Serve You Rx Select Formulary Exclusions

THERAPEUTIC CATEGORY EXCLUDED PREFERRED ALTERNATIVES

ALLERGIC REACTIONS Anaphylaxis Treatment Auvi-Q (0.15mg, 0.3mg) epinephrine injection (0.15mg, 0.3mg) Allergy Desensitization Agents Palforzia Patients are to consult with their physician for clinically appropriate alternative(s)

ALLERGIES Antihistamines Clarinex-D desloratadine PLUS pseudoephedrine

ANALGESICS Musculoskeletal Pain Norgesic Forte, Orphengesic Forte (ABA) , orphenadrine Ozobax baclofen Non-Steroidal Anti-Inflammatory Agents Cambia, capsule 35mg (ABA), , , , , Zipsor, Zorvolex , , indomethacin, , , meclofenamate, , , , , , , Ketorolac nasal spray (ABA), Sprix nasal diclofenac, ibuprofen, meloxicam spray Qmiiz ODT meloxicam Relafen DS nabumetone Oral Long-Acting Analgesics Arymo ER, Kadian ER 200mg, Nucynta hydromorphone HCl ER, morphine sulfate ER, Oxycodone ER (ABA) ER, oxymorphone HCl ER, Hysingla ER, OxyContin, Xtampza ER Conzip, Tramadol ER 100mg, 200mg, tramadol ER 300mg (ABA) Oral Short-Acting Opioid Analgesics Apadaz, Benzhydrocodone/Acetaminophen hydrocodone/acetaminophen, oxycodone/acetaminophen Nucynta, Oxycodone powder codeine sulfate, hydromorphone HCl, morphine sulfate, oxycodone HCl, oxymorphone HCl Qdolo tramadol

Postherpetic Neuralgia ZTlido lidocaine patch Transmucosal Fentanyl Analgesics Abstral, Fentanyl Citrate buccal tablet fentanyl citrate lozenge (ABA), Fentora, Lazanda, Subsys

ANTIBACTERIALS Oral Antibiotics Doryx 80mg, Doryx MPC, Doxycycline doxycycline, minocycline Hyclate DR 80mg, Minolira ANTICONVULSANTS Seizure Medications Lamictal ODT Kit lamotrigine ODT Oxtellar XR1 oxcarbazepine IR

ANTIFUNGALS Oral Antifungals Tolsura Itraconazole capsule

1 Serve You Rx Select Formulary Exclusions

THERAPEUTIC CATEGORY EXCLUDED MEDICATIONS PREFERRED ALTERNATIVES

ANTIVIRALS HIV Drugs Descovy2, Temixys1 Patients are to consult with their physician for clinically appropriate alternative(s)

AUTONOMIC AND CENTRAL NERVOUS SYSTEM ADHD Adhansia XR methylphenidate ER, Vyvanse Depression Bupropion XL (ABA)1, Forfivo XL1 bupropion XL (generic Wellbutrin XL) Lambert-Eaton Myasthenic Syndrome Firdapse Ruzurgi (LEMS) Multiple Sclerosis Extavia1, Plegridy1, Rebif1 Avonex, Betaseron Parkinson's Disease Gocovri, Osmolex ER amantadine Schizophrenia Secuado1 aripiprazole, asenipine, olanzapine,

quetiapine, quetiapine ER, risperidone

CARDIOVASCULAR Platelet Aggregation Inhibitors Aspirin/Omeprazole (ABA), Yosprala aspirin PLUS omeprazole

CHOLESTEROL Statins Livalo, Zypitamag atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

CONTRACEPTION Oral Contraceptive Lo Loestrin Junel Fe, Larin Fe, Microgestin Fe, Tarina Fe Slynd Camila, Incassia, Nora-Be, norethindrone, Norlyda, Norlyroc Transdermal Patch Twirla levonorgestrel/ethinyl estradiol generic combination oral contraceptive, Xulane

Vaginal Gel Phexxi Patients are to consult with their physician for clinically appropriate alternative(s)

Vaginal Ring Annovera etonogestrel/ethinyl estradiol vaginal ring

CORTICOSTEROIDS Oral Steroids Hemady dexamethasone Ortikos budesonide ER Rayos prednisone

DERMATOLOGIC AGENTS Actinic Keratosis Imiquimod cream pump 3.75% (ABA), imiquimod Zyclara pump Non-Steroidal Anti-Inflammatory Agents Diclofenac patch (ABA), Flector, Licart, diclofenac gel, diclofenac solution Pennsaid, Voltaren gel Plaque Psoriasis Calcipotriene foam 0.005% (ABA), Sorilux calcipotriene Halobetasol Propionate foam 0.05% (ABA), betamethasone, clobetasol, halobetasol Lexette cream/ointment Duobrii clobetasol, fluocinonide, halobetasol, tazarotene cream, Enstilar

2

Serve You Rx Select Formulary Exclusions

THERAPEUTIC CATEGORY EXCLUDED MEDICATIONS PREFERRED ALTERNATIVES Topical Acne Treatment Aklief, Aktipak, Clindagel, Clindamycin gel adapalene, adapalene/benzoyl peroxide, 1% (ABA), Dapsone 7.5% (ABA), Veltin clindamycin gel/lotion/solution, clindamycin/benzoyl peroxide, dapsone, erythromycin/benzoyl peroxide, tretinoin cream, Aczone 7.5%, Amzeeq, Epiduo Forte, Onexton Adapalene lotion (ABA), Avita, Differin adapalene cream/gel, tretinoin cream/gel, lotion Retin-A micro gel 0.06% and 0.08% Arazlo, Fabior, Tazarotene 0.1% foam tazarotene cream (ABA), Tazorac cream 0.05%, Tazorac gel 0.05%, Tazorac gel 0.1%

Topical Anti-Infectives Noritate cream metronidazole cream/gel/lotion, Finacea, Soolantra Topical Antifungals Jublia ciclopirox, tavaborole, terbinafine, Kerydin Topical Corticosteroids Halog ointment betamethasone, mometasone, triamcinolone acetonide Impeklo lotion betamethasone, clobetasol Impoyz cream clobetasol Psorcon cream, Verdeso foam betamethasone, fluocinolone Pandel cream flurandrenolide, hydrocortisone valerate, triamcinolone acetonide ALA Scalp lotion, Micort-HC cream hydrocortisone Apexicon E cream betamethasone, fluocinonide Capex shampoo Derma-Smoothe/FS, fluocinolone acetonide scalp oil Cordran tape flurandrenolide Trianex ointment hydrocortisone valerate, triamcinolone acetonide Ultravate lotion clobetasol propionate, fluocinonide, halobetasol propionate

DIABETES Basal Insulin Basaglar, Levemir, Semglee, Tresiba Lantus, Toujeo Blood Glucose Meters, Test Strips, and Examples: Abbott (FreeStyle, Precision), Ascencia (Contour, Contour Next) Control Solutions Arkray (Glucocard), Lifescan (OneTouch), Trividia (TRUEtest, TRUEtrack), Roche (Accu-Chek)

Blood Sugar Regulators Miscellaneous metformin ER modified release (generic metformin ER (generic Glucophage XR) Glumetza), metformin ER osmotic (generic Fortamet) Continuous Glucose Monitoring (CGM) Freestyle Libre Dexcom Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Alogliptin (ABA), Alogliptin/metformin Janumet, Janumet XR, Januvia, & Combinations (ABA), Alogliptin/pioglitazone (ABA), Jentadueto, Jentadueto XR, Tradjenta Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni Glucagon-Like Peptide-1 (GLP-1) Agonists Adlyxin Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza Insulins Novolin Humulin Rapid-acting Insulin Admelog, Apidra, Fiasp, Insulin Aspart Humalog, Lyumjev (ABA), Insulin Lispro (ABA), Novolog

3

Serve You Rx Select Formulary Exclusions

THERAPEUTIC CATEGORY EXCLUDED MEDICATIONS PREFERRED ALTERNATIVES SGLT2 Inhibitor and DPP-4 Inhibitor Qtern, Steglujan Glyxambi, Trijardy XR Combinations Sodium-glucose co-transporter (SGLT2) Invokana, Steglatro Farxiga, Jardiance Inhibitors – single agent Sodium-glucose co-transporter (SGLT2) Invokamet, Invokamet XR, Segluromet Synjardy, Synjardy XR, Xigduo XR Inhibitors – combination agents

ENDOCRINE Acromegaly Bynfezia Pen, Mycapssa octreotide

Adrenocortical Insufficiency Alkindi Sprinkle hydrocortisone Cushing’s Disease Isturisa ketoconazole tabs, Korlym Signifor (SQ) octreotide

Growth Hormones Genotropin, Humatrope, Omnitrope, Norditropin, Nutropin AQ Saizen, Zomacton

Hypogonadism Aveed, Jatenzo, Natesto, Testopel testosterone, Androderm, Xyosted Hypothyroidism Levothyroxine Capsules (ABA), Thyquidity, levothyroxine Tirosint Infertility Gonal-F Follistim AQ Cetrotide ganirelix (Organon manufacturer) Pituitary Hormones Noctiva desmopressin, Nocdurna

GASTROINTESTINAL Anti-Inflammatory/Anti-Ulcer Agents Duexis famotidine PLUS ibuprofen

Antiemetics Sancuso patch granisetron solution/tablet, ondansetron ODT Bowel Preparation Medications Golytely packets Gavilyte-C, Gavilyte-H, PEG 3350 OsmoPrep, Plenvu Clenpiq, Gavilyte-N, PEG 3350, Prepopik, Suprep Motofen diphenoxylate/atropine, loperamide Gastroparesis Gimoti metoclopramide Inflammatory Bowel Disease Dipentum balsalazide, mesalamine, Apriso with Amitiza, Lubiprostone (ABA), Trulance Linzess /Chronic Idiopathic Constipation Opioid-Induced Constipation Amitiza, Lubiprostone (ABA), Movantik, Symproic Relistor

Pancreatic Pancreaze, Pertzye, Viokace Creon, Zenpep Proton Pump Inhibitors omeprazole/sodium bicarbonate, esomeprazole magnesium, lansoprazole, Rabeprazole Sprinkle (ABA) omeprazole, pantoprazole, Aciphex Sprinkle Caps, Dexilant

HEMATOLOGICAL Colony-Stimulating Agents (filgrastim) Granix, Neupogen Nivestym, Zarxio Colony-Stimulating Agents (pegfilgrastim) Fulphila, Udenyca Neulasta, Ziextenzo Erythropoiesis-Stimulating Agents Epogen, Procrit Aranesp, Retacrit Hemophilia Esperoct1 Adynovate, Afstyla, Eloctate, Jivi

4

Serve You Rx Select Formulary Exclusions

THERAPEUTIC CATEGORY EXCLUDED MEDICATIONS PREFERRED ALTERNATIVES Sevenfact Novoseven Sickle Cell Disease Oxbryta hydroxyurea

HEPATITIS C Antiviral Ledipasvir/sofosbuvir (ABA), Epclusa, Harvoni, Mavyret, Vosevi Velpatasvir/sofosbuvir (ABA) HYPERTENSION Beta-Blocker Kapspargo metoprolol ER Inderal XL, Innopran XL propranolol ER Calcium Channel Blocker Conjupri, Katerzia amlodipine

IMMUNOMODULATORS Interleukin-17 (IL-17) Cosentyx1 Taltz Janus Kinase (JAK) Inhibitor Olumiant1 Rinvoq, Xeljanz, Xeljanz XR Methotrexate Products RediTrex methotrexate, Rasuvo TNF inhibitor Remicade, Renflexis Avsola, Inflectra

IMMUNOTHERAPY Immune Globulin Asceniv1, Cutaquig1, Panzyga1 Patients are to consult with their physician for clinically appropriate alternative(s)

MIGRAINE Calcitonin gene-related peptide (CGRP) Ajovy amitriptyline, atenolol, divalproex sodium, Antagonist nadolol, propranolol, timolol, topiramate, venlafaxine, Aimovig, Emgality Serotonin Receptor Agonists Onzetra Xsail, Tosymra, Zembrace rizatriptan ODT, sumatriptan injection, Symtouch sumatriptan nasal spray, zolmitriptan ODT Reyvow Nurtec ODT, Ubrelvy

ONCOLOGY Alkylating Agents Belrapzo, Bendamustine, Treanda Patients are to consult with their physician for clinically appropriate alternative(s) Inhibitor Tazverik1 Patients are to consult with their physician for clinically appropriate alternative(s) Hormone-Related Erleada1, Yonsa1 Patients are to consult with their physician for clinically appropriate alternative(s) Monoclonal Antibodies Darzalex Faspro, Herzuma, Ogivri, Patients are to consult with their physician Ontruzant, Truxima for clinically appropriate alternative(s) Mutation -Specific Gavreto1 Retevmo

Tabrecta Patients are to consult with their physician for clinically appropriate alternative(s) Myelodysplastic Syndromes (MDS) Inqovi decitabine

OPHTHALMIC Anti-Inflammatory Bromsite, Ilevro, Nevanac ophthalmic solution, diclofenac ophthalmic solution, flurbiprofen sodium ophthalmic solution, ketorolac tromethamine ophthalmic solution, Prolensa

5

Serve You Rx Select Formulary Exclusions

THERAPEUTIC CATEGORY EXCLUDED MEDICATIONS PREFERRED ALTERNATIVES

Antiglaucoma Drugs Vyzulta, Zioptan ophthalmic solution, ophthalmic solution, Lumigan Timoptic Ocudose 0.25% timolol ophthalmic solution

Antihistamine Bepreve, Lastacaft, Pazeo, Zerviate azelastine ophthalmic solution, olopatadine ophthalmic solution Dry Eye Syndrome Cequa Restasis, Xiidra

OSTEOARTHRITIS Viscosupplements Gel-One, Genvisc 850, Hyalgan, Hymovis, Durolane, Euflexxa, Gelsyn-3 Monovisc, Orthovisc, Sodium Hyaluronate, Supartz FX, Synvisc, Synvisc-One, Triluron, Trivisc, Visco-3

OTHER Duchenne Muscular Dystrophy Exondys 51, Viltepso, Vyondys 53 dexamethasone, methylprednisolone, prednisone Gout Colchicine capsule (ABA), Colcrys, colchicine tablet Gloperba, Mitigare

Hypertension and Osteoarthritis Consensi amlodipine PLUS celecoxib Interstitial Cystitis Elmiron amitriptyline, hydroxyzine Long-Chain Oxidation Disorders Dojolvi Patients are to consult with their physician (LC-FAOD) for clinically appropriate alternative(s)

Macular Degeneration Beovu ophthalmic bevacizumab (compound),

Eylea, Lucentis, Macugen Nasal Polyps Xhance mometasone furoate, Beconase AQ Opioid Overdose Evzio, 2mg/0.4mL Narcan Osteoporosis Forteo Teriparatide, Tymlos

RESPIRATORY Chronic Obstructive Pulmonary Disease Incruse Ellipta, Seebri Neohaler, Tudorza Spiriva (inhaled anticholinergics) Pressair Chronic Obstructive Pulmonary Disease Bevespi, Duaklir, Utibron Anoro Ellipta, Stiolto Respimat (long-acting beta agonist/long-acting muscarinic antagonist) Cystic Fibrosis (inhaled antibiotics) Cayston, Kitabis Pak, Tobramycin Neb tobramycin nebulizer solution, TOBI 300mg/5mL (ABA) Podhaler Pulmonary Anti-Inflammatory Inhalers Alvesco, ArmonAir Digihaler, Asmanex, Arnuity Ellipta, Flovent Diskus, Flovent QVAR HFA, Pulmicort Flexhaler Pulmonary Anti-Inflammatory/Long-Acting AirDuo Digihaler, AirDuo RespiClick, Advair Diskus, Advair HFA, Breo Ellipta, Beta Agonist Combination Inhalers Budesonide/Formoterol (ABA), Dulera Symbicort

Short-Acting Beta-2 Adrenergic Inhalers Albuterol HFA (Ventolin ABA), Levalbuterol albuterol HFA HFA (ABA), ProAir Digihaler, Proventil HFA, Xopenex HFA

UROLOGICAL Erectile Dysfunction Oral Agents Stendra sildenafil, tadalafil, vardenafil

6

Serve You Rx Select Formulary Exclusions

THERAPEUTIC CATEGORY EXCLUDED MEDICATIONS PREFERRED ALTERNATIVES

VITAMINS Multivitamins Dayavite, Dexifol, Feonyx, Folic-K, Folika- generic multivitamins T, Folika-V, Folitin-Z, Foltrexyl, Genicin Vita-S, Genicin Vita-Q, Hylavite, Hylazinc, Lorid, MultiPro, Nicadan, NicAzel, NicAzel Forte, Nicomide, Quflora Fe, Remedient, TronVite, Venexa, Venexa Fe, VitaSure, Vitranol, Vitranol Fe, Vitrexate, Vitrexate Fe, Vitrexyl, Vitrexyl + Iron, Xvite, Zyvana

Prenatal Vitamins AzesChew, Azesco, CitraNatal Assure, generic prenatal vitamins CitraNatal Bloom, CitraNatal DHA, CitraNatal Essence, CitraNatal Harmony, Duet DHA, Duet DHA Balanced, EnBrace HR, Jenliva, NataChew, NeevoDHA, Neonatal/DHA, Neonatal Fe, Neonate Complete, Nestabs DHA, Nestabs One, OB Complete One, OB Complete Petite, OB Complete Premier, PNV Tab 20-1, PreGen DHA, Pregenna, Prenara, Prenate chewable, Prenate DHA, Prenate Elite, Prenate Enhance, Prenate Essential, Prenate mini, Prenate Pixie, Prenate Restore, Prenatrix, Prenatryl, PrenatVite, PrimaCare, RediChew Rx, Select-OB, Select-OB DHA, Trinaz, TriStart DHA, TriStart Free, TriStart One, Vitafol Fe+, Vitafol gummies, Vitafol Nano, Vitafol-OB, Vitafol-OB DHA, Vitafol-One, Vitafol Ultra, vitaMedMD One, VitaPearl, Vitathely, VitaTrue, WestGel DHA, Zalvit

WEIGHT LOSS MEDICATIONS

Combination Products Contrave phentermine, Qsymia, Saxenda

7

Serve You Rx Select Formulary Exclusions

EXCLUDED BRAND-NAME MEDICATIONS WITH GENERIC EQUIVALENTS* The brand-name medications below are excluded on the formulary. These brand-name medications have been identified as having available generic equivalents covered at Tier 1 on the formulary. Speak with your pharmacist to have your excluded brand-name substituted with its generic equivalent or another preferred alternative.

A generic medication contains the same active ingredient(s) as a brand-name medication. An active ingredient is what makes the medication work. Brand-name medications are often protected by a patent. When the patent ends, drug companies can apply to the U.S. Food and Drug Administration (FDA) to begin making generic versions of the medication.

* Excluded brand-name medications without generic equivalents are included in the other medication tables.

Abilify Climara Generess Fe MoviPrep Retin-A Micro gel 0.04%, Tricor Acanya Clobex Gleevec MS Contin 0.1% Trileptal Aciphex tablet Cloderm Glumetza Nalfon Risperdal solution Truvada2 Acticlate Colestid Golytely solution Nasonex Risperdal tablet Tylenol/Codeine #3 Aczone 5% Concerta Halog cream Natroba Ritalin Tylenol/Codeine #4 Adcirca Coreg Hyzaar Neurontin Ritalin LA Uceris tab Adderall Coreg CR Imitrex Nexium Roxicodone Ultracet Adderall XR Cortef Inderal LA Niaspan Sabril Ultram Adipex-P Cosopt Intuniv Nitrostat Safyral Vagifem Afinitor 2.5, 5, 7.5mg Cosopt PF K-Tab Norco Sandostatin injection Valium Alphagan P 0.15% Cozaar Kadian 10, 20, 30, 40, Norvasc Saphris Valtrex Altace Crestor 50, 60, 80, 100mg Nulytely Seasonique Vanadom Ambien Cymbalta Kenalog spray Nuvigil Sensipar Vectical Ambien CR Cytomel Kenalog-40 Onfi Seroquel Vesicare Amrix Delestrogen 20mg/mL, Keppra Oracea Seroquel XR Viagra Androgel 40mg/mL Keppra XR Ortho Micronor Silvadene Vigamox Arimidex Delzicol Klonopin Ortho Tri Cyclen Lo Singulair Vimovo Arthrotec Depakote Kuvan Ortho-Novum Skelaxin Vivelle-Dot Asacol HD Depakote ER Lamictal chewable Pataday Solodyn Vogelxo Atacand Depakote sprinkle cap Lamictal Kit Patanol Soma Vytorin Ativan Depo-Testosterone Lamictal ODT Paxil Staxyn Welchol Atripla1 Desonate gel Lamictal tab Paxil CR Strattera Wellbutrin SR Avapro Differin cream, gel Lamictal XR Percocet Suboxone Wellbutrin XL Avodart Dilantin cap 100mg Lasix Plaquenil Synthroid Xalatan Azor Dilantin chewable Latisse Plavix Taclonex ointment Xanax Baraclude Dilantin suspension Lescol XL Pravachol Tamiflu Xanax XR Benicar Dilaudid Letairis Pred Forte Targadox Yasmin 28 Benicar HCT Diovan Levitra Prevacid Targretin Yaz Benzaclin Diovan HCT Lexapro Prinivil Tazorac cream 0.1% Zanaflex Benzamycin Doryx 50, 200mg Lialda Pristiq Tecfidera Zegerid Bethkis Duragesic Lidoderm Prometrium Tegretol Zestril Beyaz Dyazide Lipitor Propecia Tegretol-XR Zetia Brisdelle Effexor XR Loestrin 21 Protonix tab Tenormin Ziana Butrans Elidel Loestrin Fe Provigil Testim Zocor Canasa Epiduo Lotemax ophth susp Prozac Tikosyn Zohydro ER Carafate Epipen Jr 0.5% Pulmicort Respules Timoptic Zoloft Lotrel Carbatrol Estrace Qudexy XR Timoptic Ocudose 0.5% Zomig Lovaza Cardizem LA 180, 240, Evekeo Questran Timoptic-XE Zomig ZMT 300, 360, 420mg Exforge Lunesta Questran Light TOBI nebulizer Zonegran Lyrica Carnitor tablet Exforge HCT Ranexa Tobradex suspension Zovirax Carnitor solution Fioricet Maxalt Relafen Topamax Zyclara cream 3.75% Catapres-TTS Fioricet/Codeine Maxalt-MLT Relpax Topamax Sprinkle Zyprexa Metrogel Celebrex Flomax Remodulin Topicort spray Zytiga Celexa Focalin Micardis Renagel Toprol XL Cialis Focalin XR Micardis HCT Restoril Tracleer 62.5, 125mg Minastrin Ciprodex Fortamet Retin-A Treximet Clarinex tab Fortesta Mobic Tribenzor 8

Serve You Rx Select Formulary Exclusions

REQUIRED PRIOR AUTHORIZATION ADDITIONS3

THERAPEUTIC CLASS NON-PREFERRED MEDICATIONS PREFERRED MEDICATIONS Hepatitis C All other brands1 non-preferred Epclusa, Harvoni, Mavyret, Vosevi with prior authorization Immunomodulators All other brands1 non-preferred Avsola, Cimzia, Humira, Inflectra, Otezla, Rinvoq, with prior authorization Simponi, Skyrizi, Stelara, Tremfya, Xeljanz, Xeljanz XR

Multiple Sclerosis All other brands1 non-preferred with prior Avonex, Bafiertam, Betaseron, dimethyl fumarate authorization DR , Copaxone/Glatopa/glatiramer, Kesimpta, Vumerity

1 Grandfathering allowed, no duration limit. All other therapeutic classes do not allow grandfathering, no exceptions. 2 Grandfathering allowed for diagnosis of HIV only, no duration limit. All other therapeutic classes do not allow grandfathering, no exceptions. 3 All medications, preferred and non-preferred, require Prior Authorization. For new starts of non-preferred products, trial and failure of preferred brand(s) is required as a part of the Prior Authorization process

ABA = Authorized Brand Alternative

Listings are subject to change.

If you have additional questions, please call customer service at 800-759-3203 or visit serveyourx.com.

©2021 Serve You Rx ServeYouRx.com 9 190005CL(0521)