With Advanced Control $Pecialty Formulary@

October 2019 Performance Drug List - Standard Control for Glients with Advanced Control $pecialty 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. lf 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 ltalics, and generic products in lowercase lfalics.

PLAN MEMBER HEALTH GARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by CVS Caremark. Ask your doctor to consider administered by CVS Caremark. As a way to help manage health prescribing, when medically appropriate, a preferred medicine from care costs, authorize generic substitution whenever possible. lf you this list. Take this list along when you or a covered family member believe a brand-name product is necessary, consider prescribing a sees a doctor. brand name 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. this document. Products recently approved by the U.S. Food It is not all-inclusive and does not guarantee coverage. The and Drug Administration (FDA) may not be covered upon member's specific prescription benefit plan design may not release to the market. cover certain products or categories, regardless of their o You may be responsible for the full cost of non-formulary appearance in this document. Products recently approved by products that are removed from coverage. the FDA may not be covered upon release to the market. a For specific information regarding your prescription benefit a The member's prescription benefit plan may have a different coverage and copayl information, please visit Qglggqgg@ or copayl for specific products on the list. contact a CVS Caremark Customer Care representative. Unless specifically indicated, drug list products will include all a 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 copayl 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. ln 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 $ GOUT ABSTRAL $ ERYTHRoMYCTNS I $ TETRACYCLTNES allopuinol BELBUCA MACROLIDES doxycycline hyclate NSAIDS $ colchicine tablet BUTRANS azithromycin minocycline diclofenac sodium probenecid EMBEDA claithronycin tetracycline ibuprofen ULORIC HYSINGLA ER claithromycin ext+el ANTIFUNGALS meloxicam NUCYNTA erythromycins $ ANALGESTCS naproxen2 $ oPtorD NUCYNTA ER DIFICID fluconazole co d e i n e- a c et a m i n o p h e n OXYCONTIN itraconazole NSA|Ds, COMBINATIONS $ fentanyl transdermal SUBSYS $ FLU0ROQUtN0L0NES terbinafine tablet diclofenac sodium- fentanyl transmucosal ciprofloxacin ANTIVIRALS misoprostol lozenge ANTI-INFECTIVES ciprofloxacin ert+el

h y d ro co d o n e -a cet a m i n o p h e n levofloxacin $ CYToMEGALOVTRUS $ NSA|Ds, TOPICAL ANTIBACTERIALS hydromorphone moxifloxacin AGENTS diclofenac sodium gel 1% cEPHALoSPoRINS hydromorphone ext+el s valganciclovir PENTCTLLTNS (except NDC 69499031866) methadone cefdinir s HERPES AGENTS di clofe nac sod iu m soluti on morphine cefprozil amoxicillin $ morphine ext-rel cefuroxime axetil anoxi ci IIin -cl avu I an ate acyclovir s c0x.2 rNHrBrToRS morphine suppository cephalexin dicloxacillin valacyclovir celecoxib oxycodone SUPRAX penicillin VK $ INFLUENZA AGENTS o xy co d o n e -a c et a m i n o p h e n tramadol oseltamivir tramadol ext-rel RELENZA il?Jfffiii,iix1":ii:l"Tt"l,liff i,::n's"T"1i,",1#":::ffu"i'i3l,"s"T;1'::;3i:,fi5t::;;;ff5"?:,f;1'*"'" ?Grts caremarK $ MtScELLANEOUS s ANTTARRHYTHMTCS hydrochlorothiazide ANTIDEPRESSANTS guanfacine ext-rel metolazone methylphenidate clindamycin sotalol $ SELECTTVE SEROT0NTN ivermectin MULTAQ sphonolactone- REUPTAKE INHIBITORS m ethylph e ni d ate ext+el Iinezolid hydrochlorothiazide (SSRls) MYDAYIS ANTILIPEMICS torsemide VYVANSE metronidazole citalopram B|LE triamterene- nitrofurantoin $ AC|D RESTNS escitalopram hydrochlorothiazide FIBROMYALGIA sulfamethoxazole- cholestyramine fluoxetine LYRICA timethopim colesevelam HEART FAILURE paroxetine HCI EMVERM paroxetine HCI ext-rel HYPNOTICS cHoLESTERoL BIDIL XIFAMN 550 MG $ sertraline ABSORPTION INHIBITORS CORLANOR $ NONBENZODTAZEPTNES TRINTELLIX ANTINEOPLASTIC ENTRESTO eszopiclone ezetimibe VIIBRYD AGENTS zolpidem FTBRATES s NTTRATES s $ SEROTONTN zolpidem ext+el HORMONAL fenofibrate3 nitroglycerin lingual spray NOREPINEPHRINE zolpidem sublingual ANTINEOPLASTIC AGENTS fenofibic acid nitroglycein subl i ngu al REUPTAKE INHIBITORS BELSOMRA $ ANTTANDROGENS (SNRls) MtSCELLANEoUS $ HMG-CoA REDUCTASE s TRICYCLICS bicalutamide desv enl afaxi n e ext-rel INHIBITORS ranolazine ext-rel SILENOR duloxetine $ MTSCELLANEOUS COMBINATIONS' CENTRAL NERVOUS venlafaxine MIGRAINE VISTOGARD atorvastatin SYSTEM venlafaxine ext-rel capsule ezeti m i be - s i mv a stati n $ ERGoTAMTNE CARDIOVASCULAR DERIVATIVES fluvastatin ANTIANXIETY $ MTScELLANEOUS lovastatin AGENTS ergotamine-caffeine s AcE tNHtB|TORS $ BENZODTAZEPINES pravastatin bupropion fosinopil alprazolam MONOCLONAL ANTIBODIES rosuvastatin bupropion ext+el Iisinopil clonazepam AJOVY simvastatin mirtazapine quinapil diazepam EMGALITY trazodone ramipil $ NTACTNS lorazepam oxazepam $ SELECTTVE SEROT0NtN niacin ext-rel s ANTTPARKTNSONIAN s AcE TNHTBTTOR / AGONISTS AGENTS DIURETIC COMBINATIONS s ANTTCONVULSANTS $ oMEGA-3 FATTY ACIDS eletiptan amantadine p -h carbamazepine fo si n o i I y d ro c h I o rot h i azi d e omega-3 acid ethyl esters naratiptan carbidopa-levodopa p ext-rel I i s i n o i I -h yd ro c h I o roth i azi d e VASCEPA carbamazepine izatriptan carbi dopa-levodop a ext+el q p - clobazam u i n a i I hy d ro ch I o rot h i azi d e sumatriptan gel carbidopa-levodopa- $ BETA-BLoCKERS diazepam rectal zolmitiptan s ANGTOTENSTN I divalproex sodium entacapone atenolol ONZETRA XSAIL RECEPTOR ANTAGONISTS / entacapone caruedilol divalproex sodium ext-rel ZEMBMCE SYMTOUCH DIURETIC COMBINATIONS pramipexole caruedilol phosphate ext-rel ethosuximide ZOMIG NASAL SPRAY pramipexole ext+el can desartan / c an d e sa rtan - metoprolol succin ab ert+el gabapentin rasagiline hydrochlorothiazide metoprololtartrate lamotigine SELECTIVE SEROTONIN ropinirole eprosaian nadolol Iamotigine ext-rel AGONIST / NONSTEROIDAL ropinirole ext+el irbesarta n / irbesa rtan - pindolol levethacetam ANTI-INFLAMMATORY selegiline hydrochlorothiazide propranolol Ievetiracetam ext-rel DRUG (NSATD) NEUPRO Iosartan / losartan- propranolol ext+el oxcarbazepine COMBINATIONS hydrochlorothiazide phenobarbital BYSTOLIC ANTIPSYCHOTICS TREXIMET ol mes artan / ol m es artan- phenytoin ATYPTCALS hydrochlorothiazide s cAlcruM CHANNEL phenytoin sodium extended $ $ MUSCULoSKELETAL tel mi sa rtan / telmi s artan - BLOCKERS pimidone aripiprazole THERAPY AGENTS hydrochlorothiazide amlodipine tiagabine clozapine cyclobenzaprine valsartan / valsartan- diltiazem ext+ela topiramate olanzapine quetiapine NARCoLEPSY hydrochlorothiazide nifedipine ert+el valproic acid s quetiapine verapamil ert-rel zonisamide ert+el armodafinil ANGTOTENSIN il $ FYCOMPA ispeidone RECEPTOR ANTAGONIST I POSTHERPETIC s cALcruM CHANNEL OXTELLAR XR ziprasidone CALCIUM CHANNEL NEURALGTA (PHN) BLOCKER / ANTILIPEMIC TROKENDI XR ABILIFY MAINTENA BLOCKER COMBINATIONS COMBINATIONS VIMPAT ARISTADA GMLISE aml od ipin e -olmesartan a m I o d i pi n e - ato ru a st at i n ARISTADA INITIO PSYCHOTHERAPEUTIC . aml od ipi n e-tel mis qrtan s ANTTDEMENTTA LATUDA MISCELLANEOUS amlodipine-valsartan s DtGTTALTS GLYCOSTDES donepezil VMYLAR digoxin galantamine $ oPtorD ANTAGONTSTS ANGTOTENSTN il ATTENTTON DEFTCTT s galantamine ext+el s naloxone injection ANTAGONIST DIRECT RENIN INHIBITORS / HYPERACTIVITY DISORDER RECEPTOR / memantine NARCAN NASAL SPRAY DIURETIC COMBINATIONS CALCIUM CHANNEL ivastigmine amphetamine- BLOCKER / DIURETIC PARTTAL OProrD AGoNTST / TEKTURNA / ivasti gmi n e transd ermal dextroamphetamine s COMBINATIONS OPIOID ANTAGONIST TEKTURNA HCT NAMZARIC mixed salts amlod i pine-v alsa rta n - amphetamine- COMBINATIONS DTURETTCS hydrochlorothiazide $ dertroamphetamine b upren orp h ine-n al oxo n e ol mx artan -aml od i p in e- amiloide mixed salts ext-rel sublingual hydrochlorothiazide furosemide atomoxetine ZUBSOLV

[?Jilffili,:iX1":'8j':'l"Tffl..liff iTil'ffi#d":.":ffi:"i'itl,t""i;lll:;3i';fi';'3ff;;'ol!:li'.?:,ff;'".* '' ?GVS caremark' PSEUDOBULBAR AFFECT s TNSULtN SENSTTTZER / CALCIUM REGULATORS TRANSDERMAL DICLEGIS SANCUSO AGENTS SULFONYLUREA $ BtSPH0SPH0NATES CLIMAM PRO COMBINATIONS VARUBI NUEDEXTA alendronate COMBIPATCH p i o gl it azo n e g I i m e pi r i d e ibandronate vAsoMoToR SYMPTOM ESTROGEN I SELECTIVE S ANTISPASMODICS s isedronate AGENTS s MEGLtTtNTDES ESTROGEN RECEPTOR dicyclomine MODULATOR paroxetine mesylate nateglinide s cALcrToNrNs $ Hz REGEPTOR repaglinide COMBINATIONS calcitonin-salmon ANTAGONISTS ENDOCRINE AND DUAVEE ranitidine METABOLIC SODIUM.GLUCOSE $ CARN|TTNE DEFICTENCY CO.TRANSPORTER 2 AGENTS $ GLUC0C0RTTC0TDS ANDROGENS INFLAMMATORY BOWEL S (sGLT2) TNHTBTTORS dexamethasone levocamitine DISEASE testosterone gel FARXIGA fludrocottisone ORAL AGENTS fesfosferone so/ution JARDIANCE CONTRACEPTIVES hydrocortisone S ANDRODERM balsalazide $ MONoPHASTC methylprednisolone SODIUM-GLUCOSE prednisolone solution budesonide capsule ANTIDIABETICS ethinyl estradiol- CO-TRANSPORTER 2 budesonide ext-rel drospirenone prednisone AMYLIN ANALOGS {sGLT2) TNHTBTTOR sulfasalazine ethinyl estradiol- SYMLINPEN BIGUANIDE COMBINATIONS' GLUCOSE ELEVATING su lf asalazi n e d elayed +el d ro sp i re n o n e J ev o m efo I ate SYNJARDY AGENTS APRISO BTGUANTDES ethinyl estradiol- s SYNJARDY XR GLUCAGEN HYPOKIT PENTASA norethindrone acetate metformin XIGDUO XR GLUCAGON ethinyl estradiol- RECTAL AGENTS metformin ext+els EMERGENCY KIT $ n oreth in d rone acetate-iron SODIUM.GLUCOSE hydrocortisone enema SAFYML s BTGUANTDE / CO.TRANSPORTER 2 $ PHOSPHATE BINDER mesalamine suppository SULFONYLUREA TNHTBTTOR I AGENTS {sGLT2) BTPHASTC mesaiamine suspenslon COMBINATIONS s DIPEPTIDYL PEPTIDASE.4 calcium acetate CORTIFOAM LO LOESTRIN FE glipizide-metformin (DPP-4) TNHTBITOR lanthanum carbonate |RR|TABLE BOWEL COMBINATIONS TRTPHASTC sevelamer carbonate $ DIPEPTIDYL PEPTIDASE.4 $ GLYMMBI PHOSLYM SYNDROME (DPP.4) TNHTBTT0RS eth i ny I e stra d i o I - n o rg esti m ate QTERN VELPHORO alosetron JANUVIA FOUR PHASE AMITIZA s SULFoNYLUREAS POTASSIUM-REMOVING LINZESS DIPEPTIDYL PEPTIDASE-4 NATAZIA glimepiide AGENTS VIBERZI (DPP-4) TNHTBTTOR / glipizide $ EXTENDED CYCLE LOKELMA BIGUANIDE COMBINATIONS LAXATTVES glipizide ext-rel ethinyl estradiol- VELTASSA $ JANUMET levonorgestrel lactulose solution JANUMET XR SUPPLIES PROGESTINS peg 33S0clectrolytes ACCU-CHEK AVIVA PLUS $ TRANSDERMAL oRAL SUPREP INCRETIN MIMETIC AGENTS s STRIPS AND KITS 6 ethinyl estradiol- medroxyprogesterone OZEMPIC OPIOID-INDUCED ACCU-CHEK COMPACT norelgestromin megestrol acetate TRULICITY 6 CONSTIPATION PLUS STRIPS AND KITS progesteron e, mi croni zed VICTOZA ACCU-CHEK GUIDE VAGINAL MOVANTIK STRIPS AND KITS 6 NUVARING VAGINAL INCRETIN MIMETIC AGENT I PANCREATIC ENZYMES ACCU-CHEK SMARTVIEW CRINONE INSULIN COMBINATIONS ENDOMETRIOSIS STRIPS AND KITS 6 ENDOMETRIN CREON SOLIQUA VIOKACE BD ULTRAFINE ORILISSA SELECTTVE ESTROGEN ZENPEP INSULINS INSULIN SYRINGES $ ESTROGENS RECEPTOR MODULATORS AND NEEDLES BASAGLAR oRAL $ PRoToN PUMP DEXCOM CONTINUOUS $ raloxifene FIASP INHIBITORS GLUCOSE estradiol OSPHENA HUMULIN R U-5OO esomeprazole MONITORING SYSTEM PREMARIN LEVEMIR THYROID SUPPLEMENTS lansoprazole OMNIPOD INSULIN S NOVOLTN 70/30 TRANSDERMAL omeprazole INFUSION PUMP S levothyroxine NOVOLIN N pantoprazole V-GO INSULIN estradiol liothyronine NOVOLIN R DEXILANT INFUSION PUMP DIVIGEL SYNTHROID NOVOLOG EVAMIST sTERotDs, RECTAL NOVOLOG MIX 7Ol30 ANTIOBESITY GASTROINTESTINAL s TRESIBA $ VAGTNAL PROCTOFOAM-HC INJECTABLE ANTTEMETTCS estradiol $ $ TNSULTN SENSTTTZERS SAXENDA ULCER THERAPY ESTRING dronabinol S pioglitazone granisetron COMBINATIONS ORAL PREMARIN CREAM meclizine PYLEM tNsuLrN sENsrTrzER / BELVIQ $ ESTROGEN / PROGESTINS metoclopramide BIGUANIDE COMBINATIONS BELVIQ XR $ oRAL ondansetron p i o g I it a zo n e -m etf o rm i n prochlorperazine e strad i o l -n o ret h i n d ro n e promethazine PREMPHASE timethobenzamide PREMPRO

[?Jilffi::,:"""Xi:i,lfft"l[inX i::il'ffili&"i,.":H:"i:31,"$."ffi:::;3",:,fi?'3::;;'o:::L?:,ffi'*" ''. ?GVS caremarK GENITOURINARY 5 PRENATAL VITAMINS s NASAL ANT|H|STAM|NES $ ANTTFUNGALS levofloxacin prenatal vitamins azelastine ciclopirox moxifloxacin BENTGN PROSTATTC s CITMNATAL olopatadine clotimazole ofloxacin HYPERPLASIA econazole sulfacetamide alfuzosin ext+el s NASAL STERo|DS / ketoconazole tobramycin doxazosin COMBINATIONS Iuliconazole BESIVANCE $ ANAPHYLMIS dutasteide flunisolide nystatin CILOMN OINTMENT TREATMENT AGENTS d uta ste i d e -tam s u I o s i n fluticasone JUBLIA MOXEZA epi neph rin e auto-i njector finasteride mometasone NAFTIN ANTr-INFECTTVE / sl/odosin EPIPEN tiamcinolone $ ANTI.INFLAMMATORY tamsulosin EPIPEN JR DYMISTA $ ANTtPS0RTATTCS COMBINATIONS terazosin acitretin s ANTtCHoLTNERGTCS PHOSPHODIESTERASE-4 calcipoti ene oi ntm ent, neomycin-polymyxin B- ERECTILE DYSFUNCTION ipratropium INHIBITORS solution b a cit ra ci n -h y d r o c o rt i s o n e inhalation solution ALPROSTADIL AGENTS DALIRESP methoxsalen neomycin-polymyxin B- INCRUSE ELLIPTA MUSE dexamethasone I BETA AGONIST SPIRIVA STEROID $ ATOPTC DERMATTTTS to b ra my c i n - d ex a m et h as o n e S PHOSPHODIESTERASE COMBINATIONS tacrolimus TOBRADEX OINTMENT ANTICHOLINERGIC / BETA INHIBITORS ADVAIR DISKUS ELIDEL TOBMDEX ST AGONIST COMBINATIONS sildenafil ADVAIR HFA EUCRISA ZYLEI SHoRT ACTTNG tadalafil s BREO ELLIPTA ANTI-INFLAMMATORIES i p rat ro p i u m -al b ut e ro I SYMBICORT CORTICOSTEROIDS $ URTNARY inhalation solution $ Low Potency $ Nonsteroidal ANTISPASMODICS S STEROID INHALANTS COMBIVENT RESPIMAT desonide bromfenac daifenacin ext+el budesonide hydrocortisone diclofenac LONG ACTING oxybutynin inhalation suspension ketorolac oxybutynin ert-rel ANORO ELLIPTA ARNUITY ELLIPTA $ Medium Potency ACUVAIL solifenacin BEVESPI AEROSPHERE ASMANEX clocortolone ILEVRO RESPIMAT tolterodine STIOLTO FLOVENT DISKUS hy d ro c o rl i s o n e b uty r ate NEVANAC tolterodine ext+el FLOVENT HFA mometasone ANTICHOLINERGIC / BETA trospium PULMICORT FLEXHALER triamcinolone $ Steroidal AGONIST / STEROID trospium ert+el QVAR dexamethasone INHALANT COMBINATIONS MYRBETRIQ QVAR REDIHALER $ High Potency prednisolone acetate I % TOVIAZ TRELEGY ELLIPTA desoximetasone DUREZOL TOPICAL fluocinonideT FLAREX s ANTTHTSTAMTNES, HEMATOLOGIC FML FORTE LOW SEDATING DERMATOLOGY Very High Potency $ FML S.O.P. $ ANTTCOAGULANTS levocetirizine ACNE clobetasol cream, foam, gel, MAXIDEX warfain $ Topical Ioti on, oi ntment, sh am poo PRED MILD s ANTTTUSSTVES ELIQUIS adapalene benzon atate NDc{ LoCAL ANESTHETTCS MRELTO @xcept benzoyl peroxide $ BETA-BLOCKERS

693360 1 261 5, 69 4990329 1 5) lidocaine-prilocaine clindanycin solution $ Nonselective S PLATELET AGGREGATION clindamycin-benzoyl timolol maleate solution INHIBITORS BETA AGONISTS, $ RosAcEA peroxide BETIMOL clopidogrel INHALANTS doxy cycl i ne monohyd rate erythromycin solution d i py i d amol e ext+el-asphi n sHoRT ACTTNG delayed+el capsule s erythromycin-benzoyl Selective prasugrel metronidazole albuterol in h al ati on sol ution peroxide BETOPTIC S BRILINTA FINACEA FOAM albuterol sulfate tretinoin CFClree aerosol SOOLANTM CARBoNTC ANHYDRASE IMMUNOLOGIC EPIDUO $ Ievalbuterol tartrate RETIN.A MICRO INHIBITORS AGENTS MOUTH / THROAT / CFClree aerosol dorzolamide TAZORAC DENTAL AGENTS ALLERGENIC EXTRACTS PROAIR HFA AZOPT ACT|NtC KERAToSTS PROTECTANTS GMSTEK PROAIR RESPICLICK $ fluorouracil cream 5% EPISIL $ CARBoNTC ANHYDRASE RAGWITEK LONG ACTING fluorouracil solution INHIBITOR BEIA. OPHTHALMIC NUTRITIONAL / Hand-held Active lnhalation imiquimod BLOCKER COMBINATIONS' ANTTALLERGTCS SUPPLEMENTS SEREVENT PICATO $ dorzolamide-timolol STRIVERDI RESPIMAT TOLAK azelastine CARBONIC ANHYDRASE s ELECTROLYTES ZYCLARA cromolyn sodium INHIBITOR / potassi u m chloi d e liq uid Nebulized Passive lnhalation olopatadine PERFOROMIST $ ANTtBt0TtCS LASTACAFT SYMPATHOMIMETIC AND MINERALS VITAMINS gentamicin PAZEO COMBINATIONS $ FOL|C ACID / s LEUKOTRTENE mupirocin ointment SIMBRINZA COMBINATIONS MODULATORS $ ANTT.tNFECTTVES folic acid montelukast ciprofloxacin zafirlukast erythromycin zileuton ext+el gentamicin

Your specific prescnption benefit plan this document. For specific information, i::il'ffis&":::fli"i:3v"s"T;if:;3:,:,fi%1'3:,'i;'ol!::"?xf;1*'* '' ?GVS caremarK DRY EYE DISEASE $ PROSTAGLANDTNS RHO KINASE INHIBITORS SYMPATHOMIMETIC / BETA. 0Ttc BLOCKER COMBINATIONS RESTASIS latanoprost RHOPRESSA $ ANTT.|NFECTIVE I XIIDM LUMIGAN COMBIGAN ANTI.INFLAMMATORY TRAVATAN Z $ SYMPATHOMTMETTCS COMBINATIONS bimonidine CIPRODEX ALPHAGAN P

A azithromycin cholestyramine dicloxacillin ethinyl estradiol- AZOPT ciclopirox dicyclomine norelgestromin ABILIFY MAINTENA CILOMN OINTMENT DIFICID ethinyl estradiol- ABSTRAL B CIPRODEX digoxin norethindrone acetate ACCU-CHEK AVIVA PLUS balsalazide ciprofloxacin diltiazem ext+ela ethinyl estradiol- STRIPS AND KITS 6 BASAGLAR ciprofloxacin ext+el d ipy i d amole ext+el -asp iri n n oreth in d ron e acetate -iron ACCU-CHEK COMPACT BD ULTRAFINE citalopram divalproex sodium eth i nyl estrad i ol -n orge stim ate PLUS STRIPS AND KITS 6 INSULIN SYRINGES CITMNATAL divalproex sodium ert+el ethosuximide ACCU-CHEK GUIDE AND NEEDLES claithromycin DIVIGEL EUCRISA STRIPS AND KITS 6 BELBUCA claithromycin ext+el donepezil EVAMIST ACCU-CHEK SMARTVIEW CLIMAM PRO dorzolamide ezetimibe STRIPS AND KITS 6 BELSOMM clindamycin dorzolamide-timolol e zeti m i b e - si mv a stati n acitretin BELVIQ BELVIQ XR clindamycin solution doxazosin ACUVAIL clindamycin-benzoyl doxycycline hyclate F acyclovir b enzon atate (except NDcs^ peroxide d oxycycl in e m onohyd rate FARXIGA adapalene 6933601 261 5, 6949903291 5) clobazam delayed+el capsule fenofibrate3 ADVAIR DISKUS benzoyl peroxide clobetasol cream, foam, gel, dronabinol fenofibric acid ADVAIR HFA BESIVANCE loti on, oi ntment, sh a mp oo DUAVEE fentanyl transdermal AJOVY BETIMOL clocortolone duloxetine fentanyl transmucosal al buterol i n h al ation solution BETOPTIC S clonazepam DUREZOL lozenge albuterol sulfate BEVESPI AEROSPHERE clopidogrel dutasteride FIASP CFC-free aerosol bicalutamide clotinazole d ut a ste r i d e -ta m su I o s i n FINACEA FOAM alendronate BIDIL clozapine DYMISTA finasteride alfuzosin ext+el BREO ELLIPTA co d e i n e -aceta m i n o p h e n FLAREX allopuinol BRILINTA colchicine tablet E FLOVENT DISKUS alosetron brinonidine colesevelam econazole FLOVENT HFA ALPHAGAN P bromfenac COMBIGAN eletiptan fluconazole alprazolam budesonide capsule COMBIPATCH ELIDEL fludrocortisone amantadine budesonide ext-rel COMBIVENT RESPIMAT ELIQUIS flunisolide amiloide budesonide CORLANOR EMBEDA fluocinonideT AMITIZA inhalation suspension CORTIFOAM EMGALITY fluorouracil cream 5% amlodipine b upre norp hi ne-n al oxon e CREON EMVERM fluorouracil solution am I o d i p i n e - ato ru a st at i n sublingual CRINONE ENDOMETRIN fluoxetine aml odi pine -ol m es arta n bupropion crorfiolyn sodium entacapone fluticasone amlodipi ne -tel mi sart an bupropion ert+el cyclobenzaprine ENTRESTO fluvastatin amlodipine-valsartan BUTRANS BYSTOLIC EPIDUO FML FORTE amlodipine-valsaftan- D e pi neph ri n -i njector FML S.O.P. hydrochlorothiazide e auto DALIRESP EPIPEN folic acid amoxicillin c darifenacin ext+el EPIPEN JR fosinopil a moxi cil Ii n -cl av ul an ate ca lcipotriene o intment, desonide EPISIL f osi n opril -h yd roch lo roth i azi d e amphetamine- solution desoximetasone eprosartan furosemide dertroamphetamine calcitonin-salmon desv enl af axin e ext-rel ergotamine-caff eine FYCOMPA mixed salts calcium acetate dexamethasone erythromycin amphetamine- candesartan CONTINUOUS erythromycin solution G dertroamphetamine candesartan- DEXCOM GLUCOSE erythromycin-benzoyl gabapentin mixed safts ert-rel hydrochlorothiazide MONITORING SYSTEM peroxide galantamine ANDRODERM carbamazepine DEXILANT erythromycins galantamine ANORO ELLIPTA carbamazepine ext+el ert+el diazepam escitalopram gentamicin APRISO carhidopa-levodopa diazepam rectal gel esoneprazole glimepiide aipiprazole carbi d opa-l evod op a ext+e I DICLEGIS estradiol glipizide ARISTADA carbidopalevodopa- diclofenac e stra d i o l - n o ret h i n d ro n e glipizide ARISTADA INITIO entacapone ext+el diclofenac sodium ESTRING glipizide-metformin armodafinil caruedilol diclofenac sodium eszopiclone ARNUITY ELLIPTA ca ruedilol ph o sph ate ext-rel GLUCAGEN HYPOKIT ethinyl estradiol- ASMANEX cefdinir Qel 1% lexceptNDe GLUCAGON drospirenone atenolol cefprozil 69499031866) EMERGENCY KIT ethinyl estradiol- atomoxetine cefuroxime axetil d icl ofen ac sod ium solution GLYMMBI d ro s p hen o n e J ev o m efo I ate GRALISE atoruastatin celecoxib diclofenac sodium- ethinyl estradiol- azelastine cephalexin misoprostol levonorgestrel il?Jfffili,1"""xij.llfft"i,,lifii ffil's##i,",1#":::ffi:"i:3u:'."#il':l;f,"J,Jffi'3:;i;'o[:x"?x,ffi*"* ',' ?GVS caremarK granisetron lorazepam NOVOLIN R PREMPRO sulfacetamide GMSTEK losartan NOVOLOG prenatal vitamins sulf amethoxazole- guanfacine ext+el I o s artan -h yd roch I o roth i azi d e NOVOLOG MIX 7Ol30 primidone timethopim lovastatin NUCYNTA PROAIR HFA sulfasalazine H Iuliconazole NUCYNTA ER PROAIR RESPICLICK sulf asalazine delayed +e I HUMULIN R U-sOO LUMIGAN NUEDEXTA probenecid sumatiptan hydrochlorothiazide LYRICA NUVARING prochlorperazine SUPMX

hy d rocod on e -acetami noph e n nystatin PROCTOFOAM-HC SUPREP M prog este rone, m icro ni zed SYMBICORT hydrocotlisone o hy d ro c o rti s o n e b uty r ate MAXIDEX promethazine SYMLINPEN hydrocortisone enema meclizine ofloxacin propranolol SYNJARDY hydromorphone medroxyprogesterone olanzapine propranolol ext+el SYNJARDY XR hydromorphone ext+el megestrol acetate olmesaian PULMICORT FLEXHALER SYNTHROID HYSINGLA ER meloxicam ol mesalan -a mlod ipine - PYLEM memantine hydrochlorothiazide T I mesalamine suppository olmesartan- o tacrolimus ibandronate mesalamine suspension hydrochlorothiazide QTERN tadalafil ibuprofen metformin olopatadine quetiapine tamsulosin ILEVRO metformin ert+els omega-3 acid ethyl esters quetiapine ext+el TAZOMC imiquimod methadone omeprazole quinapril TEKTURNA INCRUSE ELLIPTA methoxsalen OMNIPOD INSULIN qu in api l-hyd rochl orothi azid e TEKTURNA HCT ipratropium methylphenidate INFUSION PUMP QVAR telmisartan inhalation solution methy I phenid ate ext-re I ondansetron QVAR REDIHALER telmisaftan-

ip r at ro p i u m - a I b ut e rol methylprednisolone ONZETM XSAIL hydrochlorothiazide inhalation solution metoclopramide ORILISSA R terazosin irbesartan metolazone oseltamivir RAGWITEK terbinafine tablet ibesartan- metoprolol succinate ext+el OSPHENA raloxifene testosterone gel hydrochlorothiazide metoprolol tartrate oxazepam ramipil testosterone solution itraconazole metronidazole oxcarbazepine ranitidine tetracycline ivermectin minocycline OXTELLAR XR ranolazine ert-rel tiagabine mirtazapine oxybutynin rasagiline ti molol m ale ate so I ution J mometasone oxybutynin ext+el RELENZA TOBMDEX OINT[/ENT JANUMET montelukast oxycodone repaglinide TOBMDEX ST JANUMET XR morphine oxy c o d o n e - a c et a m i n o ph e n RESTASIS tohramycin JANUVIA morphine ext+el OXYCONTIN RETIN-A MICRO to b ram y c i n - d ex a m et h a s o n e JARDIANCE morphine suppository OZEMPIC RHOPRESSA TOLAK JUBLIA MOVANTIK risedronate tolterodine MOXEZA P rispeidone tolterodine ext-rel K moxifloxacin pantoprazole rivastigmine tophamate ketoconazole MULTAQ paroxetine HCI riv astigmin e transd ermal torsenide ketorolac muphocin ointment paroxetine HCI ext+el rizatiptan TOVIM MUSE paroxetine mesylate ropinirole tramadol L MYDAYIS PAZEO ropinirole ext-rel tramadol ext-rel MYRBETRIQ peg TMVATAN Z lactulose solution 33l0+lectrolytes rosuvastatin trazodone lamotigine penicillin VK N S TRELEGY ELLIPTA lamotigine ext+el PENTASA TRESIBA lansoprazole nadolol PERFOROMIST SAFYML phenobarbital tretinoin lanthanum carbonate NAFTIN SANCUSO phenytoin TREXIMET LASTACAFT naloxone injection SAXENDA phenytoin triamcinolone latanoprost NAMZARIC sodium extended selegiline tiamterene- LATUDA naproxen2 PHOSLYRA SEREVENT hydrochlorothiazide levalbuterol taftrate naratiptan PICATO sertraline NASAL pindolol timethobenzamide CFC-free aerosol NARCAN SPRAY sevelamer carbonate pioglitazone TRINTELLIX LEVEMIR NATAZIA sildenafil p g g p TROKENDI XR levetiracetam nateglinide i o I it azo n e I i m e i i d e SILENOR p g -m trospiun Ievetiracetam ext+el neomycin-polymyxin B- i o I it azo n e etf o rm i n sliodosrn -h y potassiu q trospiun ext-rel Ievocamitine b a c itra c i n d r o c o rti s o n e m ch loi de li ui d SIMBRINZA pramipexole TRULICITY levocetirizine neomycin-polymyxin B- simvastatin pramipexole Ievofloxacin dexamethasone ext-rel solifenacin prasugrel U levothyroxine NEUPRO SOLIQUA pravastatin lidocaine-pilocaine NEVANAC SOOLANTRA ULORIC linezolid niacin ext+el PRED MILD sotalol prednisolone 1 v LINZESS nifedipine ext+el acetate % SPIRIVA prednisolone liothyronine nitrofurantoin solution spironolactone- valacycloir lisinopil n itrog lyceri n I i ngu al spray prednisone hydrochlorothiazide valganciclovir n itroglyce i n subl i n gu al PREMARIN RESPIMAT valproic li sin op i I -hyd rochloroth i azi d e STIOLTO acid NOVOLTN 70/30 PREMARIN CREAM LO LOESTRIN FE STRIVERDI RESPIMAT valsartan NOVOLIN N PREMPHASE LOKELMA SUBSYS v a I s a rt a n - hy d ro c h I o rot h i a zi d e

Your specific prescription benefit plan this document. For specific information, i:"fi3"THL"-1"T;":i:#l:"i'i3l,t""iff5l-"ffi:,Jff#::i;'o[:5"?:,?ff"*" '' ?GVS Caremark' VARUBI VIBERZI w z zolpidem sublingual VICTOZA ZOMIG NASAL SPRAY VASCEPA warfain zafirlukast VELPHORO VIIBRYD zonisamide ZEMBMCE SYMTOUCH ZUBSOLV VELTASSA VIMPAT X ZENPEP venlafaxine VIOKACE ZYCLAM XARELTO zileuton ert+el ven I afaxi n e ert-rel capsule VISTOGARD ZYLET XIFAXAN 550 MG ziprasidone verapamil ext+el VMYLAR XIGDUO XR zolmitriptan V.GO INSULIN VryVANSE XIIDM zolpidem INFUSION PUMP zolpidem ext+el

PREFERRED OPTIONS LIST

DRUG NAME(S) PREFERRED OPTION(S)- DRUG NAME(S) PREFERRED OPTION(SF

6, ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, ASCENSIA STRIPS AND KITS 8 ACCUCHEKAVIVA PLUS STRIPS AND KITS quetiapine ext-rel, isperidone, ziprasidone, ACCIICHEKCOI/PACI-PLUSSTRPSA IDKJTSq LATUDA, VRAYLAR ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCUCHEK SMARTVIEW STRIPS AND KITS 6 ACANYA ad ap alene, benzoyl peroxi de, clindanycin solution, clindamycin- ATACAND, ATACAND HCT c an d e s afta n, cande s afta n - hy d r ochl orothi azid e, benzoyl peroxide, erythromycin solution, eprosaftan, irbesaftan,

e ryth ro my ci n - b e n zoy I p e roxi d e, t reti n o i n, irhesaftan-hydrochlorothiazide, losaftan, EPIDUO, RETIN-A MICRO, TAZOMC losartan-hydrochlorolhi azide, olmesaftan, oh e s a rtan -hy d ro c h lo roth i azi d e, tel m i s a rt a n, esomeprazole, lansoprazole, omeprazole, ACIPHEX, ACIPHEX SPRINKLE te I mi s a fta n - hy d roch I o rot h i azi d e, v a I s a rtan, pantop razole, DEXILANT v al s a il a n -hy d r o c h lo roth i azi d e doxycycline hyclate, minocycline, tetracycline ACTICLATE ATROVENT HFA ip ratropi un i n h al ation soluti on, INCRUSE ELLIPTA, SPIRIVA ACTOS pioglitazone AVENOVA Consult doctor ADDERALL XR amphetamine- dextroanphetamine mixed salts ext-rel, MELEX ad apalene, benzoyl pe roxi de, methylphenidate ext-rel MYDAYIS, WVANSE clindanycin solution, clindamycin- benzoyl peroxide, erythromycin solution, ALCORTIN A de sonide, hydrocorti sone e rylh ro my ci n - b e nzoy I p e roxi d e, Alevicyn solution, ALEVICYN GEL, de sonide, hydroco rti sone lrefnoin, EPIDUO, RETIN'A MlCR0, ALEVICYN KIT, ALEVICYN SG TMORAC

ALLISON MEDICAL INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES BECONASE AQ flunisolide, fluticasone, mometasone, tiamcinolone, DYMISTA ALORA eslradlol, DIVIGEL, EVAM IST BENICAR, BENICAR HCT c an d e s a rta n, ca nd e s a fta n -hyd ro ch loroth i azi d e, alorvastatin, ezeti mibe- simv a statin, fl uva stati n, ALTOPREV ep rosartan, i rbesaft an, lovastatin, pravastatin, rosuvastatin, simvastatin irbe saftan - hyd rochlorothi azi de, los aftan, losartan-hydrochlorothiazide, olmesartan, ALVESCO ARNUIW ELLIPTA, ASMANEX, m e rt an - hy d ro ch lo roth i azi d e, te I mi s arta n, FLOVENT DISKUS, FLOVENT HFA, ol sa te I mi s a a n - hy d ro ch I o rot hi azid e, v al s afta n, PULMICORT FLEXHALER, QVAR, ft v al s a fta n -hyd ro ch lo roth i azi d e QVAR REDIHALER BENSAL HP de sonide, hyd rocorti sone AMRIX cyclobenzaprine

BENZAC AC ad a p alene, benzoyl pe roxide, ANDROGEL 1% testosterone gel, testosterone solution, clindamycin solution, clindamycin- ANDRODERM benzoyl peroxide, erythromycin solution, ANGELIQ estradiol-norethindrone, PREMPHASE, e ryth r o my ci n - b e nzoy I p e roxi d e, PREMPRO treti noin, EPIDUO, RETIN-A M lCR0, TMORAC ANTARA fenofibrate (except tenofibrate tablet 120 mg), fenofibic acid BENZACLIN adap alene, benzoyl pe roxi de, clindamycin solulion, clindanycin- nonide APEXICON E de soximetasone, fl uoci benzoyl peroxide, erythronycin solution, (exepl fl uoci nonide cre am 0. 1 %) eryth romycin- benzoyl p e roxide,

treti n oi n, EP IDUO, RETIN-A MICRO, APIDRA FIASP, NOVOLOG TMORAC ARMOUR THYROID levothyroxine, liothyronine,SYNTHROlD BENZIQ adap ale ne, benzoyl pe roxide, ARTHROTEC celecoxib; diclofenac sodiun, ibuprofen, clindamycin solution, clindamycin- meloxicam or naproxen (exceplnaproxen CR benzoyl peroxide, erythromycin solution,

ot naprcxen suspension) WITH esomeprazole, e rylh r o my ci n - b e nzoy I p e roxi d e, lansoprazole, omeprazole, pantoprazole or frellnoin, EPIDUO, RETIN-A MlCRO, DEXILANT TMORAC

ASACOL HD balsalazide, sulfa sal azine, benzonatate benzonatate sulfasalazine delayed-rel APRISO, PENTASA (NDCs^ 69336012615, 69499032915 only) (except NDCs^ 6933601261 5, 6949903291 5)

BETAPACE, BETAPACE AF sotalol

Your specific prescription benefit plan this document. For specific information,f:l'ffi #"il":::#il"i'i3["S."i,.!ll3li3?Xili%1'3::i;'o[:ll.?X,?ff "*''?CVScaremark' DRUG NAME(S) RRED OPTION(ST DRUG NAME(S)

BEYAZ ethi ny I e strad iol-d ro sphenone, DETROL LA darifenacin exfrel, oxybutynin ext-rel,

ethi n y I e st r ad i o I - d ro s p h e n o n e - I ev om efo I ate, solifenacin, tolterodine, tolterodine exlrel, ethinyl estradiol-norethindrone acetate, trospiun, trospium exf-rel MYRBETRIQ, ethinyl estradiol-norethindrone acetate-iron, TOVIM SAFYRAL Dexifol folic acid BREEZE 2 STRIPS AND KITS 8 ACCU-CHEKAVIVA PLUS STRIPS AND KITS 6, Dexpak dexameth a sone, hyd rocortisone, ACCUCHEK COil/PACT PLUS STRIPSAIID KJIS q methylprednisolone, prednisolone solution, ACCU-CHEK GUIDE STRIPS AND KITS 6, prednisone ACCU-CHEK SMARTVIEW STRIPS AND KITS 6

diclofenac sodium gel 1% diclofenac sodium, diclofenac sodium gel 1o/o b ut alb it a I - a c et a n i no p h e n diclofen ac sodium, ibuprofen, naproxen (except (NDC^ 69499031866 only) (except NDC^ 69499031866), (NDC^ 69499034230 only) naprcxen CR or naproxen suspenslon) diclofenac sodium solution, ibuprofen, b uta I b it a l - aceta m i no p h e n - c aff e i n e c ap s u le diclofenac sodium, ibuprofen, naproxen (excepl meloxicam, naproxen (excepl naproxen CR or naproxen CR or naproxen suspension) naproxen suspension\

BYDUREON OZEMPIC, TRULICITY, VICTOZA Diclofex DC diclofenac sodium, diclofenac sodium gel 1% (NDC^ 51021037201 only) (except NDC^ 69499031866), BYETTA OZEMPIC, TRULICITY, VICTOZA diclofenac sodium solution, ibuprofen, meloxicam, naprcxen (except naproxen CR or CAFERGOT eletiptan, ergotanine-catfeine, narctiptan, naproxen suspension) izatriptan, sumatiptan, zolmitiptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, Diclosaicin diclofenac sodium, diclofenac sodium gel 1% ZOMIG NASAL SPRAY (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, calcipotiene cream calcipotiene ointment, calcipotriene solution meloxicam, naprcxen (except naproxen CR or calcitiol ointment calcipotiene ointment, calcipotriene solution naproxen suspension)

CAMBIA diclofenac sodium, ibuprofen, meloxicam, diflorasone cream, diflorasone ointment de soxi metaso ne, f luoci nonide naproxen (excepl naproxen CR or (excepl fluocinoni de cre am 0. 1%) naproxen suspension) dihydroe rgotamine sp ray eletiptan, ergotamine-caffeine, naratriptan, CARAC fluorouracil cream 5%, fluorouracil solution, izatiptan, sunatiptan, zolmitiptan, imiquimod, PlCATO, T0LAK, ZYCLARA ONZETM XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY carbinoxamine tablet 6 ng levocetiizine DIOVAN, DIOVAN HCT cande sartan, can d e sartan -hyd tochlorothi azi de, exfrel CARDIZEM, CARDIZEM CD, diftiazen e p rosartan, i rbes ailan, generic CARDIZEM LA (and its generics) (except CARDIZEM LA) irbesartan-hydrochlorothiazide, losaian, los aft a n-hyd roch lo rothi azid e, olm esa rtan, CARNITOR, CARNITOR SF levocarnitine ol me sa rtan-hyd rochlorothi azi d e, telmi s artan, CHLORZOMZONE 250 MG cyclobenzaprine te lni sa rtan-hyd rochlorothiazide, v al s artan, (NDCs^ 46672086046, 69499033060 only) v al s a rla n - hy d ro c h lo r oth i azi d e

CIALIS sildenafil, tadalafil DORAL eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual BELSOMRA, SILEN0R CLINDAGEL erythromycin solution DORYX, DORYX MPC doxycycline hyclate, minocycline, tetracycline clobetasol spray clobetasol foam doxepin cream desonide, hydrocortisone, facroltmus, ELIDEL, CLOBEX SPRAY clobetasol foam EUCRISA balsalazide COLAZAL DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT COLCRYS colchicine tablet

6, metoprolol su ccin ale ex[rel WITH CONTOUR NEXT STRIPS AND KITS B ACCU{HEKAVIVA PLUS STRIPS AND KITS DUTOPROL hydrochlorothiazide ACCUCHEKCOil/PACT PLUS STRIPSAND KIIS g ACCU-CHEK GUIDE STRIPS AND KITS 6, DYRENIUM aniloride ACCU-CHEK SMARTVIEW STRIPS AND KITS 6 EDARBI, EDARBYCLOR candesartan, candesarlan-hydrochlorothiazide, 8 ACCUCHEKAVIVA PLUS STRIPS AND KITS 6, CONTOUR STRIPS AND KITS ep rosaft an, irb esartan, q ACCU-CHEK COil/PACT PLUS $RIPSAI{D KIIS irbesartan-hydrochlorothiazide, losartan, ACCU-CHEK GUIDE STRIPS AND KITS 6, lo s a rta n - hy d ro c h I o roth i azi d e, olm e s a rt a n, ACCU4HEK SMARTVIEW STRIPS AND KITS 6 olme saft an -hyd roch lorothi azi d e, telmis aftan, te lmi sa ftan-hy d rochlorothiazide, v al saftan, CONTRAVE BELVIQ, BELVIQ XR, SAXENDA v al s a rta n - h y d roc h lo r oth i azi d e CORDRAN OINTMENT clocortolone, hydrocortisone butyrate, mometasone, ti amcinolone EDLUAR eszopiclone, zolpidem, zolpiden ext-rel, zolpiden sublingual, BELSOMM, SILEN0R COUMADIN watain E.E.S. GRANULES erythromycins CRESTOR atolastati n, ezeti mibe - simv astati n, fl uv astati n, venlafaxine, lovastatin, pravastatin, rosuvastatin, simvastatin EFFEXOR XR desvenlafaxine ext-rel, duloxetine, ven lafaxi n e ext- rel cap su le CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, ENABLEX darifenacin exlrel, oxybutynin ext-rel, ve nl afaxi n e ext- rel cap sule solifenacin, tofterodine, tolterodine ext-rel, DELZICOL b al salazide, su lfasal azine, trospium, trospium exf-rel MYRBETRIQ, sulfasalazine delayed-rel APRlS0, PENTASA TOVIM

[?Jffffi*,lfT,"j'5i:lffk"l*i],:l f""in3#;11,"*'$;i:::iiil"i:tv1'""#lfl;3i'r,fi5'3::i;'ol3:5"?:f;1**" '' ?GVS caremark" DRUG NAME(S) PREFERRED OPTION(SF DRUG NAME(S) PREFERRED OPTION(ST

ERYPED erythromycins FROVA eletiptan, naratriptan, izatiptan, sumatriptan zolmitiptan, ONZETM XSAIL, EVEKEO amphetamine-dextroamphetamine nixed safts, ZEMBRACE SYMTOUCH, methylphenidate ZOMIG NASAL SPRAY

EVZIO naloxone injeclion, NARCAN NASAL SPMY Genicin Vita-S folic acid

EXFORGE amlodi pi ne -olme saian, am lodi pinelelm i sartan, GLUMETZA (and its generic) netfo rmin, metfo r min ext- rel amlodipine-valsartan (except generic FORTAMET or GLUMETZA)

EXFORGE HCT am I o d i p i ne -v al s art a n - hy d ro c h I o roth i azi d e, GLYCOPYRROLATE TABLET 1.5 MG dicyclomine olme s arlan - a mlodipi ne - hyd roch lorothi azi de HORIZANT gabapentin, GMLISE FANAPT aripiprazole, clozapine, olanzapine, quetiapine, queliapine ext-rel, isperidone, ziprasidone, HUMALOG FIASP, NOVOLOG LATUDA, VRAYLAR HUMALOG MIX 50/50 NOVOLOG MIX 7Ol30 FEMRING eslradiol ESTRING, PREMARIN CREAM HUMALOG MIX75/25 NOVOLOG MIX 7Ol30 fenofibrate tablet 120 mg fenofibrate (exceplfenofibrate tablet 120 mg), fenofibic acid HUMULIN 7Ol30 N0v0LrN 70/30

HUMULIN N NOVOLIN N FENOGLIDE TABLET,I20 MG fenofibrate (exceplfenofibrate tablet 120 mg),

fenofibic acid HUMULIN R NOVOLIN R

fenoprofen capsule diclofenac sodium, ibuprofen, meloxicam, HylaVite folic acid naproxen (except n aproxen CR or naproxen suspension) INDOCIN diclofenac sodium, ibuprofen, meloxican, naproxen (except naproxen CR or FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, naproxen suspension) naproxen (excepl naproxen CR or naproxen suspension) lnflammacin diclofenac sodium, diclofenac sodiun gel 1% (except NDC^ 69499031866), FERIVA 217 folic acid diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, naproxen suspensionl ven I afaxi n e ext- rel cap su le INNOPRAN XL atenolol, caruedilol, FINACEA GEL metronidazole, FINACEA FOAM, S0OLANTRA c arvedi lol phosp h ate ext- rel, FIORICET CAPSULE diclofenac sodiun, ibuprofen, naproxen (excepl metoprolol succinate ext-rel, metoprolol tartrate, naproxen CR or naproxen suspension) n ado lol, pi ndol ol, propr anolol, prop ranolol ext-rel, BYSTOLIC fluocinonide crean 0.1% clohetasol cream INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, zolpidem sublingual BELSOMM, SILENOR imiquimod, PlCATO, TOLAK, ZYCLARA INTUNIV amphetanine- fl ur and ren olide oi ntme nt clocortolone, hydrocortisone butyrate, dextroamphetamine mixed safts ext-rel, mometasone, ti amci nolone atomoxetine, gu anfacin e ext-rel, FML LIOUIFILM dexamethasone, prednisolone acetate 1%, methylphenidate exl+el MYDAYIS, VYVANSE DUREZOL, FLAREX, FML FORTE, INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR FML S.O,P., MAXIDEX, PRED MILD INVOKANA FARXIGA, JARDIANCE FOLIC-K folic acid ISTALOL timolol maleate solution, BETIMOL FOLIKA-D folic acid JALYN dutasteride-tamsulosin; dutasteride or Folika-T folic acid finasteride WTH alfuzosin ext-rel, doxazosin, FOLIKA.V folic acid sr'lbdosln, tamsulosin or terazosin

FORTAMET (and its generic) metformin, metformin ext-rel JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR (except generic FORTAMET or GLUMETZA) KAZANO JANUMET, JANUMET XR gel, testosterone solution, FORTESTA testosterone KOMBIGLYZE XR JANUMET, JANUMET XR ANDRODERM lactulose pak lactulose solution FOSAMAX PLUS D alendronate, ibandronate, isedronate LAMICTAL, LAMICTAL ODT, carbamazepine, carbamazepine ext-rel, FOSRENOL calcium acetate, lanthanun carbonate, LAMICTAL XR divalproex sodium, divalproex sodium ext-rel, sevelamer carbonale, PHOSLYRA, gabapentin, lanotrigine, lanotrigine ext-rel, VELPHORO levetiracetam, levetiracetam ext-rel, phenobahital, phenytoin, FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, isedronate oxcarbazepine, phenytoin sodium extended, pimidone, FREESTYLE STRIPS AND KITS 8 ACCU{HEKAVIVA PLUS STRIPS AND KITS 6, tiagabine, tophamate, valproic acid, ACCI.JCHEKCOil/PACT PLUS STRIPSAM KIIS g zonisamide, FYCOMPA, OXTELLAR XR, ACCU-CHEK GUIDE STRIPS AND KITS 6, TROKENDI XR, VIMPAT ACCU-CHEK SMARTVIEW STRIPS AND KITS 6 LANOXIN TABLET digoxin (125 MCG and 250 MCG only)

LANTUS BASAGLAR, LEVEMIR, TRESIBA

Your specific prescription benefit plan this document. For specific inlormation i::l'ffi#ff:::ffU"?f3U"S""i,.!il3l-"3?liii%?'3::i;'o[:ll.?:,?ff**" '' 9GVS caremark" NAM PREFERRED OPT DRUG NAME(S} PREFERRED O

LAZANDA fentanyl transmucosa/ /ozenge, ABSTML, NESINA JANUVIA SUBSYS NEXIUM esomeprazole, lansoprazole, omeprazole, LESCOL XL atorvastalin, ezetimibe-simvastatin, fluvastatin, p antop r azole, DEXILANT lovastalin, pravastatin, rosuvastatin, sinvastatin NICA'RIN folic acid levorphanol fentanyl transdermal, hydronorphone ext-rel, NICMEL, NICMEL FORTE folic acid methadone, morphine ext-rel, EMBEDA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN NILANDRON abiraterone, blcalulamlde, XTANDI LEXAPRO citalopram, escitaloryam, fluoxetine, NITROMIST nitroglycerin lingu al sp r ay, paroxetine HCl, paroxetine HCI ext-rel, nitrogly ce ri n sub li ngu al sertrcilne, TRINTELLIX, VIIBRYD NORITATE metronidazole, FINACEA FOAM, SOOLANTRA LIALDA b al salazi de, sulfasal azi ne, sulfasalazine delayed-rel APRISO, PENTASA NORVASC amlodipine

LIDOCAINE-TETRACAINE CREAM lidocaine-pilocaine NOVACORT de sonide, hyd roco rti sone

LIDOTREX lidocaine-pilocaine NOVO NORDISK NEEDLES 9 BD ULTMFINE NEEDLES

LIPITOR atoruastatin, ezetimibe-simvastatin, fluvastatin, NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1% lovastatin, pravastatin, rosuvastatin, simvastatin (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, o a e z i ib e - a n, fl a n, LIVALO at ru st ati n, et m si nv st ati uv st ati meloxicam, naproxen (except naproxen CR or pravastatin, lovastatin, rosuvastatin, sinvastalin naproxen suspension)

Loid folic acid NUVIGIL armodafinil

LUNESTA eszopiclone, zolpidem, zolpidem ext-rel, OLEPTRO trazodone zolpidem sublingual, BELSOMM, SILENOR OLUX-E clobetasol foam MACRODANTIN nitrofurantoin ome p razole-sodi u m bicarhonate esomeprazole, lansoprazole, omeprazole, MatzinU diftiazem ext-rel pantoprazole, DEXILANT (except generic CARDIZEM LA) OMNARIS flunisolide, fluticasone, mometasone, MEBOLIC folic acid tiamcinolone, DYMISTA

MENEST es/radroi PREMARIN OMNIVEX folic acid MENOSTAR estradiol ONETOUCH ULTRA STRIPS AND KITS 8 ACCU-CHEKAVIVA PLUS STRIPSAND KITS 6, ACCU{HEK COIVPACT RIJS SIRIPSAlD KITS 6, MIACALCIN INJECTION alendronate, calcitonin'salmon, ibandronate, 6, isedronate, FORTE0, PROLIA, TYMLOS ACCU-CHEK GUIDE STRIPS AND KITS ACCU-CHEK SMARTVIEW STRIPS AND KITS 6 MIACALCIN NASAL SPRAY calcitonin-salmon ONETOUCH VERIO STRIPS AND KITS 8 ACCU-CHEKAVIVA PLUS STRIPS AND KITS 6,

MICARDIS, MICARDIS HCT can de saftan, c ande sartan -hyd rochl orothiazi de, ACCUCHEK COIVPACT PLUS $RIPSAAID KJIS q ep rosartan, i rb esalan, ACCU-CHEK GUIDE STRIPS AND KITS 6, i rbe sa lan -hyd rochlorothi azi de, losaftan, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6 losaftan-hydrochlorothi azide, olmesaftan, ONEXTON ad ap al ene, benzoyl pe roxi de, olme sartan - hyd rochlo rothiazi de, telmis artan, clindamycin solution, clind amycin- telmi saftan-hyd roch lorothi azide, v al sartan, benzoyl peroxide, erythromycin solution, v a b a rta n - h y d r o c h I o roth i azi d e erylhrony ci n- benzoyl peroxi d e, MILLIPRED dex ameth asone, hydrocorti sone, frelinoln, EPIDUO, RETIN-A MlCR0, methylprednisolone, prednisolone solution, TMORAC prednisone ONFI clob azam, I anotigine, topi rcm atei MINASTRIN 24 FE ethi nyl estrad iol -dro spirenone, TROKENDI XR

et hi ny I e st r a d i ol - d ro sp i re n on e J ev om efo I ate, ONGLYZA JANUVIA ethinyl estradiol-norelhindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ORTHO DF folic acid SAFYRAL ORTHO TRI-CYCLEN LO et h i ny I e st r ad i ol - no rge sti m ate MINIVELLE estradiol DIVIGEL, EVAMIST OSENI JANUMET, JANUMET XR MINOCIN doxycycline hyclate, minocycline, tetracycline OWEN MUMFORD NEEDLES 9 BD ULTMFINE NEEDLES nupirocin cream ge ntamicin, mu pi roci n ointment OXYTROL daifenacin ext-rel, oxybutynin ext-rel, NAPRELAN diclofenac sodium, ibuprofen, meloxicam, solifenacin, tofterodine, tolterodine ext-rel, (excepl naproxen naproxen CR or ttospium, trospiun exf-rel MYRBETRIQ, naproxen suspensionl TOVIM naproxen CR diclofenac sodium, ibuprofen, meloxican, PANCREAZE CREON, VIOKACE, ZENPEP naproxen (except n aproxen CR ot naproxen suspension) PENNSAID diclofenac sodium, diclofenac sodium gel 1o/o (except NDC^ 69499031866), suspension ibuprofen naproxen diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or NATESTO lestosferone gef testosterone solution, naproxen ANDRODERM suspension)

[?Jfffi5,i"";',":,3::11ffi""1*,jff T""in;.T"?i,",1;3;":::ffu"i'i3v"S."#1':l;[:ifi%1'331j,3'ol3:5"?!f;j"* '' 9GVS caremark' DRUG NAME(S) PREFERRED DRUG NAME(S) PREFERRED OPTIO

PERCOCET hydrocodone- acetaminophen, hydromorphone, ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, morphine, oxycodone-acetaminophen, zolpidem sublingual, BELSOMM, SILEN0R NUCYNTA SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, PERRIGO NEEDLES 9 BD ULTRAFINE NEEDLES quetiapine ext-rel, isperidone, ziprasidone, LATUDA, VRAYLAR PERTZYE CREON, VIOKACE, ZENPEP SINGULAIR montelukast, zafrrlukast, zileuton exfrel PEXEVA citalopram, escitalopram, fluoxetine, paroxetine HCl, paroxetine HCI ext-rel, SORILUX calcipotiene ointment, calcipotriene solution seftraline, TRINTELLIX, VIIBRYD SPRIX diclofenac sodium, ibuprofen, meloxicam, PLAVIX clopidogrel, p r asugre l, BRILI NTA naproxen (except n aproxen CR ot naproxen suspensionl PRADAM warfanh, ELIQUIS, MRELTO STENDRA sildenafil, tadalafil PRECISION XTRA STRIPS AND KITS 8 ACCUCHEKAVIVA PLUS STRIPS AND KITS 6, ACCU{HEK COIVPACT PLI,JS STRIPS AAID KJIS q STRIANT fesfosferone gei testosterone solution, ACCU-CHEK GUIDE STRIPS AND KITS 6, ANDRODERM ACCU-CHEK SMARTVIEW STRIPS AND KITS 6 SUBOXONE bu p ren orphi n e-n aloxon e subli ngu al, ZU BS0LV PRED FORTE dexamelhasone, prednisolone acetate 1%, SURE-TEST STRIPS AND KITS B ACCU-CHEKAVIVA PLUS STRIPS AND KITS6, DUREZOL, FLAREX, FML FORTE, ACCUCHEKCOIiPACTPLUSSTRIPSA IDKItSg FML S.O.P., MAXIDEX, PRED MILD ACCU-CHEK GUIDE STRIPS AND KITS 6, PREFEST estradiol-norethindrone, PREMPHASE, ACCU.CHEK SMARTVIEW STRIPS AND KITS 6 PREMPRO SYNERDERM de sonide, hyd rocorli so ne PRENATAL PLUS geneic prenatal vitamr'lns, CITMNATAL TALIVA folic acid PREVACID esomeprazole, lansoprazole, omeprazole, TARGADOX doxycycline hyclate, minocycline, tetracycline pantoprazole, DEXILANT TESTIM feslosferone gel lesfosferone so/ufion, PREVIDENT Consult doctor ANDRODERM PRIMLEV hyd rocodone - acet aminoph e n, hy d romorphon e, testosterone gel 1% 10 feslosferone gei testosterone solution, morphine, oxycodone-acetaminophen, ANDRODERM NUCYNTA TIROSINT levothyroxine,SYNTHR0lD PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, ve n lafaxi ne ex!+el cap su le TOPROL.XL atenolol, carvedilol, caruedi lol p hosp h ate ext- re l, PROTONIX esomeprazole, lansoprazole, omeprazole, metoprolol succinate ext-rel, metoprolol tartrate, pantoprazole, DEXILANT n adolol, pi ndolol, propranolol, PROTOPIC tacrolimus, ELIDEL, EUCRISA propranolol ext-rel, BYSTOLIC

PROVENTIL HFA albuterol sulfate CFC-free aerosol, TOUJEO BASAGLAR, LEVEMIR, TRESIBA levalbuterol talrate CFCJree aerosol, TRADJENTA JANUVIA PROAIR HFA, PROAIR RESPICLICK TRICOR fenofibrate (exceptfenofibrate tablet 120 mg), PROZAC citalopran, escitalopram, fluoxetine, fenofibic acid paroxetine HCl, paroxeline HCI ext-rel, seilraline, TRINTELLIX, VIIBRYD TRIGLIDE fenofibrate (except fenofibrate tablet 1 20 mg\, fenofibic acid PSORCON de soximetaso ne, fl uoci nonide (exept fl u oci nonide cre am 0. 1 %) TRILIPIX fenofibrate (exceptfenofibrale tablet 120 mg), fenofibic acid QNASL fl unisolide, fluticasone, mometasone, tiamcinolone, DYMISTA TRIVIDIA INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES

QSYMIA BELVIQ, BELVIQ XR, SMENDA TronVite folic acid

RAPAFLO alfuzosin ext-rel, doxazosin,sr'lbdostn, TRUETEST STRIPS AND KITS 8 ACCU-CHEKAVIVA PLUS STRIPS AND KITS 6, tansulosin, terazosin ACCIICHEKCOI/PACT PLUSSIRIPSA ID KIIS6, ACCU-CHEK GUIDE STRIPS AND KITS 6, RAYOS dexameth a sone, hyd rocorli sone, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6 nethylprednisolone, prcdnisolone solution, prednisone TRUETRACK STRIPS AND KITS 8 ACCUCHEKAVIVA PLUS STRIPS AND KITS 6, ACCT TCHEKCOI/PACT PLUS S]RIPSAI{D KIIS RELION INSULIN NOVOLIN INSULIN E ACCU-CHEK GUIDE STRIPS AND KITS 6, RELISTOR MOVANTIK ACCU-CHEK SMARTVIEW STRIPS AND KITS 6

RHEUMATE folic acid TUDORZA INCRUSE ELLIPTA, SPIRIVA

RIBOZEL folic acid ULTIMED INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES

g RtMS0-50 Consult doctor ULTIMED NEEDLES BD ULTRAFINE NEEDLES

RIOMET metfornin, metformin ext-rel UROXATRAL alfuzosin ext-rel, doxazosin,s/odosln, (except generic FORTAMET or GLUMETZA) tamsulosin, terazosin

VALCYTE valganciclovir

[?Jfffili,:t""",":fj.i,iifft"i,liff itl'S"T"?l'?1#":i:ffU"if8f:'""ifilll-"3",liii%1'3:ii;'o[:X,?X,?ff*'* ''. ?CVS caremark" DRUG NAME(S) PREFERRED OPTION(ST DRUG NAME(S) REFERRED OPTION(SF

VALTREX acy cl ov i r, v a I a cy c lov i r Xvite folic acid

VANATOL LQ, VANATOL S diclofenac sodium, ibuprofen, naproxen (except XYZBAC folic acid naproxen CR or naproxen suspension) YM ethi nyl estrad iol-drosp i renone, Vanoxide-HC ad apalene, benzoyl pe roxide, et h i nyl e st r ad i o I - d ro sp i r e n o n e - I ev o m efo I ate, clindamycin solution, clindamycin- ethinyl estradiol-norethindrone acetate, benzoyl peroxide, erythromycin solution, ethinyl estradiol-norethindrone acetate-iron, erythromycin- benzoy I p eroxide, SAFYRAL frefinoin, EPIDUO, RETIN-A MlCR0, lansoprazole, omeprazole, TMORAC ZEGERID esomeprazole, pantoprazole, DEXILANT VASCULERA Consult doctor ZETIA ezetinibe VECTICAL calcipotiene ointment, calcipotiene solution ZETONNA fl unisolide, fluticasone, mometasone,

VELTIN ad ap ale ne, b enzoyl pe roxide, tdamcinolone, DYMISTA clindamycin solution, clindamycin- ZIANA ad ap alene, benzoyl pe roxide, benzoyl peroxide, erythromycin solution, clindamycin solution, clindamycin- eryth ronycin-benzoy I p e roxide, henzoyl peroxide, erythromycin solution, lreflnoin, EPIDUO, RETIN-A MlCRO, eryth ro mycin- benzoy I peroxi d e, TMORAC fretlnorn, EPlDU0, RETIN-A MlCR0, venl afaxi ne ext- rel tab let desvenlafaxine ext-rel, duloxetine, venlafaxine, TMORAC (except 225 mg) ven lafaxi ne ext- rel cap sule ZOLPIMIST eszopiclone, zolpidem, zolpidem exlrel, VENTOLIN HFA albuterol sulfate CFC-free aerosol, zolpidem sublingual BELSOMRA, SILENOR levalbuterol taftrate CFCJree aerosol, ZONEGRAN carbamazepine, carbamazepine ext-rel, PROAIR HFA, PROAIR RESPICLICK divalproex sodium, divalproex sodium ext-rel, VIAGRA sildenafil, tadalafil gabapentin, lanotrigine, lamotigine ext-rel, levetiracetam, levetiracetam ext-rel, geneic prenatal VITAFOL-ONE vitam,hs, CITRANATAL oxcarbazepine, phenobahital, phenytoin, phenytoin sodium extended, pimidone, VIVELLE-DOT esfradiol DIVIGEL, EVAMIST tiagabine, topiramate, valproic acid, VOGELXO testosterone gel, testosterone solution, zonisamide, FYC0MPA, OXTELLAR XR, ANDRODERM TROKENDI XR, VIMPAT

MNM,XANAXXR alprazolam, clonazepam, diazepam, lorazepam, ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, oxazepan naproxen (except n aproxen CR or naproxen suspension) Xelitral diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), ZUPLENZ granisetron, ondansetron, SANCUSO diclofenac sodium solution, ibuproten, ZYFLO, ZYFLO CR montelukast, zafirlukast, zileuton ext-rel meloxicam, naprcxen (except naproxen CR or naproxen suspension) ZYVIT folic acid

XOLEGEL ci clopi rox, ketocon azol e

XOPENEX HFA albuterol sulfate CFC-free aerosol, levalbuterol taftrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document, For specific information, visit@g!@ or contact a CVS Caremark Customer Care representative. ?CVScaremark" You may be responsible for the full cost ofcertain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

Caremark.com to check coverage and copayt information for a specific medicine.

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

size.

g Generics are available in this class and should be considered the first line of prescribing. t Copayment, copay or coinsurance means the amount a member is required to pay for a prescriptron 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 Listing does not include n aproxen CR or naproxen suspension. 3 Listing does not include fenofibrate tablet 120 mg. 4 Listing does not include generic CARDIZEM LA. 5 Listing does not include generic FORTAMET or GLUMETZA. o An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals cunently using a meter other than ACCU-CHEK. For more information on how to obtain a blood glucose meter, call: 1-877418-4746. 7 Listing does not include fluocinonide cream 0.1%. 8 ACCU-CHEK brand test strips are the only prefened options. e BD ULTMFINE syringes and needles are the only preferred options. 10 Listing reffects the authorized generics for TESTIM and V0GELXO.

Plan member privacy is important to us. 0ur employees are trained regarding the appropriate way to handle members' private health information.

conkolled 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.

I?JHffiiH':"T,":ii:lffi""l[i-:li,::,1'ffi#*":i:ffi:"i'"'3i,"1'"Hff::;3i:,fi%1'3:f ;'o[:ll.?:,n:,"*"'" ?GVS caremarK