Preferred Drug Formulary Effective June 2019, Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) ACE Inhibitors benazepril enalapril captopril Epaned fosinopril perindopril lisinopril Qbrelis solution moexipril quinapril ramipril trandolapril Alzheimer’s Agents donepezil Namenda Solution galantamine ER capsules Namenda XR memanine IR tablets Namzaric rivastigmine capsules rivastigmine patch Kits (Twinject) EpiPen Angiotensin Blockers candesartan olmesartan losartan olmesartan HCT losartan HCT Edarbi irbesartan eprosartan Irbesartan HCT telmisartan telmisartan HCT valsartan valsartan HCT Anticoagulants –Post Hip/Knee DVT enoxaparin Eliquis 2.5mg Prophylaxis heparin fondaparinux warfarin Fragmin Xarelto Anticonvulsants carbamazepine Oxtellar XR divalproex Trokendi XR gabapentin lamotrigine levetiracetam XR oxcarbazepine phenobarbital phenytoin primidone topiramate ER sprinkle capsules topiramate IR tablets & capsules zonisamide

Page 1 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Antidepressants – Other bupropion Aplenzin bupropion SR tablets bupropion XL-24H tablets duloxetine desvenlafaxine (Pristiq) mirtazapine & ODT Fetzima trazodone Forfivo XL venlafaxine immediate release tablets Oleptro venlafaxine ER Viibryd Antidepressants – Selective Serotonin citalopram citalopram 40mg Reuptake Inhibitors (SSRIs) fluoxetine escitalopram paroxetine tablet fluvoxamine ER sertraline paroxetine ER Pexeva Trintellix Antidiabetic Agents – Combination Glyxambi Invokamet Products Synjardy Invokamet XR Synjardy XR Qtern Trijardy XR Segluromet Xigduo XR Steglujan Antidiabetic Agents – DPP-4 Inhibitors Tradjenta Januvia Janumet Janumet XR

14T14TJentadueto Kombiglyze XR Onglyza Oseni Antidiabetic Agents – GLP-1 Receptor Bydureon Adlyxin Agonists Trulicity Adlyxin Starter Pack Byetta Victoza Antidiabetic Agents - Other metformin metformin ER modified release metformin ER Riomet

Antidiabetic Agents – SGLT2 Inhibitors Farxiga Invokana Jardiance Steglatro

Antiemetic/Antivertigo Agents meclizine Anzemet metoclopramide dronabinol ondansetron ODT ondansetron solution promethazine prochlorperazine Sancuso trimethobenzamide Zuplenz

Page 2 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Antifungals – Topical ciclopirox , gel, susp, , clotrimazole/betamethasone nail solution Ertaczo clotrimazole Exelderm clotrimazole/betamethasone cream Jublia 10% solution econazole cream Kerydin 5% ketoconazole 2% shampoo ketoconazole 2% cream miconazole luliconazole (Luzu 1%) nystatin Mentax terbinafine Naftin tolnaftate 1% solution nystatin/triamcinolone cream, oint Oxistat Xolegel 2% Antiparkinson Agents carbidopa-levodopa Duopa pramipexole Neupro ropinirole Rytary nd Antipsychotics – 2PP PP generation quetiapine IR, ER aripiprazole risperidone Fanapt ziprasidone Latuda Nuplazid olanzapine paliperidone ER Rexulti risperidone oral solution Saphris Vraylar Benign Prostatic Hyperplasia (BPH) alfuzosin Cardura XL Agents – Alpha Adrenergic Blockers doxazosin Rapaflo (silodosin) tamsulosin terazosin Beta-Adrenergic Blocking Agents atenolol Bystolic labetalol carvedilol ER capsules metoprolol succinate metoprolol tartrate C. Difficile Treatment Firvanq solution (vancomycin) Dificid vancomycin capsules Xifaxan COX-2 Inhibitors meloxicam celecoxib Vivlodex Erythropoietins Procrit Aranesp Mircera Retacrit Estrogens Yuvafem Vagifem Glaucoma Agents – Alpha-2 Agonists brimonidine 0.2% brimonidine 0.1% brimonidine 0.15%

Page 3 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Glaucoma Agents – Beta-Adrenergic betaxolol 0.5% Betoptic-S 0.25% Antagonists carteolol timolol XE gel levobunolol timolol opth solution Glaucoma Agents – Carbonic dorzolamide Azopt Anydrase Inhibitors Glaucoma Agents—Combination Brimonidine 0.2% and timolol 0.5% Combigan Products (ordered separately) Cosopt PF dorzolamide/timolol 2%/0.5% Simbrinza 1%/0.2% (brinzolamide 1% dorzolamide 2% and brimonidine 0.2% /brimonidine 0.2%) (ordered separately) Glaucoma Agents – Prostaglandins latanoprost 0.005% bimatoprost 0.03%, 0.01% Travatan Z 0.004% Vyzulta 0.024% Xelpros 0.005% Zioptan 0.0015% Gout Therapy (Chronic) allopurinol Uloric Histamine 2 Antagonists famotidine tablets (may be crushed) cimetidine tablets ranitidine (may be crushed) famotidine suspension ranitidine Inhaled Anticholinergic Agents ipratropium 0.02% solution Atrovent HFA ipratropium/albuterol sulfate solution Combivent Respimat Inhaled Beta-Adrenergic (Short Albuterol HFA Combivent Respimat Acting) albuterol inhalation solution levalbuterol inhalation solution ipratropium/albuterol sulfate solution Maxair levalbuterol HFA Proventil HFA Inhaled Long-Acting Beta-Adrenergic Striverdi Respimat Arcapta Agents (LABA) Brovana Perforomist Serevent Diskus Inhaled Long-Acting Beta-Adrenergic Anoro Ellipta Bevespi (LABA) and Long-Acting Muscarinic Stiolto Antagonist (LAMA) Agents Utibron neohaler Inhaled Long-Acting Muscarinic Spiriva Handihaler Incruse Ellipta Antagonist (LAMA) Agents Lonhala Magnair Seebri Neohaler Spiriva Respimat Tudorza Yupelri nebules Inhaled Steroids Arnuity Ellipta Alvesco HFA budesonide nebules Asmanex Flovent HFA Pulmicort Flexhaler Qvar

Page 4 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Inhaled Steroids & LABA combinations Wixela Inhub Advair Advair HFA Budesonide-Formoterol (generic Symbicort) Breo Ellipta Dulera Symbicort Insulins Humalog vial 3ML Admelog Humalog Mix 75/25 vial Afrezza Humulin 70/30 vial 3ML Apidra Humulin N vial 3ML Basaglar Humulin R vial 3 ML Fiasp Lantus Solostar pen Fiasp Flextouch Myxredlin Fiasp pens Soliqua Humalog 200 u/ml Humalog Mix 75/25 pens Levemir Lyumjev Lyumjev Kwikpen Novolin 70/30 Novolin N Novolin R Novolog Mix 70/30 Novolog Toujeo Tresiba Xultophy

Page 5 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) IV Therapy – Antibiotics amikacin Avelox (moxifloxacin) ampicillin Avycaz **option to convert to oral equivalent ampicillin-sulbactam Azactam azithromycin** Cubicin (daptomycin) aztreonam Dalvance cefazolin** Doribax cefepime Invanz cefoxitin nafcillin ceftazidime oxacillin ceftriaxone Sivextro Inj cefuroxime ** streptomycin ciprofloxacin** Teflaro clindamycin Tygacil (tigecycline) doxycycline** Vibativ gentamicin Zerbaxa imipenem-cilastin Zyvox (linezolid) levofloxacin** meropenem metronidazole** penicillin G piperacillin-tazobactam sulfamethoxazole/trimethoprim tobramycin vancomycin IV Therapy – Antifungals Eraxis Cancidas fluconazole** Mycamine **option to convert to oral equivalent Vfend IV Therapy – Iron ferric gluconate Inj (Ferrlecit) Venofer Laxatives/Chronic Constipation bisacodyl Amitiza docusate Entereg Miralax Linzess Senna Movantik Senna-S Relistor Inj Symproic Trulance Leukocyte Growth Factor (G-CSF) Nivestym Granix Neupogen Zarxio

Page 6 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Lipotropics – Other cholestyramine Antara colestipol colesevelam ezetimibe 10mg fenofibrate (40mg, 120mg,) fenofibric acid 105mg fenofibrate micronized 130mg, 135mg fenofibrate (48mg, 50mg, 54mg, 67mg, omega-3-acid ethyl ester 134mg, 145mg, 150mg, 160mg, Praluent 200mg) Repatha injection fenofibrate micronized (43mg, 67mg, Vascepa 134mg, 200mg) Welchol fenofibric acid 35mg, 45mg gemfibrozil omega 3 fatty acids (fish oil OTC) Lipotropics – Statins & Combinations atorvastatin Altoprev lovastatin ezetimibe/simvastatin pravastatin fluvastatin ER rosuvastastin 20mg Livalo simvastatin Rosuvastatin 5mg, 10mg Zypitamag Low Molecular Weight Heparins See Anticoagulants See Anticoagulants (LMWHs) and Related Multiple Sclerosis Agents Betaseron Extavia Avonex Muscle Relaxants cyclobenzaprine 10 mg Cyclobenzaprine ER capsules Narcotic Pain Agents fentanyl (not for Exalgo intermittent pain) fentanyl lozenge hydrocodone/acetaminophen Fentora Hysingla hydromorphone Kadian morphine sulfate ER 12H tablet morphine ER 24H morphine sulfate IR Nucynta oxycodone/acetaminophen Nucynta ER oxycodone IR oxycodone ER oxymorphone ER Zohydro ER Nasal Steroids budesonide Beconase AQ Flonase OTC Dymista fluticasone flunisolide Nasacort OTC mometasone Nasonex Omnaris Qnasl triamcinolone AQ Veramyst Zetonna Neuropathic Pain Agents - Oral duloxetine Lyrica gabapentin

Page 7 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Neuropathic Pain Agents – Topical lidocaine 4% patch lidocaine 5% patch menthol cream/gel/pach trolamine salicylate cream/lotion Ophthalmics – Antibiotics ciprofloxacin 0.3% solution Azasite 1% solution erythromycin 0.5% ointment bacitracin ophthalmic ointment gatifloxacin 0.5% solution Besivance 0.6% solution gentamicin 0.3% solution Ciloxan 0.3% ointment levofloxacin 0.5% solution moxifloxacin 0.5% solution (Moxeza) ofloxacin 0.3% solution Tobrex 0.3% ointment Polycin eye ointment Tobradex ointment sulfacetamide sodium 10% soln Vigamox0.5% /ointment Zylet tobramycin 0.3% solution tobramycin-dexamethasone 0.3%-0.1% Ophthalmics—Anti-inflammatory dexamethasone 0.1% Alrex 0.2% (Corticosteroids) fluorometholone 0.1% Durezol 0.05% prednisolone 1% Flarex 0.1% FML Forte 0.25% Inveltys 1% Lotemax 0.5% Maxidex 0.1% Pred Mild 0.12% Ophthalmics – Anti-inflammatory diclofenac 0.1% Acuvail 0.45% (NSAID) ketorolac 0.4% Bromfenac 0.09% flurbiprofen 0.03% Bromsite 0.075% Ilevro 0.3% ketorolac 0.5% Nevanac 0.1% Prolensa 0.07% Osteoporosis Treatments alendronate oral solution Binosto alendronate tablet calcitonin nasal risedronate 5mg, 30mg, 35mg tablet etidronate Forteo Fosamax Plus D ibandronate Miacalcin Injection Prolia raloxifene risedronate 150mg Tymlos Injection Xgeva Other Endocrine/Metabolism megestrol suspension 200 mg/5 ml megestrol ES 625 mg/5 ml Pancreatic Enzymes Zenpep Creon Pancreaze Viokace

Page 8 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Phosphate Binders calcium acetate tab/caps Auryxia PPPP sevelamer carbonate 800mg tab Eliphos lanthanum carbonate chew (Fosrenol) Phoslyra Renagel Renvela packets Velphoro Platelet Aggregation Inhibitors clopidogrel aspirin-dipyridamole ER cilostazol Brilinta prasugrel (Effient) Yosprala Zontivity Primary Pulmonary Hypertension sildenafil 20mg Adempas Agents Adcirca Cialis Letairis Opsumit tadalafil Tracleer Tyvaso Uptravi Viagra Proton Pump Inhibitors and Other lansoprazole Carafate suspension Gastrointestinals omeprazole Dexilant omeprazole OTC esomeprazole pantoprazole Prevacid solutab sucralfate tablets (can be crushed) rabeprazole Zegerid OTC Zegerid (omeprazole/sodium bicarbonate) Sedative – Hypnotics temazepam 7.5mg, 15mg, 30mg Belsomra zaleplon Doral zolpidem IR & ER doxepin 3mg & 6mg Edluar (zolpidem sublingual) eszopiclone Intermezzo Rozerem Silenor temazepam 22.5mg Steroids—Topical (low potency) Hydrocortisone 2.5% cream, ointment, Fluocinolone 0.01% cream, solution lotion Steroids—Topical (medium potency) Mometasone 0.1% cream, lotion, Clocortolone 0.1% cream solution Flurandrenolide 0.05% cream, lotion, Triamcinolone 0.1% cream, lotion, ointment ointment

Page 9 of 10 Symbria Rx Services Preferred Drug Formulary Effective June 2019/Updated March 2021

Non-Preferred (Note: These are the most commonly- Category Preferred prescribed non-preferred drugs. This listing is intended as a guide to prescribing and is not all-inclusive.) Steroids – Topical (High potency) betamethasone valerate 0.1% oint, amcinonide 0.1 % cream, lotion, lotion ointment betamethasone dip 0.05% cream, betamethasone diprop augmented lotion 0.05% lotion betamethasone diprop augmented betamethasone dipropionate 0.05% 0.05% cream, ointment ointment fluocinonide 0.05 % cream clobetasol 0.05% cream, lotion, oint triamcinolone 0.5% cream desoximetasone 0.05% cream, gel, ointment diflorasone 0.05% cream, ointment fluocinonide 0.05 % gel, ointment Halog 0.1% cream, ointment Trianex Topical Antibiotics metronidazole 0.75% cream, gel metronidazole 0.75% lotion mupirocin 2% ointment metronidazole 1% gel mupirocin 2% cream Noritate 1% cream Ulcerative Colitis Agents/ balsalazide Apriso Inflammatory Bowel Disease (IBD) budesonide 3mg capsules Asacol HD mesalamine 4gm Canasa mesalamine Delzicol mesalamine DR tablets Giazo Humira Lialda Pentasa Uceris (budesonide 9mg) Urinary Anti-Incontinence Agents oxybutynin XL Enablex (darifenacin ER) Oxytrol for Women patch (OTC) Gelnique tolterodine LA Oxytrol (Rx) patch trospium tolterodine Toviaz trospium ER Vesicare Vitamins & Minerals potassium Cl 20mEq tablets (dissolve potassium 20mEq powder packets in water)

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