24 DRUG NAME(S) PREFERRED OPTION(S) SYMBICORT budesonide-formoterol, fluticasone-salmeterol (except certain NDCs), Breyna, Wixela Inhub, BREO ELLIPTA (except certain NDCs) SYNERDERM desonide (except desonide gel), hydrocortisone TALIVA generic multivitamins Targadox doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline tavaborole terbinafine tablet TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol- levonorgestrel, ethinyl estradiol- levonorgestrel-iron, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol- norgestimate, LO LOESTRIN FE, NATAZIA TAZORAC adapalene (except adapalene pad), benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoyl peroxide, tazarotene, tretinoin, AKLIEF, EPIDUO, TWYNEO, WINLEVI; calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE CREAM, ZORYVE FOAM TEGRETOL, TEGRETOL XR carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, eslicarbazepine, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, topiramate ext-rel, valproic acid, zonisamide, BRIVIACT, OXTELLAR XR, XCOPRI TESTIM testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, NATESTO testosterone gel 1% (authorized generics for TESTIM and VOGELXO only) testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone DRUG NAME(S) PREFERRED OPTION(S) solution, NATESTO THEO-24 formoterol inhalation solution, ipratropium inhalation solution, SEREVENT, SPIRIVA, STRIVERDI RESPIMAT, YUPELRI TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S tiotropium bromide SPIRIVA TIROSINT levothyroxine, SYNTHROID TOBRADEX ST neomycin-polymyxin B- bacitracin-hydrocortisone, neomycin-polymyxin B- dexamethasone, tobramycin- dexamethasone, TOBRADEX OINTMENT topiramate ext-rel capsule (generics for QUDEXY XR only) carbamazepine, carbamazepine ext-rel, clobazam, clonazepam, divalproex sodium, divalproex sodium ext-rel, eslicarbazepine, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext- rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, rufinamide, tiagabine, topiramate, topiramate ext-rel, valproic acid, zonisamide, BRIVIACT, OXTELLAR XR, XCOPRI TOPROL-XL acebutolol, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, propranolol ext-rel Tovet clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment TOVIAZ darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GEMTESA TRADJENTA saxagliptin, ZITUVIO tramadol tablet 100 mg, tramadol ext-rel capsule tramadol (except tramadol tablet 100 mg), tramadol ext-rel tablet TRAVATAN Z bimatoprost, latanoprost, travoprost TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH