2021 Home Delivery and Retail 90-Day Supply List

This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Not all of the drugs listed are covered by all prescription plans; check your benefit materials and formulary for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

For the member: FDA-approved generic medications meet strict standards and contain 2021 Home Delivery and Retail the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. 90-Day Supply List For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.

KEY anastrozole bicalutamide cartia xt D Brand-name drugs are listed ANGELIQ BIDIL carvedilol in CAPITAL letters. ANORO ELLIPTA BIJUVA carvedilol er DALIRESP Generic drugs are listed ANTARA bimatoprost CASODEX darifenacin er in lower case letters. APLENZIN BINOSTO CATAPRES dasetta apri bisoprolol fumarate CATAPRES-TTS daysee A APRISO bisoprolol-hydrochlorothiazide CAVERJECT DDAVP aranelle blisovi 24 fe caziant deblitane acarbose ARAVA blisovi fe CEQUA delyla ACCOLATE ARCAPTA NEOHALER BONIVA TABLETS cevimeline hcl denta 5000 plus ACCUPRIL ARICEPT BREO ELLIPTA chateal dentagel ACCURETIC ARMONAIR RESPICLICK BREVICON chateal eq DEPEN acebutolol hcl ARMOUR THYROID briellyn chlorothiazide DEPO-PROVERA 150 MG acetazolamide ARNUITY ELLIPTA BRILINTA chlorthalidone DEPO-SUBQ PROVERA 104 acetazolamide er AROMASIN brimonidine tartrate eye drops cholestyramine desmopressin acetate tablets ACTIGALL ashlyna bromocriptine mesylate cholestyramine light and nasal spray ACTIVE OB ASMANEX BROVANA cilostazol desogesterel-e.estradiol/ ACTIVELLA ASMANEX HFA budesonide cimetidine e.estradiol ACTONEL aspirin-dipyridamole er bumetanide cinacalcet hcl desogestrel-ethinyl estradiol ACTOPLUS MET ATELVIA BUPHENYL citalopram hbr DESVENLAFAXINE ER ACTOPLUS MET XR atenolol bupropion hcl CITRANATAL 90 DHA DESVENLAFAXINE FUMARATE ER ACTOS atenolol-chlorthalidone bupropion hcl er CITRANATAL ASSURE desvenlafaxine succinate er ADALAT CC atomoxetine hcl bupropion hcl sr CITRANATAL B-CALM DEXILANT ADVAIR DISKUS atorvastatin calcium bupropion xl CITRANATAL DHA diazoxide ADVAIR HFA ATROVENT HFA buspirone hcl CITRANATAL HARMONY digitek afirmelle aubra BYDUREON CITRANATAL RX digox AFREZZA aubra eq BYDUREON BCISE CLIMARA digoxin AGRYLIN aurovela BYETTA CLINPRO 5000 DILATRATE-SR AIMOVIG AUTOINJECTOR aurovela 24 fe BYSTOLIC clonidine hcl diltiazem 12 hr er AJOVY aurovela fe BYVALSON clonidine hcl er diltiazem 24 hr cd albuterol sulfate AVANDAMET clonidine patch diltiazem 24 hr er tablets and syrup AVANDIA C clopidogrel diltiazem 24 hr la ALDACTAZIDE aviane c-nate dha diltiazem 24 hr xr ALDACTONE AYGESTIN cabergoline colesevelam hcl diltiazem hcl alendronate sodium ayuna CADUET COLESTID dilt-xr alfuzosin hcl er AZILECT CALAN colestipol hcl dipyridamole aliskiren AZOPT CALAN SR COMBIPATCH disopyramide phosphate allopurinol AZULFIDINE calcitonin-salmon COMBIVENT RESPIMAT DITROPAN XL ALORA azurette camila complete natal dha DIURIL ALTACE camrese COMTAN DIVIGEL altavera B camrese lo CONCEPT DHA donepezil hcl ALVESCO candesartan cilexetil CONCEPT OB donepezil hcl odt alyacen bal-care dha candesartan-hydrochlorothiazide CONTRAVE ER dorzolamide hcl amabelz BAL-CARE DHA ESSENTIAL captopril COREG CR dorzolamide-timolol AMARYL BALCOLTRA captopril-hydrochlorothiazide CORGARD dothelle dha amethia balziva CARAFATE CORLANOR dotti amethia lo BASAGLAR KWIKPEN carbidopa cromolyn nebulizer solution doxazosin mesylate amethyst bekyree carbidopa-levodopa cromolyn sodium doxercalciferol amiloride hcl benazepril hcl carbidopa-levodopa er oral concentrate D-PENAMINE amiloride-hydrochlorothiazide benazepril-hydrochlorothiazide carbidopa-levodopa-entacapone cryselle DRISDOL amiodarone hcl BETAPACE CARDIZEM cyanocobalamin injection drospirenone-e.estradiol- amlodipine besylate BETAPACE AF CARDIZEM CD cyclafem levomefol amlodipine besylate-benazepril betaxolol hcl CARDIZEM LA CYCLESSA drospirenone-ethinyl estradiol amlodipine-atorvastatin bethanechol chloride CARDURA CYCLOSET DUAVEE amlodipine-olmesartan BETIMOL CARDURA XL cyred DUET DHA 400 amlodipine-valsartan BETOPTIC S CARNITOR cyred eq DUET DHA BALANCED amlodipine-valsartan-hctz BEVESPI AEROSPHERE CARNITOR SF CYTOTEC DUETACT anagrelide hcl BEYAZ carteolol hcl DULERA (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2020 Express Scripts. All Rights Reserved. Page 1 DL466313-STD CRP2009_004721.1 (09/01/20) All trademarks are the property of their respective owners. duloxetine hcl fenofibrate H K losartan potassium dutasteride fenofibric acid losartan-hydrochlorothiazide dutasteride-tamsulosin FENOGLIDE hailey k effervescent LOTENSIN DYAZIDE FETZIMA hailey 24 fe kaitlib fe LOTENSIN HCT DYRENIUM FIBRICOR hailey fe kalliga lovastatin finasteride heather KAPVAY LOVAZA E flavoxate hcl HECTOROL kariva low-ogestrel flecainide acetate hemenatal ob kelnor lo-zumandimine EDARBI FLOLIPID hemenatal ob + dha KHEDEZLA LUMIGAN EDARBYCLOR FLOMAX HUMALOG kimidess lutera EDECRIN FLOVENT DISKUS HUMALOG JUNIOR KWIKPEN klor-con LYUMJEV EDEX FLOVENT HFA HUMALOG KWIKPEN klor-con ef LYUMJEV KWIKPEN effer-k fludrocortisone acetate HUMALOG MIX klor-con m lyza EFFIENT flunisolide HUMALOG MIX KWIKPEN klor-con sprinkle elinest FLUORIDEX HUMULIN 70-30 KWIKPEN KOSHER PRENATAL PLUS IRON M ELIQUIS fluoridex daily defense HUMULIN N k-sol elite-ob FLUORIDEX SENSITIVITY RELIEF HUMULIN N KWIKPEN K-TAB ER macnatal cn dha ELIXOPHYLLIN fluoxetine hcl HUMULIN R kurvelo marlissa eluryng fluoxetine hcl dr HUMULIN R KWIKPEN MARNATAL-F EMGALITY flutamide hydralazine hcl L matzim la emoquette fluticasone propionate hydrochlorothiazide MAXINATE ENABLEX fluvastatin sodium labetalol hcl MAXZIDE enalapril maleate fluvastatin sodium er I LANOXIN medroxyprogesterone acetate enalapril-hydrochlorothiazide fluvoxamine maleate lansoprazole melodetta 24 fe ENBRACE HR fluvoxamine maleate er ibandronate sodium LANTUS memantine hcl enpresse focalgin 90 dha IMVEXXY LANTUS SOLOSTAR memantine hcl er enskyce focalgin ca incassia larin MENEST entacapone FOLET ONE INCRUSE ELLIPTA larin 24 fe MENOSTAR ENTRESTO folic acid 1 mg indapamide larin fe mesalamine eplerenone folivane-ob INSPRA larissia mesalamine dr eprosartan mesylate FORFIVO XL introvale LASIX mesalamine er ergoloid mesylates FORTAMET INVOKAMET latanoprost metaproterenol sulfate errin FOSAMAX INVOKAMET XR layolis fe metformin hcl escitalopram oxalate FOSAMAX PLUS D INVOKANA leena metformin hcl er esomeprazole magnesium fosinopril sodium ipratropium bromide leflunomide methazolamide estarylla fosinopril-hydrochlorothiazide ipratropium-albuterol LESCOL methimazole estradiol fulvestrant irbesartan LESCOL XL methyldopa estradiol transdermal patch furosemide irbesartan-hydrochlorothiazide lessina methyldopa-hydrochlorothiazide estradiol-norethindrone tablets fyavolv isibloom letrozole metipranolol ESTRING ISOCHRON LEVEMIR metolazone ESTROGEL G ISOPTO CARPINE LEVEMIR FLEXTOUCH metoprolol succinate estropipate ISORDIL LEVITRA METOPROLOL SUCCINATE ethacrynic acid galantamine hbr ISORDIL TITRADOSE levobunolol hcl ER-HCTZ ethynodiol-ethinyl estradiol galantamine hbr er isosorbide dinitrate levocarnitine metoprolol tartrate etidronate disodium GASTROCROM isosorbide dinitrate er levocarnitine sf metoprolol-hydrochlorothiazide etonogestrel-ethinyl estradiol GELNIQUE isosorbide mononitrate levomefolate dha mexiletine hcl euthyrox gemfibrozil isosorbide mononitrate er levonest MIACALCIN EVAMIST gianvi isoxsuprine hcl levonorgestrel-e.estradiol mibelas 24 fe EVISTA gildagia isradipine levonorgestrel-ethinyl estradiol microgestin EVOXAC glimepiride levora-28 MICROGESTIN 24 FE EXELON glipizide J levo-t microgestin fe exemestane glipizide er levothyroxine sodium miglitol ezetimibe glipizide xl jaimiess levoxyl mili ezetimibe-simvastatin glipizide-metformin JALYN lillow mimvey GLUCOTROL JANUMET LINZESS mimvey lo F GLUCOTROL XL JANUMET XR liothyronine sodium MINIPRESS GLUCOVANCE JANUVIA LIPOFEN MINITRAN falmina glyburide JARDIANCE lisinopril minoxidil famotidine tablets glyburide micronized jasmiel lisinopril-hydrochlorothiazide MIRAPEX FARESTON glyburide-metformin hcl jencycla LIVALO MIRAPEX ER FARXIGA GLYCATE jevantique lo LO LOESTRIN FE MIRCETTE FASLODEX glycopyrrolate jinteli LODOSYN mirtazapine fayosim GLYNASE jolessa lojaimiess misoprostol febuxostat GLYSET jolivette lomedia 24 fe m-natal plus felodipine er GLYXAMBI juleber LONHALA MAGNAIR REFILL moexipril hcl FEMARA GRASTEK junel LOPID moexipril-hydrochlorothiazide FEMCON FE guanfacine hcl junel fe lopreeza mometasone furoate FEMHRT guanfacine hcl er junel fe 24 LOPRESSOR mono-linyah FEMRING LOPRESSOR HCT mononessa femynor loryna montelukast sodium (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2020 Express Scripts. All Rights Reserved. Page 2 DL466313-STD CRP2009_004721.1 (09/01/20) All trademarks are the property of their respective owners. MOTEGRITY O pnv-omega propafenone hcl RYTHMOL SR MULTAQ pnv-select propafenone hcl er MUSE OB COMPLETE pnv-vp-u PROPECIA S mynatal OB COMPLETE GOLD portia propranolol hcl mynatal advance OB COMPLETE ONE POTABA propranolol hcl er SALAGEN mynatal plus OB COMPLETE PETITE potassium bicarbonate propranolol-hydrochlorothiazide SARAFEM mynatal-z OB COMPLETE PREMIER potassium chloride propylthiouracil SAVELLA mynate 90 plus OB COMPLETE WITH DHA potassium citrate er PROSCAR SEGLUROMET MYRBETRIQ obstetrix dha pr natal PROVERA SELECT-OB myzilra OBSTETRIX EC pramipexole dihydrochloride PROVIDA DHA SELECT-OB + DHA OBSTETRIX ONE pramipexole dihydrochloride er PROVIDA OB selegiline hcl N OBTREX DHA PRANDIN PULMICORT FLEXHALER se-natal 19 O-CAL PRENATAL prasugrel hcl PUREFE OB PLUS SEREVENT DISKUS nadolol ocella pravastatin sodium pyridostigmine bromide sertraline hcl nadolol-bendroflumethiazide ODACTRA prazosin hcl pyridostigmine bromide er setlakin NAMENDA XR ogestrel PRECOSE sharobel NAMZARIC olmesartan medoxomil PREFERA OB Q sildenafil citrate NASCOBAL olmesartan-amlodipine-hctz PREFERA-OB ONE silodosin NATACHEW olmesartan-hydrochlorothiazide PREFERA-OB PLUS DHA QNASL SIMBRINZA NATAZIA omega-3 acid ethyl esters PREFEST QNASL CHILDREN simliya nateglinide omeppi PREMARIN quasense simpesse NATELLE ONE omeprazole PREMPHASE QUESTRAN simvastatin nature-throid omeprazole-sodium bicarbonate PREMPRO QUESTRAN LIGHT SINEMET necon ORIAHNN prena1 chew quinapril hcl SINEMET CR NEEVODHA ORILISSA 150 MG prena1 pearl quinapril-hydrochlorothiazide SLYND nefazodone hcl orsythia prena1 true quinidine gluconate sodium fluoride (sf) 5000 plus NESTABS ORTHO MICRONOR prenaissance quinidine sulfate sodium fluoride (sf) gel NESTABS ABC ORTHO-CYCLEN prenaissance plus QVAR REDIHALER sodium fluoride sensitive NESTABS DHA ORTHO-NOVUM PRENATA sodium phenylbutyrate NESTABS ONE OSENI prenatabs fa R solifenacin succinate NEUPRO OSPHENA prenatabs rx SOLIQUA newgen OVCON-35 PRENATAL 19 rabeprazole sodium tablets SOLTAMOX NEXA PLUS oxybutynin chloride prenatal low iron RAGWITEK sorine NEXLETOL oxybutynin chloride er prenatal plus rajani sotalol NEXLIZET OXYTROL PRENATAL PLUS-DHA raloxifene hcl sotalol af niacin OZEMPIC prenatal vitamin plus low iron ramipril SOTYLIZE niacin er prenatal-u ranolazine er SPIRIVA NIACOR P PRENATE AM rasagiline mesylate SPIRIVA RESPIMAT NIASPAN PRENATE CHEWABLE RASUVO spironolactone nicardipine hcl pacerone PRENATE DHA RAYALDEE spironolactone-hctz nifedipine pantoprazole sodium PRENATE ELITE RAZADYNE sprintec nifedipine er PARICALCITOL PRENATE ENHANCE RAZADYNE ER sronyx nikki PARLODEL PRENATE ESSENTIAL reclipsen STALEVO NILANDRON paroxetine hcl PRENATE MINI REMERON STARLIX nilutamide paroxetine hcl cr PRENATE PIXIE repaglinide STAXYN nisoldipine paroxetine hcl er PRENATE RESTORE repaglinide-metformin hcl STEGLATRO nitro-bid paroxetine mesylate PRENATE STAR REQUIP STEGLUJAN NITRO-DUR PAXIL preplus REQUIP XL STENDRA nitroglycerin capsules PAXIL CR PREQUE 10 RESTASIS STIOLTO RESPIMAT nitroglycerin patch penicillamine PRESTALIA RESTASIS MULTIDOSE STRATTERA nitro-time PENTASA pretab RHOPRESSA sucralfate nizatidine pentoxifylline prevalite RIDAURA SULAR NOCDURNA PEPCID PREVIDENT RILUTEK sulfasalazine dr nora-be PERFOROMIST PREVIDENT 5000 riluzole syeda norethindrone perindopril erbumine PREVIDENT 5000 RIOMET SYMBICORT norethindrone acetate PEXEVA ENAMEL PROTECT RIOMET ER SYMLINPEN norethindrone-e.estradiol-iron philith PREVIDENT 5000 risedronate sodium SYNJARDY norethindrone-ethinyl estradiol PHOSPHOLINE IODIDE ORTHO DEFENSE risedronate sodium dr SYNJARDY XR norgestimate-ethinyl estradiol pilocarpine hcl PREVIDENT 5000 PLUS rivastigmine SYNTHROID norgestrel-ethinyl estradiol pimtrea PREVIDENT 5000 SENSITIVE rivelsa NORINYL pindolol previfem R-NATAL OB T norlyda pioglitazone hcl PRIMACARE ROBINUL norlyroc pioglitazone-glimepiride PRINIVIL ROBINUL FORTE tadalafil (generic cialis) NORPACE pioglitazone-metformin probenecid ROCKLATAN tamoxifen citrate NORPACE CR pirmella probenecid-colchicine ropinirole hcl tamsulosin hcl nortrel PLAVIX PROCARDIA ropinirole hcl er TAPAZOLE np thyroid pnv 29-1 PROCARDIA XL rosuvastatin calcium tarina 24 fe NUVARING pnv ob+dha progesterone rulavite dha tarina fe pnv-dha PROGLYCEM RYBELSUS tarina fe 1-20 eq pnv-dha + docusate PROMETRIUM RYTARY TARKA (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2020 Express Scripts. All Rights Reserved. Page 3 DL466313-STD CRP2009_004721.1 (09/01/20) All trademarks are the property of their respective owners. taron-c dha trazodone hcl TRUSOPT VIIBRYD wymzya fe taron-prex prenatal TRELEGY ELLIPTA trust natal dha VINATE DHA RF TASMAR TRESIBA tulana viorele X TAYTULLA TRESIBA FLEXTOUCH TWIRLA virt nate taztia xt tri femynor TWYNSTA virt-advance XARELTO TEKTURNA HCT triamterene tydemy virt-c dha XENICAL telmisartan triamterene-hctz virt-nate XHANCE telmisartan-amlodipine TRICARE U virt-nate dha XIFAXAN 550 MG telmisartan-hydrochlorothiazide TRICARE PRENATAL virt-pn XIGDUO XR TENORETIC TRICARE PRENATAL DHA ONE ultimatecare one virt-pn dha XIIDRA TENORMIN TRICARE PRENATAL WITH DHA ultimatecare one nf virt-pn plus xulane terazosin hcl tri-estarylla unithroid VIRTPREX XULTOPHY terbutaline sulfate tablets TRIGLIDE URECHOLINE virt-select THEO-24 TRIJARDY XR UROCIT-K virt-vite gt Y theochron triklo UROXATRAL VITAFOL FE PLUS theophylline tri-legest fe URSO VITAFOL GUMMIES YAZ theophylline anhydrous tri-linyah URSO FORTE VITAFOL NANO YUPELRI THRIVITE RX TRILIPIX ursodiol VITAFOL ULTRA yuvafem thyroid tri-lo-estarylla VITAFOL-OB THYROLAR tri-lo-marzia V VITAFOL-OB+DHA Z tiadylt er tri-lo-mili VITAFOL-ONE TIAZAC tri-lo-sprintec valsartan VITAMEDMD ONE RX zafirlukast TIGLUTIK tri-mili valsartan-hydrochlorothiazide VITAMEDMD REDICHEW RX zarah tilia fe trinatal rx 1 vardenafil hcl vitamin d2 (prescription) zatean-pn dha timolol maleate trinate VASCEPA VITAPEARL zatean-pn plus TIMOPTIC trinessa VASERETIC VITATRUE ZEMPLAR TIMOPTIC-XE trinessa lo VASOTEC volnea zenchent TIROSINT TRI-NORINYL velivet vp-ch-pnv zenchent fe TIROSINT-SOL TRINTELLIX vemavite-prx 2 vp-ggr-b6 ZESTORETIC tolcapone tri-previfem venlafaxine hcl VP-PNV-DHA ZESTRIL tolterodine tartrate tri-sprintec venlafaxine hcl er vyfemla ZIAC tolterodine tartrate er TRISTART DHA VERAMYST vylibra zingiber toremifene citrate triveen-duo dha verapamil er VYZULTA ZIOPTAN torsemide trivora-28 verapamil er pm ZONTIVITY TOUJEO MAX SOLOSTAR tri-vylibra verapamil hcl W zovia TOUJEO SOLOSTAR tri-vylibra lo verapamil sr zumandimine TOVIAZ trospium chloride VERELAN WELCHOL TABLETS ZYLOPRIM trandolapril trospium chloride er VERELAN PM wera ZYPITAMAG trandolapril-verapamil er TRULANCE vestura westhroid travoprost TRULICITY vienva WP THYROID

This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment.

© 2020 Express Scripts. All Rights Reserved. Page 4 DL466313-STD CRP2009_004721.1 (09/01/20) All trademarks are the property of their respective owners.