The following is a list of the most commonly prescribed brand medications. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to drugs on this list, the majority of generic medications are covered under your plan and you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. Search complete formulary drug information at envisionrx.com. PLEASE NOTE: Preferred brand drugs may move to non-preferred status if a generic version becomes available during STANDARD FORMULARY the year. Any medication approved to enter the market will not be covered until reviewed by the EnvisionRx Pharmacy

and Therapeutics Committee. Not all drugs listed are covered by all prescription drug benefit programs. For specific questions about your coverage, please call the phone number printed on your member ID card or visit envisionrx.com.

ADHD / ANTI-NARCOLEPSY / ANTICONVULSANTS TREXIMET [NP] ANTI-OBESITY / Anticonvulsants - Misc. Antineoplastic Enzyme DIAGNOSTIC PRODUCTS Serotonin Agonists ANOREXIANTS BRIVIACT [NP] Inhibitors Diagnostic Tests RELPAX Amphetamines LYRICA SPRYCEL [SP] FREESTYLE (strips) VYVANSE VIMPAT [NP] TASIGNA [SP] ONETOUCH (strips) MUSCULOSKELETAL Anti-Obesity Agents PRECISION (strips) THERAPY AGENTS BELVIQ ANTIPARKINSON AGENTS Viscosupplements BELVIQ XR ANTIDEPRESSANTS Antiparkinson Dopaminergics DIGESTIVE AIDS HYALGAN [SP] CONTRAVE Serotonin Modulators NEUPRO [NP] Digestive Enzymes NASAL AGENTS - SYSTEMIC BRINTELLIX CREON AND TOPICAL ANALGESICS - TRINTELLIX ANTIVIRALS ZENPEP Nasal Agent Combinations ANTI-INFLAMMATORY VIIBRYD [NP] Hepatitis Agents DYMISTA [NP] Anti-TNF-alpha - Monoclonal Serotonin-Norepinephrine DAKLINZA [SP] ENDOCRINE AND METABOLIC Nasal Steroids Antibodies Reuptake Inhibitors (SNRIs) EPCLUSA [SP] AGENTS - MISC. QNASL HUMIRA [SP] FETZIMA [NP] HARVONI [SP] Fertility Regulators VERAMYST Soluble Tumor Necrosis Factor KHEDEZLA ER SOVALDI [SP] FOLLISTIM AQ [SP] Receptor Agents PRISTIQ Growth Hormones OPHTHALMIC AGENTS ENBREL [SP] BETA BLOCKERS GENOTROPIN [SP] Beta-blockers - Ophthalmic Nonsteroidal Anti- ANTIDIABETICS Alpha-Beta Blockers NORDITROPIN [SP] COMBIGAN inflammatory Agents (NSAIDs) Antidiabetic Combinations COREG CR Ophthalmic Adrenergic Agents TIVORBEX [NP] INVOKAMET Beta Blockers Cardio-Selective ESTROGENS ALPHAGAN P SOL 0.1% VIVLODEX [NP] INVOKAMET XR BYSTOLIC Estrogen Combinations Ophthalmic Anti-infectives ZORVOLEX [NP] JANUMET CLIMARA PRO BESIVANCE JANUMET XR CARDIOVASCULAR AGENTS - DUAVEE MOXEZA ANALGESICS - OPIOID Diabetic Other MISC. PREMPHASE VIGAMOX Opioid Agonists GLUCAGEN Combinations PREMPRO Ophthalmic BELBUCA Dipeptidyl Peptidase-4 (DPP-4) ENTRESTO Estrogens Immunomodulators HYSINGLA ER Inhibitors Impotence Agents PREMARIN RESTASIS OPANA ER JANUVIA VIAGRA Ophthalmic Steroids OXYCONTIN JENTADUETO Pulmonary Hypertension - GASTROINTESTINAL AGENTS ALREX ZOHYDRO ER [NP] TRADJENTA Endothelin Receptor - MISC. DUREZOL Opioid Partial Agonists Incretin Mimetic Agents (GLP-1 Antagonists Gastrointestinal Chloride LOTEMAX BUTRANS Receptor Agonists) OPSUMIT [SP] Channel Activators Ophthalmics - Misc. SUBOXONE BYDUREON LETAIRIS [SP] AMITIZA ACUVAIL BYETTA TRACLEER [SP] Inflammatory Bowel Agents AZOPT ANDROGENS-ANABOLIC TRULICITY [NP] Pulmonary Hypertension - Sol APRISO PATADAY Androgens VICTOZA Guanylate Cyclase Stimulator LIALDA PAZEO ANDROGEL 1.62% Insulin ADEMPAS [SP] Irritable Bowel Syndrome (IBS) PROLENSA LANTUS Sinus Node Inhibitors Agents Prostaglandins - Ophthalmic ANTIANGINAL AGENTS LEVEMIR CORLANOR LINZESS LUMIGAN Antianginals-Other NOVOLIN Phosphate Binder Agents TRAVATAN Z RANEXA NOVOLIN MIX CONTRACEPTIVES RENVELA travoprost NOVOLIN N Combination Contraceptives - ANTIARRHYTHMICS NOVOLIN R Oral GENITOURINARY AGENTS – OTIC AGENTS Antiarrhythmics Type III NOVOLOG BEYAZ MISC. Otic Combinations MULTAQ NOVOLOG MIX NATAZIA Prostatic Hypertrophy Agents CIPRODEX TOUJEO SAFYRAL RAPAFLO ANTIASTHMATIC AND TRESIBA YASMIN PSYCHOTHERAPEUTIC AND BRONCHODILATOR AGENTS Sodium-Glucose Co- YAZ GOUT AGENTS NEUROLOGICAL AGENTS - Bronchodilators - Transporter 2 (SGLT2) Combination Contraceptives - Gout Agents MISC. Anticholinergics Inhibitors Vaginal ULORIC Antidementia Agents ANORO FARXIGA NUVARING Fibromyalgia Agents INCRUSE INVOKANA HEMATOLOGICAL AGENTS - SAVELLA SPIRIVA XIGDUO CORTICOSTEROIDS MISC. Multiple Sclerosis Agents STIOLTO Glucocorticosteroids Platelet Aggregation Inhibitors AVONEX [SP] Selective Phosphodiesterase 4 ANTIHYPERLIPIDEMICS UCERIS [NP] BRILINTA COPAXONE [SP] (PDE4) Inhibitors Antihyperlipidemics - Misc. GILENYA [SP] DALIRESP VASCEPA DERMATOLOGICALS HEMATOPOIETIC AGENTS PLEGRIDY [SP] Steroid Inhalants Bile Acid Sequestrants Acne Products Hematopoietic Growth Factors TECFIDERA [SP] ARNUITY ELLIPTA WELCHOL ACANYA PROCRIT [SP] ASMANEX Fibric Acid Derivatives ONEXTON TETRACYCLINES FLOVENT LIPOFEN RETIN-A MICR GEL 0.08% HYPNOTICS/SEDATIVE/SLEEP Tetracyclines PULMICORT FLEXHALER HMG CoA Reductase Inhibitors Agents for DISORDER AGENTS SOLODYN [NP] QVAR LIVALO Wrinkles/Lipoatrophy/Other Hypnotics - Tricyclic Agents Sympathomimetics Proprotein Convertase Aesthetic Uses SILENOR [NP] ULCER DRUGS ADVAIR DISKUS/HFA Subtilisin/Kexin Type 9 RENOVA [NP] Orexin Receptor Antagonists Proton Pump Inhibitors BREO ELLIPTA Inhibitors Antifungals - Topical BELSOMRA [NP] DEXILANT COMBIVENT RESPIMAT PRALUENT [SP] JUBLIA PROAIR REPATHA [SP] LUZU [NP] LAXATIVES URINARY ANTISPASMODICS SEREVENT DISKUS MENTAX Laxative Combinations Urinary Antispasmodics - SYMBICORT ANTI-INFECTIVE AGENTS - Anti-inflammatory Agents - MOVIPREP [NP] Beta-3 Adrenergic Agonists VENTOLIN MISC. Topical SUPREP MYRBETRIQ Anti-Infective Agents - Misc. FLECTOR VESICARE [NP] ANTICOAGULANTS XIFAXAN Antineoplastic or Premalignant MEDICAL DEVICES Direct Factor Xa Inhibitors Lesion Agents - Topical Diabetic Supplies VAGINAL PRODUCTS ELIQUIS ANTINEOPLASTICS AND PICATO [NP] FREESTYLE (meters) Vaginal Estrogens SAVAYSA [NP] ADJUNCTIVE THERAPIES Immunomodulating Agents - ONETOUCH (meters) PREMARIN VAGINAL CREAM XARELTO Antineoplastic - Hormonal and Topical PRECISION (meters) VAGIFEM Thrombin Inhibitors Related Agents ZYCLARA [NP] Parenteral Therapy Supplies PRADAXA XTANDI [SP] Immunosuppressive Agents - NOVOFINE VASOPRESSORS ZYTIGA [SP] Topical NOVOTWIST Anaphylaxis Therapy Agents ELIDEL EPIPEN MIGRAINE PRODUCTS EPIPEN-JR Migraine Combinations © 2017 EnvisionRx 17-1288 envisionrx.com | 800-361-4542 As of 8/1/2017. Information subject to change.