North Carolina State Health Plan Preferred Drug List - Traditional Pharmacy Benefit

July 2021

The North Carolina State Health Plan Preferred Drug List - Traditional Pharmacy Benefit is a guide within select therapeutic categories for plan members enrolled in the traditional pharmacy benefit and their health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a doctor. on this list.

Please note: Please note: • Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in • This drug list represents a summary of prescription coverage. Itis this document. Products recently approved by the U.S. Food and not all-inclusive and does not guarantee coverage. The member’s Drug Administration (FDA) may not be covered upon release specific prescription benefit plan design may not cover certain to the market. products or categories, regardless of their appearance in this • You may be responsible for the full cost of non-formulary products document. Products recently approved by the FDA may not be that are removed from coverage. covered upon release to the market. • For specific information regarding your prescription benefit • The member's prescription benefit plan may have a different coverage and copay1 information, please visit Caremark.com copay for specific products on the list. or contact a CVS Caremark Customer Care representative. • Unless specifically indicated, drug list products will include all • CVS Caremark may contact your doctor after receiving your dosage forms. prescription to request consideration of a drug list product or • Log in to Caremark.com to check coverage and copay generic equivalent. This may result in your doctor prescribing, information for a specific medicine. when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. List is subject to change.

ANALGESICS § ERYTHROMYCINS / CARDIOVASCULAR § FIBRATES HEART FAILURE MACROLIDES fenofibrate (except fenofibrate capsule BIDIL § NSAIDs § ACE INHIBITORS azithromycin 50 mg, 130 mg; fenofibrate tablet 40 mg, CORLANOR PA diclofenac sodium clarithromycin fosinopril 120 mg) ENTRESTO PA ibuprofen clarithromycin ext-rel lisinopril fenofibric acid delayed-rel § NITRATES meloxicam erythromycins quinapril § HMG-CoA REDUCTASE naproxen (except naproxen CR or DIFICID ramipril isosorbide dinitrate (except

naproxen suspension) INHIBITORS / isosorbide dinitrate 40 mg) § ACE INHIBITOR / § FLUOROQUINOLONES COMBINATIONS isosorbide mononitrate § NSAIDs, COMBINATIONS DIURETIC COMBINATIONS ciprofloxacin atorvastatin nitroglycerin lingual spray diclofenac sodium- levofloxacin fosinopril-hydrochlorothiazide ezetimibe-simvastatin nitroglycerin sublingual misoprostol moxifloxacin lisinopril-hydrochlorothiazide fluvastatin § MISCELLANEOUS quinapril-hydrochlorothiazide lovastatin § NSAIDs, TOPICAL § PENICILLINS ranolazine ext-rel § ANGIOTENSIN II pravastatin diclofenac sodium gel 1% amoxicillin RECEPTOR ANTAGONISTS / rosuvastatin PA, QL amoxicillin-clavulanate CENTRAL NERVOUS DIURETIC COMBINATIONS simvastatin diclofenac sodium solution dicloxacillin SYSTEM PA, QL penicillin VK candesartan / candesartan- § NIACINS ANTIANXIETY hydrochlorothiazide § COX-2 INHIBITORS niacin ext-rel § TETRACYCLINES irbesartan / irbesartan- § BENZODIAZEPINES celecoxib doxycycline hyclate 20 mg hydrochlorothiazide § OMEGA-3 FATTY ACIDS alprazolam

losartan / losartan- clonazepam § GOUT doxycycline hyclate capsule omega-3 acid ethyl esters PA minocycline hydrochlorothiazide VASCEPA PA diazepam allopurinol tetracycline olmesartan / olmesartan- lorazepam colchicine tablet hydrochlorothiazide § BETA-BLOCKERS oxazepam probenecid § ANTIFUNGALS telmisartan / telmisartan- atenolol § ANTICONVULSANTS § OPIOID ANALGESICS fluconazole hydrochlorothiazide carvedilol itraconazole valsartan / valsartan- carvedilol phosphate ext-rel carbamazepine buprenorphine transdermal terbinafine tablet hydrochlorothiazide metoprolol succinate ext-rel carbamazepine ext-rel QL, ST metoprolol tartrate clobazam PA codeine-acetaminophen QL ANTIVIRALS § ANGIOTENSIN II nadolol diazepam rectal gel fentanyl transdermal PA, QL, RECEPTOR ANTAGONIST / § CYTOMEGALOVIRUS pindolol divalproex sodium ST CALCIUM CHANNEL AGENTS propranolol divalproex sodium ext-rel fentanyl transmucosal BLOCKER COMBINATIONS valganciclovir propranolol ext-rel ethosuximide lozenge PA, QL amlodipine-olmesartan BYSTOLIC gabapentin hydrocodone ext-rel PA, QL, § HERPES AGENTS amlodipine-telmisartan lamotrigine ST acyclovir capsule, tablet amlodipine-valsartan § CALCIUM CHANNEL lamotrigine ext-rel hydrocodone-acetaminophen valacyclovir BLOCKERS levetiracetam QL § ANGIOTENSIN II amlodipine levetiracetam ext-rel hydromorphone PA, QL INFLUENZA AGENTS RECEPTOR ANTAGONIST / diltiazem ext-rel (except generics oxcarbazepine hydromorphone ext-rel PA, CALCIUM CHANNEL oseltamivir PA, QL for CARDIZEM LA) phenobarbital QL, ST BLOCKER / DIURETIC RELENZA PA, QL nifedipine ext-rel phenytoin methadone QL, ST COMBINATIONS verapamil ext-rel phenytoin sodium extended morphine PA, QL § MISCELLANEOUS amlodipine-valsartan- primidone morphine ext-rel PA, QL, ST § CALCIUM CHANNEL clindamycin hydrochlorothiazide rufinamide morphine suppository BLOCKER / ANTILIPEMIC ivermectin olmesartan-amlodipine- tiagabine oxycodone PA, QL COMBINATIONS linezolid hydrochlorothiazide topiramate oxycodone-acetaminophen metronidazole amlodipine-atorvastatin valproic acid QL § ANTIARRHYTHMICS nitrofurantoin (except NDC^ zonisamide disopyramide § DIGITALIS GLYCOSIDES tramadol (except NDC^ 70408023932) FYCOMPA sotalol digoxin 52817019610) PA, QL pyrimethamine NAYZILAM MULTAQ tramadol ext-rel tablet PA, sulfamethoxazole- OXTELLAR XR § DIRECT RENIN QL, ST trimethoprim ANTILIPEMICS INHIBITORS / DIURETIC TROKENDI XR BELBUCA QL, ST vancomycin capsule VALTOCO ACL INHIBITORS / COMBINATIONS NUCYNTA PA, QL EMVERM PA, QL VIMPAT COMBINATIONS aliskiren NUCYNTA ER PA, QL, ST XIFAXAN 550 MG XCOPRI TEKTURNA HCT SUBSYS PA, QL NEXLETOL PA, ST ANTINEOPLASTIC XTAMPZA ER PA, QL, ST NEXLIZET PA, ST § ANTIDEMENTIA § DIURETICS AGENTS donepezil § BILE ACID RESINS amiloride ANTI-INFECTIVES galantamine HORMONAL furosemide cholestyramine galantamine ext-rel ANTIBACTERIALS ANTINEOPLASTIC AGENTS hydrochlorothiazide colesevelam memantine § CEPHALOSPORINS § ANTIANDROGENS metolazone rivastigmine bicalutamide § CHOLESTEROL spironolactone- cefdinir rivastigmine transdermal ABSORPTION INHIBITORS cefprozil hydrochlorothiazide § MISCELLANEOUS NAMZARIC cefuroxime axetil ezetimibe torsemide cephalexin VISTOGARD triamterene

SUPRAX triamterene- hydrochlorothiazide

ANTIDEPRESSANTS amphetamine- PSYCHOTHERAPEUTIC - NOVOLIN N BD ULTRAFINE INSULIN § SELECTIVE SEROTONIN dextroamphetamine mixed MISCELLANEOUS NOVOLIN R SYRINGES AND REUPTAKE INHIBITORS salts ext-rel PA, QL, † § OPIOID ANTAGONISTS NOVOLOG NEEDLES atomoxetine PA, QL NOVOLOG MIX 70/30 OMNIPOD DASH INSULIN (SSRIs) naloxone injection dexmethylphenidate ext-rel TOUJEO INFUSION PUMP citalopram NARCAN NASAL SPRAY PA, QL TRESIBA OMNIPOD INSULIN escitalopram guanfacine ext-rel § PARTIAL OPIOID AGONIST INFUSION PUMP fluoxetine (except fluoxetine tablet 60 § INSULIN SENSITIZERS methylphenidate PA, QL / OPIOID ANTAGONIST ONETOUCH ULTRA mg, fluoxetine tablet [generics for methylphenidate ext-rel PA, COMBINATIONS pioglitazone STRIPS AND KITS 2 SARAFEM]) QL, † ONETOUCH VERIO STRIPS paroxetine HCl buprenorphine-naloxone § INSULIN SENSITIZER / MYDAYIS PA, QL AND KITS 2 paroxetine HCl ext-rel sublingual BIGUANIDE COMBINATIONS VYVANSE PA, QL V-GO INSULIN INFUSION sertraline ZUBSOLV pioglitazone-metformin PUMP TRINTELLIX § FIBROMYALGIA PSEUDOBULBAR AFFECT § INSULIN SENSITIZER / § SEROTONIN pregabalin AGENTS ANTIOBESITY SULFONYLUREA NOREPINEPHRINE INJECTABLE HYPNOTICS NUEDEXTA PA COMBINATIONS REUPTAKE INHIBITORS SAXENDA PA § NONBENZODIAZEPINES ENDOCRINE AND pioglitazone-glimepiride (SNRIs) eszopiclone PA, QL ORAL desvenlafaxine ext-rel METABOLIC § MEGLITINIDES ramelteon QSYMIA PA duloxetine § ANDROGENS nateglinide zolpidem PA, QL venlafaxine repaglinide CALCIUM REGULATORS zolpidem ext-rel PA, QL testosterone gel (except authorized venlafaxine ext-rel capsule BELSOMRA PA generics for TESTIM and VOGELXO) SODIUM-GLUCOSE § BISPHOSPHONATES PA § MISCELLANEOUS CO-TRANSPORTER 2 alendronate § TRICYCLICS testosterone solution PA AGENTS (SGLT2) INHIBITORS ibandronate doxepin ANDRODERM PA risedronate bupropion FARXIGA NATESTO PA bupropion ext-rel (except MIGRAINE JARDIANCE § CALCITONINS

bupropion ext-rel tablet 450 mg) ACUTE MIGRAINE AGENTS ANTIDIABETICS mirtazapine SODIUM-GLUCOSE calcitonin-salmon § Triptans AMYLIN ANALOGS CO-TRANSPORTER 2 trazodone § CARNITINE DEFICIENCY eletriptan PA, QL SYMLINPEN (SGLT2) INHIBITOR / AGENTS § ANTIPARKINSONIAN naratriptan PA, QL BIGUANIDE COMBINATIONS AGENTS § BIGUANIDES levocarnitine rizatriptan PA, QL SYNJARDY metformin amantadine sumatriptan PA, QL SYNJARDY XR metformin ext-rel (except generics CONTRACEPTIVES carbidopa-levodopa zolmitriptan PA, QL XIGDUO XR for FORTAMET and GLUMETZA) § MONOPHASIC carbidopa-levodopa ext-rel ONZETRA XSAIL PA, QL SODIUM-GLUCOSE ethinyl estradiol- carbidopa-levodopa- ZEMBRACE SYMTOUCH § BIGUANIDE / CO-TRANSPORTER 2 drospirenone entacapone PA, QL SULFONYLUREA (SGLT2) INHIBITOR / ethinyl estradiol- entacapone ZOMIG NASAL SPRAY PA, COMBINATIONS pramipexole QL DIPEPTIDYL PEPTIDASE-4 drospirenone-levomefolate glipizide-metformin (DPP-4) INHIBITOR ethinyl estradiol- pramipexole ext-rel Miscellaneous rasagiline DIPEPTIDYL PEPTIDASE-4 COMBINATIONS norethindrone acetate ethinyl estradiol- ropinirole NURTEC ODT PA, QL, ST (DPP-4) INHIBITORS GLYXAMBI ropinirole ext-rel REYVOW PA, QL, ST norethindrone acetate-iron JANUVIA SODIUM-GLUCOSE selegiline UBRELVY PA, QL, ST BIPHASIC NEUPRO DIPEPTIDYL PEPTIDASE-4 CO-TRANSPORTER 2 PREVENTIVE MIGRAINE (DPP-4) INHIBITOR / (SGLT2) INHIBITOR / LO LOESTRIN FE ANTIPSYCHOTICS AGENTS DIPEPTIDYL PEPTIDASE-4 BIGUANIDE COMBINATIONS § TRIPHASIC § ATYPICALS MONOCLONAL ANTIBODIES (DPP-4) INHIBITOR / JANUMET BIGUANIDE COMBINATIONS ethinyl estradiol-norgestimate aripiprazole AIMOVIG ST JANUMET XR clozapine AJOVY ST TRIJARDY XR § EXTENDED CYCLE olanzapine EMGALITY ST INCRETIN MIMETIC AGENTS § SULFONYLUREAS ethinyl estradiol- quetiapine OZEMPIC QL levonorgestrel § MUSCULOSKELETAL quetiapine ext-rel RYBELSUS QL glimepiride THERAPY AGENTS risperidone TRULICITY QL glipizide § TRANSDERMAL ziprasidone cyclobenzaprine (except VICTOZA QL glipizide ext-rel ethinyl estradiol- cyclobenzaprine tablet 7.5 mg) ABILIFY MAINTENA SUPPLIES norelgestromin LATUDA PA INCRETIN MIMETIC AGENT / § NARCOLEPSY ACCU-CHEK AVIVA PLUS INSULIN COMBINATIONS § VAGINAL PERSERIS 2 armodafinil PA STRIPS AND KITS VRAYLAR PA SOLIQUA ethinyl estradiol-etonogestrel modafinil PA ACCU-CHEK COMPACT XULTOPHY 2 ANNOVERA § ATTENTION DEFICIT SUNOSI PA, QL PLUS STRIPS AND KITS HYPERACTIVITY DISORDER INSULINS ACCU-CHEK GUIDE ENDOMETRIOSIS POSTHERPETIC 2 amphetamine- BASAGLAR STRIPS AND KITS NEURALGIA (PHN) ORILISSA PA dextroamphetamine mixed FIASP ACCU-CHEK SMARTVIEW GRALISE 2 salts PA, QL HUMULIN R U-500 STRIPS AND KITS § GLUCOCORTICOIDS HORIZANT LEVEMIR dexamethasone

NOVOLIN 70/30 fludrocortisone

hydrocortisone GASTROINTESTINAL § PROTON PUMP NUTRITIONAL / Nebulized Passive Inhalation methylprednisolone INHIBITORS SUPPLEMENTS PERFOROMIST QL § ANTIDIARRHEALS prednisolone solution esomeprazole delayed-rel § ELECTROLYTES § LEUKOTRIENE prednisone diphenoxylate-atropine lansoprazole delayed-rel MODULATORS loperamide omeprazole delayed-rel potassium chloride liquid GLUCOSE ELEVATING pantoprazole delayed-rel montelukast AGENTS § ANTIEMETICS VITAMINS AND MINERALS tablet zafirlukast BAQSIMI aprepitant § FOLIC ACID / DEXILANT PA, ST GLUCAGEN HYPOKIT doxylamine-pyridoxine COMBINATIONS § NASAL ANTIHISTAMINES GLUCAGON EMERGENCY delayed-rel § STEROIDS, RECTAL folic acid azelastine

KIT dronabinol PA, QL PROCTOFOAM-HC olopatadine GVOKE granisetron PA, QL § PRENATAL VITAMINS meclizine § ULCER THERAPY prenatal vitamins § NASAL STEROIDS / MENOPAUSAL SYMPTOM metoclopramide COMBINATIONS CITRANATAL COMBINATIONS AGENTS ondansetron PA, QL PYLERA flunisolide § ORAL prochlorperazine RESPIRATORY fluticasone promethazine § MISCELLANEOUS mometasone estradiol § ANAPHYLAXIS estradiol-norethindrone scopolamine transdermal sucralfate tablet DYMISTA TREATMENT AGENTS DUAVEE trimethobenzamide epinephrine auto-injector PHOSPHODIESTERASE-4 PREMPHASE SANCUSO PA, QL GENITOURINARY EPIPEN INHIBITORS PREMPRO § BENIGN PROSTATIC § ANTISPASMODICS EPIPEN JR DALIRESP HYPERPLASIA § TRANSDERMAL dicyclomine SYMJEPI alfuzosin ext-rel STEROID / BETA AGONIST estradiol § H2 RECEPTOR doxazosin § ANTICHOLINERGICS COMBINATIONS CLIMARA PRO ANTAGONISTS dutasteride ipratropium inhalation COMBIPATCH ADVAIR DISKUS QL dutasteride-tamsulosin solution † DIVIGEL famotidine ADVAIR HFA , QL finasteride SPIRIVA BREO ELLIPTA †, QL EVAMIST INFLAMMATORY BOWEL silodosin YUPELRI SYMBICORT QL

§ VAGINAL DISEASE tamsulosin ANTICHOLINERGIC / BETA § ORAL AGENTS terazosin § STEROID INHALANTS estradiol vaginal cream AGONIST COMBINATIONS IMVEXXY balsalazide CIALIS ST budesonide inhalation § SHORT ACTING budesonide capsule suspension PA, QL § URINARY § PHOSPHATE BINDER budesonide ext-rel ipratropium-albuterol ARNUITY ELLIPTA QL ANTISPASMODICS AGENTS mesalamine delayed-rel inhalation solution FLOVENT DISKUS QL darifenacin ext-rel calcium acetate (except mesalamine delayed-rel tablet FLOVENT HFA QL oxybutynin LONG ACTING sevelamer carbonate 800 mg) PULMICORT FLEXHALER oxybutynin ext-rel ANORO ELLIPTA QL PHOSLYRA mesalamine ext-rel PA, QL solifenacin STIOLTO RESPIMAT QL VELPHORO sulfasalazine QVAR REDIHALER QL tolterodine sulfasalazine delayed-rel ANTICHOLINERGIC / BETA POTASSIUM-REMOVING tolterodine ext-rel TOPICAL PENTASA AGONIST / STEROID AGENTS trospium INHALANT COMBINATIONS DERMATOLOGY LOKELMA § RECTAL AGENTS trospium ext-rel BREZTRI AEROSPHERE ACNE VELTASSA hydrocortisone enema MYRBETRIQ TRELEGY ELLIPTA QL mesalamine suppository TOVIAZ § Topical PROGESTINS mesalamine suspension § ANTIHISTAMINES, adapalene PA § ORAL HEMATOLOGIC CORTIFOAM LOW SEDATING benzoyl peroxide medroxyprogesterone § ANTICOAGULANTS clindamycin gel (except NDC^ § IRRITABLE BOWEL levocetirizine megestrol acetate 68682046275) warfarin progesterone, micronized SYNDROME clindamycin solution ELIQUIS § ANTITUSSIVES alosetron clindamycin-benzoyl VAGINAL XARELTO benzonatate (except NDCs^ LINZESS peroxide 69336012615, 69499032915) CRINONE PA VIBERZI erythromycin solution § CHELATING AGENTS ENDOMETRIN PA erythromycin-benzoyl § LAXATIVES penicillamine capsule BETA AGONISTS, peroxide § SELECTIVE ESTROGEN trientine INHALANTS lactulose solution tretinoin PA RECEPTOR MODULATORS § SHORT ACTING peg 3350-electrolytes § PLATELET AGGREGATION EPIDUO PA, ST raloxifene CLENPIQ INHIBITORS albuterol inhalation solution ONEXTON PA, ST QL clopidogrel § THYROID SUPPLEMENTS OPIOID-INDUCED albuterol sulfate CFC-free § ACTINIC KERATOSIS CONSTIPATION dipyridamole ext-rel-aspirin levothyroxine aerosol QL fluorouracil cream 5% prasugrel liothyronine MOVANTIK PA levalbuterol tartrate, CFC- fluorouracil solution BRILINTA SYNTHROID SYMPROIC PA free aerosol QL, ST imiquimod

PICATO UTERINE FIBROIDS PANCREATIC ENZYMES IMMUNOLOGIC LONG ACTING AGENTS TOLAK ORIAHNN PA CREON Hand-held Active Inhalation ZYCLARA

VIOKACE ALLERGENIC EXTRACTS SEREVENT QL ZENPEP GRASTEK PA STRIVERDI RESPIMAT PA, § ANTIBIOTICS

RAGWITEK PA QL gentamicin

mupirocin ointment triamcinolone cream, lotion, cromolyn sodium loteprednol § PROSTAGLANDINS

ointment (except triamcinolone olopatadine prednisolone acetate 1% latanoprost § ANTIFUNGALS ointment 0.05%) DUREZOL travoprost ciclopirox § ANTI-INFECTIVES LUMIGAN ST clotrimazole § High Potency ciprofloxacin § ANTIVIRALS ZIOPTAN econazole desoximetasone erythromycin trifluridine ketoconazole cream 2% fluocinonide (except fluocinonide gentamicin RHO KINASE INHIBITORS BETA-BLOCKERS nystatin cream 0.1%) levofloxacin RHOPRESSA NAFTIN BRYHALI PA moxifloxacin § Nonselective

ofloxacin timolol maleate solution § SYMPATHOMIMETICS § ANTIPSORIATICS § Very High Potency sulfacetamide brimonidine Selective acitretin PA clobetasol cream, foam, gel, tobramycin ALPHAGAN P calcipotriene ointment, lotion, ointment, shampoo BESIVANCE BETOPTIC S solution SYMPATHOMIMETIC / BETA- § LOCAL ANALGESICS methoxsalen § ANTI-INFECTIVE / § CARBONIC ANHYDRASE BLOCKER COMBINATIONS INHIBITORS lidocaine patch PA, QL ANTI-INFLAMMATORY COMBIGAN

§ ANTISEBORRHEICS COMBINATIONS dorzolamide § LOCAL ANESTHETICS ketoconazole shampoo 2% neomycin-polymyxin B- AZOPT RHO KINASE INHIBITOR / selenium sulfide lotion 2.5% lidocaine-prilocaine PA, QL bacitracin-hydrocortisone PROSTAGLANDIN

neomycin-polymyxin B- § CARBONIC ANHYDRASE COMBINATIONS § ATOPIC DERMATITIS § ROSACEA INHIBITOR / BETA- dexamethasone ROCKLATAN ST azelaic acid gel BLOCKER COMBINATIONS pimecrolimus PA tobramycin-dexamethasone metronidazole OTIC tacrolimus PA TOBRADEX OINTMENT dorzolamide-timolol EUCRISA ST FINACEA FOAM PA § ANTI-INFECTIVES SOOLANTRA PA CARBONIC ANHYDRASE ANTI-INFLAMMATORIES acetic acid CORTICOSTEROIDS INHIBITOR / MOUTH / THROAT / § Nonsteroidal ofloxacin otic § Low Potency SYMPATHOMIMETIC bromfenac DENTAL AGENTS COMBINATIONS § ANTI-INFECTIVE / desonide diclofenac PROTECTANTS SIMBRINZA ANTI-INFLAMMATORY hydrocortisone ketorolac EPISIL COMBINATIONS

ILEVRO DRY EYE DISEASE § Medium Potency ciprofloxacin-dexamethasone OPHTHALMIC PROLENSA hydrocortisone butyrate RESTASIS PA neomycin-polymyxin B- § ANTIALLERGICS XIIDRA PA cream, ointment, solution § Steroidal hydrocortisone

mometasone azelastine dexamethasone QUICK REFERENCE DRUG LIST

A amantadine sublingual ciprofloxacin amiloride B bupropion ciprofloxacin-dexamethasone ABILIFY MAINTENA (except citalopram ACCU-CHEK AVIVA PLUS amlodipine balsalazide bupropion ext-rel amlodipine-atorvastatin BAQSIMI bupropion ext-rel tablet 450 mg) CITRANATAL STRIPS AND KITS 2

ACCU-CHEK COMPACT amlodipine-olmesartan BASAGLAR BYSTOLIC clarithromycin amlodipine-telmisartan clarithromycin ext-rel PLUS STRIPS AND BD ULTRAFINE INSULIN amlodipine-valsartan SYRINGES AND C CLENPIQ KITS 2 ACCU-CHEK GUIDE amlodipine-valsartan- NEEDLES calcipotriene ointment, CLIMARA PRO hydrochlorothiazide BELBUCA QL, ST solution clindamycin STRIPS AND KITS 2 amoxicillin clindamycin gel (except NDC^ ACCU-CHEK SMARTVIEW BELSOMRA PA calcitonin-salmon amoxicillin-clavulanate calcium acetate 68682046275) STRIPS AND KITS 2 benzonatate (except NDCs^ amphetamine- candesartan clindamycin solution acetic acid 69336012615, 69499032915) dextroamphetamine mixed candesartan- clindamycin-benzoyl acitretin PA benzoyl peroxide salts PA, QL hydrochlorothiazide peroxide acyclovir capsule, tablet BESIVANCE amphetamine- carbamazepine clobazam PA adapalene PA BETOPTIC S dextroamphetamine mixed clobetasol cream, foam, gel, bicalutamide carbamazepine ext-rel ADVAIR DISKUS QL † salts ext-rel PA, QL, carbidopa-levodopa lotion, ointment, shampoo ADVAIR HFA †, QL BIDIL ANDRODERM PA † carbidopa-levodopa ext-rel clonazepam AIMOVIG ST BREO ELLIPTA , QL ANNOVERA carbidopa-levodopa- clopidogrel AJOVY ST BREZTRI AEROSPHERE ANORO ELLIPTA QL clotrimazole albuterol inhalation solution BRILINTA entacapone aprepitant carvedilol clozapine QL brimonidine aripiprazole codeine-acetaminophen QL albuterol sulfate CFC-free bromfenac carvedilol phosphate ext-rel armodafinil PA cefdinir colchicine tablet aerosol QL BRYHALI PA ARNUITY ELLIPTA QL cefprozil colesevelam alendronate budesonide capsule atenolol cefuroxime axetil COMBIGAN alfuzosin ext-rel budesonide ext-rel atomoxetine PA, QL celecoxib COMBIPATCH aliskiren budesonide inhalation atorvastatin cephalexin CORLANOR PA allopurinol suspension PA, QL azelaic acid gel cholestyramine CORTIFOAM alosetron buprenorphine transdermal azelastine CIALIS ST CREON ALPHAGAN P QL, ST azithromycin ciclopirox CRINONE PA alprazolam buprenorphine-naloxone AZOPT cromolyn sodium

cyclobenzaprine (except erythromycin solution galantamine ext-rel latanoprost MYRBETRIQ

cyclobenzaprine tablet 7.5 mg) erythromycin-benzoyl gentamicin LATUDA PA peroxide glimepiride levalbuterol tartrate, CFC- N D erythromycins glipizide free aerosol QL, ST nadolol DALIRESP escitalopram glipizide ext-rel LEVEMIR NAFTIN darifenacin ext-rel esomeprazole delayed-rel glipizide-metformin levetiracetam naloxone injection desonide estradiol GLUCAGEN HYPOKIT levetiracetam ext-rel NAMZARIC desoximetasone estradiol vaginal cream GLUCAGON EMERGENCY levocarnitine naproxen (except naproxen CR or desvenlafaxine ext-rel estradiol-norethindrone KIT levocetirizine naproxen suspension) dexamethasone eszopiclone PA, QL GLYXAMBI levofloxacin naratriptan PA, QL DEXILANT PA, ST ethinyl estradiol- GRALISE levothyroxine NARCAN NASAL SPRAY dexmethylphenidate ext-rel drospirenone granisetron PA, QL lidocaine patch PA, QL nateglinide PA, QL ethinyl estradiol- GRASTEK PA lidocaine-prilocaine PA, QL NATESTO PA diazepam drospirenone-levomefolate guanfacine ext-rel linezolid NAYZILAM diazepam rectal gel ethinyl estradiol-etonogestrel GVOKE LINZESS neomycin-polymyxin B- diclofenac ethinyl estradiol- liothyronine bacitracin-hydrocortisone diclofenac sodium levonorgestrel H lisinopril neomycin-polymyxin B- diclofenac sodium gel 1% ethinyl estradiol- HORIZANT lisinopril-hydrochlorothiazide dexamethasone PA, QL norelgestromin HUMULIN R U-500 LO LOESTRIN FE neomycin-polymyxin B- diclofenac sodium solution ethinyl estradiol- hydrochlorothiazide LOKELMA hydrocortisone PA, QL norethindrone acetate hydrocodone ext-rel PA, QL, loperamide NEUPRO diclofenac sodium- ethinyl estradiol- ST lorazepam NEXLETOL PA, ST misoprostol norethindrone acetate-iron hydrocodone-acetaminophen losartan NEXLIZET PA, ST dicloxacillin ethinyl estradiol-norgestimate QL losartan-hydrochlorothiazide niacin ext-rel dicyclomine ethosuximide hydrocortisone loteprednol nifedipine ext-rel DIFICID EUCRISA ST hydrocortisone butyrate lovastatin nitrofurantoin (except NDC^ digoxin EVAMIST cream, ointment, solution LUMIGAN ST 70408023932) diltiazem ext-rel (except generics ezetimibe hydrocortisone enema nitroglycerin lingual spray for CARDIZEM LA) ezetimibe-simvastatin hydromorphone PA, QL M nitroglycerin sublingual diphenoxylate-atropine hydromorphone ext-rel PA, meclizine NOVOLIN 70/30 dipyridamole ext-rel-aspirin F QL, ST medroxyprogesterone NOVOLIN N disopyramide famotidine megestrol acetate NOVOLIN R divalproex sodium FARXIGA I meloxicam NOVOLOG divalproex sodium ext-rel fenofibrate (except fenofibrate capsule ibandronate memantine NOVOLOG MIX 70/30 DIVIGEL 50 mg, 130 mg; fenofibrate tablet 40 mg, ibuprofen mesalamine delayed-rel NUCYNTA PA, QL donepezil 120 mg) ILEVRO (except mesalamine delayed-rel tablet NUCYNTA ER PA, QL, ST dorzolamide fenofibric acid delayed-rel imiquimod 800 mg) NUEDEXTA PA dorzolamide-timolol fentanyl transdermal PA, IMVEXXY mesalamine ext-rel NURTEC ODT PA, QL, ST doxazosin QL, ST ipratropium inhalation mesalamine suppository nystatin doxepin fentanyl transmucosal solution mesalamine suspension doxycycline hyclate 20 mg lozenge PA, QL ipratropium-albuterol metformin O doxycycline hyclate capsule FIASP inhalation solution metformin ext-rel (except generics ofloxacin doxylamine-pyridoxine FINACEA FOAM PA irbesartan for FORTAMET and GLUMETZA) ofloxacin otic delayed-rel finasteride irbesartan- methadone QL, ST olanzapine dronabinol PA, QL FLOVENT DISKUS QL hydrochlorothiazide methoxsalen olmesartan DUAVEE FLOVENT HFA QL isosorbide dinitrate (except methylphenidate PA, QL olmesartan-amlodipine- duloxetine fluconazole isosorbide dinitrate 40 mg) methylphenidate ext-rel PA, hydrochlorothiazide † DUREZOL fludrocortisone isosorbide mononitrate QL, olmesartan- dutasteride flunisolide itraconazole methylprednisolone hydrochlorothiazide dutasteride-tamsulosin fluocinonide (except fluocinonide ivermectin metoclopramide olopatadine DYMISTA cream 0.1%) metolazone omega-3 acid ethyl esters

fluorouracil cream 5% J metoprolol succinate ext-rel PA E fluorouracil solution JANUMET metoprolol tartrate omeprazole delayed-rel econazole fluoxetine (except fluoxetine tablet 60 JANUMET XR metronidazole OMNIPOD DASH INSULIN eletriptan PA, QL mg, fluoxetine tablet [generics for JANUVIA minocycline INFUSION PUMP ELIQUIS SARAFEM]) JARDIANCE mirtazapine OMNIPOD INSULIN EMGALITY ST fluticasone modafinil PA INFUSION PUMP EMVERM PA, QL fluvastatin K mometasone ondansetron PA, QL

ENDOMETRIN PA folic acid ketoconazole cream 2% montelukast ONETOUCH ULTRA 2 entacapone fosinopril ketoconazole shampoo 2% morphine PA, QL STRIPS AND KITS

ENTRESTO PA fosinopril-hydrochlorothiazide ketorolac morphine ext-rel PA, QL, ST ONETOUCH VERIO STRIPS EPIDUO PA, ST furosemide morphine suppository AND KITS 2 epinephrine auto-injector FYCOMPA L MOVANTIK PA ONEXTON PA, ST

moxifloxacin EPIPEN lactulose solution ONZETRA XSAIL PA, QL G MULTAQ EPIPEN JR lamotrigine ORIAHNN PA mupirocin ointment EPISIL gabapentin lamotrigine ext-rel ORILISSA PA MYDAYIS PA, QL erythromycin galantamine lansoprazole delayed-rel oseltamivir PA, QL

oxazepam PROLENSA sertraline timolol maleate solution VELPHORO oxcarbazepine promethazine sevelamer carbonate TOBRADEX OINTMENT VELTASSA OXTELLAR XR propranolol silodosin tobramycin venlafaxine oxybutynin propranolol ext-rel SIMBRINZA tobramycin-dexamethasone venlafaxine ext-rel capsule oxybutynin ext-rel PULMICORT FLEXHALER simvastatin TOLAK verapamil ext-rel oxycodone PA, QL PA, QL solifenacin tolterodine V-GO INSULIN INFUSION oxycodone-acetaminophen PYLERA SOLIQUA tolterodine ext-rel PUMP QL pyrimethamine SOOLANTRA PA topiramate VIBERZI OZEMPIC QL sotalol torsemide VICTOZA QL Q SPIRIVA TOUJEO VIMPAT P QSYMIA PA spironolactone- TOVIAZ VIOKACE pantoprazole delayed-rel quetiapine hydrochlorothiazide tramadol (except NDC^ VISTOGARD tablet quetiapine ext-rel STIOLTO RESPIMAT QL 52817019610) PA, QL VRAYLAR PA paroxetine HCl quinapril STRIVERDI RESPIMAT PA, tramadol ext-rel tablet PA, VYVANSE PA, QL paroxetine HCl ext-rel quinapril-hydrochlorothiazide QL QL, ST W peg 3350-electrolytes QVAR REDIHALER QL SUBSYS PA, QL travoprost penicillamine capsule sucralfate tablet trazodone warfarin penicillin VK R sulfacetamide TRELEGY ELLIPTA QL PENTASA RAGWITEK PA sulfamethoxazole- TRESIBA X PERFOROMIST QL raloxifene trimethoprim tretinoin PA XARELTO PERSERIS ramelteon sulfasalazine triamcinolone cream, lotion, XCOPRI phenobarbital ramipril sulfasalazine delayed-rel ointment (except triamcinolone XIFAXAN 550 MG phenytoin ranolazine ext-rel sumatriptan PA, QL ointment 0.05%) XIGDUO XR phenytoin sodium extended rasagiline SUNOSI PA, QL triamterene XIIDRA PA PHOSLYRA RELENZA PA, QL SUPRAX triamterene- XTAMPZA ER PA, QL, ST PICATO repaglinide SYMBICORT QL hydrochlorothiazide XULTOPHY pimecrolimus PA RESTASIS PA SYMJEPI trientine pindolol REYVOW PA, QL, ST SYMLINPEN trifluridine Y pioglitazone RHOPRESSA SYMPROIC PA TRIJARDY XR YUPELRI pioglitazone-glimepiride risedronate SYNJARDY trimethobenzamide pioglitazone-metformin risperidone SYNJARDY XR TRINTELLIX Z SYNTHROID potassium chloride liquid rivastigmine TROKENDI XR zafirlukast pramipexole rivastigmine transdermal trospium ZEMBRACE SYMTOUCH T pramipexole ext-rel rizatriptan PA, QL trospium ext-rel PA, QL prasugrel ROCKLATAN ST tacrolimus PA TRULICITY QL ZENPEP pravastatin ropinirole tamsulosin ZIOPTAN U prednisolone acetate 1% ropinirole ext-rel TEKTURNA HCT ziprasidone prednisolone solution rosuvastatin telmisartan UBRELVY PA, QL, ST zolmitriptan PA, QL prednisone rufinamide telmisartan- zolpidem PA, QL pregabalin RYBELSUS QL hydrochlorothiazide V zolpidem ext-rel PA, QL PREMPHASE terazosin valacyclovir ZOMIG NASAL SPRAY PA, PREMPRO S terbinafine tablet valganciclovir QL prenatal vitamins testosterone gel (except authorized SANCUSO PA, QL valproic acid zonisamide primidone generics for TESTIM and VOGELXO) SAXENDA PA valsartan ZUBSOLV probenecid PA scopolamine transdermal valsartan-hydrochlorothiazide ZYCLARA prochlorperazine testosterone solution PA selegiline VALTOCO PROCTOFOAM-HC tetracycline selenium sulfide lotion 2.5% vancomycin capsule progesterone, micronized tiagabine SEREVENT QL VASCEPA PA PREFERRED OPTIONS LIST FOR NON-COVERED MEDICATIONS DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, ACTOS pioglitazone quetiapine ext-rel, risperidone, ziprasidone, LATUDA PA, VRAYLAR PA ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA ACANYA adapalene PA, benzoyl peroxide, clindamycin gel (except acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir NDC^ 68682046275), clindamycin solution, clindamycin- ADDERALL amphetamine-dextroamphetamine mixed salts PA, QL, benzoyl peroxide, erythromycin solution, erythromycin- methylphenidate PA, QL benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, ONEXTON PA, ST ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel † PA, QL, methylphenidate ext-rel † PA, QL, MAYDAYIS PA, QL, ACIPHEX, ACIPHEX esomeprazole delayed-rel, lansoprazole delayed-rel, VYVANSE PA, QL SPRINKLE omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT PA, ST ADZENYS ER, amphetamine-dextroamphetamine mixed salts ext-rel † PA, ADZENYS XR-ODT QL, dexmethylphenidate ext-rel PA, QL, methylphenidate ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate capsule, ext-rel † PA, QL, MAYDAYIS PA, QL, VYVANSE PA, QL minocycline, tetracycline ALCORTIN A desonide, hydrocortisone Activite folic acid

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ALEVICYN GEL, desonide, hydrocortisone BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, ALEVICYN SG, ALEVICYN irbesartan-hydrochlorothiazide, losartan, losartan- SOLUTION hydrochlorothiazide, olmesartan, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- ALLISON MEDICAL INSULIN BD ULTRAFINE INSULIN SYRINGES hydrochlorothiazide, valsartan, valsartan- 3 SYRINGES hydrochlorothiazide ALREX azelastine, cromolyn sodium, olopatadine BENSAL HP desonide, hydrocortisone ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, BENZACLIN adapalene PA, benzoyl peroxide, clindamycin gel (except pravastatin, rosuvastatin, simvastatin NDC^ 68682046275), clindamycin solution, clindamycin- ALVESCO ARNUITY ELLIPTA QL, FLOVENT DISKUS QL, benzoyl peroxide, erythromycin solution, erythromycin- FLOVENT HFA QL, PULMICORT FLEXHALER PA, QL, benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, QVAR REDIHALER QL ONEXTON PA, ST AMITIZA LINZESS, MOVANTIK PA, SYMPROIC PA benzonatate benzonatate (except NDCs^ 69336012615, 69499032915 (NDCs^ 69336012615, only) AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) 69499032915 only) ANDROGEL testosterone gel (except authorized generics for TESTIM BEPREVE azelastine, cromolyn sodium, olopatadine and VOGELXO) PA, testosterone solution PA, ANDRODERM PA, NATESTO PA BETAPACE, BETAPACE AF sotalol APEXICON E desoximetasone (except desoximetasone ointment 0.05%), BETIMOL timolol maleate solution, BETOPTIC S fluocinonide (except fluocinonide cream 0.1%), BRYHALI BEVESPI AEROSPHERE ANORO ELLIPTA QL, STIOLTO RESPIMAT QL PA BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol- APIDRA FIASP, NOVOLOG drospirenone-levomefolate, ethinyl estradiol-norethindrone APTENSIO XR amphetamine-dextroamphetamine mixed salts ext-rel † PA, acetate, ethinyl estradiol-norethindrone acetate-iron QL, dexmethylphenidate ext-rel PA, QL, methylphenidate bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN ST, ZIOPTAN ext-rel † PA, QL, MAYDAYIS PA, QL, VYVANSE PA, QL BREEZE 2 STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU- ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam or KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- naproxen (except naproxen CR or naproxen CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK suspension) WITH esomeprazole delayed-rel, lansoprazole SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA delayed-rel, omeprazole delayed-rel, pantoprazole STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND delayed-rel tablet or DEXILANT PA, ST KITS 2 ASACOL HD balsalazide, mesalamine delayed-rel, mesalamine ext-rel, BROMSITE bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA sulfasalazine, sulfasalazine delayed-rel, PENTASA Bupap diclofenac sodium, ibuprofen, naproxen (except naproxen 2 ASCENSIA STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU- CR or naproxen suspension) KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA tablet 450 mg) STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 butalbital-acetaminophen tablet diclofenac sodium, ibuprofen, naproxen (except naproxen 50-300 mg, CR or naproxen suspension) ASMANEX, ASMANEX HFA ARNUITY ELLIPTA QL, FLOVENT DISKUS QL, FLOVENT BUTALBITAL- HFA QL, PULMICORT FLEXHALER PA, QL, ACETAMINOPHEN (NDC^ QVAR REDIHALER QL 69499034230 only) ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, butalbital-acetaminophen- diclofenac sodium, ibuprofen, naproxen (except naproxen irbesartan-hydrochlorothiazide, losartan, losartan- caffeine capsule CR or naproxen suspension) hydrochlorothiazide, olmesartan, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- BUTRANS buprenorphine transdermal QL, ST, BELBUCA QL, ST hydrochlorothiazide, valsartan, valsartan- BYDUREON OZEMPIC QL, TRULICITY QL, RYBELSUS QL, hydrochlorothiazide VICTOZA QL ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam BYETTA OZEMPIC QL, TRULICITY QL, RYBELSUS QL, ATOPADERM desonide, hydrocortisone VICTOZA QL AVENOVA Consult doctor CAFERGOT eletriptan PA, QL, naratriptan PA, QL, rizatriptan PA, QL, sumatriptan PA, QL, zolmitriptan PA, QL, NURTEC ODT AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, PA, QL, ST, ONZETRA XSAIL PA, QL, REYVOW PA, QL, moxifloxacin, ofloxacin, sulfacetamide, tobramycin, ST, UBRELVY PA, QL, ST, ZEMBRACE SYMTOUCH PA, BESIVANCE QL, ZOMIG NASAL SPRAY PA, QL AZESCO 5 prenatal vitamins, CITRANATAL calcipotriene cream calcipotriene ointment, calcipotriene solution AZOR amlodipine-olmesartan, amlodipine-telmisartan, calcipotriene-betamethasone calcipotriene ointment or calcipotriene solution WITH amlodipine-valsartan desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%) or BANZEL SUSPENSION clobazam PA, lamotrigine, rufinamide, topiramate, BRYHALI PA TROKENDI XR calcitriol ointment calcipotriene ointment, calcipotriene solution BEAU RX Consult doctor BECONASE AQ flunisolide, fluticasone, mometasone, DYMISTA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CORDRAN OINTMENT hydrocortisone butyrate cream, hydrocortisone butyrate CR or naproxen suspension) ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, ointment (except triamcinolone ointment 0.05%) PICATO, TOLAK, ZYCLARA COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, CARAFATE sucralfate tablet metoprolol succinate ext-rel, metoprolol tartrate, nadolol, CARBINOXAMINE TABLET levocetirizine pindolol, propranolol, propranolol ext-rel, BYSTOLIC 6 MG CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule, CARDIZEM, CARDIZEM CD, diltiazem ext-rel (except generics for CARDIZEM LA) minocycline, tetracycline CARDIZEM LA COZAAR candesartan, irbesartan, losartan, olmesartan, telmisartan, carisoprodol 250 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) valsartan CARNITOR, CARNITOR SF levocarnitine CRESEMBA itraconazole CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam, CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, naproxen (except naproxen CR or naproxen suspension) pravastatin, rosuvastatin, simvastatin chlordiazepoxide-clidinium dicyclomine CUPRIMINE penicillamine capsule (NDCs^ 11534019701, cyclobenzaprine ext-rel cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) 42494040901, 51293069601, capsule, 51293069610 only) cyclobenzaprine tablet 7.5 mg chlorzoxazone 375 mg, cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, chlorzoxazone 500 mg (NDC^ venlafaxine ext-rel capsule 73007001303 only), chlorzoxazone 750 mg, CYTOMEL levothyroxine, liothyronine, SYNTHROID CHLORZOXAZONE 250 MG DARAPRIM pyrimethamine CICATRACE Consult doctor DAYTRANA amphetamine-dextroamphetamine mixed salts ext-rel † PA, CILOXAN ciprofloxacin, erythromycin, gentamicin, levofloxacin, QL, dexmethylphenidate ext-rel PA, QL, methylphenidate moxifloxacin, ofloxacin, sulfacetamide, tobramycin, ext-rel † PA, QL, MAYDAYIS PA, QL, VYVANSE PA, QL BESIVANCE DELZICOL balsalazide, mesalamine delayed-rel (except mesalamine CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic desoximetasone ointment hydrocortisone butyrate cream, hydrocortisone butyrate clindamycin gel (NDC^ adapalene PA, benzoyl peroxide, clindamycin gel (except 0.05% ointment, hydrocortisone butyrate solution, mometasone, 68682046275 only) NDC^ 68682046275), clindamycin solution, clindamycin- triamcinolone cream, triamcinolone lotion, triamcinolone benzoyl peroxide, erythromycin solution, erythromycin- ointment (except triamcinolone ointment 0.05%) benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, ONEXTON PA, ST DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, clobetasol spray clobetasol foam MYRBETRIQ, TOVIAZ CLOBEX SPRAY clobetasol foam dexchlorpheniramine levocetirizine clocortolone cream hydrocortisone butyrate cream, hydrocortisone butyrate Dexifol folic acid ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone Diclofex diclofenac sodium, diclofenac sodium gel 1% PA, QL, ointment (except triamcinolone ointment 0.05%) DC (NDC^ 51021037201 only) diclofenac sodium solution PA, QL, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) COLAZAL balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, Diclosaicin diclofenac sodium, diclofenac sodium gel 1% PA, QL, sulfasalazine, sulfasalazine delayed-rel, PENTASA diclofenac sodium solution PA, QL, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) colchicine capsule colchicine tablet DIFFERIN LOTION adapalene PA, benzoyl peroxide, clindamycin gel (except COLCRYS colchicine tablet NDC^ 68682046275), clindamycin solution, clindamycin- CONSENSI amlodipine WITH celecoxib benzoyl peroxide, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, CONTOUR NEXT STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU- ONEXTON PA, ST AND KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK diflorasone cream, diflorasone desoximetasone (except desoximetasone ointment 0.05%), SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA ointment fluocinonide (except fluocinonide cream 0.1%), STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND BRYHALI PA 2 KITS dihydroergotamine spray eletriptan PA, QL, naratriptan PA, QL, rizatriptan PA, QL, CONTOUR STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU- sumatriptan PA, QL, zolmitriptan PA, QL, NURETC ODT KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- PA, QL, ST, ONZETRA XSAIL PA, QL, REYVOW PA, QL, CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK ST, UBRELVY PA, QL, ST, ZEMBRACE SYMTOUCH PA, SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA QL, ZOMIG NASAL SPRAY PA, QL 2 STRIPS AND KITS , ONETOUCH VERIO STRIPS AND diltiazem ext-rel (generics for diltiazem ext-rel (except generics for CARDIZEM LA) 2 KITS CARDIZEM LA only) CONTRAVE QSYMIA PA, SAXENDA PA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, FABIOR adapalene PA, benzoyl peroxide, clindamycin gel (except irbesartan-hydrochlorothiazide, losartan, losartan- NDC^ 68682046275), clindamycin solution, clindamycin- hydrochlorothiazide, olmesartan, olmesartan- benzoyl peroxide, erythromycin solution, erythromycin- hydrochlorothiazide, telmisartan, telmisartan- benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, hydrochlorothiazide, valsartan, valsartan- ONEXTON PA, ST hydrochlorothiazide FANAPT aripiprazole, clozapine, olanzapine, quetiapine, Diphen Elixir levocetirizine quetiapine ext-rel, risperidone, ziprasidone, LATUDA PA, VRAYLAR PA DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline fenofibrate capsule 50 mg, 130 fenofibrate (except fenofibrate capsule 50 mg, 130 mg; mg; fenofibrate tablet 40 mg, fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed- doxepin cream desonide, hydrocortisone, pimecrolimus PA, tacrolimus PA, 120 mg rel EUCRISA ST FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate capsule 50 mg, 130 mg; doxycycline hyclate delayed-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed- tablet 50 mg, 200 mg minocycline, tetracycline rel doxycycline hyclate tablet 50 doxycycline hyclate 20 mg, doxycycline hyclate capsule, fenoprofen, FENOPROFEN diclofenac sodium, ibuprofen, meloxicam, naproxen (except mg (NDC^ 72143021160 only), minocycline, tetracycline CAPSULE naproxen CR or naproxen suspension) doxycycline hyclate tablet 75 mg, doxycycline hyclate tablet FERIVA 21/7 folic acid 150 mg FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM PA, doxycycline monohydrate doxycycline hyclate 20 mg, doxycycline hyclate capsule, SOOLANTRA PA capsule 75 mg, minocycline, tetracycline doxycycline monohydrate FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except naproxen capsule 150 mg CR or naproxen suspension) DULERA ADVAIR DISKUS QL, ADVAIR HFA † QL, FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, BREO ELLIPTA † QL, SYMBICORT QL DUREZOL DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide flucytosine capsule 500 mg fluconazole DYRENIUM amiloride, triamterene fluocinonide cream 0.1% clobetasol cream EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, irbesartan-hydrochlorothiazide, losartan, losartan- PICATO, TOLAK, ZYCLARA hydrochlorothiazide, olmesartan, olmesartan- fluoxetine tablet (generics for fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet hydrochlorothiazide, telmisartan, telmisartan- SARAFEM only) [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline hydrochlorothiazide, valsartan, valsartan- hydrochlorothiazide fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), E.E.S. GRANULES erythromycins paroxetine HCl, paroxetine HCl ext-rel, sertraline, EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine TRINTELLIX ext-rel capsule flurandrenolide cream, desonide, hydrocortisone ELIDEL pimecrolimus PA, tacrolimus PA, EUCRISA ST flurandrenolide lotion ELMIRON Consult doctor flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, ENABLEX darifenacin ext-rel, oxybutynin ext-rel, triamcinolone cream, triamcinolone lotion, triamcinolone solifenacin, tolterodine, tolterodine ext-rel, trospium, ointment (except triamcinolone ointment 0.05%) trospium ext-rel, MYRBETRIQ, TOVIAZ FML FORTE, FML LIQUIFILM, dexamethasone, loteprednol, prednisolone acetate 1%, ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG FML S.O.P. DUREZOL EPICERAM desonide, hydrocortisone FOCALIN XR amphetamine-dextroamphetamine mixed salts ext-rel † PA, QL, dexmethylphenidate ext-rel PA, QL, methylphenidate ergotamine-caffeine eletriptan PA, QL, naratriptan PA, QL, rizatriptan PA, QL, ext-rel † PA, QL, MAYDAYIS PA, QL, VYVANSE PA, QL sumatriptan PA, QL, zolmitriptan PA, QL, NURTEC ODT PA, QL, ST, ONZETRA XSAIL PA, QL, REYVOW PA, QL, FOLIC-K folic acid ST, UBRELVY PA, QL, ST, ZEMBRACE SYMTOUCH PA, QL, ZOMIG NASAL SPRAY PA, QL Folvite-D folic acid ERYPED erythromycins FORTAMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) estradiol vaginal tablet estradiol vaginal cream, IMVEXXY FORTESTA testosterone gel (except authorized generics for TESTIM ESTRING estradiol vaginal cream, IMVEXXY and VOGELXO) PA, testosterone solution PA, ANDRODERM PA, NATESTO PA EVEKEO amphetamine-dextroamphetamine mixed salts PA, QL, methylphenidate PA, QL FOSRENOL calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan- amlodipine-hydrochlorothiazide

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* FREESTYLE STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU- INVELTYS dexamethasone, loteprednol, prednisolone acetate 1%, KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- DUREZOL CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND INVOKANA FARXIGA, JARDIANCE KITS 2 isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), Genicin Vita-S folic acid isosorbide mononitrate GLUMETZA metformin, metformin ext-rel (except generics for JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH FORTAMET and GLUMETZA) alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, GLYCOPYRROLATE dicyclomine terazosin, or CIALIS ST TABLET 1.5 MG JENTADUETO, JANUMET, JANUMET XR GOLYTELY peg 3350-electrolytes, CLENPIQ JENTADUETO XR halcinonide cream desoximetasone (except desoximetasone ointment 0.05%), KAMDOY desonide, hydrocortisone fluocinonide (except fluocinonide cream 0.1%), BRYHALI KAZANO JANUMET, JANUMET XR PA ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5% HUMALOG FIASP, NOVOLOG Ketodan ketoconazole shampoo 2%, selenium sulfide lotion 2.5% HUMALOG MIX 50/50 NOVOLOG MIX 70/30 ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except HUMALOG MIX 75/25 NOVOLOG MIX 70/30 naproxen CR or naproxen suspension) HUMULIN 70/30 NOVOLIN 70/30 ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except HUMULIN N NOVOLIN N naproxen CR or naproxen suspension) HUMULIN R NOVOLIN R KOMBIGLYZE XR JANUMET, JANUMET XR hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate LACRISERT RESTASIS PA, XIIDRA PA lipophilic cream 0.1% ointment, hydrocortisone butyrate solution, mometasone, Lactojen Consult doctor triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) LACTULOSE PAK lactulose solution hydrocortisone butyrate lotion hydrocortisone butyrate cream, hydrocortisone butyrate LANOXIN TABLET (125 MCG digoxin ointment, hydrocortisone butyrate solution, mometasone, and 250 MCG only) triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO HylaVite folic acid LANTUS 6 BASAGLAR, LEVEMIR hyoscyamine sulfate ext-rel dicyclomine LASTACAFT azelastine, cromolyn sodium, olopatadine HYSINGLA ER fentanyl transdermal PA, QL, ST, hydrocodone ext-rel PA, QL, ST, hydromorphone ext-rel PA, QL, ST, LAZANDA fentanyl transmucosal lozenge PA, QL, SUBSYS PA, QL methadone QL, ST, morphine ext-rel PA, QL, ST, LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, NUCYNTA ER PA, QL, ST, XTAMPZA ER PA, QL, ST pravastatin, rosuvastatin, simvastatin HYZAAR candesartan-hydrochlorothiazide, irbesartan- levorphanol fentanyl transdermal PA, QL, ST, hydrocodone ext-rel PA, hydrochlorothiazide, losartan-hydrochlorothiazide, QL, ST, hydromorphone ext-rel PA, QL, ST, olmesartan-hydrochlorothiazide, telmisartan- methadone QL, ST, morphine ext-rel PA, QL, ST, hydrochlorothiazide, valsartan-hydrochlorothiazide NUCYNTA ER PA, QL, ST, XTAMPZA ER PA, QL, ST icosapent ethyl omega-3 acid ethyl esters PA, VASCEPA PA LEXAPRO citalopram, escitalopram, fluoxetine (except fluoxetine INCRUSE ELLIPTA SPIRIVA, YUPELRI tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, INDERAL LA, INDERAL XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol TRINTELLIX succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC LIALDA balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, INDOCIN diclofenac sodium, ibuprofen, meloxicam, naproxen (except sulfasalazine, sulfasalazine delayed-rel, PENTASA naproxen CR or naproxen suspension) LIBRAX dicyclomine indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) LIDOCAINE-TETRACAINE lidocaine-prilocaine PA, QL CREAM (NDC^ 71800063115 Inflammacin diclofenac sodium, diclofenac sodium gel 1% PA, QL, only) diclofenac sodium solution PA, QL, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) LIDOTREX lidocaine-prilocaine PA, QL INTRAROSA estradiol vaginal cream, IMVEXXY LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel † PA, QL, atomoxetine PA, QL, dexmethylphenidate ext-rel PA, LITHOSTAT Consult doctor QL, guanfacine ext-rel PA, QL, methylphenidate ext-rel † LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, PA, QL, MYDAYIS PA, QL, VYVANSE PA, QL pravastatin, rosuvastatin, simvastatin

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* Lorid folic acid mupirocin cream gentamicin, mupirocin ointment Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) MYTESI diphenoxylate-atropine, loperamide LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone acetate 1%, NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except DUREZOL naproxen CR or naproxen suspension) luliconazole ciclopirox, clotrimazole, econazole, ketoconazole cream naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen 2%, NAFTIN (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, LUNESTA doxepin, eszopiclone PA, QL, ramelteon, zolpidem PA, omeprazole delayed-rel, pantoprazole delayed-rel tablet or QL, zolpidem ext-rel PA, QL, BELSOMRA PA DEXILANT PA, ST LYRICA duloxetine, pregabalin naproxen CR diclofenac sodium, ibuprofen, meloxicam, naproxen (except MACRODANTIN nitrofurantoin (except NDC^ 70408023932) naproxen CR or naproxen suspension) Matzim LA diltiazem ext-rel (except generics for CARDIZEM LA) naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) MAXALT, MAXALT-MLT eletriptan PA, QL, naratriptan PA, QL, rizatriptan PA, QL, sumatriptan PA, QL, zolmitriptan PA, QL, NURTEC ODT NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol- PA, QL, ST, ONZETRA XSAIL PA, QL, REYVOW PA, QL, drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ST, UBRELVY PA, QL, ST, ZEMBRACE SYMTOUCH PA, ethinyl estradiol-norethindrone acetate, ethinyl estradiol- QL, ZOMIG NASAL SPRAY PA, QL norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE MAXIDEX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL NATURE-THROID levothyroxine, liothyronine, SYNTHROID mefenamic acid (NDC^ diclofenac sodium, ibuprofen, meloxicam, naproxen (except NEO-SYNALAR desonide or hydrocortisone WITH gentamicin 69336012830 only) naproxen CR or naproxen suspension) NESINA JANUVIA mesalamine delayed-rel tablet balsalazide, mesalamine delayed-rel (except mesalamine NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA 800 mg delayed-rel tablet 800 mg), mesalamine ext- rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) DEXILANT PA, ST metformin ext-rel (generics for metformin, metformin ext-rel (except generics for niacin tablet 500 mg niacin ext-rel FORTAMET and GLUMETZA FORTAMET and GLUMETZA) only) Niacor niacin ext-rel methocarbamol 500 mg (NDC^ cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) NICADAN folic acid 69036091010 only), methocarbamol 750 mg NICAPRIN folic acid (NDCs^ 69036093090, NICAZEL, NICAZEL FORTE folic acid 70868090190 only) NICOMIDE folic acid MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO PA, QL, PROLIA PA, QL, TYMLOS PA, QL NILANDRON abiraterone PA, QL, bicalutamide, XTANDI PA, QL, YONSA PA, QL MIACALCIN NASAL SPRAY calcitonin-salmon nitrofurantoin (NDC^ nitrofurantoin (except NDC^ 70408023932) Migergot eletriptan PA, QL, naratriptan PA, QL, rizatriptan PA, QL, 70408023932 only) sumatriptan PA, QL, zolmitriptan PA, QL, NURTEC ODT PA, QL, ST, ONZETRA XSAIL PA, QL, REYVOW PA, QL, Nolix desonide, hydrocortisone ST, UBRELVY PA, QL, ST, ZEMBRACE SYMTOUCH PA, QL, ZOMIG NASAL SPRAY PA, QL NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, NORITATE azelaic acid gel, metronidazole, FINACEA FOAM PA, prednisolone solution, prednisone SOOLANTRA PA MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol- NORPACE disopyramide drospirenone-levomefolate, ethinyl estradiol-norethindrone NORVASC amlodipine acetate, ethinyl estradiol-norethindrone acetate-iron NOURIANZ amantadine, entacapone, pramipexole, pramipexole ext-rel, MINIVELLE estradiol, DIVIGEL, EVAMIST rasagiline, ropinirole, ropinirole ext-rel, selegiline, NEUPRO MINOCIN doxycycline hyclate 20 mg, doxycycline hyclate capsule, NOVACORT desonide, hydrocortisone minocycline, tetracycline NOVO NORDISK NEEDLES 3 BD ULTRAFINE NEEDLES minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline NOXAFIL fluconazole, itraconazole MIRVASO azelaic acid gel, metronidazole, FINACEA FOAM PA, NuDiclo SoluPak, NuDiclo diclofenac sodium, diclofenac sodium gel 1% PA, QL, SOOLANTRA PA TabPak diclofenac sodium solution PA, QL, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension) Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline NUVARING ethinyl estradiol-etonogestrel, ANNOVERA MOVIPREP peg 3350-electrolytes, CLENPIQ NUVIGIL armodafinil PA, modafinil PA, SUNOSI PA, QL MultiPro Consult doctor OLEPTRO trazodone

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* OLUX-E clobetasol foam PRECISION XTRA STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU- AND KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- omeprazole-sodium esomeprazole delayed-rel, lansoprazole delayed-rel, CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK bicarbonate omeprazole delayed-rel, pantoprazole delayed-rel tablet, SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA DEXILANT PA, ST STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND OMNARIS flunisolide, fluticasone, mometasone, DYMISTA KITS 2 OMNIVEX folic acid PRED FORTE, PRED MILD dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL ONFI clobazam PA, lamotrigine, rufinamide, topiramate, TROKENDI XR PREMARIN estradiol ONGLYZA JANUVIA PREMARIN CREAM estradiol vaginal cream, IMVEXXY orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) PRENATAL PLUS 5 prenatal vitamins, CITRANATAL Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) PREVACID esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or ORTHO D folic acid DEXILANT PA, ST ORTHO DF folic acid PREVIDENT Consult doctor Oscimin SR dicyclomine PRILOSEC esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone DEXILANT PA, ST OSMOPREP peg 3350-electrolytes, CLENPIQ PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine OWEN MUMFORD BD ULTRAFINE NEEDLES ext-rel capsule 3 NEEDLES PROAIR HFA, PROAIR albuterol sulfate CFC-free aerosol, oxiconazole (NDCs^ ciclopirox, clotrimazole, econazole, ketoconazole cream RESPICLICK levalbuterol tartrate CFC-free aerosol 00168035830, 51672135902 2%, NAFTIN PRODIGEN Consult doctor only) PROMETRIUM medroxyprogesterone; progesterone, micronized OXYCONTIN fentanyl transdermal PA, QL, ST, hydrocodone ext-rel PA, QL, ST, hydromorphone ext-rel PA, QL, PROTONIX esomeprazole delayed-rel, lansoprazole delayed-rel, ST, methadone QL, ST, morphine ext-rel PA, QL, ST, omeprazole delayed-rel, pantoprazole delayed-rel tablet or NUCYNTA ER PA, QL, ST, XTAMPZA ER PA, QL, ST DEXILANT PA, ST oxymorphone ext-rel fentanyl transdermal PA, QL, ST, hydrocodone ext-rel PA, PROVAD Consult doctor QL, ST, hydromorphone ext-rel PA, QL, ST, methadone QL, ST, morphine ext-rel PA, QL, ST, PROVENTIL HFA albuterol sulfate CFC-free aerosol QL, NUCYNTA ER PA, QL, ST, XTAMPZA ER PA, QL, ST levalbuterol tartrate CFC-free aerosol QL, ST OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, PROVIGIL armodafinil PA, modafinil PA, SUNOSI PA, QL tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine MYRBETRIQ, TOVIAZ tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), pantoprazole delayed-rel esomeprazole delayed-rel, lansoprazole delayed-rel, paroxetine HCl, paroxetine HCl ext-rel, sertraline, suspension omeprazole delayed-rel, pantoprazole delayed-rel tablet or TRINTELLIX DEXILANT PA, ST PSORCON desoximetasone (except desoximetasone ointment 0.05%), paroxetine mesylate capsule paroxetine HCl fluocinonide (except fluocinonide cream 0.1%), 7.5 mg BRYHALI PA PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine QNASL flunisolide, fluticasone, mometasone, DYMISTA tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), QTERN GLYXAMBI paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX quazepam doxepin, eszopiclone PA, QL, ramelteon, zolpidem PA, QL, zolpidem ext-rel PA, QL, BELSOMRA PA PENNSAID diclofenac sodium, diclofenac sodium gel 1% PA, QL, diclofenac sodium solution PA, QL, ibuprofen, meloxicam, RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, naproxen (except naproxen CR or naproxen suspension) terazosin PERCOCET hydrocodone-acetaminophen QL, hydromorphone PA, QL, RAYOS dexamethasone, hydrocortisone, methylprednisolone, morphine PA, QL, oxycodone-acetaminophen QL, prednisolone solution, prednisone NUCYNTA PA, QL RECEDO Consult doctor PERRIGO NEEDLES 3 BD ULTRAFINE NEEDLES RELION INSULIN NOVOLIN INSULIN PLAVIX clopidogrel, prasugrel, BRILINTA RHEUMATE folic acid POLYTOZA Consult doctor RIBOZEL folic acid posaconazole delayed-rel tablet fluconazole, itraconazole RIMSO-50 Consult doctor PRADAXA warfarin, ELIQUIS, XARELTO RIOMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) ROZEREM doxepin, eszopiclone PA, QL, ramelteon, zolpidem PA, QL, zolpidem ext-rel PA, QL, BELSOMRA PA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* RyClora levocetirizine THEO-24 ipratropium inhalation solution, PERFOROMIST QL, SEREVENT QL, SPIRIVA, STRIVERDI RESPIMAT PA, RYTARY carbidopa-levodopa, carbidopa-levodopa ext-rel QL, YUPELRI SCARSILK PAD Consult doctor THIOLA, THIOLA EC Consult doctor SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol- TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol- TIROSINT levothyroxine, SYNTHROID norethindrone acetate-iron TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone, SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, neomycin-polymyxin B-dexamethasone, tobramycin- quetiapine ext-rel, risperidone, ziprasidone, LATUDA PA, dexamethasone, TOBRADEX OINTMENT VRAYLAR PA topiramate ext-rel capsule carbamazepine, carbamazepine ext-rel, clobazam PA, SILENOR doxepin, eszopiclone PA, QL, ramelteon, zolpidem PA, (generics for QUDEXY XR divalproex sodium, divalproex sodium ext-rel, gabapentin, QL, zolpidem ext-rel PA, QL, BELSOMRA PA only) lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, SIL-K PAD Consult doctor phenytoin, phenytoin sodium extended, primidone, SILIVEX Consult doctor rufinamide, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, SILTREX Consult doctor VIMPAT, XCOPRI SINGULAIR montelukast, zafirlukast TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, SORILUX calcipotriene ointment, calcipotriene solution propranolol, propranolol ext-rel, BYSTOLIC SPRIX diclofenac sodium, ibuprofen, meloxicam, naproxen (except TRADJENTA JANUVIA naproxen CR or naproxen suspension) tramadol (NDC^ 52817019610 tramadol (except NDC^ 52817019610) PA, QL, tramadol SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV only), tramadol ext-rel capsule ext-rel tablet PA, QL, ST sucralfate suspension sucralfate tablet TRANSDERM SCOP meclizine, scopolamine transdermal sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen TRAVATAN Z latanoprost, travoprost, LUMIGAN ST, ZIOPTAN CR or naproxen suspension) WITH eletriptan PA, QL, naratriptan PA, QL, rizatriptan PA, QL, sumatriptan PA, TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen QL, zolmitriptan PA, QL, NURTEC ODT PA, QL, ST, CR or naproxen suspension) WITH eletriptan PA, QL, ONZETRA XSAIL PA, QL, REYVOW PA, QL, ST, naratriptan PA, QL, rizatriptan PA, QL, sumatriptan PA, UBRELVY PA, QL, ST, ZEMBRACE SYMTOUCH PA, QL QL, zolmitriptan PA, QL, NURTEC ODT PA, QL, ST, or ZOMIG NASAL SPRAY PA, QL ONZETRA XSAIL PA, QL, REYVOW PA, QL, ST, UBRELVY PA, QL, ST, ZEMBRACE SYMTOUCH PA, QL SUPREP peg 3350-electrolytes, CLENPIQ or ZOMIG NASAL SPRAY PA, QL 2 SURE-TEST STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS , ACCU- triamcinolone aerosol 0.2% hydrocortisone butyrate cream, hydrocortisone butyrate 4 2 KITS CHEK COMPACT PLUS STRIPS AND KITS , ACCU- ointment, hydrocortisone butyrate solution, mometasone, 2 CHEK GUIDE STRIPS AND KITS , ACCU-CHEK triamcinolone cream, triamcinolone lotion, triamcinolone 2 SMARTVIEW STRIPS AND KITS , ONETOUCH ULTRA ointment (except triamcinolone ointment 0.05%) STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 triamcinolone ointment 0.05% hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, Symax-SR dicyclomine triamcinolone cream, triamcinolone lotion, triamcinolone SYNERDERM desonide, hydrocortisone ointment (except triamcinolone ointment 0.05%) SYPRINE trientine Trianex hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, TALIVA folic acid triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) TARGADOX doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline TRICOR fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed- TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol- rel drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron TRINAZ 5 prenatal vitamins, CITRANATAL TAZORAC adapalene PA, benzoyl peroxide, clindamycin gel (except TRIVIDIA INSULIN BD ULTRAFINE INSULIN SYRINGES NDC^ 68682046275), clindamycin solution, clindamycin- SYRINGES 3 benzoyl peroxide, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, TronVite folic acid ONEXTON PA, ST; calcipotriene ointment, calcipotriene TRUETEST STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU- solution KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- TESTIM testosterone gel (except authorized generics for TESTIM CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK and VOGELXO) PA, testosterone solution PA, SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA ANDRODERM PA, NATESTO PA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 testosterone gel 1% (authorized testosterone gel (except authorized generics for TESTIM generics for TESTIM and and VOGELXO) PA, testosterone solution PA, VOGELXO only) ANDRODERM PA, NATESTO PA

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* TRUETRACK STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU- XYZBAC folic acid KITS 4 CHEK COMPACT PLUS STRIPS AND KITS 2, ACCU- CHEK GUIDE STRIPS AND KITS 2, ACCU-CHEK YASMIN ethinyl estradiol-drospirenone, ethinyl estradiol- SMARTVIEW STRIPS AND KITS 2, ONETOUCH ULTRA drospirenone-levomefolate, ethinyl estradiol- STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND norethindrone acetate, ethinyl estradiol- KITS 2 norethindrone acetate-iron TUDORZA SPIRIVA, YUPELRI YAZ ethinyl estradiol-drospirenone, ethinyl estradiol- drospirenone-levomefolate, ethinyl estradiol-norethindrone ULORIC allopurinol acetate, ethinyl estradiol-norethindrone acetate-iron ULTIMED INSULIN BD ULTRAFINE INSULIN SYRINGES Yuvafem estradiol vaginal cream, IMVEXXY SYRINGES 3 ZALVIT 5 prenatal vitamins, CITRANATAL ULTIMED NEEDLES 3 BD ULTRAFINE NEEDLES ZEGERID esomeprazole delayed-rel, lansoprazole delayed-rel, UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, omeprazole delayed-rel, pantoprazole delayed-rel tablet, terazosin, CIALIS ST DEXILANT PA, ST VALCYTE valganciclovir ZELAC Consult doctor VALTREX acyclovir capsule, acyclovir tablet, valacyclovir ZERVIATE azelastine, cromolyn sodium, olopatadine Vanoxide-HC adapalene PA, benzoyl peroxide, clindamycin gel (except ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril- NDC^ 68682046275), clindamycin solution, clindamycin- hydrochlorothiazide, quinapril-hydrochlorothiazide benzoyl peroxide, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, ZETIA ezetimibe ONEXTON PA, ST ZETONNA flunisolide, fluticasone, mometasone, DYMISTA VASCULERA Consult doctor ZIANA adapalene PA, benzoyl peroxide, clindamycin gel (except VECTICAL calcipotriene ointment, calcipotriene solution NDC^ 68682046275), clindamycin solution, clindamycin- benzoyl peroxide, erythromycin solution, erythromycin- VELTIN adapalene PA, benzoyl peroxide, clindamycin gel (except benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, NDC^ 68682046275), clindamycin solution, clindamycin- ONEXTON PA, ST benzoyl peroxide, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin PA, EPIDUO PA, ST, zileuton ext-rel montelukast, zafirlukast ONEXTON, PA, ST ZIRGAN trifluridine venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ZOHYDRO ER fentanyl transdermal PA, QL, ST, hydrocodone ext-rel PA, (except 225 mg) ext-rel capsule QL, ST, hydromorphone ext-rel PA, QL, VENTOLIN HFA albuterol sulfate CFC-free aerosol QL, ST, methadone QL, ST, morphine ext-rel PA, QL, ST, levalbuterol tartrate CFC-free aerosol QL, ST NUCYNTA ER PA, QL, ST, XTAMPZA ER PA, QL, ST VEREGEN imiquimod ZOLOFT citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), VIIBRYD citalopram, escitalopram, fluoxetine (except fluoxetine paroxetine HCl, paroxetine HCl ext-rel, sertraline, tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), TRINTELLIX paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX zolpidem sublingual doxepin, eszopiclone PA, QL, ramelteon, zolpidem PA, QL, zolpidem ext-rel PA, QL, BELSOMRA PA Vitasure folic acid ZOLPIMIST doxepin, eszopiclone PA, QL, ramelteon, zolpidem PA, VIVELLE-DOT estradiol, DIVIGEL, EVAMIST QL, zolpidem ext-rel PA, QL, BELSOMRA PA VOGELXO testosterone gel (except authorized generics for TESTIM ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, and VOGELXO) PA, testosterone divalproex sodium ext-rel, gabapentin, lamotrigine, solution PA, ANDRODERM PA, NATESTO PA lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, WESTHROID levothyroxine, liothyronine, SYNTHROID phenytoin sodium extended, primidone, tiagabine, WP THYROID levothyroxine, liothyronine, SYNTHROID topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam ZONTIVITY Consult doctor XENICAL QSYMIA PA, SAXENDA PA ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except Xelitral diclofenac sodium, diclofenac sodium gel 1% (except NDC^ naproxen CR or naproxen suspension) 69499031866) PA, QL, diclofenac sodium solution PA, QL, ibuprofen, meloxicam, naproxen (except naproxen CR or ZUPLENZ granisetron PA, QL, ondansetron PA, QL, SANCUSO PA, naproxen suspension) QL XOLEGEL ciclopirox, ketoconazole cream 2% ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin-polymyxin B-dexamethasone, tobramycin- XOPENEX HFA albuterol sulfate CFC-free aerosol QL, dexamethasone, TOBRADEX OINTMENT levalbuterol tartrate CFC-free aerosol QL, ST ZYVIT folic acid Xvite folic acid

You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. † Listing does not include certain NDCs^. PA Prior Authorization QL Quantity Limit ST Step Therapy 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 3 BD ULTRAFINE syringes and needles are the only preferred options. 4 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options. 5 Generic prenatal vitamins and CITRANATAL are the only preferred options. 6 Long Acting Insulins - First Generation.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.