Clinically Preferred Drug List 2nd Quarter Edition

Last Revised: 05/17/2020 Version 2020Q2d

Table of Contents

OVERVIEW 4 CARDIOVASCULAR (HEART) DRUGS 14 Alpha & Beta Blockers 14 COVERAGE LIMITATION 4 Antihypertensive Combinations 14 Calcium Channel Blockers (CCBs) 14 COMPOUNDED DRUGS 4 ACE Inhibitors without & with Diuretics 15 DRUG PLACEMENT DETERMINATION 4 ACE Inhibitors / CCB Combinations 15 ARBs without & with Diuretics 15 PREFERRED BRAND PRODUCTS 5 ARB Combinations 15 Naprilysin Inhibitors 15 GENERIC SUBSTITUTION 5 Diuretics 15 Renin Inhibtors 16 SINGLE & DUAL SOURCE GENERICS 5 Antiarrhythmics/Anti-Ischemic 16 Cardiac Glycosides 16 PRIOR AUTHORIZATIONS, STEP EDITS & QTY LIMITS 6 Vasodilators, Coronary, Nitrates/Vasodilators, Sympatholytics 16 EXCLUDED DRUGS 6 Other Drugs 16 NON-LISTED DRUGS & DRUG CATEGORIES 7 ANTIHYPERLIPIDEMIC (CHOLESTEROL) DRUGS 17 Statins & Statin/CCB Combinations 17 FORMULARY MODIFICATIONS & CHANGES 7 Bile Acid Sequestrants, Liver Drugs 17 Fibrates 17 BIOSIMILARS 7 Other Drugs 17 MAJOR CHANGES TO THE PDL 7 PANCREATIC DRUGS 18 ANTIBIOTICS 8 KIDNEY & URINARY / UROLOGICAL DRUGS 18 Penicillins & Cephalosporins 8 Benign Prostate Hyperplasia 18 Tetracyclines 8 Urologic Drugs / Other Drugs 18 Macrolides & Clindamycins 8 Erectile Dysfunction Drugs 18 Sulfonamides, Sulfones & Ketolides 8 Gout Drugs – Purine Inhibitors 19 Quinolones 8 Urinary Ph Modifiers 19 Miscellaneous Antibiotics 8 Potassium & Electrolytes 19 Phosphorus/Calcium/Electrolyte Depleters 19 ANTI-VIRALS 9 General Antivirals 9 OSTEOPOROSIS (BONE) DRUGS 20 HIV Antiviral Drugs 9 HIV Pre-Exposure Propylaxis Drugs 9 ANTI-INFLAMMATORY / ANALGESIC (PAIN) DRUGS 20 Anti-Inflammatory Drugs (NSAIDS) 20 ANTI-INFECTIVES 10 COX-II Drugs 21 Anaerobic Anti-Infectives 10 Analgesics, Narcotics (Opioids) 21 Antiparasitics 10 Analgesics, Salicylates & Non-Salicylates 21 Antimalarials & Antiprotozoals 10 Antihelmintic Drugs 10 CENTRAL NERVOUS SYSTEM DRUGS 22 Anti-Anxiety Drugs (Benzodiazepines) 22 ANTIEMETICS 10 Sedative/Sleeping Drugs 22 A.D.D. & A.D.H.D. Drugs 22 NEUROLOGIC DRUGS 11 Excessive Sleepiness / Narcolepsy 22 Anti-Parkinsons Drugs 11 Seratonin Selective Reuptake Inhibitors (SSRIs) 23 Anti Migraine Drugs 11 Seratonin-Norepinephrine Reuptake Inhibitors (SNRIs) 23 Alzheimers Drugs 12 Other SSRI Combinations 23 Anti-Convulsants & Anti-Epileptics 12 Monoamine Oxidase Inhibitors (MAOIs) 23 Fibromyalgia, Neuropathic Pain / PHN Drugs 12 Antidepressants, Other Drugs 23 Restless Leg Syndrome (RLS) 12 Pseudobulbar Affect (PBA) Drugs 23 Antipsychotic Drugs 24 BLOOD MODIFIERS 13 Atypical Antipsychotic Drugs 24 Anticoagulants / Anti-A10 / Thrombin Inhibitors 13 Bipolar Disorders (Anti-mania) 24 Heparin Related Drugs 13 Platelet Aggregation Inhibitors / DVT 13 Other Drugs 13

PREFERRED DRUG LIST 2 GASTROINTESTINAL DRUGS 24 OPHTHALMIC (EYE) DRUGS 38 Parathyroid Drugs 24 Anti-Infectives 38 Anti-Ulcer / GERD Drugs 25 Antihistamines 38 Bowel Preps 25 Immunomodulators 38 Irritable Bowel Syndrome (IBS) Drugs 25 Mast Cell Stabilizers 38 Laxatives 26 Anti-Inflammatory Drugs 38 Colon Prep Drugs 26 Glaucoma 39 H. Pylori Drugs 26 Mydriatics 39 Antibiotic/Corticoid Combination Drugs 39 CONTRACEPTIVES & HORMONE THERAPY DRUGS 27 Other Drugs 39 Contraceptives 27 Estrogens / Estrogen Combinations (Hormone Replacement) 27 OTIC (EAR) DRUGS 40 Other Drugs (Hormonal & Non-Hormonal) 28 Endometriosis Drugs 28 MISCELLANEOUS PRODUCTS 41 Progestinal Drugs 28 Dependence & Withdrawal Symptom Drugs 41 Androgenic Drugs 28 Smoking Cessation Products 41 Dental Preparations 41 PRESCRIPTION VITAMINS 29 Parasympathetic Drugs 41 Pre-Natal Viatmins 29 Rescue Drugs 41 Iron Deficiency Drugs 29 SPECIALTY DRUG PRODUCTS 42 CORTICOSTEROIDS, THYROID MEDICATIONS 29 Specialty Drug Products 42 Anti-Thyroid & Thyroid Replacements 29 Specialty Program & Limits 42 Corticosteroids / Mineralocoticoids (Systemic) 29 Specialty Drug Product Qualifications 43 METABOLIC DRUGS 30 Antivirals – Hepatitis B (Hep B) 44 Insulins (Synthetic, Human & Inhaled) 30 Antivirals – Hepatitis C (Hep C) 44 Injectible Anti-Diabetics 30 Multiple Sclerosis (MS) 44 GLP-1, GLP-1 / Insulin Combinations 30 Rheumatoid Arthritis (RA) 45 Oral Anti-Diabetics 31 Psoriatic Arthritis & Plaque Psoriasis 45 TZDs, DPP-4 & Combos 31 Ulcerative Colitis (UC) & Crohns Disease (CD) 45 SLGT-2 Inhibitors, SLGT-2 Inhibitors/DPP-4 Combinations 31 Methotrexate & Other UC/CD Drugs 46 Hyperglycemic Drugs 31 Atopic Dermatitis 46 Osteoarthritis 46 DIABETIC PRODUCTS 32 Cholesterol Management (PCSK9/Oythers) 46 Diabetic Supplies (Meters, Strips, Lancets/Devices, Syringes & Supplies) 32 Human Growth Hormones (HGH) 46 Glucose Monitoring Devices 32 Injectible Antipsychotics 46 Insulin Pumps & Supplies 32 Cardiovascular – PAH, HAE, Other Drugs) 47 Extreme Respiratory 47 ANOREXIA DRUGS 32 Immunosuppressants (Transplant & Blood Cell Proliferation) 47 Heparin & Hematopoietic Drugs 48 RESPIRATORY & NASAL DRUGS 33 Osteoporosis 48 Oral Allergy Drugs 33 Cataplexy/Narcolepsy 48 Allergy Medications, Asthma Drugs 33 Infertility 48 Glucocorticoid Steroids / Inhaled & for Nebulization 33 Interuterine Devices 48 Leukotriene Inhibitors 34 Sickle Cell Anenia Treatments 49 COPD Drugs 34 Other Drugs 49 Nasal Polyps 34 MISCELLANEOUS NOTES 50 DERMATOLOGICAL (SKIN) DRUGS 35 Acne, Rosecea & Seborrhea Products (Oral & Topical) 35 CLINICAL GUIDELINES 51 Antifungals (Oral & Topical) 35 Psoriasis Drugs (Oral & Topical) 36 Keratolytic Drugs 36 Scabies & Pediculosis Drugs 36 Topical Immuno Drugs (Non-steroidal) 36 Atopic Dermatitis 37 Topical Local Anesthetics & Analgesics 37 Hyperhydrosis 37 Other Topical Products 37

PREFERRED DRUG LIST 3 Overview Compounded Drugs

The Clinically Preferred Drug List or “PDL” is a continually updated list Our Pharmacy & Therapeutics Committee (“P&T Committee”) has of prescription medications that represents the current clinical judgement recommended against the coverage of compounded products. This of our clinical team, providers and experts in the diagnosis and treatment decision was based on our research that compounds are not currently of different diseases. It contains clinical prescribing information that FDA approved as indicated for therapeutic use. Compounds have not assists health care professionals when prescribing the highest quality passed the standards of clinical safety nor clinical efficacy that the FDA affordable drugs to patients. The PDL represents the efforts of our clinical has set for authorization to be used in human diseases. Furthermore, team to a method to evaluate the various drug products available. Note due to ongoing reports concerning compounded pharmacy products that not all drugs that are available are listed in this document … just causing harm for their intended patients, the P&T Committee has decided those that are the most commonly dispensed by general practitioners and to take a prudent position against approval of compounding products to specialists. There are thousands of generic drugs for effective products keep the safety and best interests of our members as its highest priority. that are readily available not listed in this book. The PDL shows both If you have any questions, please contact your account executive. generic and brand names for reference and convenience. Some plan sponsors, HMOs or Health Plans, Unions or Employers may be provided While the P&T Committee does not recommend the use or coverage of with the option of imposing further restrictions or choose not to reimburse compounds, we maintain that every patient has the right to order, and some products listed in the PDL. pharmacies have the right to dispense, compounded drugs at their own risk and expense. Please note that some plan benefits may opt to include Additionally, as drug prices increase, new specialty drugs are released, them on a limited basis. and brand drugs lose patent, limiting drug selection to preferred products (generics, brands, as well as specialty) has become more critical. Our clinicians work to manage a balanced formulary, offering the best clinical Drug Placement Determination products based on (1) safety, (2) efficacy, (3) availability, (4) lowest potential for abuse, (5) limited side effects, (6) viable clinical alternatives, New Drugs are constantly being developed and approved by the FDA for (7) patient educational needs & availabilty, and finally (8) cost. While a the treatment of the different disease states. Due to vast availability of very high percentage of plan designs follow this formulary, some small medication therapies and treatments, a reasonable process of drug percentage may make plan design modifications and/or apply their own selection and drug usage has been developed. The goal of the PDL is to clinical management parameters. enhance the physicians’ and pharmacists’ abilities to provide optimal cost-effective drug therapies to patients.

Coverage Limitation The development, maintenance, and improvement of the PDL are evolutionary processes that require the constant attention of our P&T The PDL does not provide information regarding specific coverage, Committee. As stated above, the PDL is a continually reviewed and limitations or exclusions, member out-of-pocket costs (known as revised list of drug products that mirrors the prevailing clinical opinion of “member contributions” or more commonly “copays”) that may be the P&T Committee. Unfortunately, this dynamic process does not allow assigned at plan level. The PDL applies to out-patient drugs provided to this document to be completely accurate in official print at all times. members, and does not apply to medications used in the in-patient setting Updates are provided as necessary through newsletters and updates (with the exception of some physician administered office products). All made readily available on the Internet for members, physicians, applicable dosage forms and strengths of a particular drug are included pharmacists and plan sponsors. in the PDL under the specific entry unless otherwise noted and listed separately.

PREFERRED DRUG LIST 4 New Drugs being considered for formulary inclusion will be reviewed for Brand drugs that are crossed out (i.e. Drug Name) are no longer their safety, efficacy, FDA-approved indications, contraindications, side marketed but are available generically. effects, pharmacokinetic profile, patient compliance potential, drug cost and effects on other indirect health costs. A thorough medical literature Exclusions & Grandfathering: Patients on continuous therapy of a Non- review will place an emphasis on the following characteristics: Preferred brand that may excluded or is in a higher formulary tier may continue to take these drugs at the Preferred Brand copay until therapy  Safety and Effectiveness of Product is discontinued (called "grandfathering"). Restart of such brand drugs  Potential for Patient Clinical or Utilization Abuse may require restart of therapy and may be charged the higher Non-

 Comparison Studies with Similar Products if available Preferred Brand copay.

 Therapeutic Outcomes and Economic Data

Drugs that are given a "priority" review by the FDA will be reviewed for Generic Substitution possible inclusion into the formulary in as little as 7 days if necessary. New drugs will have their characteristics compared to other similar drugs Whenever available, lower cost generic drugs approved by the FDA within a therapeutic class when available. New drugs that are added to should be used regardless of the brand name indicated. Generic drugs an existing therapeutic class may result in the deletion of other drug(s) provide the patients with a more cost effective, chemically and within the particular therapeutic class as clinical applications warrant. therapeutically equivalent option that can reduce the patient’s out of This process ensures the selection of the most clinically useful and cost- pocket cost. Generic drugs will be listed in the “Generic Drugs” column, effective drugs within a specific therapeutic class. or in parenthesis next the brand drug name in the “Preferred Brands” or “Non-Preferred Brands” columns. The brand drugs listed under the “Generic Drugs” column are for reference only, do not have a generic Preferred Brand Products copay, and do not guarantee coverage. This statement is not meant to preclude or override any state statutes that may exist (e.g., Non- Brand drugs (listed in bold) that are added to the PDL in the “Preferred Substitutable Drugs). Inclusion of a brand drug for generic substitution is Brand” column include those that offer a clinical and/or cost advantage subject to the following: over other existing comparable brand drugs (listed under “Non-Preferred  An FDA Rating of "A" for generic equivalency as well as thorough Brands”) without sacrificing safety or effectiveness. Drugs will not be review by the P&T Committee for efficacy and safety placed in either column if there currently is insufficient clinical evidence of its appropriate clinical effectiveness.  A narrow therapeutic index that makes it not subject to substitution due to complex pharmacokinetics, dosage forms, etc. Brand drugs, whose generic form is also listed in the “Generic Drugs” column, should be considered as Non-Preferred brands as there have readily available generic equivalents. Brand drugs listed in the “Generic Drugs” column that have a caret (‘^’) are considered Preferred Brands Single & Dual Source Generics with preferred brand copays. Brand drugs listed in the “Generic Drugs” column that have a hash or pound sign (‘#’) are brand drugs with generic Upon patent expiration, brand drugs become available from one or more copays. Copays as always are part of the member’s defined benefits and generic manufacturers. If the brand drug becomes available from only vary by plan for brands and generics for standard and specialty drugs. one generic manufacturer – typically for an exclusivity period or when other competing generics are removed from the market – the generic drug Brand drugs that may vary from formulary to formulary are notated with is called a “Single Source Generic” or SSG. If a brand drug becomes an asterisk (*). Brand drugs that have RECOMMEND next to their name may available from two (2) manufacturers, the generic drugs are called “Dual not have any tier limitations in place, although they are subject to the Source Generics” or DSG; if a brand drug is available from many generic copay tier assigned.

PREFERRED DRUG LIST 5 manufacturers, it is then called a “Multi-Source Brand” or MSB, while the Step Edits: Many drugs on the PDL may have specific step edits or generic drugs are called “Multi-Source Generics” or MSG. quantity limits. A “step edit” is the process where another drug may be required to be used first before the prescribed drug is covered. Such While a generic drug is a SSG or DSG, its price may only be slightly drugs requiring use of another drug before it can be dispensed will be cheaper than the original equivalent brand drug. During this time, at the indicated in this PDL with an S/E or an S/E-2. clinical team’s recommendation, the SSG or DSG may be priced according to one of the following algorithms: Quantity Limits: Our clinical team strongly recommends that some method of utilization compliance, including quantity limits, be placed on  GENERIC discount with a GENERIC copay many drugs. Many products may have quantity limits implemented in

 GENERIC discount with a BRAND copay your plan benefit design that are consistent with their FDA approved package insert or appropriate clinical guidance to control utilization. They  BRAND discount with a GENERIC copay are not specifically marked in this PDL.

 BRAND discount with a BRAND copay More information on specialty drug restrictions are detailed at the end of this PDL.  NDC blocked so that the member must buy the BRAND at the full cash price (100% copay) with our discounts being applied 100% Copay vs. Excluded Drugs

Prior Authorizations, Step Edits & Quantity Limits Our P&T Committee and clinicians believe that drug exclusions limit the choice of physicians and patients in treating specific conditions. Some Prior Authorization: Some brand drugs may require approval called “prior drugs are manufactured simply for patient convenience at a much higher authorization” before the prescription can be dispensed. If a drug requires price than available equivalent generic drugs, or have other brand drug prior authorization, it may be noted in this PDL with either a P/A or P/A Req’d. options available at a much lower net cost. To maintain a complete Note that your plan may also restrict specific drugs and require a Prior patient profile of drugs, managed clients should not exclude the drugs Authorization that may not be shown on this PDL. indicated with 100% Copay but instead cover them at the 100% copay to the patient, with strong encouragement that the patient use manufacturer When a Prior Authorization is required, one or more of the following copay cards to reduce the patient’s out of pocket costs. If a patient is criteria must be fulfilled before the Prior Authorization will be issued: already on one of the drugs listed with a star(*), therapy should be 1. Patient must have failed an appropriate trial of generics or other continued at the non-preferred copay. clinically Preferred Brand drugs (“step edit” – see below). The list includes but is not limited to:

2. Use of a Preferred Brand drug(s) may cause documented Auvi-Q Dyloject Noxafil Steglujan* underlying conditions or side effects, which would be detrimental Cambia* Edecrin Pexeva Taperdex to the patient’s health. Carospir Soln Epaned Prexxartan Tivorbex Conjupri Evzio Qbrelis Soln Treximet 3. The treatment algorithim for that disease state is being followed Consensi Fortamet ER Riomet Vimovo according to the generally accepted published guidelines or the Cycloset Glumetza Sitavig Vivlodex protocol in the FDA approved package insert. Duexis Katerzia Soln Segluromet* Yosprela Durlaza Millipred Pak Steglatro* Zorvolex 4. A more cost effective, clinically equivalent agent is available as the Preferred Brand Drug.

PREFERRED DRUG LIST 6

 “No Clinically Meaningful Differences” means that the Non-Listed Drugs & Drug Categories manufacturer must demonstrate that its proposed biosimilar product has no clinically meaningful differences from the original Drug categories that are not specifically listed in the book are generally brand drug in terms of safety, purity, and potency (safety and categories of lower utilization where generic products are readily effectiveness). available (i.e. cough & cold) and shall be driven by plan design if covered. A specific brand drug may be “preferred”, “non-preferred” or “non- formulary” depending on the class. Changes to the PDL

Additionally, if a specific drug is not listed in the PDL, the drug is The following changes have been or will be implemented on the date categorized under a general statement (such as that of HIV products on shown. Placement of new drugs can be found in the formulary newsletter. page 9), is covered under a medical benefit due to the location of administration, or is in a therapeutic class generally not seen in managed Drug Disease State Date Change care. Oral products (other than oral oncology drugs) that are not listed Glucocard Shine Meters & Strips 04/01/2020 Moved to Tier 2 should be considered as having a Non-Preferred brand copay. TRUETrack Meters & Strips 04/01/2020 Moved to Tier 3

TRUETest Meters & Strips 04/01/2020 Moved to Tier 3 Formulary Modifications & Changes Onzetra XSail Migraines 04/01/2020 Moved to Tier 2 Otezla Plaque Psoriasis 06/01/2020 Stop New Starts Changes may be made to this PDL at any time based on availability or Silenor ++ Sleeping Aid 05/15/2020 Moved to Tier 3 market conditions. Drugs approved by the FDA are added as Non- Preferred Brands with the same restrictions as other Non-Preferred ++ Generic Now Available Brands in the same clinical equivalent drug class until they are reviewed by the P&T Committee unless the clinical team determines that the product is a “line extension”. Drugs that are NOT listed in this book when the competitors are should be considered as excluded, not covered, or non-preferred drugs.

Biosimilars

The FDA acknowledges a biosimilar drug as a specialty product that is highly similar to and has no clinically meaningful differences from an existing FDA-approved reference product, and listed in the FDA Purple Book, with the following definitions:

 “Highly Similar” means that a manufacturer developing a proposed biosimilar demonstrates that its product is highly similar to the original brand drug product by extensively analyzing (i.e., characterizing) the structure and function of both the reference product and the proposed biosimilar.

PREFERRED DRUG LIST 7 Antibiotics

GENERIC DRUGS PREFERRED BRANDS NON- PREFERRED BRANDS

Penicillins & Cephalosporins ANTIBIOTICS Multiple Generics available for Prescribing Cedax (Ceftibuten) Spectracef (Cefditoren Pivoxil) Suprax (Cefixime) S/E

W1 Tetracyclines Doxycycline (various) / Doryx, Vibramycin Acticlate (Doxycycline Hyclate) Minocycline / Minocin, Dynacin, Solodyn’^ Oracea (Doxycycline Monohydrate)

Multiple Generics available for Prescribing W1 Macrolides, Clindamycins & Ketolides Multiple Generics available for Prescribing Ketek (Telithromycin)

W9 Sulfonamides, Sulfones & Nitrofurantoins Multiple Generics available for Prescribing Furadantin Liquid (Nitrofurantoin)

W2 Quinolones Ciprofloxacin / Cipro, Cipro XR Baxdela (Delafloxacin) S/E Levofloxacin / Levaquin Factive (Gemifloxacin) Moxifloxacin / Avelox Noroxin (Norfloxacin) Ofloxacin / Floxin W1 Miscellaneous Antibiotics Vancomycin / Vancocin Dificid’ (Fidaxomycin~) FirVanq (Vancomycin) Linezolid / Zyvox W1

8 Antivirals

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS General Antivirals Antivirals/Herpes/Shingles/Pox: Antivirals/Herpes/Shingles/Chicken Pox: Antivirals/Herpes/Shingles/Chicken Pox: Acyclovir / Zovirax Shingrix (Zoster Vaccine, Recombinant) Sitavig (Acyclovir) 100% Copay Amantadine / Symmetrel Zostavax (Zoster Vaccine, Live) Prevymis (Letermovir) P/A Req’d Famciclovir / Famvir Ganciclovir / Cytovene Valacyclovir / Valtrex Valganciclovir / Valcyte Jynneous (Small Pox, Monkeypox, Live) W5

Flu Treatment/Flu Prevention: Flu Treatment/Flu Prevention: Flu Treatment/Flu Prevention: Oseltamivir / Tamiflu Relenza (Zanamivir) Rimantadine / Flumadine Xofluza (Baloxavir Marboxil) W5 HIV Antiviral Drugs Multiple Generics available for Prescribing All Other Single Source Brand HIV Antiviral Drugs All Multi-Source Brand HIV Antiviral Drugs

W5 HIV Pre-Exposure Prophyaxis Drugs Tenofovir/Emtricitabine / Truvada S/E/P/A Req’d Truvada (Emtricitabine/Tenofovir Disproxil (TDF)) Descovy (Emtrictabine/Tenofovir Alafenamide)

W5

9 Anti-Infectives

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anaerobic Anti-Infectives Metronidazole / Flagyl Paromomycin Sulfate / Humatin Tinidazole / Tindamax W4 Antiparasitics Alinia (Nitazoxanide) Egaten (Triclabendazole) W4 Antimalarials & Antiprotozoals Atovaquone/Proguanil / Malarone Arakoda (Tafenoquine) Hydroxychloroquine / Plaquenil Daraprim (Pyrimethamine) 100% Copay Mefloquine / Lariam Quinine Sulfate / Qualaquin W4 Antihelmintic Drugs Ivermectin / Stromectol Albenza (Albendazole) Biltricide (Praziquantel) Emverm (Mebendazole) W4

Antiemetics

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Antiemetics (Assorted Use) Aprepitant / Emend Bonjesta ER’ (Doxylamine Succinate/Vitamin B6) Akynzeo (Netupitant/Palonosetron) P/A Req’d Dronabinol / Marinol Transderm-Scop Patch (Scopalamine) Anzemet (Dolasetron) Granisetron / Kytril Cesamet (Nabilone) Meclizine / Antivert, Vertin Sancuso Patch (Granisetron) P/A Req’d Ondansetron / Zofran, Zofran ODT Sustol Injectible (Ganisetron) P/A Req’d Doxylamine/Pyridoxine / Diclegis Syndros Oral Solution (Dronabinol) P/A Req’d Prochlorperazine / Compazine Varubi (Rolapitant) Promethazine HCL / Phenergan, Promethegan Supp. Zuplenz Film (Ondansetron) Trimethobenzamide / Tigan H6

10 Neurologic: Parkinsons & Migraine Drugs

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anti-Parkinsons Drugs Amantadine / Symmetrel Apokyn Injectible (Apomorphine) Benzotropine / Cogentin Banzel (Rufinamide) Bromocriptine / Parlodel Duopa Susp. IV (Carbidopa/Levodopa) P/A Req’d Carbidopa/Levodopa / Sinemet/CR, Parcopa Imbrija Inhaler (Levodopa) P/A Req’d Carbidopa/Levodopa/Entacapone / Stalevo Neupro Patch (Rotigotine) Entacapone / Comtan Nutrianz (Istradetylline) Pramipexole / Mirapex, Mirapex ER Osmolex ER (Amantadine) Rasagiline / Azilect Peganone (Ethotoin) Ropinirole / Requip, Requip XL Rytary ER (Carbidopa/Levodopa ER) S/E Tolcapone / Tasmar Zelapar ODT (Selegiline) H6

Parkinsons Motion/Dyskinesia Drugs: Parkinsons Motion/Dyskinesia Drugs: Parkinsons Motion/Dyskinesia Drugs: Gocovri’ (Amantadine) Xadago’ (Safinamide) H6

Psychosis Drugs: Psychosis Drugs: Psychosis Drugs: Nuplazid (Pimavanserin) P/A Req’d H8 Anti-Migraine Drugs Triptans: Triptans: Triptans: Sumatriptan Tablets & Injectibles / Imitrex Onzetra Xsail’ (Sumatriptan Nasal) Alsuma Inj, Sumavel Dosepro (Sumatriptan) S/E Sumatriptan / Naproxen Sodium Treximet 100% Copay Imitrex Spray (Sumatriptan) S/E Tosymra Nasal Spray (Sumatriptan) S/E {ALL Generic TRIPTAN Tablets} Zembrace SymTouch (Sumatriptan) P/A Req’d Zomig Nasal Spray only (Zomitriptan) S/E

CGRP (Prevention): CGRP (Prevention): CGRP (Prevention): Ajovy’ Injector (Fremanezumab) Clinical P/A Aimovig Injector (Erenumab) NDC Block Emgality’ Injector (Galcanezumab~) Clinical P/A

CGRP (Acute Treatment): CGRP (Acute Treatment): CGRP (Acute Treatment): Reyvow (Lasmiditan) Clinical P/A Nurtec-ODT (Rimegepant) Clinical P/A Ubrelvy (Ubrogepant) Clinical P/A

Other Drugs: Other Drugs: Other Drugs: Ergotamine / Ergomar Botox (OnabotulinumtoxinA) Medical/Specialty Ergotamine/Caffeine / Cafergot Cambia Powder (Diclofenac Potassium) 100% Copay Dihydroergotamine/ DHE 45, Migranal Nasal GammaCore Device – VNS H3

11 Neurologic: Alzheimers, Anticonvulsants & Antiepileptics

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Alzheimer’s Drugs Donepezil / Aricept/ODT Namzaric (Memantine/Donepezil) S/E Galantamine / Razadyne/ER Memantine /Namenda/XR Pyridostigmine / Mestinon Razadyne / Reminyl, Reminyl ER Rivastigmine / Exelon Capsules/Patches H1/J1 Anticonvulsants & Anti-Epileptics Anti-Convulsants Anti-Convulsants Anti-Convulsants Carbamazepine / Carbatrol, Tegretol Aptiom (Eslicarbazepine) P/A Req’d Clonazepam / Klonopin Celontin (Methsuximide) S/E Divalproex Sodium / Depakote/ER/Sprinkles Diacomit (Stiripentol) S/E [Dravet] Gabapentin / Neurontin Diastat Acu-Dial Gel (Diazepam) P/A Req’d Lamotrigine / Lamictal, Lamictal XR, Lamictal ODT Equetro (Carbamazepine) S/E Oxcarbazepine / Trileptal Fycompa (Perampanel) S/E Pregabalin / Lyrica Lyrica CR (Pregabalin) P/A Req’d Topiramate / Topamax, Qudexy XR Nayzilam Nasal Spray (Midazolam) Valproic Acid / Depakene Oxtellar XR (Oxcarbazepine) P/A Req’d Potiga (Ezogabine) S/E (Many other Generic Products are Available) Sabril (Vigabatrin) S/E Stavzor (Valproic Acid) P/A Req’d Trokendi XR (Topiramate) P/A Req’d Valtoco Nasal Spray (Diazepam) P/A Req’d Vimpat (Lucosamide) P/A Req’d Xcopri (Cenobamate) S/E

Anti-Epileptic Drugs Anti-Epileptic Drugs Anti-Epileptic Drugs Levetiracetam / Keppra, Keppra XR Dilantin 30mg ONLY (Phenytoin) Briviact (Brivaracetam) S/E Phenytoin / Dilantin Spritam’ (Levetiracetam) S/E Elepsia XR (Levetiracetam) P/A Req’d Phenytoin Sodium / Phenytek H2/H4 Fibromyalgia, Neuropathic & PHN** Drugs Duloxetine / Cymbalta Gralise (Gabapentin) Gabapentin / Neurontin Lyrica CR (Pregabalin)** Lidocaine Patch 5% Savella (Milnacipran) Pregabalin / Lyrica ZTLido (Lidocaine Patch)** H4/H7 Restless Leg Syndrome (RLS) Drugs Pramipexole / Mirapex Horizant (Gabapentin Enacarbil) Ropinirole / Requip, Requip XL Neupro Patch (Rotigotine) H6 ** - Post-Herpatic Neuralgia Pain (PHN)

12 Blood Modifiers

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anticoagulants /Anti-10A/Thrombin Inhibitors Warfarin Sodium / Coumadin Eliquis’ (Apixaban) Savaysa (Edoxaban Tosylate) Heparin Sodium Pradaxa’ (Dabigatran Etexilate) Xarelto 2.5mg, 15mg, 20mg’ (Rivaroxaban) & Xarelto Starter Pak – all’ M9 Heparin-Related Drugs / DVT Eliquis’ (Apixaban) Bevyxxa (Betrixaban) Pradaxa’ (Dabigatran Etexilate) Savaysa (Edoxaban Tosylate) Xarelto 10mg’ (Rivaroxaban) M9 Platelet Aggregation Inhibitors / ACS Anagralide / Agrylin Brilinta’ (Ticagrelor) Durlaza ER (Aspirin) 100% Copay Cilostazol / Pletal Clopidogrel / Plavix Dipyridamole / Persantine Dipyridamole & Aspirin / Aggrenox Pentoxifylline / Trental Prasugrel / Effient M9 / N1 Other Drugs Aminocaproic Acid / Amicar Zontivity (Vorapaxar) Tranexamic Acid / Lestyda M9

13 Cardiovascular: Alpha/Beta Blockers & CCBs

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Alpha & Beta Blockers Alpha Blockers Alpha Blockers Alpha Blockers Doxazosin / Cardura Dibenzyline (Phenoxybenzamine) Prazosin / Minipress Terazosin / Hytrin J7

Beta Blockers Beta Blockers Beta Blockers Acebutolol / Sectral Bystolic’ (Nebivolol) Innopran XL (Propranolol) Atenolol / Tenormin Sotylize Solution (Sotalol) 100% Copay Betaxolol / Kerlone Bisoprolol / Zebeta Metoprolol / Lopressor, Toprol/XL Nadolol / Corgard Pindolol / Visken Propranolol / Inderal XL/LA Sotalol / Betapace/AF Timolol / Blocadren J7

Alpha-Beta Blocker Combinations Alpha-Beta Blocker Combinations Alpha-Beta Blocker Combinations Carvedilol / Coreg, Coreg CR Labetolol / Normodyne, Trandate J7 Antihypertensive Combinations, Misc. Atenolol/Chlorthalidone / Tenoretic Dutoprol (Metoprolol Succinate/HCTZ) Bisoprolol/HCTZ / Ziac Metoprolol/HCTZ/ Lopressor HCT Nadolol/Bendroflumethiazide / Corzide J7 Calcium Channel Blockers: Amlodipine / Norvasc Cardene SR (Nicardipine) Diltiazem / Cardizem/CD/LA Conjupri (Levamlodipine) 100% Copay Diltiazem / Dilacor XR, Diltia XT, Tiazac ER Consensi (Celecoxib/Amlodipine) 100% Copay Felodipine / Plendil Katerzia Solution (Amlodipine) 100% Copay Isradipine / Dynacirc Nymalize Solution (Nimodipine) 100% Copay Nicardipine / Cardene Nifedipine / Adalat/CC, Procardia/XL Nimodipine / Nimotop Nisoldipine / Sular Verapamil / Calan/SR, Covera/HS, Isoptin/SR, Verelan/PM A9

14 Cardiovascular: ACE, ARBs & Diuretics

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS ACE Inhibitors with/without Diuretics Benazepril / Lotensin (Lotensin HCT) Epaned Solution (Enalapril) 100% Copay Captopril / Capoten (Capozide) Qbrelis Solution (Lisinopril) 100% Copay Enalapril / Vasotec (Vaseretic) Fosinopril /Monopril (Monopril HCT) Lisinopril / Prinivil (Prinzide), Zestril (Zestoretic) Moexipril / Univasc (Uniretic) Quinapril / Accupril (Accuretic) Perindopril Erbumine / Aceon Ramipril / Altace Trandolapril / Mavik A4 ACE Inhibitor / CCB Combination Benazepril/Amlodipine / Lotrel (all other strengths) Prestalia (Amlodipine / Perindopril) S/E Trandolapril/Verapamil /Tarka A4 ARBs without & with Diuretics

Candesartan, Candesartan HCTZ / Atacand, Atacand HCT Edarbi', Edarbyclor' (Azilsartan/Chlorthalidone) Prexxartan Solution (Valsartan) 100% Copay Irbesartan, Irbesartan HCTZ / Avapro, Avalide Losartan, Losartan HCT / Cozaar, Hyzaar Olmesartan/HCT / Benicar, Benicar HCT Telmisartan, HCTZ / Micardis, Micardis HCT Valsartan, Valsartan HCTZ / Diovan, Diovan HCT A4 ARB Combinations Olmesartan/Amlodipine/HCT / Azor, Tribenzor Byvalson’ (Valsartan/Nebivolol) Telmisartan/Amlodipine / Twynsta Valsartan/Amlodipine/HCT / Exforge/HCT A4 Naprilysin Inhibitors Entresto’ (Naprilysin/Valsartan) A4 Diuretics Chlorothiazide / Diuril Carospir Solution (Spironolactone) 100% Copay Chlorthalidone / Hygroton Dyrenium (Triamterene) Furosemide / Lasix Edecrin (Ethacrynic Acid) 100% Copay Indapamide / Lozol Spironolactone/HCTZ / Aldactone, Aldactazide Triamterene / HCTZ / Dyazide, Maxzide

(Various other Generics) R1

15 Cardiovascular: Anti-Arrhythmia & Vasodilators

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Renin Inhibitors & Combinations## Tekturna/HCT’ (Aliskiren Hemifumarate/HCT) A4 Antiarrhythmics / Anti-Ischemic Amiodarone / Pacerone Multaq (Dronedarone) Disopyramide / Norpace/ Norpace CR 150mg Norpace CR 100mg (Disopyramide) Dofetilide / Tikosyn Ranexa ER (Ranolazine) Propafenone / Rythmol, Rythmol SR A2 Cardiac Glycosides Digoxin / Lanoxin A1 Vasodilators, Coronary, Nitrates Isosorbide Dinitrate / Isordil, Sorbitrate Bidil (Isosorbide Dinitrate/Hydralazine) Isosorbide Mononitrate’ / Imdur ER

Nitroglycerins Nitroglycerins Nitroglycerins Nitroglycerin (Patch) / Nitro-Dur, Minitran Nitrostat (Nitroglycerin Oral) Gonitro (Nitroglycerin Sublingual) Nitroglycerin Mist / NitroMist Spray, Nitrolingual Spray Nitro-BID Ointment (Nitroglycerin) A7 Vasodilators, Sympatholytics Clonidine / Catapres, Catapres TTS Patch Guanfacine / Tenex Hydralazine / Apresoline Methyldopa / Aldomet Methyldopa/HCTZ / Aldoril A4 Other Drugs Corlanor (Ivabradine) Northera (Droxidopa) Vecamyl (Mecamylamine)

## Note special warnings on use of Aliskiren containing products in treatment of diabetics

16 Cholesterol: Statins, Fibrates & Others

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Statins& Statin/CCB Combinations Atorvastatin / Lipitor Zypitamag’ (Pitavastatin) S/E Livalo (Pitavastatin) 2-S/E Atorvastatin/Amlodipine / Caduet Ezetimibe/Simvastatin / Vytorin Fluvastatin / Lescol, Lescol XL Lovastatin / Altoprev, Mevacor Pravastatin / Pravachol Rosuvastatin / Crestor Simvastatin / Zocor M4 Bile Acid Sequestrants/Liver Drugs BAS BAS BAS Cholestyramine / Questran Colesevelam / Welchol Colestipol / Colestid M4

Liver Drugs Liver Drugs Liver Drugs Ursodiol / Actigall, Urso/Urso Forte D7 Fibrates & Other Drugs Gemfibrozil / Lopid Lipofen’ (Fenofibrate, micronized) Fenofibric Acid –Choline / Fibricor, TriLipix Fenofibrate, micronized / Antara, Fenoglide Fenofibrate, nanocrystalized / Tricor, TriGlide

Other Drugs Other Drugs Other Drugs Ezetimibe / Zetia Vascepa’ (Icosapent Ethyl) Niacor (Niacin) Slo Niacin / Niacin, Niaspan ER Omega-3 Acid Ethyl Esters & Lovaza S/E M4

17 Pancreative Drugs & Urological: Diuretics, BPH, OAB & E/D

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Pancreatic Drugs Creon’ (Lipase/Protease/Amylase) Pancreaze (Lipase/Protease/Amylase) Zenpep’ (Lipase/Protease/Amylase) Pertyze, Viokase (Lipase/Protease/Amylase) D8 Benign Prostate Hyperplasia Alpha Blockers Alpha Blockers Alpha Blockers Alfuzosin / Uroxatral Cardura XL (Doxazosin Mesylate) Doxazosin / Cardura Prazosin / Minipress Silodosin / Rapaflo Tamsulosin / Flomax Terazosin / Hytrin J7/Q9

5 Alpha Reductase Inhibitors 5 Alpha Reductase Inhibitors 5 Alpha Reductase Inhibitors Finasteride / Proscar Dutasteride / Avodart Dutasteride/Tamsulosin / Jalyn Q9

Phosphodiesterase-5 Enzyme Inhibitors Phosphodiesterase-5 Enzyme Inhibitors Phosphodiesterase-5 Enzyme Inhibitors Tadalafil / Cialis 5mg Only F2 Urologic Drugs Overactive Bladder Overactive Bladder Overactive Bladder Anti-Cholinergics Oxybutynin / Ditropan XL Myrbetriq' (Mirabegron) Gelnique (Oxybutynin) S/E Darifenacin / Enablex Oxytrol Patch (Oxybutynin) Solifenacin Succinate / VESICare Toviaz (Fesoterodine Fumarate) S/E Tolterodine / Detrol,Detrol LA Trospium / Sanctura, Sanctura XR R1

Other Drugs Other Drugs Other Drugs Desmopressin Acetate / DDAVP Elmiron (Pentosan Polysulfate) Flavoxate / Urispas Nocdurna SL (Desmopressin) Phenazopyridine / Pyridium Noctiva Niasal Spray (Desmopressin) P/A Req’d R5/P2 Erectile Dysfunction Drugs Sildenafil / Viagra S/E Stendra’ (Avanafil) Staxyn (Vardenafil) S/E Tadalafil / Cialis S/E Caverject, Edex (Alprostadil) Vardenafil / Levitra S/E Muse (Alprostadil) S/E F2

18 Urological: Gout, PH / K Modifiers & Depleters

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Gout Drugs

Orals Orals Orals Allopurinol / Zyloprim Colcrys’ (Colchicine) Duzallo (Lesinurad+Allopurinol) Febuxostat / Uloric Gloperba Solution (Colchicine) 100% Copay Probenecid / Benemid, Col-Bemenid Mitigare (Colchicine) Zurampic (Lesinurad)

Topicals Topicals Topicals ColciGel’ (Colchicine Gel) C7 Urinary Ph Modifiers Potassium Citrate + Citric Acid / Citra-K K-Phos MF, N° 2 (Sod. Phos/Pot. Phos) Potassium Citrate / Urocit-K Renacidin (Mag Carb/Citric Acid/Lact) Potassium Acid Phosphate / K-Phos Original R1 Potassium & Electrolytes Potassium Bicarbonate / Effer-K Klor-Con (Potassium Chloride) Potassium Bicarb+Potassium Citrate / K-Lyte Micro-K (Potassium Chloride) Potassium Gluconate / Kaon Potassium Chloride / KTab ER# Potassium Phosphate / K-Phos C1/R1 Phosphorus/Calcium/Electrolyte Depleters Calcium Acetate / PhosLo, Eliphos HP Lokelma’ (Sodium Zirconium Cyclosilicate) HK Auryxia (Ferric Citrate) HP Lanthanum Carbonate / Fosrenol HP Phoslyra Oral Solution' (Calcium Acetate) HP Kionex (Sodium Polystyrene Sulfonate) HK Sevelamer Carbonate / Renvela HP Velphoro’ (Sucroferric Oxyhydroxide) HP Veltassa Oral Susp (Patiromer) HK Sevelamer Hydrochloride / Renagel HP Sodium Polystyrene Sulfonate / Kayexalate HK C1

HC - Hypercalcemia HK - Hyperkalemia HP - Hyperphosphatemia

19 Osteoporosis

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Osteoporosis Drugs / Paget’s Disease Bisphosphonates Bisphosphonates Bisphosphonates Alendronate / Fosamax Binosto Effervescent Tabs (Alendronate) Ibandronate / Boniva 150mg Tablets Fosamax Plus D (Alendronate w/ Vit D) Risedronate / Actonel, Atelvia

Other Drugs Other Drugs Other Drugs Raloxifene / Evista Calcitonin / Miacalcin Nasal Spray P4 Anti-Inflammatory & Pain

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anti-Inflammatory Drugs (NSAID) Diclofenac/Misoprostol / Arthrotec Sprix Spray’ (Ketorolac Tromethamine) Duexis (Ibuprofen/Famotidine) 100% Copay Diclofenac Potassium / Cataflam Dyloject (Diclofenac Sodum) 100% Copay Diclofenac Sodium / Voltaren/XR Tivorbex (Indomethacin) 100% Copay Etodolac / Lodine/XL Vimovo (Naproxen/Esomeprazole IR) 100% Copay Fenoprofen / Nalfon Vivlodex (Meloxicam) 100% Copay Flurbiprofen / Ansaid Yosprala (Aspirin/Omeprazole) 100% Copay Ibuprofen / Motrin Zipsor (Diclofenac Potassium) P/A Req’d Indomethacin / Indocin Zorvolex (Diclofenac) 100% Copay Ketoprofen / Orudis, Oruvail Ketorolac / Toradol Meclofenamate / Meclomen Mefenamic Acid / Ponstel Meloxicam/ Mobic Nabumetone / Relafen Naproxen / Naprosyn/EC, Anaprox DS, Naprelan Oxaprozin / Daypro Piroxicam / Feldene Sulindac / Clinoril Tolmetin / Tolectin DS S2

20 Anti-Inflammatory & Pain

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS COX-II Drugs Celecoxib / Celebrex Consensi (Celecoxib/Amlodipine) 100% Copay S2 Analgesics, Narcotics Opioids Opioids Opioids Dounle Step Edit for Most Orals with MME Check Acetaminophen w/Codeine / Tylenol #3/4 Belbuca Film’ (Buprenorphine) Abstral (Fentanyl Sublingual) Aspirin w/Codeine / Empirin #2/3/4 Butrans Patch’ (Buprenorphine) ►Arymo ER’ (Morphine Sulfate) Codeine/Acetaminophen/Butalbital/Caffeine / Fiorinal #3 ►Oxycontin’ (Oxycodone) Conzip Caps (Tramadol HCL) Codeine/Aspirin/Butalbital/Caffeine / Fioricet ►Zohydro ER’ (Hydrocodone) ►Embeda (Morphine Sulfate/Ntxn) ► Fentanyl Citrate / Duragesic Patches, Actiq Hysingla ER (Hydrocodone Bitartrate) Hydrocodone/Acetaminophen / Vicodin, Norco Lazanda Nasal Spray (Fentanyl) P/A Req’d ► Hydromorphone / Dilaudid, Exalgo/Exalgo ER MorphaBond ER (Morphine Sulfate) Meperidine / Demerol Nucynta/ER (Tapentadol) Morphine Sulfate / Roxanol Oxaydo (Oxycodone IR) Morphine Sulfate Extend Release / Avinza RoxyBond (Oxycodone IR) ► Morphine Sulfate Sust Release / Kadian Subsys Spray’ (Fentanyl) NDC BLOCK - P/A Req’d Oxycodone w/Acetaminophen / Percocet Troxyca ER (Oxycodone/Naloxone) S/E, P/A REQD Tramadol (w/ Acetaminophen)/ Ultram/ER, Ultracet ►Xartemis XR (Oxycodone/Acet) NDC BLOCK ►Xtampza ER (Oxycodone)

H3 Analgesics, Salicylates & Non-Salicylates Salicylates Salicylates Salicylates Aspirin / Butalbital / Caffeine/ Fiorinal Durlaza ER (Aspirin) 100% Copay Diflunisal / Dolobid Salsalate / Disalcid

Non-Salicylates Non-Salicylates Non-Salicylates Acetaminophen/Caffeine/Butalbital / Esgic, Fioricet H3

► Note: Denotes Long-Acting Opioid

21 CNS: Anxiety, Sedatives, ADD/ADHD & Narcolepsy

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anti-Anxiety Drugs (Benzodiazepines) All Generics in this Class are Preferred All Brands in this Class are Non-Preferred

H6 Sedatives/Sleeping Aids Doxepin / Silenor Tier 3 eff 05/15/2020 Belsomra (Suvoxerant) S/E Eszopiclone / Lunesta S/E Dayvigo (Lemborexant) S/E Flurazepam / Dalmane Edluar Sublingual (Zolpidem) S/E Quazepam / Doral Hetlioz (Tasimelteon) P/A Req’d Temazepam / Restoril Rozerem (Ramelteon) S/E Triazolam / Halcion Zolpimist Nasal Spray (Zolpidem) P/A Req’d Zaleplon / Sonata S/E Zolpidem / Ambien S/E, Ambien CR S/E, Intermezzo H2/H8 Sedatives/Hypnotics (Barbiturate/CNS) Phenobarbital Butisol (Butabarbital) 100% Copay Seconal (Secobarbital) 100% Copay H2 ADD & ADHD Drugs Atomoxetine / Strattera Adhansia XR (Methylphenidate) S/E Adzenys XR-ODT (Amphetamine) S/E-2 Amphetamine/D-Amphetamine / Adderall, Adderall XR’^ Daytrana Patch’ (Methylphenidate) S/E Adzenys ER Liquid (Amphetamine) S/E-2 Clonidine HCL / Kapvay Mydayis’ (Amphetamine Salts) S/E Amphetamine/D-Amphetamine [SSG] NDC BLOCK D-Amphetamine / Dexedrine QuilliChew ER’ (Methylphenidate) S/E Aptensio XR (Methylphenidate) S/E-2 Dexmethylphenidate / Focalin, *Focalin XR Quillivant XR Suspension’ (Methylphenidate) S/E Cotempla XR-ODT (Methylphenidate) S/E-2 Guanfacine / Intuniv Vyvanse’ (Lisdexamfetamine Dimesylate) S/E Evekeo (Amphetamine Sulfate) S/E-2 Methylphenidate / Concerta, *Concerta ER Dyanavel XR Susp (Amphetamine) S/E Methylphenidate / Desoxyn Methylin Solution (Methylphenidate) S/E-2 Methylphenidate / Ritalin/LA/SR Relexxii ER (Methylphenidate) S/E-2 Methylphenidate / *Metadate CD, *Metadate ER

J5/H7/H2 Excessive Sleepiness / Narcolepsy Armodafinil / Nuvigil Sunosi (Solriamfetol) Modafinil / Provigil H8

* Long-acting Methylphenidates & Amphetamines for ADD/ADHD that require failure of generics prior to approval of a brand. Additionally, Non-Preferred Brands needs a failure of a Preferred Brand prior to approval.

22 CNS: Anti-Depressants & PBA

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Serotonin Specific Reuptake Inhibitors (SSRI) Citalopram / Celexa Trintellix' (Vortioxetine) S/E Pexeva (Paroxetine Mesylate) 100% Copay Escitalopram / Lexapro Viibryd’ (Vilazodone) S/E Fluoxetine / Prozac, Sarafem Fluvoxamine / Luvox/CR Paroxetine / Paxil/CR Sertraline / Zoloft H2 Serotonin Norepinephrine Reuptake Inhibitors Duloxetine / Cymbalta Fetzima’ (Levomilnacipran) S/E Drizalma Sprinkles (Duloxetine) 2-S/E Desvenlafaxine / Pristiq, Khedezla ER Venlafaxine / Effexor XR H7 Other SSRI Combinations Olanzapine/Fluoxetine / Symbyax

H7 Monoamine Oxidase Inhibitors (MAOIs) Phenelzine Sulfate / Nardil Emsam Patches (Selegiline) Tranylcypromine Sulfate / Parnate Marplan (Isocarboxazid) H7/H2 Antidepressants, Other Drugs Amitriptyline / Elavil Forfivo XL' 450mg Only (Bupropion HCL) Aplenzin ER (Bupropion Hydrobromide) S/E Bupropion / Wellbutrin SR/XL Olepto ER (Trazadone) S/E Buspirone / Buspar Clomipramine / Anafranil Desipramine / Norpramin Imipramine / Tofranil/PM Mirtazapine / Remeron, Remeron Soltab Nortriptyline / Aventyl, Pamelor Trazadone / Desyrel

(Over 20 other ‘generic only’ Drugs exist) H2/H7 Pseudobulbar Affect (PBA) Drugs Nuedexta’ (Dextromethorphan/Quinidine) H8

23 CNS: Anti-Psychotics & Bi-Polar

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Antipsychotic Drugs Chlorpromazine / Thorazine ORAP (Pimozide) Fluphenazine / Prolixin Haloperidol / Haldol Loxapine / Loxitane Perphenazine / Trilafon Trifluoperazine / Stelazine Thioridazine / Mellaril Thiothixene / Navane H7 Atypical Antipsychotic Drugs Aripiprazole / Abilify B,S Saphris’ (Asenapine) B,S Abilify MyCite w/ Sensor (Aripiprazole) B,S, P/A Req’d Clozapine / Clozaril, Fazaclo B,S Vraylar’ (Cariprazine) B,S Caplyta (Lumateperone) S Olanzapine / Zyprexa, Zyprexa ZYDIS B,S Fanapt (Iloperidone) 2 S/E, B,S Quetiapine / Seroquel IR B,S, Seroquel XR’ B,S Invega ER (Paliperidone) 2 S/E, B,S Risperidone / Risperdal B,S Latuda (Lurasidone) B,S S/E Ziprasidone / Geodon B,S Rexulti (Brexipiprazole) 2 S/E, M,S Secuado Patch (Asenapine) S Versacloz Susp (Clozapine) H7 Bipolar Disorders (Anti-mania Drugs) Lithium Carbonate / Lithobid Equetro (Carbamazepine) Valproic Acid / Stavzor H2

B - Bi-polar indication S - Schizophrenia indication M - Manic Depressive Disorder indication

Parathyroid Drugs

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Parathyroid Drugs Calcitriol2 / Rocaltrol Natpara1 (Parathyroid Hormone) P/A Req’d Cinacalcet2 / Sensipar Rayaldee2 (Calcifediol) P/A Req’d Doxercaliferol2 / Hectorol Ergocalciferol Drops2 / Drisol Paricalcitol2 / Zemplar C6/P4 1 – Hypothyroidism, 2 – Hyperthyroidism

24 Gastrointestinal: Ulcer, GERD & IBS

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anti-Ulcer /GERD Drugs H2 Antagonists H2 Antagonists H2 Antagonists Generic Drugs Only!!

PPIs** PPIs PPIs Esomeprazole / Nexium Dexilant’ (Dexlansoprazole) Protonix Oral Suspension (Pantoprazole) Lansoprazole / Prevacid Omeprazole / Prilosec Omeprazole w/ Sodium Bicarb / Zegerid 100% Copay Pantoprazole / Protonix Rabeprazole / Aciphex

Other Drugs Other Drugs Other Drugs Metoclopramide / Reglan Enteragam Powder Pak’ (Immune Globulin) Metozolv ODT (Metoclopramide) Sucralfate / Carafate D4/J9/Z2 Bowel & Colon Drugs Inflammatory Bowel Disease/Ulcerative Colitis Inflammatory Bowel Disease/Ulcerative Colitis Inflammatory Bowel Disease/Ulcerative Colitis Mesalamine / Asacol, Rowasa Apriso' (Mesalamine) Asacol HD (Mesalamine) Balsalazide Disodium / Colazal Lialda’ (Mesalamine) Delzicol (Mesalamine) Dipentum (Olsalazine) S/E Mesalamine [Generics for Lialda] Pentasa (Mesalamine) S/E D6/Q3 Irritable Bowel Syndrome (IBS-C, OIC, CIC) Irritable Bowel Syndrome (IBS-C, OIC, CIC) Irritable Bowel Syndrome (IBS-C, OIC, CIC) Senna Glucoside / Senakot (OTC) Amitiza’ (Lubiprostone) IBS-C, OIC, CIC Isbrela (Tenapanor) IBS-C Senna + Docusate / Senna-S (OTC) Linzess’ (Linaclotide) IBS-C Movantik (Naloxegol) OIC – S/E Motegrity’ (Prucalopride) CIC Relistor Tablets (Methylnaltrexone) OIC – P/A Req’d Symproic’ (Naldemedine) OIC Trulance’ (Plecanatide) CIC Zelnorm (Tegaserod) IBS-C

Irritable Bowel Syndrome (IBS-D) Irritable Bowel Syndrome (IBS-D) Irritable Bowel Syndrome (IBS-D) Viberzi’ (Eluxadoline) IBS-D Lotronex (Alosetron) IBS-D Xifaxan 550’ (Rifaximin) IBS-D D6 Other Drugs: Other Drugs: Other Drugs: Budesonide / Entocort EC Aemcolo (Rifamycin) P/A Req’d Diphenoxylate/Atropine / Lomotil Cuvposa (Glycopyrrolate) Glycopyrrolate / Glycate Entereg (Alvimopan) Loperamide / Imodium (OTC) Motofen (Difenoxin/Atropine Sulfate) Mesalamine / Canasa Suppositories Relistor Injectible (Methylnaltrexone) P/A Req’d Uceris Foam & Tablets’ (Budesonide) D6/J2

25 Gastrointestinal: Laxatives & Colon Preps

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Laxatives

Lactulose / Granulose Kristalose’ (Lactulose) Polyethelene Glycol (PEG) 3350 / Merilax D6 Colon Prep Drugs Peg 3350/NA Sulfate,Bicarbonate CL/KCL / Colyte, Moviprep’ (Peg 3350 Solution) Clenpiq Pre-Mix (Sod Picosulf, Mag Ox, Citric Acid) Gavilyte, Golytely Osmoprep’ (Sodium Phosphate Tablets) Gialax (PEG 3350/Sod Chlor/Pot Citrate Solution) Sodium Chloride / Nulytely Plenvu’ (Peg 3350/NA Ascorbate/NA Sulfate++) Halflytely (Sodium Phosphate Solution) Suprep’ (Sodium, Potassium, & Magnesium Sulfate) Prepopik (Sod Picosulf, Mag Ox, Citric Acid) D6 H. Pylori Drugs Lansoprazole/Amox/Clarithromycin / PrevPac Pylera’ (Bismuth/Metronid/Tetracycline) Omeclamox (Omeprazole/Amox/Clarithromycin) Talicia (Omeprazole Mag/Amox/Rifabutin) D4

26 Hormone Therapy: O/Cs & Estrogens

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Contraceptives Orals Orals Orals All Oral Contraceptives flagged as Generic Beyaz’, Yaz’ All Oral Contraceptives flagged as Brand Levonorgesterol / Plan-B+ Natazia’, Safyral’

Other Drugs Other Drugs Other Drugs Generic Products All Other formulations flagged as Brand Ethin Estradiol/Etonogestrel / EluRyng, Nuvaring G8 Estrogens / Estrogen Combinations

Orals – Single Orals – Single Orals – Single Estradiol / Estrace Cenestin (Conjugated Estrogen) Estropipate / Ogen, Ortho-Est Menest (Esterified Estrogen) ME-Test/Estrogen/Ester / Covaryx/HS Premarin (Conjugated Estrogen) G1

Orals – Combination Products Orals – Combination Products Orals – Combination Products Annovera’ (Estradiol/Segesterone) Activella, FemHRT, Mimvey (Estradiol/Noreth) Bijuva’ (Estradiol/Progesterone) Angeliq (Estradiol/Drospirenone) Duavee (Conj Estrogens/Bazedoxifene) 100% Copay Prefest (Estradiol/Norgestimate) Prempro, Premphase (Conj. Estrog/Medroxyprog) G1 Patches/Gels Patches/Gels/Pumps Patches/Gels/Pumps Estradiol / Climara Patch Climara Pro Patch’ (Estradiol/Levonorgestrel) Alora Patch (Estradiol) Estradiol / Vivelle/DOT Patch Divigel’ (Estradiol Gel) Combipatch (Estradiol/Norethindrone) Minivelle Patch’ (Lo-Dose Estradiol) Elestrin Gel, Estrogel (Estradiol) S/E New Starts Xulane Patch (Norelgestromin/Estradiol) Evamist Spray (Estradiol) S/E New Starts Menostar Patch (Estrogen) G1 Vaginal (All Forms) Vaginal (All Forms) Vaginal (All Forms) Estradiol / Estrace Cream Osphena’ (Ospemifene) Estring, Femring Ring (Estradiol) S/E New Starts Estradiol / Vagifem Imvexxy (Estradiol) S/E New Starts Premarin Cream (Conj. Estrogen) S/E New Starts Q4

IMPORTANT NOTE - Contraceptive coverage varies by Plan, but most Plans cover generic Oral Contraceptives

27 Hormone Therapy: Androgenics, Progesterones & Fertility

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Endometriosis Drugs Orilissa’ (Elagolix) G1/G8 Other Hormonal & Non-Hormonal Drugs Clomiphene Citrate / Clomid, Serophene Addyi’ (Flibanserin) Brisdelle (Paroxetine Mesylate) Hydroxyprogesterone Capoate Injections / Makena Ella (Ulipristal Acetate) IntraRosa Vaginal Insert (Prasterone) S/E New Starts Vyleesi (Bremelanotide) G1/G8 Progestational Drugs Medroxyprogesterone / Provera Crinone’ (Progesterone, Micronized) Depo-Provera (Medroxyprogesterone) Norethindone Acetate / Aygestin Endometrin Supp (Progesterone, Micron.) Progesterone, Micronized / Prometrium First-Progesterone MC (Progesterone) G2 Androgenic Drugs Oxandrolone / Oxandrin Anadrol-50 (Oxymetholone) S/E Prasterone / DHEA Androderm (Testosterone Patch, Gel) S/E Testosterone / Androgel Gel, Axiron Pump, Fortesta, Jatenzo (Testosterone Undecanoate) S/E Testim Methitest (Methyltestosterone) S/E Testosterone Cypionate / Depo-Testosterone S/E Natesto Nasal Gel (Testosterone S/E) Testosterone Enanthate / Delatestryl Injectible S/E Striant (Testosterone) S/E Testopel Insert (Testosterone) S/E Testred (Methyltestosterone) S/E Vogelxo (Testosterone Gel) S/E Xyosted (Testosterone Enanthate) S/E F1

28 Prenatal Vitamins, Iron Deficiency

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Prenatal Vitamins All Generic Drugs are Covered in Tier 1 All Brand Drugs are Non-Preferred

C6 Iron Deficiency Drugs All Generic Drugs are Covered in Tier 1 All Brand Drugs are Non-Preferred

C3 Metabolic: Thyroid Replacements

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anti-Thyroid & Thyroid Replacements Thyronine (Free T3) Thyronine (Free T3) Thyronine (Free T3) Liothyronine / Cytomel

Thyroxine (Free T4) Thyroxine (Free T4) Thyroxine (Free T4) Levothyroxine / Eurthyrox, Levo-T, Levothroid, Levoxyl, Synthroid (Levothyroxine) Tirosint (Levothyroxine) Unithroid

Mixed Thyronine/ Thyroxine Mixed Thyronine/ Thyroxine Mixed Thyronine/ Thyroxine Nature-Throid (Thyroid, pork) Thyrolar (Liotrix, pork) Westhroid, WP-Thyroid (Thyroid, pork)

Other Drugs Other Drugs Other Drugs Propylthiouracil / Propylthiouracil NP-Thyroid (Thyroid, pork) Methimazole / Tapazole Thyroid, pork / Armour Thyroid P3 Glucocorticoids / Mineralocorticoids Budesonide / Entocort EC Celestone (Betamethasone) Methylprednisone / Medrol Dexpak (Dexamethasone) Prednisone / Deltasone Millipred/Pak (Prednisone ER) 100% Copay Prednisolone / Prednisolone, Prelone Syrup, Pediapred Rayos (Prednisone ER) 100% Copay Taperdex (Prednisone ER) 100% Copay Multiple Generics available for Prescribing P5

29 Diabetes: Insulins & Injectibles

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Insulins Synthetic Insulin Synthetic Insulin Synthetic Insulin Short-Acting (Bolus) Short-Acting(Bolus) Short-Acting(Bolus) Fiasp’ (Insulin Aspart) Humalog (Insulin Lispro) S/E Novolog’ (Insulin Aspart) Admelog (Insulin Lispro) S/E Apidra’ (Insulin Glulisine~)

Long-Acting (Basal) Long-Acting (Basal) Long-Acting (Basal) Lantus’ (Insulin Glargine) Basaglar (Insulin Glargine) P/A Req’d Levemir’ (Insulin Detemir) Toujeo’/Toujeo Max Solostar’ (Insulin Glargine) Tresiba’ (Insulin Degludec)

Mixed Insulin Mixed Insulin Mixed Insulin Novolog Mix’ (Insulin Aspart) Humalog Mix (Insulin Lispro) Basalog Mix (Insulin Glargine)

Human Insulin Human Insulin Human Insulin

Injectible Injectible Injectible Novolin’ (Insulin Aspart) Humulin (Insulin, Assorted)

Basalin (Insulin, Assorted)

Inhaled Inhaled Inhaled Afrezza (Insulin Regular, Human) C4

Injectible Anti-Diabetics GLP-1 GLP-1 S/E Through Metformin GLP-1 S/E Through Metformin Ozempic’ (Semaglutide) Adlyxin (Lixisenatide) Rybelsus Tablets’ (Semaglutide) Bydureon’/Bydureon BCise (Exenatide~) Trulicity’ (Dulaglutide~)# Byetta’ (Exenatide~) Victoza’ (Liraglutide)

GLP-1 / Insulin Combinations GLP-1 / Insulin Combinations S/E Through Metformin GLP-1 / Insulin Combinations S/E Through Metformin Soliqua’ (Insulin Glargine & Lixisenatide~) Xultophy’ (Insulin Degludec & Liraglutide)

Other Injectibles Other Injectibles S/E Through Metformin Other Injectibles S/E Through Metformin SymlinPen’ (Pramlintide Acetate) C4 Hyperglycemic Drugs GlucaGen Kit’ (Glucagon) Novo Nordisk Only Glucagon Emergency Kit (Glucagon) GVoke Injector’ (Glucagon) Proglycem Oral Suspension (Diazoxide) Baqsimi Nasal Powder Inhaler (Glucagon) QLL/Max Dose M4

30 Diabetes: Oral Antidiabetics

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Oral Anti-Diabetics Orals Orals Orals Glyburide / Diabeta, Glynase, Micronase Cycloset (Bromocriptine) 100% Copay Metformin ER / Fortamet ER S/E 100% Copay Riomet (Metformin) 100% Copay Metformin ER / Glumetza S/E-100% Copay Metformin / Glucophage/XR

(Over 30 other generic Drugs exist) C4 Thiazolidinediones (TZDs) & Combinations Thiazolidinediones (TZDs) S/E Through Metformin Thiazolidinediones (TZDs) S/E Through Metformin Pioglitazone Family/ Actos, Duetact, ActoPlusMet/XR Avandia/Avandamet/Avandaryl

C4 DPP-4 / DPP-4 Combos DPP-4 / DPP-4 Combos S/E Through Metformin DPP-4 / DPP-4 Combos S/E Through Metformin Alogliptin / Nesina Janumet/XR’ (Sitagliptin/Metformin) Alogliptin/Metformin / Kazano Januvia’ (Sitagliptin*) Alogliptin/Pioglitazone / Oseni Jentadueto' (Linagliptin/Metformin) Kombiglyze XR’ (Saxagliptin/Metformin) Onglyza’ (Saxagliptin) Tradjenta' (Linagliptin) C4 SGLT-2 Inhibitors SGLT-2 Inhibitors S/E Through Metformin SGLT-2 Inhibitors S/E Through Metformin Farxiga’ (Dapagliflozin) Steglatro (Ertugliflozin) 100% Copay Invokana’ (Canagliflozin) Segluromet (Ertugliflozin/Metformin) 100% Copay Invokamet/XR’ (Canagliflozin/Metformin) Jardiance’ (Empagliflozin) Synjardy' (Empagliflozin/Metformin) Xigduo’ (Dapagliflozin/Metformin)

SGLT-2 / DPP-4 Combinations SGLT-2 / DPP-4 Combinations S/E Through Metformin SGLT-2 / DPP-4 Combinations S/E Through Metformin Glyxambi’ (Empagliflozin/Linagliptin) Steglujan (Ertugliflozin/Sitagliptin) 100% Copay Qtern’ (Dapagliflozin/Saxagliptin) Qternmet XR’ (Dapagliflozin/Saxagliptin/Metformin) Trijardy XR’ (Empagliflozin/Linagliptin/Metformin) C4

31 Diabetes: Diabetic Supplies & Pumps

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Diabetic Supplies Meters Meters Meters Store Brand One Touch Verio’ GlucoCard Shine Meters’ Other Brands of Meters are either NOT Covered OR One Touch Verio Flex’ may incur a 100% copay depending on plan design. One Touch Verio Reflect’

Strips Strips Strips Store Brand OneTouch Ultra’ GlucoCard Shine Strips’ Other Brands of Strips are either NOT Covered, may OneTouch Verio’ be grandfathered for a short time, OR may incur a 100% copay depending on plan design.

M4/X2

Lancets Devices & Lancets Lancets Devices & Lancets Lancets Devices & Lancets Store Brand TechLITE Lancets’ All Other Lancets

Syringes & Supplies by: Syringes & Supplies by: Syringes & Supplies by: Store Brand Novofine & NovoTwist Pen Needles B-D, Clickfine, Monoject, Terumo TechLITE Pen Needles UltiCare, Unifine, all other brand products Y2/Y9 Continuous Glucose Monitoring Devices Dexcom Transmitter, Receiver & Sensors’ Freestyle Libre Reader & Sensors’ Y9 Insulin Pumps & Supplies CeQur Simplicity’ Minimed 50X, Paradigm & Guardian’ OmniPod System & Pods’ V-Go Disposable Units’ Y9 Weight Loss

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Anorexia Drugs Benzphetamine HCL / Didrex Contrave’ (Bupropion/Naloxone) P/A Approp Use Belviq/XR (Lorcaserin) P/A Phendimetrazine / Bontril PDM Saxenda Injection’ (Liraglutide) P/A Approp Use Lomaira (Phentermine) P/A Phentermine HCL / Adipex-P Qsymia (Phentermine/Topiramate) P/A J8

32 Respiratory: Allergy & Asthma

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Oral Allergy Drugs Grastek’, Ragwitek’, Odactra’ {All Other Oral Allergy Immunotherapy} W7 Allergy Medications

Non/Low Sedating Antihistamines Non/Low Sedating Antihistamines Non/Low Sedating Antihistamines Multiple Generics & OTCs available for Prescribing Semprex-D (Pseudoephedrine/Acrivas)

Z2 Intranasal Corticosteroids Intranasal Corticosteroids Intranasal Corticosteroids Flunisolide / Nasarel Nasonex’ (Mometasone) Beconase AQ (Beclomethasone Dipropionate) Fluticasone / Flonase, Flonase Sensimist (OTC) QNasl’ (Beclomethasone Dipropionate) Omnaris, Zetonna (Ciclesonide) Triamcinolone Acetate / Nasacort Allergy 24 HR (OTC)

Other Allergy Drugs (Sprays) Other Allergy Drugs (Sprays) Other Allergy Drugs (Sprays) Azelastine / Astepro Dymista’ (Azelastine/Fluticasone) Patanase (Olopatadine) Ticalast (Azelastine/Fluticasone) Q7 Asthma Drugs

Short Acting Beta Agonists (SABA) Short Acting Beta Agonists (SABA) Short Acting Beta Agonists (SABA) Albuterol Sulfate Inhaler ProAir HFA/RespiClick’ (Albuterol Sulfate) Proventil/HFA (Albuterol Sulfate) Levalbuterol / Xopenex Ventolin/HFA’ (Albuterol Sulfate) Terbutaline

Inhaled Corticosteroids (ICS) Inhaled Corticosteroids (ICS) Inhaled Corticosteroids (ICS) Arnuity' (Fluticasone Furoate) Aerospan (Flunisolide) Flovent’ (Fluticasone) Alvesco’ (Ciclenoside) Pulmicort Flexhaler’ (Budesonide) ArmonAir (Fluticasone) Qvar/Qvar RediHaler’ (Beclomethasone)

ICS / LABA Combination Drugs ICS / LABA Combination Drugs ICS/LABA Combination Drugs Fluticasone/Salmeterol / Wixela Inhub Advair’ (Fluticasone/Salmeterol) AirDuo (Fluticasone/Salmeterol AG) Breo’ (Fluticasone/Vilanterol) Dulera (Mometasone/Formoterol) 100% Copay Symbicort’ (Budesonide/Formoterol)

Long Acting Muscarinic Agonists (LAMA) Long Acting Muscarinic Agonists (LAMA) Long Acting Muscarinic Agonists (LAMA) Spiriva 1.25mcg’ (Tiotropium)

Other Drugs Other Drugs Other Drugs Budesonide / Pulmicort Respules for Inhalation B6

33 Respiratory: Allergy, COPD & Polyps

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Leukotriene Inhibitors Montelukast / Singulair Zafirlukast / Accolate Zileuton / Zyflo/CR Z4 COPD Drugs Beta Agonists / Muscarinic Agonists, Short Acting Beta Agonists / Muscarinic Agonists Beta Agonist / Muscarinic Agonists Albuterol/Ipratropium [SABA] Combivent' (Albuterol/Ipratropium) [SABA/SAMA] Atrovent HFA (Ipratropium) [SAMA]

Long Acting Beta Agonists (LABA) Long Acting Beta Agonists (LABA) Long Acting Beta Agonists (LABA) Arcapta' (Indacaterol Powder) Foradil (Formoterol) Serevent’ (Salmeterol) Striverdi’ (Olodaterol)

Long Acting Muscarinic Agonists (LAMA) Long Acting Muscarinic Agonists (LAMA) Long Acting Muscarinic Agonists (LAMA) Incruse’ (Umeclidinium) Seebri (Glycopyrronium Bromide) Spiriva 2.5mcg’, Spiriva Handihaler (Tiotropium) Tudorza (Aclidinium Bromide)

LABA / LAMA Combination Drugs LABA / LAMA Combination Drugs LABA / LAMA Combination Drugs Anoro’ (Umeclidinium/Vilanterol) Utibron (Indacaterol/Glycopyrronium) Stiolto’ (Tiotropium/Olodaterol) Bevespi (Fomoterol/Glycopyrronium)

ICS / LABA Combination Drugs ICS / LABA Combination Drugs ICS / LABA Combination Drugs Fluticasone/Salmeterol / Wixela Inhub Advair’ (Fluticasone/Salmeterol) Breo’ (Fluticasone/Vilanterol) Symbicort’ (Budesonide/Formoterol)

ICS / LABA / LAMA Combination Drugs ICS / LABA / LAMA Combination Drugs ICS / LABA / LAMA Combination Drugs Trelegy’ (Umeclidinium/Vilanterol/Fluticasone)

Inhalation/Nebulizer Drugs Inhalation/Nebulizer Drugs Inhalation/Nebulizer Drugs Perforomist Inhalation’ (Formoterol Fumarate) Brovana (Arformoterol Tartrate) S/E Yupelri Inhalation’ (Revefenacin) Lonhala Magnair (Glycopyrrolate) S/E B6 Other Drugs Other Drugs Other Drugs Daliresp’ (Roflumilast) Z2 Nasal Polyps XHance’ (Fluticasone Propionate) Q7

34 Dermatology: Acne, Rosacea, Psoriasis

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Acne – Topicals (Acne/Seborrhea/Dermatitis) Acne – Topicals (Acne/Seborrhea/Dermatitis) Acne – Topicals (Acne/Seborrhea/Dermatitis) Clindamycin / Cleocin-T Soln, Evoclin Foam Altreno Lotion (Tretinoin) P/A Req’d Erythromycin+Ethanol / Erygel 2% Avar (Sulfacetamide/sulfur) Fluticasone Propionate / Cutivate Lotion Eucrisa (Crisaborole) Sulfacetamide / Ovace, Plexion Sulfacetamide+Urea / Rosula Pads & Wash Tretinoin / Retin-A/Micro, Avita, Atralin Various Acne – Oral Antibiotics Acne – Oral Antibiotics Acne – Oral Antibiotics Doxycycline Hyclate / Acticlate, Doryx, Soloxide Absorica’ (Isotretinoin) Doryx (Doxycycline Hyclate) Doxycycline Monohydrate / Avidoxy, Oracea Seysara’ (Sarecycline) Minocycline / Minocin, Solodyn’^ Minolira ER, Ximino (Minocycline) W1C Acne – Topical Antibiotics Acne – Topical Antibiotics Acne – Topical Antibiotics Adapalene / Differin Acanya’ (Benzoyl Peroxide+Clindamycin) Aklief (Triferotene) Benzoyl Peroxide+a/b / Benzaclin Pump Aczone 7.5% Pump’ (Dapsone) Amzeeq Foam (Minocycline) Dapsone / Aczone 5.0% Ziana’ (Tretinoin+Clindamycin) Benzaclin, Duac (Benzoyl Peroxide+Clindamycin) Tretinoin+ Clindamycin / Veltin Epiduo Forte, Plixda (Adapalene+BP) Onexton (Benzoyl Peroxide+Clindamycin) L5H Rosacea Rosacea Rosacea Metronidazole / MetroGel, Metrolotion, MetroCream Finacea’ (Azelaic Acid) Azelex (Azelaic Acid) Rhofade’ (Oxymetazoline) Noritate (Metronidazole) Mirvaso (Brimonidine Tartrate) Rosadan (Metronidazole) Soolantra Cream (Ivermectin) L5G Eczema (Immuno Topicals) Eczema (Immuno Topicals) Eczema (Immuno Topicals) Tacrolimus / Protopic Elidel (Pimecrolimus) Q5K Psoriasis – Orals Psoriasis – Orals Psoriasis – Orals Acitretin / Soriatane Oxsoralen’ (Methoxsalen) 8-MOP (Methoxsalen) L1A Psoriasis – Topicals Psoriasis – Topicals Psoriasis – Topicals Calcipotriene / Dovonex Cream, Sorilux S/E Bryhali’ (Halobetasol Propionate) Arazlo (Tazaotene) S/E Calcipotriene/Betamethesone / Taclonex Cream (only) Duobrii’ (Halobetasol Prop / Tazarotene) Clobex, Olux (Clobestasol) S/E Calcitriol / Vectical S/E Enstilar Foam’ (Calcipotriene/Betamethesone) Fabior Foam (Tazarotene) S/E Tazarotene / Tazorac Cream (only) Taclonex Suspension’ Calcipotriene/Betameth) Impoyz (Clobestasol) S/E Tazorac Gel’ only (Tazarotene) Lexette Foam (Halobetasol Propionate) Vanos Cream’ (Fluocinonide) Sernivo Spray (Betamethasone Dipropionate) S/E Ultravate 0.05% Lotion (Halobetasol Propionate) L5F

35 Dermatology: Keratolytics, Scabies, Anesthetics/Analgesics & Hyperhydrosis

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Antifungals Orals Orals Orals Clotrimazole / Lotrimin, Mycelex Lamisil Granules only (Terbinafine) Ancobon (Flucytosine) Fluconazole / Diflucan Cresemba (Isamuconazonium) Itraconazole / Sporanox Noxafil (Posaconazole) 100% Copay Voriconazole / Vfend Oravig Buccal (Miconazole) Oxistat (Oxiconazole) Sporanox Oral Solution (Itraconazole) Tolsyra (Itraconazole)

Topicals Topicals Topicals Ciclopirox / Loprox, Penlac Jublia’ (Efinaconazole) Exelderm (Sulconazole) Econazole Nitrate / Spectazole Ertaczo’ (Sertaconazole) Kerydin Solution (Tavaborole) Halcinonide / Halog Cream’^ Locoid Lipocream’ (Hydrocortisone) Vusion (Miconazole/Zinc Oxide) Halobetasol Propionate / Ultravate Cream Luzu’ (Lulinconazole) Xolegel (Ketoconazole) Ketoconazole / Nizoral, Extina Naftin Gel 2%’ (Naftifine) Naftifine / Naftin Cream, Gel 1% Nystatin / Mycostatin, Mycolog II Terbinafine / Lamisil Solution Q5/L9 Keratolytic Drugs

Moisture Drugs Moisture Drugs Moisture Drugs Diclofenac Sodium / Solaraze S/E Picato Gel’ (Ingenol Mebutate) Carac (Fluororacil) Fluororacil / Efudex S/E Fluoroplex S/E, Tolak Cream S/E (Fluororacil) Panretin (Alitretinoin) Targretin (Bexarotene) L5F/Q5P/T0A Immunomodulators Immunomodulators Immunomodulators Imiquimod / Aldara S/E Zyclara (Imiquimod) Z2G Scabies & Pediculosis Drugs Malathion Eurax Cream/Lotion (Crotamiton) Permethrin 5% / Elimite Cream/Liquid Ovide Lotion (Malathion) Spinosad / Natroba Suspension Sklice (Ivermectin) S/E Ulesfia Lotion (Benzil Alcohol) Q5N IMPORTANT NOTE – For Topical Steroids, use Generics as First Line therapy for all products. All Single Source Brand Products are considered Non-Preferred Brands

36 Dermatology: Topicals & Others

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Topical Local Anesthetics & Analgesics Diclofenac Sodium / Pennsaid 1.5% only, Voltaren Gel Analpram-HC (HC Acetate/Pramoxine) Lidocaine Patches / Lidoderm Cetacaine (Tetracaine/Benzocaine) Epifoam (HC Acetate/Pramoxine HCL) Flector (Diclofenac Epolamine) LidoRx Pump (Lidocaine HCL) Novacort (HC Acetate/Pramoxine) Pennsaid 2% (Diclofenac Sodium) 100% Copay Pramosone (HC Acetate/Pramoxine) Proctofoam-HC (HC Acetate/Pramoxine) SpeedGel Rx Pump (Homeopathic) Zingo (Lidocaine HCL monohydrate) Q5E/Q5H Hyperhydrosis Qbrexza’ (Glycopyrronium) L8C Other Topical Products Acyclovir / Zovirax Ointment Only Zovirax 5% Cream Only’ (Acyclovir) Altabax (Retapamulin) Mupirocin / Bactroban 2% Ointment & Cream Qutenza Patches (Capsaicin) Rectiv (Nitroglycerin) Q5V/Q5W Vaginal Drugs

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Vaginal Antibiotics Metronidazole / Metrogel-Vaginal, Vandozole Gel AVC Cream (Sulfanilamide) Clindamycin / Cleocin Cream Cleocin Supp (Clindamycin Phosphate) Clindesse (Clindamycin Phosphate) Nuvessa Gel (Metronidazole)

Vaginal Antifungals Miconazole / Monistat-7 Femstat (Butoconazole) Nystatin Vaginal tabs Gynazole (Butoconazole) Terconazole / Terazol Solosec (Secnidazole)

37 Ophthalmics: Anti-Infectives, Antihistamines, Dry Eye Drugs & Anti-Inflammatories

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Ophthalmic Anti-Infectives Ciprofloxacin / Ciloxan Azasite’ (Azithromycin) Besivance (Besifloxicin) Gentamycin / Gentak Moxeza’ (Moxifloxacin) Blephamide/SOP (Na Sulfacet/Prednisolone) Ofloxacin / Ocuflox Vigamox’ (Moxifloxacin) Natacyn (Natamycin) Polymyxin/Trimethoprim / Polytrim Zirgan Gel (Ganciclovir) Prednisolone/Sulfacetamide / Blephamide Zymaxid (Gatifloxacin) Sulfacetamide 10% / Bleph-10 Tobramycin / Tobrex Trifluridine / Viroptic Q21N/Q6S-V-W Ophthalmic Antihistamines Cetirizine / Zerviate 100% Copay Pazeo’ (Olopatadine) Bepreve (Bepotastine) Epinastine / Elestat Emadine (Emedastine) Ketotifen / Zaditor OTC, Alaway Lastacaft (Alcaftadine) Olopatadine / Patanol S/E Pataday (Olopatadine) Q6R Ophthalmic Immunomodulators (Dry Eye) Restasis’ (Cyclosporine) Cequa (Cyclosporine) Xiidra (Lifitegrast) Q2C Ophthalmic Mast Cell Stabilizers Alocril (Nedocromil Sodium) Alomide (Lodoxamide) Q6U Ophthalmic Anti-Inflammatory Drugs Diclofenac Sodium / Voltaren Alrex’ (Loteprednol) Acular PF, Acuvail (Ketorolac) Fluorometholone / FML Forte Ilevro’ (Nepafenac) Bromsite’ (Bromfenac Sodium) Ketorolac / Acular, Acular-LS Lotemax Gel/Oint/Susp’ (Loteprednol) Durezol (Difluprednate) Prednisolone Acetate / Pred Forte Prolensa’ (Bromfenac Sodium) Flarex (Fluorometholone) FML Forte, FML-SOP (Fluorometholone) Inveltys (Loteprednol Etabonate) Maxidex (Dexamethasone) Nevanac (Nepafenac) Pred Mild (Prednisolone Acetate) Q6P

38 Ophthalmics: Glaucoma, Mydriatics & Others

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Ophthalmics for Glaucoma Miotics Miotics Miotics Betaxolol / Betopic Alphagan P’ (Brimonidine) Azopt (Brinzolamide) Brimonidine / Alphagan Betimol’ (Timolol) Betopic-S (Betaxolol) Dorzolamine / Trusopt Combigan’ (Brimonidine/Timolol) Iopidine (Apraclonidine) Levobunolol / Betagan Cosopt-PF’ (Timolol/Dorzolam) Istalol (Timolol Maleate) Metipranolol / Optipranolol Simbrinza’ (Brimonidine/Brinzolamide) Miochol-E (Acetylcholine Chloride) Pilocarpine / Isopto Carpine Rhopressa (Netarsudil) Timolol / Timoptic/XE Rocklatan (Netarsudil/Latanoprost) Timolol/Dorzolam / Cosopt

Prostaglandins Prostaglandins Prostaglandins Latanoprost / Xalatan Lumigan’ (Bimatoprost) Rescula (Unoprostone Isopropyl) Zioptan’ (Talfluprost) Travatan Z (Travoprost) Vyzulta (Latanoprostene Bunod) Xelphos (Latanoprost-PF Emulsion) Q6G Ophthalmic Mydriatics (Pupils) Atropine / Isopto Atropine Cyclomydril (Phenylephrine/Cyclopent) Cyclopentolate / Cyclogyl Paremyd (Hydroxyamphetamine/Tropicamide) Tropicamide / Mydriacyl Q6J Ophthalmic Antibiotic-Corticoid Drugs Neomycin/Polymyxin/Dexamethasone / Maxitrol Pred-G (Gentamicin/Prednisolone) Tobramycin/Dexamethasone / Tobradex Zylet (Tobramycin/Loteprednisolone) Q6I Other Ophthalmic Drugs Cystaran (Cysteamine) P/A Req’d Eylea (Afibercept) P/A Req’d Jetrea (Ocriplasmin) P/A Req’d Lumify (Brimonidine Tartrate) P/A Req’d Oxervate (Cenegermin) P/A Req’d Q2

39 Ear Drugs

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Ear Drugs Ciprofloxacin / Cetraxal Solution CiproDex’ (Ciprofloxacin/Dexamethasone) Cipro HC (Ciprofloxacin/HC) Fluocinolone Acetonide / Dermotic Coly-Mycin S (Neomycin/Colist Sulf) Cortane-B (HC/Pramoxine/Chlorox) Otovel (Ciprofloxacin/Fluocinolone) Q8

40 Miscellaneous: Dependence & Withdrawal, Dental, Saliva, & Rescue Drugs

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Dependence & Withdrawal Symptom Drugs Alcohol Dependence Drugs Alcohol Dependence Drugs Alcohol Dependence Drugs Disulfiram / Antabuse Vivitrol Injectible (Naltrexone) P/A Req’d C0D

Opioid Dependence Drugs Opioid Dependence Drugs Opioid Dependence Drugs Buprenorphine/Naloxone Tablets S/E / Suboxone Tablets S/E Suboxone SL Film’ (Buprenorphine/NLX) Bunavail Buccal (Buprenorphine/NLX) S/E Zubsolv SL’ (Buprenorphine/Naloxone) Cassipa Film (Buprenorphine/NLX) S/E Sublocade (Buprenorphine SR Inj.) P/A Req’d H3W

Withdrawal Symptom Drugs Withdrawal Symptom Drugs Withdrawal Symptom Drugs Lucemyra’ (Lofexidine) H33

Smoking Cessation Smoking Cessation Smoking Cessation Bupropion/ Zyban, Wellbutrin Chantix (Varenicline Tartrate) Nicotrol NS (Nicotine) H7/J3 Dental Preparations Chlorhexidine / Peridex Gel-Kam (Stannous Fluoride) Fluorabon (Sodium Fluoride) Flura-Drops (Sodium Fluoride) Prevident (Sodium Fluoride) Periomed (Stannous Fluoride) D1/D2 Parasympathetic (Saliva) Drugs Bethanechol / Urecholine Cevimeline / Evoxac Pilocarpine / Salagen J1A Rescue Drugs Anaphylaxis Drugs Anaphylaxis Drugs Anaphylaxis Drugs Epinephrine Pen / Adrenaclick S/E Epipen’, Epipen Jr’ (Epinephrine) Auvi-Q (Epinephrine) 100% Copay Epinephrine (Epipen AG) Symjepi (Epinephrine) S/E J5F

Opioid Receptor Blockers Opioid Receptor Blockers Opioid Receptor Blockers Narcan Nasal Spray (Naloxone) Evzio Injector (Naloxone) 100% Copay

H3T

41

Specialty Drug Formulary List

Specialty Drug Products

Specialty drugs are prescription medications that require special handling, administration or monitoring. These drugs typically treat complex and chronic conditions, including cancer, multiple sclerosis, various types of hepatitis, chronic kidney failure, organ transplants, rheumatoid arthritis and other diseases. Specialty drugs might be covered through either medical or prescription drug insurance. Under which benefit a specialty drug is covered usually depends on where the patient receives the drug. If the patient takes the drug orally or self-injects the drug at home, it is more likely to be covered through their prescription drug benefit, while if the patient receives the drug at a doctor’s office or an outpatient clinic, it’s more likely to be covered through the medical benefit. Prescriptions for specialty drugs can be filled at a retail pharmacy, but not many pharmacies will dispense specialty drugs or provide the extra clinical and educational services required to properly manage specialty patients due to inventory costs. Additionally, some drug manufacturers limit the distribution of specialty drugs, making their drugs available only through designated, pre-certified specialty pharmacies. For more information about limited distribution drugs, please contact your clinical Account Manager.

Specialty Programs & Limits

Some specialty drugs below are noted with letters or symbols next to them. The letters and symbols refer to the requirements of the pharmacy benefit programs and are provided to help check which drugs may have a clinical program or limitations in place. The benefit plan determines how these medications may be covered. P/A or P/A Req’d Prior Authorization – Physician is required to provide additional information to determine coverage. P/A for Diagnosis Prior Authorization may be required for clinical diagnosis Clinical P/A Prior Authorization may be required for clinical diagnosis C-P/A Prior Authorization may be required for clinical confirmation S/E Step Therapy – Trial of another drug is required before this drug is covered. RECOMMENDED Product is preferred over other drugs listed in the assigned tier – step edit may or may not apply 100% 100% Copay may apply. Lower-cost or better clinical options are available.

42 Specialty Drug Product Qualifications

The P&T Committee, using current medical literature, has developed a “specialty” pharmacy product formulary comprised of Specialty Drug Products. To be considered a “Specialty Drug", a drug should fall into at least six (6) of the following categories although still subject to assignment by the P&T Committee. 1. A drug that treats specific, mainly chronic, and often rare conditions; or is considered an orphan drug 2. A drug whose usage is initiated with a specialist 3. A drug typically not administered orally or topically 4. A drug that requires special handling 5. A drug whose use involves unique distribution channels, such as limited distribution management and specialized paperwork (REMS) 6. A drug that requires administration in a healthcare setting with oversight of a healthcare professional 7. A drug that is costs more than a specific set amount per month 8. A drug whose usage requires high degrees of patient management, increased supervision, counseling, and/or education 9. A drug whose use often may result in patients requiring reimbursement assistance to maintain regimen The current specialty pharmacy product listing is available from your Account Manager.

SPECIAL NOTES:  CGRP medications can be found on page 11

Specialty Drug Copays

While the formulary placement of a drug is determined by the P&T Committee, the copays that are assigned to brand and generic drugs are determined by the copay established under each plan benefit design. Therefore, in many cases, the copay for a preferred brand specialty drug may be different than a preferred brand drug that is not deemed as a specialty drug. This often occurs with HIV, oncology, immunology, respiratory and many other drugs. Additionally, drugs that are infused or administered intravenously often have different copays applied, especially when they are covered under a medical benefit. For more information about what a copay would be for a specific drug, the patient should contact their benefit office.

NOTE: If the member uses a member portal, online pricing tool or smartphone/tablet app, the copay returned may not always be as expected based on many factors, including whether the member’s plan follows the formulary and the recommendations of the P&T Committee, how the plan even wants a given drug covered, what stage the member is in their deductible benefit if applicable, whether the claim is filled by an in or out of network provider, and if other member level coverage overrides have been entered.

43 Specialty: Hep C & Multiple Sclerosis

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Hepatitis Treatment Drugs Hepatitis B Drugs Hepatitis B Drugs Hepatitis B Drugs Peginterferon Alfa-2B / Peg-Intron Baraclude (Entecavir) Epivir HBV (Lamivudine) Hepsera (Adefovir Dipivoxil) Pegasys (Peginterferon Alfa-2A) Tyzeka (Telbivudine) Vemlidy (Tenofovir Alafenamide) HEPB Hepatitis C Drugs – Interferons Hepatitis C Drugs – Interferons Hepatitis C Drugs – Interferons Ribavirin / Ribasphere Copegus (Ribavirin) Infergen (Interferon Alfacon-1) HEPC Hepatitis C Drugs – Other Inhibitors Hepatitis C Drugs – Other Inhibitors Hepatitis C Drugs – Other Inhibitors Mavyret’ (Glecaprevir/Pibrentasir) P/A for Diagnosis Daklinza (Daclatasvir) P/A Req’d Sofosbuvir/Ledipasvir / [Harvoni AG Only] P/A Req’d Epclusa (Sofosbuvir/Velpatasvir) P/A Req’d Sofosbuvir/Velpatasvir / [Epclusa AG Only] P/A Req’d Harvoni (Sofosbuvir/Ledipasvir) P/A Req’d Olysio (Simeprevir) P/A Req’d Sovaldi (Sofosbuvir) P/A Req’d Viekira/XR (4 Product Combo Pak) P/A Req’d Technivie (Ombitasvir/Partaprevir/Ritonevir) P/A Req Vosevi (Sofosbuvir/Velpatasvir/Voxilaprevir) P/A Zepatier (Elbasvir/Grazoprevir) P/A Req’d HEPC Multiple Sclerosis (MS) Drugs Injectibles Injectibles Injectibles Glatiramer Acetate (Glatopa’) Copaxone’ (Glatiramer Acetate) Avonex (Interferon ß -1A) S/E Betaseron (Interferon ß 1B) S/E Extavia (Interferon ß -1B) S/E Plegridy (Interferon ß -1A) 2-S/E (Inj & Oral) Rebif (Interferon ß -1A/Albumin) 2-S/E (Inj & Oral) MS_I Orals Orals Orals Gilenya’ (Fingolimod) Aubagio (Teriflunomide) S/E Mayzent’ (Siponimod) Mavenclad (Cladribine) P/A, Special Therapy Tecfidera (Dimethyl Fumerate) 2-S/E (Inj & Oral) Vumerity (Dimethyl Fumerate) 2-S/E (Inj & Oral) MS_O Infused Infused Infused Lemtrada Infusion (Alemtuzumab) S/E Ocrevus (Ocrelizumab) S/E Tysabri Infusion (Natalizumab) 2-S/E (Inj & Oral) MS_F Ambulatory Ambulatory Ambulatory Dalfampridine / Ampyra P/A Req’d MS_A

44 Specialty: Rheumatoid Arthritis, Plaque & Psoriatic Psoriasis, Ulcerative Colitis, Crohns

INDICATION Rheumatoid Plaque Psoriatic Crohns Ulcerative Ankylosing Arthritis Psoriasis Arthritis Disease Colitis Spondylitis Self Administered Products

PREFERRED Humira’ (Adalimumab) Cosentyx’ (Secukinumab) Cosentyx’ (Secukinumab) Humira’ (Adalimumab) Humira’ (Adalimumab) Cosentyx’ (Secukinumab) BRANDS Orencia’ (Abatacept) Humira’ (Adalimumab) Humira’ (Adalimumab) Humira’ (Adalimumab) Rinvoq’ (Upadacitinib) Skyrizi’ (Risankizumab)

Cimzia (Certolizumab) S/E Enbrel (Etanercept) S/E Orencia’ (Abatacept)*** Cimzia (Certolizumab) S/E Simponi (Golimumzab) S/E Cimzia (Certolizumab) S/E NON-PREFERRED Enbrel (Etanercept) S/E Ilumya (Tildrakizumab) S/E Otezla (Apremilast)*** Stelara (Ustekinumab) S/E Stelara (Ustekinumab) S/E Enbrel (Etanercept) S/E BRANDS Kineret (Anakinra) S/E Otezla (Apremilast)*** Cimzia (Certolizumab) S/E Xeljanz/XR (Tofacitinb) S/E Kineret (Anakinra) S/E

Kevzara (Sarilumab) S/E Siliq (Brodalumab) S/E Enbrel (Etanercept) S/E Simponi (Golimumzab) S/E

Olumiant (Baricitinib) S/E Simponi (Golimumzab) S/E Simponi (Golimumzab) S/E Taltz (Ixekizumab) S/E

Simponi (Golimumzab) S/E Stelara (Ustekinumab) S/E Stelara (Ustekinumab) S/E

Xeljanz/XR (Tofacitinb) S/E Taltz (Ixekizumab) S/E Taltz (Ixekizumab) S/E

Xeljanz/XR (Tofacitinb) S/E

All Biosimilars All Biosimilars All Biosimilars All Biosimilars All Biosimilars All Biosimilars Office Administered Products

Actemra (Tocilizumab) Remicade (Infliximab) Cimzia (Certolizumab) Cimzia (Certolizumab) Entyvio (Vedolizumab) Cimzia (Certolizumab)

Typically Covered Cimzia (Certolizumab) Simponi (Golimumzab) Remicade (Infliximab) Entyvio (Vedolizumab) Remicade (Infliximab) Remicade (Infliximab) Under Medical Benefit Remicade (Infliximab) Tremfya (Guselkumab) Rituxan (Rituximab) Remicade (Infliximab) Simponi (Golimumzab) Rituxan (Rituximab)

Rituxan (Rituximab) Simponi (Golimumzab) Stelara (Ustekinumab) Stelara (Ustekinumab) Simponi (Golimumzab) Simponi (Golimumzab) Tysabri (Natalizumab) All Biosimilars All Biosimilars All Biosimilars All Biosimilars All Biosimilars All Biosimilars

*** = Recommended Non-Preferred Agent Clinical Prior Authorization may be required for agents to confirm indication. Additional clinical criteria for Non-Preferred drugs may be applicable

45 Specialty: MTX, UC & CD, Atopic Dermatitis, Osteoarthritis, Human Growth & Anti-Psychotics

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Methotrexates & DMARDs Leflunomide / Arava Rasuvo Injectible' (Methotrexate) Otrexup Injectible (Methotrexate) Methotrexate / Trexall RediTrex Injectible (Methotrexate) Rheumatrex (Methotrexate)

Ulcerative Colitis & Crohns - Other Uceris / Uceris Foam (Budesonide)

Atopic Dermatitis Dupixent (Dupilumab) P/A for Indication HAE Osteoarthritis Drugs Move-Free Ultra Vitamins (Hyuronic Acid) Euflexxa, Hyalgan, Orthovisc (Hyaluronate Sodium) P/A Req’d Supartz (Hyaluronate Sodium) P/A Req’d Synvisc/Synvisc-ONE (Hylan) P/A Req’d OA_O Cholesterol Management PCSK9s PCSK9s PCSK9s Praluent Inject.' (Alirocumab) C-P/A Repatha Inject. (Evolocumab) C-P/A with S/E

Other Drugs Other Drugs Other Drugs Juxtapid (Lomitapide) P/A Req’d Kynamro SQ (Mipomersen) P/A Req’d PCS9 Human Growth Hormones (HGH) Norditropin’ (Somatropin) P/A Dosing All Other Somatropin Drugs S/E & P/A Req’d Omnitrope’ (Somatropin) P/A Dosing HGH Injectable Antipsychotic Drugs Abilify Maintena (Aripiprazole) B,S Aristada Initio Injection (Aripiprazole Lauroxil) B,S Geodon for Injection (Ziprasidone) B,S Invega Trinza (Paliperidone) B,S Perseris Inject. Suspension (Risperidone) B,S Risperdal M/Consta (Risperidone) B,S Zyprexa Relprevv (Olanzapine Pamoate) B,S ATYP

B - Bi-polar indication S - Schizophrenia indication M - Manic Depressive Disorder indication

46 Specialty: Cardiovascular, Respiratory & Immunosuppressants

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Cardiovascular Drugs Pulmonary Anti-HTN (PAH), Endothelin Pulmonary Anti-HTN, Endothelin Pulmonary Anti-HTN, Endothelin Ambrisentan / Letairis P/A Req’d Opsumit (Macitentan) P/A Req’d Bosentan / Tracleer P/A Req’d PAHE Pulmonary Anti-HTN (PAH), Prostacycline Pulmonary Anti-HTN, Prostacycline Pulmonary Anti-HTN, Prostacycline Epoprostenol / Flolan Orenitram (Treprostinil) P/A Req’d Velentri (Epoprostenol) P/A Req’d Treprostinil / Remodulin Tyvaso (Treprostinil) P/A Req’d Ventavis (Iloprost) P/A Req’d Uptravi (Selexipag) P/A Req’d PAHP Hereditary Angioedema (HAE) Hereditary Angioedema (HAE) Hereditary Angioedema (HAE) Icatibant Injection / Firazyr Berinert, Cinryze (C1 Esterase Inhibitor) P/A Req’d Haegarda, Ruconest (C1 Esterase Inhibitor) P/A Req’d

PAHP Other Cardiovascular Drugs Other Cardiovascular Drugs Other Cardiovascular Drugs Sildenafil / Revatio Adempas (Riociguat) P/A Req’d Tadalafil / Adcirca RS2P Severe Asthma Dupixent’ (Dupilumab) P/A Req’d Cinqair (Reslizumab IV) P/A Req’d Fasenra’ (Benralizumab) P/A Req’d Xolair (Omalizumab) P/A Req’d Nucala (Mepolizumab SQ) P/A Req’d RESP Immunosuppressants Organ Transplant Drugs Organ Transplant Drugs Organ Transplant Drugs Mycophenolate Mofetil / Cellcept Rapamune (Sirolimus) P/A Req’d Astagraf XL (Tacrolimus) P/A Req’d Mycophenolate Sodium / Myfortic Zortress (Everolimus) P/A Req’d Envarsus XR (Tacrolimus) P/A Req’d Tacrolimus / Prograf, Hecoria

Neutropenia Drugs Neutropenia Drugs Neutropenia Drugs Short Acting: Short Acting: Short Acting: Zarxio’ (Filgrastim-sndz) P/A for Clinical Granix (tbo-Filgrastim) P/A Req’d Neupogen (Filgrastim) P/A Req’d Nivestym (Filgrastim-aafi) P/A Req’d

Long Acting: Long Acting: Long Acting: Ziextenzo’ (Pegfilgrastim-bmez) Fulphilia (Pegfillgrastim-jmdb) Leukine (Sargramostim) P/A Req’d Neulasta (Pegfilgrastim) P/A Req’d Udenyca (Pegfilgrastim-cloqv) P/A Req’d

Lupus Drugs Lupus Drugs Lupus Drugs Benlysta (Belimumab) P/A Req’d

47 Specialty: Heparin & Hematopoietic, Osteoporosis, Narcolepsy, Infertility & Others

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Heparin-Related Drugs Enoxaparin / Lovenox Injection Fragmin Injection (Dalteparin) Fondaparinux / Arixtra Injection

DVT Hematopoietic Drugs Aranesp (Darbepoetin) Epogen (Epoetin-alfa) Procrit (Epoetin-alfa) Retacrit (Epoetin-alfa-epbx) HPOI Osteoporosis Drugs Boniva Injectible (Ibandronate) P/A Req‘d Bonsity Injectible (Teriparatide) P/A Req‘d Evenity (Romosozumab-aqqg) P/A Req‘d Forteo Injectible (Teriparatide) P/A Req‘d Prolia (Denosumab) P/A Req‘d Reclast (Zoledronic Acid) P/A Req‘d Tymlos Injectible (Abaloparatide) P/A Req‘d Zometa Injectible (Zoledronic Acid) P/A Req‘d

Cataplexy / Narcolepsy Drugs Wakix (Pitolisant) P/A, S/E Xyrem Solution (Sodium Oxybate) P/A, S/E NARC Infertility Drugs Bravelle (Urofollitropin) P/A Req’d Cetrotide (Cetrorelix Acetate) P/A Req’d Follistim AQ (Follitropin Beta) P/A Req’d Gonal-F, Gonal-F RFF (Follitropin Alfa) P/A Req‘d Novarel (Chorionic Gonadotropin, Human) P/A Req‘d Ovidrel (Choriogonadotropin Alfa) P/A Req’d INFS Intrauterine Devices Kyleena, Liletta (Levonorgesterol) P/A Req‘d Mirena, Skyla (Levonorgesterol) P/A Req‘d IUDS

48 Specialty: Sickle Cell Anemia & Others

GENERIC DRUGS PREFERRED BRANDS NON-PREFERRED BRANDS Sickle Cell Anemia Adakveo IV (Crizanlizumab) Medical Only Oxbryta (Voxelotor) P/A Req’d - Hold

SCA Other Drugs Epidiolex (Cannabidiol) P/A Req‘d [Dravet Only] MISC

49 Miscellaneous Notes

Miscellaneous Notes: Non-Listed Injectibles, Infusion & Oral Products

Injectibles: There are therapeutic categories that contain injectable specialty drugs that are not listed in this formulary listing (PDL). If you have any questions as to the tier preference of a specific non-listed injectable specialty drug, please contact your account manager for more information. Injectibles that require medical administration or medical/nursing support that not shown in this PDL. Infusion: There are infused drugs administered at home or at a facility by a healthcare professional that require medical/nursing support. If one of those drugs is not listed, those medications should be processed through medical benefits. Other Oral Products: Oral products (other than oral oncology and HIV drugs) that are not listed in this PDL should be considered having a Non- Preferred Brand copay. Single Source Brand Oral Oncology and Immunosuppresant Drugs: Unless noted, Single Source Brand oral drugs generally have a preferred brand copay applied, while Multi-Source Brand drugs have a non-preferred copay applied. Multi-Source Generic Oral Oncology and Immunosuppresant drugs generally have a generic copay applied.

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Clinical Guidelines

Clinical Guideline Sources

Clinical guidelines from recognized industry sources are utilized by our clinicians as reference for consistent treatment care. Using these guidelines, we assist physicians in understanding the “best practices” adopted by medical experts and healthcare professionals to manage and control the well-being of patients. This section, which will be expanded over time contains some of the most predominant clinical protocols available:  Diabetes Care Guidelines  COPD Gold Guidelines

51 Diabetes Care Guidelines American Diabetes Association

52 COPD GOLD Guidelines Global Initiative for Chronic Obstructive Lung Disease

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