Questions or additional info:

⊲ Contact Member Services at 866.516.3121

⊲ Visit optumrx.com

Value Formulary

EFFECTIVE JULY 1, 2020

ES.VLDL.EFF01012020.01.121019

866.516.3121 2

At CastiaRx, we want to help you understand your medication optionsA wide variety of drugs is included on the drug formulary (also known as a Preferred Drug List or PDL). When choosing medications, we encourage you and your doctor to choose the more cost-effective option available, which helps hold down costs for you and the plan.

For easy reference, this formulary is an overview of the most commonly prescribed medications and is detailed in the following sections:

Preferred medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

This is a list of drugs covered by your plan. When multiple drugs are equally effective in treating the same condition, the most cost-effective drug(s) will be listed on the Preferred Medication List. You will generally save money by choosing a drug from the preferred list.

Excluded medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

This list of drugs is not covered by your plan. When multiple drugs are equally effective in treating the same condition, drugs that cost more without providing additional clinical value are excluded from benefit coverage. If a drug you are taking is on the excluded list, we encourage you to speak with your doctor to help you find an alternative medication that will treat your condition and qualify for benefit coverage.

Specialty medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

This list of drugs may be covered by your plan. Specialty medications treat rare or complex conditions and are typically higher-cost medications. These medications require a prior authorization before coverage is determined.

This formulary includes commonly prescribed drugs, but is not a comprehensive list of all medications. If you don’t see the medication you are taking listed here, visit optumrx.com to review your pharmacy coverage.

⊲ Visit optumrx.com

⊲ Choose Drug Search

⊲ Type in the name of the drug

PLEASE NOTE: Brand drugs may move to non-preferred status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans. Login to optumrx.com to see if specific drugs are covered by your plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

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visit optumrx.com to access important information

Questions?Contact Member Services at

866.516.3121

866.516.3121 3

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

A abacavirabacavir/lamivudineabacavir/lamivudine/zidovudineABELCET [INJ]ABILIFY MAINTENA [INJ]ABRAXANE [INJ]acamprosate delayed-releaseacarboseACCU-CHEK FASTCLIX LANCETS [OTC]ACCU-CHEK MULTICLIX LANCET KIT [OTC]ACCU-CHEK MULTICLIX LANCETS [OTC]ACCU-CHEK SOFTCLIX LANCET KIT [OTC]ACCU-CHEK SOFTCLIX LANCETS [OTC]acebutololacetaminophen/codeineacetazolamideacetazolamide ext-releaseacetazolamide sodium [INJ]acetic acid ear solutionacetic acid irrigation solutionacetic acid/hydrocortisone ear solutionacetic acid/oxyquinoline vaginalacetylcysteine [INJ]acetylcysteine inhalation solutionacitretinACTEMRA [INJ]ACTHIB [INJ]ACTHREL [INJ]ACTIMMUNE [INJ]ACTIVASE [INJ]acycloviracyclovir ointmentacyclovir sodium [INJ]ADACEL [INJ]adapaleneadapalene/benzoyl peroxideADCETRIS [INJ]ADDAMEL N [INJ]ADDERALL XRadefovirADEMPAS

adenosine [INJ]ADVAIR DISKUSADVAIR HFAADVATE [INJ]ADYNOVATE [INJ]AFINITOR DISPERZAFLURIA [INJ]AFLURIA QUAD [INJ]AFSTYLA [INJ]AIMOVIG [INJ]albendazolealbumin human [INJ]albuterolalbuterol ext-releasealbuterol nebulization solutionalclometasoneALDURAZYME [INJ]alendronatealfentanil [INJ]ALFERON N [INJ]alfuzosin ext-releaseALIMTA [INJ]ALINIAALIQOPA [INJ]allopurinolallopurinol sodium [INJ]almotriptanalosetronALPHAGAN P 0.1%ALPHANATE [INJ]ALPHANINE SD [INJ]alprazolamalprazolam ext-releasealprazolam orally disintegrating tabletsALPROLIX [INJ]alprostadil [INJ]ALREXaltaveraALUNBRIGalyacenamabelzamantadineAMBISOME [INJ]amcinonideamethiaamethia loamethystamifostine [INJ]amikacin [INJ]

amilorideamiloride/hydrochlorothiazideaminocaproic acidaminophylline [INJ]AMINOSYN [INJ]amiodaroneamiodarone [INJ]amitriptylineamitriptyline/chlordiazepoxideamlodipineamlodipine/atorvastatinamlodipine/benazeprilamlodipine/olmesartanamlodipine/valsartanamlodipine/valsartan/ hydrochlorothiazideammonium lactate 12% topicalamoxapineamoxicillinamoxicillin/potassium clavulanateamoxicillin/potassium clavulanate ext-releaseamphetamine sulfateamphotericin [INJ]ampicillinampicillin sodium [INJ]ampicillin sodium/sulbactam [INJ]AMYTAL [INJ]anagrelideanastrozoleANDRODERMANORO ELLIPTAanthralinAPLISOL [INJ]APOKYN [INJ]apraclonidine eye solutionaprepitantapriAPRISOAPTIVUSAQUASOL A [INJ]ARALAST NP [INJ]aranellearipiprazolearipiprazole orally disintegrating tabletsARISTADA [INJ]ARISTOSPAN [INJ]armodafinil

ARMONAIR RESPICLICKARMOUR THYROIDARNUITY ELLIPTAARRANON [INJ]ascorbic acid [INJ]arsenic trioxide [INJ]ashlynaASMANEX HFAASMANEX TWISTHALERaspirin/dipyridamole ext-releaseatazanaviratenololatenolol/chlorthalidoneATGAM [INJ]atomoxetineatorvastatinatovaquoneatovaquone/proguanilatropine [INJ]atropine sulfate eye ointmentatropine sulfate eye solutionaubraaubra eqAUGMENTIN 125-31.25 MG/5 MLavianeavo creamAVONEX [INJ] AVYCAZ [INJ]azacitidine [INJ]AZACTAM-ISO-OSMOTIC DEXTROSE [INJ]AZASITEazathioprineazathioprine sodium [INJ]AZEDRA [INJ]azelastine eye solutionazelastine nasal sprayazithromycinazithromycin [INJ]aztreonam [INJ]azurette

B bacitracin [INJ]bacitracin eye ointmentbacitracin/polymyxin eye ointmentbaclofenBAL IN OIL [INJ]

Preferred MedicationsSave money by choosing a preferred drug. The list below includes commonly prescribed preferred drugs. If you don’t see your drug listed, check optumrx.com, for a complete list of all drugs, including preferred alternatives. A list of excluded drugs is also included in this formulary.

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[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

B (continued)

balanced salt eye irrigation solutionbal-care dha prenatal vitaminsbalsalazidebalzivaBANZELBARACLUDE SOLUTIONBAVENCIO [INJ]b-complex [INJ]BD AUTOSHIELD DUO NEEDLES [OTC]BD ULTRAFINE INSULIN SYRINGES [OTC]BD ULTRAFINE PEN NEEDLES [OTC]BEBULIN [INJ]bekyreeBELBUCAbenazeprilbenazepril/hydrochlorothiazideBENDEKA [INJ]BENEFIX [INJ]BENLYSTA [INJ]benoxinate/fluorescein eye solutionBENZNIDAZOLEbenzonatatebenzoyl peroxidebenzphetaminebenztropinebenztropine [INJ]BEPREVEBESPONSA [INJ]betamethasone acetate/ betamethasone sodium phosphate [INJ]betamethasone dipropionatebetamethasone dipropionate augmentedbetamethasone valerateBETASERON [INJ]betaxololbetaxolol eye solutionbethanecholBETHKISBEVESPI AEROSPHEREbexaroteneBEXSERO [INJ]bicalutamideBICILLIN C-R [INJ]BICILLIN L-A [INJ]BIKTARVYbimatoprost eye solutionbiolon [INJ]BIOTHRAX [INJ]

bisoprololbisoprolol/hydrochlorothiazidebivalirudin [INJ]blanchebleomycin [INJ]BLINCYTO [INJ]blisovi 24 feblisovi feBOOSTRIX [INJ]BOSULIFBOTOX [INJ]BREO ELLIPTABREVITAL [INJ]briellynBRILINTAbrimonidine eye solutionBRINEURA [INJ]bromfenac eye solutionbromocriptinebrompheniramine/ pseudoephedrine/codeinebrompheniramine/ pseudoephedrine/ dextromethorphanbudesonide ext-releasebudesonide nebulization suspensionbumetanidebumetanide [INJ]bupivacaine [INJ]bupivacaine/dextrose [INJ]bupivacaine/epinephrine [INJ]buprenorphinebuprenorphine [INJ]buprenorphine/naloxonebupropionbupropion ext-releasebupropion ext-release (smoking deterrent)buspironebusulfan [INJ]butalbital/acetaminophenbutalbital/acetaminophen/ caffeinebutalbital/acetaminophen/ caffeine/codeinebutalbital/aspirin/caffeinebutalbital/aspirin/caffeine/ codeinebutorphanol [INJ]butorphanol nasalBYDUREON [INJ]BYETTA [INJ]BYSTOLIC

C cabergolineCABOMETYXcaffeine citratedcaffeine citrated [INJ]caffeine/sodium benzoate [INJ]calcipotrienecalcipotriene/betamethasone dipropionatecalcitonin salmon nasalcalcitriolcalcitriol [INJ]calcitriol ointmentcalcium acetatecalcium chloride [INJ]CALCIUM DISODIUM VERSENATE [INJ]calcium gluconate [INJ]calcium-folic acid plus dcalcium-pnv 28-1-250 prenatal vitaminsCALDOLOR [INJ]camilacamresecamrese locandesartancandesartan/hydrochlorothiazideCAPASTAT SULFATE [INJ]capecitabineCAPRELSAcaptoprilcaptopril/hydrochlorothiazidecarbachol [INJ]CARBAGLUcarbamazepinecarbamazepine ext-releasecarbidopacarbidopa/levodopacarbidopa/levodopa ext-releasecarbidopa/levodopa orally disintegrating tabletscarbidopa/levodopa/entacaponecarbinoxaminecarboplatin [INJ]carmustine [INJ]carteolol eye solutioncarvedilolcarvedilol phosphate ext-releasecaspofungin [INJ]CATHFLO ACTIVASE [INJ]CAVERJECT [INJ]CAYSTONcaziantcefaclorcefaclor ext-release

cefadroxilcefazolin [INJ]cefdinircefditorencefepime [INJ]cefepime/dextrose [INJ]cefiximecefotaxime [INJ]cefotetan [INJ]cefoxitin [INJ]cefoxitin/dextrose [INJ]cefpodoximecefprozilceftazidime [INJ]CEFTAZIDIME/DEXTROSE [INJ]ceftibutenceftriaxone [INJ]ceftriaxone/dextrose [INJ]cefuroxime axetilcefuroxime sodium [INJ]celacyncelecoxibCELONTINcentratexcephalexinCEPROTIN [INJ]CERDELGACEREZYME [INJ]cetirizine syrupCETROTIDE [INJ]cevimelineCHANTIXchatealchateal eqCHEMETCHENODALchloramphenicol [INJ]chlorcyclizine/codeinechlorcyclizine/ pseudoephedrine/codeinechlordiazepoxidechlordiazepoxide/clidiniumchlorhexidine gluconatechloroprocaine hcl [INJ]chloroquinechlorothiazidechlorothiazide sodium [INJ]chlorpheniramine/phenylephrine/ dextromethorphanchlorpromazinechlorpromazine [INJ]chlorthalidonechlorzoxazoneCHOLBAMcholestyraminecholestyramine light

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[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

C (continued)

choline salicylate/magnesium salicylatechromium chloride [INJ]ciclopiroxciclopirox shampoocidofovir [INJ]ciferexcilostazolCIMDUOcimetidineCINACALCET HCLCINRYZE [INJ]CIPRODEXciprofloxacinciprofloxacin ear solutionciprofloxacin ext-releaseciprofloxacin eye solutionciprofloxacin lactate/dextrose [INJ]cisplatin [INJ]citalopramcitric acid/sodium citratecladribine [INJ]clarithromycinclarithromycin ext-releaseclemastineCLENPIQclindamycin hclclindamycin palmitateclindamycin phosphate [INJ]clindamycin phosphate topicalclindamycin phosphate vaginalclindamycin phosphate/benzoyl peroxideclindamycin phosphate/dextrose [INJ]clindamycin phosphate/tretinoinCLINIMIX [INJ]CLINIMIX E [INJ]clobetasol propionateclobetasol propionate shampooclobetasol propionate/emollientclofarabine [INJ]clomiphene citrateclomipramineclonazepamclonazepam orally disintegrating tabletsclonidineclonidine [INJ]clonidine ext-releaseclonidine patchesclonidine/chlorthalidoneclopidogrelclorazepate

clotrimazole topicalclotrimazole trocheclotrimazole/betamethasone dipropionateclozapineclozapine orally disintegrating tabletsc-nate dha prenatal vitaminsCOAGADEX [INJ]COARTEMcocaine topical solutioncodeine sulfatecolchicinecolchicine/probenecidcolestipolcolistimethate [INJ]COMBIGANCOMBIPATCHCOMBIVENT RESPIMATcomplete natal dha prenatal vitaminscompletenate prenatal vitaminsCONCERTAconstulosecopper chloride [INJ]CORIFACT [INJ]CORLANORcortisone acetatecorvitacorvita 150COSENTYX [INJ]cosyntropin [INJ]COTELLICCREONCRESEMBACRESEMBA [INJ]CRINONE 4%CRINONE 8%CRIXIVANCROFAB [INJ]cromolyn sodium eye solutioncromolyn sodium nebulization solutioncromolyn sodium oral solutioncrotamitoncryselleCRYSVITA [INJ]cyanocobalamin [INJ]cyclafemcyclobenzaprinecyclopentolate eye solutioncyclophosphamide [INJ]CYCLOPHOSPHAMIDE CAPSULEScyclosporinecyclosporine [INJ]cyclosporine modifiedcyproheptadine

CYRAMZA [INJ]cyredCYSTADANECYSTAGONCYSTARANcytarabine [INJ]CYTOGAM [INJ]cytra-3

D dacarbazine [INJ]dactinomycin [INJ]dalfampridine ext-releaseDALIRESPDALVANCE [INJ]danazoldantrolenedantrolene [INJ]dapsoneDAPTACEL [INJ]daptomycin [INJ]darifenacin ext-releaseDARZALEX [INJ]dasettadaunorubicin [INJ]dayseeDAYTRANAdeblitanedecitabine [INJ]deferoxamine [INJ]delflex with dextrose [INJ]delylademeclocyclineDEMSERDEPO-ESTRADIOL [INJ]DEPO-PROVERA 400 MG/ML [INJ]DESCOVYdesipraminedesloratadinedesloratadine orally disintegrating tabletsdesmopressin acetatedesmopressin acetate [INJ]desmopressin nasaldesogestrel-ethinyl estradioldesonidedesoximetasonedesvenlafaxine succinate ext-releasedexamethasonedexamethasone sodium phosphate [INJ]dexamethasone sodium phosphate eye solutionDEXCOM G4DEXCOM G5

DEXCOM G6dexmedetomidine [INJ]dexmethylphenidatedexmethylphenidate ext-releasedexrazoxane [INJ]dextran/dextrose [INJ]dextran/normal saline [INJ]dextroamphetaminedextroamphetamine ext-releasedextroamphetamine/ amphetaminedextrose/lactated ringers [INJ]dextrose/sodium chloride [INJ]dextrose/water [INJ]dialyvitedialyvite/zincdiazepamdiazepam [INJ]diazepam rectal geldiclofenac eye solutiondiclofenac potassiumdiclofenac sodium delayed-releasediclofenac sodium ext-releasediclofenac sodium geldiclofenac sodium topical solutiondiclofenac sodium/misoprostol ext-releasedicloxacillindicyclominedicyclomine [INJ]didanosine delayed-releasediethylpropiondiethylpropion ext-releasediflorasonediflorasone/emollientdiflunisaldigoxindigoxin [INJ]dihydrocodeine/acetaminophen/ caffeinedihydroergotamine [INJ]dihydroergotamine nasalDILANTIN 30 MG CAPSULESDILATRATE-SRdiltiazemdiltiazem [INJ]diltiazem ext-releasedimenhydrinate [INJ]diphenhydraminediphenhydramine [INJ]diphenoxylate/atropineDIPHTHERIA-TETANUS TOXOIDS-PED [INJ]dipyridamoledipyridamole [INJ]disulfiram

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[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

D (continued)

divalproex delayed-releasedivalproex ext-releaseDIVIGELdobutamine [INJ]dobutamine/dextrose [INJ]DOCEFREZ [INJ]docetaxel [INJ]DOCETAXEL 200 MG/10 ML [INJ]dofetilidedonepezildonepezil orally disintegrating tabletsdopamine [INJ]dopamine/dextrose [INJ]DOPTELETdorzolamide eye solutiondorzolamide/timolol eye solutiondothelle dha prenatal vitaminsdoxazosindoxepindoxepin creamdoxercalciferoldoxercalciferol [INJ]doxorubicin [INJ]doxorubicin/liposomal [INJ]doxycycline hyclatedoxycycline hyclate [INJ]doxycycline hyclate delayed-releasedoxycycline monohydratedronabinoldroperidol [INJ]drospirenone-ethinyl estradioldrospirenone-ethinyl estradiol-levomefolateDROXIADUAVEEDULERAduloxetine delayed-releaseDUPIXENT [INJ]dutasteridedutasteride/tamsulosin ext-releaseDYANAVEL XRDYMISTA

E econazoleEDARBIEDARBYCLOREDURANTefavirenzEGRIFTA [INJ]ELAPRASE [INJ]electrolyte-48 solution/ dextrose [INJ]

eletoneeletriptanELIGARD [INJ]elinesteliphosELIQUISELITEK [INJ]elite-ob prenatal vitaminsELMIRONEMCYTEMGALITY [INJ]emoquetteEMTRIVAemulsion sbEMVERMenalaprilenalapril/hydrochlorothiazideenalaprilat [INJ]ENBREL [INJ]ENDOMETRINENGERIX-B [INJ]enoxaparin [INJ]enpresseenskyceENSTILARentacaponeentecavirENTRESTOENTYVIO [INJ]EOVIST [INJ]EPCLUSAephedrine [INJ]EPIDIOLEXepinastine eye solutionEPINEPHRINE AUTO-INJECTOR (by Mylan) [INJ]epinephrine vial, ampule, syringe [INJ]epinephrine-dextrose [INJ]epinephrine-nacl [INJ] EPIPEN, EPIPEN JR [INJ]epirubicin [INJ]EPIVIR HBV SOLUTIONeplerenoneepoprostenol [INJ]epoprostenol diluent [INJ]eprosartaneptifibatide [INJ]ERAXIS [INJ]ERBITUX [INJ]ergocalciferolergoloid mesylatesergotamine tartrate/caffeineergotamine tartrate/caffeine suppositoriesERIVEDGEERLEADAerrin

ertapenem [INJ]ERYTHROCIN [INJ]erythromycinerythromycin delayed-releaseerythromycin ethylsuccinateerythromycin eye ointmenterythromycin stearateerythromycin topicalerythromycin/benzoyl peroxideESBRIETescitalopramesmolol [INJ]esmolol-nacl [INJ]esomeprazole magnesium delayed-releaseesomeprazole sodium [INJ]estaryllaestazolamesterified estrogens/ methyltestosteroneestradiolestradiol creamestradiol patchesestradiol vaginalestradiol valerate [INJ]estradiol/norethindrone acetateESTRINGestropipateeszopicloneethacrynate [INJ]ethacrynic acidethambutolETHAMOLIN [INJ]ethosuximideethyl alcohol [INJ]ethyl chloride sprayethynodiol-ethinyl estradioletidronateetodolacetodolac ext-releaseetomidate [INJ]etonogestrel-ethinyl estradiol va ringETOPOPHOS [INJ]etoposideetoposide [INJ]EUFLEXXA [INJ]everolimusexemestaneEXTRANEAL ICODEXTRIN DIALYSIS SOLUTION [INJ]EYLEA [INJ]ezetimibeezetimibe/simvastatin

F FABRAZYME [INJ]

falminafamciclovirfamotidinefamotidine [INJ]famotidine/nacl [INJ]FARESTONFARXIGAFASENRA [INJ]fayosimFEIBA NF [INJ]felbamatefelodipine ext-releasefemynorfenofibratefenofibrate micronizedfenofibric acidfenofibric acid delayed-releasefenoprofenfentanyl citrate [INJ]fentanyl citrate lozengesfentanyl citrate/nacl [INJ]fentanyl patchesFERAHEME [INJ]FERRIPROXFETZIMAFINACEAfinasterideFIRMAGON [INJ]FIRST-LANSOPRAZOLEFIRST-MOUTHWASH BLMFIRST-OMEPRAZOLEflavoxateflecainideFLECTORFLOLAN [INJ]FLOLAN DILUENT [INJ]FLOVENT DISKUSFLOVENT HFAfloxuridine [INJ]FLUAD [INJ]FLUARIX QUAD [INJ]FLUBLOK QUAD [INJ]FLUCELVAX QUAD [INJ]fluconazolefluconazole/dextrose [INJ]fluconazole/normal saline [INJ]flucytosinefludarabine [INJ]fludrocortisone acetateFLULAVAL QUAD [INJ]flumazenil [INJ]flunisolide nasal sprayfluocinolonefluocinolone acetonide oil ear solutionfluocinonidefluocinonide/emollientfluorescein [INJ]

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[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

F (continued)

fluorescein eye stripsfluorometholone eye suspensionfluorouracilfluorouracil [INJ]fluoxetinefluoxetine delayed-releasefluphenazine decanoate [INJ]fluphenazine hclfluphenazine hcl [INJ]flurandrenolideflurazepamflurbiprofenflurbiprofen sodium eye solutionflutamidefluticasone nasal sprayfluticasone topicalfluvastatinfluvastatin ext-releasefluvoxaminefluvoxamine ext-releaseFLUZONE HIGH-DOSE [INJ]FLUZONE QUAD [INJ]folic acidfolic acid [INJ]folivane-ob prenatal vitaminsFOLOTYN [INJ]fomepizole [INJ]fondaparinux [INJ]FORTAZ-ISO-OSMOTIC DEXTROSE [INJ]FORTEO [INJ]fosamprenavirfoscarnet [INJ]fosinoprilfosinopril/hydrochlorothiazidefosphenytoin [INJ]FRAGMIN [INJ]FREAMINE HBC [INJ]freamine iii [INJ]FREESTYLE FREEDOMFREESTYLE FREEDOM LITEFREESTYLE INSULINXFREESTYLE INSULINX TEST STRIPSFREESTYLE LITE METERFREESTYLE LITE STRIPSFREESTYLE LITE TEST STRIPSFREESTYLE TEST STRIPSfrovatriptanfulvestrant [INJ]furosemidefurosemide [INJ]FUZEON [INJ]

fyavolvFYCOMPA

G gabapentinGABLOFEN [INJ]galantaminegalantamine ext-releaseGAMASTAN [INJ]GAMASTAN S-D [INJ]GAMMAGARD LIQUID [INJ]GAMMAGARD S-D [INJ]GAMUNEX-C [INJ]ganciclovir [INJ]GARDASIL 9 [INJ]gatifloxacin eye solutiongavilyte-cgavilyte-ggavilyte-nGAZYVA [INJ]GELNIQUEgemcitabine [INJ]gemfibrozilGENOTROPIN [INJ]gentamicin [INJ]gentamicin eye ointmentgentamicin eye solutiongentamicin topicalgentamicin/normal saline [INJ]GENTAMICIN/NORMAL SALINE 100 MG/50 ML [INJ]GENVOYAgianvigildagiaGILENYAGILOTRIFglatiramer [INJ]glatopa [INJ]GLEOSTINEglimepirideglipizideglipizide ext-releaseglipizide/metforminGLUCAGEN [INJ] GLUCAGON [INJ]glyburideglyburide micronizedglyburide/metforminglycine irrigation solutionglycolaxGLYCOPHOS [INJ]glycopyrrolateglycopyrrolate [INJ]glycopyrrolate-water [INJ]GLYXAMBI

GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT [INJ]granisetrongranisetron [INJ]GRASTEKgriseofulvin microsizegriseofulvin ultramicrosizeguaifenesin/codeineguaifenesin/phenylephrineguanfacineguanfacine ext-releaseguanidine

H HALAVEN [INJ]halobetasolhaloperidolhaloperidol decanoate [INJ]haloperidol lactatehaloperidol lactate [INJ]HARVONIHAVRIX [INJ]heatherHELIXATE FS [INJ]HEMABATE [INJ]hemenatal ob + dha prenatal vitaminshemenatal ob prenatal vitaminsHEMLIBRA [INJ]HEMOFIL-M [INJ]HEPAGAM B [INJ]heparin lock flush [INJ]heparin sodium [INJ]heparin sodium/dextrose [INJ]heparin sodium/nacl [INJ]HEPATAMINE [INJ]hetastarch/normal saline [INJ]HEXTEND LACTATED ELECTROLYTE [INJ]HIBERIX [INJ]HIZENTRA [INJ]homatropine eye solutionhpr emollient foamhpr plushpr plus hydrogelHUMALOG [INJ]HUMATE-P [INJ]HUMIRA [INJ]HUMULIN [INJ]HUMULIN R 500 UNITS [INJ]HYCAMTIN CAPSULEShydralazinehydralazine [INJ]hydrochlorothiazidehydrocodone/acetaminophen

hydrocodone/chlorpheniramine polistirex ext-releasehydrocodone/chlorpheniramine/ pseudoephedrinehydrocodone/homatropinehydrocodone/ibuprofenhydrocortisonehydrocortisone acetate suppositorieshydrocortisone butyratehydrocortisone butyrate/ emollienthydrocortisone enemahydrocortisone sodium succinate [INJ]hydrocortisone topicalhydrocortisone valeratehydrocortisone/iodoquinolhydrocortisone/iodoquinol/aloehydrocortisone/lidocainehydrocortisone/pramoxinehydromorphonehydromorphone [INJ]hydromorphone ext-releasehydromorphone suppositorieshydromorphone/nacl [INJ]hydroquinonehydroquinone microsphereshydroxocobalamin [INJ]hydroxychloroquinehydroxyprogesterone [INJ]hydroxyureahydroxyzine hclhydroxyzine hcl [INJ]hydroxyzine pamoatehyophenhyoscyaminehyoscyamine ext-releasehyoscyamine orally disintegrating tabletsHYPERHEP B S-D [INJ]HYPERRAB [INJ]HYPERRAB S-D [INJ]HYPERRHO S-D [INJ]HYPERTET S-D [INJ]hypochlorous acid/sodium chlorideHYSINGLA ER

I

ibandronateibandronate [INJ]IBRANCEibuprofenibuprofen lysine [INJ]

866.516.3121 8

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

I (continued)

ibutilide [INJ]ICLUSIGidarubicin [INJ]IDHIFAifosfamide [INJ]ifosfamide/mesna [INJ]ILARIS [INJ]ILEVROimatinibIMBRUVICAIMFINZI [INJ]imipenem/cilastatin [INJ]imipramine hclimipramine pamoateimiquimodIMOGAM RABIES-HT [INJ]IMOVAX RABIES VACCINE [INJ]IMPAVIDOincassiaINCRELEX [INJ]INCRUSE ELLIPTAindapamideindomethacinindomethacin ext-releaseindomethacin sodium [INJ]INFANRIX [INJ]infed [INJ]INFUMORPH [INJ]INFUVITE [INJ]INLYTAINTELENCEintralipid 20% [INJ]INTRON A [INJ]introvaleINVANZ ADD-VANTAGE [INJ]INVIRASEINVOKAMETINVOKAMET XRINVOKANAiodine/potassium iodideIODOPEN [INJ]IONOSOL/DEXTROSE [INJ]IPOL [INJ]ipratropium bromide nasal sprayipratropium bromide nebulization solutionipratropium/albuterol sulfate nebulization solutionirbesartanirbesartan/hydrochlorothiazideIRESSAirinotecan [INJ]ISENTRESSisibloomISOLYTE [INJ]

isometheptene/caffeine/ acetaminophenisometheptene/ dichloralphenazone/ acetaminophenisoniazidisoniazid [INJ]isoproterenol [INJ]isosorbide dinitrateisosorbide dinitrate ext-releaseisosorbide mononitrateisosorbide mononitrate ext-releaseisotretinoinisoxsuprineisradipineISTODAX [INJ]itraconazoleivermectinIXEMPRA [INJ]IXIARO [INJ]IXINITY [INJ]

J

JAKAFIJANUMETJANUMET XRJANUVIAJARDIANCEjencyclaJENTADUETOJENTADUETO XRJETREA [INJ]jevantique loJEVTANA [INJ]jinteliJIVI [INJ]jolessajolivettejuleberjuneljunel feJUXTAPID

K KADCYLA [INJ]kaitlib feKALETRA TABLETSKALYDECOKANUMA [INJ]karivakelnorKEPIVANCE [INJ]ketamine [INJ]ketamine-nacl [INJ]

ketoconazoleketoconazole shampooketoconazole topicalketoprofenketoprofen ext-releaseketorolacketorolac [INJ]ketorolac eye solutionKEYTRUDA [INJ]kimidessKINEVAC [INJ]KITABIS PAKKOGENATE FS [INJ]KOVALTRY [INJ]K-PHOS ORIGINALKRYSTEXXA [INJ]kurveloKUVANKYLEENAKYMRIAH [INJ]KYPROLIS [INJ]

L labetalollabetalol [INJ]lactuloselamivudinelamivudine hbvlamivudine/zidovudinelamotriginelamotrigine ext-releaselamotrigine orally disintegrating tabletsLANOXIN PEDIATRIC [INJ]lansoprazole delayed-releaselansoprazole delayed-release +amoxicillin+clarithromycinlansoprazole orally disintegrating tabletslanthanumLANTUS [INJ]larinlarin felarissialatanoprost eye solutionLATUDAlayolis fel-cysteine [INJ]leenaleflunomideLENVIMAlessinaletrozoleleucovorinleucovorin [INJ]LEUKERAN

LEUKINE [INJ]leuprolide [INJ]levalbuterol nebulization solutionLEVEMIR [INJ]levetiracetamlevetiracetam [INJ]levetiracetam ext-releaselevetiracetam-nacl [INJ]levobunolol eye solutionlevocarnitinelevocetirizinelevofloxacinlevofloxacin [INJ]levofloxacin eye solutionlevofloxacin/dextrose [INJ]LEVOLEUCOVORIN [INJ]levomefolate dhalevonestlevonorgestrel-ethinyl estradiollevoralevorphanollevothyroxine sodiumlevothyroxine sodium [INJ]LEVOTHYROXINE SODIUM 100 MCG [INJ]LEVSIN [INJ]LEXISCAN [INJ]LEXIVA SUSPENSIONlidocaine [INJ]lidocaine hcl/glycerinlidocaine jellylidocaine patcheslidocaine topicallidocaine viscouslidocaine/dextrose [INJ]lidocaine/epinephrine [INJ]lidocaine/glycerinlidocaine/hydrocortisonelidocaine/prilocainelillowlincomycin [INJ]lindane shampoolinezolidlinezolid [INJ]linezolid/nacl [INJ]LINZESSLIORESAL [INJ]liothyronineliothyronine [INJ]LIPOFENlisinoprillisinopril/hydrochlorothiazidelithium carbonatelithium carbonate ext-releaselithium citrateLIVALO

866.516.3121 9

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

L (continued)

LO LOESTRIN FELOKELMALONSURFloperamidelopinavir/ritonavirlopreezalorazepamlorazepam [INJ]lorynalosartanlosartan/hydrochlorothiazideloteprednollovastatinlow-ogestrelloxapineLUMIGANLUMIZYME [INJ]LUPRON DEPOT 3.75 MG, 11.25 MG [INJ]LUTATHERA [INJ]luteraluxamendLUXTURNA [INJ]LYNPARZALYSODRENlyza

M m.v.i. adult [INJ]M.V.I. PEDIATRIC [INJ] M.V.I.-12 [INJ]mafenidemagnesium chloride [INJ]magnesium sulfate [INJ]MAGNESIUM/DEXTROSE 1 GM/100 ML [INJ]malathionmanganese chloride [INJ]manganese sulfate [INJ]mannitol [INJ]maprotilinemarlissaMARQIBO [INJ]MATULANEmb hydrogelmeclizinemeclofenamatemedroxyprogesteronemedroxyprogesterone (contraceptive) [INJ]mefenamic acidmefloquinemegestrolMEKINIST

melodetta 24 femeloxicammelphalanmelphalan [INJ]memantinememantine ext-releaseMENACTRA [INJ]MENOPUR [INJ]mepivacaine [INJ]MEPSEVII [INJ]mercaptopurinemeropenem [INJ]MEROPENEM/NACL [INJ]mesalamine delayed-releasemesalamine enemamesalamine kitmesna [INJ]MESNEX TABLETSMESTINON SYRUPmetaproterenolmetaxalonemetforminmetformin ext-releasemethadonemethadone [INJ]methamphetaminemethazolamidemethenamine hippuratemethenamine mandelatemethenamine/sodium phosphate/methylene blue/ hyoscyaminemethimazoleMETHITESTmethocarbamolmethocarbamol [INJ]methotrexatemethotrexate [INJ]methoxsalenmethyclothiazidemethyldopamethyldopa/hydrochlorothiazidemethyldopate [INJ]methylergonovinemethylergonovine [INJ]methylphenidatemethylprednisolonemethylprednisolone acetate [INJ]methylprednisolone sodium succinate [INJ]methyltestosteronemetipranolol eye solutionmetoclopramidemetoclopramide [INJ]metoclopramide orally disintegrating tabletsmetolazonemetoprolol succinate

ext-releasemetoprolol tartratemetoprolol tartrate [INJ]metoprolol/hydrochlorothiazidemetronidazolemetronidazole topicalmetronidazole vaginalmetronidazole/nacl [INJ]mexiletineMIACALCIN [INJ]mibelas 24 femiconazole vaginalmicrogestinmicrogestin femidazolammidazolam [INJ]midazolam/nacl [INJ]midodrinemiglitolmiglustatmilimilrinone [INJ]milrinone/dextrose [INJ]mimveymimvey loMINIMED INFUSION SETMINIMED RESERVOIRMINIVELLEMINOCIN [INJ]minocyclineminocycline ext-releaseminoxidilMIRENAmirtazapinemirtazapine orally disintegrating tabletsMIRVASOmisoprostolMITIGAREmitomycin [INJ]mitoxantrone [INJ]M-M-R II [INJ]modafinilmoderibamoexiprilmoexipril/hydrochlorothiazidemometasonemometasone nasal sprayMONOCLATE-P [INJ]mono-linyahmononessaMONONINE [INJ]MONOVISC [INJ]montelukastmorphine sulfatemorphine sulfate [INJ]morphine sulfate ext-releasemorphine sulfate suppositories

morphine sulfate/nacl [INJ]MOVANTIKmoxifloxacinMOXIFLOXACIN [INJ]moxifloxacin eye solutionMOZOBIL [INJ]MULTI-LANCET DEVICE [OTC]MULTITRACE-4 [INJ]MULTITRACE-5 [INJ]mupirocinMUSEMUSTARGEN [INJ]MYALEPT [INJ]MYCAMINE [INJ]mycophenolate mofetilmycophenolate mofetil hcl [INJ]mycophenolic acid delayed-releaseMYDAYISMYLERANMYLOTARG [INJ]mynatal advance prenatal vitaminsmynatal plus prenatal vitaminsmynatal prenatal vitaminsmynatal ultracaplet prenatal vitaminsmynatal-z prenatal vitaminsmynate 90 plus prenatal vitaminsMYOBLOC [INJ]MYRBETRIQmyzilra

N nabumetonenadololnadolol/bendroflumethiazidenafcillin [INJ]nafcillin/dextrose [INJ]naftifineNAGLAZYME [INJ]nalbuphine [INJ]naloxone [INJ]naltrexoneNAMZARICnaproxennaproxen delayed-releasenaproxen sodiumnaproxen sodium ext-releasenaratriptanNARCAN NASAL SPRAYNASCOBALNATACYNnateglinideNATPARA [INJ]NATRECOR [INJ]

866.516.3121 10

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

N (continued)

neconneomycinneomycin/bacitracin/polymyxin eye ointmentneomycin/bacitracin/polymyxin/ hydrocortisone eye ointmentneomycin/polymyxin irrigation solutionneomycin/polymyxin/ dexamethasone eye ointmentneomycin/polymyxin/ dexamethasone eye suspensionneomycin/polymyxin/gramicidin eye solutionneomycin/polymyxin/ hydrocortisone ear solutionneomycin/polymyxin/ hydrocortisone ear suspensionneomycin/polymyxin/ hydrocortisone eye suspensionneostigmine [INJ]NEPHRAMINE [INJ]NERLYNXNEULASTA [INJ]NEUT [INJ]nevirapinenevirapine ext-releasenewgen prenatal vitaminsNEXAVARNEXIUM PACKETSNEXPLANON [INJ]NEXTERONE [INJ]niacin ext-releasenicardipinenicardipine [INJ]nifedipine ext-releasenikkinilutamidenimodipineNINLAROnisoldipine ext-releasenitrofurantoinnitrofurantoin macrocrystalnitrofurantoin monohydrate/ macrocrystalnitroglycerin [INJ]nitroglycerin ext-releasenitroglycerin ointmentnitroglycerin patchesnitroglycerin spraynitroglycerin/dextrose [INJ]nitroprusside sodium [INJ]

NITYRnivatopic plusNIVESTYMnizatidinenora-beNORDITROPIN [INJ]norepinephrine [INJ]norepinephrine/dextrose [INJ]norepinephrine/nacl [INJ]norethindronenorethindrone acetatenorethindrone acetate-ethinyl estradiolnorethindrone acetate-ethinyl estradiol + ironnorgestimate-ethinyl estradiolnorlydanorlyrocNORMOSOL-M AND DEXTROSE [INJ]NORMOSOL-R AND DEXTROSE [INJ]NORMOSOL-R PH 7.4 [INJ]nortrelnortriptylineNORVIR CAPSULESNORVIR PACKETSNORVIR SOLUTIONNOVAREL [INJ]NOVOEIGHT [INJ]NOVOFINE AUTOSHIELD NEEDLES [OTC]NOVOFINE NEEDLES [OTC]NOVOSEVEN RT [INJ] NOVOTWIST NEEDLES [OTC]NOXAFIL [INJ]NPLATE [INJ]NUCALA [INJ]NUCYNTANUCYNTA ERNUEDEXTANULOJIX [INJ]nutrilyte [INJ]nystatinnystatin topicalnystatin/triamcinolone

O OBIZUR [INJ]obstetrix dha prenatal vitaminsOCALIVAocellaOCREVUS [INJ]octreotide [INJ]ODACTRAODEFSEY

OFEVOFIRMEV [INJ]ofloxacinofloxacin ear solutionofloxacin eye solutionogestrelolanzapineolanzapine [INJ]olanzapine orally disintegrating tabletsolanzapine/fluoxetineolmesartanolmesartan/amlodipine/ hydrochlorothiazideolmesartan/hydrochlorothiazideolopatadine eye solutionolopatadine nasal sprayomega-3 ethyl estersomeprazole delayed-releaseOMNIPAQUE [INJ]OMNIPODONCASPAR [INJ]ondansetronondansetron [INJ]ondansetron orally disintegrating tabletsONETOUCH DELICA LANCETS [OTC]ONETOUCH ULTRA 2 SYSTEM [OTC]ONETOUCH ULTRA TEST STRIPS [OTC]ONETOUCH ULTRAMINI METER [OTC]ONETOUCH ULTRASOFT LANCETS [OTC]ONETOUCH VERIO FLEX [OTC]ONETOUCH VERIO IQ METER [OTC]ONETOUCH VERIO METER SYSTEM [OTC]ONETOUCH VERIO TEST STRIPS [OTC]ONEXTONONFIONIVYDE [INJ]OPDIVO [INJ]opium tinctureopium/belladonna alkaloids suppositoriesOPSUMITORALAIRORBACTIV [INJ]ORKAMBIorphenadrine [INJ]orphenadrine ext-releaseorsythiaORTHOVISC [INJ]

oseltamivirOTEZLAOTOVELOTREXUP [INJ]OVIDREL [INJ]oxacillin [INJ]oxacillin/dextrose [INJ]oxaliplatin [INJ]oxandroloneoxaprozinoxcarbazepineoxiconazoleoxybutyninoxybutynin ext-releaseoxycodoneoxycodone/acetaminophenoxycodone/aspirinoxycodone/ibuprofenOXYCONTINoxymorphoneoxymorphone ext-releaseoxytocin [INJ]OZEMPIC [INJ]OZURDEX [INJ]

P paclitaxel [INJ]paliperidone ext-releasepalonosetron [INJ]PALYNZIQ [INJ]pamidronate [INJ]pantoprazole [INJ]pantoprazole delayed-releasepapaverine [INJ]PARADIGM INFUSION SETSPARADIGM RESERVOIRSPARADIGM SILHOUETTE SETSparegoricparicalcitolparicalcitol [INJ]paromomycinparoxetine hclparoxetine hcl ext-releaseparoxetine mesylatePAZEOPEDIARIX [INJ]PEDITRACE [INJ]PEDVAXHIB [INJ]peg 3350/electrolytes powder for 4000 ml solutionPEGANONEPEGASYS [INJ]peg-prep kitpenicillaminepenicillin g potassium [INJ]

866.516.3121 11

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

P (continued)

penicillin g procaine [INJ]penicillin g sodium [INJ]PENICILLIN GK/DEXTROSE [INJ]penicillin v potassiumPENTACEL [INJ]PENTACEL ACTHIB COMPONENT [INJ]pentamidinePENTASApentobarbital [INJ]pentoxifylline ext-releasePERFOROMISTperindoprilPERJETA [INJ]permethrinperphenazineperphenazine/amitriptylinephenazopyridinephendimetrazinephendimetrazine ext-releasephenelzinephenobarbitalphenobarbital sodium [INJ]phenobarbital/hyoscyamine/ atropine/scopolaminephenoxybenzaminephenterminephentolamine [INJ]phenylbutyratephenylephrine [INJ]phenylephrine eye solutionphenylephrine/chlorpheniraminephenylephrine/dextrose [INJ]phenylephrine/nacl [INJ]phenytoinphenytoin sodium [INJ]phenytoin sodium extendedphilithPHOSLYRAphosphasalPHOSPHOLINE IODIDEPHOTOFRIN [INJ]physostigmine [INJ]phytonadionephytonadione [INJ]PHYTONADIONE 1 MG/0.5 ML SYRINGE [INJ]PICATOpilocarpinepilocarpine eye solutionpimozidepimtreapindololpioglitazonepioglitazone/glimepiride

pioglitazone/metforminpiperacillin/tazobactam [INJ]pirmellapiroxicamPLASMA-LYTE [INJ]plasmanate [INJ]PLEGRIDY [INJ]plenamine [INJ]PNEUMOVAX 23 [INJ]pnv 29-1 prenatal vitaminspnv ob+dha prenatal vitamins pnv-dha + docusate prenatal vitaminspnv-dha prenatal vitaminspnv-ferrous fumarate-docu-fa prenatal vitaminspnv-omega prenatal vitaminspnv-select prenatal vitaminspnv-vp-u prenatal vitaminspodofiloxPOLOCAINE [INJ]polyethylene glycol 3350POLYFIN QR INFUSION SETpolymyxin [INJ]polymyxin/trimethoprim eye solutionPOMALYSTportiapotassium acetate [INJ]potassium bicarbonate/citric acid effervescent tabletspotassium chloride [INJ]potassium chloride ext-releasepotassium chloride oral solutionpotassium chloride powder packets for solutionpotassium chloride/dextrose [INJ]potassium chloride/dextrose/ nacl [INJ]potassium chloride/lactated ringers/dextrose [INJ]potassium chloride/nacl [INJ]potassium citrate ext-releasepotassium citrate/citric acidpotassium iodide/iodine solutionpotassium phosphate [INJ]POTELIGEO [INJ]pr natal 400 ec prenatal vitaminspr natal 400 prenatal vitaminspr natal 430 ec prenatal vitaminspr natal 430 prenatal vitaminsPRALUENT [INJ]pramipexolepramipexole ext-releaseprasugrelpravastatinpraziquantel

prazosinPRECISION XTRAPRECISION XTRA B-KETONE STRIPS [OTC]PRECISION XTRA MONITOR [OTC]prednicarbateprednisoloneprednisolone acetate eye suspensionprednisolone sodium phosphateprednisolone sodium phosphate disintegrating tabletsprednisolone sodium phosphate eye solutionprednisonepregabalinPREMARIN [INJ]PREMARIN CREAMPREMARIN TABLETSpremasol [INJ]PREMASOL 6% [INJ]PREMPHASEPREMPROprena1 chew prenatal vitaminsprena1 pearl prenatal vitaminsprena1 true prenatal vitaminsprenaissance plus prenatal vitaminsprenaissance prenatal vitaminsprenatabs fa prenatal vitaminsprenatabs rx prenatal vitaminsprenatal low iron prenatal vitaminsprenatal plus iron prenatal vitaminsprenatal plus prenatal vitaminsprenatal-u prenatal vitaminspreplus prenatal vitaminsPREPOPIKpretab 29-1 prenatal vitaminsprevifemPREVNAR 13 [INJ]PREVYMISPREVYMIS [INJ]PREZISTAPRIALT [INJ]PRIFTINPRIMAQUINEprimidonePRIVIGEN [INJ]PROAIR HFAPROAIR RESPICLICKprobenecidprocainamide [INJ]PROCALAMINE [INJ]prochlorperazine edisylate [INJ]prochlorperazine maleate

prochlorperazine maleate suppositoriesPROCRIT [INJ]PROFILNINE SD [INJ]progesterone in oil [INJ]progesterone micronizedPROGLYCEMPROGRAF [INJ]PROLASTIN C [INJ]PROLENSAPROLEUKIN [INJ]PROMACTApromethazinepromethazine [INJ]promethazine suppositoriespromethazine/codeinepromethazine/ dextromethorphanpromethazine/phenylephrinepromethazine/phenylephrine/ codeinepropafenonepropafenone ext-releaseproparacaine eye solutionproparacaine/fluorescein eye solutionpropofol [INJ]propranololpropranolol [INJ]propranolol ext-releasepropranolol/hydrochlorothiazidepropylthiouracilPROQUAD [INJ]PROSOL [INJ]protamine [INJ]PROTOPAM [INJ]protriptylinePROVENGE [INJ]pruclairprumyxprutectpseudoephedrine/ chlorpheniramine/ methscopolamine ext-releasepseudoephedrine/codeine/ guaifenesinPULMICORT FLEXHALERPULMOZYMEPURIXANpyrazinamidepyridostigminepyridostigmine [INJ]pyridostigmine ext-releasepyridoxine [INJ] pyrimethamine

866.516.3121 12

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

Q QBREXZAQNASLQUADRACEL DTAP-IPV [INJ]quasensequazepamQUDEXY XRquetiapinequetiapine ext-releaseQUICK RELEASE TEFLON CANNULAQUILLICHEW ERQUILLIVANT XRquinaprilquinapril/hydrochlorothiazidequinidine gluconate [INJ]quinidine gluconate ext-releasequinidine sulfatequinine sulfateQVARQVAR REDIHALER

R RABAVERT [INJ]rabeprazole delayed-releaseRADICAVA [INJ]RAGWITEKrajaniraloxifeneramiprilranitidineranitidine [INJ]RANOLAZINE ERRAPAMUNE SOLUTIONRAPIVAB [INJ]rasagilineRASUVO [INJ]RAVICTIREBIF [INJ]reclipsenRECOMBIVAX HB [INJ]RECTIVREGRANEXRELISTOR [INJ]REMICADE [INJ]remifentanil [INJ]RENACIDINREOPRO [INJ]repagliniderepaglinide/metformin hclREPATHARESCRIPTORRESECTISOLRESTASISRETROVIR [INJ]

REVLIMIDREYATAZ PACKETSR-GENE 10 [INJ]RHOPRESSARIASTAP [INJ]ribavirinribavirin nebulization solutionRIDAURArifabutinrifampinrifampin [INJ]riluzolerimantadineringers irrigation solutionringers lactated irrigation solutionringers solution [INJ]ringers solution lactated [INJ]risedronaterisedronate delayed-releaseRISPERDAL CONSTA [INJ]risperidonerisperidone orally disintegrating tabletsritonavirrivastigminerivastigmine patchesrivelsarizatriptanrizatriptan orally disintegrating tabletsropiniroleropinirole ext-releaseropivacaine/nacl [INJ]rosuvastatinROTATEQRUBRACARUCONEST [INJ]RYDAPT

S SABRILsalicylic acid shampoosalicylic acid topicalsalsalateSAMSCASANDIMMUNE SOLUTIONSANTYLSAVELLAscopolamine patchessecobarbitalSEGLUROMETselegilineselenium [INJ]selenium sulfideselenium sulfide shampooSELZENTRY

se-natal 19 prenatal vitaminsSENSORCAINE-EPI 0.75%-0.0005% [INJ]SEREVENT DISKUSSEROSTIM [INJ]sertralinesetlakinsevelamer carbonatesharobelSHINGRIX [INJ]SIGNIFOR [INJ]sildenafilsildenafil [INJ]SILHOUETTE INFUSION SETSsilver nitratesilver sulfadiazineSIMPONI 100 MG (for ulcerative colitis only) [INJ]SIMULECT [INJ]simvastatinsirolimusSIRTUROSKYLAsodium acetate [INJ]sodium benzoate/ sodium phenylacetate [INJ]sodium bicarbonate [INJ]sodium chloride [INJ]sodium chloride 0.45 % [INJ]sodium chloride 0.9 % [INJ]sodium chloride 3 % [INJ]sodium chloride 5 % [INJ]sodium chloride irrigation solutionsodium chloride nebulization solutionsodium chloride, bacteriostatic [INJ]sodium ferric gluconate complex [INJ]sodium fluoride dental cream, gelsodium lactate [INJ]sodium phosphate [INJ]sodium polystyrene sulfonatesodium polystyrene sulfonate rectalsodium tetradecyl sulfate [INJ]sodium thiosulfate [INJ]SOF-SET MICRO INFUSION SETSOF-SET ULTIMATE QR SETSOFT TOUCH LANCETS [OTC]SOLIFENACIN SUCCINATESOLIQUA [INJ]SOLIRIS [INJ]SOLU-CORTEF [INJ]SOMATULINE DEPOT [INJ]SOMAVERT [INJ]sonafine

sotalolSOTALOL [INJ]SOTYLIZEsp antipruriticsp scarspinosadSPINRAZA [INJ]spironolactonespironolactone/ hydrochlorothiazidesprintecSPRYCELsronyxSTAMARIL [INJ]stavudineSTEGLATROSTELARA SC [INJ]STIMATESTIVARGASTRENSIQ [INJ]STREPTOMYCIN SULFATE [INJ]SUBLOCADE [INJ]succinylcholine chloride [INJ]SUCRAIDsucralfatesufentanil [INJ]sulfacetamide eye ointmentsulfacetamide eye solutionsulfacetamide sodium shampoosulfacetamide sodium topicalsulfacetamide sodium/sulfursulfacetamide sodium/sulfur/ureasulfacetamide/prednisolone eye solutionsulfadiazinesulfamethoxazole/trimethoprimsulfamethoxazole/trimethoprim [INJ]SULFAMYLON CREAMsulfasalazinesulfasalazine delayed-releasesulindacsumatriptansumatriptan [INJ]sumatriptan nasalsumatriptan/naproxen sodiumSUPREPSURE-T INFUSION SETSUTENTsyedaSYLATRON [INJ]SYLVANT [INJ]SYMBICORTSYMDEKOSYMFISYMFI LOSYMLINPEN [INJ]SYMPROIC

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[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

S (continued)

SYMTUZASYNAGIS [INJ]SYNARELSYNERCID [INJ]SYNJARDYSYNJARDY XRSYNRIBO [INJ]

T

TACLONEX SUSPENSIONtacrolimustacrolimus topicaltadalafilTAFINLARTAGRISSOtamoxifentamsulosin ext-releaseTARCEVATARGRETIN GELtarina fetaron-c dha prenatal vitaminstaron-prex dha prenatal vitaminsTASIGNATAYTULLAtazaroteneTAZORAC 0.05% CREAMTAZORAC GELTECENTRIQ [INJ]TECFIDERATECHLITE BLOOD LANCETS [OTC]TEFLARO [INJ]TEKTURNATEKTURNA HCTtelmisartantelmisartan/amlodipinetelmisartan/hydrochlorothiazideTEMODAR [INJ]temozolomidetemsirolimus [INJ]TENIPOSIDE [INJ]tenofovir disoproxil fumarateterazosinterbinafineterbutalineterbutaline [INJ]terconazole vaginaltestosteronetestosterone cypionate [INJ]testosterone enanthate [INJ]TETANUS DIPHTHERIA TOXOIDS [INJ]tetrabenazinetetracaine [INJ]

tetracaine eye solutiontetracyclineTHALOMIDtheophyllinetheophylline ext-releasetheophylline/dextrose [INJ]THERACYS [INJ]thiamine [INJ]thioridazinethiotepa [INJ]thiothixeneTHROMBATE III [INJ]THYMOGLOBULIN [INJ]THYROGEN [INJ]thyroidtiagabineTIBSOVOTICE BCG [INJ]tigecycline [INJ]tilia fetimolol maleatetimolol maleate eye solutiontinidazoleTIVICAYtizanidinetl g-fol osTOBI PODHALERTOBRADEX OINTMENTTOBRADEX STtobramycin [INJ]tobramycin eye solutiontobramycin nebulization solution tobramycin/dexamethasone eye suspensiontobramycin/nacl [INJ]tolazamidetolbutamidetolcaponetolmetintolterodinetolterodine ext-releasetopiramatetopotecan [INJ]TORISEL [INJ]torsemideTOUJEO [INJ]TOVIAZTPN ELECTROLYTES [INJ]TRACE ELEMENTS-4 [INJ]TRACLEERTRADJENTAtramadoltramadol ext-releasetramadol/acetaminophentrandolapriltrandolapril/verapamil ext-releasetranexamic acidtranexamic acid [INJ]

tranylcyprominetravasol [INJ]travoprost ophth soln 0.004%trazodoneTREANDA [INJ]TRELEGY ELLIPTATREMFYA [INJ]treprostinil [INJ]TRESIBA [INJ]tretinointretinoin microspherestretinoin topicaltretinoin/emollientTRETTEN [INJ]tri femynortriamcinolone [INJ]triamcinolone dental pastetriamcinolone topicaltriamterene/hydrochlorothiazidetriazolamtrientinetri-estaryllatrifluoperazinetrifluridine eye solutiontrihexyphenidyltri-legest fetri-linyahtri-lo-estaryllatri-lo-marziatri-lo-sprintectrilyte with flavor packetstrimethobenzamidetrimethoprimtri-militrimipramineTRIMO-SANtrinatal rx 1 prenatal vitaminstrinate prenatal vitaminstrinessatrinessa lotri-previfemTRIPTODUR [INJ]tri-sprintecTRIUMEQtriveen-duo dha prenatal vitaminstrivoratri-vylibraTROGARZO [INJ]TROPHAMINE [INJ]tropicamide eye solutiontrospiumtrospium ext-releaseTRULANCETRULICITY [INJ]TRUMENBA [INJ]trust natal dha prenatal vitaminsTRUVADA

TUBERSOL [INJ]tulanaTWINRIX [INJ]tydemyTYKERBTYMLOS [INJ]TYPHIM VI [INJ]TYSABRI [INJ]TYVASO

U UCERIS FOAMultimatecare one nf prenatal vitaminsultimatecare one prenatal vitaminsUNITUXIN [INJ]UPTRAVIur n-curetron d-surimar-turin d.s.uro-458urogesicuro-mpursodiolurylustellutira-cUVADEX [INJ]

V valacyclovirVALCHLORvalganciclovirvalproate sodium [INJ]valproic acidvalrubicinvalsartanvalsartan/hydrochlorothiazidevancomycinvancomycin [INJ]VANCOMYCIN/DEXTROSE [INJ]VANCOMYCIN-NS [INJ]VANTASVARIVAX [INJ]VARIZIG [INJ]VASCEPAvasopressin [INJ]vasopressin/nacl [INJ]VAXCHORA VACCINEVECTIBIX [INJ]VELCADE [INJ]velivetVELPHOROvemavite-prx 2 prenatal vitamins

866.516.3121 14

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

V (continued)

VEMLIDYVENCLEXTAvenlafaxinevenlafaxine ext-releaseVENOFER [INJ]VENTOLIN HFAverapamilverapamil [INJ]verapamil ext-releaseveripredVERZENIOvesturaVGOVIBATIV [INJ]VIBERZIVIDEX SOLUTIONvienvavigabatrinVIIBRYDvilamit mbvilevev mbVIMIZIM [INJ]VIMPATVIMPAT [INJ]vinate care prenatal vitaminsvinate ii prenatal vitaminsvinate one prenatal vitaminsvinate-m prenatal vitaminsvinblastine [INJ]vincristine [INJ]vinorelbine [INJ]VIOKACEvioreleVIRACEPTVIREAD 150 MG, 200 MG, 250 MG TABLETSVIREAD POWDERvirt nate prenatal vitaminsvirt-advance prenatal vitaminsvirt-c dha prenatal vitaminsvirt-nate dha prenatal vitaminsvirt-pn dha prenatal vitaminsvirt-pn plus prenatal vitaminsvirt-pn prenatal vitaminsvirt-select prenatal vitaminsvirt-vite gt prenatal vitaminsVISTOGARDVISUDYNE [INJ]VIVITROL [INJ]VIVOTIFVOLUVEN [INJ]VONVENDI [INJ]VORAXAZE [INJ]voriconazolevoriconazole [INJ]

VOSEVIVOTRIENTvp-ch plus prenatal vitaminsvp-ch-pnv prenatal vitamins vp-ggr-b6 prenatal vitaminsvyfemlavylibraVYVANSEVYXEOS LIPOSOME [INJ]

W warfarinwater for injection, bacteriostatic [INJ]water for injection, sterile [INJ]water for irrigation; sterileWELCHOLweraWILATE [INJ]wymzya fe

X XALKORIXARELTOXELJANZXELJANZ XRXERMELOXGEVA [INJ]XIAFLEX [INJ]XIFAXAN 550 MGXIGDUO XRXIIDRAXOFIGO [INJ]XOLAIR [INJ]XTANDIxulane patchesXULTOPHY [INJ]XURIDENXYREM

Y YERVOY [INJ]YESCARTA [INJ]YF-VAX [INJ]YONDELIS [INJ]YONSAyuvafem

Z zafirlukastzaleplonZALTRAP [INJ]ZANOSAR [INJ]

zarahZARXIO [INJ]zatean-pn dha prenatal vitaminszatean-pn plus prenatal vitaminsZEJULAZELBORAFZEMAIRA [INJ]zenchentZENPEPZEPATIERZERBAXA [INJ]ZEVALIN [INJ]zidovudinezileuton ext-releasezinc chloride [INJ]zinc sulfate [INJ]zingiber prenatal vitaminsZIOPTANziprasidoneZOLADEX [INJ]zoledronic acid [INJ]zoledronic acid/mannitol [INJ]ZOLINZAzolmitriptanzolmitriptan orally disintegrating tabletszolpidemzolpidem ext-releaseZOMETA 4 MG/100 ML [INJ]ZOMIG NASALzonisamideZOSYN GALAXY BAGS [INJ]zoviaZOVIRAX CREAMZTLIDOZUBSOLVZYDELIGZYKADIAZYLETZYTIGA

866.516.3121 15

* Multisource brand exclusion − The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance.[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

A ABILIFY*ABSTRALACANYA*~ACIPHEX* ACIPHEX SPRINKLEACUVAILADCIRCA*ADDERALL*ADLYXINADMELOGAGGRENOX*~AKTIPAKAKYNZEOALBUTEROL SULFATE HFAALCORTIN AALECENSA~ALOCRILALOGLIPTINALOGLIPTIN/METFORMINALOGLIPTIN/PIOGLITAZONEALOMIDEALTOPREVALVESCOAMBIEN*, AMBIEN CR*AMPYRA*AMRIX*ANDROGEL 1%*ANUSOL-HC*APADAZAPIDRAARANESPARIMIDEX*ASACOL HD*ASPIRIN/OMEPRAZOLE DRATACAND*, ATACAND HCT*ATRALIN*~ATRIPLAAUBAGIOAUVI-QAVALIDE*AVAPRO*AVASTIN [INJ]~AVEED~AVODART*AZOR*

B BARACLUDE TABLETS*BAYER (BREEZE, CONTOUR)BECONASE AQBENICAR*, BENICAR HCT*BENZHYDROCODONE/ ACETAMINOPHENBERINERTBRISDELLE*BUDESONIDE – FORMOTEROLBUPAP*BUTRANS

C

CALCIPOTRIENE FOAMCALCIPOTRIENE/ BETAMETHASONE SUSPENSIONCARAC~ CELEBREX*CELEXA*CETRAXALCHORIONIC GONADOTROPINCIALIS*CINQAIRCIPROFLOXACIN/ FLUOCINOLONE OTICCLIMARA PROCLINDAGEL~CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE)~CLOCORTOLONECOMPLERACONSENSICOREG*CORTIFOAMCOSOPT*COZAAR*CRESTOR*CUPRIMINE*CYMBALTA*CYTOMEL*

D DELSTRIGODELZICOL*DETROL*, DETROL LA*DICLOFENAC EPOLAMINE PATCHESDIOVAN*, DIOVAN HCT*DIPENTUMDORAL~DOXYCYCLINE 40 MG CAPSULESDOXYCYCLINE HYCLATE DR 80 MGDRIZALMA SPRINKLEDUAKLIR PRESSAIRDUROLANEDUTOPROL

E EFFEXOR XR*ELIDEL*EMBEDAEMEND CAPSULES*, TRIFOLD PACK*EMEND POWDER PACKETSEMFLAZAEPANEDEPIDUO*~EPIDUO FORTE~EPINEPHRINE AUTO-INJECTOR (BY IMPAX)EPOGENESTROGELEVENITYEVZIOEXFORGE*, EXFORGE HCT*EXJADE*EXONDYS 51EXTAVIAEZALLOR SPRINKLE

F FEMRINGFENOPROFEN CAPSULESFENORTHO

FENTANYL CITRATE BUCCAL TABLETSFENTORAFIASPFIRAZYR [INJ]*~FLUOROURACIL 0.5% CREAMFML FORTE, FML S.O.P.FOCALIN*, FOCALIN XR*FOLLISTIM AQFOSRENOL CHEWABLE TABLET* FOSRENOL POWDER PACKET

G GANIRELIX ACETATE*GEL-ONEGELSYN-3GENVISC 850GLEEVEC*GLUCOPHAGE*, GLUCOPHAGE XR*GLUMETZA*GOCOVRI ERGRANIX

H HERCEPTIN [INJ]~ HUMATROPEHYALGANHYMOVIS

I IMIQUIMOD 3.75% CREAM PUMP IMITREX*INDERAL LA*INGREZZAINREBICINSULIN ASPARTINSULIN ASPART PROTAMINEINSULIN LISPROINTUNIV*ISTALOL*

Excluded MedicationsThe following list of drugs is excluded from coverage. When multiple drugs are equally effective in treating the same condition, drugs that have more cost-effective alternatives are excluded from coverage. If you are taking a drug on the excluded list, we encourage you to speak with your doctor to help you find a drug that is covered under your pharmacy benefit.

866.516.3121 16

* Multisource brand exclusion − The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance.[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

J

JADENU, JADENU SPRINKLE

K KAPSPARGO SPRINKLEKATERZIAKAZANOKEPPRA*, KEPPRA XR*KISQALI, KISQALI FEMARA CO- PACKKOMBIGLYZE XRKORLYM~

L LAMICTAL*, LAMICTAL ODT*, LAMICTAL XR*LAZANDALEDIPASVIR/SOFOSBUVIRLETAIRIS*~ LEVALBUTEROL HFALEXAPRO*LIBRAX*LIDOCAINE/TETRACAINELIDODERM*LIPITOR*LOCOID*~LOCOID LIPOCREAM*~LOESTRIN*, LOESTRIN FE*LOTREL*LOVENOX*LUCEMYRALULICONAZOLELUNESTA*LYRICA*LYRICA CR

M MAVYRET MAXALT*, MAXALT MLT*MAXIDEXMETOPROLOL SUCCINATE/ HCTZ ERMICARDIS*, MICARDIS HCT*MINASTRIN 24 FE*MINOLIRAMIRCERAMULPLETA

N NALFON CAPSULES

NAMENDA XR*NASONEX*NATIONAL MEDICAL (ADVOCATE)NESINANEUPOGENNEURONTIN*NEVANACNOCTIVANORCO*NORTHERA~NORVASC*NOVOLINNOVOLIN 70-30NOVOLIN NNOVOLIN RNOVOLOGNOXAFIL*~NUTROPIN AQ NUSPINNUVIGIL*NUWIQ

O OGIVRI~ OMNARISOMNIS HEALTH (EMBRACE, VICTORY)OMNITROPEONGLYZAONPATTROONZETRA XSAILORFADINORTHO TRI-CYCLEN*, ORTHO TRI-CYCLEN LO*OSMOLEX EROSMOPREP~OXBRYTAOXYCODONE EROZOBAX

P PANCREAZEPATADAY*PENNSAIDPERCOCET*~PERTZYEPIFELTROPIQRAYPLAQUENIL*PLAVIX*PRADAXAPRAVACHOL*PRED MILDPREGNYLPREVACID*

PREVACID SOLUTAB*PREZCOBIXPRILOSEC SUSPENSIONPRIMLEV~PRISTIQ*PROCYSBI~PROLIAPROTONIX*PROTONIX SUSPENSIONPROVENTIL HFAPROVIGIL*PROZAC*PULMICORT RESPULES*PYLERA~

Q QBRELISQSYMIA

R

RABEPRAZOLE DR SPRINKLERANEXA*~RAPAFLO*RECOMBINATE RELAFEN DSRELION NOVOLINRENAGELRITUXAN [INJ]~RITUXAN HYCELA [INJ]~ROCHE (ACCU-CHEK)ROZEREM*~

S SAIZENSAIZENPREPSANDOSTATIN LAR DEPOTSAVAYSASEROQUEL*, SEROQUEL XR*SENSIPAR*~SIGNIFOR LARSIKLOSSIMVASTATIN SUSPENSIONSINGULAIR*SITAVIGSODIUM HYALURONATESOFOSBUVIR/VELPATASVIRSOVALDISPIRIVA HANDIHALER, SPIRIVA RESPIMATSPRAVATOSTIOLTO RESPIMATSTRATTERA*STRIBILD

STRIVERDI RESPIMATSUBSYSSULCONAZOLESUPARTZ FXSUPPRELIN LA~SYNVISC, SYNVISC-ONE

T

TALTZTARGRETIN CAPSULE*~TAVALISSE~ TESTIM*TIKOSYN*TIMOPTIC OCUDOSETIVORBEXTOBI SOLUTION*TOLSURATOPAMAX*TOPICORT SPRAYTOPIRAMATE ER CAPSULESTOPROL XL*~TRANSDERM-SCOP*~TRELSTAR~TREXIMET*~TRIBENZOR*TRICOR*TRILEPTAL*TRILURONTRIVIDIA (TRUETEST, TRUETRACK)TRIVISCTRUXIMA~TUDORZA PRESSAIR

U ULORIC*~ UNISTRIPUROXATRAL*

V VAGIFEM*VALIUM*VALTREX*VANOS*~VELTASSAVELTINVERDESO FOAMVESICARE*~VIAGRA*VICTOZAVISCO-3VIVELLE-DOT*

866.516.3121 17

* Multisource brand exclusion − The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance.[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

V (continued)

VIVLODEXVYONDYS 53VYTORIN*

W WELLBUTRIN SR*

X XADAGO XALATAN*XANAX*, XANAX XR*XATMEPXELPROSXENAZINE*XIFAXAN 200 MG~XIMINO~XOPENEX HFAXPOVIOXTAMPZA ER~XYNTHA, XYNTHA SOLOFUSE

Y YASMIN* YOSPRALA DR

Z ZAVESCA*ZEGERID*ZELAPAR~ZETIA*ZETONNAZIPSORZOCOR*ZOLOFT*ZOMACTONZOMIG TABLETS*, ZOMIG ZMT*ZONEGRAN*ZORVOLEXZOVIRAX OINTMENT*~ZURAMPICZYCLARAZYFLO CR*ZYTIGA 250 MG*

866.516.3121 18

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

A ACTEMRA [INJ]ADCIRCAADYNOVATE [INJ]AFINITORAMPYRA ERATRIPLAAUBAGIOAVONEX [INJ]

B BARACLUDEBENLYSTA [INJ]BETASERON [INJ]BETHKISBIKTARVYBOSULIFBOTOX [INJ]

C

CABOMETYXcapecitabineCAYSTONCETROTIDE [INJ]chorionic gonadotropin [INJ]CIMZIA [INJ]CINRYZE [INJ]COMPLERACOPAXONE [INJ]COSENTYX [INJ]CUPRIMINECUVITRU [INJ]

D dalfampridine erDESCOVYDUPIXENT [INJ]

E ENBREL [INJ]entecavir

ENTYVIOEPCLUSAEPIDIOLEXERIVEDGEEUFLEXXA [INJ]EXONDYS [INJ]EXTAVIA [INJ]EYLEA [INJ]

F FASENRA [INJ]FOLLISTIM AQ [INJ]FORTEO [INJ]

G GAMMAGARD [INJ]GANIRELIX [INJ]GELSYN-3 [INJ]GENVOYAGILENYAglatiramer [INJ]GLATOPA [INJ]GLEEVECGONAL-F [INJ]

H HARVONIHETLIOZHIZENTRA [INJ]HP ACTHAR [INJ]HUMATROPE [INJ]HUMIRA [INJ]HYALGAN [INJ]hydroxyprogesterone [INJ]

I IBRANCEICLUSIGILARIS [INJ]imatinibIMBRUVICAISENTRESS

J JAKAFI

K KALETRAKALYDECOKEVZARA [INJ]KINERET [INJ]KISQALI

L lamivudine/zidovudineledipasvir/sofosbuvirleuprolide [INJ]LONSURFLUPANETA [INJ]LUPRON DEPOT [INJ]LYNPARZA

M MAKENA [INJ]MAVYRETMEKINISTMENOPUR [INJ]MESNEXMONOVISC [INJ]

N NERLYNXNEULASTA [INJ]NEUPOGEN [INJ]NEXAVARNINLARONORDITROPIN [INJ]NORVIRNOVAREL [INJ]NUCALA [INJ]NULOJIX [INJ]NUPLAZIDNUTROPIN AQ NUSPIN [INJ]

O OCALIVA [INJ]OCREVUS [INJ]ODEFSEYOFEVOLUMIANTOMNITROPE [INJ]OPSUMITORENCIA [INJ]ORKAMBIOTEZLAOVIDREL [INJ]

P PACLITAXEL [INJ]PEGASYS [INJ]PLEGRIDY [INJ]POMALYSTPRALUENT [INJ]PREGNYL [INJ]PREVYMISPREZCOBIXPREZISTAPROCRIT [INJ]PROLASTIN [INJ]PROLIA [INJ]PROMACTAPULMOZYME

R RAVICTIREBIF [INJ] REMICADE [INJ]REPATHA [INJ]REVATIOREVLIMIDREYATAZRHOGAM [INJ]ribavirin

S SABRIL

Specialty MedicationsSpecialty medications treat rare or complex conditions and are typically higher-cost medications. These medications require a prior authorization before coverage is determined. CastiaRx, powered by Diplomat, can provide most specialty medications along with helpful programs and services.

Not all specialty medications are listed in the formulary and coverage may vary by plan. For specific questions about your plan’s coverage, please call Member Services at 866.516.3121.

866.516.3121 19

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

S (continued)

SANDOSTATIN LAR [INJ]sildenafil 20mgSIMPONI [INJ]SIMPONI ARIA [INJ]sofosbuvir/velpatasvirSOLIRIS [INJ]SPRYCELSTELARA [INJ]STIVARGASTRIBILDSUBLOCADE [INJ]SUCRAIDSUPARTZ FX [INJ]SUPPRELLIN LA [INJ]SUTENTSYMDEKOSYMTUZASYNAGIS [INJ]SYNVISC [INJ]SYNVISC-ONE [INJ]

T tadalafil 20mgTAFINLARTAGRISSOTALTZ [INJ]TASIGNATECFIDERAtemozolomidetetrabenazineTIVICAYTREMFYA [INJ]TRIUMEQTRUVADATYKERBTYMLOS [INJ]TYSABRI [INJ]TYVASO

V VEMLIDYVENCLEXTAVIREADVIVITROL [INJ]VOTRIENT

X XELJANZXELJANZ XRXIAFLEX [INJ]XOLAIR [INJ]

XTANDIXYREM

Z zoledronic acid [INJ]ZYTIGA

866.516.3121 20

[INJ] - Injectable Drug. [OTC] - Over-the-counter Product. Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

“My Medications” WorksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Ditch the paperwork and switch to digital! Easily manage medications for you and your family using optumrx.com and the OptumRx app. View your prescription details, receive refill reminders and print a list of medications for your doctors.

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson

866.516.3121

ES.VLDL.EFF010120.01.121019WF3034971