Performance Drug List

1 January 2026 Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary® The CVS Caremark® Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary® 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 and does not guarantee coverage. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with prescription drug coverage that is administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list the next time you or a covered family member sees a doctor. • Your specific prescription benefit plan design may not cover certain medications, products or categories, regardless of their appearance in this document. Medications and products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered immediately upon release to the market. • Your prescription benefit plan design may alter coverage of certain products or vary cost sharing amounts based on the condition being treated. • You may be responsible for the full cost of medications and products that are removed from coverage. • For specific information regarding your prescription benefit coverage and cost sharing, or if you have additional questions, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu. • When a generic medication that is equivalent to a brand-name drug is released to the market, in most instances, that brand-name drug will be designated as a non-preferred option. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is medically necessary, consider prescribing a brand name on this list. • The member's prescription benefit plan design may alter coverage of certain products or vary cost sharing amounts based on the condition being treated. • This drug list represents a summary of prescription coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered immediately upon release to the market. • The member's prescription benefit plan may have different cost sharing for specific products on the list.

2 • Unless specifically indicated, drug list products will include all dosage forms. • Log in to Caremark.com to check coverage and cost sharing information for a specific medicine. • • ANALGESICS COX-2 INHIBITORS celecoxib GOUT allopurinol colchicine probenecid NSAIDS diclofenac sodium diclofenac sodium gel 1% diclofenac sodium solution 1.5% ibuprofen meloxicam tablet naproxen (except naproxen CR or naproxen suspension) NSAIDS, COMBINATIONS diclofenac sodium-misoprostol ibuprofen-famotidine OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal hydrocodone ext-rel hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel oxycodone oxycodone-acetaminophen tramadol (except tramadol tablet 100 mg) tramadol ext-rel tablet OPIOID PARTIAL AGONISTS buprenorphine transdermal BELBUCA ANTI-INFECTIVES ANTHELMINTICS ivermectin tablet EMVERM ANTIFUNGALS fluconazole itraconazole terbinafine tablet ANTIVIRALS acyclovir capsule, tablet oseltamivir valacyclovir valganciclovir PAXLOVID RELENZA CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin ERYTHROMYCINS/MACROLI DES azithromycin clarithromycin clarithromycin ext-rel erythromycins DIFICID FLUOROQUINOLONES ciprofloxacin levofloxacin moxifloxacin MISCELLANEOUS clindamycin linezolid metronidazole nitrofurantoin (except NDC 16571074024) pyrimethamine sulfamethoxazole- trimethoprim vancomycin capsule XIFAXAN 550 MG PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin vk TETRACYCLINES doxycycline hyclate 20 mg doxycycline hyclate capsule minocycline tetracycline ANTINEOPLASTIC AGENTS ANTIMETABOLITES pemetrexed HORMONAL ANTINEOPLASTIC AGENTS bicalutamide CARDIOVASCULAR ACE INHIBITOR COMBINATIONS fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide ACE INHIBITORS enalapril fosinopril lisinopril quinapril ramipril ALDOSTERONE RECEPTOR ANTAGONISTS spironolactone KERENDIA ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartan- hydrochlorothiazide candesartan- hydrochlorothiazide irbesartan-hydrochlorothiazide losartan-hydrochlorothiazide olmesartan-amlodipine- hydrochlorothiazide olmesartan- hydrochlorothiazide telmisartan- hydrochlorothiazide valsartan-hydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan irbesartan losartan olmesartan telmisartan valsartan ANTIARRHYTHMICS amiodarone disopyramide sotalol MULTAQ ANTILIPEMICS, ACL INHIBITORS/COMBINATION S NEXLETOL NEXLIZET ANTILIPEMICS, BILE ACID RESINS cholestyramine colesevelam ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR ezetimibe ANTILIPEMICS, FIBRATES fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg) fenofibric acid delayed-rel ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS atorvastatin fluvastatin lovastatin pitavastatin pravastatin rosuvastatin simvastatin

3 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATION S ezetimibe-simvastatin ANTILIPEMICS, MISCELLANEOUS niacin ext-rel ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3 acid ethyl esters VASCEPA BETA-BLOCKERS acebutolol atenolol carvedilol carvedilol phosphate ext-rel metoprolol succinate ext-rel metoprolol tartrate nadolol nebivolol pindolol propranolol propranolol ext-rel CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel (except generics for CARDIZEM LA) nifedipine ext-rel verapamil ext-rel DIGITALIS GLYCOSIDES digoxin DIRECT RENIN INHIBITORS/COMBINATION S aliskiren DIURETICS amiloride chlorthalidone ethacrynic acid furosemide hydrochlorothiazide metolazone spironolactone- hydrochlorothiazide torsemide triamterene triamterene- hydrochlorothiazide HEART FAILURE isosorbide dinitrate- hydralazine ivabradine sacubitril-valsartan VERQUVO MISCELLANEOUS midodrine ranolazine ext-rel NITRATES isosorbide dinitrate (except isosorbide dinitrate 40 mg) isosorbide mononitrate nitroglycerin lingual spray nitroglycerin sublingual CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam lorazepam oxazepam ANTIDEMENTIA donepezil galantamine galantamine ext-rel memantine rivastigmine rivastigmine transdermal NAMZARIC ANTIDEPRESSANTS bupropion bupropion ext-rel (except bupropion ext-rel tablet 450 mg) citalopram desvenlafaxine ext-rel duloxetine escitalopram fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]) mirtazapine paroxetine hcl paroxetine hcl ext-rel (except NDC 60505367503) sertraline trazodone venlafaxine venlafaxine ext-rel capsule vilazodone AUVELITY TRINTELLIX ANTIPARKINSONIAN AGENTS amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa- entacapone entacapone pramipexole pramipexole ext-rel rasagiline ropinirole ropinirole ext-rel selegiline CREXONT NEUPRO RYTARY ANTIPSYCHOTICS aripiprazole clozapine lurasidone olanzapine quetiapine quetiapine ext-rel risperidone ziprasidone ABILIFY ASIMTUFII ABILIFY MAINTENA PERSERIS VRAYLAR ANTISEIZURE AGENTS carbamazepine carbamazepine ext-rel clobazam clonazepam diazepam diazepam rectal gel divalproex sodium divalproex sodium ext-rel eslicarbazepine ethosuximide 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 NAYZILAM OXTELLAR XR VALTOCO XCOPRI ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine- dextroamphetamine mixed salts amphetamine- dextroamphetamine mixed salts ext-rel atomoxetine dexmethylphenidate ext-rel guanfacine ext-rel lisdexamfetamine methylphenidate methylphenidate ext-rel AZSTARYS QELBREE HYPNOTICS doxepin eszopiclone ramelteon zolpidem zolpidem ext-rel BELSOMRA QUVIVIQ MIGRAINE - MISCELLANEOUS NURTEC ODT QULIPTA UBRELVY MIGRAINE - MONOCLONAL ANTIBODIES AJOVY EMGALITY MIGRAINE - TRIPTANS AND COMBINATIONS eletriptan naratriptan rizatriptan sumatriptan zolmitriptan TOSYMRA ZEMBRACE SYMTOUCH

4 MUSCULOSKELETAL THERAPY AGENTS cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) LYVISPAH NARCOLEPSY/CATAPLEXY armodafinil modafinil SUNOSI OPIOID AGONIST/ANTAGONIST buprenorphine-naloxone sublingual ZUBSOLV OPIOID ANTAGONIST naloxone POSTHERPETIC NEURALGIA (PHN) pregabalin ext-rel GRALISE ENDOCRINE AND METABOLIC ANDROGENS testosterone gel (except authorized generics for TESTIM and VOGELXO) testosterone solution NATESTO ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN ANTIDIABETICS, BIGUANIDE metformin metformin ext-rel (except generics for FORTAMET and GLUMETZA) ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS glipizide-metformin ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS saxagliptin-metformin ext-rel TRIJARDY XR ZITUVIMET ZITUVIMET XR ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS saxagliptin ZITUVIO ANTIDIABETICS, INCRETIN MIMETIC AGENTS liraglutide MOUNJARO OZEMPIC RYBELSUS TRULICITY ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS SOLIQUA XULTOPHY ANTIDIABETICS, INSULIN FIASP HUMULIN R U-500 INSULIN GLARGINE-YFGN LANTUS NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 TOUJEO TRESIBA ANTIDIABETICS, INSULIN SENSITIZER pioglitazone ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone-metformin ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLURE A COMBINATION pioglitazone-glimepiride ANTIDIABETICS, MEGLITINIDE nateglinide repaglinide ANTIDIABETICS, SODIUM- GLUCOSE COTRANSPORTER-2 (SGLT2) INHIBITOR COMBINATIONS SYNJARDY SYNJARDY XR XIGDUO XR ANTIDIABETICS, SODIUM- GLUCOSE COTRANSPORTER-2 (SGLT2) INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI ANTIDIABETICS, SODIUM- GLUCOSE COTRANSPORTER-2 (SGLT2) INHIBITORS FARXIGA JARDIANCE ANTIDIABETICS, SULFONYLUREA glimepiride glipizide glipizide ext-rel ANTIOBESITY orlistat QSYMIA SAXENDA WEGOVY CALCIUM REGULATORS, BISPHOSPHONATES alendronate ibandronate risedronate CALCIUM REGULATORS, MISCELLANEOUS calcitonin-salmon CARNITINE DEFICIENCY AGENTS levocarnitine CONTRACEPTIVES ethinyl estradiol-drospirenone ethinyl estradiol-drospirenone- levomefolate ethinyl estradiol-etonogestrel ethinyl estradiol-levonorgestrel ethinyl estradiol- levonorgestrel-iron ethinyl estradiol- norelgestromin ethinyl estradiol-norethindrone acetate ethinyl estradiol-norethindrone acetate-iron ethinyl estradiol-norgestimate ANNOVERA LO LOESTRIN FE NATAZIA DIABETIC SUPPLIES ACCU-CHEK AVIVA PLUS STRIPS AND KITS ACCU-CHEK GUIDE STRIPS AND KITS ACCU-CHEK LANCETS / LANCING DEVICES ACCU-CHEK SMARTVIEW STRIPS AND KITS BD ULTRAFINE INSULIN SYRINGES BD ULTRAFINE NEEDLES DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM EMBECTA ULTRAFINE INSULIN SYRINGES (except certain NDCs) EMBECTA ULTRAFINE NEEDLES (except certain NDCs) OMNIPOD 5 INSULIN INFUSION PUMP OMNIPOD DASH INSULIN INFUSION PUMP OMNIPOD INSULIN INFUSION PUMP TRUE METRIX STRIPS AND KITS TWIIST INSULIN INFUSION PUMP AND SUPPLIES ENDOMETRIOSIS ORILISSA GLUCOCORTICOIDS dexamethasone fludrocortisone hydrocortisone methylprednisolone prednisolone solution (except prednisolone solution 10 mg/5 mL, 20 mg/5 mL) prednisone GLUCOSE ELEVATING AGENTS glucagon, human recombinant BAQSIMI GVOKE ZEGALOGUE MENOPAUSAL SYMPTOM AGENTS estradiol estradiol vaginal cream estradiol-norethindrone COMBIPATCH DUAVEE

5 IMVEXXY PREMPHASE PREMPRO VAGIFEM MISCELLANEOUS raloxifene PHOSPHATE BINDER AGENTS calcium acetate sevelamer carbonate AURYXIA POTASSIUM-REMOVING AGENTS VELTASSA PROGESTINS medroxyprogesterone megestrol acetate progesterone, micronized CRINONE THYROID AGENTS levothyroxine liothyronine SYNTHROID UTERINE FIBROIDS MYFEMBREE ORIAHNN GASTROINTESTINAL ANTICHOLINERGICS dicyclomine ANTIDIARRHEALS diphenoxylate-atropine loperamide ANTIEMETICS aprepitant doxylamine-pyridoxine delayed-rel dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine scopolamine transdermal trimethobenzamide SANCUSO H2-RECEPTOR ANTAGONISTS famotidine INFLAMMATORY BOWEL DISEASE balsalazide budesonide delayed-rel capsule hydrocortisone enema mesalamine delayed-rel mesalamine enema mesalamine ext-rel mesalamine suppository sulfasalazine sulfasalazine delayed-rel CORTIFOAM IRRITABLE BOWEL SYNDROME WITH CONSTIPATION lubiprostone LINZESS IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron VIBERZI LAXATIVES lactulose solution peg 3350-electrolytes (except generics for MOVIPREP) sodium sulfate-potassium sulfate-magnesium sulfate CLENPIQ MISCELLANEOUS prucalopride sucralfate tablet MOVANTIK SYMPROIC PANCREATIC ENZYMES CREON VIOKACE ZENPEP PROTON PUMP INHIBITORS esomeprazole delayed-rel lansoprazole delayed-rel capsule omeprazole delayed-rel pantoprazole delayed-rel tablet RECTAL, CORTICOSTEROIDS hydrocortisone PROCTOFOAM-HC ULCER THERAPY COMBINATIONS bismuth-metronidazole- tetracycline TALICIA GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin dutasteride dutasteride-tamsulosin finasteride silodosin tamsulosin terazosin ERECTILE DYSFUNCTION avanafil sildenafil tadalafil URINARY ANTISPASMODICS darifenacin ext-rel fesoterodine ext-rel oxybutynin oxybutynin ext-rel solifenacin tolterodine tolterodine ext-rel trospium trospium ext-rel GEMTESA HEMATOLOGIC ANTICOAGULANTS dabigatran enoxaparin fondaparinux warfarin ELIQUIS XARELTO PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole ext-rel-aspirin prasugrel BRILINTA SICKLE CELL DISEASE SIKLOS IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS GRASTEK ODACTRA RAGWITEK DISEASE-MODIFYING ANTI- RHEUMATIC DRUGS (DMARDS) methotrexate NUTRITIONAL/SUPPLEM ENTS ELECTROLYTES potassium chloride liquid PRENATAL VITAMINS prenatal vitamins VITAMINS folic acid multivitamins OPHTHALMIC ANTI-INFECTIVE/ANTI- INFLAMMATORY neomycin-polymyxin b- bacitracin-hydrocortisone neomycin-polymyxin b- dexamethasone tobramycin-dexamethasone TOBRADEX OINTMENT ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin moxifloxacin ofloxacin sulfacetamide tobramycin trifluridine BESIVANCE XDEMVY ANTI-INFLAMMATORIES bromfenac dexamethasone diclofenac difluprednate ketorolac loteprednol prednisolone acetate 1% ILEVRO ANTIALLERGICS azelastine bepotastine cromolyn sodium loteprednol olopatadine

6 ANTIGLAUCOMA BETA- BLOCKERS timolol maleate solution BETOPTIC S ANTIGLAUCOMA COMBINATION AGENTS brimonidine-timolol dorzolamide-timolol SIMBRINZA CARBONIC ANHYDRASE INHIBITORS brinzolamide dorzolamide DRY EYE DISEASE RESTASIS VEVYE PROSTAGLANDINS bimatoprost latanoprost travoprost SYMPATHOMIMETICS brimonidine solution ALPHAGAN P RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine (except NDCs 00093-XXXX-XX, 49502- XXXX-XX) AUVI-Q ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ipratropium-albuterol inhalation solution ANORO ELLIPTA STIOLTO RESPIMAT ANTICHOLINERGIC/BETA AGONIST/STEROID COMBINATIONS BREZTRI AEROSPHERE TRELEGY ELLIPTA ANTICHOLINERGICS ipratropium inhalation solution SPIRIVA YUPELRI ANTIHISTAMINE COMBINATIONS azelastine-fluticasone ANTIHISTAMINES azelastine levocetirizine olopatadine BETA AGONISTS albuterol inhalation solution albuterol sulfate cfc-free aerosol (except NDCs 00093317431, 66993001968) formoterol inhalation solution levalbuterol tartrate cfc-free aerosol SEREVENT STRIVERDI RESPIMAT COLD/COUGH benzonatate (except NDCs 69336012615, 69499032915) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast MISCELLANEOUS roflumilast NASAL STEROIDS flunisolide fluticasone mometasone XHANCE STEROID INHALANTS budesonide inhalation suspension ASMANEX HFA PULMICORT FLEXHALER STEROID/BETA-AGONIST COMBINATIONS Breyna budesonide-formoterol fluticasone-salmeterol (except certain NDCs) Wixela Inhub AIRSUPRA BREO ELLIPTA (except certain NDCs) TOPICAL DERMATOLOGY, ACNE adapalene (except adapalene pad) benzoyl peroxide clindamycin gel (except NDC 68682046275) clindamycin solution clindamycin-benzoyl peroxide dapsone erythromycin solution erythromycin-benzoyl peroxide isotretinoin capsule 10 mg, 20 mg, 30 mg, 40 mg tazarotene tretinoin AKLIEF EPIDUO TWYNEO WINLEVI DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod DERMATOLOGY, ANTIBIOTICS gentamicin mupirocin ointment DERMATOLOGY, ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole cream 2% naftifine nystatin DERMATOLOGY, ANTIPSORIATICS acitretin calcipotriene ointment, solution methoxsalen tazarotene ENSTILAR VTAMA ZORYVE CREAM ZORYVE FOAM DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2% selenium sulfide lotion 2.5% ZORYVE FOAM DERMATOLOGY, ATOPIC DERMATITIS pimecrolimus tacrolimus EUCRISA OPZELURA VTAMA ZORYVE CREAM DERMATOLOGY, CORTICOSTEROIDS clobetasol cream, foam, gel, lotion, ointment, shampoo (except clobetasol emollient foam) desonide (except desonide gel) desoximetasone (except desoximetasone ointment 0.05%) fluocinonide (except fluocinonide cream 0.1%) halobetasol cream, ointment hydrocortisone hydrocortisone butyrate cream, ointment, solution mometasone triamcinolone cream, lotion, ointment (except triamcinolone ointment 0.05%) BRYHALI DERMATOLOGY, LOCAL ANESTHETICS lidocaine patch lidocaine-prilocaine DERMATOLOGY, ROSACEA azelaic acid gel brimonidine gel ivermectin cream metronidazole FINACEA FOAM ORACEA MOUTH/THROAT/DENTAL AGENTS lidocaine viscous EPISIL OTIC acetic acid ciprofloxacin-dexamethasone neomycin-polymyxin b- hydrocortisone ofloxacin otic

7 QUICK REFERENCE DRUG LIST A ABILIFY ASIMTUFII ABILIFY MAINTENA ACCU-CHEK AVIVA PLUS STRIPS AND KITS ACCU-CHEK GUIDE STRIPS AND KITS ACCU-CHEK LANCETS / LANCING DEVICES ACCU-CHEK SMARTVIEW STRIPS AND KITS acebutolol acetic acid acitretin acyclovir capsule, tablet adapalene (except adapalene pad) AIRSUPRA AJOVY AKLIEF albuterol inhalation solution albuterol sulfate cfc-free aerosol (except NDCs 00093317431, 66993001968) alendronate alfuzosin ext-rel aliskiren allopurinol alosetron ALPHAGAN P alprazolam amantadine amiloride amiodarone 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 ANNOVERA ANORO ELLIPTA aprepitant aripiprazole armodafinil ASMANEX HFA atenolol atomoxetine atorvastatin AURYXIA AUVELITY AUVI-Q avanafil azelaic acid gel azelastine azelastine azelastine-fluticasone azithromycin AZSTARYS B balsalazide BAQSIMI BD ULTRAFINE INSULIN SYRINGES BD ULTRAFINE NEEDLES BELBUCA BELSOMRA benzonatate (except NDCs 69336012615, 69499032915) benzoyl peroxide bepotastine BESIVANCE BETOPTIC S bicalutamide bimatoprost bismuth-metronidazole- tetracycline BREO ELLIPTA (except certain NDCs) Breyna BREZTRI AEROSPHERE BRILINTA brimonidine gel brimonidine solution brimonidine-timolol brinzolamide BRIVIACT bromfenac BRYHALI budesonide delayed-rel capsule budesonide inhalation suspension budesonide-formoterol buprenorphine transdermal buprenorphine-naloxone sublingual bupropion bupropion ext-rel (except bupropion ext-rel tablet 450 mg) 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 cefprozil cefuroxime axetil celecoxib cephalexin chlorthalidone cholestyramine ciclopirox ciprofloxacin ciprofloxacin ciprofloxacin-dexamethasone citalopram clarithromycin clarithromycin ext-rel CLENPIQ clindamycin clindamycin gel (except NDC 68682046275) clindamycin solution clindamycin-benzoyl peroxide clobazam clobetasol cream, foam, gel, lotion, ointment, shampoo (except clobetasol emollient foam) clonazepam clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine colesevelam COMBIPATCH CORTIFOAM CREON CREXONT CRINONE cromolyn sodium cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) D dabigatran dapsone darifenacin ext-rel desonide (except desonide gel) desoximetasone (except desoximetasone ointment 0.05%) desvenlafaxine ext-rel dexamethasone dexamethasone DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM dexmethylphenidate ext-rel diazepam diazepam rectal gel diclofenac diclofenac sodium diclofenac sodium gel 1% diclofenac sodium solution 1.5% diclofenac sodium- misoprostol dicloxacillin dicyclomine DIFICID difluprednate digoxin diltiazem ext-rel (except generics for CARDIZEM LA) diphenoxylate-atropine dipyridamole ext-rel-aspirin disopyramide divalproex sodium divalproex sodium ext-rel donepezil dorzolamide dorzolamide-timolol doxazosin doxepin doxycycline hyclate 20 mg doxycycline hyclate capsule

8 doxylamine-pyridoxine delayed-rel dronabinol DUAVEE duloxetine dutasteride dutasteride-tamsulosin E econazole eletriptan ELIQUIS EMBECTA ULTRAFINE INSULIN SYRINGES (except certain NDCs) EMBECTA ULTRAFINE NEEDLES (except certain NDCs) EMGALITY EMVERM enalapril enoxaparin ENSTILAR entacapone EPIDUO epinephrine (except NDCs 00093-XXXX-XX, 49502- XXXX-XX) EPISIL erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins escitalopram eslicarbazepine esomeprazole delayed-rel estradiol estradiol vaginal cream estradiol-norethindrone eszopiclone ethacrynic acid ethinyl estradiol- drospirenone ethinyl estradiol- drospirenone-levomefolate ethinyl estradiol-etonogestrel ethinyl estradiol- levonorgestrel ethinyl estradiol- levonorgestrel-iron ethinyl estradiol- norelgestromin ethinyl estradiol- norethindrone acetate ethinyl estradiol- norethindrone acetate-iron ethinyl estradiol- norgestimate ethosuximide EUCRISA ezetimibe ezetimibe-simvastatin F famotidine FARXIGA fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg) fenofibric acid delayed-rel fentanyl transdermal fesoterodine ext-rel FIASP FINACEA FOAM finasteride fluconazole fludrocortisone flunisolide fluocinonide (except fluocinonide cream 0.1%) fluorouracil cream 5% fluorouracil solution fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]) fluticasone fluticasone-salmeterol (except certain NDCs) fluvastatin folic acid fondaparinux formoterol inhalation solution fosinopril fosinopril- hydrochlorothiazide furosemide G gabapentin galantamine galantamine ext-rel GEMTESA gentamicin gentamicin glimepiride glipizide glipizide ext-rel glipizide-metformin glucagon, human recombinant GLYXAMBI GRALISE granisetron GRASTEK guanfacine ext-rel GVOKE H halobetasol cream, ointment HUMULIN R U-500 hydrochlorothiazide hydrocodone ext-rel hydrocodone-acetaminophen hydrocortisone hydrocortisone hydrocortisone hydrocortisone butyrate cream, ointment, solution hydrocortisone enema hydromorphone hydromorphone ext-rel I ibandronate ibuprofen ibuprofen-famotidine ILEVRO imiquimod IMVEXXY INSULIN GLARGINE-YFGN ipratropium inhalation solution ipratropium-albuterol inhalation solution irbesartan irbesartan- hydrochlorothiazide isosorbide dinitrate (except isosorbide dinitrate 40 mg) isosorbide dinitrate- hydralazine isosorbide mononitrate isotretinoin capsule 10 mg, 20 mg, 30 mg, 40 mg itraconazole ivabradine ivermectin cream ivermectin tablet J JARDIANCE K KERENDIA ketoconazole cream 2% ketoconazole shampoo 2% ketorolac L lacosamide lactulose solution lamotrigine lamotrigine ext-rel lansoprazole delayed-rel capsule LANTUS latanoprost levalbuterol tartrate cfc-free aerosol levetiracetam levetiracetam ext-rel levocarnitine levocetirizine levofloxacin levofloxacin levothyroxine lidocaine patch lidocaine viscous lidocaine-prilocaine linezolid LINZESS liothyronine liraglutide lisdexamfetamine lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE loperamide lorazepam losartan losartan-hydrochlorothiazide loteprednol loteprednol lovastatin lubiprostone lurasidone LYVISPAH M meclizine medroxyprogesterone megestrol acetate meloxicam tablet memantine mesalamine delayed-rel mesalamine enema mesalamine ext-rel mesalamine suppository metformin metformin ext-rel (except generics for FORTAMET and GLUMETZA) methadone methotrexate methoxsalen methylphenidate methylphenidate ext-rel methylprednisolone

9 metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole metronidazole midodrine minocycline mirtazapine modafinil mometasone mometasone montelukast morphine morphine ext-rel MOUNJARO MOVANTIK moxifloxacin moxifloxacin MULTAQ multivitamins mupirocin ointment MYFEMBREE N nadolol naftifine naloxone NAMZARIC naproxen (except naproxen CR or naproxen suspension) naratriptan NATAZIA nateglinide NATESTO NAYZILAM nebivolol neomycin-polymyxin b- bacitracin-hydrocortisone neomycin-polymyxin b- dexamethasone neomycin-polymyxin b- hydrocortisone NEUPRO NEXLETOL NEXLIZET niacin ext-rel nifedipine ext-rel nitrofurantoin (except NDC 16571074024) nitroglycerin lingual spray nitroglycerin sublingual NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NURTEC ODT nystatin O ODACTRA ofloxacin ofloxacin otic olanzapine olmesartan olmesartan-amlodipine- hydrochlorothiazide olmesartan- hydrochlorothiazide olopatadine olopatadine omega-3 acid ethyl esters omeprazole delayed-rel OMNIPOD 5 INSULIN INFUSION PUMP OMNIPOD DASH INSULIN INFUSION PUMP OMNIPOD INSULIN INFUSION PUMP ondansetron OPZELURA ORACEA ORIAHNN ORILISSA orlistat oseltamivir oxazepam oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OZEMPIC P pantoprazole delayed-rel tablet paroxetine hcl paroxetine hcl ext-rel (except NDC 60505367503) PAXLOVID peg 3350-electrolytes (except generics for MOVIPREP) pemetrexed penicillin vk PERSERIS phenobarbital phenytoin phenytoin sodium extended pimecrolimus pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin pitavastatin potassium chloride liquid pramipexole pramipexole ext-rel prasugrel pravastatin prednisolone acetate 1% prednisolone solution (except prednisolone solution 10 mg/5 mL, 20 mg/5 mL) prednisone pregabalin pregabalin ext-rel PREMPHASE PREMPRO prenatal vitamins primidone probenecid prochlorperazine PROCTOFOAM-HC progesterone, micronized promethazine propranolol propranolol ext-rel prucalopride PULMICORT FLEXHALER pyrimethamine Q QELBREE QSYMIA quetiapine quetiapine ext-rel quinapril quinapril-hydrochlorothiazide QULIPTA QUVIVIQ R RAGWITEK raloxifene ramelteon ramipril ranolazine ext-rel rasagiline RELENZA repaglinide RESTASIS risedronate risperidone rivastigmine rivastigmine transdermal rizatriptan roflumilast ropinirole ropinirole ext-rel rosuvastatin rufinamide RYBELSUS RYTARY S sacubitril-valsartan SANCUSO saxagliptin saxagliptin-metformin ext-rel SAXENDA scopolamine transdermal selegiline selenium sulfide lotion 2.5% SEREVENT sertraline sevelamer carbonate SIKLOS sildenafil silodosin SIMBRINZA simvastatin sodium sulfate-potassium sulfate-magnesium sulfate solifenacin SOLIQUA sotalol SPIRIVA spironolactone spironolactone- hydrochlorothiazide STIOLTO RESPIMAT STRIVERDI RESPIMAT sucralfate tablet sulfacetamide sulfamethoxazole- trimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan SUNOSI SYMLINPEN SYMPROIC SYNJARDY SYNJARDY XR SYNTHROID T tacrolimus tadalafil TALICIA tamsulosin tazarotene telmisartan telmisartan- hydrochlorothiazide terazosin terbinafine tablet

10 testosterone gel (except authorized generics for TESTIM and VOGELXO) testosterone solution tetracycline tiagabine timolol maleate solution TOBRADEX OINTMENT tobramycin tobramycin-dexamethasone tolterodine tolterodine ext-rel topiramate topiramate ext-rel torsemide TOSYMRA TOUJEO tramadol (except tramadol tablet 100 mg) tramadol ext-rel tablet travoprost trazodone TRELEGY ELLIPTA TRESIBA tretinoin triamcinolone cream, lotion, ointment (except triamcinolone ointment 0.05%) triamterene triamterene- hydrochlorothiazide trifluridine TRIJARDY XR trimethobenzamide TRINTELLIX trospium trospium ext-rel TRUE METRIX STRIPS AND KITS TRULICITY TWIIST INSULIN INFUSION PUMP AND SUPPLIES TWYNEO U UBRELVY V VAGIFEM valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothiazide VALTOCO vancomycin capsule VASCEPA VELTASSA venlafaxine venlafaxine ext-rel capsule verapamil ext-rel VERQUVO VEVYE VIBERZI vilazodone VIOKACE VRAYLAR VTAMA W warfarin WEGOVY WINLEVI Wixela Inhub X XARELTO XCOPRI XDEMVY XHANCE XIFAXAN 550 MG XIGDUO XR XULTOPHY Y YUPELRI Z zafirlukast ZEGALOGUE ZEMBRACE SYMTOUCH ZENPEP ziprasidone ZITUVIMET ZITUVIMET XR ZITUVIO zolmitriptan zolpidem zolpidem ext-rel zonisamide ZORYVE CREAM ZORYVE CREAM ZORYVE FOAM ZUBSOLV PREFERRED OPTIONS LIST FOR FORMULARY DRUG REMOVALS AND DRUGS COVERED ONLY WHEN PREFERRED OPTIONS ARE NOT CLINICALLY APPROPRIATE The preferred options listed below are a broad representation of available treatment options and do not necessarily represent clinical equivalency. DRUG NAME(S) PREFERRED OPTION(S) ABILIFY aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR ACANYA 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 ACIPHEX, ACIPHEX SPRINKLE esomeprazole delayed-rel, lansoprazole delayed-rel capsule, DRUG NAME(S) PREFERRED OPTION(S) omeprazole delayed-rel, pantoprazole delayed-rel tablet Activite generic multivitamins ACTOS pioglitazone ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir ACZONE adapalene (except adapalene pad), benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin-benzoyl peroxide, tazarotene, tretinoin,

11 DRUG NAME(S) PREFERRED OPTION(S) AKLIEF, EPIDUO, TWYNEO, WINLEVI adapalene pad 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 ADDERALL amphetamine- dextroamphetamine mixed salts, methylphenidate ADDERALL XR amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS ADRENALIN epinephrine (except NDCs 00093-XXXX-XX, 49502-XXXX- XX), AUVI-Q ADVAIR DISKUS, ADVAIR HFA budesonide-formoterol, fluticasone-salmeterol (except certain NDCs), Breyna, Wixela Inhub, BREO ELLIPTA (except certain NDCs) ADZENYS XR-ODT amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS AIMOVIG AJOVY, EMGALITY, QULIPTA albuterol sulfate CFC-free aerosol (NDCs 00093317431, 66993001968 only) albuterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968), levalbuterol tartrate CFC-free aerosol ALEVICYN GEL, ALEVICYN SG, ALEVICYN SOLUTION desonide (except desonide gel), hydrocortisone ALIMTA pemetrexed ALLISON MEDICAL INSULIN SYRI NGES BD ULTRAFINE INSULIN SYRINGES, EMBECTA ULTRAFINE INSULIN SYRINGES (except certain NDCs) ALREX azelastine, bepotastine, cromolyn sodium, loteprednol, olopatadine ALTOPREV atorvastatin, ezetimibe- simvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin ALVESCO ASMANEX HFA, PULMICORT DRUG NAME(S) PREFERRED OPTION(S) FLEXHALER AMITIZA lubiprostone, prucalopride, LINZESS, MOVANTIK, SYMPROIC AMRIX cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) ANDROGEL testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, NATESTO APIDRA FIASP, NOVOLOG APLENZIN bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) APTENSIO XR amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS ARAZLO 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 ARNUITY ELLIPTA ASMANEX HFA, PULMICORT FLEXHALER ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam tablet or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, or pantoprazole delayed-rel tablet ASCENSIA STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU- CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS ASMANEX ASMANEX HFA, PULMICORT FLEXHALER ATACAND, ATACAND HCT candesartan, candesartan- hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-

12 DRUG NAME(S) PREFERRED OPTION(S) hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam AVENOVA Talk to your doctor AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE AZELEX 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 AZESCO generic prenatal vitamins AZOR amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan BALCOLTRA 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 BANZEL clobazam, clonazepam, lamotrigine, rufinamide, topiramate, topiramate ext-rel BASAGLAR INSULIN GLARGINE-YFGN, LANTUS BENICAR, BENICAR HCT candesartan, candesartan- hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide BENSAL HP desonide (except desonide gel), hydrocortisone benzonatate (NDCs 69336012615, 69499032915 only) benzonatate (except NDCs 69336012615, 69499032915) BEPREVE azelastine, bepotastine, cromolyn sodium, loteprednol, DRUG NAME(S) PREFERRED OPTION(S) olopatadine BETAMETHASONE ACETATE- BETAMETHASONE SODIUM PHOSPHATE dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution (except prednisolone solution 10 mg/5 mL, 20 mg/5 mL), prednisone betamethasone dipropionate ointment 0.05% desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%), BRYHALI BETAPACE, BETAPACE AF sotalol BETIMOL timolol maleate solution, BETOPTIC S BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT BEYAZ 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 BREEZE 2 STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU- CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS BROMSITE bromfenac, diclofenac, ketorolac, ILEVRO budesonide ext-rel tablet balsalazide, mesalamine delayed- rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) butalbital-acetaminophen capsule, butalbital- acetaminophen tablet 25-325 mg, butalbital-acetaminophen tablet 50-300 mg, BUTALBITAL- ACETAMINOPHEN (NDC 69499034230 only) diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) butalbital-acetaminophen- caffeine capsule diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) BUTRANS buprenorphine transdermal, BELBUCA BYDUREON BCISE liraglutide, MOUNJARO,

13 DRUG NAME(S) PREFERRED OPTION(S) OZEMPIC, RYBELSUS, TRULICITY BYETTA liraglutide, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY BYSTOLIC acebutolol, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, propranolol ext-rel calcipotriene cream, CALCIPOTRIENE FOAM calcipotriene ointment, calcipotriene solution, tazarotene, VTAMA, ZORYVE CREAM, ZORYVE FOAM calcipotriene-betamethasone calcipotriene ointment or calcipotriene solution WITH desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%) or BRYHALI; tazarotene, ENSTILAR, VTAMA, ZORYVE CREAM, ZORYVE FOAM calcitriol ointment calcipotriene ointment, calcipotriene solution, tazarotene, VTAMA, ZORYVE CREAM, ZORYVE FOAM CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) Capsinac diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) CARAFATE sucralfate tablet carbinoxamine tablet 6 mg (NDC 73684011060 only), CARBINOXAMINE TABLET 6 MG levocetirizine CARDIZEM, CARDIZEM CD, CARDIZEM LA diltiazem ext-rel (except generics for CARDIZEM LA), verapamil ext- rel carisoprodol 250 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) CARNITOR, CARNITOR SF levocarnitine CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) chlordiazepoxide-clidinium (NDCs 11534019701, 42494040901, 51293069601, 51293069610, 67877073101, 70700018501 only) dicyclomine DRUG NAME(S) PREFERRED OPTION(S) chlorzoxazone 250 mg, chlorzoxazone 375 mg, chlorzoxazone 500 mg (NDC 73007001303 only), chlorzoxazone 750 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) CIALIS avanafil, sildenafil, tadalafil CICATRACE Talk to your doctor CILOXAN ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE CIPRO HC OTIC ciprofloxacin-dexamethasone, ofloxacin otic ciprofloxacin-fluocinolone ciprofloxacin-dexamethasone, ofloxacin otic CITRANATAL generic prenatal vitamins CLIMARA estradiol CLIMARA PRO COMBIPATCH clindamycin gel (NDC 68682046275 only) 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 clobetasol emollient foam clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment clobetasol spray clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment CLOBEX SPRAY clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment clocortolone cream hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment

14 DRUG NAME(S) PREFERRED OPTION(S) 0.05%) COLAZAL balsalazide, mesalamine delayed- rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel COLCRYS colchicine COMBIGAN brimonidine-timolol CONCERTA amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS CONTOUR NEXT STRIPS AND KI TS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU- CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS CONTOUR STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU- CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS CONTRAVE orlistat, QSYMIA, SAXENDA, WEGOVY CORDRAN TAPE clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment COREG CR acebutolol, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, propranolol ext-rel COZAAR candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan CRESEMBA itraconazole CRESTOR atorvastatin, ezetimibe- simvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin cyclobenzaprine ext-rel capsule, cyclobenzaprine tablet 7.5 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule CYTOMEL levothyroxine, liothyronine, SYNTHROID DRUG NAME(S) PREFERRED OPTION(S) DALIRESP roflumilast DARAPRIM pyrimethamine DAYTRANA amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS DAYVIGO doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA, QUVIVIQ DELZICOL balsalazide, mesalamine delayed- rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel DEPAKOTE, DEPAKOTE ER, DEPAKOTE SPRINKLE carbamazepine, carbamazepine ext-rel, clonazepam, divalproex sodium, divalproex sodium ext- rel, eslicarbazepine, ethosuximide, 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 desonide gel desonide (except desonide gel), hydrocortisone desoximetasone ointment 0.05% hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) DETROL LA darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GEMTESA dexchlorpheniramine levocetirizine Dexifol generic multivitamins DEXILANT esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet dexlansoprazole delayed-rel esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel,

15 DRUG NAME(S) PREFERRED OPTION(S) pantoprazole delayed-rel tablet diclofenac potassium capsule 25 mg, diclofenac potassium tablet 25 mg diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) diclofenac potassium powder diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) diclofenac sodium solution 2% diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) Diclofex DC diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) DIFFERIN LOTION 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 diflorasone cream, diflorasone ointment desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%), BRYHALI dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY, ZEMBRACE SYMTOUCH DILANTIN 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 DRUG NAME(S) PREFERRED OPTION(S) extended, pregabalin, primidone, tiagabine, topiramate, topiramate ext-rel, valproic acid, zonisamide, BRIVIACT, OXTELLAR XR, XCOPRI diltiazem ext-rel (generics for CARDIZEM LA only) diltiazem ext-rel (except generics for CARDIZEM LA), verapamil ext- rel DIOVAN, DIOVAN HCT candesartan, candesartan- hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide Diphen Elixir levocetirizine DIVIGEL estradiol DORYX MPC doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline doxepin cream desonide (except desonide gel), hydrocortisone, pimecrolimus, tacrolimus, EUCRISA, OPZELURA, VTAMA, ZORYVE CREAM doxycycline hyclate delayed-rel tablet doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline doxycycline hyclate tablet 50 mg, doxycycline hyclate tablet 75 mg, doxycycline hyclate tablet 150 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline doxycycline monohydrate capsule 75 mg, doxycycline monohydrate capsule 150 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline doxycycline monohydrate delayed-rel capsule ORACEA DULERA budesonide-formoterol, fluticasone-salmeterol (except certain NDCs), Breyna, Wixela Inhub, BREO ELLIPTA (except certain NDCs) DUOBRII tazarotene WITH desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%) or BRYHALI; calcipotriene ointment, calcipotriene solution, ENSTILAR, VTAMA, ZORYVE CREAM, ZORYVE FOAM DYANAVEL XR amphetamine- dextroamphetamine mixed salts

16 DRUG NAME(S) PREFERRED OPTION(S) ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS DYMISTA azelastine-fluticasone, flunisolide, fluticasone, mometasone, XHANCE DYRENIUM amiloride, triamterene EDARBI, EDARBYCLOR candesartan, candesartan- hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA, QUVIVIQ E.E.S. GRANULES erythromycins EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule ELESTRIN estradiol ELIDEL pimecrolimus, tacrolimus, EUCRISA, OPZELURA, VTAMA, ZORYVE CREAM ELMIRON Talk to your doctor ENDOMETRIN CRINONE ENLITE CONTINUOUS GLUCOSE MONITORING SYSTEM DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG EPANED enalapril, fosinopril, lisinopril, quinapril, ramipril EPICERAM desonide (except desonide gel), hydrocortisone epinephrine (NDCs 00093-XXXX- XX, 49502-XXXX-XX only) epinephrine (except NDCs 00093-XXXX-XX, 49502-XXXX- XX), AUVI-Q EPIPEN, EPIPEN JR epinephrine (except NDCs 00093-XXXX-XX, 49502-XXXX- XX), AUVI-Q ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY, ZEMBRACE SYMTOUCH ERYPED erythromycins estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM DRUG NAME(S) PREFERRED OPTION(S) ESTRING estradiol vaginal cream, IMVEXXY, VAGIFEM EVAMIST estradiol EVEKEO amphetamine- dextroamphetamine mixed salts, methylphenidate EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan EXFORGE HCT amlodipine-valsartan- hydrochlorothiazide, olmesartan- amlodipine-hydrochlorothiazide FABIOR 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 FANAPT aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR FEMRING estradiol vaginal cream, IMVEXXY, VAGIFEM fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed- rel fenoprofen diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) FERIVA 21/7 generic multivitamins Fexmid cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension) FLAREX dexamethasone, difluprednate, loteprednol, prednisolone acetate 1% FLORIVA, FLORIVA PLUS generic multivitamins FLOVENT HFA ASMANEX HFA, PULMICORT FLEXHALER

17 DRUG NAME(S) PREFERRED OPTION(S) flucytosine capsule 500 mg fluconazole fluocinonide cream 0.1% clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod fluoxetine tablet (generics for SARAFEM only) fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl ext-rel (except NDC 60505367503), sertraline fluoxetine tablet 60 mg, FLUOXETINE 60 MG citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC 60505367503), sertraline, vilazodone, AUVELITY, TRINTELLIX flurandrenolide cream, flurandrenolide lotion desonide (except desonide gel), hydrocortisone flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) FML FORTE, FML LIQUIFILM dexamethasone, difluprednate, loteprednol, prednisolone acetate 1% FOCALIN XR amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS FORTAMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) FOSRENOL calcium acetate, sevelamer carbonate, AURYXIA FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING SYSTEM DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM FREESTYLE STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE DRUG NAME(S) PREFERRED OPTION(S) STRIPS AND KITS, ACCU- CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS GLUMETZA metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) GLYCOPYRROLATE TABLET 1.5 MG dicyclomine GOLYTELY peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate- magnesium sulfate, CLENPIQ GUARDIAN CONNECT CONTINUOUS GLUCOSE MONITORING SYSTEM DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM GUARDIAN REAL-TIME CONTINUOUS GLUCOSE MONITORING SYSTEM DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM halcinonide cream desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%), BRYHALI HALOG desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except fluocinonide cream 0.1%), BRYHALI HEPARIN SODIUM IN 5% DEXTROSE enoxaparin, fondaparinux HORIZANT gabapentin, pregabalin, pregabalin ext-rel, GRALISE HUMALOG FIASP, NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN 70/30 NOVOLIN 70/30 HUMULIN N NOVOLIN N HUMULIN R NOVOLIN R hydrocortisone butyrate lotion hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) HylaVite generic multivitamins hyoscyamine sulfate ext-rel dicyclomine HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel,

18 DRUG NAME(S) PREFERRED OPTION(S) hydromorphone ext-rel, methadone, morphine ext-rel HYZAAR candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide Iclofenac CP diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) icosapent ethyl omega-3 acid ethyl esters, VASCEPA INCRUSE ELLIPTA SPIRIVA INDERAL LA, INDERAL XL acebutolol, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, propranolol ext-rel Indocin, INDOCIN diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) Inflammacin diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) INNOPRAN XL acebutolol, atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, propranolol ext-rel INTRAROSA estradiol vaginal cream, IMVEXXY, VAGIFEM INTUNIV amphetamine- dextroamphetamine mixed salts ext-rel, atomoxetine, dexmethylphenidate ext-rel, guanfacine ext-rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS, QELBREE INVELTYS dexamethasone, difluprednate, loteprednol, prednisolone acetate 1% INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR DRUG NAME(S) PREFERRED OPTION(S) INVOKANA FARXIGA, JARDIANCE isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate isotretinoin capsule 25 mg, 35 mg isotretinoin capsule 10 mg, 20 mg, 30 mg, 40 mg JANUMET, JANUMET XR saxagliptin-metformin ext-rel, ZITUVIMET, ZITUVIMET XR JANUVIA saxagliptin, ZITUVIO JATENZO testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, NATESTO JENTADUETO, JENTADUETO XR saxagliptin-metformin ext-rel, ZITUVIMET, ZITUVIMET XR JORNAY PM amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS KAMDOY desonide (except desonide gel), hydrocortisone Kapzin DC diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) KEPPRA, KEPPRA 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 KETO-DIASTIX Talk to your doctor ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5%, ZORYVE FOAM Ketodan ketoconazole shampoo 2%, selenium sulfide lotion 2.5%, ZORYVE FOAM ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)

19 DRUG NAME(S) PREFERRED OPTION(S) ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) KETOSTIX Talk to your doctor lactulose pak (NDCs 69067001015, 69067002015 only) lactulose solution LAMICTAL, LAMICTAL ODT 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 LAMICTAL 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 LANOXIN TABLET (125 MCG and 250 MCG only) digoxin lansoprazole delayed-rel orally disintegrating tablet esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet lanthanum carbonate calcium acetate, sevelamer carbonate, AURYXIA LATUDA aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR LESCOL XL atorvastatin, ezetimibe- simvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin LEVEMIR INSULIN GLARGINE-YFGN, LANTUS DRUG NAME(S) PREFERRED OPTION(S) levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel LEXAPRO citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC 60505367503), sertraline, vilazodone, AUVELITY, TRINTELLIX LIALDA balsalazide, mesalamine delayed- rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel LIBRAX dicyclomine LIPITOR atorvastatin, ezetimibe- simvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin LITHOSTAT Talk to your doctor LIVALO atorvastatin, ezetimibe- simvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin Lofena diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) LOKELMA VELTASSA Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) LOTEMAX, LOTEMAX SM dexamethasone, difluprednate, loteprednol, prednisolone acetate 1% LOVAZA omega-3 acid ethyl esters, VASCEPA luliconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, naftifine LUMIGAN bimatoprost, latanoprost, travoprost LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA, QUVIVIQ LYRICA duloxetine, pregabalin, pregabalin ext-rel MACRODANTIN nitrofurantoin (except NDC 16571074024) Matzim LA diltiazem ext-rel (except generics for CARDIZEM LA), verapamil ext-

20 DRUG NAME(S) PREFERRED OPTION(S) rel MAXALT, MAXALT-MLT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY, ZEMBRACE SYMTOUCH MAXIDEX dexamethasone, difluprednate, loteprednol, prednisolone acetate 1% mefenamic acid (NDC 69336012830 only) diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) meloxicam capsule diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) MENEST estradiol MENOSTAR estradiol metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) metformin ext-rel (generics for FORTAMET and GLUMETZA only) metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) methocarbamol 500 mg (NDC 69036091010 only), methocarbamol 750 mg (NDCs 69036093090, 70868090190 only) cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, teriparatide, PROLIA, TYMLOS MICARDIS, MICARDIS HCT candesartan, candesartan- hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY, ZEMBRACE SYMTOUCH MINIVELLE estradiol minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline MIRVASO azelaic acid gel, brimonidine gel, ivermectin cream, metronidazole, FINACEA FOAM DRUG NAME(S) PREFERRED OPTION(S) MITIGARE colchicine Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline MOVIPREP peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate- magnesium sulfate, CLENPIQ MultiPro generic multivitamins mupirocin cream gentamicin, mupirocin ointment MYDAYIS amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS MYRBETRIQ darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GEMTESA MYTESI diphenoxylate-atropine, loperamide NAPRELAN diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) naproxen CR diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) naproxen suspension diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam tablet or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, or pantoprazole delayed-rel tablet NEO-SYNALAR desonide (except desonide gel) or hydrocortisone WITH gentamicin NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet NEXTERONE amiodarone niacin tablet 500 mg niacin ext-rel

21 DRUG NAME(S) PREFERRED OPTION(S) Niacor niacin ext-rel NICADAN generic multivitamins NICAPRIN generic multivitamins NICAZEL, NICAZEL FORTE generic multivitamins NICOMIDE generic multivitamins NILANDRON abiraterone, bicalutamide, ERLEADA, NUBEQA, XTANDI, YONSA nitrofurantoin (NDC 16571074024 only) nitrofurantoin (except NDC 16571074024) Norgesic Forte cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) NORITATE azelaic acid gel, brimonidine gel, ivermectin cream, metronidazole, FINACEA FOAM NORPACE disopyramide NORVASC amlodipine, nifedipine ext-rel NOURIANZ entacapone, pramipexole, pramipexole ext-rel, rasagiline, ropinirole, ropinirole ext-rel, selegiline, NEUPRO NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES, EMBECTA ULTRAFINE NEEDLES (except certain NDCs) NOXAFIL fluconazole, itraconazole NUCYNTA hydromorphone, morphine, oxycodone NUCYNTA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) NUEDEXTA Talk to your doctor NUVARING ethinyl estradiol-etonogestrel, ANNOVERA NUVIGIL armodafinil, modafinil, SUNOSI omeprazole-sodium bicarbonate esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet OMNARIS azelastine-fluticasone, flunisolide, fluticasone, mometasone, XHANCE ONETOUCH LANCETS / LANCING DEVICES ACCU-CHEK LANCETS / LANCING DEVICES ONETOUCH ULTRA STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS DRUG NAME(S) PREFERRED OPTION(S) KITS, ONETOUCH VERIO STRIPS AND KITS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU-CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS ONFI clobazam, clonazepam, lamotrigine, rufinamide, topiramate, topiramate ext-rel ONGLYZA saxagliptin, ZITUVIO ONZETRA XSAIL eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY, ZEMBRACE SYMTOUCH orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg) ORTHO D folic acid, generic multivitamins ORTHO DF folic acid, generic multivitamins OSMOPREP peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate- magnesium sulfate, CLENPIQ OSPHENA estradiol OWEN MUMFORD NEEDLES BD ULTRAFINE NEEDLES, EMBECTA ULTRAFINE NEEDLES (except certain NDCs) oxiconazole (NDCs 00168035830, 51672135902 only) ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, naftifine OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel OXYTROL darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GEMTESA pantoprazole delayed-rel suspension esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet paroxetine HCl ext-rel (NDC 60505367503 only) citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC

22 DRUG NAME(S) PREFERRED OPTION(S) 60505367503), sertraline, vilazodone, AUVELITY, TRINTELLIX paroxetine mesylate capsule 7.5 mg paroxetine HCl PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC 60505367503), sertraline, vilazodone, AUVELITY, TRINTELLIX peg 3350-electrolytes (generics for MOVIPREP only) peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate- magnesium sulfate, CLENPIQ PENNSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) PENTASA balsalazide, mesalamine delayed- rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel PERCOCET hydrocodone-acetaminophen, oxycodone-acetaminophen PERRIGO NEEDLES BD ULTRAFINE NEEDLES, EMBECTA ULTRAFINE NEEDLES (except certain NDCs) PLAVIX clopidogrel, prasugrel, BRILINTA POLYTOZA Talk to your doctor POLY-VI-FLOR generic multivitamins POLY-VI-FLOR WITH IRON generic multivitamins posaconazole delayed-rel tablet fluconazole, itraconazole PRADAXA dabigatran, warfarin, ELIQUIS, XARELTO PRECISION XTRA STRIPS AND KI TS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU- CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS PRED FORTE, PRED MILD dexamethasone, difluprednate, loteprednol, prednisolone acetate 1% prednisolone solution 10 mg/5 mL, prednisolone solution 20 mg/5 mL dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution (except prednisolone solution 10 mg/5 DRUG NAME(S) PREFERRED OPTION(S) mL, 20 mg/5 mL), prednisone PREMARIN estradiol PREMARIN CREAM estradiol vaginal cream, IMVEXXY, VAGIFEM PRENATAL PLUS generic prenatal vitamins PREVACID esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet PREVIDENT Talk to your doctor PRILOSEC esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule PROAIR RESPICLICK albuterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968), levalbuterol tartrate CFC-free aerosol PROMETRIUM medroxyprogesterone; progesterone, micronized PROTONIX esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, pantoprazole delayed-rel tablet PROVIGIL armodafinil, modafinil, SUNOSI PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC 60505367503), sertraline, vilazodone, AUVELITY, TRINTELLIX QNASL azelastine-fluticasone, flunisolide, fluticasone, mometasone, XHANCE QTERN GLYXAMBI quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA, QUVIVIQ QUILLICHEW ER amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS QUILLIVANT XR amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-

23 DRUG NAME(S) PREFERRED OPTION(S) rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS QVAR REDIHALER ASMANEX HFA, PULMICORT FLEXHALER RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin RAYOS dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution (except prednisolone solution 10 mg/5 mL, 20 mg/5 mL), prednisone RECEDO Talk to your doctor RELION INSULIN NOVOLIN INSULIN RELISTOR lubiprostone, MOVANTIK, SYMPROIC RENVELA calcium acetate, sevelamer carbonate, AURYXIA RETIN-A MICRO 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 REZDIFFRA Talk to your doctor RHEUMATE generic multivitamins RHOFADE azelaic acid gel, brimonidine gel, ivermectin cream, metronidazole, FINACEA FOAM RHOPRESSA bimatoprost, brimonidine solution, brimonidine-timolol, brinzolamide, dorzolamide, dorzolamide-timolol, latanoprost, timolol maleate solution, travoprost, ALPHAGAN P, BETOPTIC S, SIMBRINZA RIMSO-50 Talk to your doctor RIOMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA) ROCKLATAN bimatoprost, brimonidine solution, brimonidine-timolol, brinzolamide, dorzolamide, dorzolamide-timolol, latanoprost, timolol maleate solution, travoprost, ALPHAGAN P, BETOPTIC S, SIMBRINZA ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, DRUG NAME(S) PREFERRED OPTION(S) BELSOMRA, QUVIVIQ RyClora levocetirizine SCARSILK PAD Talk to your doctor SEROQUEL XR aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR SILENOR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA, QUVIVIQ SILIVEX Talk to your doctor SILTREX Talk to your doctor SINGULAIR montelukast, zafirlukast SOOLANTRA azelaic acid gel, brimonidine gel, ivermectin cream, metronidazole, FINACEA FOAM SORILUX calcipotriene ointment, calcipotriene solution, tazarotene, VTAMA, ZORYVE CREAM, ZORYVE FOAM SPRIX diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) STENDRA avanafil, sildenafil, tadalafil SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV sucralfate suspension sucralfate tablet sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY, or ZEMBRACE SYMTOUCH SUPREP peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate- magnesium sulfate, CLENPIQ Sure Result DSS Premium Pack diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) SURE-TEST STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU-CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS

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

25 DRUG NAME(S) PREFERRED OPTION(S) eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY or ZEMBRACE SYMTOUCH triamcinolone aerosol 0.2% hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) triamcinolone ointment 0.05% hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%) TRICOR fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed- rel TRILEPTAL 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 TRI-VI-FLOR generic multivitamins TRIVIDIA INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES, EMBECTA ULTRAFINE INSULIN SYRINGES (except certain NDCs) TronVite generic multivitamins TRUDHESA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, TOSYMRA, UBRELVY, ZEMBRACE SYMTOUCH TRUETEST STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU-CHEK SMARTVIEW STRIPS AND KITS, DRUG NAME(S) PREFERRED OPTION(S) TRUE METRIX STRIPS AND KITS TRUETRACK STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-CHEK GUIDE STRIPS AND KITS, ACCU-CHEK SMARTVIEW STRIPS AND KITS, TRUE METRIX STRIPS AND KITS TUDORZA SPIRIVA ULORIC allopurinol ULTIMED INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES, EMBECTA ULTRAFINE INSULIN SYRINGES (except certain NDCs) ULTIMED NEEDLES BD ULTRAFINE NEEDLES, EMBECTA ULTRAFINE NEEDLES (except certain NDCs) ULTRAVATE clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment umeclidinium-vilanterol ANORO ELLIPTA, STIOLTO RESPIMAT UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin V-GO INSULIN INFUSION PUMP OMNIPOD 5 INSULIN INFUSION PUMP, OMNIPOD DASH INSULIN INFUSION PUMP, OMNIPOD INSULIN INFUSION PUMP, TWIIST INSULIN INFUSION PUMP AND SUPPLIES VALCYTE valganciclovir VALTREX acyclovir capsule, acyclovir tablet, valacyclovir Vanoxide-HC 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 VASCULERA Talk to your doctor VECTICAL calcipotriene ointment, calcipotriene solution, tazarotene, VTAMA, ZORYVE CREAM, ZORYVE FOAM VELPHORO calcium acetate, sevelamer carbonate, AURYXIA venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine,

26 DRUG NAME(S) PREFERRED OPTION(S) venlafaxine ext-rel capsule VENTOLIN HFA albuterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968), levalbuterol tartrate CFC-free aerosol VEREGEN imiquimod VIAGRA avanafil, sildenafil, tadalafil VICTOZA liraglutide, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY VIIBRYD citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC 60505367503), sertraline, vilazodone, AUVELITY, TRINTELLIX VIMPAT 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 VITAFOL-ONE generic prenatal vitamins Vitasure generic multivitamins VIVELLE-DOT estradiol VOGELXO testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, NATESTO VYVANSE amphetamine- dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext- rel, lisdexamfetamine, methylphenidate ext-rel, AZSTARYS VYZULTA bimatoprost, latanoprost, travoprost WELLBUTRIN XL bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg) XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam XENICAL orlistat, QSYMIA, SAXENDA, DRUG NAME(S) PREFERRED OPTION(S) WEGOVY XERESE acyclovir capsule, acyclovir tablet, valacyclovir XIIDRA RESTASIS, VEVYE XOPENEX HFA albuterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968), levalbuterol tartrate CFC-free aerosol XTAMPZA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel XYOSTED testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, NATESTO XYZBAC generic multivitamins YASMIN 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 YAZ 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 Yuvafem estradiol vaginal cream, IMVEXXY, VAGIFEM ZALVIT generic prenatal vitamins ZELAC Talk to your doctor ZEPBOUND orlistat, QSYMIA, SAXENDA, WEGOVY ZERVIATE azelastine, bepotastine, cromolyn sodium, loteprednol, olopatadine ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide, quinapril-hydrochlorothiazide ZETIA ezetimibe ZIANA adapalene (except adapalene pad), benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin

27 DRUG NAME(S) PREFERRED OPTION(S) solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoyl peroxide, tazarotene, tretinoin, AKLIEF, EPIDUO, TWYNEO, WINLEVI Ziclopro diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension) zileuton ext-rel montelukast, zafirlukast ZIRGAN trifluridine ZOLOFT citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC 60505367503), sertraline, vilazodone, AUVELITY, TRINTELLIX DRUG NAME(S) PREFERRED OPTION(S) zolpidem sublingual doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA, QUVIVIQ ZONEGRAN 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 ZONTIVITY Talk to your doctor ZYLET neomycin-polymyxin B- bacitracin-hydrocortisone, neomycin-polymyxin B- dexamethasone, tobramycin- dexamethasone, TOBRADEX OINTMENT

28 FOR YOUR INFORMATION: 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. 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. Formulary removals/drugs not included on the preferred options list may be covered by the plan when preferred options are not clinically appropriate. For more information, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. Some listings do not include certain NDCs as noted above. An ACCU-CHEK or TRUE METRIX blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or TRUE METRIX. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. BD ULTRAFINE or EMBECTA ULTRAFINE (except certain NDCs) syringes and needles are the only preferred options. ACCU-CHEK or TRUE METRIX (Trividia manufactured NDCs) brand test strips are the only preferred options. ACCU-CHEK lancets and lancing devices are the only preferred options. Generic multivitamins (except Activite, Dexifol, HylaVite, Multipro, TronVite, Vitasure) are the only preferred options. Generic prenatal vitamins are the only preferred options. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2025 CVS Health and/or one of its affiliates. All rights reserved. 106-31697B 010126