Jan 1, 2021 Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements

Therapeutic Category Excluded Medications Preferred Alternatives

ALLERGIC REACTIONS epinephrine injection (0.15mg, Anaphylaxis Treatment Auvi-Q (0.15mg, 0.3mg) 0.3mg) ANALGESICS celecoxib, diflunisal, etodolac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, Cambia, Zipsor, Zorvolex ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, Oral sulindac, tolmetin

Qmiiz ODT meloxicam Non-Steroidal Anti- Inflammatory Agents Relafen DS nabumetone

Other Sprix Nasal Spray diclofenac, ibuprofen, meloxicam

Flector diclofenac patch Topical Pennsaid diclofenac solution

Opioid Apadaz, hydrocodone/acetaminophen, combinations Benzhydrocodone/acetaminophen oxycodone/acetaminophen

hydromorphone HCl ER, morphine sulfate ER, Arymo ER, Kadian ER 200 mg, oxymorphone HCl ER, Embeda, Oral Long- Nucynta ER, Oxycodone ER (M) Hysingla ER, OxyContin, Acting Xtampza ER Pain Opioid Analgesics Conzip, Tramadol ER 100mg, tramadol ER 200mg, 300mg (M)

Oral Short- codeine sulfate, hydromorphone Acting HCl, morphine sulfate, Nucynta Opioid oxycodone HCl, oxymorphone Analgesics HCl

(M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives ANALGESICS

Transmucosal Abstral, Fentora, Fentanyl Citrate Pain Fentanyl Buccal Tab (M), fentanyl citrate lozenge Analgesics Lazanda, Subsys

Norgesic Forte, Orphengesic Forte (M) orphenadrine tab, aspirin Skeletal Muscle Relaxant Combinations Ozobax baclofen

ANTIBACTERIALS, ORAL Doryx MPC, Doxycycline Hyclate delayed release Oral Antibiotics doxycycline, minocycline 80mg, Minolira ANTICONVULSANTS

Lamictal ODT Kit lamotrigine ODT, lamotrigine XR Seizure Disorders Oxtellar XR1 oxcarbazepine IR

ANTIDEPRESSANTS

Antidepressants Bupropion XL (M), Forfivo XL bupropion XL

ANTIFUNGALS, ORAL

Oral Antifungals Tolsura itraconazole cap

ANTIHEMOPHILIACS

Hemophilia A Esperoct 1 Adynovate, Afstyla, Eloctate, Jivi

ANTIMIGRAINES amitriptyline, atenolol, divalproex sodium, nadolol, propranolol, Ajovy timolol, topiramate, venlafaxine, CGRP Antagonists Aimovig, Emgality

Reyvow Nurtec ODT, Ubrelvy

rizatriptan ODT, sumatriptan Serotonin Receptor Onzetra Xsail, Tosymra, Zembrace Symtouch injection, sumatriptan nasal Agonists spray, zolmitriptan ODT ANTIPARKINSON AGENTS

Parkinson's Disease Gocovri, Osmolex ER amantadine

ANTIPSYCHOTICS aripiprazole, olanzapine, Schizophrenia Secuado 1 quetiapine, quetiapine ER, risperidone, Saphris ANTIVIRALS Ledipasvir-Sofosbuvir (M), Sofosbuvir-Velpatasvir Epclusa, Harvoni, Mavyret, Hepatitis-C drugs (M) Vosevi

(M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs.

Therapeutic Category Excluded Medications Preferred Alternatives

ANTIVIRALS

Please talk with your doctor HIV drugs Atripla1, Descovy1, Temixys1, Truvada about clinically appropriate options. AUTONOMIC & CENTRAL NERVOUS SYSTEM Attention Deficit Disorder Adhansia XR Vyvanse

Interferon Beta Extavia1, Plegridy1, Rebif 1, Medications for Multiple Avonex, Betaseron Rebif Rebidose1 Sclerosis

CARDIOVASCULAR atorvastatin, fluvastatin, Cholesterol-Lowering Livalo, Zypitamag lovastatin, pravastatin, Agents rosuvastatin, simvastatin

Inderal XL , Innopran XL propranolol ER

Hypertension Kapspargo metoprolol ER

Katerzia amlodipine

Hypertension with Consensi amlodipine/celecoxib Osteoarthritis CHEMOTHERAPY AGENTS

Alkylating Agents Belrapzo, Bendamustine, Treanda

Antiandrogens Erleada1, Yonsa1, Zytiga 500mg1

Please talk to your doctor about HER-2 inhibitors Herzuma clinically appropriate options. Methyltransferase Tazverik 1 Inhibitors

Monoclonal Antibodies Ogivri, Truxima

CONTRACEPTIVES junel FE, larin FE, microgestin Lo Loestrin FE, tarina FE Oral Camila, Incassia, Nora-Be, Slynd norethindrone, Norlyda, Norlyroc

etonogestrel-ethinyl estradiol Vaginal ring Annovera vaginal ring

CORTICOSTEROIDS

Oral Steroids Rayos prednisone

(M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs.

Therapeutic Category Excluded Medications Preferred Alternatives

DERMATOLOGICAL AGENTS adapalene, Retin-A micro gel Adapalene lotion (M), Differin lotion 0.06% and 0.08% adapalene, adapalene/benzoyl peroxide, clindamycin gel/lotion/solution, Aklief, Aktipak, Clindagel, Clindamycin phosphate Topical Acne Treatment clindamycin/benzoyl peroxide, 1% gel(M), Dapsone 7.5%, Veltin erythromycin/benzoyl peroxide, tretinoin cream, Aczone 7.5%, Amzeeq, Epiduo Forte, Onexton

Avita tretinoin cream/gel

Topical anesthetics ZTlido lidocaine patch

Topical Antifungals Jublia terbinafine, Kerydin

metronidazole cream/gel/lotion, Topical Antiinfectives Noritate cream Finacea, Soolantra

ALA Scalp lotion, Micort-HC cream hydrocortisone

Apexicon E cream fluocinonide, betamethasone

Derma-Smoothe/FS, flucinolone Capex shampoo acetonide scalp oil

Cordran tape flurandrenolide

flurandrenolide, hydrocortisone Pandel cream valerate, triamcinolone acetonide betamethasone, clobetasol, Halobetasol foam(M), Lexette Topical Corticosteroids halobetasol cream/ointment

betamethasone, mometasone, Halog ointment triamcinolone

Impoyz cream clobetasol

Psorcon cream, Verdeso foam betamethasone, fluocinolone

hydrocortisone valerate, Trianex oint 0.05% triamcinolone acetonide clobetasol proprionate, Ultravate lotion fluocinonide, halobetasol proprionate Topical Immune Imiquimod cream pump 3.75% (M), Zyclara, imiquimod 5% cream Response Modifier Zyclara Pump

Calcipotriene Foam 0.005% (M), Sorilux calcipotriene

Topical Plaque Psoriasis clobetasol, fluocinonide, Duobrii Lotion halobetasol, tazorotene, Enstilar

(M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs.

Therapeutic Category Excluded Medications Preferred Alternatives

DIABETES Blood Glucose Meters, Examples: Abbott (FreeStyle, Precision), Ascencia (Contour, Contour Test Strips and Control Arkray(Glucocard), Lifescan (Onetouch), Trividia, Next) Solutions (TRUEtest, TRUEtrack), Roche (Accu-Chek)

Continuous Glucose Freestyle Libre Dexcom Monitoring (CGM)

Blood Sugar Regulators metformin HCl 24hr ER osmotic release, metformin metformin ER Miscellaneous HCl 24hr ER modified release

Dipeptidyl Peptidase-4 Alogliptin(M), Alogliptin with metformin(M), Janumet, Janumet XR, Januvia, (DPP4) Inhibitors & Alogliptin with pioglitazone(M), Kazano, Jentadueto, Jentadueto XR, Combinations Kombiglyze XR, Nesina, Onglyza, Oseni Tradjenta

Basal insulins Basaglar, Levemir, Tresiba Lantus, Toujeo

Bydureon, Bydureon BCise, Glucagon-Like Peptide- Adlyxin Byetta, Ozempic, Rybelsus, 1(GLP1) Agonists Trulicity, Victoza

Insulins Novolin Humulin

Admelog, Apidra, Fiasp, Insulin Aspart (M), Insulin Humalog Rapid-acting insulins Lispro (M), Novolog Sodium-glucose co- transporter (SGLT2) Invokana, Steglatro Farxiga, Jardiance Inhibitors - Single agent Sodium-glucose co- transporter (SGLT2) Invokamet, Invokamet XR, Segluromet Synjardy, Synjardy XR, Trijardy inhibitors - Combination XR, Xigduo XR agents SGLT2 and DPP4 QTERN, Steglujan Glyxambi Combinations ENDOCRINE (OTHER) Genotropin, Humatrope, Omnitrope, Saizen, Growth Hormones Norditropin, Nutropin Zomacton Gonal-F, Gonal-F RFF Follistim AQ Infertility ganirelix (made by Cetrotide Organon/Merck) Nocturia Noctiva desmopressin, Nocdurna

Testosterone testosterone, Androderm, Aveed, Jatenzo, Natesto, Testopel Replacement Xyosted

ENZYME DISORDERS Duchenne Muscular dexamethasone, Exondys 51, Vyondys 53 dystrophy (DMD) methylprednisolone, prednisone GASTROINTESTINAL

diphenoxylate/atropine, Motofen Anti-Diarrheal Agents loperamide

(M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs.

Therapeutic Category Excluded Medications Preferred Alternatives

GASTROINTESTINAL granisetron solution/tablet, Antiemetics Sancuso patch ondansetron ODT

Anti-Inflammatory, Anti- Duexis famotidine with ibuprofen Ulcer Agents Irritable Bowel Syndrome with Constipation/ Amitiza, Trulance Linzess Chronic Idiopathic Constipation (IBS-C/CIC)

Opioid-Induced Amitiza, Movantik, Relistor Symproic Constipation (OIC)

Inflammatory Bowel Dipentum balsalazide, mesalamine, Apriso Disease

Gavilyte-C, Gavilyte-H, PEG Golytely packets 3350 Laxatives Clenpiq, Gavilyte, PEG 3350, Moviprep, Osmoprep, Plenvu Prepopik, Suprep

Pancreatic Enzymes Pancreaze, Pertzye, Viokace Creon, Zenpep

esomeprazole magnesium omeppi, omeprazole with sodium bicarbonate (cap, delayed release, lansoprazole, Proton pump inhibitors powder pak), Rabeprazole sprinkle cap (M) omeprazole, pantoprazole, Aciphex Sprinkle caps, Dexilant HEMATOLOGICAL Erythropoiesis- Epogen, Procrit Aranesp, Retacrit Stimulating Agents

Immune globulin, Please talk to your doctor about Asceniv 1, Panzyga1 intravenous (IVIG) clinically appropriate options.

Immune globulin, Please talk to your doctor about Cutaquig1 subcutaneous (SCIG) clinically appropriate options.

Long-Acting Granulocyte- Colony Stimulating Factor Fulphila, Udenyca Neulasta, Ziextenzo (G-CSFs)

Short-Acting Granulocyte- Colony Stimulating Factor Granix, Neupogen Nivestym, Zarxio (G-CSFs) IMMUNOMODULATORS Interleukin-17 (IL-17) Cosentyx 1 Taltz Inhibitor

JAK Inhibitor Olumiant1 Rinvoq, Xeljanz, Xeljanz XR

TNF inhibitor Remicade Inflectra, Renflexis

(M) Co-branded product

1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs.

Therapeutic Category Excluded Medications Preferred Alternatives

IMMUNOTHERAPY Please talk to your doctor about Oral Palforzia clinically appropriate options. OPHTHALMIC latanoprost ophthalmic solution, Vyzulta, Zioptan travoprost ophthalmic solution, Lumigan Antiglaucoma Drugs

Timoptic Ocudose timolol ophthalmic solution

azelastine ophthalmic solution, Antihistamines Pazeo, Zerviate olopatadine ophthalmic solution

Dry Eye Disease Cequa Restasis, Xiidra

bromfenac ophthalmic solution, diclofenac ophthalmic solution, Non-steroidal Anti- Bromsite, Ilevro, Nevanac flurbiprofen sodium ophthalmic Inflammatory Agents solution, ketorolac tromethamine ophthalmic solution, Prolensa

ophthalmic bevacizumab Wet Age-related Macular Beovu (compound), Eylea, Lucentis, Degeneration Macugen OTHER

Antigout Agents Colchicine capsule, Colcrys, Gloperba, Mitigare colchicine tablet

Antihistamines and desloratadine with Clarinex-D combinations pseudoephedrine

Corticosteroid nasal mometasone furoate, Beconase Xhance sprays AQ Lambert-Eaton Myasthenic Syndrome Firdapse Ruzurgi (LEMS)

Obesity Contrave phentermine, Qsymia, Saxenda

Opioid Reversal Agents Naloxone (M), Evzio Narcan

Gel-One, Genvisc, Hyalgan, Hymovis, Monovisc, Osteoarthritis/Hyaluronic Orthovisc, Sodium Hyaluronate, Supartz FX, Durolane, Euflexxa, Gelsyn-3 acid injections Synvisc, Synvisc-One, Triluron, Trivisc, Visco-3

Platelet-Modifying Agent Aspirin/Omeprazole (M), Yosprala aspirin with omeprazole

Examples: Azesco, Pregenna, Prenate, Trinaz, Prenatal vitamins Any preferred prenatal vitamin Vitafol FE, Vitathely, Zalvit

(M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs.

Therapeutic Category Excluded Medications Preferred Alternatives

OTHER

Sickle Cell Anemia Oxbryta hydroxyurea

Thyroid Agents Tirosint caps, solution levothyroxine

RESPIRATORY

COPD: Inhaled Incruse Ellipta, Seebri, Tudorza Spiriva Anticholinergics

COPD: Long-Acting Beta Agonist/Long-Acting Bevespi, Duaklir, Utibron Anoro Ellipta, Stiolto Respimat Muscarinic Agonist Combination inhalers

Cystic Fibrosis (inhaled tobramycin nebulizer soln, Kitabis Pak, Tobramycin Neb(M) tobramycin) Bethkis, TOBI podhaler

Arnuity Ellipta, Flovent Diskus, Pulmonary Anti- Alvesco, Asmanex, Asmanex HFA, QVAR Flovent HFA, Pulmicort Inflammatory Inhalers Redihaler Flexhaler

Pulmonary Anti- fluticasone/salmeterol inhaler, Inflammatory, Long- AirDuo, Airduo Digihaler, Armonair, Advair Diskus, Advair HFA, Breo Acting Beta Agonist Budesonide/Formoterol (M), Dulera Ellipta, Symbicort Combination Inhalers

Albuterol HFA (ABA for Ventolin HFA) (M), Short-Acting Beta-2 Levalbuterol Inhaler(M), Proair Digihaler, ProAir albuterol HFA inhaler Adrenergic Inhalers HFA, ProAir Respiclick, Proventil HFA, Ventolin HFA, Xopenex HFA UROLOGICAL Erectile Dysfunction Oral Stendra sildenafil Agents

(M) Co-branded product

1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs.

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 medication substituted with its generic equivalent.

A generic medication contains the same active ingredient(s) as a brand-name medication. An active ingredient is what makes the medication work. For example, Lipitor® and its generic both contain atorvastatin, which reduces the amount of bad cholesterol in the blood. 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.

Abilify Cozaar Keppra Plavix Timoptic-XE Acanya Crestor Keppra XR Pravachol TOBI nebulizer solution Aciphex tablet Cymbalta Klonopin Pred Forte Tobradex suspension Acticlate Cytomel K-tab Prevacid Topamax Aczone 5% Delestrogen injection Lamictal chewable Prinivil Topamax sprinkle cap Adcirca 20mg/ml, 40mg/ml Lamictal starter kit Pristiq Topicort spray Adderall Delzicol Lamictal ODT Prometrium Toprol XL Adderall XR Depakote Lamictal tab Propecia Tracleer 62.5,125mg Adipex-P Depakote ER Lamictal XR Protonix tab Treximet Afinitor 2.5,5,7.5mg Depakote sprinkle cap Lasix Provigil Tribenzor Alphagan P 0.15% Depo-testosterone Latisse Prozac Tricor Altace injection Lescol XL Pulmicort inhalation Trileptal Ambien Desonate gel Letairis suspension Tylenol/cod tab Ambien CR Differin cream, gel Levitra Qudexy XR Uceris tab Amrix Dilantin cap 100mg Lexapro Questran Ultracet Androgel Dilantin chewable Lialda Ranexa Ultram Arimidex Dilantin suspension Lidoderm Relpax Vagifem Arthrotec Dilaudid Lipitor Remodulin injection Valium Asacol HD Diovan Loestrin 21 Renagel Valtrex Atacand Diovan HCT Loestrin FE Restoril Vanadom Ativan Doryx tab Lotemax suspension Retin-A Vectical Avapro Duac Lotrel Retin-A micro gel Vesicare Avodart Duragesic Lovaza 0.04%, 0.1% Viagra Azor Dyazide Lunesta Risperdal solution, Vigamox Baraclude Effexor XR Lyrica tablet Vimovo Benicar Elidel Maxalt Ritalin Vivelle-Dot Benicar HCT Epiduo gel Maxalt-MLT Ritalin LA Volgelxo Benzaclin EpiPen Jr 0.15mg Metrogel Roxicodone Voltaren gel Benzamycin Estrace Micardis Sabril Vytorin Beyaz Evekeo Micardis HCT Safyral Welchol Brisdelle Exforge Minastrin Sandostatin injection Wellbutrin SR Butrans Exforge HCT Mobic Seasonique Wellbutrin XL Canasa Fioricet MS Contin Sensipar Xalatan Carafate Fioricet w/ codeine Nalfon Seroquel Xanax Carbatrol Flomax Nasonex Seroquel XR Xanax XR Cardizem LA Focalin Natroba Silvadene Yasmin 28 180,240,300, Focalin XR Neurontin Singulair Yaz 360, 420mg Fortamet Nexium capsule Skelaxin Zanaflex Carnitor solution, Fortesta Niaspan ER Solodyn Zegerid tablet Generess FE Nitrostat Soma Zestril Catapres-TTS patch chewable Norco Staxyn Zetia Celebrex Gleevec Norvasc Strattera Ziana Celexa Glumetza Nulytely Suboxone Zocor Cialis Golytely solution Nuvigil Synthroid Zohydro ER Clarinex 5mg tab Halog cream Onfi Taclonex ointment Zoloft Climara patch Hyzaar Oracea Tamiflu Zomig tab Clobex Imitrex Ortho Micron Targadox Zomig ZMT Cloderm Inderal LA Ortho-Tri-Cyclen Lo Targretin Zonegran Colestid Intuniv Ortho-Novum Tazorac cream 0.1% Zovirax Concerta Kadian Pataday Tegretol Zyprexa Coreg 10,20,30,40,50,60, Patanol Tegretol-XR Zytiga 250mg Coreg CR 80,100mg Paxil Tenormin Cortef Kenalog spray Paxil CR Testim gel Cosopt solution Kenalog-40 Percocet Tikosyn Cosopt PF solution Injection Plaquenil Timoptic

Required Prior Authorization +

Therapeutic Class Non-Preferred Medications Preferred Medications

All other brands non-preferred with prior Hepatitis C Epclusa, Harvoni, Mavyret, Vosevi authorization

Avonex, Bafiertam, Betaseron, All other brands non-preferred with prior Multiple Sclerosis Copaxone/Glatopa/glatiramer, authorization Tecfidera, Vumerity

Cimzia, Humira, Inflectra, Otezla, All other brands non-preferred with prior Renflexis, Rinvoq, Simponi, Simponi Immunomodulators authorization Aria, Skyrizi, Stelara, Tremfya, Xeljanz, Xeljanz XR

+ All of the products listed above are currently subject to prior authorization. Preferred medications are required prior to new requests for non-preferred medication(s). Existing utilizers of non-preferred medication(s) within the therapeutic categories of Hepatitis C, Immunomodulators and Multiple Sclerosis will be eligible to remain on current therapy if compliance and efficacy of therapy are demonstrated. Exceptions will be granted for specific indications where the preferred agents do not have FDA-approval for use.

(M) Co-branded product

About this document: Where differences exist between this formulary and your benefit plan documents, the benefit plan documents rule. This may not be a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or plan sponsor for full details.

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