April2024
CVScaremark'
Advanced Control Formulary®

The CVS Caremark· Advanced Control Formulary• isa guide within select therapeutic categories for clients, plan members and health care providers. Generics shouldbe 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 representationalpurposes only. This is not an all­ inclusive list and does not guarantee coverage. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
PLAN MEMBER
Your benefit plan provides you with prescription drug coverage that is administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list the next time you or a covered family member sees a doctor.
	Your specific prescription benefit plan design may not cover certain medications, products or categories, regardless of their appearance in this document. Medications and products recently
approved by the U.S. Food and Drug Administration (FDA) may not be covered immediately upon release to the market.
Your prescription benefit plan design may alter coverage of certain products or vary cost sharing amounts based on the condition being treated.
You may be responsible for the full cost of medications and products that are removed from coverage.
	For specific information regarding your prescription benefit coverage and cost sharing, or if you have additional questions, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu.
When a generic medication that is equivalent to a brand-name drug is released to the market, in most instances, that brand-name drug will be designated as a non-preferred option.
HEALTH CARE PROVIDER
Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is medically necessary, consider prescribing a brand name on this list.
The member's prescription benefit plan design may alter coverage of certain products or vary cost
sharing amounts based on the condition being treated.
This drug list represents a summary of prescription coverage. The member's specific prescription benefit
plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered immediately upon release to the market.
The member's prescription benefit plan may have different cost sharing for specific products on the list.
Unless specifically indicated, drug list products will include all dosage forms.

Log in to Caremark.com to check coverage andcost sharing information for a specific medicine.

ANALGESICS

COX-2 INHIBITORS
celecoxib
GOUT
allopurinol colchicine tablet probenecid MITIGARE
NSAIDS
diclofenac sodium ibuprofen me/oxicam tablet
naproxen (except naproxen CR or naproxensuspension)
NSAIDS,COMBINATIONS
diclofenac sodium-misoprostol
OPIOID ANALGESICS
codeine-acetaminophen fentanyl transdermal fentanyl transmucosal hydrocodone ext-rel
hydrocodone-acetaminophen hydromorphone
methadone morphine morphine ext-re/ oxycodone oxycodone ext-rel
oxycodone-acetaminophen tramado/ (except NDC 52817019610)
tramadol ext-rel tablet
OPIOID PARTIAL AGONISTS
buprenorphine transdermal
BELBUCA
VISCOSUPPLEMENTS
DUROLANE EUFLEXXA GELSYN-3 SUPARTZ FX

ANTI-INFECTIVES

ANTHELMINTICS
ivermectin tablet

ANTI-BACTERIAL$· MISCELLANEOUS
sulfamethoxazo/e- trimethoprfm
ANTIFUNGALS
fluconazole itraconazole terbinafine tablet
ANTIRETROVIRAL AGENTS
abacavir atazanavir darunavir efavirenz etravirine lamivudine maraviroc nevirapine nevirapine ext-rel ritonavir zidovudine
EMTRIVA FUZEON ISENTRESS TIVICAY
ANTIRETROVIRAL COMBINATION AGENTS
abacavir-lamivudine efavirenz-emtricitabine-
tenofovir disoproxil fumarate efavirenz-tamivudine-tenofovir
disoproxil fumarate emtricitabine-tenofovir
disoproxil fumarate lamivudine-zidovudine lopinavir-ritonavir BIKTARVY
CIMDUO DESCOVY DOVATO GENVOYA ODEFSEY
SYMTUZA TRIUMEQ
ANTITUBERCULAR AGENTS
ethambutol isoniazid pyrazinamide rifampin

ANTIVIRALS
acyclovir entecavir lamivudine oseltamivir
valacyclovir valganciclovir RELENZA
VEMLIDY
CEPHALOSPORINS
cefdinir cefprozil
cefuroxime axetil cephatexin SUPRAX
ERYTHROMYCINS/MACROLI DES
azithromycin c/arithromycin clarithromycin ext-rel erythromycins DIFICID
FLUOROQUINOLONES
ciprofloxacin levofloxacin moxifloxacin
HEPATITIS B AGENTS
tenofovir disoproxil fumarate
HEPATITISC
ribavirin
EPCLUSA (genotypes 1,2, 3,4, 5,6)
HARVONI (genotypes 1.4, 5.6)
VOSEVI
MISCELLANEOUS
clindamycin linezolid metronidazole
nitrofurantofn(except NOC
16571074024)
pyrimethamine, vancomycin capsule MEPRON
XIFAXAN 550 MG

NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS
tenofovir disoproxi/ fumarate
PENICILLINS
amoxicillin
amoxicillin-c/avulanate dicloxacillin
penicillin vk
TETRACYCLINES
doxycycline hyclate capsule doxycycline hyclate tablet
(except doxycyclinehyclate tablet 50 mg,
75 mg, 150 mg)
minocycline tetracycline

ANTINEOPLASTIC AGENTS

ALKYLATING AGENTS
cyc/ophosphamide melphalan temozolomide LEUKERAN MATULANE
MYLERAN
ANTIMETABOLITES
capecitabine mercaptopurine pemetrexed LONSURF TABLOID TREXALL
BIOLOGIC RESPONSE MODIFIERS
BESREMI ERIVEDGE REVLIMID THALOMID
BIOSIMILARS
HERZUMA OGIVRI RUXIENCE ZIRABEV

ANTINEOPLASTIC AGENTS
abiraterone anastrozole bicalutamide exemestane fulvestrant
/etrozole leupro/ide acetate megestrol acetate
tamoxifen
toremifene ELIGARD ERLEADA LYSODREN NUBEQA XTANDI YONSA
KINASE INHIBITORS
erlotinib evero/imus gefitinib
imatinib mesy/ate
lapatinib pazopanib sorafenib sunitinib ALECENSA ALUNBRIG BOSULIF
BRAFTOVI
BRUKINSA CABOMETYX CALQUENCE COPIKTRA COTELLIC GAVRETO IBRANCE INLYTA KISQALI
KISQALI FEMARA CO-PACK KOSELUGO
LENVIMA MEKTOVI RETEVMO ROZLYTREK RYDAPT SPRYCEL STIVARGA TAGRISSO VITRAKVI XOSPATA ZELBORAF ZYDELIG ZYKADIA
MISCELLANEOUS
bexarotene

tretinoin capsule KRAZATI LUMAKRAS LYNPARZA ODOMZO VISTOGARD ZEJULA
ZOLINZA
MONOCLONAL ANTIBODIES
PERJETA PHESGO
PROTEASOME INHIBITORS
bortezomib
NINLARO
TOPOISOMERASE INHIBITORS
etoposide

CARDIOVASCULAR

ACE INHIBITOR COMBINATIONS
fosinopri/-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydroch/orothiazide
ACE INHIBITORS
ena/april fosinopril lisinopril quinapri/ ramipril
ALDOSTERONERECEPTOR ANTAGONISTS
eplerenone
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartan-
hydrochlorothiazide candesartan-
hydrochlorothiazide irbesartan-hydrochlorothiazide losartan-hydrochlorothiazide olmesartan-amlodipine-
hydrochlorothiazide olmesartan­
hydrochlorothiazide telmisartan­
hydrochlorothiazide

ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan irbesartan losartan olmesartan telmisartan va/sartan
ANTIARRHYTHMICS
amiodarone disopyramide sotalo/ MULTAQ
ANTILIPEMICS, ACL INHIBITORS/COMBINATION
s
NEXLETOL NEXLIZET
ANTILIPEMICS, BILE ACID RESINS
cholestyramine colesevelam
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR
ezetimibe
ANTILIPEMICS, FIBRATES
fenofibrate (except fenofibrate capsule
30mg,SOmg, 90 mg,130mg;fenofibrate tablet 40 mg,120 mg)
fenofibric acid delayed-rel
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATION
s
ezetimibe-simvastatin
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS
atorvastatin fluvastatin
lovastatin pravastatin
rosuvastatin simvastatin
ANTILIPEMICS, MISCELLANEOUS
niacin ext-rel
ANTILIPEMICS, OMEGA-3 FATTYACID5
omega-3 acid ethyl esters

ANTILIPEMICS, PCSK9 INHIBITORS
REPATHA
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol-chlorthalidone
bisoprolol-hydroch/orothiazide metoprolol-
hydrochlorothiazide
BETA-BLOCKERS
acebutolol atenolol carvedilol
carvedilol phosphate ext-rel metoprolol succinate ext-re/ metoprolol tartrate
nadolo/ nebivolol propranolol
propranolol ext-rel
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine-atorvastatin
CALCIUM CHANNEL BLOCKERS
amlodipine
diltiazem ext-rel (excapt generics tor
CAROIZEM LA)
nifedipine ext-rel verapamil ext-rel
DIGITALIS GLVCOSIDES
digoxin
DIRECT RENIN INHIBITORS/COMBINATION
s
aliskiren
TEKTURNA HCT
DIURETICS
amiloride chlorthalidone ethacrynic acid furosemide hydrochlorothiazide metolazone spironolactone
spironolactone- hydrochlorothiazide
torsemide
triamterene

triamterene­ hydroch/orothiazide
HEART FAILURE
isosorbide dinitrate- hydralazine
CORLANOR
ENTRESTO VERQUVO
MISCELLANEOUS
c/onidine
clonidine transdermal guanfacine midodrine
ranolazine ext-rel
NITRATES
isosorbide dinitrate (excopt
isosorblde dinltrate 40 mg)
isosorbide mononitrate nitroglycerin lingual spray nitroglycerin sublingual
PULMONARY ARTERIAL HYPERTENSION
ambrisentan bosentan si/denafil tadalafil treprostinil ADEMPAS OPSUMIT ORENITRAM TADLIQ UPTRAVI

CENTRAL NERVOUS SYSTEM

ALCOHOL DETERRENTS
acamprosate calcium disulfiram
ANTIANXIETV
alprazolam buspirone clomipramine
fluvoxamine lorazepam oxazepam
ANTIDEMENTIA
donepezil galantamine galantamine ext-rel memantine rivastigmine
rivastigmine transdermal

NAMZARIC
ANTIDEPRESSANTS
amitriptyline bupropion
bupropion ext-rel (exceptbupropion
ext-reltablet 450mg)
citalopram desipramine desvenlafaxine ext-rel doxepin
duloxetine
escitalopram
fluoxetine (except fluoxetinetablet60
mg, fluoxetine tablet [generics for
SARAFEM))
imipramine he/ mirtazapine nortriptyline paroxetine he/
paroxetine he/ ext-rel (excopt NOC
60505367503)
sertraline trazodone venlafaxine
venlafaxine ext-rel capsule
TRINTELLIX
ANTIPARKINSONIAN AGENTS
amantadine carbidopa-levodopa
carbidopa-levodopa ext-rel
carbidopa-levodopa- entacapone
entacapone
pramipexole pramipexole ext-re/ rasagiline ropinirole
ropinirole ext-rel selegiline INBRIJA NEUPRO RYTARY
ANTIPSYCHOTICS
aripiprazole
asenapine chlorpromazine clozapine fluphenazine
haloperidol turasidone olanzapine perphenazine quetiapine
quetiapine ext-rel
risperidone

thiothixene trifluoperazine ziprasidone
ABILIFY MAINTENA
PERSERIS VRAYLAR
ANTISEIZURE AGENTS
carbamazepine carbamazepine ext-rel c/obazam
clonazepam
diazepam diazepam rectal gel divalproex sodium
divalproex sodium ext-rel ethosuximide gabapentin
lacosamide •
/amotrigine
/amotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin
phenytoin sodium extended
pregabalin primidone rufinamide tiagabine topiramate valproic acid vigabatrin zonisamide APTIOM FYCOMPA NAYZILAM OXTELLARXR TROKENDI XR VALTOCO XCOPRI
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine- dextroamphetaminemixed salts ext-rel
atomoxetine
dexmethylphenidate dexmethylphenidateext-rel dextroamphetamine dextroamphetamineext-rel guanfacine ext-rel lisdexamfetamine methylphenidate methy/phenidate ext-rel AlSTARYS
QELBREE

BOTULINUM TOXINS
DYSPORT XEOMIN
HYPNOTICS
doxepin ramelteon tamazepam zolpidem zolpidem ext-rel
MIGRAINE
eletriptan naratriptan rizatriptan sumatriptan zolmitriptan AJOVY EMGALITY NURTEC ODT QULIPTA UBRELVY
MISCELLANEOUS
lithium carbonate
lithium carbonate ext-rel tablet 300mg
lithium carbonate ext-rel tablet
450mg pyridostigmine pyridostigmineext-rel
MOVEMENT DISORDERS
tetrabenazine AUSTEDO AUSTEDOXR INGREZZA
MULTIPLE SCLEROSIS AGENTS
dimethyl fumarate delayed-rel fingolimod
glatiramer terif/unomide AVONEX BETASERON
COPAXONE 40 MG/ML KESIMPTA
MAYZENT
OCREVUS REBIF TYSABRI VUMERITY ZEPOSIA
MUSCULOSKELETAL THERAPY AGENTS
baclofen carisoprodol 350 mg

NOC73007001303)
cyclobenzaprine(except
cyclobenzaprinetablet7.5mg)
dantrolene metaxalone 800 mg
methocarbamol (except NDCs
69036091010, 69036093090,
70868090190)
tizanidine
LYVISPAH

BIGUANIDE/	MEGLITINIDE	deferoxamine
SULFONYLUREA	nateglinide	penicillamine
COMBINATIONS	repaglinide	trientine
glipizide-metformin	VELTASSA
ANTIDIABETICS, SODIUM-
ANTIDIABETICS,	GLUCOSE	CONTRACEPTIVES
DIPEPTIDYL PEPTIDASE-4	COTRANSPORTER-2 (SGLT2)	ethinyl estradiol-drospirenone
INHIBITORS	INHIBITOR COMBINATIONS	ethinyl estradiol-drospirenone-
saxag/iptin	SYNJARDY	/evomefolate
JANUVIA	SYNJARDYXR	ethinyl estradiol-levonorgestrel

NARCOLEPSY/CATAPLEXY

ANTIDIABETICS,DPP-4

XIGDUOXR	ethinyl estradiol-

armodafinil

INHIBITOR COMBINATIONS	ANTIDIABETICS, SODIUM-

levonorgestrel-iron
ethinyl estradiol-

modafinil LUMRYZ SUNOSI WAKIX XYWAV

saxagliptin-metforminext-rel	GLUCOSE	norelgestromin
JANUMET	COTRANSPORTER-2 (SGLT2)	ethinyl estradiol-norethindrone
JANUMETXR	INHIBITOR/DPP-4	acetate-iron
TRIJARDYXR	INHIBITOR COMBINATIONS	ethinyl estradiol-norgestimate
ANTIDIABETICS,INCRETIN	GLYXAMBI	medroxyprogesterone acetate

OPIOID AGONIST/ANTAGONIST
buprenorphine-na/oxone sublingual
ZUBSOLV

MIMETIC AGENTS	ANTIDIABETICS,SODIUM-
MOUNJARO	GLUCOSE
OZEMPIC	COTRANSPORTER-2 (SGLT2)
RYBELSUS	INHIBITORS
TRULICITY	FARXIGA

150mglml norethindrone ANNOVERA KYLEENA
LO LOESTRIN FE
MIRENA

OPIOID ANTAGONIST
naloxone naltrexone
POSTHERPETIC NEURALGIA (PHN)
GRALISE

VICTOZA	JARDIANCE	NATAZIA
ANTIDIABETICS, INCRETIN	ANTIDIABETICS,	NUVARING
MIMETIC COMBINATION	SULFONYLUREA	SKYLA
AGENTS	glimepiride	DIABETIC SUPPLIES
SOLIQUA	glipizide	ACCU-CHEK AVIVA PLUS
XULTOPHY	g/ipizide ext-rel	STRIPS AND KITS
ANTIDIABETICS, INSULIN	ANTIOBESITY	ACCU-CHEK GUIDE STRIPS
FIASP	orlistat	AND KITS

ENDOCRINE AND

METABOLIC

ACROMEGALY
SOMATULINE DEPOT

HUMULIN R U-500	QSYMIA
LANTUS	SAXENDA
NOVOLIN 70/30	WEGOVY NOVOLIN N

ACCU-CHEK SMARTVIEW STRIPS AND KITS
BD ULTRAFINE INSULIN SYRINGES AND NEEDLES

NOVOLIN R

BISPHOSPHONATES	DEXCOM CONTINUOUS

ANDROGENS

NOVOLOG	alendronate

GLUCOSE MONITORING

testosterone gel(except authorized generics forTESTIM andVOGELXO)

NOVOLOG MIX 70/30	ibandronate	SYSTEM
TOUJEO	risedronate	OMNIPOD 5 INSULIN

testosterone solution
NATESTO

TRESIBA	CALCIUM RECEPTOR ANTIDIABETICS, INSULIN	 AGONISTS

INFUSION PUMP
OMNIPOD DASH INSULIN INFUSION PUMP

ANTIDIABETICS, ALPHA­

SENSITIZER	cinacalcet	OMNIPOD INSULIN INFUSION

GLUCOSIDASE INHIBITORS

pioglitazone

CARNITINE DEFICIENCY

PUMP

acarbose

ANTIDIABETICS. INSULIN	AGENTS

ONETOUCH LANCETS/
LANCING DEVICE

ANTIDIABETICS, AMYLIN ANALOGS
SYMLINPEN

SENSITIZER/BIGUANIDE	levocarnitine	ONETOUCH ULTRA STRIPS
COMBINATION	CENTRAL PRECOCIOUS	AND KITS
pioglitazone-metformin	PUBERTY	ONETOUCH VERIO STRIPS

ANTIDIABETICS,BIGUANIDE
metformin
metformin ext-rel (except generics

ANTIDIABETICS, INSULIN	 FENSOLVI SENSITIZER/SULFONYLURE	 LUPRON DEPOT-PED A COMBINATION	SUPPRELIN LA

AND KITS
V-GO INSULIN INFUSION PUMP

forFORTAMET andGLUMETZA)

pioglitazone-g/imepiride

CHELATING AGENTS
deferasirox

ENDOMETRIOSIS
ORILISSA

ENZYME REPLACEMENTS
betaine carglumic acid sapropterin
sodium phenylbutyrate CYSTAGON PHEBURANE
ESTROGENS
estradiol
estradio/ vaginal cream estradiol-norethindrone BIJUVA
CLIMARA PRO COMBIPATCH DIVIGEL IMVEXXY MYFEMBREE ORIAHNN VAGIFEM
FERTILITY REGULATORS
c/omiphene FOLLISTIM AQ GANIRELIX ACETATE MENOPUR
OVIDREL
GAUCHER DISEASE
CERDELGA CEREZVME
GLUCOCORTICOIDS
dexamethasone fludrocortisone hydrocortisone methylpredniso/one prednisolone solution (except
prednisolone solution10mg/5 ml, 20
mg/5mL)
prednisone
GLUCOSE ELEVATING AGENTS
glucagon, human recombinant
BAQSIMI GVOKE
ZEGALOGUE
M&A&DITARV TVROSINl;MIA
TYPE 1 AGENTS
ORFADIN
HUMAN GROWTH HORMONES
HUMATROPE NORDITROPIN SOGROYA

MINERALOCORTICOID RECEPTOR ANTAGONISTS
KERENDIA
MISCELLANEOUS
cabergoline calcitonin-sa/mon raloxifene FORTEO
PROLIA TYMLOS
PHOSPHATE BINDER AGENTS
calcium acetate sevelamer carbonate AURYXIA
POLYNEUROPATHY
TEGSEDI
PROGESTINS
medroxyprogesterone megestrol acetate progesterone, micronized
THYROID AGENTS
levothyroxine liothyronine methimazole propylthiouracil
VASOPRESSINS
desmopressin spray, tablet
GASTROINTESTINAL ANTICHOLINERGICS
dicyclomine hyoscyamine sulfate
hyoscyamine sulfateorally
disintegrating tablet
ANTIDIARRHEALS
diphenoxylate-atropine loperamide
ANTIEMETICS
aprepitant
doxylamine-pyridoxine delayed-rel
dronabinol
granisetron meclizine metoclopramide
ondansetron
prochlorperazine promethazine scopolamine transdermal trimethobenzamide

SANCUSO
H2·RECEPTOR ANTAGONISTS
famotidine
INFLAMMATORY BOWEL DISEASE
balsalazide budesonide delayed-rel
capsule
budesonide foam hydrocortisone enema mesalamine delayed-rel mesa/amine ext-rel mesa/amine suppository mesa/amine suspension su/fasalazine su/fasalazine delayed-rel CORTIFOAM
IRRITABLE BOWEL SYNDROME WITH CONSTIPATION
lubiprostone
LINZESS
IRRITABLE BOWEL SYNDROME WITHDIARRHEA
alosetron
VIBERZI
LAXATIVES
lactulose solution
peg 335O-e/ectro/ytes(except generics forM0VIPREP)
sodium sulfate-potassium
sulfate-magnesium sulfate
CLENPIQ
MISCELLANEOUS
misoprostol sucra/fate tablet ursodiol SYMPROIC
PANCREATIC ENZYMES
CREON VIOKACE ZENPEP
PROTON PUMP INHIBITORS
esomeprazole delayed-rel lansoprazo/e delayed-rel
capsule
omeprazole delayed-rel pantoprazole delayed-rel
tablet

RECTAL, CORTICOSTEROIDS
PROCTOFOAM-HC
ULCER THERAPY COMBINATIONS
bismuth-metronidazo/e- tetracycline
lansoprazole + amoxicillin + clarithromycin
TALICIA

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA
alfuzosin ext-rel doxazosin dutasteride
dutasteride-tamsulosin finasteride
silodosin tamsu/osin terazosin
ERECTILE DYSFUNCTION
si/denafil tadalafi/ vardenafil MUSE
MISCELLANEOUS
tiopronin
PROGESTINS
ENDOMETRIN
URINARY ANTISPASMODICS
darifenacin ext-rel fesoterodine ext-rel oxybutynin ext-rel solifenacin tolterodine tolterodine ext-rel trospium
trospium ext-rel
GEMTESA
VAGINAL ANTHNFECTIVES
clindamycin metronidazole

HEMATOLOGIC

ANTICOAGULANTS
enoxaparin fondaparinux wartarin ELIQUIS XARELTO

BLEEDING DISORDERS AGENTS
NOVOSEVEN RT SEVENFACT
HEMATOPOIETIC GROWTH FACTORS
ARANESP DOPTELET
FYLNETRA NIVESTYM NYVEPRIA PROCRIT PROMACTA RETACRIT
HEMOPHILIA A AGENTS
ADVATE ADYNOVATE AFSTYLA ELOCTATE ESPEROCT JIVI KOGENATE FS KOVALTRY NOVOEIGHT NUWIQ XYNTHA
HEMOPHILIA B AGENTS
ALPROLIX REBINYN
MISCELLANEOUS
anagrelide cilostazol TAVALISSE
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS
EMPAVELI
PLATELET AGGREGATION INHIBITORS
clopidogrel
dipyridamole ext-rel-aspirin prasugre/
BRILINTA
SICKLE CELL DISEASE
ENDARI SIKLOS
IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS
GRASTEK
ORALAIR

RAGWITEK
AUTOIMMUNE AGENTS (PHYSICIAN­ ADMINISTERED)
AVSOLA ILUMYA REMICADE SIMPON! ARIA
SKYRIZI INTRAVENOUS STELARAINTRAVENOUS
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ALL OTHER CONDITIONS
ADALIMUMAB-ADAZ ENBREL
HYRIMOZ
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ANKYLOSING SPONDYLITIS
ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ RINVOQ
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), CROHN'S DISEASE
ADALIMUMAB-ADAZ HYRIMOZ
RINVOQ
SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), NON-RADIOGRAPHICAXIAL SPONDYLOARTHRITIS
CIMZIA PREFILLED SYRINGE COSENTYX
RINVOQ
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), PSORIASIS
ADALIMUMAB-ADAZ
HYRIMOZ
OTEZLA
SKYRIZI SUBCUTANEOUS SOTYKTU
STELARA SUBCUTANEOUS TALTZ
TREMFYA

AUTOIMMUNE AGENTS (SELF-ADMINISTERED), PSORIATIC ARTHRITIS
ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ OTEZLA RINVOQ
SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), RHEUMATOID ARTHRITIS
ADALIMUMAB-ADAZ ENBREL
HYRIMOZ KEVZARA
ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS RINVOQ
XELJANZ XELJANZXR
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ULCERATIVE COLITIS
ADALIMUMAB-ADAZ HYRIMOZ
RINVOQ
STELARA SUBCUTANEOUS XELJANZ
XELJANZXR ZEPOSIA
DISEASE-MODIFYING ANTI­ RHEUMATIC DRUGS (DMARDS)
hydroxych/oroquine leflunomide methotrexate RASUVO
HEREDITARY ANGIOEDEMA
icatibant
ORLADEYO RUCONEST TAKHZYRO
IMMUNOGLOBULIN
CUTAQUIG
IMMUNOSUPPRESSANTS
azathioprine cyclosporine cyclosporine modified
evero/imus

mycophenolate mofetil mycophenolate sodium sirolimus
tacrolimus
ENSPRYNG

NUTRITIONAL/SUPPLEM ENTS

ELECTROLYTES
potassium chloride ext-rel potassium chloride liquid
PRENATAL VITAMINS
prenatal vitamins
VITAMINS
calcitriol (1, 25-d3) doxercalciferol folicacid
fo/ic acid-vitamin b6-vitamin b12
multivitamins paricalcito/

OPHTHALMIC

ANTI-INFECTIVE/ANTI­ INFLAMMATORY
neomycin-polymyxin b- bacitracin-hydrocortisone
neomycin-po/ymyxin b- dexamethasone
tobramycin-dexamethasone
ANTI-INFECTIVES
ciprofloxacin erythromycin gentamicin levofloxacin moxifloxacin ofloxacin sulfacetamide tobramycin trifluridine
ANTI-INFLAMMATORIES
bromfenac dexamethasone diclofenac difluprednate ketorolac lotepredno/
prednisolone acetate 1%
ANTIALLERGICS
azelastine bepotastine cromolyn sodium

olopatadine
ANTIGLAUCOMA
bimatoprost brimonidine solution brimonidine-timolol brinzo/amide dorzolamide dorzolamide-timolol latanoprost
timolol maleate solution
travoprost ALPHAGAN P SIMBRINZA
DRY EYE DISEASE
RESTASIS
XIIDRA
RETINAL DISORDERS
BYOOVIZ CIMERLI
I
RESPIRATORY

ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS PROLASTIN-C
ZEMAIRA
ANAPHYLAXIS TREATMENT AGENTS
epinephrine (except Noes00093.
XXXX·XX. 49502-XXXX•XX)
AUVI-Q
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ipratropium-albuterol inhalation solution
ANORO ELLIPTA STIOLTO RESPIMAT
ANTICHOLINERGIC/BETA AGONIST/STEROID COMBINATIONS
BREZTRIAEROSPHERE TRELEGY ELLIPTA
ANTICHOLINERGICS
ipratropium inhalation solution
SPIRIVA YUPELRI
ANTIHISTAMINE COMBINATIONS
azelastine-fluticasone
ANTIHISTAMINES
azetastine

clemastine 2.68 mg cyproheptadine levocetirizine olopatadine
BETA AGONISTS
albuterol inhalation solution albuterol sulfate cfc-free
aerosol (except NDCs00093317431,
66993001968)
arformoterol
formoterol inhalation solution levalbuterol tartrate cfc-free
aerosol
STRIVERDI RESPIMAT
COLD/COUGH
benzonatate (except NDCs
69336012615, 69499032915)
codeine-promethazine codeine-promethazine­
phenylephrine dextromethorphan­
brompheniramine­ pseudoephedrine
dextromethorphan- promethazine
hydrocodone-homatropine
CYSTIC FIBROSIS
tobramycin inhalation solution
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast zafirlukast
MAST CELL STABILIZERS
cromolyn solution
MISCELLANEOUS
roflumilast
NASAL STEROIDS
f/unisolide fluticasone mometasone
PULMONARY FIBROSIS AGENTS
pirfenidone
OFEV
SEVERE ASTHMA AGENTS
DUPIXENT FASENRA
NUCALA (exceptlyophilizod powder) TEZSPIRE
XOLAIR

STEROID INHALANTS
budesonide inhalation suspension
PULMICORT FLEXHALER
STEROID/BETA-AGONIST COMBINATIONS
fluticasone-salmeterol (except certain NDCs)
Wixela lnhub
AIRSUPRA
BREO ELLIPTA(exceptcerteinNOCs)
TOPICAL

ATOPIC DERMATITIS, ORAL
RINVOQ
DERMATOLOGY, ACNE
adapa/ene (exceptadapalene pad) benzoyl peroxide clindamycin gel (exceptNOC
68682046275)
clindamycin solution clindamycin-benzoyl peroxide dapsone
erythromycin solution
erythromycin-benzoyl peroxide
isotretinoin capsule 10 mg, 20
mg, 30 mg,40 mg tretinoin
AKLIEF EPIDUO ONEXTON TWYNEO WINLEVI
DERMATOLOGY, ACTINIC KERATOSIS
fluorouracil cream 5% f/uorouracil solution imiquimod
DERMATOLOGY, ANTIBIOTICS
gentamicin mupirocin ointment
:.ilver sulfadiazino
DERMATOLOGY, ANTIFUNGALS
ciclopirox clotrimazole econazole
ketoconazole cream 2%
nystatin
oxiconazolo (except NDCs
00168035830. 51672135902)

DERMATOLOGY, ANTIPSORIATICS
acitretin
calcipotriene ointment, solution
methoxsalen VTAMA ZORYVE
DERMATOLOGY, ANTISEBORRHEICS
ketoconazo/e shampoo 2%
selenium sulfide lotion 2.5%
DERMATOLOGY, ATOPIC DERMATITIS
pimecrolimus tacrolimus ADBRY CIBINQO DUPIXENT EUCRISA OPZELURA
DERMATOLOGY, CORTICOSTEROIDS
clobetaso/ cream, foam, gel, lotion, ointment, shampoo (except clobetasolemollient foam)
desonide (exceptdesonide gel)
desoximetasone
f/uocinonide (except fluocinonide cream
0.1%)
halobetasol cream, ointment hydrocortisone hydrocortisone butyrate
cream, ointment, solution mometasone
triamcinolone cream, lotion, Ointment (excepttriamcinolone ointment 0.05%)
BRYHALI
ENSTILAR TACLONEX
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine patch
lidocaine-prilocaine
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
acyclovir ointment ammonium lactate 12% diclofenac sodium gel 1% diclofenac sodium solution
1.5%
penciclovir

podofilox
DERMATOLOGY,ROSACEA
azelaic acid gel brimonidine get metronidazole FINACEA FOAM ORACEA

SOOLANTRA
DERMATOLOGY,
SCABICIDES AND PEDICULICIDES
malathion permethrin 5%

MOUTH/THROAT/DENTAL
AGENTS
cevimeline pi/ocarpine tablet EPISIL
MUGARD

OTIC
acetic acid
ciprofloxacin-dexamethasone neomycin-polymyxin b-
hydrocortisone ofloxacin otic

QUICK REFERENCE DRUG LIST

A	amitriptyline	BAQSIMI	 buspirone amlodipine	BD ULTRAFINE INSULIN	BYOOVIZ
abacavir	amlodipine-atorvastatin	SYRINGES AND NEEDLES		
abacavir-lamivudine	amlodipine-olmesartan	BELBUCA	C

ammonium lactate 12%	BESREMI	calcitonin-salmon	
amoxicillin	betaine	calcitriol (1,25-d3)	
amoxicillin-clavulanate	BETASERON	calcium acetate	
amphetamine-	bexarotene	CALQUENCE	
dextroamphetaminemixed	bicalutamide	candesartan	
salts ext-rel	BIJUVA	candesartan-	

ABILIFY MAINTENA	amlodipine-telmisartan	 benzonatate (except NDCs	cabergo/ine abiraterone	amlodipine-valsartan		69336012615, 69499032915)	 CABOMETYX acamprosate calcium	amlodipine-valsartan-	 benzoyl peroxide	calcipotriene ointment, acarbose		hydrochlorothiazide	bepotastine		solution
ACCU-CHEK AVIVA PLUS
STRIPS AND KITS
ACCU-CHEK GUIDE STRIPS AND KITS
ACCU-CHEK SMARTVIEW STRIPS AND KITS
acebutolol	anagrelide	BIKTARVY		hydrochlorothiazide acetic acid	anastrozole	bimatoprost	capecitabine
acitretin	ANNOVERA	bismuth-metronidazole-	carbamazepine
acyclovir		ANORO ELLIPTA			tetracycline	 carbamazepine ext-rel acyclovir ointment	 aprepitant	 bisoprolol-	 carbidopa-levodopa ADALIMUMAB-ADAZ	 APTIOM		hydrochlorothiazide	carbidopa-levodopa ext-rel adapalene (except adapalenepad)		ARANESP	 bortezomib		carbidopa-levodopa- ADBRY	arformoterol	bosentan			entacapone
ADEMPAS	aripiprazole	BOSULIF	carglumic acid
ADVATE	armodafinil	BRAFTOVI	carisoprodol 350 mg
ADYNOVATE	asenapine	BREO ELLIPTAcexceptcertain	carvedilol
AFSTYLA	atazanavir	NDCs)	carvedilol phosphate ext-rel
AIRSUPRA	atenolol	BREZTRIAEROSPHERE	cefdinir
AJOVY	atenolol-chlorthalidone	BRILINTA	cefprozil
AKLIEF	atomoxetine	 brimonidine gel	cefuroxime axetil albuterol inhalation solution	atorvastatin	brimonidine solution	celecoxib
albuterol sulfate cfc-free	AURYXIA	brimonidine-timolol	cephalexin
aerosol(except NDC,00093317431,
66993001968)	AUSTEDO
AUSTEDOXR	brinzolamide
bromfenac	CERDELGA
CEREZYME	
ALECENSA	AUVI-Q	BRUKINSA	cevimeline	

alendronate	AVONEX	BRYHALI	chlorpromazine	
alfuzosin ext-rel	AVSOLA	budesonide delayed-rel	chlorthalidone	

aliskiren	azathioprine	capsule	chlorzoxazone 500 mg (except
allopurinol	azelaic acid gel	budesonide foam	NOC73007001303)
alosetron	azelastine	budesonide inhalation	cholestyramine
ALPHAGAN P	azelastine	suspension	CIBINQO
alprazolam	azelastine-fluticasone	buprenorphine transderma/	ciclopirox
ALPROLIX	azithromycin	buprenorphine-naloxone	cilostazol
ALUNBRIG	AZSTARYS	sublingual	CIMDUO
amantadine	bupropion	CIMERLI
ambrisentan	B	bupropion ext-re/(except	CIMZIA PREFILLED SYRINGE
amiloride	bacloten	bupropion ext-reltablet450 mg)	cinacalcet amiodarone	balsalazide		ciprofloxacin

ciprof/oxacin	deferiprone	doxycycline hyclate tablet	ESPEROCT	
ciprofloxacin-dexamethasone	deferoxamine	(except doxycycline hyclate tablet 50	estradiol	
citalopram	DESCOVY	mg, 75 mg,150mg)	estradiol vaginal cream	
clarithromycin clarithromycin ext-rel clemastine 2.68 mg	desipramine
desmopressin spray, tablet
desonide (except desonide gel)	doxylamine-pyridoxine delayed-rel
dronabinol	estradiol-norethindrone ethacrynic acid
ethambutol	
CLENPIQ	desoximetasone	duloxetine	ethinyl estradiol-	
CLIMARA PRO	desvenlafaxine ext-rel	DUPIXENT	drospirenone	
clindamycin	dexamethasone	DUPIXENT	ethinyl estradiol-	
clindamycin	dexamethasone	DUROLANE		drospirenone-levomefolate clindamycin gel (except NOC	 DEXCOM CONTINUOUS	 dutasteride	ethinyl estradiol-
68882046275)	GLUCOSE MONITORING	 dutasteride-tamsulosin		levonorgestrel clindamycin solution	 SYSTEM	DYSPORT	ethinyl estradiol-

clobazam	dextroamphetamine	econazole	
clobetasol cream, foam, gel,	dextroamphetamine ext-rel	efavirenz	
lotion, ointment, shampoo	dextromethorphan-	efavirenz-emtricitabine-	

clindamycin-benzoyl	dexmethylphenidate	levonorgestrel-iron
peroxide	dexmethylphenidateext-rel	E	ethinyl estradiol- norelgestromin
ethinyl estradiol- norethindrone acetate-iron
(except clobetasol emollient foam)	brompheniramine-	tenofovir disoproxil	ethinyl estradiol-
clomiphene		pseudoephedrine		 fumarate		norgestimate clomipramine	dextromethorphan-	efavirenz-lamivudine-	ethosuximide clonazepam		promethazine		tenofovir disoproxil	 etoposide
clonidine	diazepam	fumarate	etravirine
clonidine transdermal	diazepam rectal gel	eletriptan	EUCRISA
clopidogrel	diclofenac	ELIGARD	EUFLEXXA
clotrimazole	diclofenac sodium	ELIQUIS	everolimus
clozapine	diclofenac sodium gel 1%	ELOCTATE	everolimus
codeine-acetaminophen	diclofenac sodium solution	EMGALITY	exemestane
codeine-promethazine	1.5%	EMPAVELI	ezetimibe
codeine-promethazine-	diclofenac sodium-	emtricitabine-tenofovir	ezetimibe-simvastatin phenylephrine		misoprostol		disoproxil fumarate
co/chicine tablet	dicloxacillin	EMTRIVA	F
co/esevelam	dicyclomine	enalapril	famotidine
COMBIPATCH	DIFICID	ENBREL	FARXIGA
COPAXONE 40 MG/ML	difluprednate	ENDARI	FASENRA
COPIKTRA	 digoxin	 ENDOMETRIN	 fenofibrate (except fenofibrate capsule CORLANOR	 diltiazem ext-rel(except generics for	enoxaparin		30 mg, 50 mg, 90 mg, 130 mg; CORTIFOAM		CARDIZEM LA)	 ENSPRYNG		 fenofibrate tablet 40 mg, 120 mg) COSENTYX	dimethyl fumarate delayed-	ENSTILAR	fenofibric acid delayed-rel COTELLIC		rel	entacapone	 FENSOLVI
CREON	 diphenoxylate-atropine	 entecavir	 fentanyl transdermal cromolyn sodium	 dipyridamole ext-rel-aspirin	 ENTRESTO	 fentanyl transmucosal cromolyn solution	 disopyramide	 EPCLUSA (genotypes,. 2. 3. 4, s.s,	 fesoterodine ext-rel CUTAQUIG	disulfiram	 EPIDUO	FIASP cyclobenzaprine(except	 divalproex sodium	epinephrine (except Noes00093-	 FINACEA FOAM
cyclobonz:aprino tablet 7.5 mg)	divalproex sodium ext-rel		XXXX-XX, 49502-XXXX-XX)	 finasteride cyclophosphamide	 DIVIGEL	EPISIL	fingolimod
cyclosporine	donepezil	eplerenone	fluconazole
cyclosporine modified	DOPTELET	ERIVEDGE	fludrocortisone
cyproheptadine	dorzolamide	ERLEADA	flunisolide
CYSTAGON	dorzolamide-timolol	erlotinib	fluocinonide (except fluoclnonlde
DOVATO	erythromycin	cream0.1%)
D	doxazosin	erythromycin solution	fluorouracil cream 5%
dantrolene	doxepin	erythromycin-benzoyl	fluorouracil solution
dapsone	 doxepin		peroxide	fluoxetine (except ttuoxetlne tablet 60 darifenacin ext-rel	doxercalciferol	 erythromycins		mg, fluoxe1ine tablet [generics for darunavir	doxycycline hyclate capsule	escitalopram		 SARAFEMJ)
deferasirox	esomeprazole delayed-rel	fluphenazine

fluticasone
fluticasone-salmeterol(except	hydrocodone-homatropine
hydrocortisone	KEVZARA
KISQALI	loteprednol
lovastatin	
certainNDCs)	hydrocortisone	KISQALI FEMARA CO-PACK	lubiprostone	
fluvastatin	hydrocortisone butyrate	KOGENATEFS	LUMAKRAS	
fluvoxamine	cream, ointment, solution	KOSELUGO	LUMRYZ	
folicacid	hydrocortisone enema	KOVALTRY	LUPRON DEPOT-PED	
folic acid-vitamin b6-vitamin	hydromorphone	KRAZATI	lurasidone	
b12
FOLLISTIM AQ	hydroxych/oroquine
hydroxyurea	KYLEENA	LYNPARZA
LYSODREN	

fondaparinux
formoterol inhalation solution	hyoscyamine sulfate hyoscyamine sulfate orally	L
lacosamide	
FORTEO	disintegrating tablet	lactulose solution	

LVVISPAH
 	
M
fosinopril	HYRIMOZ	lamivudine	malathion
fosinopril-		 lamivudine	maraviroc hydroch/orothiazide			lamivudine-zidovudine	 MATULANE
fulvestrant	ibandronate	lamotrigine	MAYZENT
furosemide	IBRANCE	lamotrigine ext-rel	mec/izine
FUZEON	ibuprofen	lansoprazole + amoxicillin +	medroxyprogesterone
FYCOMPA	icatibant	clarithromycin	medroxyprogesterone
FYLNETRA	ILUMYA	lansoprazole delayed-rel		acetate 150 mg/ml imatinib mesylate		capsule	megestrol acetate
G
gabapentin
galantamine
galantamine ext-rel	imipramine he/ imiquimod IMVEXXY INBRIJA	LANTUS
lapatinib latanoprost leflunomide	megestrol acetate
MEKTOVI
meloxicam tablet me/phalan	
GANIRELIX ACETATE	INGREZZA	LENVIMA	memantine	
GAVRETO	INLYTA	/etrozole	MENOPUR	
gefitinib	ipratropium inhalation	LEUKERAN	MEPRON	
GELSYN-3		solution	 /euprolide acetate	 mercaptopurine GEMTESA	ipratropium-albutero/	levalbuterol tartrate etc-free	mesa/amine delayed-rel gentamicin		 inhalation solution		aerosol	 mesa/amine ext-rel gentamicin	 irbesartan	 levetiracetam	 mesa/amine suppository GENVOYA	 irbesartan-	levetiracetam ext-rel	 mesa/amine suspension glatiramer		 hydroch/orothiazide	 levocarnitine	 metaxa/one BOO mg
glimepiride	ISENTRESS	levocetirizine	metformin
g/ipizide	isoniazid	levofloxacin	metformin ext-rel (except generics g/ipizide ext-rel	 isosorbide dinitrate(except	levofloxacin		for FORTAMETand GLUMETZA) glipizide-metformin		lsosorbidedinitrate40mg)	levothyroxine	methadone
glucagon, human	isosorbide dinitrate-	lidocaine patch	methimazole
recombinant	hydralazine	lidocaine-prilocaine	methocarbamol (except NDCs
GLYXAMBI	isosorbide mononitrate	linezolid	69036091010, 69036093090,
GRALISE	isotretinoin capsule 10 mg, 20	LINZESS	70868090190)
granisetron	mg, 30 mg, 40 mg	liothyronine	methotrexate
GRASTEK	 itraconazole	lisdexamfetamine	methoxsalen guanfacine	ivermectin tablet	 /isinopril	methylphenidate

guanfacine ext-rel
GVOKE	J

/isinopril-hydrochlorothiazide	methylphenidateext-re/ lithium carbonate	methylprednisolone

JANUMET	lithium carbonate ext-rel	metoclopramide
H	JANUMETXR	tablet 300 mg	metolazone

haloperidol	JARDIANCE	tablet 450 mg	metoprolol tartrate	
HARVONI (genotypes 1,4,5,6)	JIVI	LO LOESTRIN FE	metoprolol-	
HERZUMA
HUMATROPE	K	LONSURF
loperamide	hydrochlorothiazi
metronidazole	
HUMULIN R U-500	KERENDIA	lopinavir-ritonavir	metronidazo/e	
hydrochlorothiazide	KESIMPTA	lorazepam	metronidazo/e	
hydrocodone ext-rel	ketoconazo/e cream 2%	losartan	midodrine	
flydrocoaone-aceramtnophen	keroconazole shampoo 2%
ketorolac	losartan-hydrochlorothiazide	minocycline	

halobetasol cream, ointment	JANUVIA	lithium carbonate ext-re/	metoprolol succinate ext-rel

de

MIRENA	NOVOEIGHT	orlistat	primidone	
mirtazapine	NOVOLIN 70/30	oseltamivir	probenecid	
misoprostol	NOVOLIN N	OTEZLA	prochlorperazine	
MITIGARE	NOVOLIN R	OVIDREL	PROCRIT	
modafinil	NOVOLOG	oxazepam	PROCTOFOAM-HC	
mometasone	NOVOLOG MIX 70/30	oxcarbazepine	progesterone, micronized	
mometasone	NOVOSEVEN RT	oxiconazole (except Noes	PROLASTIN-C	
montelukast	NUBEQA	00168035830, 51672135902)	PROLIA	
morphine	NUCALA (exceptlyoph izedpowder)	OXTELLARXR	PROMACTA	
morphine ext-rel	NURTECODT	oxybutynin ext-re/	promethazine	
MOUNJARO	NUVARING	oxycodone	propranolol	
moxifloxacin	NUWIQ	oxycodone ext-rel	propranolol ext-rel	
moxifloxacin	nystatin	oxycodone-acetaminophen	propylthiouraci/	
MUGARD	NYVEPRIA	OZEMPIC	PULMICORT FLEXHALER	

MULTAQ
multivitamins	0	p

pyrazinamide pyridostigmine

mupirocin ointment	OCREVUS	pantoprazole delayed-rel	pyridostigmine ext-rel
MUSE	ODEFSEY	tablet	pyrimethamine
mycophenolate mofetil	ODOMZO	paricalcitol
mycophenolate sodium
MYFEMBREE	OFEV
ofloxacin	paroxetine hcl
paroxetine he/ ext-rel (except	Q
QELBREE	
MYLERAN	ofloxacin otic	NDC60505367503)	QSYMIA	
 	
N	OGIVRI
olanzapine	pazopanib
peg 3350-electrolytes(except	quetiapine
quetiapine ext-rel	
nadolol	olmesartan	generics forMOVIPREP)	quinapril	
naloxone	olmesartan-amlodipine-	pemetrexed	quinapril-hydrochlorothiazide	
naltrexone	hydrochlorothiazide	penciclovir	QULIPTA	

NAMZARIC	olmesartan-	penici/lamine	
naproxen(exceptnaproxenCR o,	hydrochlorothiazide	penicillin vk	

A

naproxen suspension)	olopatadine	PERJETA	RAGWITEK	
naratriptan	olopatadine	permethrin 5%	raloxifene	
NATAZIA	omega-3 acid ethyl esters	perphenazine	ramelteon	
nateglinide	omeprazole delayed-rel	PERSERIS	ramipri/	
NATESTO	OMNIPOD 5 INSULIN	PHEBURANE	ranolazine ext-rel	
NAYZILAM	INFUSION PUMP	phenobarbital	rasagiline	
nebivolol	OMNIPOD DASH INSULIN	phenytoin	RASUVO	
neomycin-potymyxin b-	INFUSION PUMP	phenytoin sodium extended	REBIF	
bacitracin-hydrocortisone	OMNIPOD INSULIN	PHESGO	REBINYN	
neomycin-polymyxin b-	INFUSION PUMP	pilocarpine tablet	RELENZA	
dexamethasone	ondansetron	pimecrolimus	REMICADE	
neomycin-polymyxin b-	ONETOUCH LANCETS/	pioglitazone	repaglinide	
hydrocortisone	LANCING DEVICE	piog/itazone-glimepiride	REPATHA	
NEUPRO	ONETOUCH ULTRA STRIPS	pioglitazone-metformin	RESTASIS	
nevirapine	AND KITS	pirfenidone	RETACRIT	
nevirapine ext-rel	ONETOUCH VERIO STRIPS	podofilox	RETEVMO	
NEXLETOL	AND KITS	potassium chloride ext-rel	REVLIMID	
NEXLIZET	ONEXTON	potassium chloride liquid	ribavirin	
niacin ext-rel	OPSUMIT	pramipexole	rifampin	
nifedipine ext-rel	OPZELURA	pramlpexole ext-re/	RINVOQ	
NINLARO	ORACEA	prasugrel	risedronate	
nitrofurantoin(except NDC	ORALAIR	pravastatin	risperidone	
16571074024)	ORENCIA CLICKJECT	prednisolone acetate 1%	ritonavir	
nitroglycerin lingual spray	ORENCIA SUBCUTANEOUS	prednisolone solution (except	rivastigmine	
nitroglycerin sublingual	ORENITRAM	prednisolonesolution10mg/5ml,  20	rivastigmine transdermal	
NIVESTYM	ORFADIN	mg/5ml)	rizatriptan	
NORDITROPIN	ORIAHNN	prednisone	roflumilast	
norethindrone	ORILISSA	pregabalin	ropinirole	
nortriptyline	ORLADEYO	prenatal vitamins	ropinirole ext-rel	

rosuvastatin
ROZLYTREK	sulfasalazine
sulfasalazine delayed-rel	tolterodine ext-rel
topiramate	venlafaxine ext-rel capsule
verapamil ext-rel	
RUCONEST	sumatriptan	toremifene	VERQUVO	
rufinamide	sunitinib	torsemide	VIBERZI	
RUXIENCE	SUNOSI	TOUJEO	VICTOZA	
RYBELSUS	SUPARTZFX	tramadol (except NOC52817019610)	vigabatrin	
RYDAPT	SUPPRELIN LA	tramadol ext-rel tablet	VIOKACE	
RYTARY	SUPRAX	travoprost	VISTOGARD	

s

SYMLINPEN	trazodone	VITRAKVI
SYMPROIC	TRELEGY ELLIPTA	VOSEVI
SANCUSO	SYMTUZA	TREMFYA	VRAYLAR
sapropterin	SYNJARDY	treprostinil	VTAMA

w

saxagliptin	SYNJARDYXR	TRESIBA	VUMERITY

saxagliptin-metformin ext-rel
SAXENDA	T

tretinoin tretinoin capsule

scopolamine transdermal	TABLOID	TREXALL	WAKIX	
selegiline	TACLONEX	triamcinolone cream, lotion,	warfarin	
selenium sulfide lotion 2.5%	tacrolimus	Ointment (except triamcinolone	WEGOVY	
sertra/ine	tacrolimus	ointment0.05%)	WINLEVI	
sevelamer carbonate	tadalafil	triamterene	Wixela lnhub	

X

SEVENFACT	tadalafil	triamterene-	
SIKLOS	TADLIQ	hydroch/orothiazide	

sildenafil	TAGRISSO	trientine	XARELTO
sildenafil	TAKHZYRO	trif/uoperazine	XCOPRI
silodosin	TALICIA	trif/uridine	XELJANZ
silver sulfadiazine	TALTZ	TRIJARDYXR	XELJANZXR
SIMBRINZA	tamoxifen	trimethobenzamide	XEOMIN
SIMPON! ARIA	tamsulosin	TRINTELLIX	XIFAXAN 550 MG
simvastatin	TAVALISSE	TRIUMEQ	XIGDUOXR
sirolimus	TEGSEDI	TROKENDIXR	XIIDRA
SKYLA	TEKTURNA HGT	trospium	XOLAIR
SKYRIZI INTRAVENOUS	tetmisartan	trospium ext-rel	XOSPATA
SKYRIZI SUBCUTANEOUS	telmisartan-	TRULICITY	XTANDI
sodium pheny/butyrate	hydrochlorothiazide	TWYNEO	XULTOPHY
sodium sulfate-potassium	temazepam	TYMLOS	XYNTHA
sulfate-magnesium sulfate	temozolomide	TYSABRI	XYWAV

y

SOGROYA	tenofovir disoproxil fumarate
solifenacin	terazosin	u
SOLIQUA	terbinafine tablet	UBRELVY	YONSA
SOMATULINE DEPOT	teriflunomide	UPTRAVI	YUPELRI

SOOLANTRA	testosterone gel(except authorized	ursodiol

z

sorafenib
sotalol	generics for TESTIM and VOGELXO)
testosterone solution	V	
SOTYKTU	tetrabenazine	V-GO INSULIN INFUSION	
SPIRIVA	tetracycline	PUMP	
spironolactone	TEZSPIRE	VAGIFEM	
spironolactone- hydrochlorothiazide	THALOMID
thiothixene	valacyclovir
valganciclovir	
SPRYCEL	tiagablne	vatprolc acid	
STELARAINTRAVENOUS	timolol maleate solution	valsartan	
STELARA SUBCUTANEOUS	tiopronin	valsartan-hydrochlorothiazide	
STIOLTO RESPIMAT	TIVICAY	VALTOCO	
STIVARGA	tizanidine	vancomycin capsule	
STRIVERDI RESPIMAT	tobramycin	vardenafil	
sucralfate tablet	tobramycin inhalation	VASCEPA	
su/facetamide	solution	VELTASSA	
sulfamethoxazote-	tobramycin-dexamethasone	VEMLIDY	
trimethoprim	tolterodine	venlafaxine	

zafirlukast ZEGALOGUE ZEJULA ZELBORAF ZEMAIRA
ZENPEP ZEPOSIA
zidovudine ziprasidone ZIRABEV ZOLINZA
zo/mitriptan zolpidem zolpidem ext-rel zonisamide ZORYVE
ZUBSOLV

ZYDELIG	ZYKADIA

PREFERRED OPTIONS FOR EXCLUDED MEDICATIONS

The preferred options listed below are a broad representation of available treatment options and do not necessarily

represent clinical equivalency.

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
ABILIFY		aripiprazole, asenapine,	solution, erythromycin- benzoyl clozapine, lurasidone,	 peroxide, tretinoin, AKLIEF,
olanzapine, quetiapine,	EPIDUO, ONEXTON, TWYNEO,
quetiapine ext-re/, risperidone,	WINLEVI
ziprasidone, VRAYLAR	 ADCIRCA	 sildenafil, tadalafil, TADLIQ ACANYA	adapalene (except adapalene	ADDERALL	dexmethylphenidate,
pad), benzoyl peroxide,	dextroamphetamine,
clindamycin gel (except NDC	methylphenidate
68682046275), clindamycin

solution, clindamycin-benzoyl

ADDERALLXR	amphetamine-

peroxide, dapsone, erythromycin	dextroamphetamine mixed salts
solution, erythromycin- benzoyl	ext-rel, dexmethylphenidate ext-
peroxide, tretinoin, AKLIEF,	rel, dextroamphetamineext-rel,
EPIDUO, ONEXTON, TWYNEO,	lisdexamfetamine,
WINLEVI	methylphenidateext-rel,
AZSTARYS

ACIPHEX, ACIPHEX SPRINKLE	esomeprazole delayed-rel,
lansoprazole delayed-rel

ADRENALIN	epinephrine (except NDCs

capsule, omeprazole delayed-rel,	00093-XXXX-XX,  49502-XXXX-
pantoprazole delayed-rel tablet	XX), AUVI-Q
ACTEMRAINTRAVENOUS	AVSOLA, REMICADE, SIMPONI	ADVAIR DISKUS, ADVAIR HFA	fluticasone-salmeterol (except
ARIA	certain NDCs), Wixela lnhub,
BREO ELLIPTA (except certain

Activite	generic multivitamins

NDCs)

ACTOS	pioglitazone	ADZENYS XR-ODT	amphetamine-
ACUVAIL	bromfenac, diclofenac, ketorolac	dextroamphetaminemixed salts
acyclovir cream		acyclovir (except acyclovir	 ext-rel, dexmethy/phenidate ext- cream), penciclovir, valacyclovir	rel, dextroamphetamineext-rel,
lisdexamfetamine,

ACZONE	adapalene (except adapalene

methylphenidate ext-rel,

pad), benzoyl peroxide,	AZSTARYS
clindamycin gel (except NOC

68682046275), clindamycin

AFINITOR, AFINITOR DISPERZ	everolimus

solution, clindamycin-benzoy/	AIMOVIG	AJOVY. EMGALITY, QULIPTA
peroxide, dapsone, erythromycin	AKYNZEO	aprepitant WITH granisetron,
solution, erythromycin- benzoyl	ondansetron or SANCUSO
peroxide, tretinoin, AKLIEF,

EPIDUO, ONEXTON, TWYNEO,

albuterol sulfate CFC-free	a/buterol sulfate CFC-

WINLEVI	aerosol (NDCs 00093317431,	 free aerosol (except NDCs 66993001968 only)	00093317431, 66993001968),

adapalene pad	adapalene (except adapalene

leva/buterol tartrate CFC-

pad), benzoyl peroxide,	free aerosol
clindamycin gel (except NOC	ALEVICYN GEL, ALEVICYN SG,  desonide (except desonide gel),

68682046275), clindamycin solution, clindamycin-benzoyl

ALEVICYN SOLUTION	hydrocortisone

peroxide, dapsone, erythromycin	ALIMTA	pemetrexed

ALIQOPA	Talk to your doctor	solution, c/indamycin-benzoyl
ALLISON MEDICAL INSULIN	BD ULTRAFINE INSULIN	peroxide, dapsone, erythromycin
SYRINGES	SYRINGES	solution, erythromycin-benzoyl peroxide, tretinoin, AKLIEF,

ALORA	estradiol, DIVIGEL

EPIDUO, ONEXTON, TWYNEO,

ALREX	azelastine, bepotastine,	WINLEVI
cromolyn sodium, olopatadine	ARCALYST	Talk to your doctor
ALTOPREV	atorvastatin, ezetimibe-	ARNUITY ELLIPTA	PULMICORT FLEXHALER
simvastatin, fluvastatin,

lovastatin, pravastatin,

ARTHROTEC	celecoxib; diclofenac sodium,

rosuvastatin, simvastatin	ibuprofen, meloxicam tablet or
naproxen (except naproxen CR

ALVESCO	PULMICORT FLEXHALER

or naproxen suspension) WITH

AMITIZA	lubiprostone, LINZESS,	esomeprazole delayed-re/,
SYMPROIC	lansoprazole delayed-rel
AMRIX	carisoprodol 350 mg,	capsule, omeprazole delayed-rel, chlorzoxazone 500 mg (except	 or pantoprazole delayed-rel
NOC 73007001303),	tablet
cyclobenzaprine (except
cyclobenzaprine tablet 7.5 mg),	ASCENSIA STRIPS AND KITS	ACCU-CHEK AVIVA PLUS
metaxalone 800 mg,	STRIPS AND KITS, ACCU-
methocarbamol (except NDCs	CHEK GUIDE STRIPS AND KITS,
69036091010,69036093090,	ACCU-CHEK SMARTVIEW
70868090190)	STRIPS AND KITS, ONETOUCH
ANDROGEL	testosterone gel (except	ULTRA STRIPS AND KITS, authorized generics for TESTIM	 ONETOUCH VERIO STRIPS AND
and VOGELXO), testosterone	KITS
solution, NATESTO	ASMANEX, ASMANEX HFA	PULMICORT FLEXHALER
ANGELIQ	estradiol-norethindrone, BIJUVA	ATACAND,ATACAND HCT	candesartan, candesartan-
ANZEMET	granisetron, ondansetron,	hydrochlorothiazide, irbesartan,
SANCUSO	irbesartan-hydrochlorothiazide,
APEXICON E	desoximetasone (except	losartan, losartan• desoximetasone ointment	 hydrochlorothiazide, olmesartan,
0.05%), fluocinonide (except	olmesartan-hydrochlorothiazide,
fluocinonide cream 0.1%),	telmisartan, telmisartan-
BRYHALI	hydrochlorothiazide, valsartan,
valsartan-hydrochlorothiazide

APIDRA	FIASP, NOVOLOG

ATIVAN	alprazolam, clonazepam,

APLENZIN

bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450mg)

diazepam, lorazepam, oxazepam

APOKYN	INBRIJA	ATRALIN	adapalene (except adapalene pad), benzoyl peroxide,

APTENSIOXR	amphetamine-

clindamycin gel (except NDC

dextroamphetamine mixed salts	68682046275), clindamycin
ext-rel, dexmethylphenidate ext-	solution, clindamycin-benzoyl
rel, dextroamphetamineext-re/,	peroxide. dapsone. erythromycin
lisdexamfetamine,	solution, erythromycin- benzoyl
methy/phenidate ext-rel,	peroxide, tretinoin, AKLIEF,
AZSTARYS	EPIDUO, ONEXTON, TWYNEO.
APTIVUS	 Talk to your doctor		 WINLEVI ARALAST NP	PROLASTIN-C, ZEMAIRA	ATROVENT HFA	SPIRIVA
ARAZLO	adapalene (except adapalene	AUBAGIO	dimethyl fumarate delayed-rel, pad), benzoyl peroxide,		 fingo/imod. glatiramer.
clindamycin gel (except NDC	teriflunomide, AVONEX,
68682046275). clindamycin	BETASERON, COPAXONE 40

MG/ML, KESIMPTA, MAYZENT,	hydrocortisone

AVASTIN	OCREVUS, REBIF, TYSABRI,
VUMERITY, ZEPOSIA
ZIRABEV	benzonatate (NDCs 69336012615, 69499032915
only)	benzonatate (except NDCs 69336012615, 69499032915)	
AVENOVA AZASITE	Talk to your doctor
ciprofloxacin, erythromycin, gentamicin, levofloxacin,	BEPREVE

BERINERT	azelastine, bepotastine, cromolyn sodium, o/opatadine
icatibant, RUCONEST	
moxifloxacin, of/oxacin,	BESIVANCE	ciprofloxacin, erythromycin,
su/facetamide, tobramycin	gentamicin, levofloxacin,
AZELEX	adapalene (except adapalene	 moxifloxacin, ofloxacin, pad), benzoyl peroxide,	sulfacetamide, tobramycin
clindamycin gel (except NOC	BETAMETHASONE ACETATE-	dexamethasone, hydrocortisone,
68682046275), c/indamycin	 BETAMETHASONE SODIUM	methylprednisolone, solution, clindamycin-benzoyl	PHOSPHATE	prednisolone solution (except
peroxide, dapsone, erythromycin	prednisolone solution 10 mg/5
solution, erythromycin- benzoy/	mL, 20 mg/5 mL), prednisone peroxide, tretinoin. AKLIEF.

EPIDUO, ONEXTON, TWYNEO,

betamethasone dipropionate	desoximetasone (except

WINLEVI	ointment 0.05%	desoximetasone ointment
0.05%), fluocinonide (except
AZESCO	generic prenatal vitamins	f/uocinonide cream 0.1%),
AZOPT	brinzolamide, dorzolamide	BRYHALI
AZOR	amlodipine-olmesartan,	BETAPACE,BETAPACEAF	sotalol
amlodipine-telmisartan,	BETHKIS	tobramycin inhalation solution amlodipine-va/sartan

BALCOLTRA	ethiny/ estradiol-drospirenone, ethinyl estradiol-drospirenone-

BETIMOL	timolo/ maleate solution
BETOPTICS	timolol maleate solution

levomefolate, ethinyl estradiol-	BEVESPIAEROSPHERE	ANORO ELLIPTA, STIOLTO
levonorgestrel, ethinyl estradiol-	RESPIMAT
levonorgestrel-iron,	BEYAZ	ethinyl estradiol-drospirenone,
ethinyl estradiol-	ethinyl estradiol-drospirenone-
norethindrone acetate-iron,	levomefolate, ethinyl estradiol-
ethinyl estradiol-norgestimate,	levonorgestrel, ethinyl estradiol-
LO LOESTRIN FE, NATAZIA	levonorgestrel-iron, ethinyl
BANZEL	clobazam, c/onazepam,	 estradiol-norethindrone acetate- lamotrigine, rufinamide,	iron, ethinyl estradiol-
topiramate, TROKENDI XR	norgestimate, LO LOESTRIN FE,
BARACLUDE TABLET	entecavir, lamivudine, tenofovir	NATAZIA
disoproxil fumarate, VEMLIDY	BORTEZOMIB	bortezomib, NINLARO
BASAGLAR	LANTUS	BOTOX	DYSPORT, XEOMIN
BECONASEAQ	aze/astine-fluticasone,	BREEZE 2 STRIPS AND KITS	ACCU-CHEK AVIVA PLUS
flunisolide, fluticasone,	STRIPS AND KITS, ACCU-CHEK
mometasone	GUIDE STRIPS AND KITS, ACCU-
BENEFIX	ALPROLIX, REBINYN		CHEK SMARTVIEW STRIPS AND KITS, ONETOUCH ULTRA STRIPS
BENICAR, BENICAR HCT	candesartan, candesartan-	AND  KITS, ONETOUCH VERIO
hydrochlorothiazide, irbesartan,	STRIPS AND KITS
irbesartan-hydrochlorothiazide,

/osartan, losartan-

BROMSITE	bromfenac, diclofenac, ketorolac

hydrochlorothiazide, olmesartan,	BROVANA	arformoterol, formoterol
olmesartan-hydrochlorothiazide,	inhalation solution
telmisartan, telmisartan-	budesonide ext-rel tablet	balsalazide, mesa/amine hydrochlorothiazide, valsartan,		 delayed-rel, mesa/amine ext-rel,
valsartan-hydrochlorothiazide	sulfasalazine, sulfasalazine
BENSALHP	desonlde (except desontde gel),	delayed-rel

Bupap

BUPHENYL

diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension}
sodium phenylbutyrate,
PHEBURANE

CAPEX

Capsinac

ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen,

bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel
(except bupropion ext-rel tablet
450mg}

meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)

butalbital-acetaminophen capsule, butalbital­ acetaminophen tablet 25-325 mg, butalbital-acetaminophen
tablet 50-300 mg, BUTALBITAL·

dic/ofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)

CARAC

CARAFATE CARBAGLU

fluorouraci/ cream 5%,
f/uorouracil solution, imiquimod sucralfate tablet
carglumic acid

ACETAMINOPHEN (NDC
69499034230 only)
butalbitat-acetaminophen­ caffeine capsule

diclofenac sodium, ibuprofen, naproxen (except naproxen CR

CARBINOXAMINE TABLET 6 MG levocetirizine
CARDIZEM, CARDIZEM CD,	di/tiazem ext-rel (except CARDIZEM LA	 generics for CARDIZEM LA),
verapamil ext-rel

BUTRANS BYDUREON BCISE BYETTA SYSTOLIC

catcipotriene cream, catcipotriene foam, CALCIPOTRIENE FOAM
calcipotriene-betamethasone

calcitriol ointment

CAMBIA

CANASA

or naproxen suspension)
buprenorphine transdermal,
BELBUCA
MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
acebutolol, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, nebivolo/, propranolol, proprano/ol ext-rel

calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE
calcipotriene ointment or calcipotriene solution WITH desoximetasone (except desoximetasone ointment 0.05%), f/uocinonide (except fluocinonide cream 0.1%) or
BRYHALI; ENSTILAR, TACLONEX, VTAMA, ZORYVE
calcipotriene ointment, calcipotriene solution, VTAMA, ZORVVE
diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
budesonide foam, hydrocortisone enema, mesa/amine suppository, mesa/amine suspension,
CORTIFOAM

carisoprodol 250 mg

CARNITOR, CARNITOR SF CAYSTON
CELEBREX

CETROTIDE
chlordiazepoxide-clidinium
(NDCs 11534019701,
42494040901, 51293069601,
51293069610, 67877073101,
70700018501 only)
chlorzoxazone 250 mg,
chlorzoxazone 375 mg, chlorzoxazone 500 mg (NDC 73007001303 only),
chlorzoxazone 750 mg

CHORIONIC GONADOTROPIN
CIALIS
CICATRACE
CILOXAN

carisoprodol 350 mg, chlorzoxazone 500 mg (except NOC 73007001303),
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs 69036091010, 69036093090,
70868090190}
tevocarnitine
tobramycin inhalation solution
ce/ecoxib, diclofenac sodium, ibuprofen, me/oxicam tablet, naproxen (except naproxen CR or naproxen suspension)
GANIRELIX ACETATE
dicyclomine, hyoscyamine sulfate, hyoscyamine sulfate orally disintegrating tablet

carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC 73007001303),
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxatone 800 mg, methocarbamol (except NDCs 69036091010, 69036093090,
70868090190)
OVIDREL
sildenafil, tada/afil, vardenafi/
Talk to your doctor
ciprofloxacin, erythromycin, gentamicin, /evofloxacin, moxif/oxacin, ofloxacin, sulfacetamide, tobramycin

CIMZIA LYOPHILIZED POWDER  AVSOLA, ILUMYA, REMICADE,	ointment, hydrocortisone
SIMPON! ARIA, SKYRIZI	butyrate solution, mometasone,
INTRAVENOUS, STELARA	triamcinolone cream,
INTRAVENOUS	triamcinolone lotion,
ClNRYZE	ORLADEYO,TAKHZYRO	triamcinolone ointment
(except triamcinolone ointment

CIPRO HC OTIC	ciprofloxacin-dexamethasone, ofloxacin otic
CIPRODEX	ciprofloxacin-dexamethasone, ofloxacin otic

0.05%)
COLAZAL		balsalazide, mesa/amine delayed-rel, mesa/amine ext-rel, sulfasalazine, sulfasalazine

ciprofloxacin-fluocinolone	ciprofloxacin-dexamethasone,	delayed-rel
ofloxacin otic	colchicine capsule	colchicine tablet, MITIGARE CITRANATAL	generic prenatal vitamins	 COLCRYS	colchicine tablet, MITIGARE
CLIMARA (except CLIMARA	estradio/, DIVIGEL	COMBIGAN	brimonidine-timolol
PRO)

CLINDAGEL	adapalene (except adapalene pad), benzoyl peroxide, clindamycin gel (except NOC 68682046275), c/indamycin solution, clindamycin-benzoyl
peroxide, dapsone, erythromycin

COMPLERA	efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz- lamivudine-tenofovir disoproxil fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ

solution, erythromycin- benzoyl	CONCERTA	amphetamine-
peroxide, tretinoin, AKLIEF,	dextroamphetamine mixed salts
EPIDUO, ONEXTON, TWYNEO,	ext-rel, dexmethylphenidateext-
WINLEVI	rel, dextroamphetamine ext-rel,
lisdexamfetamine,

c/indamycin gel (NOC	adapalene (except adapalene
68682046275 only)	pad), benzoyl peroxide,
clindamycin gel (except NOC

methylphenidate ext-rel,
AZSTARYS

68682046275), clindamycin	CONTOUR NEXT STRIPS AND	ACCU-CHEK AVIVA PLUS
solution, clindamycin-benzoyl	KITS	STRIPS AND KITS, ACCU-CHEK
peroxide, dapsone, erythromycin	GUIDE STRIPS AND KITS, ACCU-
solution, erythromycin- benzoyl	CHEK SMARTVIEW STRIPS AND
peroxide, tretinoin, AKLIEF,	KITS, ONETOUCH ULTRA STRIPS
EPIDUO, ONEXTON, TWYNEO,	AND KITS, ONETOUCH VERIO
WINLEVI	STRIPS AND KITS
c/obetasol emollient foam	c/obetaso/ cream, clobetasol	CONTOUR STRIPS AND KITS	ACCU-CHEK AVIVA PLUS
foam (except c/obetaso/	STRIPS AND KITS, ACCU-CHEK
emollient foam), clobetasol gel,	GUIDE STRIPS AND KITS, ACCU-
clobetasol lotion, clobetasol	CHEK SMARTVIEW STRIPS AND
ointment, halobetasol cream,	KITS, ONETOUCH ULTRA STRIPS
halobetasol ointment	AND KITS, ONETOUCH VERIO STRIPS AND KITS
c/obetaso/ spray	clobetasol cream, clobetasol
foam (except clobetasol	CONTRAVE	orlistat, QSYMIA, SAXENDA,
emollient foam}, clobetasol gel,	WEGOVY
clobetasol lotion, clobetasol	COPAXONE 20 MG/ML	dimethyl fumarate delayed-rel,
ointment, halobetasol cream,	fingo/imod, g/atiramer.
na1ooecaso1 ointment	teriflunomide, AVONEX,
CLOBEX SPRAY	c/obetaso/ cream, c/obetasol	BETASERON, COPAXONE 40
foam (except clobetasol	MG/ML, KESIMPTA, MAYZENT,
emollient foam), clobetasol gel,	OCREVUS, REBIF, TYSABRI,
clobetasol lotion, clobetasol	VUMERITY, ZEPOSIA
ointment, ha/obetasol cream,	CORDRAN CREAM, CORDRAN  desonide (except desonide gel), halobetasol ointment	 LOTION	hydrocortisone
clocortolone cream	hydrocortisone butyrate cream,	CORDRAN OINTMENT	hydrocortisone butyrate cream, hydrocortisone butyrate		hydrocortisone butyrate

CORDRAN TAPE

COREGCR

CoreMino

COSOPTPF COZAAR

CRESEMBA CRESTOR

CRINONE CUPRIMINE

ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
(except triamcinolone ointment
0.05%)
c/obetasol cream, clobetasol foam (except clobetasol emollient foam), clobetaso/ gel, clobetasol lotion, clobetasol ointment, halobetasol cream,
halobetasol ointment
acebutolol, atenolol, carvedilol, carvedilo/ phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, nebivolol, propranolol, propranolol ext-rel
doxycyctine hyc/ate capsule, doxycycline hyclate tablet
{except doxycycline hyclate tablet 50 mg,75 mg, 150 mg), minocycline, tetracycline
dorzolamide-timolol
candesartan, irbesartan, /osartan, olmesartan, telmisartan, valsartan
itraconazole
atorvastatin, ezetimibe­ simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
ENDOMETRIN
penlc/llamine

DELZICOL

DENAVIR

DEPAKOTE,DEPAKOTEE DEPAKOTE SPRINKLE

DEPO-SUBQ PROVERA 104 DESFERAL
desonide gel

desoximetasone ointment 0.05%

dextroamphetamine mixed salts ext-rel, dexmethylphenidateext­ rel, dextroamphetamine ext-rel,
lisdexamfetamine,
methylphenidate ext-rel,
AZSTARYS
balsalazide, mesa/amine delayed-rel, mesa/amine ext-rel, sulfasalazine,sulfasalazine delayed-rel
acyclovir (except acyclovir
cream), penciclovir, valacyctovir
carbamazepine, carbamazepine ext-rel, clonazepam, divalproex sodium, divalproex sodium ext­ rel, ethosuximide, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext­ rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, va/proic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI
medroxyprogesterone acetate 150mglmL
deferasirox, deferiprone, deferoxamine
desonide (except desonide gel), hydrocortisone
hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone

cyc/obenzaprine ext-rel capsule, carisoprodol 350 mg, cyc/obenzaprine tablet 7.5 mg	chlorzoxazone 500 mg (except
NDC 73007001303),
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxa/one 800 mg, methocarbamol {except NDCs 69036091010, 69036093090,
70868090190)

DesRx

DESVENLAFAXINE ER

butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
{except triamcinolone ointment
0.05%)
desonide (except desonide gel), hydrocortisone
desvenlafaxineext-rel,

CYCLOSET CYMBALTA

CYSTADANE CYTOMEL DALIRESP
DARAPRIM
DAYTRANA

Talk to your doctor desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
betaine
levothyroxine, liothyronine rof/umilast
pyrimethamine
amphetamine-

DETROL LA

dexchlorpheniramine

e1uIoxer1ne, ventafaxlne, venlafaxine ext-rel capsule
darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-re/, GEMTESA
clemastine 2.68 mg, cyprohepcactine, levocertrrzme

Dexifol
DEXILANT

dexlansoprazole delayed-rel

DIACOMIT DIASTAT

generic multivitamins
esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet
esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet
Talk to your doctor
diazepam rectal gel, NAYZILAM, VALTOCO

DILANTIN

NURTEC ODT, UBRELVY
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext­ ra/, oxcarbazepine, phenobarbital,phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA,

diclofenac potassium capsule25 diclofenac sodium, ibuprofen, mg, diclofenac potassium tablet meloxicam tablet, naproxen 25 mg	(except naproxen CR or
naproxen suspension)
diclofenac potassium powder	dic/ofenac sodium, ibuprofen,
naproxen (except naproxen CR
or naproxen suspension)
diclofenac sodium solution 2%	diclofenac sodium, diclofenac
sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)

diltiazem ext-rel (generics for CARDIZEM LA only)

DIOVAN, DIOVAN HCT

OXTELLAR XR, TROKENDI XR,
XCOPRI
diltiazem ext-rel (except generics for CARDIZEM LA), verapamil ext-rel
candesartan, candesartan­ hydrochlorothiazide, lrbesartan, irbesartan-hydrochlorothiazide, losartan, losartan­ hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan­ hydrochlorothiazide, valsartan,

DiclofexDC

Diclosaicin

DIFFERIN LOTION

diflorasone cream, diflorasone ointment

dihydroergotamine spray

diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen
{except naproxen CR or
naproxen suspension)
diclofenac sodium, diclofenac sodium gel 1%, dic/ofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
adapalene (except adapalene pad), benzoyl peroxide, clindamycin gel {except NOC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoy/ peroxide, tretinoin, AKLIEF, EPIDUO, ONEXTON, TWYNEO,
WINLEVI
desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except
fluocinonide cream 0.1%}, BRYHALI
eletriptan, naratriptan, rizatriptan,
sumatrtptan, zo1mtcr1pran,

Diphen Elixir

DORYX, DORYX MPC

doxepin cream

doxycycline hyclate delayed-rel tablet

doxycycline hyclate tablet 50 mg, doxycyc/ine hyclate tablet 75 mg, doxycycline hyclate
tablet 15Dmg

doxycycline monohydrate capsule 75 mg, doxycycline monohydrate capsule 150 mg

doxycycline monohydrate delayed-rel capsule
DUAVEE

valsartan-hydrochlorothiazide
clemastine 2.68 mg, cyproheptadine, levocetirizine
doxycycline hyclate capsule, doxycyc/ine hyclate tablet (except doxycycline hyclate tablet 50 mg, 75 mg, 150 mg), minocycline, tetracycline
desonide (except desonide gel), hydrocortisone,pimecrolimus, tacro/imus, EUCRISA, OPZELURA
doxycycline hyclate capsule, doxycycline hyc/ate tablet (except doxycycline hyclate tablet 50 mg, 75 mg, 150 mg), minocycline, tetracycline
doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate
tsblot 50 l'Yl/:1, 75 rYl!iJ, 150 m9),
minocycline, tetracycline
doxycycline hyc/ate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg, 75 mg, 150 mg), minocyc/ine, tetracycline
ORACEA

estradiol-norethindrone,

DUOBRII

raloxifene, BIJUVA
calcipotriene ointment or
ca/cipotriene solution WITH

ENTYVIO INTRAVENOUS (For
Crohn's Disease Only)

AVSOLA, REMICADE, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS

desoximetasone (except
desoximetasone ointment

EPANED	enalapril, fosinopril, lisinoprll, quinapril, ramipril

0.05%), f/uocinonide (except fluocinonide cream 0.1%) or BRYHALI; ENSTILAR,

EPICERAM

desonide (except desonide gel), hydrocortisone

TACLONEX, VTAMA, ZORYVE
DYANAVELXR	amphetamine­ dextroamphetaminemixed salts

epinephrine (NDCs 00093-	epinephrine (except NDCs
XXXX-XX, 49502-XXXX-XX only) 00093-XXXX-XX, 49502-XXXX­
XX), AUVI-Q

DYMISTA

DYRENIUM ECOZA

EDARBI, EDARBYCLOR

EDLUAR EDURANT
E.E.S. GRANULES EFFEXORXR

ELELYSO ELESTRIN ELIDEL

ext-re/, dexmethylphenidateext­ rel, dextroamphetamine ext-rel, lisdexamfetamine, methy/phenidate ext-re/, AZSTARYS
aze/astine-fluticasone, flunisolide, fluticasone, mometasone
amiloride, triamterene
ciclopirox, c/otrimazole, econazole, ketoconazole cream 2%, oxiconazo/e (except NDCs 00168035830, 51672135902)
candesartan, candesartan­ hydrochlorothiazide, irbesartan, irbesartan-hydroch/orothiazide, losartan, losartan­ hydrochlorothiazide, o/mesartan, olmesartan-hydroch/orothiazide, telmisartan, telmisartan­ hydrochlorothiazide, va/sartan, valsartan-hydrochlorothiazide
doxepin, ramelteon, temazepam, zo/pidem, zolpidem ext-rel
efavirenz erythromycins
desvenlafaxine ext-rel, du/oxetine, venlafaxine, venlafaxine ext-rel capsule
CERDELGA, CEREZYME
estradiol, DIVIGEL
pimecrolimus, tacrolimus,
EUCRISA, OPZELURA

EPIPEN, EPIPEN JR

EPOGEN
ergotamine-caffeine

ERTACZO

ERYPED ESBRIET
estradiol vaginal tablet
ESTRING ESTROGEL
ethiny/ estradiol-etonogestrel
EVEKEO

EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM
EXFORGE

EXFORGEHCT

epinephrine (except NDCs 00093-XXXX-XX, 49502-XXXX­ XX), AUVI-Q

ARANESP, PROCRIT, RETACRIT
eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY
ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazo/e (except NDCs 00168035830, 51672135902)
erythromycins pirfenidone, OFEV
estradiol vaginal cream,
IMVEXXY, VAGIFEM
estradiol vaginal cream,
IMVEXXY, VAGIFEM
estradiol, DIVIGEL ANNOVERA, NUVARING
dexmethylphenidate, dextroamphetamine, methylphenidate
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan
amlodipine-valsartan­ hydrochlorothiazide, olmesartan­ amlodipine-hydrochlorothiazide

ELMIRON	Talk to your doctor
EluRyng	ANNOVERA, NUVARING
EMEND	aprepitant
ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS MONITORING SYSTEM	GLUCOSE MONITORING
SYSTEM
ENTERAGAM	alosetron, VIBERZI, XIFAXAN 550 MG

EXJADE

EXTAVIA

EYLEA

deferasirox, deferiprone, deferoxamine
dimethyl fumarate delayed-re/, fingolimod, glatiramer, teriflunomide, AVONEX, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, YUMERITY, ZEPOSIA
BYOOVIZ, CIMERLI

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION{S)	
FABIOR	adapalene (except adapalene	FIORICET CAPSULE	diclofenac sodium, ibuprofen,	
	pad), benzoy/ peroxide,
clindamycin gel {except NOC		naproxen (except naproxen CR
or naproxen suspension)	
68682046275), clindamycin	FIRAZYR	icatibant, RUCONEST
solution, clindamycin-benzoyl

peroxide, dapsone, erythromycin

FIRMAGON	ELIGARD

solution, erythromycin- benzoyl	FLAREX	dexamethasone, dif/uprednate,
peroxide, tretinoin, AKLIEF,	loteprednol, prednisolone
EPIDUO, ONEXTON, TWYNEO,	acetate 1%
WINLEVI	FLECTOR	dic/ofenac sodium, diclofenac
FANAPT	aripiprazole, asenapine,	sodium gel 1%, diclofenac c/ozapine, lurasidone,	sodium solution 1.5%, ibuprofen,
o/anzapine, quetiapine,	meloxicam tablet, naproxen
quetiapine ext-rel, risperidone,	(except naproxen CR or
ziprasidone, VRAYLAR	naproxen suspension)
FEIBA	NOVOSEVEN RT, SEVENFACT	FLORIVA, FLORIVA PLUS	generic multivitamins
FEMRING	estradiol vaginal cream,	FLOVENT DISKUS, FLOVENT	PULMICORT FLEXHALER IMVEXXY, VAGIFEM	HFA
fenofibrate capsule 30 mg, 50	fenofibrate (except fenofibrate	flucytosine capsule 500 mg	fluconazole
mg, 90 mg, 130 mg; fenofibrate capsule 30 mg, 50 mg, 90 mg,	fluocinonide cream 0.1%	clobetasol cream, clobetaso/ tablet 40 mg, 120 mg	130 mg; fenofibrate tablet 40 mg,		 foam (except clobetasol
120 mg), fenofibric acid delayed-	emollient foam), clobetasol gel,
rel	clobetasol lotion, clobetasol
FENOGLIDE TABLET 120 MG		fenofibrate (except fenofibrate	ointment, halobetasol cream, capsule 30 mg, 50 mg, 90 mg,	 halobetasol ointment
130 mg;fenofibrate tablet 40 mg,	fluorouraci/ cream 0.5%	fluorouracil cream 5%,
120 mg), fenofibric acid delayed-	fluorouracil solution, imiquimod rel

fenoprofen, FENOPROFEN	diclofenac sodium, ibuprofen,

fluoxetine tablet (generics for	fluoxetine (except fluoxetine
SARAFEM only)	tablet 60 mg, fluoxetine tablet

CAPSULE	meloxicam tablet,	[generics for SARAFEM]),
naproxen (except naproxen CR	paroxetine HCI ext-rel (except
or naproxen suspension)	NDC 60505367503), sertraline
FENTORA	 fentanyl transmucosal	 fluoxetine tablet 60 mg,	 citalopram, escita/opram, FERIVA21/7	generic multivitamins	FLUOXETINE 60 MG	 fluoxetine (except fluoxetine FERRIPROX	 deferasirox, deferiprone,		tablet 60 mg, fluoxetine tablet
deferoxamine	[generics for SARAFEM]),

FETZIMA	desvenlafaxine ext-rel, duloxetine, ven/afaxine, venlafaxine ext-rel capsule

paroxetine HCl, paroxetine HCl
ext-re/ (except NDC 60505367503), sertraline, TRINTELLIX

Fexmid	carisoprodol 350 mg,	flurandrenolide cream,	 desonide (except desonide gel), chlorzoxazone 500 mg (except	flurandrenolide lotion	hydrocortisone
NOC 73007001303),

cyclobenzaprine (except

flurandrenolide ointment	hydrocortisone butyrate cream,

cyclobenzaprine tablet 7.5mg),	hydrocortisone butyrate
mGtaYalong 800 mo,	ointment, hydrocortisone
methocarbamol (except NDCs	butyrate solution, mometasone,
69036091010,69036093090,	triamcinolone cream,
70868090190)	triamcinolone lotion,

FINACEAGEL	azelaic acid gel, brimonidine gel,

triamcinolone ointment
(except triamcinolone ointment

metronidazole, FINACEA FOAM,	0.05%)
SOOLANTRA

FINTEPLA	clobazam, clonazepam, lamotrigine, rufinamide, topiramate, TROKENDI XR

FML FORTE, FML LIQUIFILM	dexamethasone, difluprednate,
loteprednol, prednisolone acetate 1%

EXCLUDED DRUG NAME($)	PREFERRED OPTION($)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
FOCALIN XR	amphetamine-	BETASERON, COPAXONE 40
dextroamphetamine mixed salts	MG/ML, KESIMPTA, MAYZENT,
ext-rel, dexmethylphenidate ext-	OCREVUS, REBIF, TYSABRI,
rel, dextroamphetamineext-rel,	VUMERITY, ZEPOSIA
lisdexamfetamine,	GLASSIA	PROLASTIN-C, ZEMAIRA
methylphenidate ext-rel,

AZSTARYS
Folvite-D	folic acid, generic multivitamins

GLEEVEC		imatinib mesylate, BOSULIF, SPRYCEL
GLUCAGEN HYPOKIT	glucagon, human recombinant;

FORTAMET	metformin, metformin ext-rel	BAQSIMI; GVOKE; ZEGALOGUE (except generics for FORTAMET

and GLUMETZA)

GLUCAGON EMERGENCY KIT	glucagon, human recombinant;

FORTESTA	testosterone gel (except		BAQSIMI; GVOKE; ZEGALOGUE authorized generics for TESTIM	GLUMETZA	metformin, metformin ext-rel
and VOGELXO), testosterone	(except generics for FORTAM ET
solution, NATESTO	and GLUMETZA)
FOSRENOL	calcium acetate, seve/amer	 GLYCOPYRROLATE TABLET 1.5 dicyctomine carbonate, AURYXIA	MG
FOSTEUM, FOSTEUM PLUS	alendronate, ibandronate,	GOLYTELY	peg 3350-electrolytes (except
risedronate	generics for MOVIPREP), sodium
FRAGMIN	enoxaparin, fondaparinux	sulfate-potassium sulfate- magnesium sulfate, CLENPIQ
FREESTYLE LIBRE	DEXCOM CONTINUOUS	GONAL-F	FOLLISTIM AQ
CONTINUOUS GLUCOSE	GLUCOSE MONITORING
MONITORING SYSTEM	SYSTEM	GRANIX	NIVESTYM
FREESTYLE STRIPS AND KITS  ACCU-CHEK AVIVA PLUS	GUARDIAN	DEXCOM CONTINUOUS STRIPS AND KITS, ACCU-CHEK  CONNECT CONTINUOUS	 GLUCOSE MONITORING GUIDE STRIPS AND KITS, ACCU-  GLUCOSE MONITORING	 SYSTEM
CHEK SMARTVIEW STRIPS AND  SYSTEM
KITS, ONETOUCH ULTRA STRIPS  GUARDIAN REAL-TIME	 DEXCOM CONTINUOUS AND KITS, ONETOUCH VERIO   CONTINUOUS GLUCOSE	GLUCOSE MONITORING STRIPS AND KITS	MONITORING SYSTEM	 SYSTEM
FULPHILA	FYLNETRA, NYVEPRIA	halcinonide cream	desoximetasone (except
Fyremadel	GANIRELIX ACETATE	desoximetasone ointment
ganirelix acetate	GANIRELIX ACETATE	0.05%), fluocinonide (except
fluocinonide cream 0.1%},
GEL-ONE	DUROLANE, EUFLEXXA,	BRYHALI
GELSYN-3, SUPARTZ FX	HALOG	 desoximetasone (except GELNIQUE	darifenacin ext-rel, fesoterodine		desoximetasone ointment
ext-rel, oxybutynin ext-rel,	0.05%), fluocinonide (except
solifenacin, tolterodine,	fluocinonide cream 0.1%},
tolterodine ext-rel, trospium,	BRYHALI
trospium ext-rel, GEMTESA	HEPARIN SODIUM IN 5%	enoxaparin, fondaparinux
Genicin Vita-S	generic multivitamins	DEXTROSE
GENOTROPIN	HUMATROPE, NORDITROPIN,	HERCEPTIN, HERCEPTIN	HERZUMA, OGIVRI SOGROYA	HYLECTA
GEODON CAPSULE	arfpFprazote, asenapine,	HORIZANT	gabapentin, pregabalin, GRALISE
clozapine, lurasidone,	HUMALOG	FIASP, NOVOLOG
olanzapine, quetiapine,

quetiapine ext-rel, risperidone,

HUMALOG MIX 50/50	NOVOLOG MIX 70/30

ziprasidone, VRAYLAR	HUMALOG MIX 75/25	NOVOLOG MIX 70/30
GEOOON INTRAMUSCULAR	 haloperidol, ziprasidone	HUMULIN 70/30	NOVOLIN 70/30 GILENYA	dimethyl fumarate delayed-rel,	HUMULIN N	NOVOLIN N
fingolimod, glatiramer,	HUMULIN R	NOVOLIN R
teriflunomide, AVONEX,
HYALGAN	DUROLANE, EUFLEXXA,

EXCLUDED DRUG NAME($)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
GELSYN-3, SUPARTZ FX	propranolol ext-rel
hydrocortisone butyrate	hydrocortisone butyrate cream,	lndocin, INDOCIN	dic/ofenac sodium, ibuprofen, lipophilic cream 0.1%	hydrocortisone butyrate		 meloxicam tablet,
ointment, hydrocortisone	naproxen (except naproxen CR
butyrate solution, mometasone,	or naproxen suspension)
triamcinolone cream,	indomethacin capsule 20 mg	diclofenac sodium, ibuprofen, triamcinolone lotion,		 meloxicam tablet,
triamcinolone ointment	naproxen (except naproxen CR
{except triamcinolone ointment	or naproxen suspension)
0.05%)

hydrocortisone butyrate lotion	hydrocortisone butyrate cream,

lnflammacin	dic/ofenac sodium, diclofenac
sodium gel 1%, diclofenac

hydrocortisone butyrate	sodium solution 1.5%, ibuprofen,
ointment, hydrocortisone	meloxicam tablet, naproxen
butyrate solution, mometasone,	(except naproxen CR or
triamcinolone cream,	naproxen suspension)
triamcinolone lotion,

triamcinolone ointment (except triamcinolone ointment 0.05%)
HylaVite	generic multivitamins

INFLECTRA	AVSOLA, ILUMYA, REMICADE,
SIMPON! ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
INNOPRANXL	acebutolol, ateno/ol, carvedilol,

hyoscyamine sulfate ext-rel	dicyclomine, hyoscyamine	carvedilol phosphate ext-rel,
sulfate, hyoscyamine sulfate	metoprolol succinate ext-rel,
orally disintegrating tablet	metoprolol tartrate, nadolol,
HYQVIA	CUTAQUIG	nebivolol, propranolol,
HYSINGLAER		fentanyl transdermal,		 propranolol ext-rel hydrocodone ext-rel,	INTELENCE	etravirine
methadone, morphine ext-rel,	INTRAROSA	estradiol vaginal cream,
oxycodone ext-rel	IMVEXXY, VAGIFEM
HYZAAR	candesartan-	INTUNIV	amphetamine- hydrochlorothiazide, irbesartan-		 dextroamphetamine mixed salts
hydrochlorothiazide, losartan-	ext-rel, atomoxetine,
hydrochlorothiazide, olmesartan-	dexmethylphenidateext-rel,
hydrochlorothiazide, telmisartan-	dextroamphetamineext-rel,
hydrochlorothiazide, va/sartan-	guanfacine ext-re/,
hydrochlorothiazide	lisdexamfetamine,
/clofenac GP	diclofenac sodium, diclofenac	methylphenidate ext-rel, sodium gel 1%,dic/ofenac	 AZSTARYS, QELBREE
sodium solution 1.5%, ibuprofen,	INVELTYS	dexamethasone, difluprednate,
me/oxicam tablet, naproxen	loteprednol, prednisolone
(except naproxen CR or	acetate 1%
naproxen suspension)
INVOKAMET, INVOKAMET XR	SYNJARDY, SYNJARDY XR,
ICLUSIG	imatinib mesylate, BOSULIF,	XIGDUOXR
SPRYCEL

icosapent ethyl	omega-3 acid ethyl esters,
VASCEPA

INVOKANA	FARXIGA, JARDIANCE
IRESSA	erlotinib, gefitinib

ILEVRO

bromfenac, diclofenac, ketorolac	ISORDIL	isosorbide dinitrate (except
isosorbide dinitrate 40 mg),

IMBRUVICA	BRUKINSA, CALQUENCE	isosorbide mononitrate

INCRUSE ELLIPTA

SPIRIVA	isosorbide dinitrate 40 mg	isosorbide dinitrate (except
isosorbide dinitrate 40 mg),

INDERAL LA, INDERAL XL		acebutolot, atenolol, carvedilol,	isosorbide mononitrate carvedilol phosphate ext-rel,

metoprolol succinate ext-rel, metoprolol tartrate, nadolol,

isotretinoin capsule25 mg, 35	isotretinoin capsule20 mg, 30
mg	mg,40mg

nebivolol, propranolol,	ISTALOL	timolol maleate solution

ivermectin cream

IXINITY JADENU

aze/aic acidgel, brimonidine gel, metronidazole, FINACEA FOAM, SOOLANTRA
ALPROLIX, REBINYN
deferasirox, deferiprone, deferoxamine

KEPPRA, KEPPRA XR

0.05%)
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-re/, gabapentin, lacosamide, lamotrigine, lamotrigine ext-re/,

JAKAFI (For Polycythemia Vera BESREMI Only)
JALYN		dutasteride-tamsulosin; dutasteride or finasteride WITH a/fuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin
JENTADUETO, JENTADUETO XR saxag/iptin-metformin ext-re/,
JANUMET, JANUMET XR

levetiracetam, levetiracetam ext­ ra/, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended,
pregabalin, primidone, tiagabine,
topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI

JORNAYPM

JUXTAPID JYNARQUE KALETRA

KAMDOY

KANJINTI KAPVAY

KapzinDC

KAZANO KENALOG

amphetamine­ dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext­ ra/, dextroamphetamineext-rel,
/isdexamfetamine, methylphenidate ext-rel, AZSTARYS
REPATHA
Talk to your doctor
atazanavir, darunavir, lopinavir­ ritonavir
desonide (except desonide gel}, hydrocortisone
HERZUMA, OGIVRI
amphetamine­ dextroamphetamine mixed salts ext-rel, atomoxetine, dexmethylphenidate ext-rel, dextroamphetamineext-rel, guanfacine ext-rel, lisdexamfetamine, methylphenidate ext-re/, AZSTARYS,QELBREE
dic/ofenac sodium, dic/ofenac sodium gel 1%,diclofenac sodium solution 1.5%, ibuprofen, me/oxicam tablet, naproxen (except naproxen CR or naproxen suspension)
saxag/iptin-metforminext-rel.
JANUMET, JANUMET XR
hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
(except triamcinolone ointment

KERYDIN
ketoconazole foam2%

Ketodan

ketoprofen capsule 25 mg

ketoprofen ext-rel capsule

KITABISPAK KOMBIGLYZE XR

KORLYM KUVAN KYPROLIS LACRISERT
LACTULOSE PAK LAMICTAL, LAMICTALODT

LAMICTALXR

terbinafine tablet
ketoconazo/e shampoo 2%, selenium sulfide lotion 2.5%
ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
tobramycin inhalation solution
saxagliptin-metformin ext-re/,
JANUMET, JANUMET XR
Talk to your doctor sapropterin bortezomib, NINLARO RESTASIS, XIIDRA
lactu/ose solution
carbamazepine, carbamazepine ext-re/, c/obazam, clonazepam, divalproex sodium, divalproex sodium ext-rel, gabapentin,
lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext­ rel. oxcarba:zepinG, phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, rufinamide, tiagabine, topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI
carbamazepine, carbamazepine

ext-rel, divalproex sodium, diva/proex sodium ext-rel, gabapentin, lacosamide,
lamotrigine, lamotrigine ext-rel,
levetiracetam, levetiracetam ext­ rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI
LANOXIN TABLET (125 MCG and digoxin
250 MCG only)

LEXIVA LIALDA

LIBRAX

LILETTA LIPITOR

TRINTELLIX
atazanavir, darunavir, lopinavir­ ritonavir
balsalazide, mesa/amine delayed-rel, mesa/amine ext-rel, su/fasalazine, su/fasalazine delayed-re/
dicyclomine, hyoscyamine sulfate, hyoscyamine sulfate orally disintegrating tablet
KYLEENA, MIRENA, SKYLA
atorvastatin, ezetimibe­ simvastatin, fluvastatin,
/ovastatin, pravastatin,

lansoprazole delayed-rel orally disintegrating tablet

lanthanum carbonate LASTACAFT LATUDA

LEMTRADA

LESCOLXL

LETAIRIS

LEUKINE LEVEMIR
levorphanol

LEXAPRO

esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet
calcium acetate, seve/amer carbonate, AURYXIA
azelastine, bepotastine, cromolyn sodium, olopatadine
aripiprazole, asenapine, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR
dimethyl fumarate delayed-re/, fingolimod, glatiramer, teriflunomide, AVONEX, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
atorvastatin, ezetimibe­ simvastatin, fluvastatin,
/ovastatin, pravastatin, rosuvastatin, simvastatin
ambrisentan, bosentan,
OPSUMIT NIVESTYM LANTUS
fentanyl transdermal,
hydrocodone ext-rel. methadone, morphine ext-rel, oxycodone ext-rel
citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, f/uoxetine tablet [generics for SARAFEM]}, paroxetine HCI, paroxetine HCI ext-rel (except NOC

LITHOSTAT LIVALO

Lofena

LOKELMA LORBRENA
Lorzone

LOTEMAX, LOTEMAX SM

LOVAZA LUCENTIS
luliconazole

LUMIGAN

LUNESTA LUPRON DEPOT

rosuvastatin, simvastatin
Talk to your doctor
atorvastatin, ezetimibe­ simvastatin, f/uvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
dic/ofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
VELTASSA
ALECENSA, ALUNBRIG
carisoprodol 350 mg, chlorzoxazone 500 mg (except NOC 73007001303),
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs 69036091010, 69036093090,
70868090190)
dexamethasone, difluprednate, loteprednol, prednisolone acetate 1%
omega-3 acid ethyl esters,
VASCEPA
BVOOVIZ, CIMERLI
ciclopirox, clotrimazole, econazole, ketoconazole cream
Z'J6, oxiconazole (except NDCs
00168035830, 51672135902)
bimatoprost, latanoprost, travoprost
doxepin, rame/teon, temazepam, zolpidem, zolpidem ext-rel
ELIGARD

60505367503), sertraline,

LUZU	ciclopirox, clotrimazole,

econazole, ketoconazole cream	70868090190)
2%,oxiconazole (except NDCs	METROGEL	azelaic acid gel, brimonidine gel,
00168035830, 51672135902)	metronidazole, FINACEA FOAM,
LYRICA	duloxetine, pregabalin	SOOLANTRA
MACRODANTIN	nitrofurantoin (except NDC	MIACALCIN INJECTION	alendronate, calcitonin-salmon,
16571074024)	ibandronate, risedronate,
MatzimLA	diltiazem ext-rel (except		 FORTEO, PROLIA, TYMLOS generics for CARDIZEM LA),	MICARDIS, MICARDIS HCT	candesartan,candesartan- verapamil ext-rel		 hydrochlorothiazide, irbesartan,
MAVYRET	EPCLUSA (genotypes 1, 2, 3, 4, 5,	irbesartan-hydrochlorothiazide,

6), HARVONI (genotypes 1, 4, 5,
6), VOSEVI
MAXALT, MAXALT-MLT	eletriptan, naratriptan, rizatriptan,
sumatriptan, zolmitriptan,

losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-
hydrochlorothiazide, valsartan,

NURTEC OOT, UBRELVY	valsartan-hydrochlorothiazide
MAXIOEX	dexamethasone,difluprednate,	Migergot	eletriptan, naratriptan, rizatriptan, loteprednol, prednisolone		 sumatriptan, zolmitriptan,
acetate 1%	NURTEC OOT, UBRELVY
mefenamic acid (NOC	diclofenac sodium, ibuprofen,	MIGRANAL	eletriptan, naratriptan, rizatriptan,
69336012830 only)	meloxicam tablet,	sumatriptan, zolmitriptan,
naproxen (except naproxen CR	NURTEC OOT, UBRELVY
or naproxen suspension)
Millipred	dexamethasone, hydrocortisone,
MEKINIST	COTELLIC, MEKTOVI	methylprednisolone,
meloxicam capsule	diclofenac sodium, ibuprofen,	prednisolone solution (except
meloxicam tablet,	prednisolone solution 10 mg/5
naproxen (except naproxen CR	mL, 20 mg/5 mL), prednisone
or naproxen suspension)	MINASTRIN 24 FE	ethinyl estradiol-drospirenone,
MENEST	estradiol	ethinyl estradiol-drospirenone-
MENOSTAR	estradiol	/evomefolate, ethinyl estradiol-

meperidine	hydromorphone, morphine, oxycodone

/evonorgestrel, ethinyl estradiol-
/evonorgestrel-iron, ethinyl estradiol-norethindrone acetate-

MESTINON	pyridostigmine,	iron, ethinyl estradiol-
pyridostigmine ext-rel	norgestimate, LO LOESTRIN FE,
metaxalone 400 mg	carisoprodol 350 mg,	NATAZIA
chlorzoxazone 500 mg (except	MINIVELLE	estradio/, OIVIGEL
NDC 73007001303),	minocycline ext-rel	doxycycline hyclate capsule, cyclobenzaprine (except		 doxycyc/ine hyclate tablet
cyclobenzaprine tablet 7.5 mg),	(except doxycycline hyclate
metaxalone 800 mg,	tablet 50 mg, 75 mg, 150 mg),
methocarbamol (except NDCs	minocycline, tetracycline
69036091010, 69036093090,

70868090190)	MINOLIRA
metformin ext-rel (generics for	metformin, metformin ext-rel

doxycyc/ine hyclate capsule,
doxycycline hyclate tablet
(except doxycyc/ing hye/at9

J:O TAM!;T and GLUMtTZA	(excopt generic:, for FORTAMET	tablet 50 mg, 75 mg, 150 mg),
only)	and GLUMETZA)	minocycline, tetracycline
methocarbamol 500 mg (NOC	carisoprodol 350 mg,	MIRVASO	azelaic acidgel, brimonidine gel,
69036091010 only),	chlorzoxazone 500 mg (except	metronidazole, FINACEA FOAM,
methocarbamol 750 mg (NOCs NOC 73007001303),	SOOLANTRA
69036093090,70868090190	cyclobenzaprine (except

only)		cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol {except NDCs

Mondoxyne NL capsule 75 mg	doxycycline hyclate capsule,
doxycycline hyclate tablet
{except doxycycline hyclate

69036091010, 69036093090,	tablet 50 mg, 75 mg, 150 mg),

minocycline, tetracycline	gentamicin
MONOVISC	DUROLANE, EUFLEXXA,	NESINA	saxagliptin, JANUVIA
GELSYN-3, SUPARTZ FX	NEULASTA, NEULASTA ONPRO FYLNETRA, NYVEPRIA MOVANTIK	lubiprostone, SYMPROIC	 NEUPOGEN	NIVESTYM
MOVIPREP	peg 3350-electrolytes (except	NEVANAC	bromfenac, dic/ofenac, ketorolac
generics for MOVIPREP), sodium

sulfate-potassium sulfate-

NEXAVAR	pazopanib, sorafenib, sunitinib,

magnesium sulfate, CLENPIQ	CABOMETYX, INLYTA, LENVIMA
MultiPro	generic multivitamins	NEXIUM	esomeprazole delayed-rel,
/ansoprazo/e delayed-rel

mupirocin cream	gentamicin, mupirocin ointment

capsule, omeprazole delayed-rel,

MYDAYIS	amphetamine-		 pantoprazole delayed-rel tablet dextroamphetaminemixed salts	NEXTERONE	amiodarone

rel, dextroamphetamineext-rel,

ext-rel, dexmethylphenidateext-	niacin tablet 500 mg	niacin ext-rel
/isdexamfetamine,	Niacor	niacin ext-rel
methy/phenidate ext-rel,	NICADAN	generic multivitamins
AZSTARYS	NICAPRIN	generic multivitamins
MYOBLOC	DYSPORT, XEOMIN	NICAZEL, NICAZEL FORTE	generic multivitamins
MYRBETRIQ	darifenacin ext-rel, fesoterodine	NILANDRON	abiraterone, bicalutamide,

ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium,

ERLEADA, NUBEQA, XTANDI,
YONSA

trospium ext-rel, GEMTESA	nitrofurantoin (NOC	nitrofurantoin {except NDC
MYTESI	diphenoxylate-atropine,	16571074024 only)	16571074024)
loperamide	NITYR	ORFADIN
NAFTIN	cic/opirox, c/otrimazole,	NORGESIC FORTE	carisoprodol 350 mg, econazole, ketoconazole cream		 chlorzoxazone 500 mg (except
2%, oxiconazole (except NDCs	NDC 73007001303),
00168035830, 51672135902)	cyclobenzaprine (except
NAMENDAXR	memantine	cyclobenzaprine tablet 7.5 mg),
metaxalone BOO mg,
NAPRELAN	diclofenac sodium, ibuprofen,	methocarbamol (except NDCs
meloxicam tablet,	69036091010,69036093090,
naproxen {except naproxen CR	70868090190)
or naproxen suspension)	NORITATE	azelaic acid gel, brimonidine gel, naproxenCR	diclofenac sodium, ibuprofen,		 metronidazole, FINACEA FOAM,
me/oxicam tablet,	SOOLANTRA
naproxen (except naproxen CR	NORPACE	disopyramide
or naproxen suspension)
naproxen suspension	diclofenac sodium, ibuprofen,	NORTHERA	midodrine
meloxicam tablet,	NORVASC	amlodipine, nifedipine ext-rel
naproxen (except naproxen CR	NORVIR	ritonavir
or naproxen suspension)	NOURIANZ	entacapone, pramipexole, naproxen-esomeprazole	dic/ofenac sodium, ibuprofen,		 pramipexote ext-rel, rasagillne,
meloxicam tablet or naproxen	ropiniro/e, ropinirole ext-rel,
(except naproxen CR or	se/egiline, NEUPRO
naproxen suspension) WITH	NOVAREL	OVIDREL
esomeprazole delayed-rel,
lansoprazole delayed-rel	NOVO NORDISK NEEDLES	BD ULTRAFINE NEEDLES
capsule, omeprazole delayed-rel,	NOXAFIL	f/uconazole, itraconazole
or pantoprazole delayed-rel	NPLATE	DOPTELET, PROMACTA,
tablet	TAVALISSE
NEO-SYNALAR	desonide (except desonide gel)	 NUCALA LYOPHILIZED	DUPIXENT, FASENRA, NUCALA or hydrocortisone WITH	POWDER	 {except lyophilized powder),

NUCYNTA NUCYNTAER

NuDic/o So/uPak, NuDic/o TabPak

NUEDEXTA NUTROPINAQ

NUVESSA NUVIGIL

OCTAGAM OLUX-E

TEZSPIRE, XOLAIR
hydromorphone, morphine, oxycodone
fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, oxycodone ext-rel
diclofenac sodium, dic/ofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen,
meloxicam tablet, naproxen
{except naproxen CR or
naproxen suspension)
Talk to your doctor
HUMATROPE, NORDITROPIN, SOGROYA
clindamycin, metronidazole
armodafini/, modafinil, LUMRYZ, SUNOSI, WAKIX, XYWAV
Talk to your doctor
clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment

ORTHOD ORTHODF ORTHOVISC
OSENI

OSMOPREP

OSPHENA OTOVEL

OTREXUP
OWEN MUMFORD NEEDLES
oxiconazole (NDCs
00168035830, 51672135902
only}

cyclobenzaprine (except cyclobenzaprinetablet 7.5 mg), metaxalone BOO mg, methocarbamol (except NDCs 69036091010, 69036093090,
70868090190)
folio acid, generic multivitamins folic acid, generic multivitamins
DUROLANE, EUFLEXXA. GELSYN-3, SUPARTZ FX
saxagliptin-metforminext-rel,
JANUMET, JANUMET XR;
saxagliptin or JANUVIA WITH
pioglitazone
peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate­ magnesium sulfate, CLENPIQ
estradiol
ciprofloxacin-dexamethasone, ofloxacin otic
RASUVO
BD ULTRAFINE NEEDLES
ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs

omeprazole-sodium bicarbonate esomeprazole delayed-rel,
lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet
OMNARIS	azelastine-fluticasone, flunisolide, fluticasone, mometasone
OMNITROPE	HUMATROPE, NORDITROPIN, SOGROYA
ONFI	clobazam, clonazepam, lamotrigine, rufinamide, topiramate, TROKENDI XR
ONGLYZA	saxagliptin, JANUVIA
ORENCIA INTRAVENOUS	AVSOLA, REMICADE, SIMPON!
ARIA
orphenadrine-aspirin-caffeine	carisoprodol 350 mg,
chlorzoxazone 500 mg (except
NOC 73007001303),
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxalone BOO mg, methocarbamol (except NDCs 69036091010,69036093090,
70868090190)
Orphengesic Forte		carisoprodol 350 mg, chlorzoxazone 500 mg (except NOC 73007001303),

OXISTAT

OXYCONTIN

oxymorphone ext-rel

OXYTROL

PANCREAZE
pantoprazole delayed-rel suspension

paroxetine HCI ext-rel {NDC
60505367503 only)

00168035830, 51672135902)
ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs 00168035830, 51672135902)
fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, oxycodone ext-rel
fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, oxycodone ext-rel
darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodina ext-rel, trospium,
trospium ext-rel, GEMTESA
CREON, VIOKACE, ZENPEP
esomeprazole delayed-re/, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet
citalopram, escitalopram, fluoxetine (except f/uoxetine tab/at 60 mg, fluoxetine tablet [generics for SARAFEMJ),

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
paroxetine HCI, paroxetine HC/ ext-rel (except NOC

EXCLUDED DRUG NAME($)	PREFERRED OPTION(S)
AND KITS, ONETOUCH VERIO STRIPS AND KITS

60505367503), sertraline,
TRINTELLIX
paroxetine mesylate capsule 7.5 paroxetine HCI mg
PAXIL, PAXIL CR	citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, f/uoxetine tablet [generics for SARAFEM]), paroxetine HG/, paroxetine HCI ext-rel (except NDC 60505367503), sertraline, TRINTELLIX
peg 3350-electrolytes {generics peg 3350-e/ectro/ytes {except for MOVIPREP only)	generics for MOVIPREP), sodium
sulfate-potassium sulfate­ magnesium sulfate, CLENPIQ
PEGASYS	Talk to your doctor

PRED FORTE, PRED MILD

prednisolone solution 10 mg/5 ml, prednisolone solution 20 mg/5mL

PREFEST PREGNYL PREMARIN PREMARIN CREAM

PREMPHASE PREMPRO PRENATAl PLUS
PREVACID

dexamethasone, difluprednate,
/oteprednol, prednisolone acetate 1%
dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution (except
prednisolone solution 10 mg/5 ml, 20 mg/5 ml),prednisone
estradiol-norethindrone, BIJUVA OVIDREL
estradio/
estradiol vaginal
cream, IMVEXXY, VAGIFEM
estradiol-norethindrone,BIJUVA estradiol-norethindrone, BIJUVA generic prenatal vitamins
esomeprazole delayed-rel,

PENNSAID

PENTASA

PERCOCET

PERRIGO NEEDLES PERTZYE

PLAVIX PLENVU

POLYTOZA POLY-VI-FLOR
POLY-VI-FLOR WITH IRON

diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
ba/salazide, mesa/amine delayed-rel, mesa/amine ext-rel, sulfasa/azine, sulfasalazine delayed-rel
hydrocodone-acetaminophen, oxycodone-acetaminophen
BO ULTRAFINE NEEDLES CREON, VIOKACE, ZENPEP

clopidogrel, dipyridamole ext-re/­ aspirin, prasugrel, BRILINTA
peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate­ magnesium sulfate, CLENPIQ
Talk to your doctor generic multivitamins generic multivitamins

PREVIDENT PREZISTA PRILOSEC

PRISTIQ

PROAIR RESPICLICK

PROCORT PROCTOCORT

PROCYSBI

lansoprazole delayed-re/ capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet
Talk to your doctor
atazanavir, darunavir
esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazo/e delayed-rel, pantoprazole delayed-re/ tablet
desvenlafaxine ext-rel, du/oxetine, venlafaxine, venlafaxine ext-rel capsule
albuterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968),
levalbuterol tartrate CFC- free aerosol
hydrocortisone
budesonide foam, hydrocortisone enema, mesa/amine suppository, mesa/amine suspension, CORTIFOAM
CYSTAGON

posaconazole delayed-rel tablet fluconazole, itraconazo/e

PROLENSA

bromfenac, diclofenac, ketorotac

PRADAXA PRALUENT
PRECISION XTRA STRIPS AND KITS

warfarin, ELIQUIS, XARELTO REPATHA
ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS ANO KITS, ACCU­ CHEK SMARTVIEW STRIPS AND KITS, ONETOUCH ULTRA STRIPS

PROMETRIUM PROTONIX

PROVENTIL HFA

medroxyprogesterone; progesterone, micronized
esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet
a/buterol sulfate CFC-free

EXCLUDED DRUG NAME{S)	PREFERRED OPTION{S)	EXCLUDED DRUG NAME{S)	PREFERRED OPTION{S)	
	aerosol (except NDCs	RENFLEXIS	AVSOLA, ILUMYA, REMICADE,	
	00093317431, 66993001968),		SIMPON! ARIA, SKYRIZI	
	levalbuterol tartrate CFC-		INTRAVENOUS, STELARA	
	free aerosol		INTRAVENOUS	
PROVIGIL	armodafinil, modafinil, LUMRYZ,	RENVELA	calcium acetate, sevelamer	
	SUNOSI, WAKIX, XYWAV		carbonate, AURYXIA	
PROZAC	cita/opram, escitalopram,	RETIN-A MICRO	adapalene (except adapalene	
	fluoxetine (except fluoxetine		pad), benzoyl peroxide,	
	tablet 60 mg, fluoxetine tablet
[generics for SARAFEM]),		c/indamycin gel (except NDC
68682046275), clindamycin	
	paroxetine HCI, paroxetine HCI		solution, clindamycin-benzoyl	
	ext-rel (except NOC		peroxide, dapsone, erythromycin	
	60505367503), sertraline,		solution, erythromycin-benzoy/	
	TRINTELLIX		peroxide, tretinoin, AKLIEF,	
PULMICORT RESPULES	budesonide inhalation		EPIDUO, ONEXTON, TWYNEO,	
	suspension, PULMICORT		WINLEVI	
	FLEXHALER	REVATIO	sildenafil, tadalafil, TADLIQ	
QNASL	azelastine-fluticasone,	REYATAZ	atazanavir, darunavir	
flunisolide, fluticasone,	RHEUMATI:	generic multivitamins mometasone
RHOFADE	azelaic acid gel, brimonidine gel,
QTERN	GLYXAMBI	metronidazole, FINACEA FOAM,
SOOLANTRA
quazepam		doxepin, ramelteon, temazepam,	RHOPRESSA	 bimatoprost, brimonidine zolpidem, zolpidem ext-rel		solution, brimonidine-timolol,
QUILLICHEW ER	amphetamine-	 brinzolamide, dorzolamide, dextroamphetaminemixed salts	dorzolamide-timolo/, /atanoprost,
ext-rel, dexmethylphenidateext-	timolol maleate solution,
rel, dextroamphetamine ext-rel,	travoprost, ALPHAGAN P,
lisdexamfetamine,	SIMBRINZA
methylphenidate ext-rel,	RIABNI	RUXIENCE
AZSTARYS	RIMSO-50	 Talk to your doctor QUILLIVANT XR	amphetamine-	 RIOMET	metformin, metformin ext-rel
dextroamphetaminemixed salts	(except generics for FORTAMET
ext-rel, dexmethylphenidateext-	and GLUMETZA)
rel, dextroamphetamineext-rel,

/isdexamfetamine,

RITUXAN	RUXIENCE

methylphenidateext-rel,	RIXUBIS	ALPROLIX, REBINYN
AZSTARYS	ROCKLATAN	bimatoprost, brimonidine
QVAR REDIHALER	PULMICORT FLEXHALER	solution, brimonidine-timolo/,
RAPAFLO	alfuzosin ext-rel, doxazosin,	 brinzolamide, dorzolamide, silodosin, tamsulosin, terazosin	dorzolamide-timolol, latanoprost,
timolol maleate solution,

RAVICTI	sodium phenylbutyrate,

travoprost, ALPHAGAN P,

PHEBURANE	SIMBRINZA
RAYOS	dexamethasone, hydrocortisone,	ROWASA	mesa/amine suspension methylpredniso/one,

prednisolone solution (except

ROZEREM	doxepin, ramelteon, temazepam,

prednisolone solution 10 mg/5	zolpidem, zolpidem ext-rel
mL,20 mg/5 mL), prednisone	RUBRACA	LYNPARZA, ZEJULA
RECEDO	Talk to your doctor	RyC/ora	clemastine 2.68 mg,
RELION INSULIN	NOVOLIN INSULIN	cyproheptadine, levocetirizine
RELISTOR	lubiprostone, SYMPROIC	SABRIL	vigabatrin
REMODULIN	treprostinil	SAIZEN	HUMATROPE NORDITROPIN,
SOGROYA

EXCLUDED DRUG NAME($)	PREFERRED OPTION($)	EXCLUDED DRUG NAME($)	PREFERRED OPTION(S)	
SANDOSTATIN LAR	SOMATULINE DEPOT		naproxen {except naproxen CR	
SCARSILK PAD	Talk to your doctor		or naproxen suspension) WITH
eletriptan, naratriptan, rizatriptan,	
			sumatriptan, zolmitriptan,	
SELZENTRY	maraviroc		NURTEC ODT or UBRELVY	
SEREVENT	STRIVERDI RESPIMAT	SUPREP	peg 3350-electrolytes (except	
SEROQUELXR	aripiprazole, asenapine,	generics for MOVIPREP), sodium
clozapine, lurasidone,	sulfate-potassium sulfate-
o/anzapine, quetiapine,	magnesium sulfate, CLENPIQ
quetiapine ext-rel, risperidone,	Sure Result DSS Premium Pack diclofenac sodium, diclofenac ziprasidone, VRAYLAR		sodium gel 1%,diclofenac
SEYSARA	doxycycline hyclate capsule,	sodium solution 1.5%, ibuprofen, doxycycline hyc/ate tablet	 meloxicam tablet, naproxen
(except doxycycline hyclate	(except naproxen CR or
tablet 50 mg, 75 mg, 150 mg),	naproxen suspension)
minocycline, tetracycline	SUTENT	pazopanib, sunitinib,
SFROWASA	mesa/amine suspension	CABOMETYX, INLYTA, LENVIMA
SIGNIFOR LAR	SOMATULINE DEPOT	SYMBICORT	fluticasone-satmeterol (except
certain NDCs). Wixela lnhub,

SILENOR	doxepin, ramelteon, temazepam,

BREO ELLIPTA (except certain

zolpidem, zolpidem ext-rel	NDCs)
SILIVEX	Talk to your doctor	SYMJEPI	epinephrine (except NDCs SILTREX	Talk to your doctor		 00093-XXXX-XX, 49502-XXXX-
SINGULAIR	montelukast, zafirlukast	XX), AUVI-Q
SOLODYN	doxycycline hyclate capsule,	SYNDROS	dronabinol
doxycycline hyclate tablet	SYNERDERM	desonide (except desonide gel),
(except doxycycline hyclate	hydrocortisone
tablet 50 mg, 75 mg, 150 mg),	SYNVISC, SYNVISC-ONE	DUROLANE, EUFLEXXA,
minocycline, tetracycline	GELSYN-3, SUPARTZ FX
SOLOSEC	clindamycin, metronidazole	SYPRINE	trientine
SOMAVERT	SOMATULINE DEPOT	TAFINLAR	BRAFTOVI, ZELBORAF
SORILUX	calcipotriene ointment,	TALIVA	generic multivitamins calcipotriene solution, VTAMA,
ZORYVE	Targadox	doxycycline hyclate capsule,
doxycycline hyclate tablet

SPORANOX CAPSULE	itraconazole, terbinafine tablet

(except doxycycline hyclate

SPORANOX SOLUTION	f/uconazole	tablet 50 mg, 75 mg, 150 mg),
SPRIX	diclofenac sodium, ibuprofen,		minocyc/ine, tetracycline meloxicam tablet,	TARGRETIN	bexarotene
naproxen (except naproxen CR	TASIGNA	imatinib mesytate, BOSULIF,
or naproxen suspension)	SPRYCEL
STENDRA	si/denafil, tadalafil, vardenafil	tavaboro/e	terbinafine tablet
STRIBILD	efavirenz-emtricitabine-tenofovir	TAYTULLA	ethinyl estradiol-drospirenone, disoproxil fumarate, efavirenz-		 ethinyl estradiol-drospirenone-
lamivudine-tenofovir disoproxil	tevomefotate, ethinyl estradiol-
fumarate, BIKTARVY, DOVATO,	/evonorgestrel, ethinyl estradiol-
GENVOYA, ODEFSEY, SYMTUZA,	levonorgestrel-iron, ethinyl
TRIUMEQ	estradiol-norethindrone acetate-
SUBOXONE	buprenorphine-naloxone	iron, ethinyl estradiol- sublingual, ZUBSOLV	norgestimate, LO LOESTRIN FE,
SUBSYS	fentanyl transmucosa/	NATAZIA
sucralfate suspension	sucralfate tablet	TAZORAC	adapalene (except adapalene sumatriptan-naproxen	 dictofenac sodium, ibuprofen or		 pad), bcn oyl poroxido,
c/indamycin gel (except NOC

TECFIDERA

TEGRETOL, TEGRETOL XR

TESTIM

testosterone gel 1% (authorized generics for TESTIM and VOGELXO only)

THE0-24

THIOLA, THIOLA EC TIMOPTIC OCUDOSE TIROSINT
TOBI, TOBI PODHALER
TOBRADEX, TOBRADEX ST

topiramate ext-rel capsule
(generics for QUDEXY XR only)

68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoy/ peroxide, tretinoin, AKLIEF, EPIDUO, ONEXTON, TWYNEO,
WINLEVI; calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE
dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext­ rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, pregaba/in, primidone, tiagabine, topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI
testosterone gel (except authorized generics for TESTIM and VOGELXO),
testosterone solution, NATESTO
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, NATESTO
arformoterol, formoterol inhalation solution, ipratropium inhalation solution, SPIRIVA,
STRIVERDI RESPIMAT, YUPELRI
tiopronin
timolo/ maleate solution levothyroxine
tobramycin inhalation solution
neomycin-polymyxin B­ bacitracin-hydrocortisone, neomycin-polymyxin B­ dexamethasone, tobramycin­ dexamethasone
carbamazepine, carbamazepine ext-rel, clobazam, clonazepam,
divalproex sodium, c:Jivalprol/1x
sodium ext-rel, gabapentin,

TOPROL-XL

Tovet

TOVIAZ

TRACLEER TRADJENTA
tramadol (NDC 52817019610 only), tramadol ext-rel capsule

TRANSDERM SCOP TRAVATANZ
TRAZIMERA TRELSTAR MIXJECT TREXIMET

triamcinolone aerosol 0.2%

lacosamide, lamotrigine, lamotrigine ext-re/, levetiracetam, levetiracetam ext­ rel, oxcarbazepine, phenobarbital, phenytoin,
phenytoin sodium extended, pregabalin, primidone, rufinamide, tiagabine, topiramate, valproic acid,
zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI
acebutolol, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolo/, nebivolol, propranolol, propranolol ext-rel
clobetaso/ cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, ha/obetaso/ cream, halobetaso/ ointment
darifenacin ext-rel, fesoterodine ext-re/, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-re/, trospium, trospium ext-re/, GEMTESA
ambrisentan, bosentan,
OPSUMIT
saxagliptin, JANUVIA
tramadol {except NDC 52817019610), tramadol ext-rel tablet
meclizine, scopolamine transdermal
bimatoprost, latanoprost, travoprost
HERZUMA, OGIVRI
ELIGARD
diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan,
sumatriptan, zolmitriptan,
NURTEC ODT or UBRELVY
hydrocortisonebutyrate cream, hydrocortisonebutyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment

triamcinolone ointment 0.05%

Trianex

TRICOR

TRILEPTAL

TRIPTODUR TRI-VI-FLOR
TRIVIDIA INSULIN SYRINGES

TronVite

(except triamcinolone ointment
0.05%)
hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion,
triamcinolone ointment (except triamcinolone ointment 0.05%)
hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
(except triamcinolone ointment
0.05%)
fenofibrate {except fenofibrate capsule 30 mg, 50 mg, 90 mg,
130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed­ rel
carbamazepine,carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext­ rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA,
OXTELLAR XR, TROKENDI XR, XCOPRI
FENSOLVI, LUPRON DEPOT­ PED, SUPPRELIN LA
generic multivitamins BD UL TRAFINE INSULIN SYRINGES
generic multivitamins

UDENYCA ULORIC
ULTIMED INSULIN SYRINGES

ULTIMED NEEDLES
ULTRAVATE

UROXATRAL

VALCYTE VALTREX

VANOS

Vanoxide-HC

VARUBI VASCULERA VECTICAL

VELPHORO

mesa/amine suppository, mesa/amine suspension, CORTIFOAM
FYLNETRA, NYVEPRIA
allopurinol
8D UL TRAFINE INSULIN SYRINGES
BDULTRAFINE NEEDLES
clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment
alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
valganciclovir
acyclovir (except acyclovir
cream, ointment), valacyclovir
clobetasol cream, clobetasol foam (except clobetaso/ emollient foam), clobetasol gel, clobetasol lotion, c/obetasol ointment, halobetasol cream, ha/obetasol ointment
adapalene (except adapalene pad), benzoyl peroxide, c/indamycin gel (except NOC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, AKLIEF, EPIDUO, ONEXTON, TWVNEO. WINLEVI
aprepitant
Talk to your doctor
calcipotriene ointment, ca/cipotriene solution, VTAMA, ZORYVE
calcium acetate, sevelamer
carbonate, AURYXIA

TRUVADA

TRUXIMA TUDORZA TYVASO DPI UCERISFOAM

abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate, lamivudine-zidovudine, CIMDUO, DESCOVY
RUXIENCE SPIRIVA
Talk to your doctor
budesonide foam, hydrocortisone enema,

VELTIN		adapa/ene (except adapalene pad), benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, AKLIEF, EPIDUO, ONEXTON, TWYNEO, WINLEVI

venlafaxine ext-re/ tablet (except desven/afaxine ext-re/,
225 mg)	duloxetine, venlafaxine, venlafaxine ext-rel capsule
VENTOLIN HFA	a/buterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968),
levalbuterol tartrate CFC- free aerosol

VUSION WELLBUTRIN XL

XALKORI

XANAX, XANAX XR

CABOMETYX, INLYTA, LENVIMA
nystatin
bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450mg)
ALECENSA, ALUNBRIG, ZYKADIA
alprazolam, c/onazepam,

VERDESO

VEREGEN VESICARE

VIAGRA

VIIBRYD

VIMPAT

VIRACEPT
VISC0-3 VITAFOL-ONE
Vitasure VIVELLE-DOT VOGELXO

VOTRIENT

desonide (except desonide gel), hydrocortisone
imiquimod, podofilox
darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GEMTESA
sildenafil, tadalafil, vardenafil

citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HG/, paroxetine HG/ ext-rel (except NOC 60505367503), senraline, TRINTELLIX
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel,
/evetiracetam, levetiracetam ext­ rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended,
pregaba/in, primidone, tiagabine, topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI
atazanavir, darunavir, lopinavir­ ritonavir
DUROLANE, EUFLEXXA.
GELSYN-3. SUPARTZ FX
generic prenatal vitamins generic multivitamins estradiol, DIVIGEL
testosterone gel (except authorized generics for TESTIM and VOGELXO),
testosterone solution, NATESTO
pazopanib, sunitinib,

XENAZINE XENICAL XERESE
XIFAXAN 200 MG
XIMINO

XOLEGEL COREPAK XOLEGELDUO

XOPENEX HFA

XTAMPZAER

XYREM XYZBAC YASMIN

VAZ

diazepam, lorazepam, oxazepam
tetrabenazine, AUSTEDO, AUSTEDO XR
or/istat, QSYMIA, SAXENDA, WEGOVY
acyclovir (except acyclovir cream, ointment), valacyctovir
su/famethoxazo/e-trimethoprim
doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyc/ate tablet 50 mg, 75 mg, 150 mg), minocycline, tetracycline
ciclopirox, ketoconazole cream 2%
ciclopirox, ketoconazole cream 2%, ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
a/buterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968),
levalbuterol tartrate CFC- free aerosol
fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, oxycodone ext-rel
LUMRYZ, WAKIX, XYWAV
generic multivitamins
ethinyl estradio/-drospirenone, ethinyl estradio/-drospirenone­ levomefolate, ethinyt estradiol­ levonorgestrel, ethinyl estradiol­
/evonorgestrel-iron, ethinyl
estradio/-norethindrone acetate­ iron, ethinyl estradiol­ norgestimate, LO LOESTRIN FE,
NATAZIA
ethinyl estradio/-drospirenone, ethinyl estradiol-drospirenone­ levomefolate, ethinyl estradiol­
/evonorgestrel,ethinyl estradiol­ levonorgestrel-iron, ethinyl estradiol-norethindrone ac;etate­ iron, ethinyl estradio/-

norgestimate, LO LOESTRIN FE,	ORILISSA
NATAZIA	ZOLOFT	citalopram, escitalopram, Yuvafem	estradiol vaginal cream,		 fluoxetine (except fluoxetine
IMVEXXY, VAGIFEM	tablet 60 mg, fluoxetine tablet
ZALVIT	generic prenatal vitamins	[generics for SARAFEM]),
ZARXIO	NIVESTYM		paroxetine HCI, paroxetine HG/ ext-rel (except NOC
ZEGERID	esomeprazole delayed-rel,	60505367503), sertra/ine, lansoprazole delayed-rel	 TRINTELLIX
capsule, omeprazole delayed-rel,	zo/pidem sublingual	doxepin, ramelteon, temazepam, pantoprazole delayed-rel tablet		 zolpidem, zolpidem ext-re/
ZELAC	Talk to your doctor

ZELAPAR
ZEPATIER	rasagi/ine, se/egiline
EPCLUSA (genotypes 1, 2, 3, 4, 5,	ZONEGRAN	carbamazepine, carbamazepine ext-rel, divalproex sodium,	
	6), HARVONI (genotypes 1, 4, 5,
6)		divalproex sodium ext-rel, gabapentin, lacosamide,	
ZESTORETIC	fosinopri/-hydrochlorothiazide, lisinopril-hydrochlorothiazide,
quinapril-hydroch/orothiazide		lamotrigine, lamotrigine ext-rel,
/evetiracetam, levetiracetam ext- rel, oxcarbazepine,	
ZETIA	ezetimibe	phenobarbital, phenytoin, phenytoin sodium extended,
ZETONNA	azelastine-fluticasone,	 pregabalin, primidone, tiagabine, flunisolide, fluticasone,	topiramate, valproic acid,
mometasone	zonisamide, APTIOM, FYCOMPA,
ZIANA	adapalene (except adapalene	OXTELLAR XR, TROKENDI XR,
pad), benzoy/ peroxide,	XCOPRI
clindamycin gel (except NDC	ZONTIVITY	Talk to your doctor
68682046275), clindamycin
solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, AKLIEF, EPIDUO, ONEXTON, TWYNEO, WINLEVI	ZORVOLEX

ZOVIRAX	diclofenac sodium, ibuprofen, meloxicam tablet,
naproxen (except naproxen CR
or naproxen suspension)
acyclovir (except acyclovir
cream), penciclovir, valacyclovir	

Zic/opro	dic/ofenac sodium, dic/ofenac	ZYCLARA	fluorouracil 5% cream, fluorouracil solution, imiquimod	

sodium gel 1%, dic/ofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen
(except naproxen CR or	ZYLET	neomycin-polymyxin B- bacitracin-hydrocortisone, neomycin-polymyxin B- dexamethasone, tobramycin-	
naproxen suspension)		dexamethasone	
ZIEXTENZO	FYLNETRA, NYVEPRIA	ZYMAXID	ciprofloxacin, erythromycin,	

zileuton ext-rel	montelukast, zafirlukast	gentamicin, levofloxacin, moxifloxacin, ofloxacin,
ZIPSOR		diclofenac sodium, ibuprofen,		sulfacetamide, tobramycin meloxicam tablet, naproxen	ZYTIGA	 abiraterone, bicalutarnida,
(except naproxen CR or	ERLEADA, NUBEQA, XTANDI,
naproxen suspension}	YONSA
ZIRGAN	trifluridine	ZYVOX	linezolid
ZOLADEX	ELIGARD, MYFEMBREE,

TABLE 1- PREFERRED OPTIONS FOR INDICATION BASED SELF-ADMINISTERED AUTOIMMUNE EXCLUDED MEDICATIONS

		ADALIMUMAB-ADAZ	
		COSENTYX ENBREL	
		HYRIMOZ	
		RINVOQ	
		ADALIMUMAB-ADAZ	
		HYRIMOZ	
		RINVOQ	
		SKYRIZI SUBCUTANEOUS	
		STELARA SUBCUTANEOUS	
		CIMZIA PREFILLED SYRINGE	
		COSENTYX	
		RINVOQ	
		ADALIMUMAB-ADAZ	
		HYRIMOZ	
		OTEZLA	
		SKYRIZI SUBCUTANEOUS	
		SOTYKTU	
		STELARA SUBCUTANEOUS
TALTZ	
		TREMFYA	
AMJEVITA	ADALIMUMAB-ADAZ	
HUMIRA	COSENTYX	
ORENCIA CLICKJECT	ENBREL	
ORENCIA SUBCUTANEOUS	HYRIMOZ	
SIMPON!	OTEZLA	
	RINVOQ	
	SKYRIZI SUBCUTANEOUS	
XELJANZXR	STELARA SUBCUTANEOUS TREMFVA	
ACTEMRA ACTPEN	ADALIMUMAB-ADAZ	
ACTEMRASUBCUTANEOUS	ENBREL	
	HYRIMOZ	
	KEVZARA	
	ORENCIA CLICKJECT	
	ORENCIA SUBCUTANEOUS	

	RINVOQ XELJANZ XELJANZXR	
AMJEVITA HUMIRA	ADALIMUMAB-ADAZ HYRIMOZ	
SIMPONI	RINVOQ	
	STELARA SUBCUTANEOUS XELJANZ
XELJANZXR ZEPOSIA	
ACTEMRA ACTPEN	ADALIMUMAB-ADAZ	
ACTEMRASUBCUTANEOUS	ENBREL	
AMJEVITA
HUMIRA	HYRIMOZ	
KINERET		
ORENCIA CLICKJECT		
ORENCIA SUBCUTANEOUS		

FOR YOUR INFORMATION: New-to-market products and new variations of products already in the marketplace willnot 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. 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.

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.
Some listings do not include certain NDCs as noted above.

For VOSEVI listing above: For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor {for genotypes 1a or 3).
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.
BD ULTRAFINE syringes and needles are the only preferred options.

ACCU-CHEK or ONETOUCH brand test strips are the only preferred options.

Generic multivitamins {except Activite, Dexifol, Folvite-D, Genicin Vita-S, HylaVite, Multipro, TronVite, Vitasure) are the only preferred options.
Generic prenatal vitamins are the only preferred options.
An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication. For more information, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu.
QVAR REDIHALER and fluticasone HFA are covered for members 6 years of age and under.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers not affiliated with CVS Caremark. 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.
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