University System of Georgia Performance Drug List - Standard Control with Advanced Control ® Specialty Formulary

January 2021 University System of Georgia Performance Drug List - Standard Control with Advanced Control ® Specialty Formulary

The University System of Georgia Performance Drug List- Standard Control with Advanced Control Specialty Formulary® is a guide within select therapeutic categories for USG 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 administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a doctor. 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 • This drug list represents a summary of prescription coverage. It is this document. Products recently approved by the U.S. Food and not all-inclusive and does not guarantee coverage. The member’s Drug Administration (FDA) may not be covered upon release specific prescription benefit plan design may not cover certain to the market. products or categories, regardless of their appearance in this • You may be responsible for the full cost of non-formulary products document. Products recently approved by the FDA may not be that are removed from coverage. covered upon release to the market. • For specific information regarding your prescription benefit • The member's prescription benefit plan may have a different coverage and copay1 information, please visit Caremark.com copay1 for specific products on the list. or 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 • Log in to Caremark.com to check coverage and copay1 generic equivalent. This may result in your doctor prescribing, information for a specific medicine. when medically appropriate, a different brand-name product or 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 methadone SUBSYS § NSAIDs, TOPICAL § OPIOID ANALGESICS morphine XTAMPZA ER § NSAIDs diclofenac sodium gel 1% buprenorphine transdermal morphine ext-rel diclofenac sodium diclofenac sodium solution codeine-acetaminophen morphine suppository ANTI-INFECTIVES ibuprofen fentanyl transdermal oxycodone § COX-2 INHIBITORS ANTIBACTERIALS meloxicam fentanyl transmucosal oxycodone-acetaminophen § CEPHALOSPORINS naproxen (except naproxen CR or celecoxib lozenge tramadol (except NDC^ 52817019610)

naproxen suspension) hydrocodone ext-rel tramadol ext-rel cefdinir § GOUT hydrocodone-acetaminophen BELBUCA cefprozil § NSAIDs, COMBINATIONS allopurinol hydromorphone NUCYNTA cefuroxime axetil colchicine tablet diclofenac sodium- hydromorphone ext-rel NUCYNTA ER cephalexin misoprostol probenecid 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.

CARDIOVASCULAR fenofibric acid delayed-rel ENTRESTO mg, fluoxetine tablet [generics for § ERYTHROMYCINS / SARAFEM]) MACROLIDES § HMG-CoA REDUCTASE § NITRATES § ACE INHIBITORS paroxetine HCl INHIBITORS / azithromycin fosinopril isosorbide dinitrate (except paroxetine HCl ext-rel COMBINATIONS clarithromycin lisinopril isosorbide dinitrate 40 mg) sertraline clarithromycin ext-rel quinapril atorvastatin isosorbide mononitrate TRINTELLIX erythromycins ramipril ezetimibe-simvastatin nitroglycerin lingual spray DIFICID fluvastatin nitroglycerin sublingual § SEROTONIN § ACE INHIBITOR / lovastatin NOREPINEPHRINE § FLUOROQUINOLONES § MISCELLANEOUS DIURETIC COMBINATIONS pravastatin REUPTAKE INHIBITORS ciprofloxacin fosinopril-hydrochlorothiazide rosuvastatin ranolazine ext-rel (SNRIs) levofloxacin lisinopril-hydrochlorothiazide simvastatin desvenlafaxine ext-rel moxifloxacin quinapril-hydrochlorothiazide CENTRAL NERVOUS duloxetine § NIACINS SYSTEM venlafaxine § PENICILLINS § ANGIOTENSIN II niacin ext-rel ANTIANXIETY venlafaxine ext-rel capsule amoxicillin RECEPTOR ANTAGONISTS / amoxicillin-clavulanate DIURETIC COMBINATIONS § OMEGA-3 FATTY ACIDS § BENZODIAZEPINES § MISCELLANEOUS dicloxacillin candesartan / candesartan- omega-3 acid ethyl esters alprazolam AGENTS penicillin VK hydrochlorothiazide VASCEPA clonazepam bupropion

irbesartan / irbesartan- diazepam bupropion ext-rel (except § TETRACYCLINES § BETA-BLOCKERS hydrochlorothiazide lorazepam bupropion ext-rel tablet 450 mg) doxycycline hyclate 20 mg losartan / losartan- atenolol oxazepam mirtazapine doxycycline hyclate capsule hydrochlorothiazide carvedilol trazodone § ANTICONVULSANTS minocycline olmesartan / olmesartan- carvedilol phosphate ext-rel tetracycline hydrochlorothiazide metoprolol succinate ext-rel carbamazepine § ANTIPARKINSONIAN telmisartan / telmisartan- metoprolol tartrate carbamazepine ext-rel AGENTS § ANTIFUNGALS hydrochlorothiazide nadolol clobazam amantadine fluconazole valsartan / valsartan- pindolol diazepam rectal gel carbidopa-levodopa itraconazole hydrochlorothiazide propranolol divalproex sodium carbidopa-levodopa ext-rel terbinafine tablet propranolol ext-rel divalproex sodium ext-rel carbidopa-levodopa-

§ ANGIOTENSIN II BYSTOLIC ethosuximide entacapone ANTIVIRALS RECEPTOR ANTAGONIST / gabapentin entacapone § CYTOMEGALOVIRUS § CALCIUM CHANNEL CALCIUM CHANNEL lamotrigine pramipexole AGENTS BLOCKERS BLOCKER COMBINATIONS lamotrigine ext-rel pramipexole ext-rel valganciclovir amlodipine-olmesartan amlodipine levetiracetam rasagiline

amlodipine-telmisartan diltiazem ext-rel (except generics levetiracetam ext-rel ropinirole § HERPES AGENTS amlodipine-valsartan for CARDIZEM LA) oxcarbazepine ropinirole ext-rel acyclovir capsule, tablet nifedipine ext-rel phenobarbital selegiline valacyclovir § ANGIOTENSIN II verapamil ext-rel phenytoin NEUPRO

RECEPTOR ANTAGONIST / phenytoin sodium extended § INFLUENZA AGENTS § CALCIUM CHANNEL CALCIUM CHANNEL primidone ANTIPSYCHOTICS oseltamivir BLOCKER / ANTILIPEMIC BLOCKER / DIURETIC tiagabine § ATYPICALS COMBINATIONS RELENZA COMBINATIONS topiramate aripiprazole amlodipine-valsartan- amlodipine-atorvastatin valproic acid § MISCELLANEOUS clozapine hydrochlorothiazide zonisamide clindamycin § DIGITALIS GLYCOSIDES olanzapine olmesartan-amlodipine- NAYZILAM quetiapine ivermectin digoxin hydrochlorothiazide OXTELLAR XR quetiapine ext-rel linezolid TROKENDI XR risperidone metronidazole § ANTIARRHYTHMICS § DIRECT RENIN INHIBITORS / DIURETIC VALTOCO ziprasidone nitrofurantoin sotalol COMBINATIONS VIMPAT ABILIFY MAINTENA pyrimethamine MULTAQ XCOPRI LATUDA sulfamethoxazole- aliskiren PERSERIS trimethoprim ANTILIPEMICS TEKTURNA HCT § ANTIDEMENTIA VRAYLAR vancomycin capsule ACL INHIBITORS / § DIURETICS donepezil EMVERM COMBINATIONS galantamine § ATTENTION DEFICIT XIFAXAN 550 MG amiloride NEXLETOL galantamine ext-rel HYPERACTIVITY DISORDER furosemide NEXLIZET memantine ANTINEOPLASTIC hydrochlorothiazide amphetamine- rivastigmine AGENTS metolazone dextroamphetamine mixed § BILE ACID RESINS rivastigmine transdermal spironolactone- salts HORMONAL cholestyramine NAMZARIC amphetamine- hydrochlorothiazide ANTINEOPLASTIC AGENTS colesevelam dextroamphetamine mixed torsemide ANTIDEPRESSANTS § ANTIANDROGENS salts ext-rel † § CHOLESTEROL triamterene § SELECTIVE SEROTONIN atomoxetine bicalutamide ABSORPTION INHIBITORS triamterene- REUPTAKE INHIBITORS guanfacine ext-rel ezetimibe hydrochlorothiazide (SSRIs) § MISCELLANEOUS methylphenidate citalopram † VISTOGARD § FIBRATES HEART FAILURE methylphenidate ext-rel

escitalopram MYDAYIS fenofibrate (except fenofibrate tablet BIDIL fluoxetine (except fluoxetine tablet 60 VYVANSE 120 mg) CORLANOR

PSEUDOBULBAR AFFECT § INSULIN SENSITIZER / CALCIUM REGULATORS PREMPRO § FIBROMYALGIA AGENTS BIGUANIDE COMBINATIONS § BISPHOSPHONATES pregabalin § TRANSDERMAL NUEDEXTA pioglitazone-metformin alendronate estradiol HYPNOTICS ibandronate § VASOMOTOR SYMPTOM § INSULIN SENSITIZER / CLIMARA PRO § NONBENZODIAZEPINES risedronate AGENTS SULFONYLUREA COMBIPATCH eszopiclone paroxetine mesylate COMBINATIONS § CALCITONINS DIVIGEL EVAMIST ramelteon pioglitazone-glimepiride calcitonin-salmon zolpidem ENDOCRINE AND § VAGINAL zolpidem ext-rel METABOLIC § MEGLITINIDES § CARNITINE DEFICIENCY zolpidem sublingual nateglinide AGENTS estradiol § ANDROGENS IMVEXXY BELSOMRA repaglinide levocarnitine testosterone gel (except authorized § PHOSPHATE BINDER § TRICYCLICS generics for TESTIM and VOGELXO) SODIUM-GLUCOSE CONTRACEPTIVES AGENTS doxepin testosterone solution CO-TRANSPORTER 2 § MONOPHASIC ANDRODERM (SGLT2) INHIBITORS calcium acetate MIGRAINE ethinyl estradiol- FARXIGA sevelamer carbonate drospirenone ACUTE MIGRAINE AGENTS ANTIDIABETICS PHOSLYRA JARDIANCE ethinyl estradiol- § Triptans AMYLIN ANALOGS VELPHORO drospirenone-levomefolate SYMLINPEN SODIUM-GLUCOSE eletriptan CO-TRANSPORTER 2 ethinyl estradiol- POTASSIUM-REMOVING naratriptan § BIGUANIDES (SGLT2) INHIBITOR / norethindrone acetate AGENTS rizatriptan ethinyl estradiol- metformin BIGUANIDE COMBINATIONS LOKELMA sumatriptan norethindrone acetate-iron metformin ext-rel (except generics SYNJARDY VELTASSA zolmitriptan for FORTAMET and GLUMETZA) SYNJARDY XR BIPHASIC ONZETRA XSAIL PROGESTINS XIGDUO XR

ZEMBRACE SYMTOUCH § BIGUANIDE / LO LOESTRIN FE § ORAL

ZOMIG NASAL SPRAY SULFONYLUREA SODIUM-GLUCOSE § TRIPHASIC medroxyprogesterone COMBINATIONS CO-TRANSPORTER 2 megestrol acetate Miscellaneous ethinyl estradiol-norgestimate glipizide-metformin (SGLT2) INHIBITOR / progesterone, micronized NURTEC ODT DIPEPTIDYL PEPTIDASE-4 § EXTENDED CYCLE REYVOW DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR VAGINAL UBRELVY ethinyl estradiol- (DPP-4) INHIBITORS COMBINATIONS CRINONE levonorgestrel PREVENTIVE MIGRAINE JANUVIA GLYXAMBI ENDOMETRIN

AGENTS § TRANSDERMAL DIPEPTIDYL PEPTIDASE-4 SODIUM-GLUCOSE § SELECTIVE ESTROGEN ethinyl estradiol- Monoclonal Antibodies (DPP-4) INHIBITOR / CO-TRANSPORTER 2 RECEPTOR MODULATORS norelgestromin AIMOVIG BIGUANIDE COMBINATIONS (SGLT2) INHIBITOR / raloxifene AJOVY JANUMET DIPEPTIDYL PEPTIDASE-4 § VAGINAL EMGALITY JANUMET XR (DPP-4) INHIBITOR / § THYROID SUPPLEMENTS ethinyl estradiol-etonogestrel BIGUANIDE COMBINATIONS levothyroxine § MUSCULOSKELETAL ANNOVERA INCRETIN MIMETIC AGENTS liothyronine THERAPY AGENTS TRIJARDY XR OZEMPIC ENDOMETRIOSIS SYNTHROID cyclobenzaprine (except RYBELSUS § SULFONYLUREAS ORILISSA cyclobenzaprine tablet 7.5 mg) TRULICITY GASTROINTESTINAL glimepiride VICTOZA glipizide § GLUCOCORTICOIDS § NARCOLEPSY § ANTIDIARRHEALS glipizide ext-rel dexamethasone armodafinil INCRETIN MIMETIC AGENT / diphenoxylate-atropine fludrocortisone SUNOSI INSULIN COMBINATIONS SUPPLIES loperamide hydrocortisone SOLIQUA POSTHERPETIC BD ULTRAFINE INSULIN methylprednisolone § ANTIEMETICS XULTOPHY SYRINGES AND prednisolone solution NEURALGIA (PHN) aprepitant NEEDLES prednisone GRALISE INSULINS doxylamine-pyridoxine

DEXCOM CONTINUOUS BASAGLAR delayed-rel PSYCHOTHERAPEUTIC - GLUCOSE MONITORING GLUCOSE ELEVATING FIASP dronabinol MISCELLANEOUS SYSTEM AGENTS HUMULIN R U-500 granisetron § OPIOID ANTAGONISTS OMNIPOD DASH INSULIN BAQSIMI LEVEMIR meclizine INFUSION PUMP GLUCAGEN HYPOKIT naloxone injection metoclopramide NOVOLIN 70/30 OMNIPOD INSULIN GLUCAGON EMERGENCY NARCAN NASAL SPRAY NOVOLIN N ondansetron INFUSION PUMP KIT NOVOLIN R prochlorperazine § PARTIAL OPIOID AGONIST ONETOUCH ULTRA GVOKE NOVOLOG promethazine / OPIOID ANTAGONIST STRIPS AND KITS 2 NOVOLOG MIX 70/30 MENOPAUSAL SYMPTOM scopolamine transdermal COMBINATIONS ONETOUCH VERIO STRIPS TOUJEO AGENTS trimethobenzamide AND KITS 2 buprenorphine-naloxone SANCUSO TRESIBA V-GO INSULIN INFUSION § ORAL sublingual PUMP estradiol ZUBSOLV § INSULIN SENSITIZERS § ANTISPASMODICS

estradiol-norethindrone pioglitazone dicyclomine DUAVEE PREMPHASE

§ H2 RECEPTOR finasteride SYMJEPI tacrolimus STEROID / BETA AGONIST ANTAGONISTS silodosin EUCRISA § ANTICHOLINERGICS COMBINATIONS famotidine tamsulosin CORTICOSTEROIDS terazosin ipratropium inhalation ADVAIR DISKUS INFLAMMATORY BOWEL solution ADVAIR HFA § Low Potency ERECTILE DYSFUNCTION DISEASE SPIRIVA BREO ELLIPTA desonide § ORAL AGENTS ALPROSTADIL AGENTS YUPELRI SYMBICORT hydrocortisone balsalazide MUSE ANTICHOLINERGIC / BETA § STEROID INHALANTS § Medium Potency budesonide capsule § PHOSPHODIESTERASE AGONIST COMBINATIONS budesonide inhalation hydrocortisone butyrate budesonide ext-rel INHIBITORS § SHORT ACTING suspension cream, lotion, ointment, mesalamine delayed-rel sildenafil ipratropium-albuterol ARNUITY ELLIPTA solution mesalamine ext-rel tadalafil inhalation solution FLOVENT DISKUS mometasone sulfasalazine FLOVENT HFA triamcinolone cream, lotion, sulfasalazine delayed-rel § URINARY LONG ACTING PULMICORT FLEXHALER ointment PENTASA ANTISPASMODICS ANORO ELLIPTA QVAR REDIHALER

§ RECTAL AGENTS darifenacin ext-rel STIOLTO RESPIMAT § High Potency oxybutynin TOPICAL desoximetasone hydrocortisone enema ANTICHOLINERGIC / BETA oxybutynin ext-rel fluocinonide (except fluocinonide mesalamine suppository AGONIST / STEROID DERMATOLOGY solifenacin cream 0.1%) mesalamine suspension INHALANT COMBINATIONS ACNE tolterodine BRYHALI CORTIFOAM

tolterodine ext-rel BREZTRI AEROSPHERE § Topical § Very High Potency § IRRITABLE BOWEL trospium TRELEGY ELLIPTA adapalene

SYNDROME trospium ext-rel benzoyl peroxide clobetasol cream, foam, gel, § ANTIHISTAMINES, lotion, ointment, shampoo alosetron MYRBETRIQ clindamycin gel (except NDC^ LOW SEDATING TOVIAZ 68682046275) LINZESS § LOCAL ANESTHETICS levocetirizine clindamycin solution VIBERZI HEMATOLOGIC clindamycin-benzoyl lidocaine-prilocaine § ANTITUSSIVES § LAXATIVES peroxide § ANTICOAGULANTS benzonatate (except NDCs^ § ROSACEA lactulose solution erythromycin solution warfarin azelaic acid gel peg 3350-electrolytes 69336012615, 69499032915) erythromycin-benzoyl ELIQUIS metronidazole CLENPIQ peroxide XARELTO BETA AGONISTS, FINACEA FOAM tretinoin OPIOID-INDUCED INHALANTS ORACEA § PLATELET AGGREGATION EPIDUO SOOLANTRA CONSTIPATION § SHORT ACTING ONEXTON INHIBITORS MOVANTIK albuterol inhalation solution clopidogrel § ACTINIC KERATOSIS MOUTH / THROAT / SYMPROIC albuterol sulfate CFC-free dipyridamole ext-rel-aspirin DENTAL AGENTS aerosol fluorouracil cream 5% prasugrel PROTECTANTS PANCREATIC ENZYMES levalbuterol tartrate CFC-free fluorouracil solution BRILINTA CREON aerosol imiquimod EPISIL

VIOKACE PICATO IMMUNOLOGIC OPHTHALMIC ZENPEP LONG ACTING TOLAK AGENTS Hand-held Active Inhalation ZYCLARA § ANTIALLERGICS § PROTON PUMP ALLERGENIC EXTRACTS SEREVENT azelastine INHIBITORS § ANTIBIOTICS cromolyn sodium GRASTEK STRIVERDI RESPIMAT esomeprazole gentamicin olopatadine RAGWITEK lansoprazole Nebulized Passive Inhalation mupirocin ointment LASTACAFT omeprazole NUTRITIONAL / PERFOROMIST PAZEO § ANTIFUNGALS pantoprazole SUPPLEMENTS DEXILANT § LEUKOTRIENE ciclopirox § ANTI-INFECTIVES § ELECTROLYTES MODULATORS clotrimazole ciprofloxacin § STEROIDS, RECTAL potassium chloride liquid montelukast econazole erythromycin PROCTOFOAM-HC zafirlukast ketoconazole cream 2% gentamicin VITAMINS AND MINERALS zileuton ext-rel luliconazole levofloxacin § ULCER THERAPY § FOLIC ACID / nystatin moxifloxacin COMBINATIONS COMBINATIONS § NASAL ANTIHISTAMINES NAFTIN ofloxacin PYLERA folic acid azelastine sulfacetamide § ANTIPSORIATICS olopatadine tobramycin § MISCELLANEOUS § PRENATAL VITAMINS acitretin BESIVANCE sucralfate tablet § NASAL STEROIDS / prenatal vitamins calcipotriene ointment, CILOXAN OINTMENT COMBINATIONS CITRANATAL solution GENITOURINARY flunisolide methoxsalen § ANTI-INFECTIVE / RESPIRATORY fluticasone ANTI-INFLAMMATORY § BENIGN PROSTATIC § ANTISEBORRHEICS mometasone COMBINATIONS HYPERPLASIA § ANAPHYLAXIS DYMISTA ketoconazole shampoo 2% neomycin-polymyxin B- alfuzosin ext-rel TREATMENT AGENTS selenium sulfide lotion 2.5% bacitracin-hydrocortisone doxazosin epinephrine auto-injector PHOSPHODIESTERASE-4 neomycin-polymyxin B- dutasteride INHIBITORS § ATOPIC DERMATITIS EPIPEN dexamethasone dutasteride-tamsulosin EPIPEN JR DALIRESP pimecrolimus

tobramycin-dexamethasone FML FORTE § CARBONIC ANHYDRASE XIIDRA ALPHAGAN P TOBRADEX OINTMENT FML S.O.P. INHIBITORS § PROSTAGLANDINS SYMPATHOMIMETIC / BETA- TOBRADEX ST MAXIDEX dorzolamide latanoprost BLOCKER COMBINATIONS PRED MILD AZOPT ANTI-INFLAMMATORIES travoprost COMBIGAN § Nonsteroidal § ANTIVIRALS § CARBONIC ANHYDRASE LUMIGAN OTIC bromfenac trifluridine INHIBITOR / BETA- ZIOPTAN § ANTI-INFECTIVES diclofenac BLOCKER COMBINATIONS BETA-BLOCKERS RHO KINASE INHIBITORS ketorolac dorzolamide-timolol acetic acid § Nonselective RHOPRESSA ACUVAIL ofloxacin otic CARBONIC ANHYDRASE ILEVRO timolol maleate solution RHO KINASE INHIBITOR / § ANTI-INFECTIVE / BETIMOL INHIBITOR / NEVANAC PROSTAGLANDIN SYMPATHOMIMETIC ANTI-INFLAMMATORY § Steroidal Selective COMBINATIONS COMBINATIONS COMBINATIONS ROCKLATAN dexamethasone BETOPTIC S SIMBRINZA ciprofloxacin-dexamethasone loteprednol neomycin-polymyxin B- DRY EYE DISEASE § SYMPATHOMIMETICS prednisolone acetate 1% hydrocortisone brimonidine DUREZOL RESTASIS QUICK REFERENCE DRUG LIST

A atomoxetine calcium acetate CORLANOR delayed-rel atorvastatin candesartan CORTIFOAM dronabinol ABILIFY MAINTENA azelaic acid gel candesartan- CREON DUAVEE acetic acid azelastine hydrochlorothiazide CRINONE duloxetine acitretin azithromycin carbamazepine cromolyn sodium DUREZOL ACUVAIL AZOPT carbamazepine ext-rel cyclobenzaprine (except dutasteride acyclovir capsule, tablet carbidopa-levodopa cyclobenzaprine tablet 7.5 mg) dutasteride-tamsulosin adapalene B carbidopa-levodopa ext-rel DYMISTA

ADVAIR DISKUS balsalazide carbidopa-levodopa- D ADVAIR HFA BAQSIMI entacapone DALIRESP E AIMOVIG BASAGLAR carvedilol darifenacin ext-rel econazole AJOVY BD ULTRAFINE INSULIN carvedilol phosphate ext-rel desonide eletriptan albuterol inhalation solution albuterol sulfate CFC-free SYRINGES AND cefdinir desoximetasone ELIQUIS NEEDLES cefprozil desvenlafaxine ext-rel EMGALITY aerosol BELBUCA cefuroxime axetil dexamethasone EMVERM alendronate BELSOMRA celecoxib DEXCOM CONTINUOUS ENDOMETRIN alfuzosin ext-rel cephalexin GLUCOSE MONITORING entacapone aliskiren benzonatate (except NDCs^ cholestyramine SYSTEM ENTRESTO allopurinol 69336012615, 69499032915) ciclopirox DEXILANT EPIDUO alosetron benzoyl peroxide CILOXAN OINTMENT diazepam epinephrine auto-injector ALPHAGAN P BESIVANCE ciprofloxacin diazepam rectal gel EPIPEN alprazolam BETIMOL ciprofloxacin-dexamethasone diclofenac EPIPEN JR amantadine BETOPTIC S citalopram diclofenac sodium EPISIL amiloride bicalutamide CITRANATAL diclofenac sodium gel 1% erythromycin amlodipine BIDIL clarithromycin diclofenac sodium solution erythromycin solution amlodipine-atorvastatin BREO ELLIPTA clarithromycin ext-rel diclofenac sodium- erythromycin-benzoyl amlodipine-olmesartan BREZTRI AEROSPHERE CLENPIQ misoprostol peroxide amlodipine-telmisartan BRILINTA CLIMARA PRO dicloxacillin erythromycins amlodipine-valsartan brimonidine clindamycin amlodipine-valsartan- bromfenac dicyclomine escitalopram clindamycin gel (except NDC^ DIFICID esomeprazole hydrochlorothiazide BRYHALI 68682046275) digoxin estradiol amoxicillin budesonide capsule clindamycin solution diltiazem ext-rel (except generics estradiol-norethindrone amoxicillin-clavulanate budesonide ext-rel clindamycin-benzoyl amphetamine- budesonide inhalation for CARDIZEM LA) eszopiclone peroxide dextroamphetamine mixed suspension diphenoxylate-atropine ethinyl estradiol- clobazam dipyridamole ext-rel-aspirin drospirenone salts buprenorphine transdermal amphetamine- buprenorphine-naloxone clobetasol cream, foam, gel, divalproex sodium ethinyl estradiol- lotion, ointment, shampoo dextroamphetamine mixed sublingual divalproex sodium ext-rel drospirenone-levomefolate clonazepam DIVIGEL ethinyl estradiol-etonogestrel salts ext-rel † bupropion clopidogrel donepezil ethinyl estradiol- ANDRODERM bupropion ext-rel (except clotrimazole dorzolamide levonorgestrel ANNOVERA bupropion ext-rel tablet 450 mg) clozapine dorzolamide-timolol ethinyl estradiol- ANORO ELLIPTA BYSTOLIC codeine-acetaminophen doxazosin norelgestromin aprepitant colchicine tablet doxepin ethinyl estradiol- aripiprazole C colesevelam doxycycline hyclate 20 mg norethindrone acetate armodafinil calcipotriene ointment, COMBIGAN doxycycline hyclate capsule ethinyl estradiol- ARNUITY ELLIPTA solution COMBIPATCH doxylamine-pyridoxine norethindrone acetate-iron atenolol calcitonin-salmon

ethinyl estradiol-norgestimate solution LUMIGAN NOVOLIN 70/30 potassium chloride liquid ethosuximide hydrocortisone enema NOVOLIN N pramipexole EUCRISA hydromorphone M NOVOLIN R pramipexole ext-rel EVAMIST hydromorphone ext-rel MAXIDEX NOVOLOG prasugrel ezetimibe meclizine NOVOLOG MIX 70/30 pravastatin ezetimibe-simvastatin I medroxyprogesterone NUCYNTA PRED MILD

ibandronate megestrol acetate NUCYNTA ER prednisolone acetate 1% F ibuprofen meloxicam NUEDEXTA prednisolone solution famotidine ILEVRO memantine NURTEC ODT prednisone FARXIGA imiquimod mesalamine delayed-rel nystatin pregabalin fenofibrate (except fenofibrate tablet IMVEXXY mesalamine ext-rel PREMPHASE 120 mg) ipratropium inhalation mesalamine suppository O PREMPRO fenofibric acid delayed-rel solution mesalamine suspension ofloxacin prenatal vitamins fentanyl transdermal ipratropium-albuterol metformin ofloxacin otic primidone fentanyl transmucosal inhalation solution metformin ext-rel (except generics olanzapine probenecid lozenge irbesartan for FORTAMET and GLUMETZA) olmesartan prochlorperazine FIASP irbesartan- methadone olmesartan-amlodipine- PROCTOFOAM-HC FINACEA FOAM hydrochlorothiazide methoxsalen hydrochlorothiazide progesterone, micronized finasteride isosorbide dinitrate (except methylphenidate olmesartan- promethazine † FLOVENT DISKUS isosorbide dinitrate 40 mg) methylphenidate ext-rel hydrochlorothiazide propranolol FLOVENT HFA isosorbide mononitrate methylprednisolone olopatadine propranolol ext-rel fluconazole itraconazole metoclopramide omega-3 acid ethyl esters PULMICORT FLEXHALER fludrocortisone ivermectin metolazone omeprazole PYLERA flunisolide metoprolol succinate ext-rel OMNIPOD DASH INSULIN pyrimethamine fluocinonide (except fluocinonide J metoprolol tartrate INFUSION PUMP Q cream 0.1%) JANUMET metronidazole OMNIPOD INSULIN fluorouracil cream 5% JANUMET XR minocycline INFUSION PUMP quetiapine fluorouracil solution JANUVIA mirtazapine ondansetron quetiapine ext-rel fluoxetine (except fluoxetine tablet 60 JARDIANCE mometasone ONETOUCH ULTRA quinapril 2 mg, fluoxetine tablet [generics for montelukast STRIPS AND KITS quinapril-hydrochlorothiazide SARAFEM]) K morphine ONETOUCH VERIO STRIPS QVAR REDIHALER 2 fluticasone ketoconazole cream 2% morphine ext-rel AND KITS R fluvastatin ketoconazole shampoo 2% morphine suppository ONEXTON FML FORTE ketorolac MOVANTIK ONZETRA XSAIL RAGWITEK FML S.O.P. moxifloxacin ORACEA raloxifene folic acid L MULTAQ ORILISSA ramelteon fosinopril lactulose solution mupirocin ointment oseltamivir ramipril fosinopril-hydrochlorothiazide lamotrigine MUSE oxazepam ranolazine ext-rel furosemide lamotrigine ext-rel MYDAYIS oxcarbazepine rasagiline

lansoprazole MYRBETRIQ OXTELLAR XR RELENZA G LASTACAFT oxybutynin repaglinide N gabapentin latanoprost oxybutynin ext-rel RESTASIS galantamine LATUDA nadolol oxycodone REYVOW galantamine ext-rel levalbuterol tartrate CFC-free NAFTIN oxycodone-acetaminophen RHOPRESSA gentamicin aerosol naloxone injection OZEMPIC risedronate glimepiride LEVEMIR NAMZARIC risperidone P glipizide levetiracetam naproxen (except naproxen CR or rivastigmine glipizide ext-rel levetiracetam ext-rel naproxen suspension) pantoprazole rivastigmine transdermal glipizide-metformin levocarnitine naratriptan paroxetine HCl rizatriptan GLUCAGEN HYPOKIT levocetirizine NARCAN NASAL SPRAY paroxetine HCl ext-rel ROCKLATAN GLUCAGON EMERGENCY levofloxacin nateglinide paroxetine mesylate ropinirole KIT levothyroxine NAYZILAM PAZEO ropinirole ext-rel GLYXAMBI lidocaine-prilocaine neomycin-polymyxin B- peg 3350-electrolytes rosuvastatin GRALISE linezolid bacitracin-hydrocortisone penicillin VK RYBELSUS granisetron LINZESS neomycin-polymyxin B- PENTASA S GRASTEK liothyronine dexamethasone PERFOROMIST guanfacine ext-rel lisinopril neomycin-polymyxin B- PERSERIS SANCUSO GVOKE lisinopril-hydrochlorothiazide hydrocortisone phenobarbital scopolamine transdermal

LO LOESTRIN FE NEUPRO phenytoin selegiline H LOKELMA NEVANAC phenytoin sodium extended selenium sulfide lotion 2.5% HUMULIN R U-500 loperamide NEXLETOL PHOSLYRA SEREVENT hydrochlorothiazide lorazepam NEXLIZET PICATO sertraline hydrocodone ext-rel losartan niacin ext-rel pimecrolimus sevelamer carbonate hydrocodone-acetaminophen losartan-hydrochlorothiazide nifedipine ext-rel pindolol sildenafil hydrocortisone loteprednol nitrofurantoin pioglitazone silodosin hydrocortisone butyrate lovastatin nitroglycerin lingual spray pioglitazone-glimepiride SIMBRINZA cream, lotion, ointment, luliconazole nitroglycerin sublingual pioglitazone-metformin simvastatin

solifenacin T tramadol (except NDC^ 52817019610) valproic acid XIFAXAN 550 MG SOLIQUA tramadol ext-rel valsartan XIGDUO XR tacrolimus SOOLANTRA travoprost valsartan-hydrochlorothiazide XIIDRA tadalafil sotalol trazodone VALTOCO XTAMPZA ER tamsulosin SPIRIVA TRELEGY ELLIPTA vancomycin capsule XULTOPHY TEKTURNA HCT spironolactone- TRESIBA VASCEPA telmisartan hydrochlorothiazide tretinoin VELPHORO Y telmisartan- STIOLTO RESPIMAT triamcinolone cream, lotion, VELTASSA YUPELRI hydrochlorothiazide STRIVERDI RESPIMAT ointment venlafaxine terazosin SUBSYS triamterene venlafaxine ext-rel capsule Z terbinafine tablet sucralfate tablet triamterene- verapamil ext-rel testosterone gel (except authorized zafirlukast sulfacetamide hydrochlorothiazide V-GO INSULIN INFUSION generics for TESTIM and VOGELXO) ZEMBRACE SYMTOUCH sulfamethoxazole- trifluridine PUMP testosterone solution ZENPEP trimethoprim TRIJARDY XR VIBERZI tetracycline zileuton ext-rel sulfasalazine trimethobenzamide VICTOZA tiagabine ZIOPTAN sulfasalazine delayed-rel TRINTELLIX VIMPAT timolol maleate solution ziprasidone sumatriptan TROKENDI XR VIOKACE TOBRADEX OINTMENT zolmitriptan SUNOSI trospium VISTOGARD TOBRADEX ST zolpidem SUPRAX trospium ext-rel VRAYLAR tobramycin zolpidem ext-rel SYMBICORT TRULICITY VYVANSE tobramycin-dexamethasone zolpidem sublingual SYMJEPI TOLAK ZOMIG NASAL SPRAY SYMLINPEN U W tolterodine zonisamide SYMPROIC UBRELVY warfarin tolterodine ext-rel ZUBSOLV SYNJARDY topiramate ZYCLARA SYNJARDY XR V X torsemide SYNTHROID valacyclovir XARELTO TOUJEO TOVIAZ valganciclovir XCOPRI PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- INSULIN SYRINGES 4 rel, risperidone, ziprasidone, LATUDA, VRAYLAR ALORA estradiol, DIVIGEL, EVAMIST ACANYA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl ALREX azelastine, cromolyn sodium, olopatadine, LASTACAFT, peroxide, erythromycin solution, erythromycin-benzoyl peroxide, PAZEO tretinoin, EPIDUO, ONEXTON ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, ACCU-CHEK AVIVA ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO pravastatin, rosuvastatin, simvastatin PLUS STRIPS AND KITS STRIPS AND KITS 2 ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, 3 PULMICORT FLEXHALER, QVAR REDIHALER ACCU-CHEK COMPACT ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO AMITIZA LINZESS, MOVANTIK, SYMPROIC PLUS STRIPS AND KITS STRIPS AND KITS 2 3 AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) ACCU-CHEK GUIDE ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO ANDROGEL 1% testosterone gel (except authorized generics for TESTIM and STRIPS AND KITS 3 STRIPS AND KITS 2 VOGELXO), testosterone solution, ANDRODERM ACCU-CHEK ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO SMARTVIEW STRIPS STRIPS AND KITS 2 AND KITS 3 ANTARA fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel ACIPHEX, ACIPHEX esomeprazole, lansoprazole, omeprazole, pantoprazole, SPRINKLE DEXILANT APEXICON E desoximetasone, fluocinonide (except fluocinonide cream 0.1%), BRYHALI ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline APIDRA FIASP, NOVOLOG Activite folic acid APLENZIN bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) ACTOS pioglitazone APTENSIO XR amphetamine-dextroamphetamine mixed salts ext-rel †, acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir methylphenidate ext-rel †, MYDAYIS, VYVANSE ADZENYS ER, ADZENYS amphetamine-dextroamphetamine mixed salts ext-rel †, APTIOM carbamazepine, carbamazepine ext-rel, divalproex sodium, XR-ODT methylphenidate ext-rel †, MYDAYIS, VYVANSE divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, ALCORTIN A desonide, hydrocortisone oxcarbazepine, phenobarbital, phenytoin, ALEVICYN GEL, desonide, hydrocortisone phenytoin sodium extended, primidone, tiagabine, topiramate, ALEVICYN SG, valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, ALEVICYN SOLUTION VIMPAT, XCOPRI ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or BRIVIACT carbamazepine, carbamazepine ext-rel, divalproex sodium, naproxen (except naproxen CR or naproxen suspension) WITH divalproex sodium ext-rel, gabapentin, lamotrigine, esomeprazole, lansoprazole, omeprazole, pantoprazole or lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, DEXILANT oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, ASACOL HD balsalazide, mesalamine delayed-rel, mesalamine ext-rel, valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, sulfasalazine, sulfasalazine delayed-rel, PENTASA VIMPAT, XCOPRI 2 ASCENSIA STRIPS AND ONETOUCH ULTRA STRIPS AND KITS , ONETOUCH VERIO Bupap diclofenac sodium, ibuprofen, naproxen (except naproxen CR or 3 2 KITS STRIPS AND KITS naproxen suspension) ASMANEX, ASMANEX ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, bupropion ext-rel tablet bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 HFA PULMICORT FLEXHALER, QVAR REDIHALER 450 mg mg) ATACAND, candesartan, candesartan-hydrochlorothiazide, irbesartan, butalbital-acetaminophen diclofenac sodium, ibuprofen, naproxen (except naproxen CR or ATACAND HCT irbesartan-hydrochlorothiazide, losartan, losartan- tablet 50-300 mg, naproxen suspension) hydrochlorothiazide, olmesartan, olmesartan- BUTALBITAL- hydrochlorothiazide, telmisartan, telmisartan- ACETAMINOPHEN hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide (NDC^ 69499034230 only) ATOPADERM desonide, hydrocortisone butalbital-acetaminophen- diclofenac sodium, ibuprofen, naproxen (except naproxen CR or ATROVENT HFA ipratropium inhalation solution, SPIRIVA, YUPELRI caffeine capsule naproxen suspension) AVENOVA Consult doctor BUTRANS buprenorphine transdermal, BELBUCA AZELEX adapalene, benzoyl peroxide, clindamycin gel (except NDC^ BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA 68682046275), clindamycin solution, clindamycin-benzoyl BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, AZESCO prenatal vitamins, CITRANATAL ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY BEAU RX Consult doctor calcipotriene cream calcipotriene ointment, calcipotriene solution BECONASE AQ flunisolide, fluticasone, mometasone, DYMISTA calcipotriene- calcipotriene ointment or calcipotriene solution WITH BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, betamethasone desoximetasone, fluocinonide (except fluocinonide cream 0.1%) irbesartan-hydrochlorothiazide, losartan, losartan- or BRYHALI hydrochlorothiazide, olmesartan, olmesartan- calcitriol ointment calcipotriene ointment, calcipotriene solution hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) BENSAL HP desonide, hydrocortisone CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, BENZAC AC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ TOLAK, ZYCLARA 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, CARAFATE sucralfate tablet tretinoin, EPIDUO, ONEXTON CARBINOXAMINE levocetirizine BENZACLIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ TABLET 6 MG 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, CARDIZEM, CARDIZEM diltiazem ext-rel tretinoin, EPIDUO, ONEXTON CD, (except generics for CARDIZEM LA) CARDIZEM LA BENZIQ adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl CARNITOR, CARNITOR levocarnitine peroxide, erythromycin solution, erythromycin-benzoyl peroxide, SF tretinoin, EPIDUO, ONEXTON chlordiazepoxide-clidinium dicyclomine benzonatate benzonatate (except NDCs^ 69336012615, 69499032915) (NDC^ 42494040901 only) (NDCs^ 69336012615, chlorzoxazone 375 mg, cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) 69499032915 only) chlorzoxazone 500 mg BEPREVE azelastine, cromolyn sodium, olopatadine, LASTACAFT, (NDC^ 73007001303 PAZEO only), chlorzoxazone 750 mg, CHLORZOXAZONE BETAPACE, sotalol 250 MG BETAPACE AF CIALIS sildenafil, tadalafil BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT CICATRACE Consult doctor BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-norethindrone acetate, CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic ethinyl estradiol-norethindrone acetate-iron CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic bimatoprost solution latanoprost, travoprost, LUMIGAN, ZIOPTAN CLINDAGEL erythromycin solution 0.03% clindamycin gel (NDC^ adapalene, benzoyl peroxide, clindamycin gel (except NDC^ BREEZE 2 STRIPS AND ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO 68682046275 only) 68682046275), clindamycin solution, clindamycin-benzoyl KITS 3 STRIPS AND KITS 2 peroxide, erythromycin solution, erythromycin-benzoyl peroxide,

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* tretinoin, EPIDUO, ONEXTON hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide clobetasol spray clobetasol foam Diphen Elixir levocetirizine CLOBEX SPRAY clobetasol foam COLAZAL balsalazide DORAL doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, COLCRYS colchicine tablet zolpidem sublingual, BELSOMRA CONSENSI amlodipine WITH celecoxib DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline CONTOUR NEXT STRIPS ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO AND KITS 3 STRIPS AND KITS 2 doxepin cream desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA CONTOUR STRIPS AND ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO doxycycline hyclate doxycycline hyclate 20 mg, doxycycline hyclate capsule, KITS 3 STRIPS AND KITS 2 delayed-rel tablet 200 mg minocycline, tetracycline CORDRAN OINTMENT hydrocortisone butyrate cream, hydrocortisone butyrate lotion, doxycycline hyclate tablet doxycycline hyclate 20 mg, doxycycline hyclate capsule, hydrocortisone butyrate ointment, hydrocortisone butyrate 50 mg (NDC^ minocycline, tetracycline solution, mometasone, triamcinolone cream, triamcinolone 72143021160 only), lotion, triamcinolone ointment doxycycline hyclate tablet 75 mg, doxycycline CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule, hyclate tablet 150 mg minocycline, tetracycline doxycycline monohydrate doxycycline hyclate 20 mg, doxycycline hyclate capsule, CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, capsule 75 mg, minocycline, tetracycline pravastatin, rosuvastatin, simvastatin doxycycline monohydrate capsule 150 mg cyclobenzaprine ext-rel cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) capsule, doxycycline monohydrate ORACEA cyclobenzaprine tablet 7.5 delayed-rel capsule mg DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- rel capsule DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide DARAPRIM pyrimethamine DYRENIUM amiloride, triamterene DaVite folic acid EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- DAYTRANA amphetamine-dextroamphetamine mixed salts ext-rel †, hydrochlorothiazide, olmesartan, olmesartan- methylphenidate ext-rel †, MYDAYIS, VYVANSE hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide DELZICOL balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, E.E.S. GRANULES erythromycins TOVIAZ EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- dexchlorpheniramine levocetirizine rel capsule Dexifol folic acid ENABLEX darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, Diclofex diclofenac sodium, diclofenac sodium gel 1%, TOVIAZ DC (NDC^ 51021037201 diclofenac sodium solution, ibuprofen, meloxicam, only) naproxen (except naproxen CR or naproxen suspension) ENLITE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM GLUCOSE MONITORING Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, SYSTEM diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG DIFFERIN LOTION adapalene, benzoyl peroxide, clindamycin gel (except NDC^ EPICERAM desonide, hydrocortisone 68682046275), clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, erythromycin- ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, benzoyl peroxide, tretinoin, EPIDUO, ONEXTON NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY diflorasone cream, desoximetasone, fluocinonide (except fluocinonide cream diflorasone ointment 0.1%), BRYHALI ERYPED erythromycins dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ESTRING estradiol, IMVEXXY NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, EVEKEO amphetamine-dextroamphetamine mixed salts, methylphenidate ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY EVERSENSE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM diltiazem ext-rel diltiazem ext-rel CONTINUOUS GLUCOSE (generics for CARDIZEM (except generics for CARDIZEM LA) MONITORING SYSTEM LA only) EVZIO naloxone injection, NARCAN NASAL SPRAY DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- hydrochlorothiazide, olmesartan, olmesartan- valsartan

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan- FREESTYLE LIBRE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM amlodipine-hydrochlorothiazide CONTINUOUS GLUCOSE MONITORING SYSTEM FABIOR adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl FREESTYLE STRIPS ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO peroxide, erythromycin solution, erythromycin-benzoyl peroxide, AND KITS 3 STRIPS AND KITS 2 tretinoin, EPIDUO, ONEXTON FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, FANAPT aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, rel, risperidone, ziprasidone, LATUDA, VRAYLAR ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY FEMRING estradiol, IMVEXXY FYCOMPA carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, delayed-rel oxcarbazepine, phenobarbital, phenytoin, FENOGLIDE TABLET 120 fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid phenytoin sodium extended, primidone, tiagabine, topiramate, MG delayed-rel valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI fenoprofen, diclofenac sodium, ibuprofen, meloxicam, naproxen (except FENOPROFEN CAPSULE naproxen CR or naproxen suspension) Genicin Vita-S folic acid FERIVA 21/7 folic acid GLUMETZA metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- rel capsule GLYCOPYRROLATE dicyclomine TABLET 1.5 MG Fexmid cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) GOLYTELY peg 3350-electrolytes, CLENPIQ FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA GUARDIAN DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except naproxen CR or CONNECT CONTINUOUS naproxen suspension) GLUCOSE MONITORING SYSTEM flucytosine capsule 500 fluconazole mg HORIZANT gabapentin, GRALISE fluocinonide cream 0.1% clobetasol cream HUMALOG FIASP, NOVOLOG fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, HUMALOG MIX 50/50 NOVOLOG MIX 70/30 TOLAK, ZYCLARA HUMALOG MIX 75/25 NOVOLOG MIX 70/30 fluoxetine tablet (generics fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet for SARAFEM only) [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline HUMULIN 70/30 NOVOLIN 70/30 HUMULIN N NOVOLIN N

HUMULIN R NOVOLIN R fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate lotion, paroxetine HCl ext-rel, sertraline, TRINTELLIX lipophilic cream 0.1% hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone flurandrenolide lotion desonide, hydrocortisone lotion, triamcinolone ointment (NDC^ 24470092112 only) HylaVite folic acid flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- solution, mometasone, triamcinolone cream, triamcinolone rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER lotion, triamcinolone ointment INCRUSE ELLIPTA SPIRIVA, YUPELRI FML LIQUIFILM dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD INDERAL LA, INDERAL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol XL succinate ext-rel, metoprolol tartrate, nadolol, pindolol, FOLIC-K folic acid propranolol, propranolol ext-rel, BYSTOLIC Folvik-D folic acid INDOCIN diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) Folvite-D folic acid indomethacin capsule 20 diclofenac sodium, ibuprofen, meloxicam, naproxen (except mg naproxen CR or naproxen suspension) FORTAMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) Inflammacin diclofenac sodium, diclofenac sodium gel 1%, FORTESTA testosterone gel (except authorized generics for TESTIM and diclofenac sodium solution, ibuprofen, meloxicam, VOGELXO), testosterone solution, ANDRODERM naproxen (except naproxen CR or naproxen suspension) FOSAMAX PLUS D alendronate, ibandronate, risedronate INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, FOSRENOL calcium acetate, sevelamer carbonate, PHOSLYRA, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, VELPHORO pindolol, propranolol, propranolol ext-rel, BYSTOLIC FOSTEUM, FOSTEUM alendronate, ibandronate, risedronate INTERMEZZO doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, PLUS zolpidem sublingual, BELSOMRA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* INTRAROSA estradiol, IMVEXXY DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel †, LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, zolpidem sublingual, BELSOMRA MYDAYIS, VYVANSE MACRODANTIN nitrofurantoin INVEGA SUSTENNA ABILIFY MAINTENA, PERSERIS Matzim LA diltiazem ext-rel (except generics for CARDIZEM LA) INVOKAMET, SYNJARDY, SYNJARDY XR, XIGDUO XR INVOKAMET XR mefenamic acid (NDC^ diclofenac sodium, ibuprofen, meloxicam, naproxen (except 69336012830 only) naproxen CR or naproxen suspension) INVOKANA FARXIGA, JARDIANCE isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), MENEST estradiol isosorbide mononitrate MENOSTAR estradiol ISTALOL timolol maleate solution, BETIMOL, BETOPTIC S metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin metformin ext-rel metformin, metformin ext-rel (except generics for FORTAMET (generics for FORTAMET and GLUMETZA) JENTADUETO, JANUMET, JANUMET XR and GLUMETZA only) JENTADUETO XR methocarbamol 500 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) KAMDOY desonide, hydrocortisone (NDC^ 69036091010 only), methocarbamol 750 KAZANO JANUMET, JANUMET XR mg (NDCs^ 69036093090, ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5% 70868090190 only) Ketodan ketoconazole shampoo 2%, selenium sulfide lotion 2.5% MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, TYMLOS ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) MIACALCIN NASAL calcitonin-salmon SPRAY ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) MICARDIS, candesartan, candesartan-hydrochlorothiazide, irbesartan, MICARDIS HCT irbesartan-hydrochlorothiazide, losartan, losartan- KOMBIGLYZE XR JANUMET, JANUMET XR hydrochlorothiazide, olmesartan, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- LACRISERT RESTASIS, XIIDRA hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide LACTULOSE PAK lactulose solution Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, LANOXIN TABLET digoxin NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, (125 MCG and 250 MCG ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY only) MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, prednisolone solution, prednisone VELPHORO MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- LANTUS 5 BASAGLAR, LEVEMIR levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron LAZANDA fentanyl transmucosal lozenge, SUBSYS MINIVELLE estradiol, DIVIGEL, EVAMIST LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin MINOCIN doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline LEXAPRO citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, MIRVASO azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA paroxetine HCl ext-rel, sertraline, TRINTELLIX Mondoxyne NL capsule 75 doxycycline hyclate 20 mg, doxycycline hyclate capsule, LIALDA balsalazide, mesalamine delayed-rel, mesalamine ext-rel, mg minocycline, tetracycline sulfasalazine, sulfasalazine delayed-rel, PENTASA MOVIPREP peg 3350-electrolytes, CLENPIQ LIDOCAINE- lidocaine-prilocaine MultiPro Consult doctor TETRACAINE CREAM (NDC^ 71800063115 only) mupirocin cream gentamicin, mupirocin ointment LIDOTREX lidocaine-prilocaine MYTESI diphenoxylate-atropine, loperamide LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except pravastatin, rosuvastatin, simvastatin naproxen CR or naproxen suspension) LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except pravastatin, rosuvastatin, simvastatin naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT Lorid folic acid naproxen CR diclofenac sodium, ibuprofen, meloxicam, naproxen (except Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) naproxen CR or naproxen suspension) LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone acetate 1%,

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except 00168035830, luliconazole naproxen CR or naproxen suspension) 51672135902 only) NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol- rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER norethindrone acetate, ethinyl estradiol-norethindrone acetate- iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER NATESTO testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, NESINA JANUVIA TOVIAZ NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, PANCREAZE CREON, VIOKACE, ZENPEP DEXILANT PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 niacin tablet 500 mg niacin ext-rel mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX Niacor niacin ext-rel PENNSAID diclofenac sodium, diclofenac sodium gel 1%, NICADAN folic acid diclofenac sodium solution, ibuprofen, meloxicam, NICAPRIN folic acid naproxen (except naproxen CR or naproxen suspension) NICAZEL, NICAZEL folic acid PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, FORTE oxycodone-acetaminophen, NUCYNTA NICOMIDE folic acid PERRIGO NEEDLES 4 BD ULTRAFINE NEEDLES NILANDRON abiraterone, bicalutamide, XTANDI, YONSA PERTZYE CREON, VIOKACE, ZENPEP NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual PEXEVA citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) paroxetine HCl ext-rel, sertraline, TRINTELLIX NORITATE azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA PLAVIX clopidogrel, prasugrel, BRILINTA NORVASC amlodipine POLYTOZA Consult doctor NOVACORT desonide, hydrocortisone posaconazole delayed-rel fluconazole, itraconazole tablet NOVO NORDISK BD ULTRAFINE NEEDLES NEEDLES 4 PRADAXA warfarin, ELIQUIS, XARELTO NuDiclo SoluPak, NuDiclo diclofenac sodium, diclofenac sodium gel 1%, PRECISION XTRA ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO TabPak diclofenac sodium solution, ibuprofen, meloxicam, STRIPS AND KITS 3 STRIPS AND KITS 2 naproxen (except naproxen CR or naproxen suspension) PRED FORTE dexamethasone, loteprednol, prednisolone acetate 1%, NUVARING ethinyl estradiol-etonogestrel, ANNOVERA DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD NUVIGIL armodafinil, SUNOSI PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO OLEPTRO trazodone PREMARIN estradiol OLUX-E clobetasol foam PREMARIN CREAM estradiol, IMVEXXY omeprazole-sodium esomeprazole, lansoprazole, omeprazole, pantoprazole, PRENATAL PLUS prenatal vitamins, CITRANATAL bicarbonate DEXILANT PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, OMNARIS flunisolide, fluticasone, mometasone, DYMISTA DEXILANT OMNIVEX folic acid PREVIDENT Consult doctor ONFI clobazam, lamotrigine, topiramate, TROKENDI XR PRIMLEV hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA ONGLYZA JANUVIA PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- orphenadrine-aspirin- cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) rel capsule caffeine PROAIR HFA, PROAIR albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) RESPICLICK free aerosol ORTHO D folic acid PRODIGEN Consult doctor ORTHO DF folic acid PROLENSA bromfenac, diclofenac, ketorolac, ACUVAIL, ILEVRO, OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone NEVANAC OSMOPREP peg 3350-electrolytes, CLENPIQ PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT OSPHENA estradiol PROTOPIC pimecrolimus, tacrolimus, EUCRISA OWEN MUMFORD BD ULTRAFINE NEEDLES NEEDLES 4 PROVAD Consult doctor oxiconazole (NDCs^ ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, PROVENTIL HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* free aerosol TAZORAC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 peroxide, erythromycin solution, erythromycin-benzoyl peroxide, mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, tretinoin, EPIDUO, ONEXTON; calcipotriene ointment, paroxetine HCl ext-rel, sertraline, TRINTELLIX calcipotriene solution PSORCON desoximetasone, fluocinonide (except fluocinonide cream TESTIM testosterone gel (except authorized generics for TESTIM and 0.1%), BRYHALI VOGELXO), testosterone solution, ANDRODERM QNASL flunisolide, fluticasone, mometasone, DYMISTA testosterone gel 1% testosterone gel (except authorized generics for TESTIM and QTERN GLYXAMBI (authorized generics for VOGELXO), testosterone solution, ANDRODERM TESTIM and VOGELXO quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, only) zolpidem sublingual, BELSOMRA TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, BETOPTIC S RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin TIROSINT levothyroxine, SYNTHROID RAYOS dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, RECEDO Consult doctor pindolol, propranolol, propranolol ext-rel, BYSTOLIC RELION INSULIN NOVOLIN INSULIN TRADJENTA JANUVIA RHEUMATE folic acid tramadol (NDC^ tramadol (except NDC^ 52817019610), tramadol ext-rel 52817019610 only) RIBOZEL folic acid TRANSDERM SCOP meclizine, scopolamine transdermal RIMSO-50 Consult doctor TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR RIOMET metformin, metformin ext-rel (except generics for FORTAMET or naproxen suspension) WITH eletriptan, naratriptan, and GLUMETZA) rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or zolpidem sublingual, BELSOMRA ZOMIG NASAL SPRAY RyClora levocetirizine triamcinolone acetonide hydrocortisone butyrate cream, hydrocortisone butyrate lotion, aerosol 0.2% hydrocortisone butyrate ointment, hydrocortisone butyrate SCARSILK PAD Consult doctor solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext- rel, risperidone, ziprasidone, LATUDA, VRAYLAR TRICOR fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel SIL-K PAD Consult doctor TRIGLIDE fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid SILIVEX Consult doctor delayed-rel SILTREX Consult doctor TRILIPIX fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid SINGULAIR montelukast, zafirlukast, zileuton ext-rel delayed-rel SORILUX calcipotriene ointment, calcipotriene solution TRIVIDIA INSULIN BD ULTRAFINE INSULIN SYRINGES SYRINGES 4 SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) TronVite folic acid STENDRA sildenafil, tadalafil TRUETEST STRIPS AND ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO KITS 3 STRIPS AND KITS 2 SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV TRUETRACK STRIPS ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO sucralfate suspension sucralfate tablet AND KITS 3 STRIPS AND KITS 2 sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR TRULANCE LINZESS or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA TUDORZA SPIRIVA, YUPELRI XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ULTIMED INSULIN BD ULTRAFINE INSULIN SYRINGES ZOMIG NASAL SPRAY SYRINGES 4 SUPREP peg 3350-electrolytes, CLENPIQ ULTIMED NEEDLES 4 BD ULTRAFINE NEEDLES 2 SURE-TEST STRIPS ONETOUCH ULTRA STRIPS AND KITS , ONETOUCH VERIO UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin AND KITS 3 STRIPS AND KITS 2 VALCYTE valganciclovir SYNERDERM desonide, hydrocortisone VALTREX acyclovir capsule, acyclovir tablet, valacyclovir TALIVA folic acid Vanatol LQ, Vanatol S diclofenac sodium, ibuprofen, naproxen (except naproxen CR or TARGADOX doxycycline hyclate 20 mg, doxycycline hyclate capsule, naproxen suspension) minocycline, tetracycline Vanoxide-HC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- 68682046275), clindamycin solution, clindamycin-benzoyl levomefolate, ethinyl estradiol-norethindrone acetate, peroxide, erythromycin solution, erythromycin-benzoyl peroxide, ethinyl estradiol-norethindrone acetate-iron tretinoin, EPIDUO, ONEXTON

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* VASCULERA Consult doctor DEXILANT VECTICAL calcipotriene ointment, calcipotriene solution ZELAC Consult doctor VELTIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ ZETIA ezetimibe 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, ZETONNA flunisolide, fluticasone, mometasone, DYMISTA tretinoin, EPIDUO, ONEXTON ZIANA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- 68682046275), clindamycin solution, clindamycin-benzoyl (except 225 mg) rel capsule peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON VENTOLIN HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- free aerosol ZIRGAN trifluridine VEREGEN imiquimod ZOHYDRO ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER VIAGRA sildenafil, tadalafil ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, VIIBRYD citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 zolpidem sublingual, BELSOMRA mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, VITAFOL-ONE prenatal vitamins, CITRANATAL lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, Vitasure folic acid phenytoin sodium extended, primidone, tiagabine, topiramate, VIVELLE-DOT estradiol, DIVIGEL, EVAMIST valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI VOGELXO testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM ZONTIVITY Consult doctor XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) XOLEGEL ciclopirox, ketoconazole cream 2% ZUPLENZ granisetron, ondansetron, SANCUSO XOPENEX HFA albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC- free aerosol ZYFLO montelukast, zafirlukast, zileuton ext-rel Xvite folic acid ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin- polymyxin B-dexamethasone, tobramycin-dexamethasone, XYZBAC folic acid TOBRADEX OINTMENT, TOBRADEX ST YAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- ZYVIT folic acid levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron ZALVIT prenatal vitamins, CITRANATAL ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole,

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 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 3 ONETOUCH brand test strips are the only preferred options. 4 BD ULTRAFINE syringes and needles are the only preferred options. 5 Long Acting Insulins - First Generation.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. 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.