 70/30 AND NEEDLES dexamethasone ZENPEP NOVOLIN N fludrocortisone NOVOLIN R hydrocortisone

§ PROTON PUMP prasugrel levalbuterol tartrate PICATO MOUTH / THROAT / INHIBITORS BRILINTA CFC-free aerosol TOLAK DENTAL AGENTS esomeprazole delayed-rel ZYCLARA PROTECTANTS IMMUNOLOGIC LONG ACTING lansoprazole delayed-rel EPISIL AGENTS Hand-held Active Inhalation § ANTIBIOTICS omeprazole delayed-rel gentamicin pantoprazole ALLERGENIC EXTRACTS SEREVENT OPHTHALMIC mupirocin ointment delayed-rel tablet STRIVERDI RESPIMAT § ANTIALLERGICS GRASTEK DEXILANT § ANTIFUNGALS azelastine RAGWITEK Nebulized Passive Inhalation cromolyn sodium § STEROIDS, RECTAL PERFOROMIST ciclopirox NUTRITIONAL / clotrimazole olopatadine PROCTOFOAM-HC SUPPLEMENTS § LEUKOTRIENE econazole § ANTI-INFECTIVES § ULCER THERAPY MODULATORS ketoconazole cream 2% § ELECTROLYTES ciprofloxacin COMBINATIONS montelukast nystatin potassium chloride liquid erythromycin PYLERA zafirlukast NAFTIN gentamicin VITAMINS AND MINERALS § MISCELLANEOUS § NASAL ANTIHISTAMINES § ANTIPSORIATICS levofloxacin § FOLIC ACID / moxifloxacin sucralfate tablet azelastine acitretin COMBINATIONS ofloxacin olopatadine calcipotriene ointment, folic acid solution sulfacetamide GENITOURINARY § NASAL STEROIDS / tobramycin § PRENATAL VITAMINS methoxsalen § BENIGN PROSTATIC COMBINATIONS BESIVANCE HYPERPLASIA prenatal vitamins flunisolide § ANTISEBORRHEICS CITRANATAL § ANTI-INFECTIVE / alfuzosin ext-rel fluticasone ketoconazole shampoo 2% ANTI-INFLAMMATORY doxazosin mometasone selenium sulfide lotion 2.5% RESPIRATORY COMBINATIONS dutasteride DYMISTA dutasteride-tamsulosin § ANAPHYLAXIS § ATOPIC DERMATITIS neomycin-polymyxin B- finasteride TREATMENT AGENTS PHOSPHODIESTERASE-4 pimecrolimus bacitracin-hydrocortisone silodosin INHIBITORS tacrolimus neomycin-polymyxin B- epinephrine auto-injector EUCRISA dexamethasone tamsulosin DALIRESP EPIPEN terazosin tobramycin-dexamethasone EPIPEN JR STEROID / BETA AGONIST CORTICOSTEROIDS TOBRADEX OINTMENT SYMJEPI ERECTILE DYSFUNCTION COMBINATIONS § Low Potency ANTI-INFLAMMATORIES ALPROSTADIL AGENTS § ANTICHOLINERGICS ADVAIR DISKUS desonide † § Nonsteroidal MUSE ipratropium ADVAIR HFA hydrocortisone BREO ELLIPTA † bromfenac inhalation solution § PHOSPHODIESTERASE SYMBICORT § Medium Potency diclofenac SPIRIVA INHIBITORS hydrocortisone butyrate ketorolac YUPELRI § STEROID INHALANTS sildenafil cream, ointment, solution ILEVRO tadalafil ANTICHOLINERGIC / BETA budesonide mometasone PROLENSA AGONIST COMBINATIONS inhalation suspension triamcinolone cream, lotion, § URINARY § Steroidal § SHORT ACTING ARNUITY ELLIPTA ointment (except ANTISPASMODICS FLOVENT DISKUS dexamethasone ipratropium-albuterol triamcinolone ointment 0.05%) darifenacin ext-rel FLOVENT HFA loteprednol inhalation solution § High Potency oxybutynin PULMICORT FLEXHALER prednisolone acetate 1% oxybutynin ext-rel LONG ACTING QVAR REDIHALER desoximetasone DUREZOL solifenacin fluocinonide (except ANORO ELLIPTA § ANTIVIRALS tolterodine TOPICAL fluocinonide cream 0.1%) STIOLTO RESPIMAT tolterodine ext-rel BRYHALI trifluridine DERMATOLOGY trospium ANTICHOLINERGIC / BETA ACNE § Very High Potency BETA-BLOCKERS trospium ext-rel AGONIST / STEROID § Nonselective MYRBETRIQ INHALANT COMBINATIONS § Topical clobetasol cream, foam, gel, lotion, ointment, shampoo timolol maleate solution TOVIAZ BREZTRI AEROSPHERE adapalene

benzoyl peroxide TRELEGY ELLIPTA § LOCAL ANALGESICS Selective HEMATOLOGIC clindamycin gel (except

§ ANTIHISTAMINES, NDC^ 68682046275) lidocaine patch BETOPTIC S § ANTICOAGULANTS LOW SEDATING clindamycin solution warfarin § LOCAL ANESTHETICS § CARBONIC ANHYDRASE levocetirizine clindamycin-benzoyl lidocaine-prilocaine INHIBITORS ELIQUIS peroxide XARELTO § ANTITUSSIVES dorzolamide erythromycin solution § ROSACEA AZOPT benzonatate (except erythromycin-benzoyl § CHELATING AGENTS azelaic acid gel NDCs^ 69336012615, 69499032915) peroxide penicillamine capsule metronidazole § CARBONIC ANHYDRASE tretinoin trientine BETA AGONISTS, FINACEA FOAM INHIBITOR / BETA- EPIDUO INHALANTS ORACEA BLOCKER COMBINATIONS § PLATELET AGGREGATION ONEXTON § SHORT ACTING SOOLANTRA dorzolamide-timolol INHIBITORS § ACTINIC KERATOSIS albuterol inhalation solution clopidogrel albuterol sulfate fluorouracil cream 5% dipyridamole ext-rel-aspirin fluorouracil solution CFC-free aerosol imiquimod

CARBONIC ANHYDRASE § PROSTAGLANDINS RHO KINASE INHIBITOR / SYMPATHOMIMETIC / BETA- § ANTI-INFECTIVE / INHIBITOR / latanoprost PROSTAGLANDIN BLOCKER COMBINATIONS ANTI-INFLAMMATORY SYMPATHOMIMETIC travoprost COMBINATIONS COMBIGAN COMBINATIONS COMBINATIONS LUMIGAN ROCKLATAN ciprofloxacin-dexamethasone OTIC SIMBRINZA ZIOPTAN neomycin-polymyxin B- § SYMPATHOMIMETICS § ANTI-INFECTIVES hydrocortisone DRY EYE DISEASE RHO KINASE INHIBITORS brimonidine acetic acid RESTASIS RHOPRESSA ALPHAGAN P ofloxacin otic XIIDRA QUICK REFERENCE DRUG LIST

A atorvastatin cefdinir diclofenac sodium estradiol vaginal cream azelaic acid gel cefprozil diclofenac sodium gel 1% estradiol-norethindrone ABILIFY MAINTENA azelastine cefuroxime axetil diclofenac sodium solution eszopiclone ACCU-CHEK AVIVA PLUS azithromycin celecoxib diclofenac sodium- ethinyl estradiol- STRIPS AND KITS 2 AZOPT cephalexin misoprostol drospirenone ACCU-CHEK COMPACT cholestyramine dicloxacillin ethinyl estradiol- PLUS STRIPS AND KITS 2 B ciclopirox dicyclomine drospirenone-levomefolate ACCU-CHEK GUIDE balsalazide ciprofloxacin DIFICID ethinyl estradiol-etonogestrel STRIPS AND KITS 2 ciprofloxacin-dexamethasone digoxin ethinyl estradiol- ACCU-CHEK SMARTVIEW BAQSIMI BASAGLAR citalopram diltiazem ext-rel (except levonorgestrel STRIPS AND KITS 2 BD ULTRAFINE CITRANATAL generics for CARDIZEM LA) ethinyl estradiol- acetic acid INSULIN SYRINGES clarithromycin diphenoxylate-atropine norelgestromin acitretin AND NEEDLES clarithromycin ext-rel dipyridamole ext-rel-aspirin ethinyl estradiol- acyclovir capsule, tablet BELBUCA CLENPIQ disopyramide norethindrone acetate adapalene BELSOMRA CLIMARA PRO divalproex sodium ethinyl estradiol- ADVAIR DISKUS benzonatate (except clindamycin divalproex sodium ext-rel norethindrone acetate-iron ADVAIR HFA † clindamycin gel (except DIVIGEL ethinyl estradiol-norgestimate AIMOVIG NDCs^ 69336012615, 69499032915) benzoyl peroxide NDC^ 68682046275) donepezil ethosuximide AJOVY BESIVANCE clindamycin solution dorzolamide EUCRISA albuterol inhalation solution clindamycin-benzoyl dorzolamide-timolol EVAMIST albuterol sulfate CFC-free BETOPTIC S bicalutamide peroxide doxazosin ezetimibe aerosol BIDIL clobazam doxepin ezetimibe-simvastatin alendronate BREO ELLIPTA † clobetasol cream, foam, gel, doxycycline hyclate 20 mg alfuzosin ext-rel BREZTRI AEROSPHERE lotion, ointment, shampoo doxycycline hyclate capsule F aliskiren BRILINTA clonazepam doxylamine-pyridoxine famotidine allopurinol brimonidine clopidogrel delayed-rel FARXIGA alosetron bromfenac clotrimazole dronabinol fenofibrate (except ALPHAGAN P BRYHALI clozapine DUAVEE fenofibrate capsule 50 mg, 130 mg; alprazolam budesonide capsule codeine-acetaminophen duloxetine fenofibrate tablet 40 mg, 120 mg) amantadine budesonide ext-rel colchicine tablet DUREZOL fenofibric acid delayed-rel amiloride budesonide colesevelam dutasteride fentanyl transdermal amlodipine inhalation suspension COMBIGAN dutasteride-tamsulosin fentanyl transmucosal amlodipine-atorvastatin COMBIPATCH DYMISTA buprenorphine transdermal lozenge amlodipine-olmesartan buprenorphine-naloxone CORLANOR FIASP amlodipine-telmisartan sublingual CORTIFOAM E FINACEA FOAM amlodipine-valsartan CREON amlodipine-valsartan- bupropion econazole finasteride bupropion ext-rel (except CRINONE eletriptan FLOVENT DISKUS hydrochlorothiazide bupropion ext-rel tablet 450 mg) cromolyn sodium ELIQUIS FLOVENT HFA amoxicillin BYSTOLIC cyclobenzaprine (except EMGALITY fluconazole amoxicillin-clavulanate amphetamine- cyclobenzaprine tablet 7.5 mg) EMVERM fludrocortisone C dextroamphetamine ENDOMETRIN flunisolide D entacapone fluocinonide (except mixed salts calcipotriene ointment, amphetamine- solution DALIRESP ENTRESTO fluocinonide cream 0.1%) dextroamphetamine calcitonin-salmon darifenacin ext-rel EPIDUO fluorouracil cream 5% desonide epinephrine auto-injector fluorouracil solution mixed salts ext-rel † calcium acetate desoximetasone EPIPEN fluoxetine (except fluoxetine tablet 60 mg, ANDRODERM candesartan desvenlafaxine ext-rel EPIPEN JR fluoxetine tablet [generics for SARAFEM]) ANNOVERA candesartan- dexamethasone EPISIL fluticasone ANORO ELLIPTA hydrochlorothiazide DEXCOM CONTINUOUS erythromycin fluvastatin aprepitant carbamazepine GLUCOSE erythromycin solution folic acid aripiprazole carbamazepine ext-rel MONITORING SYSTEM erythromycin-benzoyl fosinopril armodafinil carbidopa-levodopa DEXILANT peroxide fosinopril-hydrochlorothiazide ARNUITY ELLIPTA carbidopa-levodopa ext-rel dexmethylphenidate ext-rel erythromycins furosemide ASACOL HD carbidopa-levodopa- diazepam escitalopram FYCOMPA atenolol entacapone diazepam rectal gel esomeprazole delayed-rel atomoxetine carvedilol carvedilol phosphate ext-rel diclofenac estradiol

G LATUDA N oxybutynin repaglinide levalbuterol tartrate oxybutynin ext-rel RESTASIS gabapentin nadolol CFC-free aerosol oxycodone REYVOW galantamine NAFTIN LEVEMIR oxycodone-acetaminophen RHOPRESSA galantamine ext-rel naloxone injection levetiracetam OZEMPIC risedronate gentamicin NAMZARIC levetiracetam ext-rel risperidone glimepiride naproxen (except naproxen CR or levocarnitine P rivastigmine glipizide naproxen suspension) levocetirizine pantoprazole rivastigmine transdermal glipizide ext-rel naratriptan levofloxacin delayed-rel tablet rizatriptan glipizide-metformin NARCAN NASAL SPRAY levothyroxine paroxetine HCl ROCKLATAN GLUCAGEN HYPOKIT nateglinide lidocaine patch paroxetine HCl ext-rel ropinirole GLUCAGON NATESTO lidocaine-prilocaine peg 3350-electrolytes ropinirole ext-rel EMERGENCY KIT NAYZILAM linezolid penicillamine capsule rosuvastatin GLYXAMBI neomycin-polymyxin B- LINZESS penicillin VK rufinamide GRALISE bacitracin-hydrocortisone liothyronine PENTASA RYBELSUS granisetron neomycin-polymyxin B- lisinopril PERFOROMIST GRASTEK dexamethasone lisinopril-hydrochlorothiazide PERSERIS S guanfacine ext-rel neomycin-polymyxin B- LO LOESTRIN FE phenobarbital SANCUSO GVOKE hydrocortisone LOKELMA phenytoin SAXENDA NEUPRO loperamide phenytoin sodium extended scopolamine transdermal H NEXLETOL lorazepam PHOSLYRA selegiline HUMULIN R U-500 NEXLIZET losartan PICATO selenium sulfide lotion 2.5% hydrochlorothiazide niacin ext-rel losartan-hydrochlorothiazide pimecrolimus SEREVENT hydrocodone ext-rel nifedipine ext-rel loteprednol pindolol sertraline hydrocodone-acetaminophen nitrofurantoin (except lovastatin pioglitazone sevelamer carbonate hydrocortisone NDC^ 70408023932) LUMIGAN pioglitazone-glimepiride sildenafil hydrocortisone butyrate nitroglycerin lingual spray pioglitazone-metformin silodosin cream, ointment, solution nitroglycerin sublingual M potassium chloride liquid SIMBRINZA hydrocortisone enema NOVOLIN 70/30 meclizine pramipexole simvastatin hydromorphone NOVOLIN N medroxyprogesterone pramipexole ext-rel solifenacin hydromorphone ext-rel NOVOLIN R megestrol acetate prasugrel SOLIQUA NOVOLOG meloxicam pravastatin SOOLANTRA I NOVOLOG MIX 70/30 memantine prednisolone acetate 1% sotalol ibandronate NUCYNTA mesalamine delayed-rel (except prednisolone solution SPIRIVA ibuprofen NUCYNTA ER mesalamine delayed-rel tablet 800 mg) prednisone spironolactone- ILEVRO NUEDEXTA mesalamine ext-rel pregabalin hydrochlorothiazide imiquimod NURTEC ODT mesalamine suppository PREMPHASE STIOLTO RESPIMAT IMVEXXY nystatin mesalamine suspension PREMPRO STRIVERDI RESPIMAT ipratropium metformin O prenatal vitamins SUBSYS inhalation solution metformin ext-rel (except generics primidone sucralfate tablet ipratropium-albuterol ofloxacin for FORTAMET and GLUMETZA) probenecid sulfacetamide inhalation solution ofloxacin otic methadone prochlorperazine sulfamethoxazole- irbesartan olanzapine methoxsalen PROCTOFOAM-HC trimethoprim irbesartan- olmesartan methylphenidate progesterone, micronized sulfasalazine hydrochlorothiazide olmesartan-amlodipine- methylphenidate ext-rel † PROLENSA sulfasalazine delayed-rel isosorbide dinitrate (except hydrochlorothiazide methylprednisolone promethazine sumatriptan isosorbide dinitrate 40 mg) olmesartan- metoclopramide propranolol SUNOSI isosorbide mononitrate hydrochlorothiazide metolazone propranolol ext-rel SUPRAX itraconazole olopatadine metoprolol succinate ext-rel PULMICORT FLEXHALER SYMBICORT ivermectin omega-3 acid ethyl esters metoprolol tartrate PYLERA SYMJEPI omeprazole delayed-rel metronidazole pyrimethamine SYMLINPEN J OMNIPOD DASH INSULIN minocycline SYMPROIC JANUMET INFUSION PUMP mirtazapine Q SYNJARDY JANUMET XR OMNIPOD INSULIN MITIGARE QSYMIA SYNJARDY XR JANUVIA INFUSION PUMP modafinil quetiapine SYNTHROID JARDIANCE ondansetron mometasone ONETOUCH ULTRA quetiapine ext-rel montelukast quinapril T K STRIPS AND KITS 2 morphine ONETOUCH VERIO quinapril-hydrochlorothiazide tacrolimus ketoconazole cream 2% morphine ext-rel QVAR REDIHALER tadalafil STRIPS AND KITS 2 ketoconazole shampoo 2% morphine suppository tamsulosin ONEXTON ketorolac MOVANTIK R TEKTURNA HCT ONZETRA XSAIL moxifloxacin telmisartan L ORACEA RAGWITEK MULTAQ telmisartan- ORIAHNN raloxifene lactulose solution mupirocin ointment hydrochlorothiazide ORILISSA ramelteon lamotrigine MUSE terazosin oseltamivir ramipril lamotrigine ext-rel MYDAYIS terbinafine tablet oxazepam ranolazine ext-rel lansoprazole delayed-rel MYRBETRIQ rasagiline testosterone gel (except authorized oxcarbazepine latanoprost generics for TESTIM and VOGELXO) OXTELLAR XR RELENZA

testosterone solution TRESIBA U V-GO INSULIN XTAMPZA ER tetracycline tretinoin INFUSION PUMP XULTOPHY UBRELVY tiagabine triamcinolone cream, lotion, VIBERZI Y timolol maleate solution ointment (except V VICTOZA TOBRADEX OINTMENT triamcinolone ointment 0.05%) VIMPAT YUPELRI VAGIFEM tobramycin triamterene VIOKACE valacyclovir tobramycin-dexamethasone triamterene- VISTOGARD Z valganciclovir TOLAK hydrochlorothiazide VRAYLAR zafirlukast valproic acid tolterodine trientine VYVANSE ZEMBRACE SYMTOUCH valsartan tolterodine ext-rel trifluridine ZENPEP valsartan-hydrochlorothiazide W topiramate TRIJARDY XR ZIOPTAN VALTOCO torsemide trimethobenzamide warfarin ziprasidone vancomycin capsule TOUJEO TRINTELLIX zolmitriptan VASCEPA TOVIAZ TROKENDI XR X zolpidem VELPHORO tramadol (except NDC^ 52817019610) trospium XARELTO zolpidem ext-rel VELTASSA tramadol ext-rel tablet trospium ext-rel XCOPRI ZOMIG NASAL SPRAY venlafaxine travoprost TRULICITY XIFAXAN 550 MG zonisamide venlafaxine ext-rel capsule trazodone XIGDUO XR ZUBSOLV verapamil ext-rel TRELEGY ELLIPTA XIIDRA ZYCLARA

PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, AMITIZA LINZESS, MOVANTIK, SYMPROIC quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) ACANYA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), ANDROGEL testosterone gel (except authorized generics clindamycin solution, clindamycin- for TESTIM and VOGELXO), benzoyl peroxide, erythromycin solution, testosterone solution, ANDRODERM, erythromycin-benzoyl peroxide, tretinoin, NATESTO EPIDUO, ONEXTON ANGELIQ estradiol-norethindrone, PREMPHASE, ACIPHEX, ACIPHEX SPRINKLE esomeprazole delayed-rel, lansoprazole PREMPRO delayed-rel, omeprazole delayed-rel, ANTARA fenofibrate (except fenofibrate capsule 50 mg, pantoprazole delayed-rel tablet, DEXILANT 130 mg; fenofibrate tablet 40 mg, 120 mg), ACTICLATE doxycycline hyclate 20 mg, doxycycline fenofibric acid delayed-rel hyclate capsule, minocycline, tetracycline APEXICON E desoximetasone (except Activite folic acid desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%), ACTOS pioglitazone BRYHALI ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, APIDRA FIASP, NOVOLOG PROLENSA APTENSIO XR amphetamine- acyclovir cream acyclovir capsule, acyclovir tablet, dextroamphetamine mixed salts ext-rel †, valacyclovir dexmethylphenidate ext-rel, methylphenidate ext-rel †, MYDAYIS, ADDERALL amphetamine-dextroamphetamine mixed salts, VYVANSE methylphenidate ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID ADZENYS ER, ADZENYS XR-ODT amphetamine- dextroamphetamine mixed salts ext-rel †, ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, dexmethylphenidate ext-rel, meloxicam or naproxen (except naproxen CR methylphenidate ext-rel †, MYDAYIS, or naproxen suspension) WITH VYVANSE esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, ALCORTIN A desonide, hydrocortisone pantoprazole delayed-rel tablet or DEXILANT ALEVICYN GEL, ALEVICYN SG, desonide, hydrocortisone ASCENSIA STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ALEVICYN SOLUTION ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, 2 ALLISON MEDICAL INSULIN SYRINGES 3 BD ULTRAFINE INSULIN SYRINGES ACCU-CHEK GUIDE STRIPS AND KITS , ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ALORA estradiol, DIVIGEL, EVAMIST ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 ALREX azelastine, cromolyn sodium, olopatadine ASMANEX, ASMANEX HFA ARNUITY ELLIPTA, FLOVENT DISKUS, ALTOPREV atorvastatin, ezetimibe-simvastatin, FLOVENT HFA, PULMICORT FLEXHALER, fluvastatin, lovastatin, pravastatin, QVAR REDIHALER rosuvastatin, simvastatin

ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, BREEZE 2 STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, irbesartan, irbesartan-hydrochlorothiazide, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, losartan, losartan-hydrochlorothiazide, ACCU-CHEK GUIDE STRIPS AND KITS 2, olmesartan, olmesartan-hydrochlorothiazide, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, telmisartan, telmisartan-hydrochlorothiazide, ONETOUCH ULTRA STRIPS AND KITS 2, valsartan, valsartan-hydrochlorothiazide ONETOUCH VERIO STRIPS AND KITS 2 ATIVAN alprazolam, clonazepam, diazepam, BROMSITE bromfenac, diclofenac, ketorolac, ILEVRO, lorazepam, oxazepam PROLENSA ATOPADERM desonide, hydrocortisone Bupap diclofenac sodium, ibuprofen, naproxen (except naproxen CR or ATROVENT HFA ipratropium inhalation solution, SPIRIVA, naproxen suspension) YUPELRI bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel AVENOVA Consult doctor (except bupropion ext-rel tablet 450 mg) AZASITE ciprofloxacin, erythromycin, gentamicin, butalbital-acetaminophen tablet 50-300 mg, diclofenac sodium, ibuprofen, levofloxacin, moxifloxacin, ofloxacin, BUTALBITAL-ACETAMINOPHEN naproxen (except naproxen CR or sulfacetamide, tobramycin, BESIVANCE (NDC^ 69499034230 only) naproxen suspension) AZELEX adapalene, benzoyl peroxide, butalbital-acetaminophen-caffeine capsule diclofenac sodium, ibuprofen, clindamycin gel (except NDC^ 68682046275), naproxen (except naproxen CR or clindamycin solution, clindamycin- naproxen suspension) benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BUTRANS buprenorphine transdermal, BELBUCA EPIDUO, ONEXTON BYDUREON OZEMPIC, RYBELSUS, TRULICITY, AZESCO 5 prenatal vitamins, CITRANATAL VICTOZA AZOR amlodipine-olmesartan, amlodipine-telmisartan, BYETTA OZEMPIC, RYBELSUS, TRULICITY, amlodipine-valsartan VICTOZA BANZEL SUSPENSION clobazam, lamotrigine, rufinamide, CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, topiramate, TROKENDI XR zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, BEAU RX Consult doctor ZOMIG NASAL SPRAY BECONASE AQ flunisolide, fluticasone, mometasone, calcipotriene cream calcipotriene ointment, calcipotriene solution DYMISTA calcipotriene-betamethasone calcipotriene ointment or calcipotriene BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, solution WITH desoximetasone irbesartan, irbesartan-hydrochlorothiazide, (except desoximetasone ointment 0.05%), losartan, losartan-hydrochlorothiazide, fluocinonide (except fluocinonide cream 0.1%) olmesartan, olmesartan-hydrochlorothiazide, or BRYHALI telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide calcitriol ointment calcipotriene ointment, calcipotriene solution BENSAL HP desonide, hydrocortisone CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or BENZAC AC adapalene, benzoyl peroxide, naproxen suspension) clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- CARAC fluorouracil cream 5%, fluorouracil solution, benzoyl peroxide, erythromycin solution, imiquimod, PICATO, TOLAK, ZYCLARA erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON CARAFATE sucralfate tablet BENZACLIN adapalene, benzoyl peroxide, CARBINOXAMINE TABLET 6 MG levocetirizine clindamycin gel (except NDC^ 68682046275), CARDIZEM, CARDIZEM CD, diltiazem ext-rel clindamycin solution, clindamycin- CARDIZEM LA (except generics for CARDIZEM LA) benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, carisoprodol 250 mg cyclobenzaprine EPIDUO, ONEXTON (except cyclobenzaprine tablet 7.5 mg) benzonatate benzonatate CARNITOR, CARNITOR SF levocarnitine (NDCs^ 69336012615, 69499032915 only) (except NDCs^ 69336012615, 69499032915) CELEBREX celecoxib, diclofenac sodium, ibuprofen, BEPREVE azelastine, cromolyn sodium, olopatadine meloxicam, naproxen (except naproxen CR or naproxen suspension) BETAPACE, BETAPACE AF sotalol chlordiazepoxide-clidinium dicyclomine BETIMOL timolol maleate solution, BETOPTIC S (NDCs^ 11534019701, 42494040901, BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT 51293069601, 51293069610 only) BEYAZ ethinyl estradiol-drospirenone, chlorzoxazone 375 mg, cyclobenzaprine ethinyl estradiol-drospirenone-levomefolate, chlorzoxazone 500 mg (NDC^ 73007001303 only), (except cyclobenzaprine tablet 7.5 mg) ethinyl estradiol-norethindrone acetate, chlorzoxazone 750 mg, ethinyl estradiol-norethindrone acetate-iron CHLORZOXAZONE 250 MG bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN CIALIS sildenafil, tadalafil CICATRACE Consult doctor

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* CILOXAN ciprofloxacin, erythromycin, gentamicin, cyclobenzaprine ext-rel capsule, cyclobenzaprine levofloxacin, moxifloxacin, ofloxacin, cyclobenzaprine tablet 7.5 mg (except cyclobenzaprine tablet 7.5 mg) sulfacetamide, tobramycin, BESIVANCE CYMBALTA desvenlafaxine ext-rel, duloxetine, CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic venlafaxine, venlafaxine ext-rel capsule CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic CYTOMEL levothyroxine, liothyronine, SYNTHROID CLINDAGEL erythromycin solution DARAPRIM pyrimethamine clindamycin gel (NDC^ 68682046275 only) adapalene, benzoyl peroxide, DAYTRANA amphetamine- clindamycin gel (except NDC^ 68682046275), dextroamphetamine mixed salts ext-rel †, clindamycin solution, clindamycin- dexmethylphenidate ext-rel, benzoyl peroxide, erythromycin solution, methylphenidate ext-rel †, MYDAYIS, erythromycin-benzoyl peroxide, tretinoin, VYVANSE EPIDUO, ONEXTON DELZICOL balsalazide, mesalamine delayed-rel (except clobetasol spray clobetasol foam mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, CLOBEX SPRAY clobetasol foam sulfasalazine delayed-rel, ASACOL HD, clocortolone cream hydrocortisone butyrate cream, PENTASA hydrocortisone butyrate ointment, desoximetasone ointment 0.05% hydrocortisone butyrate cream, hydrocortisone butyrate solution, hydrocortisone butyrate ointment, mometasone, triamcinolone cream, hydrocortisone butyrate solution, triamcinolone lotion, triamcinolone ointment mometasone, triamcinolone cream, (except triamcinolone ointment 0.05%) triamcinolone lotion, triamcinolone ointment COLAZAL balsalazide, mesalamine delayed-rel (except (except triamcinolone ointment 0.05%) mesalamine delayed-rel tablet 800 mg), DETROL LA darifenacin ext-rel, oxybutynin ext-rel, mesalamine ext-rel, sulfasalazine, solifenacin, tolterodine, tolterodine ext-rel, sulfasalazine delayed-rel, ASACOL HD, trospium, trospium ext-rel, MYRBETRIQ, PENTASA TOVIAZ colchicine capsule colchicine tablet, MITIGARE dexchlorpheniramine levocetirizine COLCRYS colchicine tablet, MITIGARE Dexifol folic acid CONSENSI amlodipine WITH celecoxib Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1%, CONTOUR NEXT STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, diclofenac sodium solution, ibuprofen, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, meloxicam, naproxen (except naproxen CR or ACCU-CHEK GUIDE STRIPS AND KITS 2, naproxen suspension) 2 ACCU-CHEK SMARTVIEW STRIPS AND KITS , Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, 2 ONETOUCH ULTRA STRIPS AND KITS , diclofenac sodium solution, ibuprofen, 2 ONETOUCH VERIO STRIPS AND KITS meloxicam, naproxen (except naproxen CR or CONTOUR STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, naproxen suspension) 2 ACCU-CHEK COMPACT PLUS STRIPS AND KITS , DIFFERIN LOTION adapalene, benzoyl peroxide, 2 ACCU-CHEK GUIDE STRIPS AND KITS , clindamycin gel (except NDC^ 68682046275), 2 ACCU-CHEK SMARTVIEW STRIPS AND KITS , clindamycin solution, clindamycin- 2 ONETOUCH ULTRA STRIPS AND KITS , benzoyl peroxide, erythromycin solution, 2 ONETOUCH VERIO STRIPS AND KITS erythromycin-benzoyl peroxide, tretinoin, CONTRAVE QSYMIA, SAXENDA EPIDUO, ONEXTON CORDRAN OINTMENT hydrocortisone butyrate cream, diflorasone cream, diflorasone ointment desoximetasone (except hydrocortisone butyrate ointment, desoximetasone ointment 0.05%), hydrocortisone butyrate solution, fluocinonide (except fluocinonide cream 0.1%), mometasone, triamcinolone cream, BRYHALI triamcinolone lotion, triamcinolone ointment dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, (except triamcinolone ointment 0.05%) zolmitriptan, NURTEC ODT, ONZETRA XSAIL, COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, metoprolol succinate ext-rel, ZOMIG NASAL SPRAY metoprolol tartrate, nadolol, pindolol, diltiazem ext-rel diltiazem ext-rel propranolol, propranolol ext-rel, BYSTOLIC (generics for CARDIZEM LA only) (except generics for CARDIZEM LA) CoreMino doxycycline hyclate 20 mg, doxycycline DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, hyclate capsule, minocycline, tetracycline irbesartan, irbesartan-hydrochlorothiazide, COZAAR candesartan, irbesartan, losartan, losartan, losartan-hydrochlorothiazide, olmesartan, telmisartan, valsartan olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, CRESEMBA itraconazole valsartan, valsartan-hydrochlorothiazide CRESTOR atorvastatin, ezetimibe-simvastatin, Diphen Elixir levocetirizine fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin DORAL doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA CUPRIMINE penicillamine capsule

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline FABIOR adapalene, benzoyl peroxide, hyclate capsule, minocycline, tetracycline clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- doxepin cream desonide, hydrocortisone, pimecrolimus, benzoyl peroxide, erythromycin solution, tacrolimus, EUCRISA erythromycin-benzoyl peroxide, tretinoin, doxycycline hyclate delayed-rel tablet doxycycline hyclate 20 mg, doxycycline EPIDUO, ONEXTON 50 mg, 200 mg hyclate capsule, minocycline, tetracycline FANAPT aripiprazole, clozapine, olanzapine, doxycycline hyclate tablet 50 mg doxycycline hyclate 20 mg, doxycycline quetiapine, quetiapine ext-rel, risperidone, (NDC^ 72143021160 only), hyclate capsule, minocycline, tetracycline ziprasidone, LATUDA, VRAYLAR doxycycline hyclate tablet 75 mg, FEMRING estradiol vaginal cream, IMVEXXY, VAGIFEM doxycycline hyclate tablet 150 mg fenofibrate capsule 50 mg, 130 mg; fenofibrate (except fenofibrate capsule 50 mg, doxycycline monohydrate capsule 75 mg, doxycycline hyclate 20 mg, doxycycline fenofibrate tablet 40 mg, 120 mg 130 mg; fenofibrate tablet 40 mg, 120 mg), doxycycline monohydrate capsule 150 mg hyclate capsule, minocycline, tetracycline fenofibric acid delayed-rel doxycycline monohydrate delayed-rel capsule ORACEA FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate capsule 50 mg, DULERA ADVAIR DISKUS, ADVAIR HFA †, 130 mg; fenofibrate tablet 40 mg, 120 mg), BREO ELLIPTA †, SYMBICORT fenofibric acid delayed-rel DUTOPROL metoprolol succinate ext-rel WITH fenoprofen, FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, hydrochlorothiazide naproxen (except naproxen CR or naproxen suspension) DYRENIUM amiloride, triamterene FERIVA 21/7 folic acid EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, FETZIMA desvenlafaxine ext-rel, duloxetine, losartan, losartan-hydrochlorothiazide, venlafaxine, venlafaxine ext-rel capsule olmesartan, olmesartan-hydrochlorothiazide, Fexmid cyclobenzaprine telmisartan, telmisartan-hydrochlorothiazide, (except cyclobenzaprine tablet 7.5 mg) valsartan, valsartan-hydrochlorothiazide FINACEA GEL azelaic acid gel, metronidazole, EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, FINACEA FOAM, SOOLANTRA zolpidem ext-rel, BELSOMRA FIORICET CAPSULE diclofenac sodium, ibuprofen, E.E.S. GRANULES erythromycins naproxen (except naproxen CR or EFFEXOR XR desvenlafaxine ext-rel, duloxetine, naproxen suspension) venlafaxine, venlafaxine ext-rel capsule FLAREX dexamethasone, loteprednol, ELIDEL pimecrolimus, tacrolimus, EUCRISA prednisolone acetate 1%, DUREZOL ELMIRON Consult doctor flucytosine capsule 500 mg fluconazole ENABLEX darifenacin ext-rel, oxybutynin ext-rel, fluocinonide cream 0.1% clobetasol cream solifenacin, tolterodine, tolterodine ext-rel, fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, trospium, trospium ext-rel, MYRBETRIQ, imiquimod, PICATO, TOLAK, ZYCLARA TOVIAZ fluoxetine tablet (generics for SARAFEM only) fluoxetine (except fluoxetine tablet 60 mg, ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE fluoxetine tablet [generics for SARAFEM]), MONITORING SYSTEM MONITORING SYSTEM paroxetine HCl ext-rel, sertraline ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except EPICERAM desonide, hydrocortisone fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, paroxetine HCl ext-rel, sertraline, TRINTELLIX zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, flurandrenolide cream, flurandrenolide lotion desonide, hydrocortisone ZOMIG NASAL SPRAY flurandrenolide ointment hydrocortisone butyrate cream, ERYPED erythromycins hydrocortisone butyrate ointment, hydrocortisone butyrate solution, estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment ESTRING estradiol vaginal cream, IMVEXXY, VAGIFEM (except triamcinolone ointment 0.05%) EVEKEO amphetamine-dextroamphetamine mixed salts, FML FORTE, FML LIQUIFILM, FML S.O.P. dexamethasone, loteprednol, methylphenidate prednisolone acetate 1%, DUREZOL EVERSENSE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE FOCALIN XR amphetamine- MONITORING SYSTEM MONITORING SYSTEM dextroamphetamine mixed salts ext-rel †, EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, dexmethylphenidate ext-rel, amlodipine-valsartan methylphenidate ext-rel †, MYDAYIS, VYVANSE EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide FOLIC-K folic acid Folvite-D folic acid

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* FORTAMET metformin, metformin ext-rel (except generics HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, for FORTAMET and GLUMETZA) hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, FORTESTA testosterone gel (except authorized generics XTAMPZA ER for TESTIM and VOGELXO), testosterone solution, ANDRODERM, HYZAAR candesartan-hydrochlorothiazide, NATESTO irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, FOSAMAX PLUS D alendronate, ibandronate, risedronate olmesartan-hydrochlorothiazide, FOSRENOL calcium acetate, sevelamer carbonate, telmisartan-hydrochlorothiazide, PHOSLYRA, VELPHORO valsartan-hydrochlorothiazide FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate icosapent ethyl omega-3 acid ethyl esters, VASCEPA FREESTYLE LIBRE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE INCRUSE ELLIPTA SPIRIVA, YUPELRI GLUCOSE MONITORING SYSTEM MONITORING SYSTEM INDERAL LA, INDERAL XL atenolol, carvedilol, carvedilol phosphate ext-rel, FREESTYLE STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, metoprolol succinate ext-rel, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, metoprolol tartrate, nadolol, pindolol, ACCU-CHEK GUIDE STRIPS AND KITS 2, propranolol, propranolol ext-rel, BYSTOLIC 2 ACCU-CHEK SMARTVIEW STRIPS AND KITS , INDOCIN diclofenac sodium, ibuprofen, meloxicam, 2 ONETOUCH ULTRA STRIPS AND KITS , naproxen (except naproxen CR or 2 ONETOUCH VERIO STRIPS AND KITS naproxen suspension) FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, naproxen (except naproxen CR or REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, naproxen suspension) ZOMIG NASAL SPRAY Inflammacin diclofenac sodium, diclofenac sodium gel 1%, Genicin Vita-S folic acid diclofenac sodium solution, ibuprofen, GLUMETZA metformin, metformin ext-rel (except generics meloxicam, naproxen (except naproxen CR or for FORTAMET and GLUMETZA) naproxen suspension) GLYCOPYRROLATE TABLET 1.5 MG dicyclomine INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, GOLYTELY peg 3350-electrolytes, CLENPIQ metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC GUARDIAN CONNECT CONTINUOUS DEXCOM CONTINUOUS GLUCOSE GLUCOSE MONITORING SYSTEM MONITORING SYSTEM INTRAROSA estradiol vaginal cream, IMVEXXY, VAGIFEM GUARDIAN REAL-TIME CONTINUOUS DEXCOM CONTINUOUS GLUCOSE INTUNIV amphetamine- GLUCOSE MONITORING SYSTEM MONITORING SYSTEM dextroamphetamine mixed salts ext-rel †, atomoxetine, dexmethylphenidate ext-rel, halcinonide cream desoximetasone (except guanfacine ext-rel, methylphenidate ext-rel †, desoximetasone ointment 0.05%), MYDAYIS, VYVANSE fluocinonide (except fluocinonide cream 0.1%), BRYHALI INVELTYS dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL HORIZANT gabapentin, GRALISE INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR HUMALOG FIASP, NOVOLOG INVOKANA FARXIGA, JARDIANCE HUMALOG MIX 50/50 NOVOLOG MIX 70/30 isosorbide dinitrate 40 mg isosorbide dinitrate HUMALOG MIX 75/25 NOVOLOG MIX 70/30 (except isosorbide dinitrate 40 mg), HUMULIN 70/30 NOVOLIN 70/30 isosorbide mononitrate HUMULIN N NOVOLIN N ISTALOL timolol maleate solution, BETOPTIC S HUMULIN R NOVOLIN R JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate cream, silodosin, tamsulosin or terazosin hydrocortisone butyrate ointment, hydrocortisone butyrate solution, JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR mometasone, triamcinolone cream, KAMDOY desonide, hydrocortisone triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) KAZANO JANUMET, JANUMET XR hydrocortisone butyrate lotion hydrocortisone butyrate cream, ketoconazole foam 2% ketoconazole shampoo 2%, hydrocortisone butyrate ointment, selenium sulfide lotion 2.5% hydrocortisone butyrate solution, mometasone, triamcinolone cream, Ketodan ketoconazole shampoo 2%, triamcinolone lotion, triamcinolone ointment selenium sulfide lotion 2.5% (except triamcinolone ointment 0.05%) ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, HylaVite folic acid naproxen (except naproxen CR or naproxen suspension) hyoscyamine sulfate ext-rel dicyclomine

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, MAXALT, MAXALT-MLT eletriptan, naratriptan, rizatriptan, sumatriptan, naproxen (except naproxen CR or zolmitriptan, NURTEC ODT, ONZETRA XSAIL, naproxen suspension) REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY KOMBIGLYZE XR JANUMET, JANUMET XR MAXIDEX dexamethasone, loteprednol, LACRISERT RESTASIS, XIIDRA prednisolone acetate 1%, DUREZOL Lactojen Consult doctor mefenamic acid (NDC^ 69336012830 only) diclofenac sodium, ibuprofen, meloxicam, LACTULOSE PAK lactulose solution naproxen (except naproxen CR or naproxen suspension) LANOXIN TABLET digoxin (125 MCG and 250 MCG only) MENEST estradiol lanthanum carbonate calcium acetate, sevelamer carbonate, MENOSTAR estradiol PHOSLYRA, VELPHORO mesalamine delayed-rel tablet 800 mg balsalazide, mesalamine delayed-rel (except LANTUS 6 BASAGLAR, LEVEMIR mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, LASTACAFT azelastine, cromolyn sodium, olopatadine sulfasalazine delayed-rel, ASACOL HD, PENTASA LAZANDA fentanyl transmucosal lozenge, SUBSYS metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine LESCOL XL atorvastatin, ezetimibe-simvastatin, tablet 7.5 mg) fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin metformin ext-rel metformin, metformin ext-rel (except generics (generics for FORTAMET and GLUMETZA only) for FORTAMET and GLUMETZA) levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, methocarbamol 500 mg cyclobenzaprine morphine ext-rel, NUCYNTA ER, (NDC^ 69036091010 only), (except cyclobenzaprine tablet 7.5 mg) XTAMPZA ER methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only) LEXAPRO citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, [generics for SARAFEM]), paroxetine HCl, risedronate, FORTEO, PROLIA, TYMLOS paroxetine HCl ext-rel, sertraline, TRINTELLIX MIACALCIN NASAL SPRAY calcitonin-salmon LIALDA balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, mesalamine ext-rel, sulfasalazine, irbesartan, irbesartan-hydrochlorothiazide, sulfasalazine delayed-rel, ASACOL HD, losartan, losartan-hydrochlorothiazide, PENTASA olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, LIBRAX dicyclomine valsartan, valsartan-hydrochlorothiazide LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, (NDC^ 71800063115 only) zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, LIDOTREX lidocaine-prilocaine ZOMIG NASAL SPRAY LIPITOR atorvastatin, ezetimibe-simvastatin, MILLIPRED dexamethasone, hydrocortisone, fluvastatin, lovastatin, pravastatin, methylprednisolone, prednisolone solution, rosuvastatin, simvastatin prednisone LITHOSTAT Consult doctor MINASTRIN 24 FE ethinyl estradiol-drospirenone, LIVALO atorvastatin, ezetimibe-simvastatin, ethinyl estradiol-drospirenone-levomefolate, fluvastatin, lovastatin, pravastatin, ethinyl estradiol-norethindrone acetate, rosuvastatin, simvastatin ethinyl estradiol-norethindrone acetate-iron Lorid folic acid MINIVELLE estradiol, DIVIGEL, EVAMIST Lorzone cyclobenzaprine MINOCIN doxycycline hyclate 20 mg, doxycycline (except cyclobenzaprine tablet 7.5 mg) hyclate capsule, minocycline, tetracycline LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, minocycline ext-rel doxycycline hyclate 20 mg, doxycycline prednisolone acetate 1%, DUREZOL hyclate capsule, minocycline, tetracycline luliconazole ciclopirox, clotrimazole, econazole, MIRVASO azelaic acid gel, metronidazole, ketoconazole cream 2%, NAFTIN FINACEA FOAM, SOOLANTRA LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, doxycycline zolpidem ext-rel, BELSOMRA hyclate capsule, minocycline, tetracycline LYRICA duloxetine, pregabalin MOVIPREP peg 3350-electrolytes, CLENPIQ MACRODANTIN nitrofurantoin (except NDC^ 70408023932) MultiPro Consult doctor Matzim LA diltiazem ext-rel mupirocin cream gentamicin, mupirocin ointment (except generics for CARDIZEM LA) MYTESI diphenoxylate-atropine, loperamide

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* NAPRELAN diclofenac sodium, ibuprofen, meloxicam, NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1%, naproxen (except naproxen CR or diclofenac sodium solution, ibuprofen, naproxen suspension) meloxicam, naproxen (except naproxen CR or naproxen suspension) naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen NUVARING ethinyl estradiol-etonogestrel, ANNOVERA suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole NUVIGIL armodafinil, modafinil, SUNOSI delayed-rel, pantoprazole delayed-rel tablet or OLEPTRO trazodone DEXILANT OLUX-E clobetasol foam naproxen CR diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or omeprazole-sodium bicarbonate esomeprazole delayed-rel, lansoprazole naproxen suspension) delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or OMNARIS flunisolide, fluticasone, mometasone, naproxen suspension) DYMISTA NATAZIA ethinyl estradiol-drospirenone, OMNIVEX folic acid ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ONFI clobazam, lamotrigine, rufinamide, ethinyl estradiol-norethindrone acetate, topiramate, TROKENDI XR ethinyl estradiol-norethindrone acetate-iron, ONGLYZA JANUVIA ethinyl estradiol-norgestimate, LO LOESTRIN FE orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) NATURE-THROID levothyroxine, liothyronine, SYNTHROID Orphengesic Forte cyclobenzaprine NEO-SYNALAR desonide or hydrocortisone WITH gentamicin (except cyclobenzaprine tablet 7.5 mg) NESINA JANUVIA ORTHO D folic acid NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO, ORTHO DF folic acid PROLENSA Oscimin SR dicyclomine NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, OSENI JANUMET, JANUMET XR; JANUVIA WITH pantoprazole delayed-rel tablet, DEXILANT pioglitazone niacin tablet 500 mg niacin ext-rel OSMOPREP peg 3350-electrolytes, CLENPIQ Niacor niacin ext-rel OSPHENA estradiol NICADAN folic acid OWEN MUMFORD NEEDLES 3 BD ULTRAFINE NEEDLES NICAPRIN folic acid oxiconazole ciclopirox, clotrimazole, econazole, (NDCs^ 00168035830, 51672135902 only) ketoconazole cream 2%, NAFTIN NICAZEL, NICAZEL FORTE folic acid OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, NICOMIDE folic acid hydromorphone ext-rel, methadone, NILANDRON abiraterone, bicalutamide, XTANDI, YONSA morphine ext-rel, NUCYNTA ER, XTAMPZA ER nitrofurantoin (NDC^ 70408023932 only) nitrofurantoin (except NDC^ 70408023932) oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, NITROMIST nitroglycerin lingual spray, hydromorphone ext-rel, methadone, nitroglycerin sublingual morphine ext-rel, NUCYNTA ER, XTAMPZA ER Nolix desonide, hydrocortisone OXYTROL darifenacin ext-rel, oxybutynin ext-rel, NORGESIC FORTE cyclobenzaprine solifenacin, tolterodine, tolterodine ext-rel, (except cyclobenzaprine tablet 7.5 mg) trospium, trospium ext-rel, MYRBETRIQ, NORITATE azelaic acid gel, metronidazole, TOVIAZ FINACEA FOAM, SOOLANTRA PANCREAZE CREON, VIOKACE, ZENPEP NORPACE disopyramide pantoprazole delayed-rel suspension esomeprazole delayed-rel, lansoprazole NORVASC amlodipine delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT NOURIANZ amantadine, entacapone, pramipexole, pramipexole ext-rel, rasagiline, ropinirole, paroxetine mesylate capsule 7.5 mg paroxetine HCl ropinirole ext-rel, selegiline, NEUPRO PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except NOVACORT desonide, hydrocortisone fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, NOVO NORDISK NEEDLES 3 BD ULTRAFINE NEEDLES paroxetine HCl ext-rel, sertraline, TRINTELLIX NOXAFIL fluconazole, itraconazole PENNSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* PERCOCET hydrocodone-acetaminophen, QNASL flunisolide, fluticasone, mometasone, hydromorphone, morphine, DYMISTA oxycodone-acetaminophen, NUCYNTA QTERN GLYXAMBI PERRIGO NEEDLES 3 BD ULTRAFINE NEEDLES quazepam doxepin, eszopiclone, ramelteon, zolpidem, PERTZYE CREON, VIOKACE, ZENPEP zolpidem ext-rel, BELSOMRA PEXEVA citalopram, escitalopram, fluoxetine (except RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, fluoxetine tablet 60 mg, fluoxetine tablet tamsulosin, terazosin [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX RAYOS dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, PLAVIX clopidogrel, prasugrel, BRILINTA prednisone POLYTOZA Consult doctor RECEDO Consult doctor posaconazole delayed-rel tablet fluconazole, itraconazole RELION INSULIN NOVOLIN INSULIN PRADAXA warfarin, ELIQUIS, XARELTO RHEUMATE folic acid PRECISION XTRA STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, RIBOZEL folic acid ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE STRIPS AND KITS 2, RIMSO-50 Consult doctor 2 ACCU-CHEK SMARTVIEW STRIPS AND KITS , RIOMET metformin, metformin ext-rel (except generics ONETOUCH ULTRA STRIPS AND KITS 2, for FORTAMET and GLUMETZA) ONETOUCH VERIO STRIPS AND KITS 2 ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, PRED FORTE, PRED MILD dexamethasone, loteprednol, zolpidem ext-rel, BELSOMRA prednisolone acetate 1%, DUREZOL RyClora levocetirizine PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO RYTARY carbidopa-levodopa, carbidopa-levodopa ext-rel PREMARIN estradiol SCARSILK PAD Consult doctor PREMARIN CREAM estradiol vaginal cream, IMVEXXY, VAGIFEM SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, PRENATAL PLUS 5 prenatal vitamins, CITRANATAL ethinyl estradiol-levonorgestrel, PREVACID esomeprazole delayed-rel, lansoprazole ethinyl estradiol-norethindrone acetate, delayed-rel, omeprazole delayed-rel, ethinyl estradiol-norethindrone acetate-iron pantoprazole delayed-rel tablet, DEXILANT SEROQUEL XR aripiprazole, clozapine, olanzapine, PREVIDENT Consult doctor quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR PRILOSEC esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, SILENOR doxepin, eszopiclone, ramelteon, zolpidem, pantoprazole delayed-rel tablet, DEXILANT zolpidem ext-rel, BELSOMRA PRISTIQ desvenlafaxine ext-rel, duloxetine, SIL-K PAD Consult doctor venlafaxine, venlafaxine ext-rel capsule SILIVEX Consult doctor PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol, SILTREX Consult doctor levalbuterol tartrate CFC-free aerosol SINGULAIR montelukast, zafirlukast PRODIGEN Consult doctor SORILUX calcipotriene ointment, calcipotriene solution PROMETRIUM medroxyprogesterone; progesterone, micronized SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or PROTONIX esomeprazole delayed-rel, lansoprazole naproxen suspension) delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT STENDRA sildenafil, tadalafil PROTOPIC pimecrolimus, tacrolimus, EUCRISA SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV PROVAD Consult doctor sucralfate suspension sucralfate tablet PROVENTIL HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) PROVIGIL armodafinil, modafinil, SUNOSI WITH eletriptan, naratriptan, rizatriptan, PROZAC citalopram, escitalopram, fluoxetine (except sumatriptan, zolmitriptan, NURTEC ODT, fluoxetine tablet 60 mg, fluoxetine tablet ONZETRA XSAIL, REYVOW, UBRELVY, [generics for SARAFEM]), paroxetine HCl, ZEMBRACE SYMTOUCH or paroxetine HCl ext-rel, sertraline, TRINTELLIX ZOMIG NASAL SPRAY PSORCON desoximetasone (except SUPREP peg 3350-electrolytes, CLENPIQ desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%), BRYHALI

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* SURE-TEST STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, TREXIMET diclofenac sodium, ibuprofen or naproxen ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, (except naproxen CR or naproxen suspension) ACCU-CHEK GUIDE STRIPS AND KITS 2, WITH eletriptan, naratriptan, rizatriptan, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, sumatriptan, zolmitriptan, NURTEC ODT, ONETOUCH ULTRA STRIPS AND KITS 2, ONZETRA XSAIL, REYVOW, UBRELVY, ONETOUCH VERIO STRIPS AND KITS 2 ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY Symax-SR dicyclomine triamcinolone aerosol 0.2% hydrocortisone butyrate cream, SYNERDERM desonide, hydrocortisone hydrocortisone butyrate ointment, SYPRINE trientine hydrocortisone butyrate solution, mometasone, triamcinolone cream, TALIVA folic acid triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) TARGADOX doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline triamcinolone ointment 0.05% hydrocortisone butyrate cream, hydrocortisone butyrate ointment, TAYTULLA ethinyl estradiol-drospirenone, hydrocortisone butyrate solution, ethinyl estradiol-drospirenone-levomefolate, mometasone, triamcinolone cream, ethinyl estradiol-norethindrone acetate, triamcinolone lotion, triamcinolone ointment ethinyl estradiol-norethindrone acetate-iron (except triamcinolone ointment 0.05%) TAZORAC adapalene, benzoyl peroxide, Trianex hydrocortisone butyrate cream, clindamycin gel (except NDC^ 68682046275), hydrocortisone butyrate ointment, clindamycin solution, clindamycin- hydrocortisone butyrate solution, benzoyl peroxide, erythromycin solution, mometasone, triamcinolone cream, erythromycin-benzoyl peroxide, tretinoin, triamcinolone lotion, triamcinolone ointment EPIDUO, ONEXTON; calcipotriene ointment, (except triamcinolone ointment 0.05%) calcipotriene solution TRICOR fenofibrate (except fenofibrate capsule 50 mg, TESTIM testosterone gel (except authorized generics 130 mg; fenofibrate tablet 40 mg, 120 mg), for TESTIM and VOGELXO), fenofibric acid delayed-rel testosterone solution, ANDRODERM, NATESTO TRILIPIX fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), testosterone gel 1% testosterone gel (except authorized generics fenofibric acid delayed-rel (authorized generics for TESTIM and for TESTIM and VOGELXO), VOGELXO only) testosterone solution, ANDRODERM, TRINAZ 5 prenatal vitamins, CITRANATAL NATESTO TRIVIDIA INSULIN SYRINGES 3 BD ULTRAFINE INSULIN SYRINGES THEO-24 ipratropium inhalation solution, PERFOROMIST, SEREVENT, SPIRIVA, TronVite folic acid STRIVERDI RESPIMAT, YUPELRI TRUETEST STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, THIOLA, THIOLA EC Consult doctor ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE STRIPS AND KITS 2, TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, TIROSINT levothyroxine, SYNTHROID ONETOUCH VERIO STRIPS AND KITS 2 TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone, TRUETRACK STRIPS AND KITS 4 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, neomycin-polymyxin B-dexamethasone, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 2, tobramycin-dexamethasone, ACCU-CHEK GUIDE STRIPS AND KITS 2, TOBRADEX OINTMENT ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, topiramate ext-rel capsule carbamazepine, carbamazepine ext-rel, ONETOUCH ULTRA STRIPS AND KITS 2, (generics for QUDEXY XR only) clobazam, divalproex sodium, ONETOUCH VERIO STRIPS AND KITS 2 divalproex sodium ext-rel, gabapentin, TUDORZA SPIRIVA, YUPELRI lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, ULORIC allopurinol phenobarbital, phenytoin, 3 phenytoin sodium extended, primidone, ULTIMED INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES rufinamide, tiagabine, topiramate, ULTIMED NEEDLES 3 BD ULTRAFINE NEEDLES valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, XCOPRI tamsulosin, terazosin TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, VALCYTE valganciclovir metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, VALTREX acyclovir capsule, acyclovir tablet, propranolol, propranolol ext-rel, BYSTOLIC valacyclovir TRADJENTA JANUVIA Vanoxide-HC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), tramadol (NDC^ 52817019610 only), tramadol (except NDC^ 52817019610), clindamycin solution, clindamycin- tramadol ext-rel capsule tramadol ext-rel tablet benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, TRANSDERM SCOP meclizine, scopolamine transdermal EPIDUO, ONEXTON TRAVATAN Z latanoprost, travoprost, LUMIGAN, ZIOPTAN VASCULERA Consult doctor

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* VECTICAL calcipotriene ointment, calcipotriene solution ZERVIATE azelastine, cromolyn sodium, olopatadine VELTIN adapalene, benzoyl peroxide, ZESTORETIC fosinopril-hydrochlorothiazide, clindamycin gel (except NDC^ 68682046275), lisinopril-hydrochlorothiazide, clindamycin solution, clindamycin- quinapril-hydrochlorothiazide benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ZETIA ezetimibe EPIDUO, ONEXTON ZETONNA flunisolide, fluticasone, mometasone, venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, DYMISTA venlafaxine, venlafaxine ext-rel capsule ZIANA adapalene, benzoyl peroxide, VENTOLIN HFA albuterol sulfate CFC-free aerosol, clindamycin gel (except NDC^ 68682046275), levalbuterol tartrate CFC-free aerosol clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, VEREGEN imiquimod erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON VIAGRA sildenafil, tadalafil zileuton ext-rel montelukast, zafirlukast VIIBRYD citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet ZIRGAN trifluridine [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, VITAFOL-ONE 5 prenatal vitamins, CITRANATAL morphine ext-rel, NUCYNTA ER, XTAMPZA ER Vitasure folic acid ZOLOFT citalopram, escitalopram, fluoxetine (except VIVELLE-DOT estradiol, DIVIGEL, EVAMIST fluoxetine tablet 60 mg, fluoxetine tablet VOGELXO testosterone gel (except authorized generics [generics for SARAFEM]), paroxetine HCl, for TESTIM and VOGELXO), paroxetine HCl ext-rel, sertraline, TRINTELLIX testosterone solution, ANDRODERM, zolpidem sublingual doxepin, eszopiclone, ramelteon, zolpidem, NATESTO zolpidem ext-rel, BELSOMRA WESTHROID levothyroxine, liothyronine, SYNTHROID ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, WP THYROID levothyroxine, liothyronine, SYNTHROID zolpidem ext-rel, BELSOMRA XANAX, XANAX XR alprazolam, clonazepam, diazepam, ZONEGRAN carbamazepine, carbamazepine ext-rel, lorazepam, oxazepam divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, XENICAL QSYMIA, SAXENDA levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, XOLEGEL ciclopirox, ketoconazole cream 2% phenytoin sodium extended, primidone, XOPENEX HFA albuterol sulfate CFC-free aerosol, tiagabine, topiramate, valproic acid, levalbuterol tartrate CFC-free aerosol zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI Xvite folic acid ZONTIVITY Consult doctor XYZBAC folic acid ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, YASMIN ethinyl estradiol-drospirenone, naproxen (except naproxen CR or ethinyl estradiol-drospirenone-levomefolate, naproxen suspension) ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron ZUPLENZ granisetron, ondansetron, SANCUSO YAZ ethinyl estradiol-drospirenone, ZYFLO montelukast, zafirlukast ethinyl estradiol-drospirenone-levomefolate, ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, ethinyl estradiol-norethindrone acetate, neomycin-polymyxin B-dexamethasone, ethinyl estradiol-norethindrone acetate-iron tobramycin-dexamethasone, Yuvafem estradiol vaginal cream, IMVEXXY, VAGIFEM TOBRADEX OINTMENT ZALVIT 5 prenatal vitamins, CITRANATAL ZYVIT folic acid ZEGERID esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ZELAC Consult doctor

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

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

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

§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. † Listing does not include certain NDCs^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 3 BD ULTRAFINE syringes and needles are the only preferred options. 4 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 5 Generic prenatal vitamins and CITRANATAL are the only preferred options. 6 Long Acting Insulins - First Generation.

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

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