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2021 PharmAvail Open Formulary

The 2021 PharmAvail Open Formulary drug list is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes.

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 plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card. KEY For the member: FDA-approved generic medications meet strict standards and [INJ] – Injectable Drug contain the same active ingredients as their corresponding brand-name medications, [OTC] – Over-the-counter Product although they may have a different appearance. [SP] – Specialty Drug For the physician: Please prescribe preferred products and allow generic Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA substitutions when medically appropriate. Generic drugs are listed in lower-case letters. Example: ibuprofen

A ADVATE [INJ] [SP] amabelz APLISOL [INJ] ADYNOVATE [INJ] [SP] amantadine APOKYN [INJ] [SP] abacavir [SP] AFINITOR 10 MG TABLETS [SP] AMBISOME [INJ] apraclonidine eye solution abacavir/lamivudine [SP] AFINITOR DISPERZ [SP] ambrisentan [SP] aprepitant abacavir/lamivudine/zidovudine [SP] afirmelle amcinonide apri ABELCET [INJ] AFLURIA QUAD [INJ] amethia APTIVUS [SP] ABILIFY MAINTENA [INJ] AFSTYLA [INJ] [SP] amethia lo AQUASOL A [INJ] [SP] AIMOVIG [INJ] amethyst ARALAST NP [INJ] [SP] ABRAXANE [INJ] [SP] AJOVY [INJ] amikacin [INJ] aranelle acamprosate delayed-release albendazole amiloride ARANESP [INJ] [SP] acarbose albumin human [INJ] amiloride/hydrochlorothiazide ARIKAYCE [SP] ACCU-CHEK FASTCLIX LANCETS [OTC] albuterol aminocaproic acid aripiprazole acebutolol albuterol ext-release aminocaproic acid [INJ] aripiprazole orally disintegrating tablets acetaminophen [INJ] albuterol nebulization solution aminophylline [INJ] ARISTADA [INJ] acetaminophen/codeine albuterol sulfate hfa (by Cipla, Lupin, Par, AMINOSYN [INJ] ARISTOSPAN [INJ] acetazolamide Perrigo, Proficient Rx, Sandoz & Teva) amiodarone armodafinil acetazolamide ext-release alclometasone amiodarone [INJ] ARMOUR THYROID acetazolamide sodium [INJ] ALDURAZYME [INJ] [SP] amiodarone/dextrose [INJ] ARNUITY ELLIPTA acetic acid ear solution ALECENSA [SP] amitriptyline ARRANON [INJ] [SP] acetic acid irrigation solution alendronate amitriptyline/chlordiazepoxide arsenic trioxide [INJ] acetic acid/hydrocortisone ear solution alfentanil [INJ] amlodipine ascorbic acid [INJ] acetic acid/oxyquinoline vaginal ALFERON N [INJ] amlodipine/atorvastatin asenapine maleate acetylcysteine [INJ] alfuzosin ext-release amlodipine/benazepril ashlyna acetylcysteine inhalation solution ALIMTA [INJ] amlodipine/olmesartan ASMANEX HFA acitretin ALINIA amlodipine/valsartan ASMANEX TWISTHALER ACTEMRA [INJ] [SP] ALIQOPA [INJ] [SP] amlodipine/valsartan/hydrochlorothiazide aspirin/dipyridamole ext-release ACTHIB [INJ] aliskiren ammonium lactate 12% topical atazanavir [SP] ACTHREL [INJ] allopurinol amoxapine atenolol ACTIMMUNE [INJ] [SP] allopurinol sodium [INJ] amoxicillin atenolol/chlorthalidone ACTIVASE [INJ] almotriptan amoxicillin/potassium clavulanate ATGAM [INJ] acyclovir alosetron amoxicillin/potassium clavulanate atomoxetine acyclovir ointment ALPHAGAN P 0.1% ext-release atorvastatin acyclovir sodium [INJ] ALPHANATE [INJ] [SP] amphetamine sulfate ADACEL [INJ] ALPHANINE SD [INJ] [SP] amphotericin [INJ] atovaquone/proguanil ADAKVEO [INJ] [SP] alprazolam ampicillin atropine [INJ] adapalene alprazolam ext-release ampicillin sodium [INJ] atropine sulfate eye ointment adapalene/benzoyl peroxide alprazolam orally disintegrating tablets ampicillin sodium/sulbactam [INJ] atropine sulfate eye solution ADCETRIS [INJ] [SP] ALPROLIX [INJ] [SP] AMYTAL [INJ] AUBAGIO [SP] ADDAMEL N [INJ] alprostadil [INJ] AMZEEQ aubra adefovir altavera anagrelide aubra eq ADEMPAS [SP] ALUNBRIG [SP] anastrozole AUGMENTIN 125-31.25 MG/5 ML adenosine [INJ] alvimopan ANDRODERM aurovela ADVAIR HFA alyacen ANORO ELLIPTA aurovela 24 fe (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 1 aurovela fe bicalutamide calcipotriene/betamethasone dipropionate cevimeline AUSTEDO [SP] BICILLIN C-R [INJ] calcitonin salmon nasal CHANTIX aviane BICILLIN L-A [INJ] calcitriol charlotte 24 fe AVONEX [INJ] [SP] BIKTARVY [SP] calcitriol [INJ] chateal AVYCAZ [INJ] bimatoprost eye solution calcitriol ointment chateal eq ayuna biolon [INJ] calcium acetate CHEMET azacitidine [INJ] [SP] BIOTHRAX [INJ] calcium chloride [INJ] CHENODAL [SP] AZASITE bisoprolol CALCIUM DISODIUM VERSENATE [INJ] chloramphenicol [INJ] azathioprine [SP] bisoprolol/hydrochlorothiazide calcium gluconate [INJ] chlordiazepoxide azathioprine sodium [INJ] [SP] bivalirudin [INJ] CALDOLOR VIALS [INJ] chlordiazepoxide/clidinium AZEDRA [INJ] [SP] blanche camila chlorhexidine gluconate azelaic acid bleomycin [INJ] camrese chloroprocaine hcl [INJ] azelastine eye solution BLINCYTO [INJ] [SP] camrese lo chloroquine azelastine nasal spray blisovi 24 fe candesartan chlorothiazide sodium [INJ] azelastine/fluticasone blisovi fe candesartan/hydrochlorothiazide chlorpromazine azithromycin BOOSTRIX [INJ] CAPASTAT SULFATE [INJ] chlorpromazine [INJ] azithromycin [INJ] [SP] capecitabine [SP] chlorthalidone aztreonam [INJ] BOSULIF [SP] CAPRELSA [SP] chlorzoxazone azurette BOTOX [INJ] [SP] captopril CHOLBAM [SP] BREO ELLIPTA captopril/hydrochlorothiazide cholestyramine B bretylium tosylate [INJ] carbachol [INJ] cholestyramine light BREVITAL [INJ] CARBAGLU [SP] choline salicylate/magnesium salicylate bacitracin [INJ] BREZTRI AEROSPHERE carbamazepine chromium chloride [INJ] bacitracin eye ointment briellyn carbamazepine ext-release bacitracin/polymyxin eye ointment BRILINTA carbidopa ciclopirox shampoo baclofen brimonidine eye solution carbidopa/levodopa cidofovir [INJ] baclofen [INJ] BRINEURA [INJ] [SP] carbidopa/levodopa ext-release cilostazol BAFIERTAM [SP] brinzolamide eye solution carbidopa/levodopa orally CIMDUO [SP] BAL IN OIL [INJ] bromfenac eye solution disintegrating tablets cimetidine balanced salt eye irrigation solution bromocriptine carbidopa/levodopa/entacapone cinacalcet bal-care dha prenatal vitamins brompheniramine// carbinoxamine CINRYZE [INJ] [SP] balsalazide codeine carboplatin [INJ] CINVANTI [INJ] BALVERSA [SP] brompheniramine/pseudoephedrine/ carmustine [INJ] ciprofloxacin balziva dextromethorphan carteolol eye solution ciprofloxacin ear solution BANZEL TABLETS budesonide ext-release carvedilol ciprofloxacin eye solution BAQSIMI budesonide nebulization suspension carvedilol phosphate ext-release ciprofloxacin lactate/dextrose [INJ] BARACLUDE SOLUTION bumetanide [INJ] ciprofloxacin/dexamethasone BAVENCIO [INJ] [SP] bumetanide [INJ] CATHFLO ACTIVASE [INJ] ear suspension BAXDELA bupivacaine [INJ] CAVERJECT [INJ] cisplatin [INJ] BAXDELA [INJ] bupivacaine/dextrose [INJ] CAYSTON [SP] citalopram b-complex [INJ] bupivacaine/epinephrine [INJ] caziant cladribine [INJ] BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine cefaclor clarithromycin BD NANO 2ND GEN PEN NEEDLES buprenorphine [INJ] cefaclor ext-release clarithromycin ext-release BD ULTRAFINE INSULIN SYRINGES [OTC] buprenorphine patches cefadroxil clemastine BD ULTRAFINE PEN NEEDLES [OTC] buprenorphine/naloxone cefazolin [INJ] CLENPIQ bekyree bupropion cefazolin/dextrose [INJ] clindamycin hcl BELBUCA bupropion ext-release cefdinir clindamycin palmitate benazepril bupropion ext-release (smoking deterrent) cefditoren clindamycin phosphate [INJ] benazepril/hydrochlorothiazide buspirone cefepime [INJ] clindamycin phosphate topical BENDEKA [INJ] [SP] busulfan [INJ] cefepime/dextrose [INJ] clindamycin phosphate vaginal BENEFIX [INJ] [SP] butalbital/acetaminophen cefixime clindamycin phosphate/benzoyl peroxide BENLYSTA [INJ] [SP] butalbital/acetaminophen/caffeine cefotaxime [INJ] clindamycin phosphate/dextrose [INJ] BENZNIDAZOLE butalbital/acetaminophen/caffeine/ cefotetan [INJ] clindamycin phosphate/tretinoin benzonatate codeine cefoxitin [INJ] CLINIMIX [INJ] benzoyl peroxide butalbital/aspirin/caffeine cefoxitin/dextrose [INJ] CLINIMIX E [INJ] benzphetamine butalbital/aspirin/caffeine/codeine cefpodoxime clobazam benztropine butorphanol [INJ] cefprozil clobetasol propionate benztropine [INJ] butorphanol nasal ceftazidime [INJ] clobetasol propionate shampoo BESPONSA [INJ] [SP] BYDUREON [INJ] CEFTAZIDIME/DEXTROSE [INJ] clobetasol propionate/emollient betamethasone acetate/betamethasone BYETTA [INJ] ceftriaxone [INJ] clofarabine [INJ] sodium phosphate [INJ] BYSTOLIC ceftriaxone/dextrose [INJ] clomiphene citrate betamethasone dipropionate cefuroxime axetil clomipramine betamethasone dipropionate augmented C cefuroxime sodium [INJ] clonazepam betamethasone valerate celecoxib clonazepam orally disintegrating tablets BETASERON [INJ] [SP] cabergoline CELONTIN clonidine betaxolol CABLIVI [INJ] [SP] cephalexin clonidine [INJ] betaxolol eye solution CABOMETYX [SP] CEPROTIN [INJ] [SP] clonidine ext-release bethanechol caffeine citrated CERDELGA [SP] clonidine patches BEVESPI AEROSPHERE caffeine citrated [INJ] CEREZYME [INJ] [SP] clopidogrel bexarotene [SP] caffeine/sodium benzoate [INJ] cetirizine syrup clorazepate BEXSERO [INJ] calcipotriene CETROTIDE [INJ] [SP] topical (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 2 clotrimazole troche dasetta dihydroergotamine [INJ] efavirenz/lamivudine/ clotrimazole/betamethasone dipropionate daunorubicin [INJ] dihydroergotamine nasal tenofovir disoproxil fumarate [SP] clozapine daysee DILANTIN 30 MG CAPSULES EGRIFTA [INJ] [SP] clozapine orally disintegrating tablets DAYTRANA DILATRATE-SR EGRIFTA SV [INJ] [SP] c-nate dha prenatal vitamins DDAVP RHINAL SOLUTION diltiazem ELAPRASE [INJ] [SP] COAGADEX [INJ] [SP] deblitane diltiazem [INJ] electrolyte-48 solution/dextrose [INJ] COARTEM decitabine [INJ] [SP] diltiazem ext-release eletriptan codeine sulfate deferasirox [SP] dimenhydrinate [INJ] ELIGARD [INJ] [SP] colchicine tablets deferiprone [SP] dimethyl fumarate [SP] elinest colchicine/probenecid deferoxamine [INJ] diphenhydramine ELIQUIS colesevelam hcl delflex with dextrose [INJ] diphenhydramine [INJ] ELITEK [INJ] colestipol demeclocycline diphenoxylate/atropine elite-ob prenatal vitamins colistimethate [INJ] DEPO-ESTRADIOL [INJ] DIPHTHERIA-TETANUS TOXOIDS-PED [INJ] ELMIRON COMBIGAN DEPO-PROVERA 400 MG/ML [INJ] dipyridamole ELOCTATE [INJ] [SP] COMBIPATCH DESCOVY [SP] dipyridamole [INJ] eluryng vaginal ring COMBIVENT RESPIMAT desipramine disulfiram ELZONRIS [INJ] [SP] COMETRIQ [SP] desloratadine divalproex delayed-release EMCYT complete natal dha prenatal vitamins desloratadine orally disintegrating tablets divalproex ext-release EMGALITY [INJ] constulose desmopressin acetate DIVIGEL emoquette copper chloride [INJ] desmopressin acetate [INJ] [SP] dobutamine [INJ] emtricitabine [SP] CORIFACT [INJ] [SP] desmopressin nasal dobutamine/dextrose [INJ] emtricitabine/ CORLANOR desogestrel-ethinyl estradiol DOCEFREZ [INJ] tenofovir disoproxil fumarate [SP] cosyntropin [INJ] desonide docetaxel [INJ] EMTRIVA SOLUTION [SP] COTELLIC [SP] desoximetasone DOCETAXEL 200 MG/10 ML [INJ] EMVERM CREON desvenlafaxine succinate ext-release dofetilide enalapril CRESEMBA dexamethasone dolishale enalapril/hydrochlorothiazide CRESEMBA [INJ] dexamethasone sodium phosphate [INJ] donepezil enalaprilat [INJ] CRIXIVAN [SP] dexamethasone sodium phosphate donepezil orally disintegrating tablets ENBREL [INJ] [SP] CROFAB [INJ] eye solution dopamine [INJ] ENDOMETRIN [SP] cromolyn sodium eye solution dexchlorpheniramine dopamine/dextrose [INJ] ENGERIX-B [INJ] cromolyn sodium nebulization solution DEXCOM RECEIVER, SENSOR, DOPTELET [SP] enoxaparin [INJ] [SP] cromolyn sodium oral solution TRANSMITTER dorzolamide eye solution enpresse crotamiton dexmedetomidine [INJ] dorzolamide/timolol eye solution enskyce cryselle dexmedetomidine/nacl [INJ] DOVATO [SP] ENSPRYNG [INJ] [SP] CRYSVITA [INJ] [SP] dexmethylphenidate doxazosin ENSTILAR cyanocobalamin [INJ] dexmethylphenidate ext-release doxepin entacapone cyclafem dexrazoxane [INJ] doxepin cream entecavir cyclobenzaprine dextran/dextrose [INJ] doxercalciferol ENTRESTO cyclobenzaprine ext-release dextran/normal saline [INJ] doxercalciferol [INJ] ENTYVIO [INJ] [SP] cyclopentolate eye solution dextroamphetamine doxorubicin [INJ] EOVIST [INJ] cyclophosphamide [INJ] dextroamphetamine ext-release doxorubicin/liposomal [INJ] ephedrine [INJ] cyclophosphamide capsules dextroamphetamine/amphetamine doxycycline hyclate EPIDIOLEX [SP] cyclosporine [INJ] [SP] dextroamphetamine/amphetamine doxycycline hyclate [INJ] epinastine eye solution cyclosporine [SP] ext-release doxycycline hyclate delayed-release epinephrine auto-injector cyclosporine modified [SP] dextrose/lactated ringers [INJ] doxycycline monohydrate (by Mylan, Teva) [INJ] cyproheptadine dextrose/sodium chloride [INJ] doxylamine succinate/vit b6 epinephrine nasal CYRAMZA [INJ] [SP] dextrose/water [INJ] D-PENAMINE epinephrine vials, ampules, syringes [INJ] cyred DIACOMIT [SP] dronabinol epinephrine/dextrose [INJ] cyred eq diazepam droperidol [INJ] epinephrine/nacl [INJ] CYSTADANE [SP] diazepam [INJ] DROPLET LANCETS [OTC] EPIPEN, EPIPEN JR [INJ] CYSTAGON [SP] diazepam rectal gel drospirenone-ethinyl estradiol epirubicin [INJ] CYSTARAN [SP] diazoxide drospirenone-ethinyl EPIVIR HBV SOLUTION cytarabine [INJ] diclofenac eye solution estradiol-levomefolate eplerenone CYTOGAM [INJ] [SP] diclofenac potassium DROXIA epoprostenol [INJ] [SP] diclofenac sodium delayed-release DUAVEE epoprostenol diluent [INJ] [SP] D diclofenac sodium ext-release DULERA eprosartan diclofenac sodium gel duloxetine delayed-release eptifibatide [INJ] dacarbazine [INJ] diclofenac sodium topical solution DUPIXENT [INJ] [SP] ERAXIS [INJ] dactinomycin [INJ] diclofenac sodium/misoprostol ext-release dutasteride ERBITUX [INJ] [SP] dalfampridine ext-release [SP] dicloxacillin dutasteride/tamsulosin ext-release ergocalciferol DALIRESP dicyclomine DYANAVEL XR ergoloid mesylates DALVANCE [INJ] dicyclomine [INJ] ergotamine tartrate/caffeine danazol didanosine delayed-release [SP] E ergotamine tartrate/caffeine dantrolene diethylpropion suppositories dantrolene [INJ] diethylpropion ext-release ERIVEDGE [SP] diflorasone EDARBI ERLEADA [SP] dapsone topical diflorasone/emollient EDARBYCLOR erlotinib [SP] DAPTACEL [INJ] diflunisal EDURANT [SP] errin daptomycin [INJ] digoxin efavirenz [SP] ertapenem [INJ] darifenacin ext-release digoxin [INJ] efavirenz/emtricitabine/ ERYTHROCIN [INJ] DARZALEX [INJ] [SP] dihydrocodeine/acetaminophen/caffeine tenofovir disoproxil fumarate [SP] (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 3 erythromycin citrate lozenges FRAGMIN [INJ] [SP] glyburide micronized erythromycin delayed-release fentanyl citrate/nacl [INJ] freamine iii [INJ] glyburide/metformin erythromycin ethylsuccinate fentanyl patches FREESTYLE FREEDOM KIT [OTC] glycine irrigation solution erythromycin eye ointment FERAHEME [INJ] FREESTYLE FREEDOM LITE METER [OTC] GLYCOPHOS [INJ] erythromycin stearate FERRIPROX [SP] FREESTYLE INSULINX GLUCOSE glycopyrrolate erythromycin topical FETZIMA SYSTEM [OTC] glycopyrrolate [INJ] erythromycin/benzoyl peroxide FINACEA FOAM FREESTYLE INSULINX TEST STRIPS [OTC] glycopyrrolate-water [INJ] ESBRIET [SP] finasteride FREESTYLE LIBRE & LIBRE 2 READER, GLYXAMBI escitalopram FIRMAGON [INJ] [SP] SENSOR GONAL-F, GONAL-F RFF, esmolol [INJ] flavoxate FREESTYLE LITE METER [OTC] GONAL-F RFF REDI-JECT [INJ] [SP] esmolol/nacl [INJ] flecainide FREESTYLE LITE TEST STRIPS [OTC] granisetron esomeprazole magnesium delayed-release FLECTOR FREESTYLE TEST STRIPS [OTC] granisetron [INJ] esomeprazole sodium [INJ] FLOLAN [INJ] [SP] frovatriptan GRANIX [INJ] [SP] ESPEROCT [INJ] [SP] FLOVENT DISKUS FULPHILA [INJ] [SP] GRASTEK estarylla FLOVENT HFA fulvestrant [INJ] microsize estazolam floxuridine [INJ] furosemide griseofulvin ultramicrosize esterified estrogens/methyltestosterone FLUAD [INJ] furosemide [INJ] guaifenesin/codeine estradiol FLUAD QUAD [INJ] FUZEON [INJ] [SP] guaifenesin/phenylephrine estradiol cream FLUARIX QUAD [INJ] fyavolv guanfacine estradiol patches FLUBLOK QUAD [INJ] FYCOMPA guanfacine ext-release estradiol vaginal FLUCELVAX QUAD [INJ] guanidine estradiol valerate [INJ] G GVOKE [INJ] estradiol/norethindrone acetate fluconazole/nacl [INJ] ESTRING gabapentin H eszopiclone fludarabine [INJ] GABLOFEN SYRINGES [INJ] ethacrynate [INJ] fludrocortisone acetate galantamine hailey ethacrynic acid FLULAVAL QUAD [INJ] galantamine ext-release hailey 24 fe ethambutol flumazenil [INJ] GAMASTAN [INJ] [SP] hailey fe ETHAMOLIN [INJ] flunisolide nasal spray GAMASTAN S-D [INJ] [SP] HALAVEN [INJ] [SP] ethosuximide fluocinolone GAMIFANT [INJ] [SP] halcinonide ethyl alcohol [INJ] fluocinolone acetonide oil ear solution GAMMACORE halobetasol ethynodiol-ethinyl estradiol fluocinonide GAMMAGARD LIQUID [INJ] [SP] etidronate fluocinonide/emollient GAMMAGARD S-D [INJ] [SP] haloperidol decanoate [INJ] haloperidol etodolac fluorescein [INJ] GAMUNEX-C [INJ] [SP] lactate etodolac ext-release fluorescein eye strips ganciclovir [INJ] haloperidol lactate [INJ] etomidate [INJ] fluorometholone eye suspension ganirelix acetate [INJ] [SP] HAVRIX [INJ] etonogestrel-ee vaginal ring fluorouracil GARDASIL 9 [INJ] heather ETOPOPHOS [INJ] fluorouracil [INJ] gatifloxacin eye solution HEMABATE [INJ] etoposide fluoxetine gavilyte-c HEMLIBRA [INJ] [SP] etoposide [INJ] fluoxetine delayed-release gavilyte-g HEMOFIL-M [INJ] [SP] EUFLEXXA [INJ] [SP] fluphenazine decanoate [INJ] gavilyte-n HEPAGAM B [INJ] everolimus [SP] fluphenazine hcl GAVRETO [SP] heparin lock flush [INJ] exemestane fluphenazine hcl [INJ] GAZYVA [INJ] [SP] heparin sodium [INJ] EXTRANEAL ICODEXTRIN DIALYSIS flurandrenolide GELNIQUE heparin sodium/dextrose [INJ] SOLUTION [INJ] flurazepam gemcitabine [INJ] heparin sodium/nacl [INJ] EYLEA [INJ] [SP] flurbiprofen gemfibrozil HEPATAMINE [INJ] ezetimibe flurbiprofen sodium eye solution gemmily hetastarch/nacl [INJ] ezetimibe/simvastatin flutamide GENOTROPIN [INJ] [SP] HEXTEND LACTATED ELECTROLYTE [INJ] fluticasone nasal spray gentamicin [INJ] HIBERIX [INJ] F fluticasone topical gentamicin eye ointment homatropine eye solution fluticasone/salmeterol powder inhaler gentamicin eye solution HUMALOG [INJ] FABRAZYME [INJ] [SP] fluvastatin gentamicin topical HUMATE-P [INJ] [SP] falmina fluvastatin ext-release gentamicin/nacl [INJ] HUMATROPE [INJ] [SP] famciclovir fluvoxamine GENTAMICIN/NORMAL SALINE HUMIRA [INJ] [SP] fluvoxamine ext-release 100 MG/50 ML [INJ] HUMULIN [INJ] famotidine [INJ] FLUZONE HIGH-DOSE QUAD [INJ] GENVOYA [SP] HUMULIN R 500 UNITS [INJ] famotidine/nacl [INJ] FLUZONE QUAD [INJ] gianvi HYCAMTIN CAPSULES [SP] FARXIGA folic acid GILENYA [SP] hydralazine FASENRA [INJ] [SP] folic acid [INJ] GILOTRIF [SP] hydralazine [INJ] fayosim folivane-ob prenatal vitamins GLASSIA [INJ] [SP] hydrochlorothiazide febuxostat FOLOTYN [INJ] [SP] glatiramer [INJ] [SP] hydrocodone ext-release FEIBA NF [INJ] [SP] fomepizole [INJ] glatopa [INJ] [SP] hydrocodone/acetaminophen felbamate fondaparinux [INJ] [SP] GLEOSTINE hydrocodone/chlorpheniramine polistirex felodipine ext-release FORTEO [INJ] [SP] glimepiride ext-release femynor fosamprenavir [SP] glipizide hydrocodone/homatropine fenofibrate fosaprepitant [INJ] glipizide ext-release hydrocodone/ibuprofen fenofibrate micronized foscarnet [INJ] glipizide/metformin hydrocortisone fenofibric acid fosfomycin sashet GLUCAGEN [INJ] hydrocortisone acetate suppositories fenofibric acid delayed-release fosinopril GLUCAGON [INJ] hydrocortisone butyrate fenoprofen fosinopril/hydrochlorothiazide glucagon emergency kit [INJ] fentanyl citrate [INJ] fosphenytoin [INJ] glyburide (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 4 hydrocortisone butyrate/emollient INTELENCE [SP] KANUMA [INJ] [SP] levocarnitine hydrocortisone enema intralipid 20% [INJ] kariva levocetirizine hydrocortisone sodium succinate [INJ] INTRON A [INJ] [SP] kelnor levofloxacin hydrocortisone topical INVELTYS KEPIVANCE [INJ] [SP] levofloxacin [INJ] hydrocortisone valerate INVIRASE [SP] KESIMPTA [INJ] [SP] levofloxacin eye solution hydrocortisone/lidocaine INVOKAMET ketamine [INJ] levofloxacin/dextrose [INJ] hydrocortisone/pramoxine INVOKAMET XR ketamine/nacl [INJ] levoleucovorin [INJ] hydromorphone INVOKANA levonest hydromorphone [INJ] iodine/ ketoconazole shampoo levonorgestrel-ethinyl estradiol hydromorphone ext-release iodine/sodium iodide ketoconazole topical levora hydromorphone suppositories IODOPEN [INJ] ketoconazole/skin cleanser kit levorphanol hydromorphone/nacl [INJ] IONOSOL/DEXTROSE [INJ] ketoprofen levothyroxine sodium hydroquinone IPOL [INJ] ketoprofen ext-release levothyroxine sodium [INJ] hydroxocobalamin [INJ] ipratropium bromide nasal spray ketorolac LEVSIN [INJ] hydroxychloroquine ipratropium bromide nebulization solution ketorolac [INJ] LEXISCAN [INJ] hydroxyprogesterone [INJ] ipratropium/albuterol sulfate nebulization ketorolac eye solution LEXIVA SUSPENSION [SP] hydroxyprogesterone [INJ] [SP] solution KEYTRUDA [INJ] [SP] LIBTAYO [INJ] [SP] hydroxyurea irbesartan KINEVAC [INJ] LICART hydroxyzine hcl irbesartan/hydrochlorothiazide KITABIS PAK [SP] lidocaine [INJ] hydroxyzine hcl [INJ] IRESSA [SP] KOGENATE FS [INJ] [SP] lidocaine jelly hydroxyzine pamoate irinotecan [INJ] KOVALTRY [INJ] [SP] lidocaine patches hyophen ISENTRESS [SP] K-PHOS ORIGINAL lidocaine topical hyoscyamine isibloom KRYSTEXXA [INJ] [SP] lidocaine viscous hyoscyamine ext-release ISOLYTE [INJ] kurvelo lidocaine/dextrose [INJ] hyoscyamine orally disintegrating tablets isoniazid KYLEENA [SP] lidocaine/epinephrine [INJ] HYPERHEP B S-D [INJ] isoniazid [INJ] KYMRIAH [INJ] [SP] lidocaine/hydrocortisone HYPERRAB [INJ] isoproterenol [INJ] KYNMOBI lidocaine/nacl [INJ] HYPERRAB S-D [INJ] isosorbide dinitrate KYPROLIS [INJ] [SP] lidocaine/prilocaine HYPERRHO S-D [INJ] isosorbide mononitrate lillow HYPERTET S-D [INJ] isosorbide mononitrate ext-release L lincomycin [INJ] HYSINGLA ER isotretinoin lindane shampoo isoxsuprine labetalol linezolid I isradipine labetalol [INJ] linezolid [INJ] ISTODAX [INJ] [SP] lactulose linezolid/nacl [INJ] ibandronate lamivudine [SP] LINZESS ibandronate [INJ] [SP] ivermectin lamivudine hbv LIORESAL [INJ] IBRANCE [SP] IXEMPRA [INJ] [SP] lamivudine/zidovudine [SP] liothyronine ibuprofen IXIARO [INJ] lamotrigine liothyronine [INJ] ibuprofen lysine [INJ] IXINITY [INJ] [SP] lamotrigine ext-release LIPOFEN ibutilide [INJ] lamotrigine orally disintegrating tablets lisinopril icatibant [INJ] [SP] J LANOXIN PEDIATRIC AMPULES [INJ] lisinopril/hydrochlorothiazide iclevia lansoprazole delayed-release lithium carbonate ICLUSIG [SP] jaimiess lansoprazole delayed-release lithium carbonate ext-release icosapent ethyl JAKAFI [SP] +amoxicillin+clarithromycin lithium citrate idarubicin [INJ] JANSSEN COVID-19 VACCINE (EUA) [INJ] lansoprazole orally disintegrating tablets LIVALO IDHIFA [SP] JANUMET lanthanum LO LOESTRIN FE ifosfamide [INJ] JANUMET XR LANTUS [INJ] lojaimiess ILARIS [INJ] [SP] JANUVIA lapatinib [SP] LOKELMA imatinib [SP] JARDIANCE larin LONSURF [SP] IMBRUVICA [SP] jasmiel larin fe IMFINZI [INJ] [SP] jencycla larissia lopinavir/ritonavir [SP] imipenem/cilastatin [INJ] JENTADUETO latanoprost eye solution lorazepam imipramine hcl JENTADUETO XR LATUDA lorazepam [INJ] imipramine pamoate JEVTANA [INJ] [SP] layolis fe LORBRENA [SP] imiquimod jinteli leena loryna IMOGAM RABIES-HT [INJ] JIVI [INJ] [SP] leflunomide losartan IMOVAX RABIES VACCINE [INJ] jolessa LENVIMA [SP] losartan/hydrochlorothiazide IMPAVIDO juleber lessina LOTEMAX GEL, OINTMENT INBRIJA [SP] JULUCA [SP] letrozole LOTEMAX SM incassia junel leucovorin loteprednol eye suspension INCRELEX [INJ] [SP] junel fe leucovorin [INJ] lovastatin INCRUSE ELLIPTA JUXTAPID [SP] LEUKERAN low-ogestrel indapamide LEUKINE [INJ] [SP] loxapine indomethacin K leuprolide [INJ] [SP] lo-zumandimine indomethacin ext-release levalbuterol nebulization solution LUCEMYRA indomethacin sodium [INJ] KADCYLA [INJ] [SP] LEVEMIR [INJ] LUMIGAN INFANRIX [INJ] kaitlib fe levetiracetam LUMIZYME [INJ] [SP] INFED [INJ] KALETRA TABLETS [SP] levetiracetam [INJ] LUPANETA PACK [INJ] [SP] INFUMORPH [INJ] kalliga levetiracetam ext-release LUPRON DEPOT 3.75 MG, 11.25 MG INFUVITE [INJ] KALYDECO [SP] levetiracetam/nacl [INJ] [INJ] [SP] INLYTA [SP] KANJINTI [INJ] [SP] levobunolol eye solution (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 5 LUPRON DEPOT-PED [INJ] [SP] methimazole m-natal prenatal vitamins neomycin/bacitracin/polymyxin LUTATHERA [INJ] [SP] METHITEST modafinil eye ointment lutera methocarbamol MODERNA COVID-19 VACCINE (EUA) [INJ] neomycin/bacitracin/polymyxin/ LUXTURNA [INJ] [SP] methocarbamol [INJ] moexipril hydrocortisone eye ointment lyleq methotrexate molindone neomycin/polymyxin irrigation solution LYNPARZA [SP] methotrexate [INJ] mometasone neomycin/polymyxin/dexamethasone LYSODREN [SP] methoxsalen mometasone nasal spray eye ointment LYUMJEV [INJ] methyldopa mono-linyah neomycin/polymyxin/dexamethasone lyza methyldopa/hydrochlorothiazide MONONINE [INJ] [SP] eye suspension methyldopate [INJ] MONOVISC [INJ] [SP] neomycin/polymyxin/gramicidin M methylergonovine montelukast eye solution methylergonovine [INJ] morphine sulfate neomycin/polymyxin/hydrocortisone m.v.i. adult [INJ] morphine sulfate [INJ] ear solution M.V.I. PEDIATRIC [INJ] methylphenidate ext-release morphine sulfate ext-release neomycin/polymyxin/hydrocortisone M.V.I.-12 [INJ] methylprednisolone morphine sulfate suppositories ear suspension mafenide methylprednisolone acetate [INJ] morphine sulfate/nacl [INJ] neomycin/polymyxin/hydrocortisone magnesium chloride [INJ] methylprednisolone sodium MOVANTIK eye suspension magnesium sulfate [INJ] succinate [INJ] moxifloxacin neostigmine [INJ] magnesium sulfate/nacl [INJ] methyltestosterone MOXIFLOXACIN [INJ] NEPHRAMINE [INJ] MAGNESIUM/DEXTROSE metipranolol eye solution moxifloxacin eye solution NERLYNX [SP] 1 GM/100 ML [INJ] metoclopramide moxifloxacin/nacl [INJ] NEULASTA [INJ] [SP] malathion metoclopramide [INJ] MOZOBIL [INJ] [SP] NEUPOGEN [INJ] [SP] manganese chloride [INJ] metoclopramide orally MULTI-LANCET DEVICE [OTC] nevirapine [SP] manganese sulfate [INJ] disintegrating tablets MULTITRACE-4 [INJ] nevirapine ext-release [SP] mannitol [INJ] metolazone mupirocin newgen prenatal vitamins maprotiline metoprolol succinate ext-release MUSE NEXAVAR [SP] marlissa metoprolol tartrate MVASI [INJ] [SP] NEXLETOL MARQIBO [INJ] [SP] metoprolol tartrate [INJ] MYALEPT [INJ] [SP] NEXLIZET MATULANE [SP] metoprolol/hydrochlorothiazide mycophenolate mofetil [SP] NEXPLANON [INJ] [SP] MAVYRET metronidazole mycophenolate mofetil hcl [INJ] [SP] NEXTERONE [INJ] MAYZENT [SP] metronidazole topical mycophenolic acid delayed-release [SP] niacin meclizine metronidazole vaginal MYDAYIS niacin ext-release meclofenamate metronidazole/nacl [INJ] MYLERAN nicardipine medroxyprogesterone metyrosine MYLOTARG [INJ] [SP] nicardipine [INJ] medroxyprogesterone (contraceptive) [INJ] mexiletine mynatal plus prenatal vitamins nifedipine ext-release mefenamic acid mibelas 24 fe mynatal prenatal vitamins nikki mefloquine [INJ] mynatal ultracaplet prenatal vitamins nilutamide megestrol vaginal mynatal-z prenatal vitamins nimodipine MEKINIST [SP] microgestin MYOBLOC [INJ] [SP] NINLARO [SP] melodetta 24 fe microgestin fe MYRBETRIQ nisoldipine ext-release meloxicam MICROLET NEXT LANCING DEVICE [OTC] nitazoxanide melphalan midazolam N nitisinone [SP] melphalan [INJ] midazolam [INJ] nitrofurantoin memantine midazolam/nacl [INJ] nabumetone nitrofurantoin macrocrystal memantine ext-release midodrine nadolol nitrofurantoin monohydrate/macrocrystal MENACTRA [INJ] mifepristone nadolol/bendroflumethiazide nitroglycerin [INJ] MENOPUR [INJ] [SP] miglitol nafcillin [INJ] nitroglycerin ext-release mepivacaine [INJ] miglustat [SP] nafcillin/dextrose [INJ] nitroglycerin ointment MEPSEVII [INJ] [SP] mili nitroglycerin patches mercaptopurine milrinone [INJ] NAGLAZYME [INJ] [SP] nitroglycerin spray meropenem [INJ] milrinone/dextrose [INJ] nalbuphine [INJ] nitroglycerin/dextrose [INJ] MEROPENEM/NACL [INJ] mimvey naloxone [INJ] nitroprusside sodium [INJ] merzee MINIMED INFUSION SETS naltrexone NITYR [SP] mesalamine delayed-release MINIMED MIO NAMZARIC NIVESTYM [INJ] [SP] mesalamine enema MINIMED QUICK SETS naproxen nizatidine mesalamine ext-release MINIMED RESERVOIR naproxen delayed-release nora-be mesalamine kit MINIMED SILHOUETTE naproxen sodium NORDITROPIN [INJ] [SP] mesalamine suppositories MINIMED SURE T naproxen sodium ext-release norepinephrine [INJ] mesna [INJ] MINOCIN [INJ] naproxen/esomeprazole magnesium norepinephrine/dextrose [INJ] MESNEX TABLETS minocycline ext-release norepinephrine/nacl [INJ] metaproterenol minocycline ext-release naratriptan norethindrone metaxalone NARCAN NASAL SPRAY norethindrone acetate metformin MIRENA [SP] NASCOBAL norethindrone acetate-ethinyl estradiol metformin ext-release mirtazapine NATACYN norethindrone acetate-ethinyl estradiol methadone mirtazapine orally disintegrating tablets nateglinide + iron methadone [INJ] MIRVASO NATESTO norgestimate-ethinyl estradiol methamphetamine misoprostol NATPARA [INJ] [SP] norlyda methazolamide MITIGARE NAYZILAM NORMOSOL-M AND DEXTROSE [INJ] methenamine hippurate mitomycin [INJ] necon NORMOSOL-R AND DEXTROSE [INJ] methenamine mandelate mitoxantrone [INJ] [SP] neomycin NORMOSOL-R PH 7.4 [INJ] methenamine/sodium phosphate/ M-M-R II [INJ] nortrel (continued) methylene blue/hyoscyamine Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 6 nortriptyline ONIVYDE [INJ] [SP] penicillin g potassium [INJ] podofilox NORVIR PACKETS [SP] OPDIVO [INJ] [SP] penicillin g procaine [INJ] POLOCAINE [INJ] NORVIR SOLUTION [SP] opium tincture penicillin g sodium [INJ] polyethylene glycol 3350 NOVAREL [INJ] [SP] opium/belladonna alkaloids suppositories PENICILLIN GK/DEXTROSE [INJ] polymyxin [INJ] NOVOEIGHT [INJ] [SP] OPSUMIT [SP] penicillin v potassium polymyxin/trimethoprim eye solution NOVOFINE AUTOSHIELD NEEDLES [OTC] ORALAIR [SP] PENTACEL [INJ] POMALYST [SP] NOVOFINE NEEDLES [OTC] ORBACTIV [INJ] PENTACEL ACTHIB COMPONENT [INJ] PONVORY [SP] NOVOSEVEN RT [INJ] [SP] ORIAHNN [INJ] portia NOVOTWIST NEEDLES [OTC] ORILISSA pentamidine inhalation NOXAFIL [INJ] ORKAMBI [SP] PENTASA potassium acetate [INJ] NOXAFIL SUSPENSION orphenadrine [INJ] pentobarbital [INJ] potassium bicarbonate/citric acid NPLATE [INJ] [SP] orphenadrine ext-release pentoxifylline ext-release effervescent tablets NUBEQA [SP] orphenadrine/aspirin/caffeine PERFOROMIST potassium chloride [INJ] NUCALA [INJ] [SP] orsythia perindopril potassium chloride ext-release NUEDEXTA ORTHOVISC [INJ] [SP] PERJETA [INJ] [SP] potassium chloride oral solution NULOJIX [INJ] [SP] oseltamivir permethrin potassium chloride powder packets for nutrilyte [INJ] OTEZLA [SP] perphenazine solution nylia OTOVEL perphenazine/amitriptyline potassium chloride/dextrose [INJ] nymyo OTREXUP [INJ] PFIZER COVID-19 VACCINE (EUA) [INJ] potassium chloride/dextrose/nacl [INJ] OVIDREL [INJ] [SP] phenazopyridine potassium chloride/lactated ringers/ nystatin topical oxacillin [INJ] phendimetrazine dextrose [INJ] nystatin/triamcinolone oxacillin/dextrose [INJ] phendimetrazine ext-release potassium chloride/lidocaine/nacl [INJ] NYVEPRIA [INJ] [SP] oxaliplatin [INJ] phenelzine potassium chloride/nacl [INJ] oxandrolone phenobarbital potassium chloride/water [INJ] O oxaprozin phenobarbital sodium [INJ] potassium citrate ext-release oxcarbazepine phenobarbital/hyoscyamine/atropine/ potassium iodide/iodine solution OBIZUR [INJ] [SP] OXERVATE [SP] scopolamine potassium phosphate [INJ] obstetrix dha prenatal vitamins phenoxybenzamine POTELIGEO [INJ] [SP] OCALIVA [SP] oxybutynin phentermine pr natal 400 ec prenatal vitamins ocella oxybutynin ext-release phentolamine [INJ] pr natal 400 prenatal vitamins OCREVUS [INJ] [SP] oxycodone phenylbutyrate pr natal 430 ec prenatal vitamins octreotide [INJ] [SP] oxycodone/acetaminophen phenylephrine [INJ] pr natal 430 prenatal vitamins ODACTRA oxycodone/aspirin phenylephrine eye solution pramipexole ODEFSEY [SP] OXYCONTIN phenylephrine/chlorpheniramine pramipexole ext-release ODOMZO [SP] oxymorphone phenylephrine/nacl [INJ] prasugrel OFEV [SP] oxymorphone ext-release phenytoin pravastatin ofloxacin oxytocin [INJ] phenytoin sodium [INJ] praziquantel ofloxacin ear solution OZEMPIC [INJ] phenytoin sodium extended prazosin ofloxacin eye solution OZURDEX [INJ] [SP] philith PRECISION XTRA B-KETONE STRIPS [OTC] olanzapine PHOSLYRA PRECISION XTRA MONITOR [OTC] olanzapine [INJ] P phosphasal PRECISION XTRA TEST STRIPS [OTC] olanzapine orally disintegrating tablets PHOSPHOLINE IODIDE prednicarbate olanzapine/fluoxetine paclitaxel [INJ] PHOTOFRIN [INJ] prednisolone olmesartan ext-release physostigmine [INJ] prednisolone acetate eye suspension olmesartan/amlodipine/ palonosetron [INJ] phytonadione prednisolone sodium phosphate hydrochlorothiazide PALYNZIQ [INJ] [SP] phytonadione [INJ] prednisolone sodium phosphate olmesartan/hydrochlorothiazide pamidronate [INJ] PHYTONADIONE 1 MG/0.5 ML disintegrating tablets olopatadine eye solution PANCREAZE SYRINGES [INJ] prednisolone sodium phosphate olopatadine nasal spray pantoprazole [INJ] PICATO eye solution OLUMIANT [SP] pantoprazole delayed-release pilocarpine prednisone omega-3 ethyl esters pantoprazole suspension pilocarpine eye solution pregabalin omeprazole delayed-release papaverine [INJ] pimecrolimus pregabalin ext-release omeprazole/sodium bicarbonate PARADIGM RESERVOIRS pimozide PREMARIN [INJ] OMNIPAQUE [INJ] PARADIGM SILHOUETTE SETS pimtrea PREMARIN CREAM OMNIPOD paricalcitol pindolol PREMARIN TABLETS OMNIPOD DASH paricalcitol [INJ] pioglitazone PREMPHASE ONCASPAR [INJ] paromomycin pioglitazone/glimepiride PREMPRO ondansetron paroxetine hcl pioglitazone/metformin premasol [INJ] ondansetron [INJ] paroxetine hcl ext-release piperacillin/tazobactam [INJ] prena1 chew prenatal vitamins ondansetron orally disintegrating tablets paroxetine mesylate pirmella prena1 pearl prenatal vitamins ONETOUCH DELICA LANCETS [OTC] PAZEO piroxicam prena1 true prenatal vitamins ONETOUCH DELICA PLUS LANCETS [OTC] PEDIARIX [INJ] PLASMA-LYTE [INJ] prenaissance plus prenatal vitamins ONETOUCH ULTRA 2 SYSTEM [OTC] PEDITRACE [INJ] plasmanate [INJ] prenaissance prenatal vitamins ONETOUCH ULTRA TEST STRIPS [OTC] PEDVAXHIB [INJ] PLEGRIDY [INJ] [SP] prenatabs fa prenatal vitamins ONETOUCH ULTRAMINI METER [OTC] peg 3350/electrolytes powder for 4000 ml plenamine [INJ] prenatabs rx prenatal vitamins ONETOUCH ULTRASOFT LANCETS [OTC] solution PNEUMOVAX 23 [INJ] prenatal low iron prenatal vitamins ONETOUCH VERIO FLEX METER [OTC] peg3350/sod sul/nacl/kcl/asb/c pnv 29-1 prenatal vitamins prenatal plus iron prenatal vitamins ONETOUCH VERIO IQ METER [OTC] PEGANONE pnv-dha + docusate prenatal vitamins prenatal plus prenatal vitamins ONETOUCH VERIO REFLECT METER [OTC] PEGASYS [INJ] [SP] pnv-dha prenatal vitamins prenatal-u prenatal vitamins ONETOUCH VERIO TEST STRIPS [OTC] peg-prep kit pnv-omega prenatal vitamins preplus prenatal vitamins ONEXTON penicillamine pnv-select prenatal vitamins (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 7 pretab 29-1 prenatal vitamins quinapril ROTATEQ sodium tetradecyl sulfate [INJ] previfem quinapril/hydrochlorothiazide ROZLYTREK [SP] [INJ] PREVNAR 13 [INJ] quinidine gluconate ext-release RUBRACA [SP] solifenacin PREVYMIS quinidine sulfate RUCONEST [INJ] [SP] SOLIQUA [INJ] PREVYMIS [INJ] quinine sulfate rufinamide SOLIRIS [INJ] [SP] PREZISTA [SP] QVAR REDIHALER RUXIENCE [INJ] [SP] SOLOSEC PRIALT [INJ] [SP] RUZURGI [SP] SOLU-CORTEF [INJ] PRIFTIN R RYBELSUS SOMATULINE DEPOT [INJ] [SP] PRIMAQUINE RYDAPT [SP] SOMAVERT [INJ] [SP] primaquine phosphate RABAVERT [INJ] sotalol primidone rabeprazole delayed-release S SOTALOL [INJ] probenecid RADICAVA [INJ] [SP] SOTRADECOL 1% [INJ] procainamide [INJ] RAGWITEK salsalate SOTYLIZE PROCALAMINE [INJ] raloxifene SAMSCA 15 MG TABLETS [SP] spinosad prochlorperazine edisylate [INJ] ramelteon SANDIMMUNE SOLUTION [SP] SPINRAZA [INJ] [SP] prochlorperazine maleate ramipril SANTYL SPIRIVA HANDIHALER prochlorperazine maleate suppositories ranolazine ext-release sapropterin [SP] SPIRIVA RESPIMAT PROCRIT [INJ] [SP] RAPIVAB [INJ] SAVELLA spironolactone PROFILNINE SD [INJ] [SP] rasagiline scopolamine patches spironolactone/hydrochlorothiazide progesterone in oil [INJ] [SP] RASUVO [INJ] secobarbital sprintec progesterone micronized RAVICTI [SP] SEGLUROMET SPRYCEL [SP] PROGRAF [INJ] [SP] REBIF [INJ] [SP] selegiline sronyx PROGRAF PACKETS [SP] reclipsen selenium [INJ] STAMARIL [INJ] PROLASTIN C [INJ] [SP] RECOMBIVAX HB [INJ] selenium sulfide stavudine [SP] PROLEUKIN [INJ] [SP] RECTIV selenium sulfide shampoo STEGLATRO PROMACTA [SP] REGRANEX SELZENTRY [SP] STEGLUJAN promethazine RELISTOR [INJ] se-natal 19 prenatal vitamins STELARA SC [INJ] [SP] promethazine [INJ] RELISTOR TABLETS SENSORCAINE-EPI 0.75%-0.0005% [INJ] STIMATE [SP] promethazine suppositories REMICADE [INJ] [SP] SEREVENT DISKUS STIOLTO RESPIMAT promethazine/codeine remifentanil [INJ] SEROSTIM [INJ] [SP] STIVARGA [SP] promethazine/dextromethorphan RENACIDIN sertraline STRENSIQ [INJ] [SP] promethazine/phenylephrine repaglinide setlakin STREPTOMYCIN SULFATE [INJ] promethazine/phenylephrine/codeine repaglinide/metformin hcl sevelamer carbonate STRIVERDI RESPIMAT propafenone REPATHA [INJ] sevelamer hcl SUBLOCADE [INJ] [SP] propafenone ext-release RESECTISOL SEVENFACT [INJ] [SP] SUCRAID [SP] proparacaine eye solution RESTASIS sharobel sucralfate proparacaine/fluorescein eye solution RETROVIR [INJ] [SP] SHINGRIX [INJ] sufentanil [INJ] propofol [INJ] REVCOVI [INJ] [SP] SIGNIFOR [INJ] [SP] sulfacetamide eye ointment propranolol REVLIMID [SP] sildenafil sulfacetamide eye solution propranolol [INJ] REYATAZ PACKETS [SP] sildenafil [INJ] [SP] sulfacetamide sodium shampoo propranolol ext-release R-GENE 10 [INJ] sildenafil [SP] sulfacetamide sodium topical propranolol/hydrochlorothiazide RHOPRESSA SILHOUETTE INFUSION SETS sulfacetamide sodium/sulfur propylthiouracil RIASTAP [INJ] [SP] silodosin sulfacetamide/prednisolone eye solution PROQUAD [INJ] ribavirin [SP] silver sulfadiazine sulfadiazine PROSOL [INJ] ribavirin nebulization solution simliya sulfamethoxazole/trimethoprim protamine [INJ] RIDAURA simpesse sulfamethoxazole/trimethoprim [INJ] PROTOPAM [INJ] rifabutin SIMPONI 100 MG [INJ] [SP] SULFAMYLON CREAM protriptyline rifampin SIMULECT [INJ] [SP] sulfasalazine PROVENGE [INJ] [SP] rifampin [INJ] simvastatin sulfasalazine delayed-release pseudoephedrine/chlorpheniramine/ riluzole sirolimus [SP] sulindac methscopolamine ext-release rimantadine SIRTURO sumatriptan pseudoephedrine/codeine/guaifenesin ringers irrigation solution SKYLA [SP] sumatriptan [INJ] PULMICORT FLEXHALER ringers lactated irrigation solution SKYRIZI [INJ] [SP] sumatriptan nasal PULMOZYME [SP] ringers solution [INJ] sodium acetate [INJ] sumatriptan/naproxen sodium PURIXAN [SP] ringers solution lactated [INJ] sodium benzoate/ SUNOSI pyrazinamide RINVOQ ER [SP] sodium phenylacetate [INJ] SUPREP pyridostigmine risedronate sodium bicarbonate [INJ] SURE-T INFUSION SETS pyridostigmine [INJ] risedronate delayed-release sodium bicarbonate/dextrose [INJ] SUTAB pyridostigmine ext-release RISPERDAL CONSTA [INJ] sodium chloride [INJ] SUTENT [SP] pyridoxine [INJ] sodium chloride 0.45% [INJ] syeda pyrimethamine [SP] risperidone orally disintegrating tablets sodium chloride 0.9% [INJ] SYLATRON [INJ] [SP] ritonavir [SP] sodium chloride 3% [INJ] SYLVANT [INJ] [SP] Q rivastigmine sodium chloride 5% [INJ] SYMBICORT rivastigmine patches sodium chloride irrigation solution SYMDEKO [SP] QNASL rivelsa sodium chloride nebulization solution SYMFI [SP] QUADRACEL DTAP-IPV [INJ] rizatriptan sodium chloride, bacteriostatic [INJ] SYMFI LO [SP] QUDEXY XR rizatriptan orally disintegrating tablets sodium ferric gluconate complex [INJ] SYMJEPI [INJ] quetiapine ropinirole sodium fluoride dental cream, gel SYMLINPEN [INJ] quetiapine ext-release ropinirole ext-release sodium phosphate [INJ] SYMPROIC QUILLICHEW ER ropivacaine/nacl [INJ] sodium polystyrene sulfonate SYMTUZA [SP] QUILLIVANT XR rosuvastatin sodium polystyrene sulfonate rectal SYNAGIS [INJ] [SP] (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 8 SYNAREL TIBSOVO [SP] TRIKAFTA [SP] VANCOMYCIN/NACL [INJ] SYNERCID [INJ] TICE BCG [INJ] tri-legest fe VANTAS [SP] SYNJARDY tigecycline [INJ] tri-linyah vardenafil SYNJARDY XR tilia fe tri-lo-estarylla vardenafil orally disintegrating tablets SYNRIBO [INJ] [SP] timolol maleate tri-lo-marzia VARIVAX [INJ] timolol maleate eye solution tri-lo-mili VARIZIG [INJ] T tinidazole tri-lo-sprintec VARUBI TIVICAY [SP] trilyte with flavor packets VASCEPA TABRECTA [SP] TIVICAY PD [SP] trimethobenzamide VECTIBIX [INJ] [SP] tacrolimus [SP] tizanidine trimethoprim VELCADE [INJ] [SP] tacrolimus topical TOBI PODHALER [SP] tri-mili velivet tadalafil TOBRADEX OINTMENT trimipramine VELPHORO tadalafil [SP] TOBRADEX ST TRIMO-SAN VEMLIDY TAFINLAR [SP] tobramycin [INJ] trinatal rx 1 prenatal vitamins VENCLEXTA [SP] TAGRISSO [SP] tobramycin eye solution trinate prenatal vitamins venlafaxine TAKHZYRO [INJ] [SP] tobramycin nebulization solution [SP] tri-nymyo venlafaxine ext-release TALICIA tobramycin/dexamethasone tri-previfem VENOFER [INJ] TALTZ [INJ] [SP] eye suspension TRIPTODUR [INJ] [SP] VENTOLIN HFA TALZENNA [SP] tobramycin/nacl [INJ] tri-sprintec verapamil tamoxifen tolcapone TRIUMEQ [SP] verapamil [INJ] tamsulosin ext-release tolmetin triveen-duo dha prenatal vitamins verapamil ext-release TARGRETIN GEL [SP] tolterodine trivora veripred tarina fe tolterodine ext-release tri-vylibra VERQUVO taron-c dha prenatal vitamins tolvaptan [SP] TROGARZO [INJ] [SP] VERZENIO [SP] taron-prex dha prenatal vitamins TROPHAMINE [INJ] vestura TASIGNA [SP] topiramate ext-release tropicamide eye solution VGO tavaborole topotecan [INJ] [SP] trospium VIBATIV [INJ] tazarotene toremifene trospium ext-release VIBERZI TAZORAC 0.05% CREAM torsemide TRULANCE VICTOZA [INJ] TAZORAC GEL TOUJEO [INJ] TRULICITY [INJ] vienva TECENTRIQ [INJ] [SP] TOVIAZ TRUMENBA [INJ] vigabatrin [SP] TECHLITE BLOOD LANCETS [OTC] TPN ELECTROLYTES [INJ] TUBERSOL [INJ] VIIBRYD TEFLARO [INJ] TRACE ELEMENTS-4 [INJ] tulana VIMIZIM [INJ] [SP] TEGSEDI [INJ] [SP] TRACLEER SUSPENSION [SP] TWINRIX [INJ] VIMPAT TEKTURNA HCT TRADJENTA tydemy VIMPAT [INJ] telmisartan TYMLOS [INJ] [SP] vinblastine [INJ] telmisartan/amlodipine tramadol ext-release TYPHIM VI [INJ] vincristine [INJ] telmisartan/hydrochlorothiazide tramadol/acetaminophen TYSABRI [INJ] [SP] vinorelbine [INJ] TEMIXYS [SP] trandolapril TYVASO [SP] VIOKACE TEMODAR [INJ] [SP] trandolapril/verapamil ext-release viorele temozolomide [SP] tranexamic acid U VIRACEPT [SP] temsirolimus [INJ] [SP] tranexamic acid [INJ] VIREAD 150 MG, 200 MG, 250 MG TENIPOSIDE [INJ] tranylcypromine UCERIS FOAM TABLETS [SP] tenofovir disoproxil fumarate [SP] travasol [INJ] UDENYCA [INJ] [SP] VIREAD POWDER [SP] terazosin travoprost eye solution UNITUXIN [INJ] [SP] virt-c dha prenatal vitamins TRAZIMERA [INJ] [SP] UPTRAVI [SP] virt-nate dha prenatal vitamins terbutaline trazodone uretron d-s virt-pn dha prenatal vitamins terbutaline [INJ] TREANDA [INJ] [SP] urimar-t virt-pn plus prenatal vitamins vaginal TRELEGY ELLIPTA urin d.s. VISTOGARD [SP] testosterone TREMFYA [INJ] [SP] uro-458 VISUDYNE [INJ] [SP] testosterone cypionate [INJ] treprostinil diluent [INJ] [SP] urogesic VITRAKVI [SP] testosterone enanthate [INJ] treprostinil sodium [INJ] [SP] uro-mp VIVITROL [INJ] [SP] TETANUS DIPHTHERIA TOXOIDS [INJ] TRESIBA [INJ] ursodiol VIVOTIF tetrabenazine [SP] tretinoin uryl VIZIMPRO [SP] tetracaine [INJ] tretinoin microspheres ustell volnea tetracaine eye solution tretinoin topical utira-c VONVENDI [INJ] [SP] tetracycline tretinoin/emollient UVADEX [INJ] VORAXAZE [INJ] THALOMID [SP] TRETTEN [INJ] [SP] theophylline tri femynor V voriconazole [INJ] theophylline ext-release triamcinolone [INJ] VOTRIENT [SP] theophylline/dextrose [INJ] triamcinolone dental paste valacyclovir VUMERITY [SP] THERACYS [INJ] triamcinolone topical VALCHLOR [SP] vyfemla thiamine [INJ] triamterene valganciclovir vylibra thioridazine triamterene/hydrochlorothiazide valproate sodium [INJ] VYNDAMAX [SP] thiotepa [INJ] triazolam valproic acid VYNDAQEL [SP] thiothixene trientine valrubicin [SP] VYVANSE THROMBATE III [INJ] tri-estarylla valsartan VYXEOS LIPOSOME [INJ] [SP] THYMOGLOBULIN [INJ] [SP] trifluoperazine valsartan/hydrochlorothiazide THYROGEN [INJ] [SP] trifluridine eye solution vancomycin thyroid trihexyphenidyl vancomycin [INJ] tiagabine TRIJARDY XR VANCOMYCIN/DEXTROSE [INJ] (continued) Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

© 2021 All Rights Reserved. All trademarks are the property of their respective owners. Page 9 W XIIDRA zaleplon ZIRABEV [INJ] [SP] XOFIGO [INJ] [SP] ZALTRAP [INJ] [SP] ZOLADEX [INJ] [SP] warfarin XOLAIR [INJ] [SP] ZANOSAR [INJ] zoledronic acid [INJ] [SP] water for injection, bacteriostatic [INJ] XOSPATA [SP] zarah zoledronic acid/mannitol [INJ] [SP] water for injection, sterile [INJ] XTANDI [SP] ZARXIO [INJ] [SP] ZOLGENSMA [INJ] [SP] water for irrigation, sterile xulane patches zatean-pn dha prenatal vitamins ZOLINZA [SP] wera XULTOPHY [INJ] zatean-pn plus prenatal vitamins zolmitriptan westab plus prenatal vitamins XURIDEN [SP] ZEJULA [SP] zolmitriptan orally disintegrating tablets westgel dha prenatal vitamins XYREM [SP] ZELBORAF [SP] zolpidem WILATE [INJ] [SP] XYWAV [SP] ZEMAIRA [INJ] [SP] zolpidem ext-release wixela inhub ZENPEP ZOMIG NASAL wymzya fe Y ZEPOSIA (for Multiple Sclerosis only) [SP] zonisamide ZERBAXA [INJ] ZORTRESS 1 MG TABLETS [SP] X YERVOY [INJ] [SP] ZERVIATE ZOSYN GALAXY BAGS [INJ] YESCARTA [INJ] [SP] ZEVALIN [INJ] zovia XALKORI [SP] YF-VAX [INJ] zidovudine [SP] ZTLIDO XARELTO YONDELIS [INJ] [SP] ZIEXTENZO [INJ] [SP] ZUBSOLV XELJANZ [SP] YONSA [SP] zileuton ext-release ZULRESSO [INJ] [SP] XELJANZ XR [SP] YUPELRI zinc chloride [INJ] zumandimine XEMBIFY [INJ] [SP] yuvafem zinc sulfate [INJ] ZYDELIG [SP] XERMELO [SP] zingiber prenatal vitamins ZYKADIA [SP] XGEVA [INJ] [SP] Z ZIOPTAN ZYLET XIAFLEX [INJ] [SP] ziprasidone XIFAXAN zafemy patches ziprasidone mesylate [INJ] XIGDUO XR zafirlukast

Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE.

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