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

Performance Drug List - Page 27 Performance Drug List Page 26 Page 28