Clinical Focus (2021) the Phone Number Printed on Your Member ID Card

Home , Brimonidine, Fluocinonide, Suvorexant

The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. PLEASE NOTE: Brand name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription drug benefit program. For specific questions about your coverage, please call Clinical Focus (2021) the phone number printed on your member ID card.

A azithromycin clotrimazole Endometrin glatopaQL, PA, † abirateroneQL, PA,† B clotrimazole- ENJUVIA glimepiride acetaminophen-codeine baclofen betamethasone enoxaparin sodium glipizide QL acyclovir benazepril COLCRYS ENSTILARQL glipizide ER adapalene-benzoyl benazepril-HCTZ colestipol ENTRESTOQL, PA glipizide XL AE QL peroxide BETASERONQL, PA, † COMBIPATCH epinastine drops GLUCAGONQL [INJ] QL, PA, † QL ADEMPAS bimatoprostST COMBIVENT RESPIMAT epinephrineQL [INJ] glyburide QL QL PA ADVAIR DISKUS bisoprolol-HCTZ CORLANOR EPIPENQL GLYXAMBIQL QL PA, † ADVAIR HFA bosentanQL, PA, † COSENTYX ergocalciferol GONAL-F RFF† † AFSTYLA BREO ELLIPTAQL CREON erlotinibQL, PA, † GONAL-F† [INJ] QL,PA, † AIMOVIG BRILINTAQL cromolyn drops erythromycin GRANIXPA, † QL, PA, † AJOVY brimonidine drops cyanocobalamin [INJ] escitalopram oxalate guanfacine QL, PA AKYNZEO bromfenac drops cyclobenzaprine esomeprazole guanfacine ERQL QL QL, ST albuterol HFA budesonide ER cyproheptadine magnesium H QL alendronate budesonideQL D estradiol HUMIRAPA, † QL, PA, † QL, ST alfuzosin ER buprenorphineQL dalfampridine ER eszopiclone hydralazine QL QL, PA aliskiren fumarate bupropion DALIRESP etodolac hydrochlorothiazide QL, AE QL, PA, † allopurinol bupropion ER (smoking DAYTRANA EUFLEXXA hydrocodone- alprazolam deterrent)QL deferasiroxPA, † exemestane acetaminophen ambrisentanQL, PA, † bupropion ER (SR) DESCOVYQL, † ezetimibeQL, ST hydrocodone-ibuprofen amiodarone bupropion ER (XL) desloratadineQL ezetimibe-simvastatinQL, ST hydrocortisone AMITIZAQL, PA buspirone desonideST F hydromorphone amitriptyline butalbital-apap-caffeineQL desvenlafaxine ERQL, ST FARXIGAQL hydromorphone ER amlodipine butalbital-asa-caffeineQL dexamethasone febuxostat hydroxychloroquine sulfate amlodipine-benazeprilST BYSTOLICQL, ST dexmethylphenidate ERQL, AE fenofibrate micronizedQL hydroxyzine amlodipine-valsartanQL, ST C dexmethylphenidateQL, AE fentanylQL hyoscyamine sulfate amoxicillin cabergoline diazepam FETZIMAQL HYSINGLA ERQL amoxicillin-clavulanate calcitriol diclofenac finasteride I amphetamine CANASA dicyclomine FLOVENT DISKUSQL ibandronateQL, PA,† ST AE dextroamphetamine ER carbamazepine digoxin FLOVENT HFAQL ICLUSIGQL, PA, † QL ST ,AE amphetamine sulfate carbidopa-levodopa diltiazem ER fluconazole imatinib mesylateQL, PA, † amphetamine- carbidopa-levodopa ER dimethyl fumarateQL, PA, † fludrocortisone acetate IMBRUVICAQL, PA, † dextroamphetamineAE carvedilol diphenoxylate-atropine fluocinonide indomethacin anastrozole cefadroxil divalproex fluorometholone INLYTAQL, PA, † ANORO ELLIPTAQL cefdinir divalproex ER fluorouracil† ipratropium bromide aprepitantQL cefuroxime DIVIGEL fluoxetine ipratropium-albuterol APRISOQL celecoxibQL donepezilQL fluvoxamine maleate irbesartan ARCAPTA NEOHALERQL cephalexin dorzolamide-timolol drops folic acid irbesartan-HCTZ aripiprazoleQL CETROTIDEPA,† doxazosin mesylate FORTEOQL, PA, † IRESSAQL, PA, † ARISTADAQL, PA CHANTIXQL doxepin FRAGMINQL isosorbide dinitrate armodafinilQL, PA chlorhexidine gluconate doxycycline hyclate FULPHILAQL, PA, † isosorbide mononitrate ER ARMOUR THYROID ciclopirox doxycycline monohydrate furosemide isotretinoinAE ARNUITY ELLIPTAQL cinacalcetPA, † DUAVEEQL FYCOMPAQL J ASMANEX HFAQL ciprofloxacin duloxetineQL G JANUMET XRQL atenolol ciprofloxacin- DUPIXENTQL, PA, † gabapentin JANUMETQL atenolol-chlorthalidone dexamethasone drops QL PA, † QL QL, AE dutasteride GAMMAGARD JANUVIA atomoxetine QL citalopram E GAMUNEX-CPA, † JARDIANCEQL atorvastatin clarithromycin econazole nitrate GELNIQUEST K ATRIPLAQL, † clindamycin ELIQUISQL gemfibrozil KALBITORPA, † ATROVENT HFAQL clindamycin-benzoyl ELMIRON GENOTROPINPA, † ketoconazole AUBAGIOQL,PA, † peroxideAE EMGALITYQL, PA, † gentamicin sulfate ketorolac drops AZASITE clobetasol propionate enalapril maleate GENVOYAQL, † ketorolac tromethamine azathioprine clonazepam enalapril-HCTZ GILENYAQL, PA, † KISQALIQL, PA, † azelaic acidAE clonidine ENBRELQL, PA, † GILOTRIFQL, PA, † KITABIS PAKQL, PA, † azelastine clopidogrel glatiramer acetateQL, PA, † azelastine-fluticasoneQL (continued)

THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 7/1/2021. THIS LIST IS SUBJECT TO CHANGE.

WellDyne.com ©2021. WellDyne® is a servicemark of WellDyneRx, LLC. KOVALTRY† mometasone furoate pantoprazole S tramadol-acetaminophen L MONOVISCQL, PA, † paroxetine SANCUSOQL, PA trazodone labetalol montelukast sodium paroxetine ERST SAVELLAQL TREMFYAQL, PA, † lactulose morphine sulfate peg 3350 electrolyte soln SEREVENT DISKUSQL TRESIBA lamotrigine morphine sulfate ERQL penicillin v potassium sertraline triamcinolone lansoprazole MOVANTIKQL, PA PENTASA sevelamer carbonate triamterene-HCTZ LANTUS MOXEZAST PERFOROMIST SIGNIFOR LARQL, PA, † triazolam latanoprost moxifloxacinST permethrin SIGNIFORQL, PA, † TRIUMEQQL, † LATUDAQL, ST mupirocin phenazopyridine sildenafil citrateQL TRULICITYQL, PA LAZANDAQL, PA mycophenolate mofetil phenytoin silodosin TRUVADAQL, † leflunomide MYRBETRIQQL, ST pimecrolimus simvastatin TYMLOSQL, PA, † letrozole N pioglitazone SKYRIZIQL, PA, † U LEVEMIR nabumetone polymyxin b-trimethoprim sodium fluoride UPTRAVIQL, PA, † levetiracetam naltrexoneQL drops sodium sulfacetamide V PA levocetirizine NAMZARICQL, ST posaconazole solifenacin succinateQL, ST valacyclovir levofloxacin naproxen potassium chloride ER SOMATULINE DEPOTQL, PA, † valsartan levothyroxine sodium naratriptanQL potassium citrate ER sotalol valsartan-HCTZ lidocaine viscous NARCAN pramipexole SPIRIVA HANDIHALERQL VELTASSAQL QL lidocaineQL neomycin-polymyxin- prasugrel SPIRIVA RESPIMATQL VENCLEXTAQL, PA, † LINZESSQL, PA hydrocortisone pravastatin spironolactone venlafaxine PA, † liothyronine sodium NEUPOGEN [INJ] prazosin SPRYCELQL, PA, † venlafaxine ER lisinopril NEVANAC prednisolone STELARAPA, † verapamil ER lithium nifedipine ER prednisone STIOLTO RESPIMATQL VIBERZIQL, PA QL ST lithium ER nitrofurantoin pregabalin STRIBILDQL, † VICTOZAQL, PA QL LIVALOQL, ST nitroglycerin PREMARIN SUBOXONEQL VIIBRYDQL, ST QL LO LOESTRIN FE nortriptyline PREMPRO sucralfate VIMPATQL † lorazepam NOVOEIGHT prochlorperazine sulfamethoxazole- VIOKACE PA, † losartan NOVOLIN 70/30 PROCRIT [INJ] trimethoprim VIREADQL, † losartan-HCTZ NOVOLIN N progesterone sulfasalazine VIVITROLPA, † QL loteprednol etabonate NOVOLIN R [INJ] progesterone micronized sumatriptan VYVANSEQL, AE, ST lovastatin NOVOLOG promethazine SUPREP W QL LUMIGANST NOVOLOG FLEXPEN promethazine-codeine SYMBICORT warfarin sodium PA QL M NOXAFIL promethazine-DM SYNJARDY XR X PA, † QL MAKENAQL, † NUCALA propranolol SYNJARDY XARELTOQL MAVYRETQL, PA, † nystatin propranolol ER SYNTHROID XELJANZ XRQL, PA, † QL MAYZENTQL, LD, PA, † O PULMICORT FLEXHALER T XELJANZQL, PA, † QL, PA, † meclizine OFEV pyridostigmine tacrolimus XEMBIFYPA, † QL QL ST medroxyprogesterone olanzapine Q tadalafil XIFAXANQL, PA QL QL acetate olmesartan-amlodipine- QNASL tamoxifen QL QL, ST XIGDUO XR QL ST meloxicam HCTZ quetiapine ER tamsulosin QL, PA QL, ST XIIDRA QL, ST QL memantine ER olmesartan-HCTZ quetiapine temazepam PA, † QL, ST XOLAIR QL memantine olmesartan quinapril tenofovir disoproxil QL QL, † XULTOPHY mercaptopurine olopatadine QVAR REDIHALERQL fumarate QL Y-Z QL omega-3-acid ethyl esters terazosin mesalamine R zaleplon ondansetron QL terbinafine metformin raloxifene ZENPEP QL ONETOUCH ULTRA terconazole metformin ER QL ramipril ZIEXTENZOQL, PA, † BLUE QL testosterone cypionate methadone QL ranolazine ER QL PA zolmitriptan ONETOUCH VERIO QL ST testosterone methimazole PA, † rasagiline zolpidem ERQL, ST OPDIVO QL, PA, † timolol maleate methocarbamol QL, PA, † RASUVO QL QL, † zolpidem ORILISSA QL, PA, † TIVICAY methotrexate QL, PA, † REBIF QL QL ST ZOMIG QL, AE ORTHOVISC QL, PA tizanidine methylphenidate ER QL RELISTOR QL, PA, † zonisamide QL, AE oseltamivir PA, † methylphenidate REMICADE TOBI PODHALER QL OTEZLAQL, PA, † ZONTIVITY methylprednisolone REPATHAQL, PA, † TOBRADEX ST oxcarbazepine ZYLET metoclopramide RESTASISQL, PA tobramycin oxybutynin metoprolol succinate ER REVLIMIDQL, PA, † tobramycin inhalation oxybutynin ER solutionQL, PA, † metoprolol tartrate RINVOQQL, PA, † oxycodone tobramycin-dexamethasone metronidazole risperidone OXYCONTINQL tolterodine minocycline ritonavirQL, † oxyycodone- tolterodine ERQL,ST MIRENA QL rizatriptanQL acetaminophen topiramate mirtazapine QL, PA ropinirole OZEMPIC TOUJEO MIRVASOQL, PA ropinirole ERQL ST P TOVIAZQL, ST misoprostol QL ST rosuvastatinQL, ST paliperidone ER tramadol modafinilQL, PA RUZURGIQL, PA, † (continued)

THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 7/1/2021. THIS LIST IS SUBJECT TO CHANGE.

WellDyne.com ©2021. WellDyne® is a servicemark of WellDyneRx, LLC. Examples of Excluded Medications with Selected Formulary Alternatives The following is a list of some excluded medications with examples of selected covered formulary alternatives. This is not an all-inclusive list.

Excluded Medication(s) Selected Preferred Alternative(s) ACANYA and ONEXTON (clindamycin phosphate-benzoyl peroxide) clindamycin and benzoyl peroxide (separate agents) ACIPHEX (rabeprazole) lansoprazole, omeprazole, pantoprazole ACTEMRA ENBREL, HUMIRA ADMELOG (insulin lispro) NOVOLOG ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, AEROSPAN (flunisolide) FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL AIRDUO (fluticasone-salmeterol) ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL ALPHAGAN-P (brimonidine) brimonidine 0.15% ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, ALVESCO (ciclesonide) FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL ANDROGEL 1.62% (testosterone gel) testosterone cypionate, testosterone enanthate, testosterone gel APIDRA, APIDRA SOLOSTAR (insulin glulisine) NOVOLOG AUVI-Q (epinephrine solution) epinephrine 0.15 mgQL, epinephrine 0.3 mgQL, EPIPENQL, EPIPEN JRQL BASAGLAR (insulin glargine) LANTUS, LEVEMIR, TOUJEO, TRESIBA BELSOMRA (suvorexant) zolpidem IRQL, zaleplon BONJESTA and DICLEGIS (doxylamine-pyridoxine) OTC doxylamine and OTC pyridoxine BRAVELLE (urofollitropin) GONAL-F†, GONAL-F RFF† BYETTA (exenatide) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL BYDUREON (exenatide extended-release) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL CALQUENCE (acalabrutinib) IMBRUVICAQL, PA, †, VENCLEXTAQL, PA, † CAMBIA (diclofenac) diclofenac sodium DR chlorzoxazone cyclobenzaprine CIMZIA ENBREL, HUMIRA COMBIGAN (brimonidine-timolol) brimonidine 0.2% and timolol 0.5% (separate agents) CONCERTA ER (methylphedniate extended-release) amphetamine-dextroamphetamine ERQL, methylphenidate ERQL DENAVIR (penciclovir) acyclovir ointment DEXILANT (dexlansoprazole) lansoprazole, omeprazole, pantoprazole DIABETES TEST STRIPS (e.g., Accu-Chek, Ascensia, Breeze, Contour, Freestyle, etc.) ONETOUCHQL DORYX (doxycycline hyclate DR) doxycycline hyclate DULERA (mometasone-formoterol) ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL DUREZOL (difluprednate) prednisolone acetate ophth solution EPIDUO FORTE clindamycin and tretinoin EXTAVIA (interferon beta-1b) BETASERON† PA QL, REBIF† PA QL fenoprofen ibuprofen, meloxicam FOLLISTIM AQ (follitropin beta) GONAL-F†, GONAL-F RFF† FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate FORFIVO XL (bupropion ER) bupropion ER GAMMAKED (immune globulin) GAMMAGARDPA, †, GAMUNEX-CPA, †, XEMBIFYPA, † GLEEVEC (imatinib) imatinib† PA, QL GLUMETZA and FORTAMET (metformin ER modified/osmotic) metformin ER (generic Glucophage XR) GRALISE (gabapentin) gabapentin HIZENTRA (immune globulin) GAMMAGARDPA, †, GAMUNEX-CPA, †, XEMBIFYPA, † HORIZANT (gabapentin ER) gabapentin HUMALOG (insulin lispro) NOVOLOG HUMULIN N (insulin isophane), HUMULIN R (insulin regular), HUMULIN 70/30 (insulin NPH NOVOLIN N, NOVOLIN R, NOVOLIN 70/30 and regular) ILUMYA STELARA, TREMFYA INCRUSE ELLIPTA (umeclidinium) SPIRIVAQL INVOKANA (canagliflozin) FARXIGAQL, JARDIANCEQL INVOKAMET (canagliflozin-metformin), INVOKAMET XR (canagliflozin-metformin ER) SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL JADENU† PA (deferasirox) deferasirox† PA JENTADUETO,JENTADUETO XR (linagliptin and metformin) JANUMETQL, JANUMET XRQL KAZANO (alogliptin-metformin) JANUMETQL, JANUMET XRQL ketoprofen ibuprofen, meloxicam KEVZARA ENBREL, HUMIRA KINERET ENBREL, HUMIRA KOMBIGLYZE XR (saxagliptin-metformin ER) JANUMETQL, JANUMET XRQL MINIVELLE (estradiol transdermal) estradiol patchQL MOVIPREP (polyethylene glycol electrolyte solution) peg-3350 electrolyte solutionQL NASCOBAL (cyanocobalamin nasal) OTC vitamin B12

(continued)

THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 7/1/2021. THIS LIST IS SUBJECT TO CHANGE.

Excluded Medication(s) Selected Preferred Alternative(s) NESINA (alogliptin) JANUVIAQL NEULASTA (pegfilgrastim) FULPHILAPA, QL, †, ZIEXTENZOPA, QL, † NORDITROPIN (somatropin) GENOTROPIN†, PA NORITATE (metronidazole) azelaic acid gel, metronidazole NUCYNTA (tapentadol) hydrocodone-acetaminophen, morphine sulfate, oxycodone, tramadol NUCYNTA ER (tapentadol ER) hydromorphne ERQL, morphine sulfate ERQL, oxymorphone ERQL OLUMIANT RINVOQ, XELJANZ ONGLYZA (saxagliptin) JANUVIAQL ORENCIA ENBREL, HUMIRA ORTHO DF (folic acid-vitamin D3) OTC vitamins or folic acid OSENI (alogliptin-pioglitazone) JANUVIAQL and pioglitazone PANCREAZE (pancrelipase DR) CREON, ZENPEP PERTZYE (pancrelipase DR) CREON, ZENPEP PROAIR, PROAIR RESPICLICK (albuterol sulfate) albuterol HFAQL PRODIGEN (lactobacillus-acidophilus) OTC alternatives PROVENTIL HFA (albuterol) albuterol HFAQL QTERN (dapagliflozin-saxagliptin) GLYXAMBIQL rabeprazole lansoprazole, omeprazole, pantoprazole SEGLUROMET (ertugliflozin-metformin) SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL SILIQ STELARA, TREMFYA SIMPONI, SIMPONI ARIA ENBREL, HUMIRA SITAVIG (acyclovir) acyclovir , valacyclovir SPRIX (ketorolac) ibuprofen, meloxicam STEGLATRO (ertugliflozin) FARXIGAQL, JARDIANCEQL STEGLUJAN (ertugliflozin-sitagliptin) GLYXAMBIQL SOLIQUA (insulin glargine-lixisenatide) XULTOPHYPA QL SOLODYN (minocycline ER) minocycline SOOLANTRA (ivermectin cream) metronidazole cream TALTZ STELARA, TREMFYA TECFIDERA (dimethyl fumarate) dimethyl fumaratePA, QL, † TEKTURNA (aliskiren) enalapril, lisinopril, irbesartan, losartan, valsartan TIROSINT (levothyroxine) levothyroxine, SYNTHROID TRADJENTA (linagliptin) JANUVIAQL TREXIMET (sumatriptan-naproxen) sumatriptanQL and naproxen (separate agents) TUDORZA PRESSAIR (aclidinium) SPIRIVAQL UDENYCA (pegfilgrastim-cbqv) FULPHILAPA, QL, †, ZIEXTENZOPA, QL, † VENTOLIN HFA (albuterol sulfate) albuterol HFAQL VIMOVO (esomeprazole-naproxen) OTC esomeprazole and OTC naproxen XOPENEX HFA (levalbuterol) albuterol HFAQL ZEGERID (omeprazole-sodium bicarbonate) OTC omeprazole-sodium bicarbonate ZELAC (lactobacillus-acidophilus) OTC alternatives ZIANA and VELTIN (clindamycin phosphate-tretinoin) clindamycin and tretinoinAE (separate agents) ZIOPTAN (tafluprost) latanoprost ZORVOLEX (diclofenac) diclofenac sodium DR ZOVIRAX CREAM acyclovir ointment ZYTIGA (abiraterone) abiraterone† PA QL

KEY For the member: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the US Food and Drug Administration (FDA) may not be covered upon [INJ] = Injectable Drug release to market. ER = Extended-Release WellDyne may contact your provider after receiving a prescription to request consideration of a drug list product or generic DR = Delayed Release equivalent. This may result in your provider prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of the original prescription. Generic medications contain the same active ingredients as their corresponding AE = Age Edit brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. LD= Limited Distribution In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred or PA = Prior Authorization excluded option upon release of the generic product to the market.

QL = Quantity Limits For the physician: Generics should be considered the first-line of prescribing. Please prescribe preferredproducts and allow generic ST = Step Therapy substitutions when medically appropriate. Brand-name drugs are listed in CAPITAL letters; generic drugs are listed in lower case letters.

† Indicates specialty This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The medications member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to market.

THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 7/1/2021. THIS LIST IS SUBJECT TO CHANGE.