2020 HealthChoice Standard Medication List...January 2020 HealthChoice Standard Medication List. The...

July 2020

HealthChoice Standard Medication List The HealthChoice Standard Medication List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER HealthChoice provides you with prescription benefits administered by CVS Caremark®. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor.

Please note:

• Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.

You may be responsible for the full cost of non-formulary • products that are removed from coverage.

• For specific information regarding your prescription benefit coverage and copay1 information, please visit Caremark.com or contact a CVS Caremark Customer Care representative at 1-877-720-9375. If you have a hearing impairment and need telecommunications device (TDD) assistance, please dial 1-800-863-5488.

• CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.

• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the

HEALTH CARE PROVIDER Your patient is covered under HealthChoice prescription benefits administered by CVS Caremark. As a way to help manage health care costs, we encourage you to authorize generic substitutions whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand-name product on this list.

Please note:

• Generics should be considered the first line of prescribing.

• This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. HealthChoice prescription benefits may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market.

• HealthChoice may have a different copay1 for specific products on the list.

• Unless specifically indicated, drug list products will include all dosage forms.

• Log on to Caremark.com to check coverage and copay1

information for a specific medicine.

market.

ANALGESICS

§ NSAIDs diclofenac sodium ibuprofen meloxicam naproxen 2

§ NSAIDs, COMBINATIONS diclofenac sodium-

misoprostol

§ NSAIDs, TOPICAL diclofenac sodium gel 1%

(except NDC^ 69499031866)

diclofenac sodium solution

§ COX-2 INHIBITORS celecoxib

§ GOUT allopurinol colchicine tablet probenecid

§ OPIOID ANALGESICS buprenorphine transdermal codeine-acetaminophen fentanyl transdermal fentanyl transmucosal

lozenge hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone

oxycodone-acetaminophen § ERYTHROMYCINS / tramadol (except NDC^ 52817019610) MACROLIDES tramadol ext-rel azithromycin BELBUCA clarithromycin NUCYNTA clarithromycin ext-rel NUCYNTA ER erythromycins SUBSYS DIFICID XTAMPZA ER

ANTI-INFECTIVES § FLUOROQUINOLONES ciprofloxacin levofloxacin ANTIBACTERIALS moxifloxacin

§ CEPHALOSPORINS cefdinir § PENICILLINS cefprozil amoxicillin cefuroxime axetil amoxicillin-clavulanate cephalexin dicloxacillin SUPRAX penicillin VK

§ TETRACYCLINES doxycycline hyclate 20 mg doxycycline hyclate capsule minocycline tetracycline

§ ANTIFUNGALS fluconazole itraconazole terbinafine tablet

ANTIVIRALS § CYTOMEGALOVIRUS AGENTS valganciclovir

§ HERPES AGENTS acyclovir capsule, tablet valacyclovir

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

https://Caremark.com



BLOCKER / DIURETIC § DIRECT RENIN § ANTIDEMENTIA § ATTENTION DEFICIT§ INFLUENZA AGENTS COMBINATIONS INHIBITORS / DIURETIC donepezil HYPERACTIVITY DISORDER oseltamivir amlodipine-valsartan- COMBINATIONS galantamine amphetamine-RELENZA hydrochlorothiazide aliskiren galantamine ext-rel dextroamphetamine mixed

olmesartan-amlodipine- TEKTURNA HCT memantine salts § MISCELLANEOUS hydrochlorothiazide rivastigmine amphetamine-

clindamycin § DIURETICS rivastigmine transdermal dextroamphetamine mixed ivermectin § ANTIARRHYTHMICS †amiloride NAMZARIC salts ext-rellinezolid sotalol furosemide atomoxetine metronidazole MULTAQ hydrochlorothiazide ANTIDEPRESSANTS guanfacine ext-relnitrofurantoin metolazone § SELECTIVE SEROTONIN methylphenidate sulfamethoxazole- ANTILIPEMICS spironolactone- REUPTAKE INHIBITORS methylphenidate ext-rel †

trimethoprim § BILE ACID RESINS hydrochlorothiazide (SSRIs) MYDAYIS vancomycin capsule cholestyramine torsemide citalopram VYVANSEEMVERM colesevelam triamterene escitalopram XIFAXAN 550 MG § FIBROMYALGIAtriamterene- fluoxetine 5

ANTINEOPLASTIC AGENTS

§ CHOLESTEROL hydrochlorothiazide paroxetine HCl pregabalin ABSORPTION INHIBITORS paroxetine HCl ext-relHEART FAILURE HYPNOTICSezetimibe sertraline

BIDIL § NONBENZODIAZEPINES HORMONAL TRINTELLIX§ FIBRATESANTINEOPLASTIC AGENTS CORLANOR VIIBRYD eszopiclone fenofibrate 3 ENTRESTO ramelteon§ ANTIANDROGENS fenofibric acid delayed-rel § SEROTONIN zolpidem bicalutamide § NITRATES NOREPINEPHRINE zolpidem ext-rel§ HMG-CoA REDUCTASE nitroglycerin lingual spray REUPTAKE INHIBITORS § MISCELLANEOUS zolpidem sublingualINHIBITORS / nitroglycerin sublingual (SNRIs) BELSOMRAVISTOGARD COMBINATIONS

desvenlafaxine ext-rel CARDIOVASCULAR

§ MISCELLANEOUS atorvastatin TRICYCLICSduloxetine ezetimibe-simvastatin ranolazine ext-rel venlafaxine SILENOR

§ ACE INHIBITORS fluvastatin CENTRAL NERVOUS

SYSTEM

venlafaxine ext-rel capsule MIGRAINElovastatin fosinopril

pravastatin § MISCELLANEOUS ACUTE MIGRAINE AGENTS rosuvastatin AGENTS

lisinopril quinapril ANTIANXIETY Newer Agents

simvastatinramipril bupropion § BENZODIAZEPINES NURTEC ODT bupropion ext-rel 6 REYVOW§ ACE INHIBITOR / § NIACINS alprazolam mirtazapine UBRELVYDIURETIC COMBINATIONS niacin ext-rel clonazepam trazodone diazepam fosinopril-hydrochlorothiazide § Triptans § OMEGA-3 FATTY ACIDS lorazepam lisinopril-hydrochlorothiazide § ANTIPARKINSONIAN eletriptan omega-3 acid ethyl esters oxazepam quinapril-hydrochlorothiazide AGENTS naratriptan VASCEPA amantadine § ANTICONVULSANTS rizatriptan§ ANGIOTENSIN II carbidopa-levodopa § BETA-BLOCKERS sumatriptan carbamazepine RECEPTOR ANTAGONISTS / carbidopa-levodopa ext-rel zolmitriptan carbidopa-levodopa-DIURETIC COMBINATIONS atenolol carbamazepine ext-rel

ONZETRA XSAILcarvedilol clobazam candesartan / candesartan- entacapone ZEMBRACE SYMTOUCHcarvedilol phosphate ext-rel diazepam rectal gelhydrochlorothiazide entacapone metoprolol succinate ext-rel divalproex sodium ZOMIG NASAL SPRAY eprosartan pramipexolemetoprolol tartrate divalproex sodium ext-relirbesartan / irbesartan- pramipexole ext-rel PREVENTIVE MIGRAINE

nadolol ethosuximide hydrochlorothiazide rasagiline AGENTS pindolol gabapentin losartan / losartan- ropinirole Monoclonal Antibodies propranolol lamotrigine hydrochlorothiazide ropinirole ext-relpropranolol ext-rel lamotrigine ext-rel AIMOVIG

olmesartan / olmesartan- selegiline BYSTOLIC levetiracetam AJOVYhydrochlorothiazide NEUPROlevetiracetam ext-rel EMGALITY

telmisartan / telmisartan- § CALCIUM CHANNEL oxcarbazepine hydrochlorothiazide BLOCKERS ANTIPSYCHOTICS § MUSCULOSKELETALphenobarbitalvalsartan / valsartan- § ATYPICALS THERAPY AGENTSamlodipine phenytoin hydrochlorothiazide diltiazem ext-rel 4 phenytoin sodium extended aripiprazole cyclobenzaprine 7

clozapine § ANGIOTENSIN II nifedipine ext-rel primidone § NARCOLEPSYolanzapine RECEPTOR ANTAGONIST / verapamil ext-rel tiagabine quetiapine armodafinilCALCIUM CHANNEL topiramate

§ CALCIUM CHANNEL quetiapine ext-rel SUNOSIBLOCKER COMBINATIONS valproic acidBLOCKER / ANTILIPEMIC risperidone zonisamide amlodipine-olmesartan POSTHERPETICCOMBINATIONS ziprasidone FYCOMPAamlodipine-telmisartan NEURALGIA (PHN) amlodipine-atorvastatin ABILIFY MAINTENAOXTELLAR XRamlodipine-valsartan GRALISEARISTADATROKENDI XR§ DIGITALIS GLYCOSIDES ARISTADA INITIO§ ANGIOTENSIN II VIMPATdigoxin LATUDARECEPTOR ANTAGONIST /

VRAYLARCALCIUM CHANNEL



ENDOCRINE AND METABOLIC

GASTROINTESTINAL

GENITOURINARY

PSYCHOTHERAPEUTIC -MISCELLANEOUS § OPIOID ANTAGONISTS naloxone injection

NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 TRESIBA

§ CARNITINE DEFICIENCY AGENTS levocarnitine

hydrocortisone methylprednisolone prednisolone solution prednisone

INFLAMMATORY BOWEL DISEASE § ORAL AGENTS balsalazide

NARCAN NASAL SPRAY

§ PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST COMBINATIONS buprenorphine-naloxone

sublingual ZUBSOLV

PSEUDOBULBAR AFFECT AGENTS NUEDEXTA

§ VASOMOTOR SYMPTOM AGENTS paroxetine mesylate

§ ANDROGENS

§ INSULIN SENSITIZERS pioglitazone

§ INSULIN SENSITIZER / BIGUANIDE COMBINATIONS pioglitazone-metformin

§ INSULIN SENSITIZER / SULFONYLUREA COMBINATIONS pioglitazone-glimepiride

§ MEGLITINIDES nateglinide repaglinide

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA

CONTRACEPTIVES § MONOPHASIC ethinyl estradiol-

drospirenone ethinyl estradiol-

drospirenone-levomefolate ethinyl estradiol-

norethindrone acetate ethinyl estradiol-

norethindrone acetate-iron

BIPHASIC LO LOESTRIN FE

§ TRIPHASIC ethinyl estradiol-norgestimate

§ EXTENDED CYCLE ethinyl estradiol-

levonorgestrel

GLUCOSE ELEVATING AGENTS BAQSIMI GLUCAGEN HYPOKIT GLUCAGON EMERGENCY

KIT

§ PHOSPHATE BINDER AGENTS calcium acetate sevelamer carbonate PHOSLYRA VELPHORO

POTASSIUM-REMOVING AGENTS LOKELMA VELTASSA

PROGESTINS

budesonide capsule budesonide ext-rel mesalamine delayed-rel mesalamine ext-rel sulfasalazine sulfasalazine delayed-rel PENTASA

§ RECTAL AGENTS hydrocortisone enema mesalamine suppository mesalamine suspension CORTIFOAM

§ IRRITABLE BOWEL SYNDROME alosetron AMITIZA LINZESS VIBERZI

testosterone gel 8

testosterone solution ANDRODERM

ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN

§ BIGUANIDES metformin metformin ext-rel 9

§ BIGUANIDE / SULFONYLUREA COMBINATIONS glipizide-metformin

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS JANUMET JANUMET XR

INCRETIN MIMETIC AGENTS OZEMPIC RYBELSUS

JARDIANCE

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE COMBINATIONS SYNJARDY SYNJARDY XR XIGDUO XR

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS GLYXAMBI

§ SULFONYLUREAS glimepiride glipizide glipizide ext-rel

SUPPLIES ACCU-CHEK AVIVA PLUS

STRIPS AND KITS 10

ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10

ACCU-CHEK GUIDE

§ TRANSDERMAL ethinyl estradiol-

norelgestromin

§ VAGINAL ethinyl estradiol-etonogestrel

ENDOMETRIOSIS ORILISSA

ESTROGENS § ORAL estradiol PREMARIN

§ TRANSDERMAL estradiol DIVIGEL EVAMIST

§ VAGINAL estradiol ESTRING PREMARIN CREAM

ESTROGEN / PROGESTINS § ORAL estradiol-norethindrone PREMPHASE

§ ORAL medroxyprogesterone megestrol acetate progesterone, micronized

VAGINAL CRINONE ENDOMETRIN

§ SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene OSPHENA

§ THYROID SUPPLEMENTS levothyroxine liothyronine SYNTHROID

§ ANTIEMETICS doxylamine-pyridoxine

delayed-rel dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine

§ LAXATIVES lactulose solution peg 3350-electrolytes SUPREP

OPIOID-INDUCED CONSTIPATION MOVANTIK SYMPROIC

PANCREATIC ENZYMES CREON VIOKACE ZENPEP

§ PROTON PUMP INHIBITORS esomeprazole lansoprazole omeprazole pantoprazole DEXILANT

§ STEROIDS, RECTAL PROCTOFOAM-HC

§ ULCER THERAPY COMBINATIONS PYLERA

TRULICITY STRIPS AND KITS 10 PREMPRO promethazine § MISCELLANEOUS VICTOZA

INCRETIN MIMETIC AGENT / INSULIN COMBINATIONS SOLIQUA XULTOPHY

INSULINS BASAGLAR FIASP HUMULIN R U-500 LEVEMIR NOVOLIN 70/30

ACCU-CHEK SMARTVIEW STRIPS AND KITS 10

BD ULTRAFINE INSULIN SYRINGES AND NEEDLES

CALCIUM REGULATORS § BISPHOSPHONATES alendronate ibandronate risedronate

§ CALCITONINS

TRANSDERMAL CLIMARA PRO COMBIPATCH

ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE

§ GLUCOCORTICOIDS dexamethasone

scopolamine transdermal trimethobenzamide SANCUSO VARUBI

§ ANTISPASMODICS dicyclomine

§ H2 RECEPTOR ANTAGONISTS famotidine

sucralfate

§ BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin dutasteride dutasteride-tamsulosin finasteride silodosin tamsulosin

NOVOLIN N calcitonin-salmon fludrocortisone terazosin



TOPICAL

HEMATOLOGIC

IMMUNOLOGIC AGENTS

NUTRITIONAL / SUPPLEMENTS

RESPIRATORY

§ URINARY ANTISPASMODICS

inhalation solution

LONG ACTING

FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER

solution mometasone triamcinolone cream, lotion,

NEVANAC

§ Steroidal darifenacin ext-rel ANORO ELLIPTA QVAR REDIHALER ointment dexamethasone oxybutynin BEVESPI AEROSPHERE loteprednol oxybutynin ext-rel STIOLTO RESPIMAT § High Potency prednisolone acetate 1% solifenacin tolterodine tolterodine ext-rel trospium trospium ext-rel MYRBETRIQ TOVIAZ

§ ANTICOAGULANTS warfarin ELIQUIS XARELTO

§ PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole ext-rel-aspirin prasugrel BRILINTA

ALLERGENIC EXTRACTS GRASTEK RAGWITEK

ANTICHOLINERGIC / BETA AGONIST / STEROID INHALANT COMBINATIONS TRELEGY ELLIPTA

§ ANTIHISTAMINES, LOW SEDATING levocetirizine

§ ANTITUSSIVES

benzonatate (except NDCs^

69336012615, 69499032915)

BETA AGONISTS, INHALANTS § SHORT ACTING albuterol inhalation solution albuterol sulfate CFC-free

aerosol levalbuterol tartrate CFC-free

aerosol

LONG ACTING Hand-held Active Inhalation SEREVENT STRIVERDI RESPIMAT

DERMATOLOGY ACNE § Topical adapalene benzoyl peroxide clindamycin gel (except NDC^

68682046275)

clindamycin solution clindamycin-benzoyl

peroxide erythromycin solution erythromycin-benzoyl

peroxide tretinoin EPIDUO ONEXTON TAZORAC

§ ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod PICATO TOLAK ZYCLARA

§ ANTIBIOTICS

desoximetasone fluocinonide 11

BRYHALI

§ Very High Potency clobetasol cream, foam, gel,

lotion, ointment, shampoo

§ LOCAL ANESTHETICS lidocaine-prilocaine

§ ROSACEA azelaic acid gel doxycycline monohydrate

delayed-rel capsule metronidazole FINACEA FOAM SOOLANTRA

MOUTH / THROAT / DENTAL AGENTS PROTECTANTS EPISIL

OPHTHALMIC § ANTIALLERGICS azelastine cromolyn sodium

DUREZOL FML FORTE FML S.O.P. MAXIDEX PRED MILD

BETA-BLOCKERS § Nonselective timolol maleate solution BETIMOL

Selective BETOPTIC S

§ CARBONIC ANHYDRASE INHIBITORS dorzolamide AZOPT

§ CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONS dorzolamide-timolol

CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC COMBINATIONS

§ ELECTROLYTES

Nebulized Passive Inhalation PERFOROMIST

§ LEUKOTRIENE

gentamicin mupirocin ointment

§ ANTIFUNGALS

olopatadine LASTACAFT PAZEO

SIMBRINZA

DRY EYE DISEASE RESTASIS

potassium chloride liquid MODULATORS ciclopirox § ANTI-INFECTIVES XIIDRA

VITAMINS AND MINERALS § FOLIC ACID / COMBINATIONS folic acid

montelukast zafirlukast zileuton ext-rel

§ NASAL ANTIHISTAMINES

clotrimazole econazole ketoconazole cream 2% luliconazole nystatin

ciprofloxacin erythromycin gentamicin levofloxacin moxifloxacin

§ PROSTAGLANDINS latanoprost LUMIGAN TRAVATAN Z

§ PRENATAL VITAMINS prenatal vitamins CITRANATAL

§ ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector EPIPEN EPIPEN JR SYMJEPI

azelastine olopatadine

§ NASAL STEROIDS / COMBINATIONS flunisolide fluticasone mometasone DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS DALIRESP

NAFTIN

§ ANTIPSORIATICS acitretin calcipotriene ointment,

solution methoxsalen

§ ANTISEBORRHEICS ketoconazole shampoo 2% selenium sulfide lotion 2.5%

§ ATOPIC DERMATITIS

ofloxacin sulfacetamide tobramycin BESIVANCE CILOXAN OINTMENT MOXEZA

§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS neomycin-polymyxin B-

bacitracin-hydrocortisone neomycin-polymyxin B-

RHO KINASE INHIBITORS RHOPRESSA

RHO KINASE INHIBITOR / PROSTAGLANDIN COMBINATIONS ROCKLATAN

§ SYMPATHOMIMETICS brimonidine ALPHAGAN P

SYMPATHOMIMETIC / BETA-

§ ANTICHOLINERGICS ipratropium inhalation

solution INCRUSE ELLIPTA SPIRIVA YUPELRI

STEROID / BETA AGONIST COMBINATIONS ADVAIR DISKUS ADVAIR HFA BREO ELLIPTA SYMBICORT

pimecrolimus tacrolimus EUCRISA

CORTICOSTEROIDS § Low Potency desonide

dexamethasone tobramycin-dexamethasone TOBRADEX OINTMENT TOBRADEX ST

ANTI-INFLAMMATORIES § Nonsteroidal

BLOCKER COMBINATIONS COMBIGAN

OTIC § ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS

ANTICHOLINERGIC / BETA AGONIST COMBINATIONS § SHORT ACTING ipratropium-albuterol

§ STEROID INHALANTS budesonide inhalation

suspension ARNUITY ELLIPTA

hydrocortisone

§ Medium Potency hydrocortisone butyrate

cream, lotion, ointment,

bromfenac diclofenac ketorolac ACUVAIL ILEVRO

CIPRODEX



QUICK REFERENCE DRUG LIST

A BAQSIMI 68682046275) DYMISTA fluorouracil cream 5%

ABILIFY MAINTENA ACCU-CHEK AVIVA PLUS

STRIPS AND KITS 10

ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10

ACCU-CHEK GUIDE STRIPS AND KITS 10

ACCU-CHEK SMARTVIEW STRIPS AND KITS 10

acitretin ACUVAIL acyclovir capsule, tablet adapalene ADVAIR DISKUS ADVAIR HFA AIMOVIG AJOVY albuterol inhalation solution albuterol sulfate CFC-free

aerosol alendronate alfuzosin ext-rel aliskiren allopurinol alosetron ALPHAGAN P alprazolam amantadine amiloride AMITIZA amlodipine amlodipine-atorvastatin amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartan-

hydrochlorothiazide amoxicillin amoxicillin-clavulanate amphetamine-

dextroamphetamine mixed salts

amphetamine-dextroamphetamine mixed

†salts ext-rel ANDRODERM ANORO ELLIPTA

BASAGLAR BD ULTRAFINE INSULIN

SYRINGES AND NEEDLES

BELBUCA BELSOMRA benzonatate (except NDCs^

69336012615, 69499032915)

benzoyl peroxide BESIVANCE BETIMOL BETOPTIC S BEVESPI AEROSPHERE bicalutamide BIDIL BREO ELLIPTA BRILINTA brimonidine bromfenac BRYHALI budesonide capsule budesonide ext-rel budesonide inhalation

suspension buprenorphine transdermal buprenorphine-naloxone

sublingual bupropion bupropion ext-rel 6

BYSTOLIC

C

calcipotriene ointment, solution

calcitonin-salmon calcium acetate candesartan candesartan-

hydrochlorothiazide carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-

entacapone carvedilol carvedilol phosphate ext-rel cefdinir

clindamycin solution clindamycin-benzoyl

peroxide clobazam clobetasol cream, foam, gel,

lotion, ointment, shampoo clonazepam clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine tablet colesevelam COMBIGAN COMBIPATCH CORLANOR CORTIFOAM CREON CRINONE cromolyn sodium cyclobenzaprine 7

D

DALIRESP darifenacin ext-rel desonide desoximetasone desvenlafaxine ext-rel dexamethasone DEXILANT diazepam diazepam rectal gel diclofenac diclofenac sodium diclofenac sodium gel 1%

(except NDC^ 69499031866)

diclofenac sodium solution diclofenac sodium-

misoprostol dicloxacillin dicyclomine DIFICID digoxin diltiazem ext-rel 4

dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGEL

E

econazole eletriptan ELIQUIS EMGALITY EMVERM ENDOMETRIN entacapone ENTRESTO EPIDUO epinephrine auto-injector EPIPEN EPIPEN JR EPISIL eprosartan erythromycin erythromycin solution erythromycin-benzoyl

peroxide erythromycins escitalopram esomeprazole estradiol estradiol-norethindrone ESTRING eszopiclone ethinyl estradiol-

drospirenone ethinyl estradiol-

drospirenone-levomefolate ethinyl estradiol-etonogestrel ethinyl estradiol-

levonorgestrel ethinyl estradiol-

norelgestromin ethinyl estradiol-

norethindrone acetate ethinyl estradiol-

norethindrone acetate-iron ethinyl estradiol-norgestimate ethosuximide EUCRISA EVAMIST ezetimibe ezetimibe-simvastatin

F

fluorouracil solution fluoxetine 5

fluticasone fluvastatin FML FORTE FML S.O.P. folic acid fosinopril fosinopril-hydrochlorothiazide furosemide FYCOMPA

G

gabapentin galantamine galantamine ext-rel gentamicin glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY

KIT GLYXAMBI GRALISE granisetron GRASTEK guanfacine ext-rel

H

HUMULIN R U-500 hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate

cream, lotion, ointment, solution

hydrocortisone enema hydromorphone hydromorphone ext-rel

I

ibandronate ibuprofen ILEVRO imiquimod INCRUSE ELLIPTA

aripiprazole ARISTADA

cefprozil cefuroxime axetil

donepezil dorzolamide

famotidine FARXIGA

ipratropium inhalation solution

ARISTADA INITIO armodafinil ARNUITY ELLIPTA atenolol atomoxetine atorvastatin azelaic acid gel azelastine azithromycin AZOPT

B

celecoxib cephalexin cholestyramine ciclopirox CILOXAN OINTMENT CIPRODEX ciprofloxacin citalopram CITRANATAL clarithromycin clarithromycin ext-rel CLIMARA PRO

dorzolamide-timolol doxazosin doxycycline hyclate 20 mg doxycycline hyclate capsule doxycycline monohydrate

delayed-rel capsule doxylamine-pyridoxine

delayed-rel dronabinol DUAVEE duloxetine DUREZOL

fenofibrate 3

fenofibric acid delayed-rel fentanyl transdermal fentanyl transmucosal

lozenge FIASP FINACEA FOAM finasteride FLOVENT DISKUS FLOVENT HFA fluconazole fludrocortisone

ipratropium-albuterol inhalation solution

irbesartan irbesartan-

hydrochlorothiazide itraconazole ivermectin

J

JANUMET JANUMET XR JANUVIA

balsalazide clindamycin clindamycin gel (except NDC^

dutasteride dutasteride-tamsulosin

flunisolide fluocinonide 11

JARDIANCE



K MOVANTIK paroxetine HCl ext-rel ropinirole torsemide

ketoconazole cream 2% MOXEZA paroxetine mesylate ropinirole ext-rel TOVIAZ

ketoconazole shampoo 2% moxifloxacin PAZEO rosuvastatin tramadol (except NDC^ 52817019610)

ketorolac MULTAQ peg 3350-electrolytes RYBELSUS tramadol ext-rel mupirocin ointment penicillin VK TRAVATAN Z

L MYDAYIS PENTASA S trazodone MYRBETRIQ PERFOROMIST SANCUSO TRELEGY ELLIPTA

lactulose solution phenobarbital scopolamine transdermal TRESIBAlamotrigine N phenytoin selegiline tretinoin lamotrigine ext-rel

nadolol phenytoin sodium extended selenium sulfide lotion 2.5% triamcinolone cream, lotion, lansoprazole

NAFTIN PHOSLYRA SEREVENT ointment LASTACAFT

naloxone injection PICATO sertraline triamterene latanoprost LATUDA NAMZARIC pimecrolimus sevelamer carbonate triamterene-

levalbuterol tartrate CFC-free naproxen 2 pindolol SILENOR hydrochlorothiazide

aerosol naratriptan pioglitazone silodosin trimethobenzamide

LEVEMIR NARCAN NASAL SPRAY pioglitazone-glimepiride SIMBRINZA TRINTELLIX

levetiracetam nateglinide pioglitazone-metformin simvastatin TROKENDI XR

levetiracetam ext-rel neomycin-polymyxin B- potassium chloride liquid solifenacin trospium

levocarnitine bacitracin-hydrocortisone pramipexole SOLIQUA trospium ext-rel

levocetirizine neomycin-polymyxin B- pramipexole ext-rel SOOLANTRA TRULICITY

levofloxacin dexamethasone NEUPRO

prasugrel pravastatin

sotalol SPIRIVA U

levothyroxine lidocaine-prilocaine NEVANAC PRED MILD spironolactone- UBRELVY

linezolid LINZESS

niacin ext-rel nifedipine ext-rel

prednisolone acetate 1% prednisolone solution

hydrochlorothiazide STIOLTO RESPIMAT V

liothyronine nitrofurantoin prednisone STRIVERDI RESPIMAT valacyclovir

lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE

nitroglycerin lingual spray nitroglycerin sublingual NOVOLIN 70/30

pregabalin PREMARIN PREMARIN CREAM

SUBSYS sucralfate sulfacetamide

valganciclovir valproic acid valsartan

LOKELMA NOVOLIN N PREMPHASE sulfamethoxazole- valsartan-hydrochlorothiazide

lorazepam NOVOLIN R PREMPRO trimethoprim vancomycin capsule

losartan NOVOLOG prenatal vitamins sulfasalazine VARUBI NOVOLOG MIX 70/30 primidone sulfasalazine delayed-rel VASCEPAlosartan-hydrochlorothiazide

loteprednol NUCYNTA probenecid sumatriptan VELPHORO

lovastatin NUCYNTA ER prochlorperazine SUNOSI VELTASSA

luliconazole NUEDEXTA PROCTOFOAM-HC SUPRAX venlafaxine

LUMIGAN NURTEC ODT progesterone, micronized SUPREP venlafaxine ext-rel capsule nystatin promethazine SYMBICORT verapamil ext-rel

M propranolol SYMJEPI VIBERZI O propranolol ext-rel SYMLINPEN VICTOZAMAXIDEX ofloxacin PULMICORT FLEXHALER SYMPROIC VIIBRYDmeclizine olanzapine PYLERA SYNJARDY VIMPATmedroxyprogesterone olmesartan SYNJARDY XR VIOKACEmegestrol acetate

meloxicam olmesartan-amlodipine- Q SYNTHROID VISTOGARD

memantine hydrochlorothiazide olmesartan-

quetiapine quetiapine ext-rel T

VRAYLAR VYVANSEmesalamine delayed-rel

mesalamine ext-rel mesalamine suppository

hydrochlorothiazide olopatadine

quinapril quinapril-hydrochlorothiazide

tacrolimus tamsulosin W

mesalamine suspension metformin

omega-3 acid ethyl esters omeprazole ondansetron

QVAR REDIHALER

R

TAZORAC TEKTURNA HCT telmisartan

warfarin

Xmetformin ext-rel 9

methadone ONEXTON RAGWITEK telmisartan- XARELTO methoxsalen ONZETRA XSAIL raloxifene hydrochlorothiazide XIFAXAN 550 MG methylphenidate ORILISSA ramelteon terazosin XIGDUO XR methylphenidate ext-rel † oseltamivir ramipril terbinafine tablet XIIDRA methylprednisolone OSPHENA ranolazine ext-rel testosterone gel 8 XTAMPZA ER metoclopramide metolazone

oxazepam oxcarbazepine

rasagiline RELENZA

testosterone solution tetracycline

XULTOPHY

metoprolol succinate ext-rel metoprolol tartrate metronidazole

OXTELLAR XR oxybutynin oxybutynin ext-rel

repaglinide RESTASIS REYVOW

tiagabine timolol maleate solution TOBRADEX OINTMENT

Y

YUPELRI

minocycline oxycodone RHOPRESSA TOBRADEX ST Z

mirtazapine oxycodone-acetaminophen risedronate tobramycin zafirlukast mometasone OZEMPIC risperidone tobramycin-dexamethasone ZEMBRACE SYMTOUCH montelukast morphine

P rivastigmine rivastigmine transdermal

TOLAK tolterodine

ZENPEP zileuton ext-rel

morphine ext-rel pantoprazole rizatriptan tolterodine ext-rel ziprasidone morphine suppository paroxetine HCl ROCKLATAN topiramate zolmitriptan



zolpidem zolpidem sublingual zonisamide ZYCLARA zolpidem ext-rel ZOMIG NASAL SPRAY ZUBSOLV

PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)*

ABILIFY

ACANYA

ACIPHEX, ACIPHEX SPRINKLE

ACTICLATE

Activite

ACTOS

acyclovir cream

ALCORTIN A

ALEVICYN GEL, ALEVICYN SG, ALEVICYN SOLUTION

ALLISON MEDICAL INSULIN SYRINGES 12

ALORA

ALREX

ALTOPREV

ALVESCO

AMRIX

ANDROGEL 1%

ANGELIQ

ANTARA

APEXICON E

APIDRA

ARMOUR THYROID

ARTHROTEC

ASACOL HD

ASCENSIA STRIPS AND KITS 13

aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR

adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, ONEXTON, TAZORAC

esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline

folic acid

pioglitazone

acyclovir capsule, acyclovir tablet, valacyclovir

desonide, hydrocortisone


BD ULTRAFINE INSULIN SYRINGES

estradiol, DIVIGEL, EVAMIST

azelastine, cromolyn sodium, olopatadine, LASTACAFT, PAZEO

atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER

cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)

testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM

estradiol-norethindrone, PREMPHASE, PREMPRO

fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel

desoximetasone, fluocinonide (except fluocinonide cream 0.1%), BRYHALI

FIASP, NOVOLOG

levothyroxine, liothyronine, SYNTHROID

celecoxib; diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT

balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA

ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, ACCU-CHEK GUIDE STRIPS AND KITS 10, ACCU-

ASMANEX, ASMANEX HFA

ATACAND, ATACAND HCT

ATOPADERM

ATROVENT HFA

AVENOVA

AZELEX

BEAU RX

BECONASE AQ

BENICAR, BENICAR HCT

BENSAL HP

BENZAC AC

BENZACLIN

BENZIQ

benzonatate (NDCs^ 69336012615, 69499032915 only)

BETAPACE, BETAPACE AF

BEYAZ

bimatoprost solution 0.03%

CHEK SMARTVIEW STRIPS AND KITS 10

ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER

candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide


ipratropium inhalation solution, INCRUSE ELLIPTA, SPIRIVA, YUPELRI

Consult doctor


Consult doctor

flunisolide, fluticasone, mometasone, DYMISTA






benzonatate (except NDCs^ 69336012615, 69499032915)

sotalol

ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

latanoprost, LUMIGAN, TRAVATAN Z



DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)*

BREEZE 2 STRIPS AND KITS 13

bupropion ext-rel tablet 450 mg

BUTALBITAL-ACETAMINOPHEN (NDC^ 69499034230 only)

butalbital-acetaminophen-caffeine capsule

BUTRANS

BYDUREON

BYETTA

CAFERGOT

calcipotriene cream

calcitriol ointment

CAMBIA

CARAC

CARAFATE

CARBINOXAMINE TABLET 6 MG

CARDIZEM, CARDIZEM CD, CARDIZEM LA

CARNITOR, CARNITOR SF

chlordiazepoxide-clidinium (NDC^ 42494040901 only)

chlorzoxazone 375 mg, chlorzoxazone 750 mg, CHLORZOXAZONE 250 MG

CICATRACE

CLINDAGEL

clindamycin gel (NDC^ 68682046275 only)

clobetasol spray

CLOBEX SPRAY

COLAZAL

COLCRYS

COMBIVENT RESPIMAT

CONSENSI

CONTOUR NEXT STRIPS AND KITS 13

ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 10, ACCU-CHEK GUIDE STRIPS AND KITS 10, ACCU-CHEK SMARTVIEW STRIPS AND KITS 10

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

diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)


buprenorphine transdermal, BELBUCA

OZEMPIC, RYBELSUS, TRULICITY, VICTOZA

OZEMPIC, RYBELSUS, TRULICITY, VICTOZA

eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY

calcipotriene ointment, calcipotriene solution


diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA

sucralfate

levocetirizine

diltiazem ext-rel (except generic CARDIZEM LA)

levocarnitine

dicyclomine


Consult doctor

erythromycin solution


clobetasol foam

clobetasol foam

balsalazide

colchicine tablet

ipratropium-albuterol inhalation solution, ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT

amlodipine WITH celecoxib

ACCU-CHEK AVIVA PLUS STRIPS AND KITS 10, ACCU-CHEK COMPACT PLUS

CONTOUR STRIPS AND KITS 13

CORDRAN OINTMENT

CoreMino

COUMADIN

CRESTOR

cyclobenzaprine ext-rel capsule, cyclobenzaprine tablet 7.5 mg

CYMBALTA

DELZICOL

DETROL LA

dexchlorpheniramine

Dexifol

Dexpak

diclofenac sodium gel 1% (NDC^ 69499031866 only)

Diclofex DC (NDC^ 51021037201 only)

Diclosaicin

diflorasone cream, diflorasone ointment

dihydroergotamine spray

diltiazem ext-rel (generic CARDIZEM LA only)

DIOVAN, DIOVAN HCT

STRIPS AND KITS 10, ACCU-CHEK GUIDE STRIPS AND KITS 10, ACCU-CHEK SMARTVIEW STRIPS AND KITS 10


hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment


warfarin



desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule


darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ

levocetirizine

folic acid

dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone

diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)






candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan,




DORAL

DORYX, DORYX MPC

doxepin cream

doxycycline hyclate delayed-rel tablet 200 mg

doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only), doxycycline hyclate tablet 75 mg, doxycycline hyclate tablet 150 mg

doxycycline monohydrate capsule 75 mg, doxycycline monohydrate capsule 150 mg

DULERA

DUTOPROL

DYRENIUM

EDARBI, EDARBYCLOR

EDLUAR

E.E.S. GRANULES

EFFEXOR XR

ENABLEX

ENTERAGAM

EPICERAM

ergotamine-caffeine

ERYPED

EVEKEO

EVZIO

EXFORGE

EXFORGE HCT

FANAPT

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

eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR


desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA




ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT

metoprolol succinate ext-rel WITH hydrochlorothiazide

amiloride, triamterene



erythromycins



alosetron, VIBERZI, XIFAXAN 550 MG



erythromycins

amphetamine-dextroamphetamine mixed salts, methylphenidate

naloxone injection, NARCAN NASAL SPRAY

amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan

amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide

aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone,

FEMRING

fenofibrate tablet 120 mg

FENOGLIDE TABLET 120 MG

fenoprofen capsule

FENOPROFEN CAPSULE

FERIVA 21/7

FETZIMA

Fexmid

FINACEA GEL

FIORICET CAPSULE

FLAREX

flucytosine capsule 500 mg

fluocinonide cream 0.1%

fluorouracil cream 0.5%

fluoxetine tablet 60 mg

flurandrenolide lotion (NDC^ 24470092112 only)

flurandrenolide ointment

FML LIQUIFILM

FOLIC-K

Folvite-D

FORTAMET

FORTESTA

FOSAMAX PLUS D

FOSRENOL

FOSTEUM, FOSTEUM PLUS

ziprasidone, LATUDA, VRAYLAR

estradiol, ESTRING, PREMARIN CREAM





folic acid



azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA


dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

fluconazole

clobetasol cream

fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA

citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD




folic acid

folic acid

metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)


alendronate, ibandronate, risedronate

calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO

alendronate, ibandronate, risedronate




FREESTYLE STRIPS AND KITS 13

FROVA

Genicin Vita-S

GLUMETZA

GLYCOPYRROLATE TABLET 1.5 MG

HORIZANT

HUMALOG

HUMALOG MIX 50/50

HUMALOG MIX 75/25

HUMULIN 70/30

HUMULIN N

HUMULIN R

hydrocortisone butyrate lipophilic cream 0.1%

HylaVite

HYSINGLA ER

INDOCIN

Inflammacin

INNOPRAN XL

INTERMEZZO

INTUNIV

INVOKAMET, INVOKAMET XR

INVOKANA

ISTALOL

JALYN

JENTADUETO, JENTADUETO XR



folic acid


dicyclomine

gabapentin, GRALISE

FIASP, NOVOLOG

NOVOLOG MIX 70/30

NOVOLOG MIX 70/30

NOVOLIN 70/30

NOVOLIN N

NOVOLIN R


folic acid

fentanyl transdermal, hydromorphone ext-rel, methadone, morphine ext-rel, NUCYNTA ER, XTAMPZA ER



atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC


amphetamine-dextroamphetamine mixed salts ext-rel †, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE

SYNJARDY, SYNJARDY XR, XIGDUO XR

FARXIGA, JARDIANCE

timolol maleate solution, BETIMOL, BETOPTIC S

dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin

JANUMET, JANUMET XR

KAMDOY

KAZANO

ketoconazole foam 2%

Ketodan

ketoprofen capsule 25 mg

ketoprofen ext-rel capsule

KOMBIGLYZE XR

LACTULOSE PAK

LAMICTAL, LAMICTAL ODT, LAMICTAL XR

LANOXIN TABLET (125 MCG and 250 MCG only)

lanthanum carbonate

LANTUS

LAZANDA

LESCOL XL

levorphanol

LEXAPRO

LIALDA

LIDOCAINE-TETRACAINE CREAM

LIDOTREX

LIPITOR

LIVALO

Lorid

Lorzone

LOTEMAX, LOTEMAX SM

LUNESTA


JANUMET, JANUMET XR

ketoconazole shampoo 2%, selenium sulfide lotion 2.5%

ketoconazole shampoo 2%, selenium sulfide lotion 2.5%



JANUMET, JANUMET XR

lactulose solution

carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

digoxin

calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO

BASAGLAR, LEVEMIR

fentanyl transmucosal lozenge, SUBSYS





lidocaine-prilocaine

lidocaine-prilocaine



folic acid



eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual,




MACRODANTIN

Matzim LA

MENEST

MENOSTAR

metformin ext-rel (generics for FORTAMET and GLUMETZA only)

MIACALCIN INJECTION

MIACALCIN NASAL SPRAY

MICARDIS, MICARDIS HCT

Migergot

MILLIPRED

MINASTRIN 24 FE

MINIVELLE

MINOCIN

minocycline ext-rel tablet

Mondoxyne NL capsule 75 mg

MOVIPREP

mupirocin cream

NAPRELAN

naproxen-esomeprazole

naproxen CR

naproxen suspension

NATAZIA

BELSOMRA, SILENOR

nitrofurantoin


estradiol, PREMARIN

estradiol


alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, TYMLOS

calcitonin-salmon









peg 3350-electrolytes, SUPREP

gentamicin, mupirocin ointment


diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT


ibuprofen

ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE

NATESTO

NESINA

NEXIUM

NICADAN

NICAPRIN

NICAZEL, NICAZEL FORTE

NICOMIDE

NILANDRON

NITROMIST

NORGESIC FORTE

NORITATE

NORVASC

NOVACORT

NOVO NORDISK NEEDLES 12

NuDiclo SoluPak, NuDiclo TabPak

NUVIGIL

Okebo

OLEPTRO

OLUX-E

omeprazole-sodium bicarbonate

OMNARIS

OMNIVEX

ONETOUCH ULTRA STRIPS AND KITS 13

ONETOUCH VERIO STRIPS AND KITS 13

ONFI

ONGLYZA

orphenadrine-aspirin-caffeine

Orphengesic Forte

ORTHO D

ORTHO DF

ORTHO TRI-CYCLEN LO


JANUVIA


folic acid

folic acid

folic acid

folic acid

abiraterone, bicalutamide, XTANDI, YONSA

nitroglycerin lingual spray, nitroglycerin sublingual


azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA

amlodipine


BD ULTRAFINE NEEDLES


armodafinil, SUNOSI


trazodone

clobetasol foam



folic acid



clobazam, lamotrigine, topiramate, TROKENDI XR

JANUVIA



folic acid

folic acid

ethinyl estradiol-norgestimate




OSENI

OSMOPREP

OWEN MUMFORD NEEDLES 12

OXYCONTIN

OXYTROL

PANCREAZE

PENNSAID

PERCOCET

PERRIGO NEEDLES 12

PERTZYE

PEXEVA

PLAVIX

POLYTOZA

posaconazole delayed-rel tablet

PRADAXA

PRECISION XTRA STRIPS AND KITS 13

PRED FORTE

PREFEST

PRENATAL PLUS

PREVACID

PREVIDENT

PRIMLEV

PRISTIQ

PROAIR HFA, PROAIR RESPICLICK

PRODIGEN

PROTONIX

PROTOPIC

PROVENTIL HFA

JANUMET, JANUMET XR; JANUVIA WITH pioglitazone

peg 3350-electrolytes, SUPREP




CREON, VIOKACE, ZENPEP


hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA


CREON, VIOKACE, ZENPEP


clopidogrel, prasugrel, BRILINTA

Consult doctor

fluconazole, itraconazole

warfarin, ELIQUIS, XARELTO



estradiol-norethindrone, PREMPHASE, PREMPRO

generic prenatal vitamins, CITRANATAL


Consult doctor

hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA


albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Consult doctor


pimecrolimus, tacrolimus, EUCRISA

albuterol sulfate CFC-free aerosol,

PROZAC

PSORCON

QNASL

QTERN

RAPAFLO

RAYOS

RECEDO

RELION INSULIN

RHEUMATE

RIBOZEL

RIMSO-50

RIOMET

ROZEREM

RyClora

SCARSILK PAD

SEROQUEL XR

SIL-K PAD

SILIVEX

SILTREX

SINGULAIR

SORILUX

SPRIX

STRIANT

SUBOXONE

sumatriptan-naproxen

SURE-TEST STRIPS AND KITS 13

SYNERDERM

levalbuterol tartrate CFC-free aerosol




GLYXAMBI

alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin


Consult doctor

NOVOLIN INSULIN

folic acid

folic acid

Consult doctor



levocetirizine

Consult doctor

aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR

Consult doctor

Consult doctor

Consult doctor

montelukast, zafirlukast, zileuton ext-rel




buprenorphine-naloxone sublingual, ZUBSOLV

diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY






TALIVA

TARGADOX

TAYTULLA

TESTIM

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

TIMOPTIC OCUDOSE

TIROSINT

TOPROL-XL

TOUJEO

TRADJENTA

tramadol (NDC^ 52817019610 only)

TRANSDERM SCOP

TREXIMET

triamcinolone acetonide aerosol 0.2%

TRICOR

TRIGLIDE

TRILIPIX

TRIVIDIA INSULIN SYRINGES 12

TronVite

TRUETEST STRIPS AND KITS 13

TRUETRACK STRIPS AND KITS 13

TUDORZA

ULTIMED INSULIN SYRINGES 12

ULTIMED NEEDLES 12

folic acid





timolol maleate solution, BETIMOL, BETOPTIC S

levothyroxine, SYNTHROID

atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC

TRESIBA

JANUVIA

tramadol (except NDC^ 52817019610), tramadol ext-rel

meclizine, scopolamine transdermal

diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY






folic acid



INCRUSE ELLIPTA, SPIRIVA, YUPELRI



UROXATRAL

VALCYTE

VALTREX

Vanatol LQ, Vanatol S

Vanoxide-HC

VASCULERA

VECTICAL

VELTIN

venlafaxine ext-rel tablet (except 225 mg)

VENTOLIN HFA

VEREGEN

VITAFOL-ONE

Vitasure

VIVELLE-DOT

VOGELXO

XANAX, XANAX XR

XOLEGEL

XOPENEX HFA

Xvite

XYZBAC

YAZ

ZEGERID

ZETIA

ZETONNA

ZIANA

ZOHYDRO ER

alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

valganciclovir

acyclovir capsule, acyclovir tablet, valacyclovir



Consult doctor





imiquimod

generic prenatal vitamins, CITRANATAL

folic acid



alprazolam, clonazepam, diazepam, lorazepam, oxazepam

ciclopirox, ketoconazole cream 2%


folic acid

folic acid



ezetimibe







ZOLPIMIST eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR ZUPLENZ

suspension)

granisetron, ondansetron, SANCUSO

ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

ZYFLO

ZYLET

ZYVIT

montelukast, zafirlukast, zileuton ext-rel

neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST

folic acid

ZONTIVITY Consult doctor

ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen

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

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay1 information for a specific medicine.

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

§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package

size. † Listing does not include certain NDCs^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the

prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Listing does not include naproxen CR or naproxen suspension. 3 Listing does not include fenofibrate tablet 120 mg. 4 Listing does not include generic CARDIZEM LA. 5 Listing does not include fluoxetine tablet 60 mg. 6 Listing does not include bupropion ext-rel tablet 450 mg. 7 Listing does not include cyclobenzaprine tablet 7.5 mg. 8 Listing does not include the authorized generics for TESTIM and VOGELXO. 9 Listing does not include generics for FORTAMET and GLUMETZA. 10 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on

how to obtain a blood glucose meter, call: 1-877-418-4746. 11 Listing does not include fluocinonide cream 0.1%. 12 BD ULTRAFINE syringes and needles are the only preferred options. 13 ACCU-CHEK brand test strips are the only preferred options.

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

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

©2020. All rights reserved. 106-1063953-1-070120 Caremark.com





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