Performance Drug List - Standard Control

October 2020

The CVS Caremark® Performance Drug List - Standard Control 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 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. If 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 • The member's prescription benefit plan design may alter this document. Products recently approved by the U.S. Food 1 and Drug Administration (FDA) may not be covered upon coverage of certain products or vary copay amounts based on release to the market. the condition being treated. This drug list represents a summary of prescription coverage. • Your prescription benefit plan design may alter coverage of • certain products or vary copay1 amounts based on the condition It is not all-inclusive and does not guarantee coverage. The being treated. member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their • 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. • For specific information regarding your prescription benefit The member's prescription benefit plan may have a different 1 • coverage and copay information, please visit Caremark.com or copay1 for specific products on the list. contact a CVS Caremark Customer Care representative. • Unless specifically indicated, drug list products will include all • CVS Caremark may contact your doctor after receiving your dosage forms. prescription to request consideration of a drug list product or 1 generic equivalent. This may result in your doctor prescribing, • Log in to Caremark.com to check coverage and copay when medically appropriate, a different brand-name product or information for a specific medicine. generic equivalent in place of your original prescription.

• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non- preferred option upon release of the generic product to the market.

ANALGESICS § GOUT tramadol ext-rel § ERYTHROMYCINS / minocycline allopurinol BELBUCA MACROLIDES tetracycline § NSAIDs colchicine tablet NUCYNTA azithromycin § ANTIFUNGALS diclofenac sodium probenecid NUCYNTA ER clarithromycin fluconazole ibuprofen SUBSYS clarithromycin ext-rel § OPIOID ANALGESICS itraconazole meloxicam XTAMPZA ER erythromycins 2 terbinafine tablet naproxen buprenorphine transdermal DIFICID VISCOSUPPLEMENTS codeine-acetaminophen § NSAIDs, COMBINATIONS ANTIRETROVIRAL AGENTS fentanyl transdermal DUROLANE § FLUOROQUINOLONES § ANTIRETROVIRAL diclofenac sodium- fentanyl transmucosal GEL-ONE ciprofloxacin COMBINATIONS misoprostol lozenge GELSYN-3 levofloxacin

SUPARTZ FX abacavir-lamivudine § NSAIDs, TOPICAL hydrocodone ext-rel moxifloxacin hydrocodone-acetaminophen VISCO-3 ATRIPLA diclofenac sodium § PENICILLINS hydromorphone BIKTARVY gel 1% (except NDC^ ANTI-INFECTIVES hydromorphone ext-rel amoxicillin CIMDUO 69499031866) methadone ANTIBACTERIALS amoxicillin-clavulanate COMPLERA diclofenac sodium solution morphine dicloxacillin DESCOVY § CEPHALOSPORINS morphine ext-rel penicillin VK DOVATO § COX-2 INHIBITORS cefdinir morphine suppository EVOTAZ celecoxib cefprozil § TETRACYCLINES oxycodone GENVOYA

cefuroxime axetil oxycodone-acetaminophen doxycycline hyclate 20 mg ODEFSEY cephalexin tramadol (except NDC^ 52817019610) doxycycline hyclate capsule PREZCOBIX SUPRAX

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.

STRIBILD XTANDI § ANGIOTENSIN II § CALCIUM CHANNEL lorazepam SYMFI YONSA RECEPTOR ANTAGONIST / BLOCKER / ANTILIPEMIC oxazepam SYMFI LO CALCIUM CHANNEL COMBINATIONS § LUTEINIZING HORMONE- § ANTICONVULSANTS SYMTUZA BLOCKER / DIURETIC amlodipine-atorvastatin RELEASING HORMONE TEMIXYS COMBINATIONS carbamazepine (LHRH) AGONISTS TRIUMEQ amlodipine-valsartan- § DIGITALIS GLYCOSIDES carbamazepine ext-rel ELIGARD clobazam TRUVADA hydrochlorothiazide digoxin LUPRON DEPOT olmesartan-amlodipine- diazepam rectal gel INTEGRASE INHIBITORS § DIRECT RENIN divalproex sodium § KINASE INHIBITORS hydrochlorothiazide ISENTRESS INHIBITORS / DIURETIC divalproex sodium ext-rel TIVICAY imatinib mesylate § ANTIARRHYTHMICS COMBINATIONS ethosuximide AFINITOR sotalol aliskiren gabapentin § NUCLEOSIDE REVERSE BOSULIF MULTAQ TEKTURNA HCT lamotrigine TRANSCRIPTASE CABOMETYX lamotrigine ext-rel INHIBITORS COPIKTRA ANTILIPEMICS § DIURETICS levetiracetam abacavir tablet IBRANCE § BILE ACID RESINS amiloride levetiracetam ext-rel lamivudine IRESSA furosemide oxcarbazepine cholestyramine KISQALI hydrochlorothiazide phenobarbital § PROTEASE INHIBITORS colesevelam KISQALI FEMARA metolazone phenytoin atazanavir CO-PACK § CHOLESTEROL spironolactone- phenytoin sodium extended NORVIR RYDAPT ABSORPTION INHIBITORS hydrochlorothiazide primidone PREZISTA SPRYCEL ezetimibe torsemide tiagabine

triamterene topiramate ANTIVIRALS § MISCELLANEOUS § FIBRATES triamterene- valproic acid § CYTOMEGALOVIRUS LYNPARZA fenofibrate 4 hydrochlorothiazide vigabatrin AGENTS ODOMZO fenofibric acid delayed-rel zonisamide HEART FAILURE valganciclovir RUBRACA FYCOMPA § HMG-CoA REDUCTASE VISTOGARD BIDIL OXTELLAR XR § HEPATITIS B AGENTS INHIBITORS / ZEJULA CORLANOR TROKENDI XR entecavir COMBINATIONS ENTRESTO VIMPAT lamivudine CARDIOVASCULAR atorvastatin § NITRATES VEMLIDY ezetimibe-simvastatin § ANTIDEMENTIA § ACE INHIBITORS fluvastatin nitroglycerin lingual spray donepezil § HEPATITIS C AGENTS fosinopril lovastatin nitroglycerin sublingual galantamine ribavirin lisinopril pravastatin galantamine ext-rel EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) quinapril PULMONARY ARTERIAL rosuvastatin memantine HARVONI (genotypes 1, 4, 5, 6) ramipril HYPERTENSION simvastatin rivastigmine 3 VOSEVI § ENDOTHELIN RECEPTOR § ACE INHIBITOR / rivastigmine transdermal § NIACINS ANTAGONISTS § HERPES AGENTS DIURETIC COMBINATIONS NAMZARIC niacin ext-rel ambrisentan acyclovir capsule, tablet fosinopril-hydrochlorothiazide bosentan ANTIDEPRESSANTS valacyclovir lisinopril-hydrochlorothiazide § OMEGA-3 FATTY ACIDS OPSUMIT § SELECTIVE SEROTONIN quinapril-hydrochlorothiazide omega-3 acid ethyl esters REUPTAKE INHIBITORS § INFLUENZA AGENTS § PHOSPHODIESTERASE § ANGIOTENSIN II VASCEPA (SSRIs) oseltamivir INHIBITORS RECEPTOR ANTAGONISTS / RELENZA PCSK9 INHIBITORS citalopram sildenafil DIURETIC COMBINATIONS escitalopram

PRALUENT 6 § MISCELLANEOUS candesartan / candesartan- PROSTACYCLIN RECEPTOR fluoxetine clindamycin hydrochlorothiazide § BETA-BLOCKERS AGONISTS paroxetine HCl ivermectin irbesartan / irbesartan- paroxetine HCl ext-rel atenolol UPTRAVI sertraline linezolid hydrochlorothiazide carvedilol TRINTELLIX metronidazole losartan / losartan- carvedilol phosphate ext-rel § PROSTAGLANDIN VIIBRYD nitrofurantoin hydrochlorothiazide metoprolol succinate ext-rel VASODILATORS sulfamethoxazole- olmesartan / olmesartan- metoprolol tartrate ORENITRAM § SEROTONIN trimethoprim hydrochlorothiazide nadolol NOREPINEPHRINE vancomycin capsule telmisartan / telmisartan- SOLUBLE GUANYLATE pindolol REUPTAKE INHIBITORS EMVERM hydrochlorothiazide CYCLASE STIMULATORS propranolol (SNRIs) XIFAXAN 550 MG valsartan / valsartan- propranolol ext-rel ADEMPAS desvenlafaxine ext-rel hydrochlorothiazide BYSTOLIC ANTINEOPLASTIC § MISCELLANEOUS duloxetine AGENTS § ANGIOTENSIN II § CALCIUM CHANNEL ranolazine ext-rel venlafaxine RECEPTOR ANTAGONIST / BLOCKERS venlafaxine ext-rel capsule HORMONAL CALCIUM CHANNEL CENTRAL NERVOUS ANTINEOPLASTIC AGENTS amlodipine § MISCELLANEOUS BLOCKER COMBINATIONS 5 SYSTEM diltiazem ext-rel AGENTS § ANTIANDROGENS amlodipine-olmesartan nifedipine ext-rel ANTIANXIETY abiraterone amlodipine-telmisartan bupropion verapamil ext-rel 7 bicalutamide amlodipine-valsartan § BENZODIAZEPINES bupropion ext-rel ERLEADA alprazolam mirtazapine

NUBEQA clonazepam trazodone

diazepam

§ ANTIPARKINSONIAN § Triptans ENDOCRINE AND § MEGLITINIDES CALCIUM REGULATORS AGENTS eletriptan METABOLIC nateglinide § BISPHOSPHONATES amantadine naratriptan repaglinide alendronate ACROMEGALY carbidopa-levodopa rizatriptan ibandronate SOMATULINE DEPOT SODIUM-GLUCOSE carbidopa-levodopa ext-rel sumatriptan risedronate CO-TRANSPORTER 2 carbidopa-levodopa- zolmitriptan SOMAVERT (SGLT2) INHIBITORS § CALCITONINS entacapone ONZETRA XSAIL § ANDROGENS entacapone ZEMBRACE SYMTOUCH FARXIGA calcitonin-salmon testosterone gel 9 pramipexole ZOMIG NASAL SPRAY JARDIANCE testosterone solution pramipexole ext-rel PARATHYROID HORMONES PREVENTIVE MIGRAINE ANDRODERM SODIUM-GLUCOSE rasagiline FORTEO AGENTS CO-TRANSPORTER 2 ropinirole ANTIDIABETICS TYMLOS (SGLT2) INHIBITOR / ropinirole ext-rel Monoclonal Antibodies AMYLIN ANALOGS BIGUANIDE COMBINATIONS MISCELLANEOUS selegiline AIMOVIG SYMLINPEN NEUPRO SYNJARDY PROLIA AJOVY SYNJARDY XR EMGALITY § BIGUANIDES ANTIPSYCHOTICS XIGDUO XR § CARNITINE DEFICIENCY § ATYPICALS § MOVEMENT DISORDERS metformin AGENTS 10 metformin ext-rel SODIUM-GLUCOSE levocarnitine tetrabenazine aripiprazole CO-TRANSPORTER 2 AUSTEDO clozapine § BIGUANIDE / (SGLT2) INHIBITOR / CONTRACEPTIVES olanzapine INGREZZA SULFONYLUREA DIPEPTIDYL PEPTIDASE-4 § MONOPHASIC quetiapine COMBINATIONS § MULTIPLE SCLEROSIS (DPP-4) INHIBITOR ethinyl estradiol- quetiapine ext-rel glipizide-metformin AGENTS COMBINATIONS drospirenone risperidone glatiramer GLYXAMBI ethinyl estradiol- ziprasidone DIPEPTIDYL PEPTIDASE-4 AUBAGIO drospirenone-levomefolate ABILIFY MAINTENA (DPP-4) INHIBITORS SODIUM-GLUCOSE BETASERON ethinyl estradiol- ARISTADA JANUVIA CO-TRANSPORTER 2 COPAXONE norethindrone acetate ARISTADA INITIO (SGLT2) INHIBITOR / GILENYA ethinyl estradiol- LATUDA DIPEPTIDYL PEPTIDASE-4 DIPEPTIDYL PEPTIDASE-4 norethindrone acetate-iron VRAYLAR MAYZENT (DPP-4) INHIBITOR / (DPP-4) INHIBITOR / REBIF BIGUANIDE COMBINATIONS BIGUANIDE COMBINATIONS BIPHASIC § ATTENTION DEFICIT TECFIDERA JANUMET TRIJARDY XR HYPERACTIVITY DISORDER TYSABRI LO LOESTRIN FE JANUMET XR amphetamine- VUMERITY § SULFONYLUREAS § TRIPHASIC dextroamphetamine INCRETIN MIMETIC AGENTS § MUSCULOSKELETAL glimepiride ethinyl estradiol-norgestimate mixed salts OZEMPIC THERAPY AGENTS glipizide amphetamine- RYBELSUS glipizide ext-rel § EXTENDED CYCLE cyclobenzaprine 8 dextroamphetamine TRULICITY ethinyl estradiol- mixed salts ext-rel † VICTOZA SUPPLIES § NARCOLEPSY levonorgestrel atomoxetine ACCU-CHEK AVIVA PLUS armodafinil INCRETIN MIMETIC AGENT / guanfacine ext-rel STRIPS AND KITS 11 PROGESTIN INTRAUTERINE SUNOSI INSULIN COMBINATIONS methylphenidate ACCU-CHEK COMPACT DEVICES † SOLIQUA methylphenidate ext-rel POSTHERPETIC PLUS STRIPS AND KITS 11 KYLEENA XULTOPHY MYDAYIS NEURALGIA (PHN) ACCU-CHEK GUIDE MIRENA

VYVANSE STRIPS AND KITS 11 SKYLA GRALISE INSULINS ACCU-CHEK SMARTVIEW § FIBROMYALGIA BASAGLAR § TRANSDERMAL PSYCHOTHERAPEUTIC - STRIPS AND KITS 11 FIASP pregabalin MISCELLANEOUS BD ULTRAFINE ethinyl estradiol- HUMULIN R U-500 § OPIOID ANTAGONISTS INSULIN SYRINGES norelgestromin HYPNOTICS LEVEMIR AND NEEDLES § NONBENZODIAZEPINES naloxone injection NOVOLIN 70/30 § VAGINAL NARCAN NASAL SPRAY DEXCOM CONTINUOUS eszopiclone NOVOLIN N GLUCOSE ethinyl estradiol-etonogestrel ramelteon NOVOLIN R § PARTIAL OPIOID AGONIST / MONITORING SYSTEM NOVOLOG ENDOMETRIOSIS zolpidem OPIOID ANTAGONIST OMNIPOD INSULIN zolpidem ext-rel COMBINATIONS NOVOLOG MIX 70/30 ORILISSA INFUSION PUMP zolpidem sublingual TRESIBA buprenorphine-naloxone V-GO INSULIN ESTROGENS BELSOMRA INFUSION PUMP sublingual § INSULIN SENSITIZERS § ORAL ZUBSOLV § TRICYCLICS pioglitazone ANTIOBESITY estradiol doxepin PSEUDOBULBAR AFFECT SAXENDA PREMARIN § INSULIN SENSITIZER / AGENTS BIGUANIDE COMBINATIONS MIGRAINE § CALCIUM RECEPTOR § TRANSDERMAL NUEDEXTA ACUTE MIGRAINE AGENTS pioglitazone-metformin ANTAGONISTS estradiol

DIVIGEL Newer Agents § VASOMOTOR SYMPTOM § INSULIN SENSITIZER / cinacalcet

NURTEC ODT AGENTS EVAMIST SULFONYLUREA REYVOW paroxetine mesylate COMBINATIONS

UBRELVY pioglitazone-glimepiride

§ VAGINAL POTASSIUM-REMOVING § IRRITABLE BOWEL trospium HEREDITARY ANGIOEDEMA estradiol AGENTS SYNDROME trospium ext-rel FIRAZYR ESTRING LOKELMA alosetron MYRBETRIQ RUCONEST PREMARIN CREAM VELTASSA AMITIZA TOVIAZ TAKHZYRO

LINZESS ESTROGEN / PROGESTINS PROGESTINS HEMATOLOGIC IMMUNOSUPPRESSANTS VIBERZI § ORAL § ORAL § ANTICOAGULANTS § RAPAMYCIN DERIVATIVES § LAXATIVES estradiol-norethindrone medroxyprogesterone everolimus warfarin PREMPHASE megestrol acetate lactulose solution ELIQUIS PREMPRO progesterone, micronized peg 3350-electrolytes NUTRITIONAL / XARELTO

SUPREP SUPPLEMENTS TRANSDERMAL VAGINAL HEMATOPOIETIC GROWTH OPIOID-INDUCED § ELECTROLYTES CLIMARA PRO CRINONE FACTORS CONSTIPATION COMBIPATCH ENDOMETRIN potassium chloride liquid ARANESP MOVANTIK NEULASTA VITAMINS AND MINERALS ESTROGEN / SELECTIVE § SELECTIVE ESTROGEN SYMPROIC ESTROGEN RECEPTOR RECEPTOR MODULATORS NIVESTYM § FOLIC ACID / PANCREATIC ENZYMES RETACRIT MODULATOR raloxifene COMBINATIONS UDENYCA COMBINATIONS CREON OSPHENA folic acid

DUAVEE VIOKACE HEMOPHILIA A AGENTS § THYROID SUPPLEMENTS ZENPEP § PRENATAL VITAMINS ADYNOVATE FERTILITY REGULATORS levothyroxine prenatal vitamins § PROTON PUMP JIVI GNRH / LHRH liothyronine CITRANATAL INHIBITORS KOGENATE FS ANTAGONISTS SYNTHROID KOVALTRY esomeprazole RESPIRATORY CETROTIDE NOVOEIGHT GASTROINTESTINAL lansoprazole NUWIQ ALPHA-1 ANTITRYPSIN OVULATION STIMULANTS, omeprazole § ANTIEMETICS DEFICIENCY AGENTS GONADOTROPINS pantoprazole HEMOPHILIA B AGENTS doxylamine-pyridoxine DEXILANT PROLASTIN-C GONAL-F delayed-rel REBINYN OVIDREL § ANAPHYLAXIS dronabinol § STEROIDS, RECTAL § PLATELET AGGREGATION TREATMENT AGENTS GAUCHER DISEASE granisetron PROCTOFOAM-HC INHIBITORS meclizine epinephrine auto-injector CERDELGA clopidogrel metoclopramide § ULCER THERAPY EPIPEN CEREZYME dipyridamole ext-rel-aspirin ondansetron COMBINATIONS EPIPEN JR prasugrel § GLUCOCORTICOIDS prochlorperazine PYLERA SYMJEPI BRILINTA promethazine dexamethasone § MISCELLANEOUS § ANTICHOLINERGICS fludrocortisone scopolamine transdermal THROMBOCYTOPENIA sucralfate tablet ipratropium hydrocortisone trimethobenzamide AGENTS inhalation solution methylprednisolone SANCUSO GENITOURINARY MULPLETA INCRUSE ELLIPTA prednisolone solution VARUBI SPIRIVA prednisone § BENIGN PROSTATIC IMMUNOLOGIC § ANTISPASMODICS YUPELRI HYPERPLASIA AGENTS GLUCOSE ELEVATING dicyclomine alfuzosin ext-rel ANTICHOLINERGIC / BETA AGENTS ALLERGENIC EXTRACTS § H2 RECEPTOR doxazosin AGONIST COMBINATIONS BAQSIMI GRASTEK ANTAGONISTS dutasteride § SHORT ACTING

GLUCAGEN HYPOKIT ORALAIR dutasteride-tamsulosin ipratropium-albuterol famotidine GLUCAGON RAGWITEK finasteride inhalation solution EMERGENCY KIT INFLAMMATORY BOWEL silodosin AUTOIMMUNE AGENTS 12 GVOKE DISEASE tamsulosin LONG ACTING COSENTYX HEREDITARY TYROSINEMIA § ORAL AGENTS terazosin ANORO ELLIPTA ENBREL BEVESPI AEROSPHERE TYPE 1 AGENTS balsalazide ERECTILE DYSFUNCTION HUMIRA STIOLTO RESPIMAT ORFADIN budesonide capsule OTEZLA ALPROSTADIL AGENTS

budesonide ext-rel RINVOQ MUSE ANTICHOLINERGIC / BETA HUMAN GROWTH mesalamine delayed-rel SKYRIZI AGONIST / STEROID HORMONES mesalamine ext-rel § PHOSPHODIESTERASE STELARA INHALANT COMBINATIONS GENOTROPIN sulfasalazine INHIBITORS SUBCUTANEOUS TRELEGY ELLIPTA HUMATROPE sulfasalazine delayed-rel TREMFYA sildenafil PENTASA XELJANZ § ANTIHISTAMINES, LOW § PHOSPHATE BINDER tadalafil XELJANZ XR SEDATING AGENTS § RECTAL AGENTS § URINARY levocetirizine calcium acetate hydrocortisone enema § DISEASE-MODIFYING ANTISPASMODICS sevelamer carbonate mesalamine suppository ANTIRHEUMATIC DRUGS darifenacin ext-rel § ANTITUSSIVES PHOSLYRA mesalamine suspension (DMARDs) oxybutynin benzonatate (except NDCs^ VELPHORO CORTIFOAM RASUVO

oxybutynin ext-rel 69336012615, 69499032915) POLYNEUROPATHY solifenacin

tolterodine TEGSEDI tolterodine ext-rel

BETA AGONISTS, STEROID / BETA AGONIST § ANTIPSORIATICS OPHTHALMIC § CARBONIC ANHYDRASE INHALANTS COMBINATIONS acitretin § ANTIALLERGICS INHIBITORS § SHORT ACTING ADVAIR DISKUS calcipotriene ointment, azelastine dorzolamide albuterol inhalation solution ADVAIR HFA solution cromolyn sodium AZOPT albuterol sulfate BREO ELLIPTA methoxsalen olopatadine § CARBONIC ANHYDRASE CFC-free aerosol SYMBICORT LASTACAFT § ANTISEBORRHEICS INHIBITOR / BETA- levalbuterol tartrate PAZEO § STEROID INHALANTS ketoconazole shampoo 2% BLOCKER COMBINATIONS CFC-free aerosol budesonide selenium sulfide lotion 2.5% § ANTI-INFECTIVES dorzolamide-timolol

LONG ACTING inhalation suspension ciprofloxacin ATOPIC DERMATITIS CARBONIC ANHYDRASE Hand-held Active Inhalation ARNUITY ELLIPTA erythromycin Injectable INHIBITOR / FLOVENT DISKUS gentamicin SEREVENT SYMPATHOMIMETIC FLOVENT HFA DUPIXENT STRIVERDI RESPIMAT levofloxacin COMBINATIONS PULMICORT FLEXHALER moxifloxacin § Topical SIMBRINZA Nebulized Passive Inhalation QVAR REDIHALER ofloxacin

pimecrolimus PERFOROMIST sulfacetamide TOPICAL DRY EYE DISEASE tacrolimus tobramycin § CYSTIC FIBROSIS EUCRISA RESTASIS DERMATOLOGY BESIVANCE tobramycin XIIDRA ACNE CORTICOSTEROIDS CILOXAN OINTMENT inhalation solution § Topical § Low Potency § PROSTAGLANDINS BETHKIS § ANTI-INFECTIVE / latanoprost adapalene desonide ANTI-INFLAMMATORY travoprost § LEUKOTRIENE benzoyl peroxide hydrocortisone COMBINATIONS LUMIGAN MODULATORS clindamycin gel (except NDC^ neomycin-polymyxin B- § Medium Potency montelukast 68682046275) bacitracin-hydrocortisone RETINAL DISORDERS zafirlukast clindamycin solution hydrocortisone butyrate neomycin-polymyxin B- EYLEA zileuton ext-rel clindamycin-benzoyl cream, lotion, ointment, dexamethasone LUCENTIS peroxide solution tobramycin-dexamethasone § NASAL ANTIHISTAMINES erythromycin solution mometasone TOBRADEX OINTMENT RHO KINASE INHIBITORS azelastine erythromycin-benzoyl triamcinolone cream, lotion, TOBRADEX ST RHOPRESSA olopatadine peroxide ointment

tretinoin ANTI-INFLAMMATORIES RHO KINASE INHIBITOR / § NASAL STEROIDS / § High Potency EPIDUO § Nonsteroidal PROSTAGLANDIN COMBINATIONS desoximetasone ONEXTON bromfenac COMBINATIONS flunisolide fluocinonide 13 TAZORAC diclofenac ROCKLATAN fluticasone BRYHALI ketorolac mometasone § ACTINIC KERATOSIS § SYMPATHOMIMETICS § Very High Potency ACUVAIL DYMISTA fluorouracil cream 5% brimonidine ILEVRO fluorouracil solution clobetasol cream, foam, gel, PHOSPHODIESTERASE-4 NEVANAC ALPHAGAN P imiquimod lotion, ointment, shampoo INHIBITORS § Steroidal SYMPATHOMIMETIC / BETA- PICATO § LOCAL ANESTHETICS DALIRESP TOLAK dexamethasone BLOCKER COMBINATIONS lidocaine-prilocaine ZYCLARA PULMONARY FIBROSIS loteprednol COMBIGAN

§ ROSACEA prednisolone acetate 1% AGENTS § ANTIBIOTICS OTIC DUREZOL ESBRIET azelaic acid gel gentamicin FML FORTE § ANTI-INFECTIVE / OFEV doxycycline monohydrate mupirocin ointment FML S.O.P. ANTI-INFLAMMATORY delayed-rel capsule MAXIDEX COMBINATIONS SEVERE ASTHMA AGENTS § ANTIFUNGALS metronidazole CIPRODEX DUPIXENT FINACEA FOAM PRED MILD ciclopirox FASENRA clotrimazole SOOLANTRA BETA-BLOCKERS NUCALA econazole MOUTH / THROAT / § Nonselective XOLAIR ketoconazole cream 2% DENTAL AGENTS timolol maleate solution luliconazole

PROTECTANTS BETIMOL nystatin NAFTIN EPISIL Selective MUGARD BETOPTIC S QUICK REFERENCE DRUG LIST

A ACCU-CHEK COMPACT acyclovir capsule, tablet AJOVY alosetron PLUS STRIPS AND KITS 11 adapalene albuterol inhalation solution ALPHAGAN P abacavir tablet ACCU-CHEK GUIDE ADEMPAS albuterol sulfate alprazolam abacavir-lamivudine STRIPS AND KITS 11 ADVAIR DISKUS CFC-free aerosol amantadine ABILIFY MAINTENA ACCU-CHEK SMARTVIEW ADVAIR HFA alendronate ambrisentan abiraterone STRIPS AND KITS 11 ADYNOVATE alfuzosin ext-rel amiloride ACCU-CHEK AVIVA PLUS acitretin AFINITOR aliskiren AMITIZA STRIPS AND KITS 11 ACUVAIL AIMOVIG allopurinol amlodipine

amlodipine-atorvastatin buprenorphine-naloxone CRINONE ENTRESTO FML S.O.P. amlodipine-olmesartan sublingual cromolyn sodium EPCLUSA folic acid amlodipine-telmisartan bupropion cyclobenzaprine 8 EPIDUO FORTEO amlodipine-valsartan bupropion ext-rel 7 epinephrine auto-injector fosinopril amlodipine-valsartan- BYSTOLIC D EPIPEN fosinopril-hydrochlorothiazide

hydrochlorothiazide DALIRESP EPIPEN JR furosemide amoxicillin C darifenacin ext-rel EPISIL FYCOMPA amoxicillin-clavulanate CABOMETYX DESCOVY ERLEADA G amphetamine- calcipotriene ointment, desonide erythromycin dextroamphetamine solution desoximetasone erythromycin solution gabapentin mixed salts calcitonin-salmon desvenlafaxine ext-rel erythromycin-benzoyl galantamine amphetamine- calcium acetate dexamethasone peroxide galantamine ext-rel dextroamphetamine candesartan DEXCOM CONTINUOUS erythromycins GEL-ONE † mixed salts ext-rel candesartan- GLUCOSE ESBRIET GELSYN-3 ANDRODERM hydrochlorothiazide MONITORING SYSTEM escitalopram GENOTROPIN ANORO ELLIPTA carbamazepine DEXILANT esomeprazole gentamicin ARANESP carbamazepine ext-rel diazepam estradiol GENVOYA aripiprazole carbidopa-levodopa diazepam rectal gel estradiol-norethindrone GILENYA ARISTADA carbidopa-levodopa ext-rel diclofenac ESTRING glatiramer ARISTADA INITIO carbidopa-levodopa- diclofenac sodium eszopiclone glimepiride armodafinil entacapone diclofenac sodium ethinyl estradiol- glipizide ARNUITY ELLIPTA carvedilol gel 1% (except NDC^ drospirenone glipizide ext-rel atazanavir carvedilol phosphate ext-rel 69499031866) ethinyl estradiol- glipizide-metformin atenolol drospirenone-levomefolate cefdinir diclofenac sodium solution GLUCAGEN HYPOKIT atomoxetine cefprozil diclofenac sodium- ethinyl estradiol-etonogestrel GLUCAGON atorvastatin ethinyl estradiol- cefuroxime axetil misoprostol EMERGENCY KIT ATRIPLA levonorgestrel celecoxib dicloxacillin GLYXAMBI AUBAGIO ethinyl estradiol- cephalexin dicyclomine GONAL-F AUSTEDO norelgestromin CERDELGA DIFICID GRALISE azelaic acid gel ethinyl estradiol- CEREZYME digoxin granisetron azelastine norethindrone acetate CETROTIDE diltiazem ext-rel 5 GRASTEK azithromycin ethinyl estradiol- cholestyramine dipyridamole ext-rel-aspirin guanfacine ext-rel AZOPT norethindrone acetate-iron ciclopirox divalproex sodium GVOKE ethinyl estradiol-norgestimate CILOXAN OINTMENT divalproex sodium ext-rel B ethosuximide H CIMDUO DIVIGEL EUCRISA balsalazide cinacalcet donepezil HARVONI EVAMIST BAQSIMI CIPRODEX dorzolamide HUMATROPE everolimus BASAGLAR ciprofloxacin dorzolamide-timolol HUMIRA EVOTAZ BD ULTRAFINE citalopram DOVATO HUMULIN R U-500 EYLEA INSULIN SYRINGES CITRANATAL doxazosin hydrochlorothiazide ezetimibe AND NEEDLES clarithromycin doxepin hydrocodone ext-rel ezetimibe-simvastatin BELBUCA clarithromycin ext-rel doxycycline hyclate 20 mg hydrocodone-acetaminophen

BELSOMRA CLIMARA PRO doxycycline hyclate capsule hydrocortisone F benzonatate (except NDCs^ clindamycin doxycycline monohydrate hydrocortisone butyrate 69336012615, 69499032915) clindamycin gel (except NDC^ delayed-rel capsule famotidine cream, lotion, ointment, benzoyl peroxide 68682046275) doxylamine-pyridoxine FARXIGA solution BESIVANCE clindamycin solution delayed-rel FASENRA hydrocortisone enema 4 BETASERON clindamycin-benzoyl dronabinol fenofibrate hydromorphone BETHKIS peroxide DUAVEE fenofibric acid delayed-rel hydromorphone ext-rel

BETIMOL clobazam duloxetine fentanyl transdermal I BETOPTIC S clobetasol cream, foam, gel, DUPIXENT fentanyl transmucosal BEVESPI AEROSPHERE lotion, ointment, shampoo DUREZOL lozenge ibandronate bicalutamide clonazepam DUROLANE FIASP IBRANCE BIDIL clopidogrel dutasteride FINACEA FOAM ibuprofen BIKTARVY clotrimazole dutasteride-tamsulosin finasteride ILEVRO bosentan clozapine DYMISTA FIRAZYR imatinib mesylate BOSULIF codeine-acetaminophen FLOVENT DISKUS imiquimod BREO ELLIPTA colchicine tablet E FLOVENT HFA INCRUSE ELLIPTA colesevelam fluconazole BRILINTA econazole INGREZZA COMBIGAN fludrocortisone brimonidine eletriptan ipratropium COMBIPATCH flunisolide bromfenac ELIGARD inhalation solution COMPLERA fluocinonide 13 BRYHALI ELIQUIS ipratropium-albuterol COPAXONE fluorouracil cream 5% budesonide capsule EMGALITY inhalation solution COPIKTRA fluorouracil solution budesonide ext-rel EMVERM irbesartan CORLANOR fluoxetine 6 budesonide ENBREL irbesartan- CORTIFOAM fluticasone inhalation suspension ENDOMETRIN hydrochlorothiazide COSENTYX fluvastatin buprenorphine transdermal entacapone IRESSA CREON FML FORTE entecavir ISENTRESS

itraconazole mesalamine suppository NUWIQ prednisolone solution SEREVENT ivermectin mesalamine suspension nystatin prednisone sertraline metformin pregabalin sevelamer carbonate J metformin ext-rel 10 O PREMARIN sildenafil JANUMET methadone ODEFSEY PREMARIN CREAM silodosin JANUMET XR methoxsalen ODOMZO PREMPHASE SIMBRINZA JANUVIA methylphenidate OFEV PREMPRO simvastatin † JARDIANCE methylphenidate ext-rel ofloxacin prenatal vitamins SKYLA JIVI methylprednisolone olanzapine PREZCOBIX SKYRIZI metoclopramide olmesartan PREZISTA solifenacin K metolazone olmesartan-amlodipine- primidone SOLIQUA ketoconazole cream 2% metoprolol succinate ext-rel hydrochlorothiazide probenecid SOMATULINE DEPOT ketoconazole shampoo 2% metoprolol tartrate olmesartan- prochlorperazine SOMAVERT ketorolac metronidazole hydrochlorothiazide PROCTOFOAM-HC SOOLANTRA KISQALI minocycline olopatadine progesterone, micronized sotalol KISQALI FEMARA MIRENA omega-3 acid ethyl esters PROLASTIN-C SPIRIVA CO-PACK mirtazapine omeprazole PROLIA spironolactone- KOGENATE FS mometasone OMNIPOD INSULIN promethazine hydrochlorothiazide KOVALTRY montelukast INFUSION PUMP propranolol SPRYCEL KYLEENA morphine ondansetron propranolol ext-rel STELARA morphine ext-rel ONEXTON PULMICORT FLEXHALER SUBCUTANEOUS L morphine suppository ONZETRA XSAIL PYLERA STIOLTO RESPIMAT MOVANTIK STRIBILD lactulose solution OPSUMIT moxifloxacin Q STRIVERDI RESPIMAT lamivudine ORALAIR MUGARD SUBSYS lamotrigine ORENITRAM quetiapine MULPLETA sucralfate tablet lamotrigine ext-rel ORFADIN quetiapine ext-rel lansoprazole MULTAQ ORILISSA quinapril sulfacetamide

LASTACAFT mupirocin ointment oseltamivir quinapril-hydrochlorothiazide sulfamethoxazole- latanoprost MUSE OSPHENA QVAR REDIHALER trimethoprim

LATUDA MYDAYIS OTEZLA sulfasalazine R levalbuterol tartrate MYRBETRIQ OVIDREL sulfasalazine delayed-rel

CFC-free aerosol oxazepam RAGWITEK sumatriptan N LEVEMIR oxcarbazepine raloxifene SUNOSI levetiracetam nadolol OXTELLAR XR ramelteon SUPARTZ FX levetiracetam ext-rel NAFTIN oxybutynin ramipril SUPRAX levocarnitine naloxone injection oxybutynin ext-rel ranolazine ext-rel SUPREP SYMBICORT levocetirizine NAMZARIC oxycodone rasagiline 2 SYMFI levofloxacin naproxen oxycodone-acetaminophen RASUVO SYMFI LO levothyroxine naratriptan OZEMPIC REBIF SYMJEPI lidocaine-prilocaine NARCAN NASAL SPRAY REBINYN P SYMLINPEN linezolid nateglinide RELENZA SYMPROIC LINZESS neomycin-polymyxin B- pantoprazole repaglinide liothyronine bacitracin-hydrocortisone paroxetine HCl RESTASIS SYMTUZA lisinopril neomycin-polymyxin B- paroxetine HCl ext-rel RETACRIT SYNJARDY lisinopril-hydrochlorothiazide dexamethasone paroxetine mesylate REYVOW SYNJARDY XR

LO LOESTRIN FE NEULASTA PAZEO RHOPRESSA SYNTHROID

LOKELMA NEUPRO peg 3350-electrolytes ribavirin T lorazepam NEVANAC penicillin VK RINVOQ losartan niacin ext-rel PENTASA risedronate tacrolimus losartan-hydrochlorothiazide nifedipine ext-rel PERFOROMIST risperidone tadalafil loteprednol nitrofurantoin phenobarbital rivastigmine TAKHZYRO lovastatin nitroglycerin lingual spray phenytoin rivastigmine transdermal tamsulosin LUCENTIS nitroglycerin sublingual phenytoin sodium extended rizatriptan TAZORAC luliconazole NIVESTYM PHOSLYRA ROCKLATAN TECFIDERA LUMIGAN NORVIR PICATO ropinirole TEGSEDI LUPRON DEPOT NOVOEIGHT pimecrolimus ropinirole ext-rel TEKTURNA HCT LYNPARZA NOVOLIN 70/30 pindolol rosuvastatin telmisartan NOVOLIN N pioglitazone RUBRACA telmisartan- M NOVOLIN R pioglitazone-glimepiride RUCONEST hydrochlorothiazide

MAXIDEX NOVOLOG pioglitazone-metformin RYBELSUS TEMIXYS

MAYZENT NOVOLOG MIX 70/30 potassium chloride liquid RYDAPT terazosin meclizine NUBEQA PRALUENT terbinafine tablet S 9 medroxyprogesterone NUCALA pramipexole testosterone gel megestrol acetate NUCYNTA pramipexole ext-rel SANCUSO testosterone solution meloxicam NUCYNTA ER prasugrel SAXENDA tetrabenazine memantine NUEDEXTA pravastatin scopolamine transdermal tetracycline mesalamine delayed-rel NURTEC ODT PRED MILD selegiline tiagabine mesalamine ext-rel prednisolone acetate 1% selenium sulfide lotion 2.5% timolol maleate solution

TIVICAY triamcinolone cream, lotion, V VIOKACE Y TOBRADEX OINTMENT ointment VISCO-3 valacyclovir YONSA TOBRADEX ST triamterene VISTOGARD valganciclovir YUPELRI tobramycin triamterene- VOSEVI 3 valproic acid tobramycin hydrochlorothiazide VRAYLAR valsartan Z inhalation solution TRIJARDY XR VUMERITY valsartan-hydrochlorothiazide zafirlukast tobramycin-dexamethasone trimethobenzamide VYVANSE vancomycin capsule ZEJULA TOLAK TRINTELLIX VARUBI ZEMBRACE SYMTOUCH tolterodine TRIUMEQ W VASCEPA ZENPEP tolterodine ext-rel TROKENDI XR warfarin VELPHORO zileuton ext-rel topiramate trospium VELTASSA ziprasidone torsemide trospium ext-rel X VEMLIDY zolmitriptan TOVIAZ TRULICITY XARELTO venlafaxine zolpidem tramadol (except NDC^ 52817019610) TRUVADA XELJANZ venlafaxine ext-rel capsule zolpidem ext-rel tramadol ext-rel TYMLOS XELJANZ XR verapamil ext-rel zolpidem sublingual travoprost TYSABRI XIFAXAN 550 MG V-GO INSULIN ZOMIG NASAL SPRAY trazodone XIGDUO XR U INFUSION PUMP zonisamide TRELEGY ELLIPTA XIIDRA VIBERZI ZUBSOLV TREMFYA UBRELVY XOLAIR VICTOZA ZYCLARA TRESIBA UDENYCA vigabatrin XTAMPZA ER tretinoin UPTRAVI VIIBRYD XTANDI

VIMPAT XULTOPHY

PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, AMRIX cyclobenzaprine quetiapine, quetiapine ext-rel, risperidone, (except cyclobenzaprine tablet 7.5 mg) ziprasidone, LATUDA, VRAYLAR ANDROGEL 1% testosterone gel (except authorized generics ACANYA adapalene, benzoyl peroxide, for TESTIM and VOGELXO), clindamycin gel (except NDC^ 68682046275), testosterone solution, ANDRODERM clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, ANGELIQ estradiol-norethindrone, PREMPHASE, erythromycin-benzoyl peroxide, tretinoin, PREMPRO EPIDUO, ONEXTON, TAZORAC ANTARA fenofibrate (except fenofibrate tablet 120 mg), ACIPHEX, ACIPHEX SPRINKLE esomeprazole, lansoprazole, omeprazole, fenofibric acid delayed-rel pantoprazole, DEXILANT APEXICON E desoximetasone, ACTEMRA ENBREL, HUMIRA, RINVOQ, XELJANZ, fluocinonide (except fluocinonide cream 0.1%), XELJANZ XR BRYHALI ACTICLATE doxycycline hyclate 20 mg, APIDRA FIASP, NOVOLOG doxycycline hyclate capsule, minocycline, APLENZIN bupropion, bupropion ext-rel tetracycline (except bupropion ext-rel tablet 450 mg) Activite folic acid ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID ACTOS pioglitazone ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, acyclovir cream acyclovir capsule, acyclovir tablet, meloxicam or naproxen (except naproxen CR valacyclovir or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, ALCORTIN A desonide, hydrocortisone pantoprazole or DEXILANT ALEVICYN GEL, ALEVICYN SG, desonide, hydrocortisone ASACOL HD balsalazide, mesalamine delayed-rel, ALEVICYN SOLUTION mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA ALIQOPA COPIKTRA ASCENSIA STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, 14 ALLISON MEDICAL INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, 11 ALORA estradiol, DIVIGEL, EVAMIST ACCU-CHEK GUIDE STRIPS AND KITS , ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 ALPROLIX Consult doctor ASMANEX, ASMANEX HFA ARNUITY ELLIPTA, FLOVENT DISKUS, ALREX azelastine, cromolyn sodium, olopatadine, FLOVENT HFA, PULMICORT FLEXHALER, LASTACAFT, PAZEO QVAR REDIHALER ALTOPREV atorvastatin, ezetimibe-simvastatin, ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, fluvastatin, lovastatin, pravastatin, irbesartan, irbesartan-hydrochlorothiazide, rosuvastatin, simvastatin losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, telmisartan, telmisartan-hydrochlorothiazide, FLOVENT HFA, PULMICORT FLEXHALER, valsartan, valsartan-hydrochlorothiazide QVAR REDIHALER ATOPADERM desonide, hydrocortisone

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ATROVENT HFA ipratropium inhalation solution, butalbital-acetaminophen tablet 50-300 mg, diclofenac sodium, ibuprofen, INCRUSE ELLIPTA, SPIRIVA, YUPELRI BUTALBITAL-ACETAMINOPHEN naproxen (except naproxen CR or (NDC^ 69499034230 only) naproxen suspension) AVENOVA Consult doctor butalbital-acetaminophen-caffeine capsule diclofenac sodium, ibuprofen, AVONEX glatiramer, AUBAGIO, BETASERON, naproxen (except naproxen CR or COPAXONE, GILENYA, MAYZENT, REBIF, naproxen suspension) TECFIDERA, TYSABRI, VUMERITY BUTRANS buprenorphine transdermal, BELBUCA AZELEX adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), BYDUREON OZEMPIC, RYBELSUS, TRULICITY, clindamycin solution, clindamycin- VICTOZA benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BYETTA OZEMPIC, RYBELSUS, TRULICITY, EPIDUO, ONEXTON, TAZORAC VICTOZA BARACLUDE TABLET entecavir, lamivudine, VEMLIDY CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, BEAU RX Consult doctor ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, BECONASE AQ flunisolide, fluticasone, mometasone, ZOMIG NASAL SPRAY DYMISTA calcipotriene cream calcipotriene ointment, calcipotriene solution BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, calcitriol ointment calcipotriene ointment, calcipotriene solution losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, CAMBIA diclofenac sodium, telmisartan, telmisartan-hydrochlorothiazide, ibuprofen, naproxen (except naproxen CR or valsartan, valsartan-hydrochlorothiazide naproxen suspension) BENSAL HP desonide, hydrocortisone CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA BENZAC AC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), CARAFATE sucralfate tablet clindamycin solution, clindamycin- CARBINOXAMINE TABLET 6 MG levocetirizine benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, CARDIZEM, CARDIZEM CD, diltiazem ext-rel EPIDUO, ONEXTON, TAZORAC CARDIZEM LA (except generics for CARDIZEM LA) BENZACLIN adapalene, benzoyl peroxide, CARNITOR, CARNITOR SF levocarnitine clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- chlordiazepoxide-clidinium dicyclomine benzoyl peroxide, erythromycin solution, (NDC^ 42494040901 only) erythromycin-benzoyl peroxide, tretinoin, chlorzoxazone 375 mg, cyclobenzaprine EPIDUO, ONEXTON, TAZORAC chlorzoxazone 500 mg (NDC^ 73007001303 only), (except cyclobenzaprine tablet 7.5 mg) BENZIQ adapalene, benzoyl peroxide, chlorzoxazone 750 mg, clindamycin gel (except NDC^ 68682046275), CHLORZOXAZONE 250 MG clindamycin solution, clindamycin- CIALIS sildenafil, tadalafil benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, CICATRACE Consult doctor EPIDUO, ONEXTON, TAZORAC CIMZIA COSENTYX, ENBREL, HUMIRA, OTEZLA, benzonatate benzonatate RINVOQ, SKYRIZI, (NDCs^ 69336012615, 69499032915 only) (except NDCs^ 69336012615, 69499032915) STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR BERINERT FIRAZYR, RUCONEST CLINDAGEL erythromycin solution BETAPACE, BETAPACE AF sotalol clindamycin gel (NDC^ 68682046275 only) adapalene, benzoyl peroxide, BEYAZ ethinyl estradiol-drospirenone, clindamycin gel (except NDC^ 68682046275), ethinyl estradiol-drospirenone-levomefolate, clindamycin solution, clindamycin- ethinyl estradiol-norethindrone acetate, benzoyl peroxide, erythromycin solution, ethinyl estradiol-norethindrone acetate-iron erythromycin-benzoyl peroxide, tretinoin, bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN EPIDUO, ONEXTON, TAZORAC BREEZE 2 STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, clobetasol spray clobetasol foam ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, CLOBEX SPRAY clobetasol foam ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 COLAZAL balsalazide Bupap diclofenac sodium, ibuprofen, COLCRYS colchicine tablet naproxen (except naproxen CR or naproxen suspension) CONSENSI amlodipine WITH celecoxib 15 11 bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel CONTOUR NEXT STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS , 11 (except bupropion ext-rel tablet 450 mg) ACCU-CHEK COMPACT PLUS STRIPS AND KITS , ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* CONTOUR STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, irbesartan, irbesartan-hydrochlorothiazide, ACCU-CHEK GUIDE STRIPS AND KITS 11, losartan, losartan-hydrochlorothiazide, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, CONTRAVE SAXENDA valsartan, valsartan-hydrochlorothiazide CORDRAN OINTMENT hydrocortisone butyrate cream, Diphen Elixir levocetirizine hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, DORAL doxepin, eszopiclone, ramelteon, zolpidem, hydrocortisone butyrate solution, zolpidem ext-rel, zolpidem sublingual, mometasone, triamcinolone cream, BELSOMRA triamcinolone lotion, triamcinolone ointment DORYX, DORYX MPC doxycycline hyclate 20 mg, CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, doxycycline hyclate capsule, minocycline, tetracycline tetracycline doxepin cream desonide, hydrocortisone, pimecrolimus, COUMADIN warfarin tacrolimus, EUCRISA CRESTOR atorvastatin, ezetimibe-simvastatin, doxycycline hyclate delayed-rel tablet 200 mg doxycycline hyclate 20 mg, fluvastatin, lovastatin, pravastatin, doxycycline hyclate capsule, minocycline, rosuvastatin, simvastatin tetracycline cyclobenzaprine ext-rel capsule, cyclobenzaprine doxycycline hyclate tablet 50 mg doxycycline hyclate 20 mg, cyclobenzaprine tablet 7.5 mg (except cyclobenzaprine tablet 7.5 mg) (NDC^ 72143021160 only), doxycycline hyclate capsule, minocycline, doxycycline hyclate tablet 75 mg, tetracycline CYMBALTA desvenlafaxine ext-rel, duloxetine, doxycycline hyclate tablet 150 mg venlafaxine, venlafaxine ext-rel capsule doxycycline monohydrate capsule 75 mg, doxycycline hyclate 20 mg, DaVite folic acid doxycycline monohydrate capsule 150 mg doxycycline hyclate capsule, minocycline, DELZICOL balsalazide, mesalamine delayed-rel, tetracycline mesalamine ext-rel, sulfasalazine, DULERA ADVAIR DISKUS, ADVAIR HFA, sulfasalazine delayed-rel, PENTASA BREO ELLIPTA, SYMBICORT DETROL LA darifenacin ext-rel, oxybutynin ext-rel, DUTOPROL metoprolol succinate ext-rel WITH solifenacin, tolterodine, tolterodine ext-rel, hydrochlorothiazide trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ DYRENIUM amiloride, triamterene dexchlorpheniramine levocetirizine EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, Dexifol folic acid losartan, losartan-hydrochlorothiazide, Dexpak dexamethasone, hydrocortisone, olmesartan, olmesartan-hydrochlorothiazide, methylprednisolone, prednisolone solution, telmisartan, telmisartan-hydrochlorothiazide, prednisone valsartan, valsartan-hydrochlorothiazide diclofenac sodium gel 1% diclofenac sodium, diclofenac sodium gel 1% EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, (NDC^ 69499031866 only) (except NDC^ 69499031866), zolpidem ext-rel, zolpidem sublingual, diclofenac sodium solution, ibuprofen, BELSOMRA meloxicam, naproxen (except naproxen CR or E.E.S. GRANULES erythromycins naproxen suspension) EFFEXOR XR desvenlafaxine ext-rel, duloxetine, Diclofex DC (NDC^ 51021037201 only) diclofenac sodium, diclofenac sodium gel 1% venlafaxine, venlafaxine ext-rel capsule (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, ELELYSO CERDELGA, CEREZYME meloxicam, naproxen (except naproxen CR or naproxen suspension) ELOCTATE ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ Diclosaicin diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), ENABLEX darifenacin ext-rel, oxybutynin ext-rel, diclofenac sodium solution, ibuprofen, solifenacin, tolterodine, tolterodine ext-rel, meloxicam, naproxen (except naproxen CR or trospium, trospium ext-rel, MYRBETRIQ, naproxen suspension) TOVIAZ diflorasone cream, diflorasone ointment desoximetasone, ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE fluocinonide (except fluocinonide cream 0.1%), MONITORING SYSTEM MONITORING SYSTEM BRYHALI ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG dihydroergotamine spray eletriptan, naratriptan, rizatriptan, ENTYVIO HUMIRA, STELARA SUBCUTANEOUS, sumatriptan, zolmitriptan, NURTEC ODT, XELJANZ, XELJANZ XR ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, EPICERAM desonide, hydrocortisone ZOMIG NASAL SPRAY EPOGEN ARANESP, RETACRIT diltiazem ext-rel diltiazem ext-rel (generics for CARDIZEM LA only) (except generics for CARDIZEM LA)

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ergotamine-caffeine eletriptan, naratriptan, rizatriptan, flurandrenolide lotion desonide, hydrocortisone sumatriptan, zolmitriptan, NURTEC ODT, (NDC^ 24470092112 only) ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, flurandrenolide ointment hydrocortisone butyrate cream, ZOMIG NASAL SPRAY hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, ERYPED erythromycins hydrocortisone butyrate solution, mometasone, triamcinolone cream, EUFLEXXA DUROLANE, GEL-ONE, GELSYN-3, triamcinolone lotion, triamcinolone ointment SUPARTZ FX, VISCO-3 FML LIQUIFILM dexamethasone, loteprednol, EVEKEO amphetamine- prednisolone acetate 1%, DUREZOL, dextroamphetamine mixed salts, FML FORTE, FML S.O.P., MAXIDEX, methylphenidate PRED MILD EVERSENSE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE FOLIC-K folic acid MONITORING SYSTEM MONITORING SYSTEM FOLLISTIM AQ GONAL-F EVZIO naloxone injection, NARCAN NASAL SPRAY Folvik-D folic acid EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan Folvite-D folic acid EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, FORTAMET metformin, metformin ext-rel (except generics olmesartan-amlodipine-hydrochlorothiazide for FORTAMET and GLUMETZA) EXTAVIA glatiramer, AUBAGIO, BETASERON, FORTESTA testosterone gel (except authorized generics COPAXONE, GILENYA, MAYZENT, REBIF, for TESTIM and VOGELXO), TECFIDERA, TYSABRI, VUMERITY testosterone solution, ANDRODERM FANAPT aripiprazole, clozapine, olanzapine, FOSAMAX PLUS D alendronate, ibandronate, risedronate quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR FOSRENOL calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO FEMRING estradiol, ESTRING, PREMARIN CREAM FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel FREESTYLE LIBRE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE GLUCOSE MONITORING SYSTEM MONITORING SYSTEM FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate tablet 120 mg), 15 11 fenofibric acid delayed-rel FREESTYLE STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, fenoprofen, FENOPROFEN CAPSULE diclofenac sodium, ibuprofen, meloxicam, ACCU-CHEK GUIDE STRIPS AND KITS 11, naproxen (except naproxen CR or ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 naproxen suspension) FROVA eletriptan, naratriptan, rizatriptan, FERIVA 21/7 folic acid sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, FETZIMA desvenlafaxine ext-rel, duloxetine, ZEMBRACE SYMTOUCH, venlafaxine, venlafaxine ext-rel capsule ZOMIG NASAL SPRAY Fexmid cyclobenzaprine FULPHILA NEULASTA, UDENYCA (except cyclobenzaprine tablet 7.5 mg) Genicin Vita-S folic acid FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL FIORICET CAPSULE diclofenac sodium, ibuprofen, GLUMETZA metformin, metformin ext-rel (except generics naproxen (except naproxen CR or for FORTAMET and GLUMETZA) naproxen suspension) GLYCOPYRROLATE TABLET 1.5 MG dicyclomine FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, GRANIX NIVESTYM FML FORTE, FML S.O.P., MAXIDEX, GUARDIAN CONNECT CONTINUOUS DEXCOM CONTINUOUS GLUCOSE PRED MILD GLUCOSE MONITORING SYSTEM MONITORING SYSTEM flucytosine capsule 500 mg fluconazole HORIZANT gabapentin, GRALISE fluocinonide cream 0.1% clobetasol cream HUMALOG FIASP, NOVOLOG fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, HUMALOG MIX 50/50 NOVOLOG MIX 70/30 imiquimod, PICATO, TOLAK, ZYCLARA HUMALOG MIX 75/25 NOVOLOG MIX 70/30 fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, (generics for SARAFEM only) fluoxetine tablet [generics for SARAFEM]), HUMULIN 70/30 NOVOLIN 70/30 paroxetine HCl ext-rel, sertraline HUMULIN N NOVOLIN N fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, HUMULIN R NOVOLIN R fluoxetine tablet [generics for SARAFEM]), HYALGAN DUROLANE, GEL-ONE, GELSYN-3, paroxetine HCl, paroxetine HCl ext-rel, SUPARTZ FX, VISCO-3 sertraline, TRINTELLIX, VIIBRYD

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate cream, KINERET ENBREL, HUMIRA, RINVOQ, XELJANZ, hydrocortisone butyrate lotion, XELJANZ XR hydrocortisone butyrate ointment, hydrocortisone butyrate solution, KOMBIGLYZE XR JANUMET, JANUMET XR mometasone, triamcinolone cream, LACTULOSE PAK lactulose solution triamcinolone lotion, triamcinolone ointment LAMICTAL, LAMICTAL ODT, LAMICTAL XR carbamazepine, carbamazepine ext-rel, HylaVite folic acid divalproex sodium, divalproex sodium ext-rel, HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, hydromorphone ext-rel, methadone, levetiracetam, levetiracetam ext-rel, morphine ext-rel, NUCYNTA ER, oxcarbazepine, phenobarbital, phenytoin, XTAMPZA ER phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, INDERAL LA, INDERAL XL atenolol, carvedilol, zonisamide, FYCOMPA, OXTELLAR XR, carvedilol phosphate ext-rel, TROKENDI XR, VIMPAT metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, LANOXIN TABLET digoxin propranolol, propranolol ext-rel, BYSTOLIC (125 MCG and 250 MCG only) INDOCIN diclofenac sodium, ibuprofen, meloxicam, lanthanum carbonate calcium acetate, sevelamer carbonate, naproxen (except naproxen CR or PHOSLYRA, VELPHORO naproxen suspension) LANTUS BASAGLAR, LEVEMIR indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, LAZANDA fentanyl transmucosal lozenge, SUBSYS naproxen (except naproxen CR or naproxen suspension) LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, Inflammacin diclofenac sodium, diclofenac sodium gel 1% rosuvastatin, simvastatin (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, LETAIRIS ambrisentan, bosentan, OPSUMIT meloxicam, naproxen (except naproxen CR or naproxen suspension) levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, INNOPRAN XL atenolol, carvedilol, morphine ext-rel, NUCYNTA ER, carvedilol phosphate ext-rel, XTAMPZA ER metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, LEXAPRO citalopram, escitalopram, propranolol, propranolol ext-rel, BYSTOLIC fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), INTERMEZZO doxepin, eszopiclone, ramelteon, zolpidem, paroxetine HCl, paroxetine HCl ext-rel, zolpidem ext-rel, zolpidem sublingual, sertraline, TRINTELLIX, VIIBRYD BELSOMRA LIALDA balsalazide, mesalamine delayed-rel, INTUNIV amphetamine- mesalamine ext-rel, sulfasalazine, dextroamphetamine mixed salts ext-rel †, sulfasalazine delayed-rel, PENTASA atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine VYVANSE (NDC^ 71800063115 only) INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR LIDOTREX lidocaine-prilocaine INVOKANA FARXIGA, JARDIANCE LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, ISTALOL timolol maleate solution, BETIMOL, rosuvastatin, simvastatin BETOPTIC S LIVALO atorvastatin, ezetimibe-simvastatin, JALYN dutasteride-tamsulosin; dutasteride or fluvastatin, lovastatin, pravastatin, finasteride WITH alfuzosin ext-rel, doxazosin, rosuvastatin, simvastatin silodosin, tamsulosin or terazosin Lorid folic acid JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR Lorzone cyclobenzaprine KAMDOY desonide, hydrocortisone (except cyclobenzaprine tablet 7.5 mg) KAZANO JANUMET, JANUMET XR LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, ketoconazole foam 2% ketoconazole shampoo 2%, FML FORTE, FML S.O.P., MAXIDEX, selenium sulfide lotion 2.5% PRED MILD Ketodan ketoconazole shampoo 2%, LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, selenium sulfide lotion 2.5% zolpidem ext-rel, zolpidem sublingual, ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, BELSOMRA naproxen (except naproxen CR or MACRODANTIN nitrofurantoin naproxen suspension) Matzim LA diltiazem ext-rel ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, (except generics for CARDIZEM LA) naproxen (except naproxen CR or naproxen suspension) MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 3

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* mefenamic acid (NDC^ 69336012830 only) diclofenac sodium, ibuprofen, meloxicam, naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen (except naproxen CR or naproxen suspension) naproxen suspension) MENEST estradiol, PREMARIN NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, MENOSTAR estradiol ethinyl estradiol-levonorgestrel, metformin ext-rel metformin, metformin ext-rel (except generics ethinyl estradiol-norethindrone acetate, (generics for FORTAMET and GLUMETZA only) for FORTAMET and GLUMETZA) ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, methocarbamol 750 mg cyclobenzaprine LO LOESTRIN FE (NDCs^ 69036093090, 70868090190 only) (except cyclobenzaprine tablet 7.5 mg) NATESTO testosterone gel (except authorized generics MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, for TESTIM and VOGELXO), risedronate, FORTEO, PROLIA, TYMLOS testosterone solution, ANDRODERM MIACALCIN NASAL SPRAY calcitonin-salmon NESINA JANUVIA MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, NEUPOGEN NIVESTYM irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, NEXIUM esomeprazole, lansoprazole, omeprazole, olmesartan, olmesartan-hydrochlorothiazide, pantoprazole, DEXILANT telmisartan, telmisartan-hydrochlorothiazide, niacin tablet 500 mg niacin ext-rel valsartan, valsartan-hydrochlorothiazide Niacor niacin ext-rel Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, NICADAN folic acid ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, NICAPRIN folic acid ZOMIG NASAL SPRAY NICAZEL, NICAZEL FORTE folic acid MILLIPRED dexamethasone, hydrocortisone, NICOMIDE folic acid methylprednisolone, prednisolone solution, prednisone NILANDRON abiraterone, bicalutamide, XTANDI, YONSA MINASTRIN 24 FE ethinyl estradiol-drospirenone, NITROMIST nitroglycerin lingual spray, ethinyl estradiol-drospirenone-levomefolate, nitroglycerin sublingual ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron NORDITROPIN GENOTROPIN, HUMATROPE MINIVELLE estradiol, DIVIGEL, EVAMIST NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) MINOCIN doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, NORITATE azelaic acid gel, metronidazole, tetracycline FINACEA FOAM, SOOLANTRA minocycline ext-rel doxycycline hyclate 20 mg, NORVASC amlodipine doxycycline hyclate capsule, minocycline, NOVACORT desonide, hydrocortisone tetracycline NOVO NORDISK NEEDLES 14 BD ULTRAFINE NEEDLES Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1% tetracycline (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, MONOVISC DUROLANE, GEL-ONE, GELSYN-3, meloxicam, naproxen (except naproxen CR or SUPARTZ FX, VISCO-3 naproxen suspension) MOVIPREP peg 3350-electrolytes, SUPREP NUTROPIN AQ GENOTROPIN, HUMATROPE MultiPro Consult doctor NUVIGIL armodafinil, SUNOSI mupirocin cream gentamicin, mupirocin ointment Okebo doxycycline hyclate 20 mg, MYTESI Consult doctor doxycycline hyclate capsule, minocycline, tetracycline NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or OLEPTRO trazodone naproxen suspension) OLUX-E clobetasol foam naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole, naproxen (except naproxen CR or pantoprazole, DEXILANT naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or OMNARIS flunisolide, fluticasone, mometasone, DEXILANT DYMISTA naproxen CR diclofenac sodium, ibuprofen, meloxicam, OMNITROPE GENOTROPIN, HUMATROPE naproxen (except naproxen CR or naproxen suspension) OMNIVEX folic acid

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ONETOUCH ULTRA STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, posaconazole delayed-rel tablet fluconazole, itraconazole ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, PRADAXA warfarin, ELIQUIS, XARELTO 11 ACCU-CHEK SMARTVIEW STRIPS AND KITS PRECISION XTRA STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, 11 ONETOUCH VERIO STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS , 11 ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS , 11 ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 PRED FORTE dexamethasone, loteprednol, ONFI clobazam, lamotrigine, topiramate, prednisolone acetate 1%, DUREZOL, TROKENDI XR FML FORTE, FML S.O.P., MAXIDEX, PRED MILD ONGLYZA JANUVIA PREFEST estradiol-norethindrone, PREMPHASE, ORENCIA CLICKJECT, COSENTYX, ENBREL, HUMIRA, OTEZLA, PREMPRO ORENCIA INTRAVENOUS, RINVOQ, STELARA SUBCUTANEOUS, ORENCIA SUBCUTANEOUS XELJANZ, XELJANZ XR PRENATAL PLUS generic prenatal vitamins, CITRANATAL orphenadrine-aspirin-caffeine cyclobenzaprine PREVACID esomeprazole, lansoprazole, omeprazole, (except cyclobenzaprine tablet 7.5 mg) pantoprazole, DEXILANT Orphengesic Forte cyclobenzaprine PREVIDENT Consult doctor (except cyclobenzaprine tablet 7.5 mg) PRIMLEV hydrocodone-acetaminophen, ORTHO D folic acid hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA ORTHO DF folic acid PRISTIQ desvenlafaxine ext-rel, duloxetine, ORTHO TRI-CYCLEN LO ethinyl estradiol-norgestimate venlafaxine, venlafaxine ext-rel capsule ORTHOVISC DUROLANE, GEL-ONE, GELSYN-3, PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol, SUPARTZ FX, VISCO-3 levalbuterol tartrate CFC-free aerosol OSENI JANUMET, JANUMET XR; PROCRIT ARANESP, RETACRIT JANUVIA WITH pioglitazone PRODIGEN Consult doctor OSMOPREP peg 3350-electrolytes, SUPREP PROTONIX esomeprazole, lansoprazole, omeprazole, OWEN MUMFORD NEEDLES 14 BD ULTRAFINE NEEDLES pantoprazole, DEXILANT oxiconazole ciclopirox, clotrimazole, econazole, PROTOPIC pimecrolimus, tacrolimus, EUCRISA (NDCs^ 00168035830, 51672135902 only) ketoconazole cream 2%, luliconazole PROVENTIL HFA albuterol sulfate CFC-free aerosol, OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, levalbuterol tartrate CFC-free aerosol hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, OXYTROL darifenacin ext-rel, oxybutynin ext-rel, fluoxetine tablet [generics for SARAFEM]), solifenacin, tolterodine, tolterodine ext-rel, paroxetine HCl, paroxetine HCl ext-rel, trospium, trospium ext-rel, MYRBETRIQ, sertraline, TRINTELLIX, VIIBRYD TOVIAZ PSORCON desoximetasone, PANCREAZE CREON, VIOKACE, ZENPEP fluocinonide (except fluocinonide cream 0.1%), BRYHALI PENNSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), QNASL flunisolide, fluticasone, mometasone, diclofenac sodium solution, ibuprofen, DYMISTA meloxicam, naproxen (except naproxen CR or naproxen suspension) QSYMIA SAXENDA PERCOCET hydrocodone-acetaminophen, QTERN GLYXAMBI hydromorphone, morphine, quazepam doxepin, eszopiclone, ramelteon, zolpidem, oxycodone-acetaminophen, NUCYNTA zolpidem ext-rel, zolpidem sublingual, PERRIGO NEEDLES 14 BD ULTRAFINE NEEDLES BELSOMRA PERTZYE CREON, VIOKACE, ZENPEP RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin PEXEVA citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, RAYOS dexamethasone, hydrocortisone, fluoxetine tablet [generics for SARAFEM]), methylprednisolone, prednisolone solution, paroxetine HCl, paroxetine HCl ext-rel, prednisone sertraline, TRINTELLIX, VIIBRYD RECEDO Consult doctor PLAVIX clopidogrel, prasugrel, BRILINTA RELION INSULIN NOVOLIN INSULIN PLEGRIDY glatiramer, AUBAGIO, BETASERON, REPATHA PRALUENT COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY RHEUMATE folic acid POLYTOZA Consult doctor RIBOZEL folic acid

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* RIMSO-50 Consult doctor TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, RIOMET metformin, metformin ext-rel (except generics ethinyl estradiol-norethindrone acetate, for FORTAMET and GLUMETZA) ethinyl estradiol-norethindrone acetate-iron ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, TESTIM testosterone gel (except authorized generics zolpidem ext-rel, zolpidem sublingual, for TESTIM and VOGELXO), BELSOMRA testosterone solution, ANDRODERM RyClora levocetirizine testosterone gel 1% testosterone gel (except authorized generics SABRIL vigabatrin (authorized generics for TESTIM and for TESTIM and VOGELXO), VOGELXO only) testosterone solution, ANDRODERM SAIZEN GENOTROPIN, HUMATROPE TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, SCARSILK PAD Consult doctor BETOPTIC S SEROQUEL XR aripiprazole, clozapine, olanzapine, TIROSINT levothyroxine, SYNTHROID quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS SIL-K PAD Consult doctor TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, SILIVEX Consult doctor metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, SILTREX Consult doctor propranolol, propranolol ext-rel, BYSTOLIC SIMPONI COSENTYX, ENBREL, HUMIRA, OTEZLA, TOUJEO TRESIBA RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR TRADJENTA JANUVIA SINGULAIR montelukast, zafirlukast, zileuton ext-rel tramadol (NDC^ 52817019610 only) tramadol (except NDC^ 52817019610), tramadol ext-rel SORILUX calcipotriene ointment, calcipotriene solution TRANSDERM SCOP meclizine, scopolamine transdermal SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or TREXIMET diclofenac sodium, ibuprofen or naproxen suspension) naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, STENDRA sildenafil, tadalafil naratriptan, rizatriptan, sumatriptan, STRIANT testosterone gel (except authorized generics zolmitriptan, NURTEC ODT, for TESTIM and VOGELXO), ONZETRA XSAIL, REYVOW, UBRELVY, testosterone solution, ANDRODERM ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV triamcinolone acetonide aerosol 0.2% hydrocortisone butyrate cream, hydrocortisone butyrate lotion, sucralfate suspension sucralfate tablet hydrocortisone butyrate ointment, hydrocortisone butyrate solution, sumatriptan-naproxen diclofenac sodium, ibuprofen or mometasone, triamcinolone cream, naproxen (except naproxen CR or triamcinolone lotion, triamcinolone ointment naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, TRICOR fenofibrate (except fenofibrate tablet 120 mg), zolmitriptan, NURTEC ODT, fenofibric acid delayed-rel ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or TRIGLIDE fenofibrate (except fenofibrate tablet 120 mg), ZOMIG NASAL SPRAY fenofibric acid delayed-rel SURE-TEST STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, TRILIPIX fenofibrate (except fenofibrate tablet 120 mg), ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, fenofibric acid delayed-rel 11 ACCU-CHEK GUIDE STRIPS AND KITS , TRIVIDIA INSULIN SYRINGES 14 BD ULTRAFINE INSULIN SYRINGES ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 TronVite folic acid SYNERDERM desonide, hydrocortisone TRUETEST STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, SYNVISC, SYNVISC-ONE DUROLANE, GEL-ONE, GELSYN-3, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, SUPARTZ FX, VISCO-3 ACCU-CHEK GUIDE STRIPS AND KITS 11, TALIVA folic acid ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, TRUETRACK STRIPS AND KITS 15 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, SKYRIZI, STELARA SUBCUTANEOUS, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, TREMFYA, XELJANZ, XELJANZ XR ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11 TARGADOX doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, TUDORZA INCRUSE ELLIPTA, SPIRIVA, YUPELRI tetracycline ULTIMED INSULIN SYRINGES 14 BD ULTRAFINE INSULIN SYRINGES TASIGNA imatinib mesylate, BOSULIF, SPRYCEL ULTIMED NEEDLES 14 BD ULTRAFINE NEEDLES UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* VALCYTE valganciclovir ZARXIO NIVESTYM VALTREX acyclovir capsule, acyclovir tablet, ZEGERID esomeprazole, lansoprazole, omeprazole, valacyclovir pantoprazole, DEXILANT Vanatol LQ, Vanatol S diclofenac sodium, ibuprofen, ZEMAIRA PROLASTIN-C naproxen (except naproxen CR or naproxen suspension) ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) Vanoxide-HC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), ZETIA ezetimibe clindamycin solution, clindamycin- ZETONNA flunisolide, fluticasone, mometasone, benzoyl peroxide, erythromycin solution, DYMISTA erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON, TAZORAC ZIANA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), VASCULERA Consult doctor clindamycin solution, clindamycin- VECTICAL calcipotriene ointment, calcipotriene solution benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, VELTIN adapalene, benzoyl peroxide, EPIDUO, ONEXTON, TAZORAC clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin- ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, benzoyl peroxide, erythromycin solution, hydromorphone ext-rel, methadone, erythromycin-benzoyl peroxide, tretinoin, morphine ext-rel, NUCYNTA ER, EPIDUO, ONEXTON, TAZORAC XTAMPZA ER venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, venlafaxine, venlafaxine ext-rel capsule 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, VEREGEN imiquimod gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, VIAGRA sildenafil, tadalafil oxcarbazepine, phenobarbital, phenytoin, VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), phenytoin sodium extended, primidone, HARVONI (genotypes 1, 4, 5, 6) tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, VITAFOL-ONE generic prenatal vitamins, CITRANATAL TROKENDI XR, VIMPAT Vitasure folic acid ZONTIVITY Consult doctor VIVELLE-DOT estradiol, DIVIGEL, EVAMIST ZORTRESS everolimus VOGELXO testosterone gel (except authorized generics ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, for TESTIM and VOGELXO), naproxen (except naproxen CR or testosterone solution, ANDRODERM naproxen suspension) XANAX, XANAX XR alprazolam, clonazepam, diazepam, ZUPLENZ granisetron, ondansetron, SANCUSO lorazepam, oxazepam ZYDELIG COPIKTRA XENAZINE tetrabenazine, AUSTEDO ZYFLO montelukast, zafirlukast, zileuton ext-rel XOLEGEL ciclopirox, ketoconazole cream 2% ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, XOPENEX HFA albuterol sulfate CFC-free aerosol, neomycin-polymyxin B-dexamethasone, levalbuterol tartrate CFC-free aerosol tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST Xvite folic acid ZYTIGA abiraterone, bicalutamide, XTANDI, YONSA XYZBAC folic acid ZYVIT folic acid YAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

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

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 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 copay1 information for a specific medicine.

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

§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. † Listing does not include certain NDCs^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Listing does not include naproxen CR or naproxen suspension. 3 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 4 Listing does not include fenofibrate tablet 120 mg. 5 Listing does not include generics for CARDIZEM LA. 6 Listing does not include fluoxetine tablet 60 mg, fluoxetine tablet (generics for SARAFEM). 7 Listing does not include bupropion ext-rel tablet 450 mg. 8 Listing does not include cyclobenzaprine tablet 7.5 mg. 9 Listing does not include the authorized generics for TESTIM and VOGELXO. 10 Listing does not include generics for FORTAMET and GLUMETZA. 11 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 12 Coverage may be altered or copay1 amounts may vary based on the condition being treated (e.g. psoriasis). 13 Listing does not include fluocinonide cream 0.1%. 14 BD ULTRAFINE syringes and needles are the only preferred options. 15 ACCU-CHEK brand test strips are the only preferred options.

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

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