GEHA Standard Option, High Option, HDHP Drug List

July 2021

This list only applies to Standard Option, High Option and HDHP members.

The GEHA Standard Option, High Option, HDHP Drug List 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 physician 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 physician. 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 • For specific information regarding your prescription benefit document. Products recently approved by the FDA may not be coverage and copay1 information, please visit Caremark.com covered upon release to the market. or contact a CVS Caremark Customer Care representative. • The member's prescription benefit plan may have a different • CVS Caremark may contact your physician after receiving your copay for specific products on the list. prescription to request consideration of a drug list product or • Unless specifically indicated, drug list products will include all generic equivalent. This may result in your physician prescribing, dosage forms. when medically appropriate, a different brand-name product or • Log in to Caremark.com to check coverage and copay generic equivalent in place of your original prescription. information for a specific medicine. • 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 XTAMPZA ER § HERPES AGENTS § OPIOID ANALGESICS § PENICILLINS acyclovir capsule, tablet § NSAIDs buprenorphine transdermal amoxicillin ANTI-INFECTIVES valacyclovir diclofenac sodium codeine-acetaminophen amoxicillin-clavulanate ANTIBACTERIALS ibuprofen fentanyl transdermal dicloxacillin § INFLUENZA AGENTS § CEPHALOSPORINS meloxicam fentanyl transmucosal penicillin VK oseltamivir naproxen (except naproxen CR or lozenge cefdinir RELENZA § TETRACYCLINES naproxen suspension) hydrocodone ext-rel cefprozil hydrocodone-acetaminophen cefuroxime axetil doxycycline hyclate 20 mg § MISCELLANEOUS § NSAIDs, COMBINATIONS hydromorphone cephalexin doxycycline hyclate capsule clindamycin diclofenac sodium- hydromorphone ext-rel SUPRAX minocycline ivermectin

misoprostol methadone tetracycline linezolid § ERYTHROMYCINS / morphine metronidazole § NSAIDs, TOPICAL MACROLIDES § ANTIFUNGALS morphine ext-rel nitrofurantoin fluconazole diclofenac sodium solution morphine suppository azithromycin pyrimethamine

oxycodone clarithromycin itraconazole sulfamethoxazole- § COX-2 INHIBITORS terbinafine tablet oxycodone-acetaminophen clarithromycin ext-rel trimethoprim celecoxib tramadol (except NDC^ 52817019610) erythromycins vancomycin capsule ANTIVIRALS tramadol ext-rel DIFICID EMVERM § GOUT § CYTOMEGALOVIRUS BELBUCA XIFAXAN 550 MG allopurinol § FLUOROQUINOLONES AGENTS NUCYNTA colchicine tablet ciprofloxacin NUCYNTA ER valganciclovir probenecid levofloxacin SUBSYS MITIGARE moxifloxacin

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 NEXLIZET § DIURETICS XCOPRI ABILIFY MAINTENA

AGENTS amiloride LATUDA § BILE ACID RESINS § ANTIDEMENTIA furosemide PERSERIS HORMONAL cholestyramine donepezil hydrochlorothiazide VRAYLAR ANTINEOPLASTIC AGENTS colesevelam galantamine metolazone § ANTIANDROGENS galantamine ext-rel § ATTENTION DEFICIT § CHOLESTEROL spironolactone- memantine HYPERACTIVITY DISORDER bicalutamide hydrochlorothiazide ABSORPTION INHIBITORS rivastigmine amphetamine- torsemide § MISCELLANEOUS ezetimibe rivastigmine transdermal dextroamphetamine mixed triamterene NAMZARIC salts VISTOGARD § FIBRATES triamterene- atomoxetine hydrochlorothiazide (except fenofibrate tablet ANTIDEPRESSANTS CARDIOVASCULAR fenofibrate dexmethylphenidate ext-rel 120 mg) HEART FAILURE § SELECTIVE SEROTONIN guanfacine ext-rel § ACE INHIBITORS fenofibric acid delayed-rel REUPTAKE INHIBITORS BIDIL methylphenidate fosinopril CORLANOR (SSRIs) ADDERALL XR lisinopril § HMG-CoA REDUCTASE ENTRESTO citalopram CONCERTA quinapril INHIBITORS / escitalopram MYDAYIS ramipril COMBINATIONS § NITRATES fluoxetine (except fluoxetine tablet 60 VYVANSE atorvastatin isosorbide dinitrate (except mg, fluoxetine tablet [generics for § ACE INHIBITOR / ezetimibe-simvastatin § FIBROMYALGIA isosorbide dinitrate 40 mg) SARAFEM]) DIURETIC COMBINATIONS fluvastatin isosorbide mononitrate paroxetine HCl pregabalin fosinopril-hydrochlorothiazide lovastatin nitroglycerin lingual spray paroxetine HCl ext-rel lisinopril-hydrochlorothiazide pravastatin HYPNOTICS nitroglycerin sublingual sertraline quinapril-hydrochlorothiazide rosuvastatin TRINTELLIX § NONBENZODIAZEPINES simvastatin § MISCELLANEOUS eszopiclone § ANGIOTENSIN II § SEROTONIN RECEPTOR ANTAGONISTS / § NIACINS ranolazine ext-rel ramelteon NOREPINEPHRINE zolpidem DIURETIC COMBINATIONS niacin ext-rel CENTRAL NERVOUS REUPTAKE INHIBITORS zolpidem ext-rel candesartan / candesartan- SYSTEM (SNRIs) zolpidem sublingual hydrochlorothiazide § OMEGA-3 FATTY ACIDS desvenlafaxine ext-rel BELSOMRA irbesartan / irbesartan- omega-3 acid ethyl esters ANTIANXIETY duloxetine hydrochlorothiazide VASCEPA § BENZODIAZEPINES venlafaxine § TRICYCLICS losartan / losartan- § BETA-BLOCKERS alprazolam venlafaxine ext-rel capsule doxepin hydrochlorothiazide clonazepam atenolol olmesartan / olmesartan- diazepam § MISCELLANEOUS MIGRAINE carvedilol hydrochlorothiazide lorazepam AGENTS ACUTE MIGRAINE AGENTS telmisartan / telmisartan- carvedilol phosphate ext-rel oxazepam bupropion § Triptans hydrochlorothiazide metoprolol succinate ext-rel bupropion ext-rel (except valsartan / valsartan- metoprolol tartrate § ANTICONVULSANTS eletriptan bupropion ext-rel tablet 450 mg) naratriptan hydrochlorothiazide nadolol carbamazepine mirtazapine pindolol rizatriptan carbamazepine ext-rel trazodone § ANGIOTENSIN II propranolol sumatriptan clobazam RECEPTOR ANTAGONIST / propranolol ext-rel zolmitriptan diazepam rectal gel § ANTIPARKINSONIAN CALCIUM CHANNEL BYSTOLIC ONZETRA XSAIL divalproex sodium AGENTS BLOCKER COMBINATIONS ZEMBRACE SYMTOUCH § CALCIUM CHANNEL divalproex sodium ext-rel amantadine amlodipine-olmesartan ZOMIG NASAL SPRAY BLOCKERS ethosuximide carbidopa-levodopa amlodipine-telmisartan gabapentin carbidopa-levodopa ext-rel Miscellaneous amlodipine amlodipine-valsartan lamotrigine carbidopa-levodopa- diltiazem ext-rel (except generics NURTEC ODT lamotrigine ext-rel entacapone § ANGIOTENSIN II for CARDIZEM LA) REYVOW levetiracetam entacapone RECEPTOR ANTAGONIST / nifedipine ext-rel UBRELVY levetiracetam ext-rel pramipexole CALCIUM CHANNEL verapamil ext-rel BLOCKER / DIURETIC oxcarbazepine pramipexole ext-rel PREVENTIVE MIGRAINE COMBINATIONS § CALCIUM CHANNEL phenobarbital rasagiline AGENTS BLOCKER / ANTILIPEMIC phenytoin ropinirole amlodipine-valsartan- Monoclonal Antibodies COMBINATIONS phenytoin sodium extended ropinirole ext-rel hydrochlorothiazide AIMOVIG primidone selegiline olmesartan-amlodipine- amlodipine-atorvastatin AJOVY rufinamide NEUPRO EMGALITY hydrochlorothiazide § DIGITALIS GLYCOSIDES tiagabine ANTIPSYCHOTICS § ANTIARRHYTHMICS digoxin topiramate § MUSCULOSKELETAL valproic acid § ATYPICALS THERAPY AGENTS disopyramide § DIRECT RENIN zonisamide sotalol aripiprazole cyclobenzaprine (except INHIBITORS / DIURETIC FYCOMPA MULTAQ clozapine cyclobenzaprine tablet 7.5 mg) COMBINATIONS NAYZILAM olanzapine ANTILIPEMICS aliskiren OXTELLAR XR quetiapine § NARCOLEPSY ACL INHIBITORS / TEKTURNA HCT TROKENDI XR quetiapine ext-rel armodafinil

COMBINATIONS VALTOCO risperidone modafinil VIMPAT ziprasidone SUNOSI NEXLETOL

INCRETIN MIMETIC AGENT / prednisolone solution POSTHERPETIC GASTROINTESTINAL INSULIN COMBINATIONS SUPPLIES prednisone NEURALGIA (PHN) ACCU-CHEK AVIVA PLUS § ANTIDIARRHEALS SOLIQUA 2 GRALISE STRIPS AND KITS GLUCOSE ELEVATING XULTOPHY diphenoxylate-atropine

ACCU-CHEK COMPACT AGENTS loperamide PSYCHOTHERAPEUTIC - 2 INSULINS PLUS STRIPS AND KITS BAQSIMI MISCELLANEOUS § ANTIEMETICS BASAGLAR ACCU-CHEK GUIDE GLUCAGEN HYPOKIT 2 § OPIOID ANTAGONISTS FIASP STRIPS AND KITS GLUCAGON EMERGENCY aprepitant naloxone injection HUMULIN R U-500 ACCU-CHEK SMARTVIEW KIT doxylamine-pyridoxine 2 NARCAN NASAL SPRAY LEVEMIR STRIPS AND KITS GVOKE delayed-rel

NOVOLIN 70/30 BD ULTRAFINE INSULIN dronabinol § PARTIAL OPIOID AGONIST MENOPAUSAL SYMPTOM NOVOLIN N SYRINGES AND granisetron / OPIOID ANTAGONIST AGENTS NOVOLIN R NEEDLES metoclopramide COMBINATIONS NOVOLOG ONETOUCH ULTRA § ORAL ondansetron 2 buprenorphine-naloxone NOVOLOG MIX 70/30 STRIPS AND KITS estradiol prochlorperazine sublingual TOUJEO ONETOUCH VERIO STRIPS estradiol-norethindrone promethazine 2 ZUBSOLV TRESIBA AND KITS DUAVEE scopolamine transdermal

PREMPHASE trimethobenzamide PSEUDOBULBAR AFFECT CALCIUM REGULATORS § INSULIN SENSITIZERS PREMPRO SANCUSO AGENTS pioglitazone § BISPHOSPHONATES § ANTISPASMODICS NUEDEXTA alendronate § TRANSDERMAL § INSULIN SENSITIZER / ibandronate estradiol dicyclomine § VASOMOTOR SYMPTOM BIGUANIDE COMBINATIONS CLIMARA PRO AGENTS risedronate INFLAMMATORY BOWEL pioglitazone-metformin COMBIPATCH DISEASE paroxetine mesylate § CALCITONINS DIVIGEL § INSULIN SENSITIZER / calcitonin-salmon EVAMIST § ORAL AGENTS ENDOCRINE AND SULFONYLUREA balsalazide METABOLIC COMBINATIONS § CARNITINE DEFICIENCY § VAGINAL budesonide capsule AGENTS § ANDROGENS pioglitazone-glimepiride estradiol budesonide ext-rel

levocarnitine estradiol vaginal cream mesalamine delayed-rel testosterone gel (except authorized § MEGLITINIDES IMVEXXY mesalamine ext-rel generics for TESTIM and VOGELXO) CONTRACEPTIVES nateglinide VAGIFEM sulfasalazine testosterone solution repaglinide § MONOPHASIC sulfasalazine delayed-rel ANDRODERM § PHOSPHATE BINDER ethinyl estradiol- ASACOL HD NATESTO SODIUM-GLUCOSE AGENTS drospirenone PENTASA CO-TRANSPORTER 2 ANTIDIABETICS ethinyl estradiol- calcium acetate (SGLT2) INHIBITORS sevelamer carbonate § RECTAL AGENTS AMYLIN ANALOGS drospirenone-levomefolate FARXIGA ethinyl estradiol- PHOSLYRA hydrocortisone enema SYMLINPEN JARDIANCE VELPHORO norethindrone acetate mesalamine suppository

ethinyl estradiol- mesalamine suspension § BIGUANIDES SODIUM-GLUCOSE POTASSIUM-REMOVING CORTIFOAM metformin CO-TRANSPORTER 2 norethindrone acetate-iron AGENTS metformin ext-rel (except generics (SGLT2) INHIBITOR / BIPHASIC LOKELMA § IRRITABLE BOWEL for FORTAMET and GLUMETZA) BIGUANIDE COMBINATIONS VELTASSA SYNDROME LO LOESTRIN FE SYNJARDY § BIGUANIDE / alosetron SYNJARDY XR § TRIPHASIC PROGESTINS SULFONYLUREA LINZESS XIGDUO XR ethinyl estradiol-norgestimate § ORAL VIBERZI COMBINATIONS medroxyprogesterone glipizide-metformin SODIUM-GLUCOSE § EXTENDED CYCLE megestrol acetate § LAXATIVES CO-TRANSPORTER 2 ethinyl estradiol- progesterone, micronized lactulose solution DIPEPTIDYL PEPTIDASE-4 (SGLT2) INHIBITOR / levonorgestrel peg 3350-electrolytes (DPP-4) INHIBITORS DIPEPTIDYL PEPTIDASE-4 VAGINAL CLENPIQ JANUVIA (DPP-4) INHIBITOR § TRANSDERMAL CRINONE COMBINATIONS OPIOID-INDUCED DIPEPTIDYL PEPTIDASE-4 ethinyl estradiol- § SELECTIVE ESTROGEN CONSTIPATION (DPP-4) INHIBITOR / GLYXAMBI norelgestromin

RECEPTOR MODULATORS MOVANTIK BIGUANIDE COMBINATIONS SODIUM-GLUCOSE § VAGINAL raloxifene SYMPROIC JANUMET CO-TRANSPORTER 2 ethinyl estradiol-etonogestrel JANUMET XR (SGLT2) INHIBITOR / § THYROID SUPPLEMENTS PANCREATIC ENZYMES ANNOVERA DIPEPTIDYL PEPTIDASE-4 levothyroxine CREON INCRETIN MIMETIC AGENTS ENDOMETRIOSIS (DPP-4) INHIBITOR / liothyronine VIOKACE OZEMPIC BIGUANIDE COMBINATIONS ORILISSA SYNTHROID ZENPEP RYBELSUS TRIJARDY XR TRULICITY § GLUCOCORTICOIDS UTERINE FIBROIDS § PROTON PUMP VICTOZA § SULFONYLUREAS dexamethasone INHIBITORS ORIAHNN glimepiride fludrocortisone esomeprazole glipizide hydrocortisone esomeprazole delayed-rel glipizide ext-rel methylprednisolone lansoprazole

lansoprazole delayed-rel VITAMINS AND MINERALS § LEUKOTRIENE § ANTIFUNGALS cromolyn sodium omeprazole § FOLIC ACID / MODULATORS ciclopirox LASTACAFT omeprazole delayed-rel COMBINATIONS montelukast econazole PAZEO pantoprazole zafirlukast ketoconazole cream 2% folic acid § ANTI-INFECTIVES pantoprazole delayed-rel zileuton ext-rel luliconazole ciprofloxacin tablet § PRENATAL VITAMINS nystatin § NASAL ANTIHISTAMINES erythromycin DEXILANT prenatal vitamins NAFTIN

azelastine gentamicin § STEROIDS, RECTAL CITRANATAL olopatadine § ANTIPSORIATICS levofloxacin PROCTOFOAM-HC RESPIRATORY acitretin moxifloxacin § NASAL STEROIDS / calcipotriene ointment, ofloxacin § ULCER THERAPY § ANAPHYLAXIS COMBINATIONS solution sulfacetamide COMBINATIONS TREATMENT AGENTS flunisolide methoxsalen tobramycin PYLERA epinephrine auto-injector fluticasone BESIVANCE

EPIPEN mometasone § ANTISEBORRHEICS CILOXAN OINTMENT § MISCELLANEOUS EPIPEN JR DYMISTA ketoconazole shampoo 2% sucralfate tablet § ANTI-INFECTIVE / SYMJEPI selenium sulfide lotion 2.5%

PHOSPHODIESTERASE-4 ANTI-INFLAMMATORY GENITOURINARY § ANTICHOLINERGICS INHIBITORS § ATOPIC DERMATITIS COMBINATIONS § BENIGN PROSTATIC ipratropium inhalation DALIRESP pimecrolimus neomycin-polymyxin B- HYPERPLASIA solution tacrolimus bacitracin-hydrocortisone STEROID / BETA AGONIST SPIRIVA EUCRISA neomycin-polymyxin B- alfuzosin ext-rel YUPELRI COMBINATIONS dexamethasone doxazosin ADVAIR DISKUS CORTICOSTEROIDS tobramycin-dexamethasone dutasteride ANTICHOLINERGIC / BETA ADVAIR HFA § Low Potency TOBRADEX OINTMENT dutasteride-tamsulosin AGONIST COMBINATIONS BREO ELLIPTA desonide TOBRADEX ST finasteride § SHORT ACTING SYMBICORT hydrocortisone silodosin ipratropium-albuterol ANTI-INFLAMMATORIES tamsulosin § STEROID INHALANTS inhalation solution § Medium Potency § Nonsteroidal terazosin budesonide inhalation hydrocortisone butyrate bromfenac LONG ACTING § URINARY suspension cream, lotion, ointment, diclofenac ANTISPASMODICS ANORO ELLIPTA ARNUITY ELLIPTA solution ketorolac STIOLTO RESPIMAT FLOVENT DISKUS mometasone ACUVAIL darifenacin ext-rel FLOVENT HFA triamcinolone cream, lotion, ILEVRO oxybutynin ANTICHOLINERGIC / BETA PULMICORT FLEXHALER ointment oxybutynin ext-rel NEVANAC AGONIST / STEROID QVAR REDIHALER solifenacin PROLENSA INHALANT COMBINATIONS § High Potency tolterodine BREZTRI AEROSPHERE TOPICAL desoximetasone § Steroidal tolterodine ext-rel TRELEGY ELLIPTA fluocinonide (except fluocinonide dexamethasone trospium DERMATOLOGY cream 0.1%) loteprednol trospium ext-rel § ANTIHISTAMINES, ACNE BRYHALI prednisolone acetate 1% MYRBETRIQ LOW SEDATING § Topical DUREZOL

TOVIAZ levocetirizine § Very High Potency adapalene FML FORTE

benzoyl peroxide clobetasol cream, foam, gel, HEMATOLOGIC § ANTITUSSIVES FML S.O.P. clindamycin gel (except NDC^ lotion, ointment, shampoo MAXIDEX benzonatate (except NDCs^ § ANTICOAGULANTS 68682046275) PRED MILD § LOCAL ANALGESICS warfarin 69336012615, 69499032915) clindamycin solution lidocaine patch ELIQUIS clindamycin-benzoyl § ANTIVIRALS BETA AGONISTS, XARELTO peroxide trifluridine INHALANTS § LOCAL ANESTHETICS erythromycin solution § CHELATING AGENTS § SHORT ACTING erythromycin-benzoyl lidocaine-prilocaine BETA-BLOCKERS § Nonselective penicillamine capsule albuterol inhalation solution peroxide § ROSACEA trientine albuterol sulfate CFC-free tretinoin timolol maleate solution azelaic acid gel aerosol EPIDUO BETIMOL metronidazole § PLATELET AGGREGATION levalbuterol tartrate CFC-free ONEXTON FINACEA FOAM INHIBITORS aerosol Selective ORACEA clopidogrel § ACTINIC KERATOSIS BETOPTIC S SOOLANTRA dipyridamole ext-rel-aspirin LONG ACTING fluorouracil cream 5% prasugrel Hand-held Active Inhalation fluorouracil solution § CARBONIC ANHYDRASE MOUTH / THROAT / INHIBITORS BRILINTA SEREVENT imiquimod DENTAL AGENTS PICATO dorzolamide STRIVERDI RESPIMAT PROTECTANTS NUTRITIONAL / TOLAK AZOPT

SUPPLEMENTS Nebulized Passive Inhalation ZYCLARA EPISIL § CARBONIC ANHYDRASE § ELECTROLYTES PERFOROMIST OPHTHALMIC § ANTIBIOTICS INHIBITOR / BETA- potassium chloride liquid gentamicin § ANTIALLERGICS BLOCKER COMBINATIONS

mupirocin ointment azelastine dorzolamide-timolol

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

folic acid morphine ext-rel ONZETRA XSAIL quetiapine ext-rel fosinopril L morphine suppository ORACEA quinapril fosinopril-hydrochlorothiazide lactulose solution MOVANTIK ORIAHNN quinapril-hydrochlorothiazide furosemide lamotrigine moxifloxacin ORILISSA QVAR REDIHALER

FYCOMPA lamotrigine ext-rel MULTAQ oseltamivir

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

T tolterodine ext-rel TROKENDI XR venlafaxine ext-rel capsule Y topiramate trospium verapamil ext-rel tacrolimus YUPELRI torsemide trospium ext-rel VIBERZI tamsulosin TOUJEO TRULICITY VICTOZA TEKTURNA HCT Z TOVIAZ VIMPAT telmisartan zafirlukast tramadol (except NDC^ 52817019610) U VIOKACE telmisartan- ZEMBRACE SYMTOUCH tramadol ext-rel UBRELVY VISTOGARD hydrochlorothiazide ZENPEP travoprost VRAYLAR terazosin zileuton ext-rel trazodone V VYVANSE terbinafine tablet ZIOPTAN TRELEGY ELLIPTA VAGIFEM testosterone gel (except authorized ziprasidone TRESIBA valacyclovir W generics for TESTIM and VOGELXO) zolmitriptan tretinoin warfarin testosterone solution valganciclovir zolpidem triamcinolone cream, lotion, valproic acid tetracycline zolpidem ext-rel ointment valsartan X tiagabine zolpidem sublingual triamterene valsartan-hydrochlorothiazide XARELTO timolol maleate solution ZOMIG NASAL SPRAY triamterene- VALTOCO XCOPRI TOBRADEX OINTMENT zonisamide hydrochlorothiazide vancomycin capsule XIFAXAN 550 MG TOBRADEX ST ZUBSOLV trientine VASCEPA XIGDUO XR tobramycin ZYCLARA trifluridine tobramycin-dexamethasone VELPHORO XIIDRA TRIJARDY XR TOLAK VELTASSA XTAMPZA ER trimethobenzamide tolterodine venlafaxine XULTOPHY TRINTELLIX PREFERRED OPTIONS LIST FOR MEDICINES REQUIRING PRIOR AUTHORIZATION FOR MEDICAL NECESSITY OR NON-PREFERRED MEDICINES DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- ANDROGEL testosterone gel (except authorized generics for TESTIM and rel, risperidone, ziprasidone, LATUDA, VRAYLAR VOGELXO), testosterone solution, ANDRODERM, NATESTO ACANYA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl ANTARA fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid peroxide, tretinoin, EPIDUO, ONEXTON delayed-rel ACIPHEX, esomeprazole, esomeprazole delayed-rel, lansoprazole, APEXICON E desoximetasone, fluocinonide (except fluocinonide cream ACIPHEX SPRINKLE lansoprazole delayed-rel, omeprazole, omeprazole delayed-rel, 0.1%), BRYHALI pantoprazole, pantoprazole delayed-rel tablet, DEXILANT APIDRA FIASP, NOVOLOG ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate capsule, APTENSIO XR dexmethylphenidate ext-rel, ADDERALL XR, CONCERTA, minocycline, tetracycline MYDAYIS, VYVANSE Activite folic acid ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID ACTOS pioglitazone ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, esomeprazole delayed-rel, lansoprazole, ADZENYS ER, dexmethylphenidate ext-rel, ADDERALL XR, CONCERTA, lansoprazole delayed-rel, omeprazole, omeprazole delayed-rel, ADZENYS XR-ODT MYDAYIS, VYVANSE pantoprazole, pantoprazole delayed-rel tablet, or DEXILANT ALCORTIN A desonide, hydrocortisone ASCENSIA STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE ALEVICYN GEL, desonide, hydrocortisone STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND ALEVICYN SG, KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ALEVICYN SOLUTION ONETOUCH VERIO STRIPS AND KITS 2 ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES ASMANEX, ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, 3 INSULIN SYRINGES ASMANEX HFA PULMICORT FLEXHALER, QVAR REDIHALER ALORA estradiol, DIVIGEL, EVAMIST ATACAND, candesartan, candesartan-hydrochlorothiazide, irbesartan, ALREX azelastine, cromolyn sodium, LASTACAFT, PAZEO ATACAND HCT irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan- ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, hydrochlorothiazide, telmisartan, telmisartan- pravastatin, rosuvastatin, simvastatin hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, ATOPADERM desonide, hydrocortisone PULMICORT FLEXHALER, QVAR REDIHALER ATROVENT HFA ipratropium inhalation solution, SPIRIVA, YUPELRI AMITIZA LINZESS, MOVANTIK, SYMPROIC AVENOVA Consult physician AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)

DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity AZELEX adapalene, benzoyl peroxide, clindamycin gel (except NDC^ CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, 68682046275), clindamycin solution, clindamycin-benzoyl NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, peroxide, erythromycin solution, erythromycin-benzoyl ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY peroxide, tretinoin, EPIDUO, ONEXTON calcipotriene cream calcipotriene ointment, calcipotriene solution AZESCO 5 prenatal vitamins, CITRANATAL calcipotriene- calcipotriene ointment or calcipotriene solution WITH BEAU RX Consult physician betamethasone desoximetasone, fluocinonide (except fluocinonide cream 0.1%) or BRYHALI BECONASE AQ flunisolide, fluticasone, mometasone, DYMISTA calcitriol ointment calcipotriene ointment, calcipotriene solution BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR hydrochlorothiazide, olmesartan, olmesartan- or naproxen suspension) hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA BENSAL HP desonide, hydrocortisone CARAFATE sucralfate tablet BENZAC AC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl CARBINOXAMINE levocetirizine peroxide, erythromycin solution, erythromycin-benzoyl TABLET 6 MG peroxide, tretinoin, EPIDUO, ONEXTON CARDIZEM, diltiazem ext-rel BENZACLIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ CARDIZEM CD, (except generics for CARDIZEM LA) 68682046275), clindamycin solution, clindamycin-benzoyl CARDIZEM LA peroxide, erythromycin solution, erythromycin-benzoyl CARNITOR, levocarnitine peroxide, tretinoin, EPIDUO, ONEXTON CARNITOR SF benzonatate benzonatate (except NDCs^ 69336012615, 69499032915) chlordiazepoxide- dicyclomine (NDCs^ 69336012615, clidinium (NDC^ 69499032915 only) 42494040901 only) BEPREVE azelastine, cromolyn sodium, LASTACAFT, PAZEO chlorzoxazone 375 mg, cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) BETAPACE, sotalol chlorzoxazone 500 mg BETAPACE AF (NDC^ 73007001303 only), chlorzoxazone BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT 750 mg, CHLORZOXAZONE BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- 250 MG levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron CICATRACE Consult physician bimatoprost solution latanoprost, travoprost, LUMIGAN, ZIOPTAN CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic 0.03% CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic BREEZE 2 STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE CLINDAGEL erythromycin solution 2 STRIPS AND KITS , ACCU-CHEK SMARTVIEW STRIPS AND clindamycin gel (NDC^ adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 2 2 KITS , ONETOUCH ULTRA STRIPS AND KITS , 68682046275 only) 68682046275), clindamycin solution, clindamycin-benzoyl 2 ONETOUCH VERIO STRIPS AND KITS peroxide, erythromycin solution, erythromycin-benzoyl Bupap diclofenac sodium, ibuprofen, naproxen (except naproxen CR peroxide, tretinoin, EPIDUO, ONEXTON or naproxen suspension) clobetasol spray clobetasol foam bupropion ext-rel tablet bupropion, bupropion ext-rel (except bupropion ext-rel tablet CLOBEX SPRAY clobetasol foam 450 mg 450 mg) COLAZAL balsalazide, mesalamine delayed-rel, mesalamine ext-rel, butalbital-acetaminophen diclofenac sodium, ibuprofen, naproxen (except naproxen CR sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, tablet 50-300 mg, or naproxen suspension) PENTASA BUTALBITAL- ACETAMINOPHEN (NDC^ COLCRYS colchicine tablet, MITIGARE 69499034230 only) CONSENSI amlodipine WITH celecoxib butalbital- diclofenac sodium, ibuprofen, naproxen (except naproxen CR 2 acetaminophen- or naproxen suspension) CONTOUR NEXT STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU-CHEK 4 2 caffeine capsule AND KITS COMPACT PLUS STRIPS AND KITS , ACCU-CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND BUTRANS buprenorphine transdermal, BELBUCA KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA CONTOUR STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2,

DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity ONETOUCH VERIO STRIPS AND KITS 2 doxycycline hyclate doxycycline hyclate 20 mg, doxycycline hyclate capsule, delayed-rel tablet 200 mg minocycline, tetracycline CORDRAN OINTMENT hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate doxycycline hyclate doxycycline hyclate 20 mg, doxycycline hyclate capsule, solution, mometasone, triamcinolone cream, triamcinolone tablet 50 mg (NDC^ minocycline, tetracycline lotion, triamcinolone ointment 72143021160 only), doxycycline hyclate CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule, tablet 75 mg, doxycycline minocycline, tetracycline hyclate tablet 150 mg CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, doxycycline doxycycline hyclate 20 mg, doxycycline hyclate capsule, pravastatin, rosuvastatin, simvastatin monohydrate capsule minocycline, tetracycline cyclobenzaprine ext-rel cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) 75 mg, doxycycline capsule, cyclobenzaprine monohydrate capsule tablet 7.5 mg 150 mg CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- doxycycline ORACEA rel capsule monohydrate delayed-rel capsule DARAPRIM pyrimethamine DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, DAYTRANA dexmethylphenidate ext-rel, ADDERALL XR, CONCERTA, SYMBICORT MYDAYIS, VYVANSE DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide DELZICOL balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, DYRENIUM amiloride, triamterene PENTASA EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, irbesartan-hydrochlorothiazide, losartan, losartan- tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, hydrochlorothiazide, olmesartan, olmesartan- TOVIAZ hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide dexchlorpheniramine levocetirizine EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, Dexifol folic acid zolpidem sublingual, BELSOMRA Diclofex DC diclofenac sodium, diclofenac sodium solution, ibuprofen, E.E.S. GRANULES erythromycins (NDC^ 51021037201 meloxicam, naproxen (except naproxen CR or naproxen only) suspension) EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- rel capsule Diclosaicin diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen ENABLEX darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, suspension) tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ DIFFERIN LOTION adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG benzoyl peroxide, erythromycin solution, erythromycin- EPICERAM desonide, hydrocortisone benzoyl peroxide, tretinoin, EPIDUO, ONEXTON ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, diflorasone cream, desoximetasone, fluocinonide (except fluocinonide cream NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, diflorasone ointment 0.1%), BRYHALI ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ERYPED erythromycins NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY ESTRING estradiol, estradiol vaginal cream, IMVEXXY, VAGIFEM diltiazem ext-rel diltiazem ext-rel EVEKEO amphetamine-dextroamphetamine mixed salts, (generics for CARDIZEM (except generics for CARDIZEM LA) methylphenidate LA only) EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, valsartan irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan- EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- amlodipine-hydrochlorothiazide hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide FABIOR adapalene, benzoyl peroxide, clindamycin gel (except NDC^ Diphen Elixir levocetirizine 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON DORAL doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA FANAPT aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- rel, risperidone, ziprasidone, LATUDA, VRAYLAR DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline FEMRING estradiol, estradiol vaginal cream, IMVEXXY, VAGIFEM doxepin cream desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA

DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid Genicin Vita-S folic acid delayed-rel GLUMETZA metformin, metformin ext-rel (except generics for FORTAMET FENOGLIDE TABLET fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid and GLUMETZA) 120 MG delayed-rel GLYCOPYRROLATE dicyclomine fenoprofen, diclofenac sodium, ibuprofen, meloxicam, naproxen (except TABLET 1.5 MG FENOPROFEN CAPSULE naproxen CR or naproxen suspension) GOLYTELY peg 3350-electrolytes, CLENPIQ FERIVA 21/7 folic acid HORIZANT gabapentin, GRALISE FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- rel capsule HUMALOG FIASP, NOVOLOG Fexmid cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) HUMALOG MIX 50/50 NOVOLOG MIX 70/30 FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, HUMALOG MIX 75/25 NOVOLOG MIX 70/30 SOOLANTRA HUMULIN 70/30 NOVOLIN 70/30 FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except naproxen CR HUMULIN N NOVOLIN N or naproxen suspension) HUMULIN R NOVOLIN R flucytosine capsule fluconazole 500 mg hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate lotion, lipophilic cream 0.1% hydrocortisone butyrate ointment, hydrocortisone butyrate fluocinonide cream 0.1% clobetasol cream solution, mometasone, triamcinolone cream, triamcinolone fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, lotion, triamcinolone ointment PICATO, TOLAK, ZYCLARA HylaVite folic acid fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- (generics for SARAFEM [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline rel, methadone, morphine ext-rel, NUCYNTA ER, only) XTAMPZA ER

INCRUSE ELLIPTA SPIRIVA, YUPELRI fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet INDERAL LA, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine INDERAL XL succinate ext-rel, metoprolol tartrate, nadolol, pindolol, HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX propranolol, propranolol ext-rel, BYSTOLIC flurandrenolide lotion desonide, hydrocortisone INDOCIN diclofenac sodium, ibuprofen, meloxicam, naproxen (except (NDC^ 24470092112 only) naproxen CR or naproxen suspension) flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate lotion, indomethacin capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except hydrocortisone butyrate ointment, hydrocortisone butyrate 20 mg naproxen CR or naproxen suspension) solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment Inflammacin diclofenac sodium, diclofenac sodium solution, ibuprofen, FML LIQUIFILM dexamethasone, loteprednol, prednisolone acetate 1%, meloxicam, naproxen (except naproxen CR or naproxen DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD suspension) FOLIC-K folic acid INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, Folvite-D folic acid pindolol, propranolol, propranolol ext-rel, BYSTOLIC FORTAMET metformin, metformin ext-rel (except generics for FORTAMET INTRAROSA estradiol, estradiol vaginal cream, IMVEXXY, VAGIFEM and GLUMETZA) INTUNIV dexmethylphenidate ext-rel, ADDERALL XR, CONCERTA, FORTESTA testosterone gel (except authorized generics for TESTIM and MYDAYIS, VYVANSE VOGELXO), testosterone solution, ANDRODERM, NATESTO INVOKAMET, SYNJARDY, SYNJARDY XR, XIGDUO XR FOSAMAX PLUS D alendronate, ibandronate, risedronate INVOKAMET XR FOSRENOL calcium acetate, sevelamer carbonate, PHOSLYRA, INVOKANA FARXIGA, JARDIANCE VELPHORO isosorbide dinitrate isosorbide dinitrate (except isosorbide dinitrate 40 mg), FOSTEUM, alendronate, ibandronate, risedronate 40 mg isosorbide mononitrate FOSTEUM PLUS ISTALOL timolol maleate solution, BETIMOL, BETOPTIC S FREESTYLE STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 JENTADUETO, JANUMET, JANUMET XR JENTADUETO XR FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, KAMDOY desonide, hydrocortisone ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY

DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity KAZANO JANUMET, JANUMET XR metformin ext-rel metformin, metformin ext-rel (except generics for FORTAMET (generics for FORTAMET and GLUMETZA) ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5% and GLUMETZA only) Ketodan ketoconazole shampoo 2%, selenium sulfide lotion 2.5% methocarbamol 500 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) ketoprofen capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except (NDC^ 69036091010 25 mg naproxen CR or naproxen suspension) only), methocarbamol 750 mg (NDCs^ ketoprofen ext-rel diclofenac sodium, ibuprofen, meloxicam, naproxen (except 69036093090, capsule naproxen CR or naproxen suspension) 70868090190 only) KOMBIGLYZE XR JANUMET, JANUMET XR MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, TYMLOS LACRISERT RESTASIS, XIIDRA MIACALCIN NASAL calcitonin-salmon LACTULOSE PAK lactulose solution SPRAY LANOXIN TABLET digoxin MICARDIS, candesartan, candesartan-hydrochlorothiazide, irbesartan, (125 MCG and 250 MICARDIS HCT irbesartan-hydrochlorothiazide, losartan, losartan- MCG only) hydrochlorothiazide, olmesartan, olmesartan- lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, hydrochlorothiazide, telmisartan, telmisartan- VELPHORO hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide LANTUS 6 BASAGLAR, LEVEMIR Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, LAZANDA fentanyl transmucosal lozenge, SUBSYS ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, pravastatin, rosuvastatin, simvastatin prednisolone solution, prednisone levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- rel, methadone, morphine ext-rel, NUCYNTA ER, levomefolate, ethinyl estradiol-norethindrone acetate, XTAMPZA ER ethinyl estradiol-norethindrone acetate-iron LEXAPRO citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 MINIVELLE estradiol, DIVIGEL, EVAMIST mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX MINOCIN doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline LIALDA balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA, minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, ASACOL HD minocycline, tetracycline LIDOCAINE-TETRACAINE lidocaine-prilocaine MIRVASO azelaic acid gel, metronidazole, FINACEA FOAM, CREAM (NDC^ SOOLANTRA 71800063115 only) Mondoxyne NL capsule doxycycline hyclate 20 mg, doxycycline hyclate capsule, LIDOTREX lidocaine-prilocaine 75 mg minocycline, tetracycline LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, MOVIPREP peg 3350-electrolytes, CLENPIQ pravastatin, rosuvastatin, simvastatin MultiPro Consult physician LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, mupirocin cream gentamicin, mupirocin ointment pravastatin, rosuvastatin, simvastatin MYTESI diphenoxylate-atropine, loperamide Lorid folic acid NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) naproxen CR or naproxen suspension) LOTEMAX, dexamethasone, loteprednol, prednisolone acetate 1%, naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except LOTEMAX SM DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD naproxen CR or naproxen suspension) WITH esomeprazole, LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, esomeprazole delayed-rel, lansoprazole, lansoprazole delayed- zolpidem sublingual, BELSOMRA rel, omeprazole, omeprazole delayed-rel, pantoprazole, pantoprazole delayed-rel tablet, or DEXILANT MACRODANTIN nitrofurantoin naproxen CR diclofenac sodium, ibuprofen, meloxicam, naproxen (except Matzim LA diltiazem ext-rel (except generics for CARDIZEM LA) naproxen CR or naproxen suspension) mefenamic acid (NDC^ diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except 69336012830 only) naproxen CR or naproxen suspension) naproxen CR or naproxen suspension)

NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- MENEST estradiol levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol- norethindrone acetate, ethinyl estradiol-norethindrone acetate- MENOSTAR estradiol iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) NESINA JANUVIA

DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity NEXIUM esomeprazole, esomeprazole delayed-rel, lansoprazole, OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- lansoprazole delayed-rel, omeprazole, omeprazole delayed-rel, rel, methadone, morphine ext-rel, NUCYNTA ER, pantoprazole, pantoprazole delayed-rel tablet, DEXILANT XTAMPZA ER niacin tablet 500 mg niacin ext-rel oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- rel, methadone, morphine ext-rel, NUCYNTA ER, Niacor niacin ext-rel XTAMPZA ER NICADAN folic acid OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, NICAPRIN folic acid tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ NICAZEL, NICAZEL folic acid FORTE PANCREAZE CREON, VIOKACE, ZENPEP NICOMIDE folic acid PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), NILANDRON abiraterone, bicalutamide, XTANDI, YONSA paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual PENNSAID diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) suspension) NORITATE azelaic acid gel, metronidazole, FINACEA FOAM, PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, SOOLANTRA oxycodone-acetaminophen, NUCYNTA NORVASC amlodipine PERRIGO NEEDLES 3 BD ULTRAFINE NEEDLES NOVACORT desonide, hydrocortisone PERTZYE CREON, VIOKACE, ZENPEP NOVO NORDISK BD ULTRAFINE NEEDLES PEXEVA citalopram, escitalopram, fluoxetine (except fluoxetine tablet 3 NEEDLES 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine NuDiclo SoluPak, diclofenac sodium, diclofenac sodium solution, ibuprofen, HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX NuDiclo TabPak meloxicam, naproxen (except naproxen CR or naproxen PLAVIX clopidogrel, prasugrel, BRILINTA suspension) POLYTOZA Consult physician NUVARING ethinyl estradiol-etonogestrel, ANNOVERA posaconazole delayed-rel fluconazole, itraconazole NUVIGIL armodafinil, modafinil, SUNOSI tablet OLEPTRO trazodone PRADAXA warfarin, ELIQUIS, XARELTO OLUX-E clobetasol foam PRECISION XTRA ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK omeprazole-sodium esomeprazole, esomeprazole delayed-rel, lansoprazole, STRIPS AND KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE bicarbonate lansoprazole delayed-rel, omeprazole, omeprazole delayed-rel, STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND pantoprazole, pantoprazole delayed-rel tablet, DEXILANT KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 OMNARIS flunisolide, fluticasone, mometasone, DYMISTA PRED FORTE dexamethasone, loteprednol, prednisolone acetate 1%, OMNIVEX folic acid DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD ONFI clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO ONGLYZA JANUVIA PREMARIN estradiol orphenadrine-aspirin- cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) PREMARIN CREAM estradiol, estradiol vaginal cream, IMVEXXY, VAGIFEM caffeine PRENATAL PLUS 5 prenatal vitamins, CITRANATAL Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) PREVACID esomeprazole, esomeprazole delayed-rel, lansoprazole, ORTHO D folic acid lansoprazole delayed-rel, omeprazole, omeprazole delayed-rel, pantoprazole, pantoprazole delayed-rel tablet, DEXILANT ORTHO DF folic acid PREVIDENT Consult physician OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- OSMOPREP peg 3350-electrolytes, CLENPIQ rel capsule OSPHENA estradiol PROAIR HFA, albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- OWEN MUMFORD BD ULTRAFINE NEEDLES PROAIR RESPICLICK free aerosol 3 NEEDLES PRODIGEN Consult physician oxiconazole (NDCs^ ciclopirox, econazole, ketoconazole cream 2%, luliconazole, PROTONIX esomeprazole, esomeprazole delayed-rel, lansoprazole, 00168035830, NAFTIN lansoprazole delayed-rel, omeprazole, omeprazole delayed-rel, 51672135902 only) pantoprazole, pantoprazole delayed-rel tablet, DEXILANT PROTOPIC pimecrolimus, tacrolimus, EUCRISA

DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity PROVAD Consult physician TALIVA folic acid PROVENTIL HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- TARGADOX doxycycline hyclate 20 mg, doxycycline hyclate capsule, free aerosol minocycline, tetracycline PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine levomefolate, ethinyl estradiol-norethindrone acetate, HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX ethinyl estradiol-norethindrone acetate-iron PSORCON desoximetasone, fluocinonide (except fluocinonide cream TAZORAC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 0.1%), BRYHALI 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl QNASL flunisolide, fluticasone, mometasone, DYMISTA peroxide, tretinoin, EPIDUO, ONEXTON; calcipotriene QTERN GLYXAMBI ointment, calcipotriene solution quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, TESTIM testosterone gel (except authorized generics for TESTIM and zolpidem sublingual, BELSOMRA VOGELXO), testosterone solution, ANDRODERM, NATESTO RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin testosterone gel 1% testosterone gel (except authorized generics for TESTIM and (authorized generics for VOGELXO), testosterone solution, ANDRODERM, NATESTO RAYOS dexamethasone, hydrocortisone, methylprednisolone, TESTIM and VOGELXO prednisolone solution, prednisone only) RECEDO Consult physician TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, BETOPTIC S RELION INSULIN NOVOLIN INSULIN TIROSINT levothyroxine, SYNTHROID RHEUMATE folic acid TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, RIBOZEL folic acid pindolol, propranolol, propranolol ext-rel, BYSTOLIC RIMSO-50 Consult physician TRADJENTA JANUVIA RIOMET metformin, metformin ext-rel (except generics for FORTAMET tramadol (NDC^ tramadol (except NDC^ 52817019610), tramadol ext-rel and GLUMETZA) 52817019610 only) ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, TRANSDERM SCOP scopolamine transdermal zolpidem sublingual, BELSOMRA TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR RyClora levocetirizine or naproxen suspension) WITH eletriptan, naratriptan, SCARSILK PAD Consult physician rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- SYMTOUCH or ZOMIG NASAL SPRAY rel, risperidone, ziprasidone, LATUDA, VRAYLAR triamcinolone hydrocortisone butyrate cream, hydrocortisone butyrate lotion, SIL-K PAD Consult physician aerosol 0.2% hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone SILIVEX Consult physician lotion, triamcinolone ointment SILTREX Consult physician TRICOR fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid SINGULAIR montelukast, zafirlukast, zileuton ext-rel delayed-rel SORILUX calcipotriene ointment, calcipotriene solution TRILIPIX fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) TRIVIDIA INSULIN BD ULTRAFINE INSULIN SYRINGES SYRINGES 3 SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV TronVite folic acid sucralfate suspension sucralfate tablet TRUETEST STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE or naproxen suspension) WITH eletriptan, naratriptan, STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE ONETOUCH VERIO STRIPS AND KITS 2 SYMTOUCH or ZOMIG NASAL SPRAY TRUETRACK STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK SUPREP peg 3350-electrolytes, CLENPIQ AND KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND SURE-TEST STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, KITS 4 COMPACT PLUS STRIPS AND KITS 2, ACCU-CHEK GUIDE ONETOUCH VERIO STRIPS AND KITS 2 STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, TUDORZA SPIRIVA, YUPELRI ONETOUCH VERIO STRIPS AND KITS 2 ULTIMED INSULIN BD ULTRAFINE INSULIN SYRINGES SYNERDERM desonide, hydrocortisone SYRINGES 3

DRUG NAME(S) Bolded PREFERRED OPTION(S)* DRUG NAME(S) Bolded PREFERRED OPTION(S)* medicines require prior medicines require prior authorization for medical authorization for medical necessity necessity ULTIMED NEEDLES 3 BD ULTRAFINE NEEDLES ZALVIT 5 prenatal vitamins, CITRANATAL UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin ZEGERID esomeprazole, esomeprazole delayed-rel, lansoprazole, lansoprazole delayed-rel, omeprazole, omeprazole delayed-rel, VALCYTE valganciclovir pantoprazole, pantoprazole delayed-rel tablet, DEXILANT VALTREX acyclovir capsule, acyclovir tablet, valacyclovir ZELAC Consult physician Vanoxide-HC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ ZETIA ezetimibe 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl ZETONNA flunisolide, fluticasone, mometasone, DYMISTA peroxide, tretinoin, EPIDUO, ONEXTON ZIANA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ VASCULERA Consult physician 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl VECTICAL calcipotriene ointment, calcipotriene solution peroxide, tretinoin, EPIDUO, ONEXTON VELTIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ ZIRGAN trifluridine 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- peroxide, tretinoin, EPIDUO, ONEXTON rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- (except 225 mg) rel capsule ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA VENTOLIN HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- free aerosol ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, VEREGEN imiquimod lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, VIIBRYD citalopram, escitalopram, fluoxetine (except fluoxetine tablet oxcarbazepine, phenobarbital, phenytoin, 60 mg, fluoxetine tablet [generics for SARAFEM]), phenytoin sodium extended, primidone, tiagabine, topiramate, paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI VITAFOL-ONE 5 prenatal vitamins, CITRANATAL ZONTIVITY Consult physician Vitasure folic acid ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except VIVELLE-DOT estradiol, DIVIGEL, EVAMIST naproxen CR or naproxen suspension) VOGELXO testosterone gel (except authorized generics for TESTIM and ZUPLENZ granisetron, ondansetron, SANCUSO VOGELXO), testosterone solution, ANDRODERM, NATESTO ZYFLO montelukast, zafirlukast, zileuton ext-rel XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin- XOLEGEL ciclopirox, ketoconazole cream 2% polymyxin B-dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST XOPENEX HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- free aerosol ZYVIT folic acid Xvite folic acid XYZBAC folic acid YAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

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. * 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: (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.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. 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.