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
Performance Drug List Page 15 Page 17