January 2025
•CVScaremark·
Advanced Control Formulary ®

The CVS Caremark• Advanced Control 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 listedin therapeutic categories are for representational purposes only. Thisis 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.
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
ce/ecoxib
GOUT
allopurinol colchicine tablet probenecid MITIGARE
NSAIDS
diclofenac sodium 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 fentanyl transmucosal hydrocodone ext-rel
hydrocodone-acetaminophen hydromorphone
methadone morphine morphine ext-rel oxycodone oxycodone ext-rel
oxycodone-acetaminophen tramadol (except tramadol tablet 100 mgl tramadol ext-rel tablet
OPIOID PARTIAL AGONISTS
buprenorphine transdermal
BELBUCA
VISCOSUPPLEMENTS
DUROLANE EUFLEXXA GELSYN-3 SUPARTZFX

ANTI-INFECTIVES

ANTHELMINTICS
ivermectin tablet
EMVERM
ANTIFUNGALS
fluconazole itraconazole terbinafine tablet
ANTIRETROVIRAL AGENTS
abacavir atazanavir darunavir efavirenz emtricitabine etravirine lamivudine maraviroc nevirapine nevirapine ext-rel ritonavir
tenofovir disoproxil fumarate zidovudine
APRETUDE ISENTRESS TIVICAY
ANTIRETROVIRAL COMBINATION AGENTS
abacavir-lamivudine efavirenz-emtricitabine-
tenofovir disoproxil fumarate efavirenz-lamivudine-tenofovir
disoproxil fumarate emtricitabine-tenofovir
disoproxil fumarate lamivudine-zidovudine lopinavir-ritonavir BIKTARVY
CABENUVA
CIMDUO DESCOVY DOVATO
GENVOYA
ODEFSEY SYMTUZA TRIUMEQ
ANTITUBERCULAR AGENTS
ethambutol isoniazid pyrazinamide

rifampin
ANTIVIRALS
acyclovir 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
HEPATITIS B
entecavir lamivudine
tenofovir disoproxil fumarate
VEMLIDY
HEPATITISC
ribavirin
EPCLUSA (genotypes 1, 2, 3. 4, 5, 6l
HARVONI (genotypes 1. 4, 5, 6l
VOSEVI
MISCELLANEOUS
clindamycin linezolid metronidazole
nitrofurantoin (except NOC
16571074024)
pyrimethamine sulfamethoxazole-
trimethoprim vancomycin capsule MEPRON
XIFAXAN 550 MG

PENICILLINS
amoxicillin
amoxicillin-clavulanate dicloxacillin
penicillin vk
TETRACYCLINES
doxycycline hyclate capsule doxycycline hyclate tablet
(except doxycycllne hyclate tablet 50 mg, 75 mg, 150 mg)
minocycline
tetracycline

ANTINEOPLASTIC AGENTS

ALKYLATING AGENTS
cyclophosphamide melphalan temozolomide
ANTIMETABOLITES
capecitabine mercaptopurine pemetrexed LONSURF
BIOLOGIC RESPONSE MODIFIERS
BESREMI ERIVEDGE REVLIMID THALOMID
BIOSIMILARS
KANJINTI RUXIENCE TRAZIMERA ZIRABEV
HORMONAL ANTINEOPLASTIC AGENTS
abiraterone anastrozole bicalutamide exemestane fulvestrant letrozole leuprolide acetate megestrol acetate tamoxifen

toremifene ELIGARD ERLEADA NUBEQA XTANDI YONSA
KINASE INHIBITORS
erlotinib everolimus gefitinib
imatinib mesylate lapatinib pazopanib sorafenib sunitinib
ALECENSA ALUNBRIG AUGTYRO BOSULIF BRAFTOVI BRUKINSA CABOMETYX CALQUENCE COPIKTRA COTELLIC GAVRETO IBRANCE INLYTA KISQALI
KISQALI FEMARA CO-PACK
KOSELUGO LENVIMA MEKTOVI RETEVMO ROZLYTREK RYDAPT SPRYCEL STIVARGA TAGRISSO VITRAKVI XOSPATA ZELBORAF ZYDELIG ZYKADIA
MISCELLANEOUS
bexarotene hydroxyurea tretinoin capsule KRAZATI LUMAKRAS LYNPARZA
ODOMZO VISTOGARD ZEJULA
MONOCLONAL ANTIBODIES
PERJETA

PHESGO
PROTEASOME INHIBITORS
bortezomib
NINLARO
TOPOISOMERASE INHIBITORS
etoposide

CARDIOVASCULAR

ACE INHIBITOR COMBINATIONS
fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide
ACE INHIBITORS
enalapril fosinopril lisinopril quinapril ramipril
ALDOSTERONERECEPTOR ANTAGONISTS
eplerenone 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 tenofibrate capsule 30 mg, somg, 90 mg, 130 mg; fenolibrate
tablet 40 mg, 120 mg)
fenofibric acid delayed-rel
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS
atorvastatin f/uvastatin lovastatin pitavastatin pravastatin rosuvastatin simvastatin
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATION
s
ezetimibe-simvastatin
ANTILIPEMICS, MISCELLANEOUS
niacin ext-rel
ANTILIPEMICS, OMEGA-3 FATTY ACIDS
icosapent ethyl
omega-3 acid ethyl esters
ANTILIPEMICS, PCSK9 INHIBITORS
REPATHA
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol-chlorthalidone

bisoprolol-hydrochlorothiazide metoprolol-
hydrochlorothiazide
BETA-BLOCKERS
acebutolol atenolol carvedilol
carvedilol phosphate ext-rel metoprolol succinate ext-rel metoprolol tartrate
nadolol nebivolol propranolol
propranolol ext-rel
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine-atorvastatin
CALCIUM CHANNEL BLOCKERS
amlodipine
diltiazem ext-rel (except generics tor
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
CORLANOR ENTRESTO VERQUVO
MISCELLANEOUS
clonidine

clonidine transdermal guanfacine midodrine
ranolazine ext-rel

bupropion ext-rel (except bupropion	ABILIFY ASIMTUFII	BOTULINUM TOXINS
ext--n,itablet 450 mg)	ABILIFY MAINTENA	DAXXIFY
citalopram	PERSERIS	XEOMIN
desipramine	VRAYLAR

NITRATES

desvenlafaxine ext-rel doxepin

ANTISEIZURE AGENTS

HYPNOTICS
doxepin

isosorbide dinitrate (except
isosorbide dinltrate 40 mg)
isosorbide mononitrate nitroglycerin lingual spray nitroglycerin sublingual
PULMONARY ARTERIAL HYPERTENSION
ambrisentan bosentan sildenafil

duloxetine	carbamazepine	ramelteon
escitalopram	 carbamazepine ext-rel	 temazepam fluoxetine (except fluoxetine tablet 60	clobazam	zolpidem
mg, fluoxetine tab4et [generics lo.-	clonazepam	zolpidem ext-rel
SARAFEMJ)	diazepam
imipramine hcl	diazepam rectal gel	MIGRAINE-
mirtazapine	divalproex sodium	MISCELLANEOUS
nortriptyline	divalproex sodium ext-rel	NURTECODT
paroxetine hcl	ethosuximide	QULIPTA
paroxetine he/ ext-rel (except NOC	gabapentin	UBRELVY
lacosamide

tadalafil treprostinil

60505367503)
sertraline

lamotrigine lamotrigine ext-rel

MIGRAINE - MONOCLONAL
ANTIBODIES

ADEMPAS OPSUMIT
OPSYNVI

trazodone
venlafaxine
venlafaxine ext-rel capsule

levetiracetam	AJOVY
levetiracetam ext-rel	EMGALITY
oxcarbazepine

ORENITRAM TADLIQ TYVASO

vilazodone TRINTELLIX ZURZUVAE

phenobarbital phenytoin
phenytoin sodium extended

MIGRAINE - TRIPTANS AND COMBINATIONS
eletriptan

TYVASODPI UPTRAVI

ANTIPARKINSONIAN	pregabalin	naratriptan
AGENTS	primidone	rizatriptan
amantadine	rufinamide	sumatriptan

CENTRAL NERVOUS
I
SYSTEM

ALCOHOL DETERRENTS
acamprosate calcium
disulfiram
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
RADICAVA ORS
ANTIANXIETY
alprazolam buspirone clomipramine fluvoxamine lorazepam oxazepam

carbidopa-/evodopa	tiagabine	zolmitriptan
carbidopa-levodopa ext-rel	topiramate	MISCELLANEOUS
carbidopa-/evodopa-	topiramate ext-rel	ENSPRYNG
entacapone	valproic acid	VYVGART
entacapone	vigabatrin	VYVGART HYTRULO
pramipexole	zonisamide
pramipexole ext-rel	APTIOM	MOOD STABILIZERS
rasagiline	BRIVIACT	lithium carbonate
ropinirole	FYCOMPA	lithium carbonate ext-rel tablet
ropinirole ext-rel	NAYZILAM	300mg
selegiline	OXTELLARXR	lithium carbonate ext-rel tablet
INBRIJA	VALTOCO	450mg
NEUPRO	XCOPRI
RYTARY	MOVEMENT DISORDERS
ATTENTION DEFICIT	tetrabenazine
ANTIPSYCHOTICS	HYPERACTIVITY DISORDER	AUSTEDO
aripiprazole	amphetamine-	AUSTEDOXR
asenapine	dextroamphetaminemixed	INGREZZA

ANTIDEMENTIA
donepezil galantamine galantamine ext-rel memantine rivastigmine
rivastigmine transdermal
NAMZARIC
ANTIDEPRESSANTS
amitriptyline bupropion

chlorpromazine	salts ext-rel

fluphenazine haloperidol	dexmethylphenidate dexmethylphenidateext-rel	AGENTS
dimethyl fumarate delayed-rel	
lurasidone	dextroamphetamine	fingolimod	
olanzapine	dextroamphetamine ext-rel	glatiramer	
perphenazine	guanfacine ext-rel	teriflunomide	
quetiapine	lisdexamfetamine	AVONEX	
quetiapine ext-rel	methylphenidate	BAFIERTAM	
risperidone	methylphenidateext-rel	BETASERON	
thiothixene	AZSTARYS	COPAXONE 40 MG/ML	
trifluoperazine ziprasidone	QELBREE	KESIMPTA
MAYZENT	

clozapine	atomoxetine

MULTIPLE SCLEROSIS

OCREVUS REBIF TYSABRI VUMERITY ZEPOSIA
MUSCULOSKELETAL THERAPY AGENTS

ANTIDIABETICS, ALPHA-	 ANTIDIABETICS, INSULIN	CALCIUM RECEPTOR GLUCOSIDASE INHIBITORS	SENSITIZER	 AGONISTS
acarbose	pioglitazone	cinacalcet
ANTIDIABETICS, AMYLIN	 ANTIDIABETICS, INSULIN	 CALCIUM REGULATORS, ANALOGS	SENSITIZER/BIGUANIDE	BISPHOSPHONATES
SYMLINPEN	COMBINATION	alendronate pioglitazone-metformin	 ibandronate

baclofen
carisoprodol 350 mg

ANTIDIABETICS, BIGUANIDE
metformin	ANTIDIABETICS, INSULIN

risedronate

chlorzoxazone 500 mg (except NOC 73007001303)
cyclobenzaprine(except cyclobenzaprine tablet 7.5 mg)
dantrolene
metaxalone 800 mg methocarbamol (except NDCs
69036091010, 69036093090,
70868090190)
tizanidine
LYVISPAH
MYASTHENIA GRAVIS
pyridostigmine

metformin ext-rel (except generics	SENSITIZER/SULFONYLURE	CALCIUM REGULATORS,
for FORTAMET and GLUMEnA)	A COMBINATION	MISCELLANEOUS
ANTIDIABETICS,	pioglitazone-glimepiride	calcitonin-salmon
BIGUANIDE/	ANTIDIABETICS,	PROLIA
SULFONYLUREA	MEGLITINIDE	CALCIUM REGULATORS,
COMBINATIONS	nateglinide	PARATHYROID HORMONES
glipizide-metformin	repaglinide	teriparatide
ANTIDIABETICS,	ANTIDIABETICS,	TYMLOS
DIPEPTIDYL PEPTIDASE-4	MISCELLANEOUS	CARNITINE DEFICIENCY
(DPP-4) INHIBITOR	mifepristone	AGENTS
COMBINATIONS	levocarnitine
saxagliptin-metformin ext-rel	ANTIDIABETICS, SODIUM-

pyridostigmine ext-rel

TRIJARDYXR ZITUVIMET

GLUCOSE	CENTRAL PRECOCIOUS COTRANSPORTER-2(SGLT2)	 PUBERTY

NARCOLEPSY/CATAPLEXY
armodafinil modafinil
LUMRVZ

ZITUVIMET XR	INHIBITOR COMBINATIONS	FENSOLVI
SYNJARDY	LUPRON DEPOT-PED
ANTIDIABETICS,	SYNJARDYXR	SUPPRELIN LA
DIPEPTIDYL PEPTIDASE-4	XIGDUOXR	TRIPTODUR

SUNOSI WAKIX XYWAV

(DPP-4) INHIBITORS
saxag/iptin
ZITUVIO

ANTIDIABETICS, SODIUM-	CHELATING AGENTS
GLUCOSE	deferasirox
COTRANSPORTER-2(SGLT2)	deferiprone

OPIOID
AGONIST/ ANTAGONIST
buprenorphine-naloxone sublingual

ANTIDIABETICS, INCRETIN	INHIBITOR/DPP-4	deferoxamine
MIMETIC AGENTS	INHIBITOR COMBINATIONS	penicillamine
/iraglutide	GLYXAMBI	trientine
MOUNJARO	ANTIDIABETICS, SODIUM-	CONTRACEPTIVES

ZUBSOLV
OPIOID ANTAGONIST

OZEMPIC RYBELSUS TRULICITY

GLUCOSE	ethiny/ estradiol-drospirenone COTRANSPORTER-2(SGLT2)	ethinyl estradiol-drospirenone- INHIBITORS		levomefolate

naloxone
naltrexone
POSTHERPETIC NEURALGIA (PHN)
GRALISE

ENDOCRINE AND METABOLIC

ACROMEGALY
SOMATULINE DEPOT
ANDROGENS
testosterone gel (except authorized generics for TESTlM and VOGEL.XO)
testosterone solution
NATESTO XYOSTED

ANTIDIABETICS, INCRETIN	FARXIGA	ethinyl estradiol-etonogestrel
MIMETIC COMBINATION	JARDIANCE	ethinyl estradiol-levonorgestrel
AGENTS	ethinyl estradiol-
SOLIQUA	ANTIDIABETICS,	levonorgestrel-iron
XULTOPHY	SULFONYLUREA	ethinyl estradiol-
glimepiride	norelgestromin
ANTIDIABETICS, INSULIN	glipizide	ethinyl estradiol-norethindrone
FIASP	glipizide ext-rel	acetate-iron
HUMULIN R U-500	ANTIOBESITY	ethinyl estradiol-norgestimate
INSULIN GLARGINE-YFGN	medroxyprogesterone acetate
LANTUS	orlistat	150mglml
NOVOLIN 70/30	QSYMIA	norethindrone
NOVOLIN N	SAXENDA	ANNOVERA
NOVOLIN R	WEGOVY	KYLEENA
NOVOLOG	ZEPBOUND	LO LOESTRIN FE
NOVOLOG MIX 70/30	MIRENA
TOUJEO	NATAZIA
TRESIBA	SKYLA

DIABETIC SUPPLIES
ACCU-CHEK AVIVA PLUS STRIPS AND KITS
ACCU-CHEK GUIDE STRIPS AND KITS
ACCU-CHEK SMARTVIEW STRIPS AND KITS
BD ULTRAFINE INSULIN SYRINGES AND NEEDLES
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
OMNIPOD 5 INSULIN INFUSION PUMP
OMNIPOD DASH INSULIN INFUSION PUMP
OMNIPOD INSULIN INFUSION PUMP
ONETOUCH LANCETS/ LANCING DEVICE
ONETOUCH ULTRA STRIPS
AND KITS
ONETOUCH VERIO STRIPS AND KITS
TWIIST INSULIN INFUSION PUMP AND SUPPLIES
ENDOMETRIOSIS
ORILISSA
FERTILITY REGULATORS
cetrorelix acetate clomiphene FOLLISTIM AQ GANIRELIX ACETATE MENOPUR
PREGNYL
GLUCOCORTICOIDS
dexamethasone f/udrocortisone hydrocortisone methylprednisolone prednisolone solution (except
predniso!one solution10 mg/5ml. 20
mg/Sml)
prednisone
GLUCOSE ELEVATING AGENTS
glucagon, human recombinant
BAQSIMI GVOKE ZEGALOGUE
HEREDITARY TYROSINEMIA TYPE 1 AGENTS
ORFADIN

HUMAN GROWTH HORMONES
HUMATROPE NORDITROPIN SOGROYA
LYSOSOMAL STORAGE DISORDERS
NEXVIAZYME
LYSOSOMAL STORAGE DISORDERS - FABRY DISEASE
ELFABRIO FABRAZYME GALAFOLD
LYSOSOMAL STORAGE DISORDERS - GAUCHER DISEASE
CERDELGA CEREZYME
MENOPAUSAL SYMPTOM AGENTS
estradio/
estradiol vaginal cream estradiol-norethindrone BIJUVA
CLIMARAPRO COMBIPATCH IMVEXXY VAGIFEM
MISCELLANEOUS
betaine cabergoline raloxifene sapropterin CYSTAGON
PHOSPHATE BINDER AGENTS
calcium acetate sevelamer carbonate AURYXIA
POLYNEUROPATHY
TEGSEDI
POTASSIUM-REMOVING AGENTS
VELTASSA
PROGESTINS
medroxyprogesterone megestrol acetate progesterone, micronized ENDOMETRIN

THYROID AGENTS
levothyroxine liothyronine methimazole propylthiouraci/
UREA CYCLE DISORDER
carglumic acid
sodium phenylbutyrate
PHEBURANE
UTERINE FIBROIDS
MYFEMBREE ORIAHNN
VASOPRESSINS
desmopressin spray, tablet
VITAMIN D ANALOGS
calcitriol (1, 25-d3) doxercalciferol paricalcitol
GASTROINTESTINAL ANTICHOLINERGICS
dicyc/omine
ANTIDIARRHEALS
diphenoxylate-atropine
/operamide
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
budesonide foam hydrocortisone enema mesa/amine delayed-rel mesa/amine enema

mesa/amine ext-rel mesa/amine suppository su/fasalazine su/fasa/azine 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
misoprostol sucralfate tablet ursodiol SYMPROIC
PANCREATIC ENZYMES
CREON VIOKACE ZENPEP
PROTON PUMP INHIBITORS
esomeprazole delayed-rel lansoprazo/e delayed-rel
capsule
omeprazole delayed-rel pantoprazo/e delayed-rel
tablet
RECTAL, CORTICOSTEROIDS
PROCTOFOAM-HC
ULCER THERAPY COMBINATIONS
bismuth-metronidazole- tetracycline
lansoprazole + amoxicillin + c/arithromycin
TALICIA

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA
alfuzosin ext-rel

doxazosin dutasteride
dutasteride-tamsulosin finasteride
silodosin tamsulosin terazosin
ERECTILE DYSFUNCTION
sildenafil tadalafil vardenafil
MISCELLANEOUS
tiopronin
tiopronin delayed-rel
URINARY ANTISPASMODICS
darifenacin ext-rel fesoterodine ext-rel oxybutynin ext-rel solifenacin tolterodine tolterodine ext-rel trospium
trospium ext-rel
GEMTESA
VAGINAL ANTI-INFECTIVE$
c/indamycin metronidazole

HEMATOLOGIC

ANTICOAGULANTS
enoxaparin fondaparinux warfarin ELIQUIS XARELTO
BLEEDING DISORDERS AGENTS
NOVOSEVEN RT SEVENFACT
HEMATOPOIETIC GROWTH FACTORS
ARANESP FYLNETRA NIVESTYM NYVEPRIA PROCRIT RETACRIT
HEMOPHILIA A AGENTS
ADVATE ADYNOVATE AFSTYLA ALTUVIIIO

ELOCTATE ESPEROCT JIVI KOGENATEFS KOVALTRY NOVOEIGHT NUWIQ XYNTHA
HEMOPHILIA B AGENTS
ALPROLIX BENEFIX REBINYN
MISCELLANEOUS
anagrelide cilostazol
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS
EMPAVELI
PLATELET AGGREGATION INHIBITORS
clopidogrel
dipyridamole ext-rel-aspirin prasugrel
BRILINTA
SICKLE CELL DISEASE
ENDARI SIKLOS
THROMBOCYTOPENIA AGENTS
ALVAIZ DOPTELET

IMMUNOLOGIC AGENTS

ALLERGENIC EXTRACTS
GRASTEK ORALAIR RAGWITEK
ALOPECIA AREATA
LITFULO
AUTOIMMUNE AGENTS (PHYSICIAN­ ADMINISTERED)
AVSOLA ILUMYA REMICADE SIMPONI ARIA
SKYRIZI INTRAVENOUS STELARAINTRAVENOUS

AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ALL OTHER CONDITIONS
ADALIMUMAB-ADAZ ENBREL
HYRIMOZ
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ANKYLOSING SPONDYLITIS
ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ RINVOQ
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), CROHN'S DISEASE
ADALIMUMAB-ADAZ HYRIMOZ
RINVOQ
SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), NON-RADIOGRAPHICAXIAL SPONDYLOARTHRITIS
CIMZIA PREFILLED SYRINGE COSENTYX
RINVOQ
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), PSORIASIS
ADALIMUMAB-ADAZ BIMZELX
HYRIMOZ OTEZLA
SKYRIZI SUBCUTANEOUS SOTYKTU STELARASUBCUTANEOUS TREMFYA
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), PSORIATIC ARTHRITIS
ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ OTEZLA RINVOQ
SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA

AUTOIMMUNE AGENTS (SELF-ADMINISTERED), RHEUMATOID ARTHRITIS
ADALIMUMAB-ADAZ ENBREL
HYRIMOZ KEVZARA
ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS RINVOQ
XELJANZ XELJANZXR
AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ULCERATIVE COLITIS
ADALIMUMAB-ADAZ HYRIMOZ
RINVOQ
SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA
VELSIPITY XELJANZ XELJANZXR ZEPOSIA
DISEASE-MODIFYINGANTI­ RHEUMATIC DRUGS (DMARDS)
hydroxychloroquine leflunomide methotrexate RASUVO
HEREDITARY ANGIOEDEMA
icatibant ORLADEYO RUCONEST TAKHZYRO
IMMUNOGLOBULIN
CUTAQUIG
IMMUNOSUPPRESSANTS
azathioprine cyclosporine cyclosporine modified everolimus mycophenolate mofetil mycophenolate sodium sirolimus
tacrolimus

NUTRITIONAL/SUPPLEM ENTS

ELECTROLYTES
potassium chloride ext-rel

potassium chloride liquid
PRENATAL VITAMINS
prenatal vitamins
VITAMINS
folic acid
folic acid-vitamin b6-vitamin b12
multivitamins

OPHTHALMIC

ANTI-INFECTIVE/ANTI­ INFLAMMATORY
neomycin-polymyxin b- bacitracin-hydrocortisone
neomycin-polymyxin b- dexamethasone
tobramycin-dexamethasone
ANTI-INFECTIVES
ciprofloxacin erythromycin gentamicin levofloxacin moxif/oxacin ofloxacin sulfacetamide tobramycin trifluridine
ANTI-INFLAMMATORIES
bromfenac dexamethasone diclofenac difluprednate ketorolac loteprednol
prednisolone acetate 1%
ANTIALLERGICS
azelastine bepotastine cromolyn sodium loteprednol olopatadine
ANTIGLAUCOMA BETA­ BLOCKERS
timolol maleate solution
ANTIGLAUCOMA COMBINATION AGENTS
brimonidine-timolol dorzolamide-timolol SIMBRINZA

CARBONIC ANHYDRASE INHIBITORS
brinzolamide
dorzolamide
DRY EYE DISEASE
RESTASIS XIIDRA
PROSTAGLANDINS
bimatoprost latanoprost travoprost
RETINAL DISORDERS
BYOOVIZ CIMERLI
SYMPATHOMIMETICS
brimonidine solution
ALPHAGAN P

RESPIRATORY

ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS
PROLASTIN-C ZEMAIRA
ANAPHYLAXIS TREATMENT AGENTS
epinephrine (except NOCs00093-
xxxx-xx.-49502-)0()()(-XXJ
AUVI-Q
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ipratropium-albuterol inhalation solution
ANORO ELLIPTA STIOLTO RESPIMAT
ANTICHOLINERGIC/BETA AGONIST/STEROID COMBINATIONS
BREZTRIAEROSPHERE TRELEGY ELLIPTA
ANTICHOLINERGICS
ipratropium inhalation solution
SPIRIVA YUPELRI
ANTIHISTAMINE COMBINATIONS
azelastine-f/uticasone
ANTIHISTAMINES
azelastine clemastine 2.68 mg

cyproheptadine levocetirizine olopatadine
BETA AGONISTS
albuterol inhalation solution albuterol sulfate cfc-free
aerosol(except NOCs00093317431, 66993001968)
arformoterol
formoterol inhalation solution
levalbuterol tartrate cfc-free
aerosol
STRIVERDI RESPIMAT
COLD/COUGH
benzonatate (except Noes 69336012615, 69499032915)
codeine-promethazine
codeine-promethazine­ phenylephrine
dextromethorphan­ brompheniramine­ pseudoephedrine
dextromethorphan- promethazine
hydrocodone-homatropine
CYSTIC FIBROSIS
tobramycin inhalation solution
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast zafirlukast
MAST CELL STABILIZERS
cromolyn solution
MISCELLANEOUS
roflumilast
NASAL STEROIDS
flunisolide fluticasone mometasone
PULMONARY FIBROSIS AGENTS
pirfenidone
OFEV
SEVERE ASTHMA AGENTS
DUPIXENT FASENRA
NUCALA (except 1yop1,111ze<1 powder)
TEZSPIRE XOLAIR

STEROID INHALANTS
budesonide inhalation suspension
ASMANEX HFA PULMICORT FLEXHALER
STEROID/BETA-AGONIST COMBINATIONS
Breyna
budesonide-formoterol fluticasone-salmeterol(except
certain NOCs)
Wixela lnhub
AIRSUPRA
BREO ELLIPTA (except certain NOCsl
TOPICAL DERMATOLOGY, ACNE
adapalene (except adapelene ped) benzoyl peroxide clindamycin gel (except NOC
68682046275)
clindamycin solution clindamycin-benzoyl peroxide dapsone
erythromycin solution erythromycin-benzoyl
peroxide
isotretinoin capsule 10 mg, 20
mg, 30 mg, 40 mg tretinoin
AKLIEF EPIDUO TWYNEO WINLEVI
DERMATOLOGY, ACTINIC KERATOSIS
fluorouracil cream 5% fluorouracil solution imiquimod
DERMATOLOGY, ANTIBIOTICS
gentamicin mupirocin ointment silver sulfadiazine
DERMATOLOGY, ANTIFUNGALS
ciclopirox clotrimazole econazole
ketoconazole cream 2% nystatin
oxiconazole (except NOCs 00168035830, 51672135902)

DERMATOLOGY,
ANTIPSORIATICS	CIBINQO
DUPIXENT	triamcinolone cream, lotion,
ointment (except triamcinolone	FINACEA FOAM
ORACEA	
acitretin	EUCRISA	ointment 0.05%)	SOOLANTRA	
calcipotriene ointment,	OPZELURA	BRYHALI	DERMATOLOGY,	

solution methoxsalen ENSTILAR TACLONEX VTAMA
ZORYVE CREAM

RINVOQ
DERMATOLOGY,	DERMATOLOGY, LOCAL ANESTHETICS	SCABICIDES AND PEDICULICIDES	
CORTICOSTEROIDS
clobetasol cream, foam, gel,	lidocaine patch lidocaine-prilocaine	malathion permethrin 5%	

lotion, ointment, shampoo

DERMATOLOGY,	MOUTH/THROAT /DENTAL

(except clobetasol emollient foam)	MISCELLANEOUS SKIN AND	AGENTS

DERMATOLOGY,	desonide (except desonide gel)	MUCOUS MEMBRANE ANTISEBORRHEICS	desoximetasone

cevimeline

ketoconazole shampoo 2%	 fluocinonide <except 11uoc1nonlde cream	 acyclovir ointment	 pilocarpine tablet selenium sulfide lotion 2.5%		0.1%)	 ammonium lactate 12%	 EPISIL ZORYVEFOAM	halobetasol cream, ointment	diclofenac sodium gel 1%	MUGARD
hydrocortisone	penciclovir	OTIC
DERMATOLOGY, ATOPIC	hydrocortisone butyrate	podofilox

DERMATITIS	cream, ointment, solution
pimecrolimus	mometasone

DERMATOLOGY, ROSACEA

acetic acid
ciprofloxacin-dexamethasone

tacrolimus

azelaic acid gel	neomycin-polymyxin b-

ADBRY	brimonidine gel	hydrocortisone
metronidazole	ofloxacin otic
QUICK REFERENCE DRUG LIST

 		albuterol sulfate cfc-free	amphetamine-	azelastine-fluticasone	
A	aerosol (except NDCs 00093317431,	dextroamphetamine mixed	azithromycin	
abacavir	66993001968)	salts ext-rel	AZSTARYS	
abacavir-lamivudine
ABILIFY ASIMTUFII	ALECENSA
alendronate	anagrelide anastrozole	

B	
ABILIFY MAINTENA	alfuzosin ext-rel	ANNOVERA	baclofen	
abiraterone	aliskiren	ANORO ELLIPTA	BAFIERTAM	
acamprosate calcium	al/opurinol	aprepitant	balsalazide	
acarbose	alosetron	APRETUDE	BAQSIMI	
ACCU-CHEK AVIVA PLUS	ALPHAGAN P	APTIOM	BD ULTRAFINE INSULIN	
STRIPS AND KITS	alprazolam	ARANESP	SYRINGES AND NEEDLES	
ACCU-CHEK GUIDE STRIPS	ALPROLIX	arformoterol	BELBUCA	
AND KITS	ALTUVIIIO	aripiprazole	BENEFIX	
ACCU-CHEK SMARTVIEW	ALUNBRIG	armodafinil	benzonatate (except NOCs	
STRIPS AND KITS	ALVAIZ	asenapine	69336012615, 69499032915)	
acebutolo/	amantadine	ASMANEX HFA	benzoyl peroxide	
acetic acid	ambrisentan	atazanavir	bepotastine	
acitretin	amiloride	atenolol	BESREMI	
acyclovir	amiodarone	atenolol-chlorthalidone	betaine	
acyclovir ointment	amitriptyline	atomoxetine	BETASERON	
ADALIMUMAB-ADAZ	amlodipine	atorvastatin	bexarotene	
adapalene (except adapalene pad)	amlodipine-atorvastatin	AUGTYRO	bicalutamide	
ADBRY	amlodipine-olmesartan	AURYXIA	BIJUVA	
ADEMPAS	amlodipine-telmisartan	AUSTEDO	BIKTARVY	
ADVATE	amlodipine-valsartan	AUSTEDOXR	bimatoprost	
ADYNOVATE	amlodipine-valsartan-	AUVI-Q	BIMZELX	
AFSTYLA	hydrochlorothiazide	AVONEX	bismuth-metronidazole-	
AIRSUPRA	ammonium lactate 12%	AVSOLA	tetracycline	
AJOVY	amoxicillin	azathioprine	bisoprolol-	
AKLIEF	amoxicillin-clavulanate	azelaic acid gel	hydrochlorothiazide	
albuterol inhalation solution		azelastine	bortezomib	
		azelastine	bosentan	

BOSULIF
BRAFTOVI	cephalexin
CERDELGA	CREON	dimethyl fumarate delayed-
cromolyn sodium	rel	
BREO ELLIPTAcexceptcertain	CEREZYME	cromolyn solution	diphenoxylate-atropine	
NDCs)	cetrorelix acetate	CUTAQUIG	dipyridamole ext-rel-aspirin	
Breyna	cevimeline	cyclobenzaprine(except	disopyramide	
BREZTRIAEROSPHERE	chlorpromazine	c netablet7.5mg)	disulfiram	
BRILINTA	chlorthalidone	cyclophosphamide	diva/proex sodium	
brimonidine gel	chlorzoxazone 500 mg (except	cyclosporine	divalproex sodium ext-rel	
brimonidine solution	NOC 73007001303)	cyclosporine modified	donepezil	
brimonidine-timolol	cholestyramine	cyproheptadine	DOPTELET	
brinzolamide	CIBINQO	CYSTAGON	dorzolamide	
BRIVIACT	ciclopirox			 dorzolamide-timolol bromfenac	ci/ostazol		D		DOVATO	
BRUKINSA	CIMDUO	dantrolene	doxazosin	
BRYHALI	CIMERLI	dapsone	doxepin	
budesonide delayed-rel	CIMZIA PREFILLED SYRINGE	darifenacin ext-rel	doxepin	
capsule	cinacalcet	darunavir	doxercalcifero/	
budesonide foam	ciprof/oxacin	DAXXIFY	doxycycline hyclate capsule	
budesonide inhalation	ciprofloxacin	deferasirox	doxycycline hyclate tablet	
suspension	ciprofloxacin-dexamethasone	deferiprone	(exceptdoxycyciinehyciatetablet50	
budesonide-formoterol	citalopram	deferoxamine	mg,75mg,150mg)	
buprenorphine transdermal	clarithromycin	DESCOVY	doxylamine-pyridoxine	
buprenorphine-naloxone	c/arithromycin ext-rel	desipramine	delayed-rel	
sublingual	clemastine 2.68 mg	desmopressin spray, tablet	dronabinol	
bupropion	CLENPIQ	desonide (exceptdesonide ge(J	duloxetine	
bupropion ext-rel (except	CLIMARA PRO	desoximetasone	DUPIXENT	
bupropion ext-rettablet 450 mg)	clindamycin	desvenlafaxine ext-rel	DUPIXENT	
buspirone	clindamycin	dexamethasone	DUROLANE	
BYOOVIZ	clindamycin gel(except NOC	dexamethasone	dutasteride	
	68682046275)	DEXCOM CONTINUOUS	dutasteride-tamsulosin	
C	clindamycin solution	GLUCOSE MONITORING		
CABENUVA	clindamycin-benzoyl	SYSTEM	E
cabergoline	peroxide	dexmethylphenidate	econazole
CABOMETYX	clobazam	dexmethylphenidate ext-rel	efavirenz
calcipotriene ointment,	clobetasol cream, foam, gel,	dextroamphetamine	efavirenz-emtricitabine- solution		lotion, ointment, shampoo	dextroamphetamineext-rel		tenofovir disoproxil
ca/citonin-salmon	(except clobetasolemollient foam)	dextromethorphan-	fumarate

ca/citrio/ (1, 25-d3)	 clomiphene		brompheniramine-	efavirenz-lamivudine- calcium acetate	 clomipramine		pseudoephedrine		 tenofovir disoproxil CALQUENCE	clonazepam	dextromethorphan-		fumarate candesartan	 clonidine		promethazine	eletriptan candesartan-	 clonidine transdermal	 diazepam	 ELFABRIO
hydrochlorothiazide	clopidogrel	diazepam rectal gel	 ELIGARD capecitabine	clotrimazole	diclofenac	 ELIQUIS carbamazepine	clozapine	diclofenac sodium	 ELOCTATE carbamazepine ext-rel	codeine-acetaminophen	diclofenac sodium gel 1%	 EMGALITY carbidopa-levodopa	codeine-promethazine	dic/ofenac sodium solution	 EMPAVELI carbidopa-levodopa ext-rel	codeine-promethazine-		1.5%	emtricitabine
carbidopa-levodopa-		phenylephrine	diclofenac sodium-	emtricitabine-tenofovir entacapone	colchicine tablet		misoprosto/		disoproxil fumarate
carglumic acid
carisoprodol 350 mg carvedilol	colesevelam
COMBIPATCH COPAXONE 40 MG/ML	dicloxacillin dicyclomine
DIFICID	EMVERM
enalapril
ENBREL	
carvedilol phosphate ext-rel	COPIKTRA	difluprednate	ENDARI	
cefdinir	CORLANOR	digoxin	ENDOMETRIN	
cefprozil	CORTI FOAM	diltiazem ext-rel!exceptgenerics tor	enoxaparin	
cefuroxime axetil	COSENTYX	CARDIZEM LA)	ENSPRYNG	
celecoxib	COTELLIC		ENSTILAR	

entacapone	fenofibrate (except fenofibmtecapsule	glipizide ext-rel	isosorbide dinitrate (except
entecavir	30 mg, 50 mg, 90 mg, 130 mg;	glipizide-metformin	isosorbidedinitrate40mg)
ENTRESTO	fenofibrate tablet 40 mg,120mg)	g/ucagon, human	isosorbide dinitrate-
EPCLUSA (genotypes 1,2, 3, 4, s.6l	fenofibric acid delayed-rel	recombinant	hydralazine
EPIDUO	 FENSOLVI	 GLYXAMBI	isosorbide mononitrate epinephrine (except NDCs00093-	fentanyl transdermal	GRALISE	isotretinoin capsule 10 mg, 20
XXXX-XX, 49502-XXXX-XX)	 fentanyl transmucosal	 granisetron		mg, 30 mg, 40 mg EPISIL	fesoterodine ext-rel	GRASTEK	itraconazole eplerenone	 FIASP	guanfacine	 ivermectin tablet
ERIVEDGE	FINACEA FOAM	guanfacine ext-rel		
ERLEADA	finasteride	GVOKE	J
erlotinib	fingolimod		 JARDIANCE
erythromycin	fluconazole	H	JIVI	
erythromycin solution	f/udrocortisone	ha/obetaso/ cream, ointment			
erythromycin-benzoyl	fluniso/ide	ha/operidol	K	
peroxide	fluocinonide (excepftluocinonide	HARVONI(genotypes,.•· s. 6J	KANJINTI
erythromycins	cream0.1'11.)	HUMATROPE	KERENDIA	
escitalopram	f/uorouracil cream 5%	HUMULIN R U-500	KESIMPTA	
esomeprazo/e delayed-rel	f/uorouracil solution	hydrochlorothiazide	ketoconazole cream 2%	
ESPEROCT	fluoxetine (except nuoxetine tabletso	hydrocodone ext-rel	ketoconazole shampoo 2%	
estradiol	mg, fluoxetinetablet [generics for	hydrocodone-acetaminophen	ketorolac	
estradiol vaginal cream	SARAFEM))	hydrocodone-homatropine	KEVZARA	
estradiol-norethindrone	f/uphenazine	hydrocortisone	KISQALI	
ethacrynic acid	f/uticasone	hydrocortisone	KISQALI FEMARA CO-PACK	
ethambutol	fluticasone-salmeterol(except	hydrocortisonebutyrate	KOGENATE FS	
ethinyl estradiol- drospirenone	certainNDCs)
fluvastatin	cream, ointment, solution
hydrocortisone enema	KOSELUGO
KOVALTRY	
ethinyl estradiol-	fluvoxamine	hydromorphone	KRAZATI	
drospirenone-levomefolate	folic acid	hydroxychloroquine	KYLEENA
ethinyl estradiol-etonogestrel	folic acid-vitamin b6-vitamin	hydroxyurea		
ethinyl estradiol-	b12	HYRIMOZ	L

fondaparinux		lactulose solution	
formoterol inhalation solution	ibandronate	lamivudine	
fosinopril	IBRANCE	lamivudine	
fosinopril- hydrochlorothiazide	ibuprofen
ibuprofen-famotidine	lamivudine-zidovudine
lamotrigine	

levonorgestrel	FOLLISTIM AQ		 lacosamide ethinyl estradio/-
levonorgestrel-iron ethiny/ estradiol-

fu/vestrant	icatibant	lamotrigine ext-re/	
furosemide	icosapent ethyl	lansoprazole + amoxicillin +	
FYCOMPA	ILUMYA	clarithromycin	
FYLNETRA	imatinib mesylate	lansoprazole delayed-rel	
	 imipramine he/	capsule	

norelgestromin ethinyl estradiol-
norethindrone acetate-iron ethinyl estradiol-

G
gabapentin	imiquimod
IMVEXXY	LANTUS
lapatinib	
GALAFOLD	INBRIJA	latanoprost	
galantamine	INGREZZA	leflunomide	
galantamine ext-rel	INLYTA	LENVIMA	
GANIRELIX ACETATE	INSULIN GLARGINE-YFGN	letrozole	
GAVRETO	ipratropium inhalation	leuprolide acetate	

norgestimate ethosuximide etoposide etravirine EUCRISA
EUFLEXXA
everolimus everolimus exemestane ezetimibe
ezetimibe-simvastatin	gefitinib	solution	leva/buterol tartrate cfc-free
	  GELSYN-3	ipratropium-albuterol	aerosol
F	 GEMTESA		inhalation solution	 levetiracetam FABRAZYME	gentamicin	irbesartan	levetiracetam ext-rel famotidine	 gentamicin	 irbesartan-	 levocarnitine

glatiramer	ISENTRESS	levof/oxacin	
glimepiride	isoniazid	levofloxacin	
glipizide		/evothyroxine	
		lidocaine patch	

FARXIGA	GENVOYA	hydrochlorothiazide	levocetirizine
FASENRA

lidocaine-prilocaine	methimazole	neomycin-polymyxin b-	ondansetron
linezolid	methocarbamol (except NDCs	dexamethasone	ONETOUCH LANCETS/
LINZESS	69036091010, 69036093090,	neomycin-polymyxin b-	LANCING DEVICE
liothyronine		70868090190)		hydrocortisone	ONETOUCH ULTRA STRIPS liraglutide	methotrexate	 NEUPRO		AND KITS lisdexamfetamine	methoxsalen	nevirapine	ONETOUCH VERIO STRIPS lisinopril	methylphenidate	 nevirapine ext-rel		AND KITS
lisinopril-hydrochlorothiazide	methylphenidate ext-rel	NEXLETOL	OPSUMIT
LITFULO	methylprednisolone	NEXLIZET	 OPSYNVI lithium carbonate	metoclopramide	 NEXVIAZVME	OPZELURA lithium carbonate ext-rel	metolazone	niacin ext-rel	 ORACEA
tablet 300 mg	metopro/ol succinate ext-rel	nifedipine ext-rel	ORALAIR
lithium carbonate ext-rel	metoprolol tartrate	NINLARO	ORENCIA CLICKJECT
tablet 450 mg	metoprolol-	nitrofurantoin(exceptNDC	ORENCIA SUBCUTANEOUS LO LOESTRIN FE		hydrochlorothiazide		16571074024)	 ORENITRAM
LONSURF	metronidazole	nitroglycerin lingual spray	ORFADIN
/operamide	metronidazo/e	nitroglycerin sublingual	 ORIAHNN lopinavir-ritonavir	metronidazo/e	 NIVESTYM	ORILISSA lorazepam	midodrine	 NORDITROPIN	ORLADEYO
losartan	mifepristone	norethindrone	orlistat losartan-hydrochlorothiazide	minocycline	nortriptyline	ose/tamivir
/oteprednol	MIRENA	NOVOEIGHT	OTEZLA
loteprednol	mirtazapine	NOVOLIN 70/30	oxazepam
lovastatin	misoprosto/	 NOVOLIN N	 oxcarbazepine lubiprostone	 MITIGARE	NOVOLIN R	OXiCOnazo/e (except NDCs LUMAKRAS	 modafinil	 NOVOLOG		00168035830, 51672135902) LUMRVZ	mometasone	 NOVOLOG MIX 70/30	 OXTELLARXR
LUPRON DEPOT-PED	 mometasone	 NOVOSEVEN RT	 oxybutynin ext-rel lurasidone	montelukast	NUBEQA	oxycodone LYNPARZA	 morphine	 NUCALA(excepttyophillzedpowder)	 oxycodone ext-rel
LYVISPAH	morphine ext-rel	NURTECODT	oxycodone-acetaminophen
MOUNJARO	NUWIQ	OZEMPIC
M	moxifloxacin	nystatin		
malathion	moxifloxacin	NYVEPRIA	p
maraviroc	MUGARD			pantoprazole delayed-rel
MAVZENT	MULTAQ	0	tablet
meclizine	multivitamins	OCREVUS	paricalcitol
medroxyprogesterone	mupirocin ointment	ODEFSEY	paroxetine he/ medroxyprogesterone	mycophenolate mofetil	ODOMZO	paroxetine he/ ext-rel (except
acetate 150 mg/ml		mycophenolate sodium		 OFEV		NDC 60505367503) megestrol acetate		 MYFEMBREE		ofloxacin	 PAXLOVID megestrol acetate				ofloxacin otic	pazopanib
MEKTOVI	N	olanzapine	peg 3350-electro/ytes(except
meloxicam tablet	nadolol	olmesartan	generics for MOVIPREP)
melphalan	naloxone	olmesartan-amlodipine-	pemetrexed
memantine	naltrexone	hydrochlorothiazide	penciclovir
MENOPUR	NAMZARIC	olmesartan-	penicillamine
MEPRON	naproxen (exceptnaproxenCRor		hydrochlorothiazide	penicillin vk mercaptopurine		nap,oxen suspension)	olopatadine	 PERJETA mesa/amine delayed-rel	naratriptan	olopatadine	 permethrin 5% mesa/amine enema	 NATAZIA	omega-3 acid ethyl esters	 perphenazine
mesa/amine ext-rel	nateglinide	omeprazole delayed-rel	PERSERIS
mesa/amine suppository	NATESTO	OMNIPOD 5 INSULIN	PHEBURANE
metaxa/one 800 mg	NAVZILAM	INFUSION PUMP	phenobarbital
metformin	nebivolol	OMNIPOD DASH INSULIN	phenytoin
metformin ext-rel (exceptgenerics	neomycin-polymyxin b-	INFUSION PUMP	phenytoin sodium extended
for FORTAMET and GLUMETZA)	bacitracin-hydrocortisone	OMNIPOD INSULIN	PHESGO
methadone	INFUSION PUMP	pilocarpine tablet

pimecrolimus	REBINYN	solifenacin	testosterone gel (except authorized	
pioglitazone	RELENZA	SOLIQUA	generics fo, TESTIM and VOGEL.XO)	
pioglitazone-glimepiride	REMICADE	SOMATULINE DEPOT	testosterone solution	
pioglitazone-metformin	repaglinide	SOOLANTRA	tetrabenazine	
pirfenidone	REPATHA	sorafenib	tetracycline	
pitavastatin	RESTASIS	sotalol	TEZSPIRE	
podofilox	RETACRIT	SOTYKTU	THALOMID	
potassium chloride ext-rel	RETEVMO	SPIRIVA	thiothixene	
potassium chloride liquid	REVLIMID	spironolactone	tiagabine	
pramipexole	ribavirin	spironolactone-	timolol maleate solution	
pramipexole ext-rel	rifampin	hydrochlorothiazide	tiopronin	
prasugrel	RINVOQ	SPRYCEL	tiopronin delayed-rel	
pravastatin	risedronate	STELARAINTRAVENOUS	TIVICAY	
prednisolone acetate 1%	risperidone	STELARA SUBCUTANEOUS	tizanidine	
prednisolone solution (except	ritonavir	STIOLTO RESPIMAT	tobramycin	
prednisolone solution 10 mg/5 ml, 20	rivastigmine	STIVARGA	tobramycin inhalation	
mg/5ml)	rivastigmine transdermal	STRIVERDI RESPIMAT	solution	
prednisone	rizatriptan	sucralfate tablet	tobramycin-dexamethasone	
pregabalin	roflumilast	sulfacetamide	tolterodine	
PREGNYL	ropinirole	sulfamethoxazole-	tolterodine ext-rel	
prenatal vitamins	ropinirole ext-rel	trimethoprim	topiramate	
primidone	rosuvastatin	sulfasalazine	topiramate ext-rel	
probenecid	ROZLYTREK	sulfasalazine delayed-rel	toremifene	
prochlorperazine	RUCONEST	sumatriptan	torsemide	
PROCRIT	rufinamide	sunitinib	TOUJEO	
PROCTOFOAM-HC	RUXIENCE	SUNOSI	tramadol (except tramadol tablet 100	
progesterone, micronized	RYBELSUS	SUPARTZ FX	mg)	
PROLASTIN-C	RYDAPT	SUPPRELIN LA	tramadol ext-rel tablet	
PROLIA	RYTARY	SYMLINPEN	travoprost	

s

promethazine propranolol

SYMPROIC	TRAZIMERA
SYMTUZA	trazodone

propranolol ext-rel	SANCUSO	SYNJARDY	TRELEGY ELLIPTA
propylthiouracil	sapropterin	SYNJARDYXR	TREMFYA
PULMICORT FLEXHALER	saxagliptin	treprostinil
pyrazinamide	saxagliptin-metformin ext-rel	T	TRESIBA	
pyridostigmine	SAXENDA	TACLONEX	tretinoin	
pyridostigmine ext-rel	scopolamine transdermal	tacrolimus	tretinoin capsule	
pyrimethamine	se/egiline	tacrolimus	triamcinolone cream, lotion,	

Q

selenium sulfide lotion 2.5%	tadalafil	ointment (except triamcinolone
sertraline	tadalafil	ointment 0.05%)
QELBREE	sevelamer carbonate	TADLIQ	triamterene
QSYMIA	SEVENFACT	TAGRISSO	triamterene-
quetiapine	SIKLOS	TAKHZYRO	hydrochlorothiazide
quetiapine ext-rel	si/denafil	TALICIA	trientine
quinapril	sildenafil	tamoxifen	trifluoperazine
quinapril-hydrochlorothiazide	si/odosin	tamsulosin	trifluridine
QULIPTA	silver sulfadiazine	TEGSEDI	TRIJARDYXR
SIMBRINZA	telmisartan	trimethobenzamide
R	SIMPONI ARIA	telmisartan-	TRINTELLIX
RADICAVA ORS	simvastatin	hydrochlorothiazide	TRIPTODUR	
RAGWITEK	sirolimus	temazepam	TRIUMEQ	
raloxifene	SKYLA	temozo/omide	trospium	
ramelteon	SKYRIZI INTRAVENOUS	tenofovir disoproxil fumarate	trospium ext-rel	
ramipril	SKYRIZI SUBCUTANEOUS	terazosin	TRULICITY	
ranolazine ext-rel	sodium phenylbutyrate	terbinafine tablet	TWIIST INSULIN INFUSION	
rasagiline	sodium sulfate-potassium	teriflunomide	PUMP AND SUPPLIES	
RASUVO	sulfate-magnesium sulfate	teriparatide	TWYNEO	
REBIF	SOGROYA		TYMLOS	

TYSABRI	venlafaxine ext-rel capsule	X	ZEGALOGUE	
TYVASO	verapamil ext-rel	XARELTO	ZEJULA	
TYVASO DPI	VERQUVO	XCOPRI	ZELBORAF	

u

VIBERZI	XELJANZ	ZEMAIRA
vigabatrin	XELJANZXR	ZENPEP
UBRELVY	vilazodone	XEOMIN	ZEPBOUND
UPTRAVI	VIOKACE	XIFAXAN 550 MG	ZEPOSIA
ursodiol	VISTOGARD	XIGDUOXR	zidovudine

VITRAKVI	XIIDRA	ziprasidone
V	VOSEVI	XOLAIR	ZIRABEV
VAGIFEM	VRAYLAR	XOSPATA	ZITUVIMET
valacyclovir	VTAMA	XTANDI	ZITUVIMET XR
valganciclovir	VUMERITY	XULTOPHY	ZITUVIO
valproic acid	VYVGART	XYNTHA	zolmitriptan
valsartan	VYVGART HYTRULO	XYOSTED	zolpidem

valsartan-hydrochlorothiazide
VALTOCO	w

XYWAV	zolpidem ext-rel
zonisamide

vancomycin capsule	WAKIX	y	ZORYVE CREAM
vardenafil	warfarin	YONSA	ZORYVEFOAM
VELSIPITY	WEGOVY	YUPELRI	ZUBSOLV

VELTASSA	WINLEVI
VEMLIDY	Wixela lnhub	z

ZURZUVAE ZYDELIG

venlafaxine			zafirlukast	ZYKADIA

PREFERRED OPTIONS FOR EXCLUDED MEDICATIONS

The preferred options listed below are a broad representation of available treatment options and do not necessarily

represent clinical equivalency.

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)

ABILIFY		aripiprazo/e, asenapine, clozapine, lurasidone, o/anzapine, 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- benzoy/ peroxide, tretinoin, AKLIEF, EPIDUO, TWYNEO, WINLEVI
ACIPHEX, ACIPHEX SPRINKLE  esomeprazo/e delayed-re/,
lansoprazole delayed-rel capsule, omeprazole delayed­ rel, pantoprazo/e delayed-rel tablet

EXCLUDED DRUG NAME(S)

ACTEMRAINTRAVENOUS

Activite ACTOS ACUVAIL

acyclovir cream

ACZONE

PREFERRED OPTION(S)

AVSOLA, REMICADE, SIMPONI ARIA
generic multivitamins pioglitazone
bromfenac, diclofenac, ketorolac
acyclovir (except acyclovir cream), penciclovir, valacyc/ovir
adapa/ene (except adapalene pad), benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoy/

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)

peroxide, tretinoin, AKLIEF,	free aerosol
EPIDUO, TWYNEO, WINLEVI
ALEVICYN GEL,	desonide (except desonide
adapalene pad	adapa/ene (except adapalene	 ALEVICYN SG, ALEVICYN	gel), hydrocortisone pad), benzoyl peroxide,	SOLUTION
clindamycin gel (except NDC

68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone,

ALIMTA	pemetrexed
ALIQOPA	Talk to your doctor

erythromycin solution,	ALLISON MEDICAL INSULIN	BD ULTRAFINE INSULIN
erythromycin- benzoyl	SYRINGES	SYRINGES
peroxide, tretinoin, AKLIEF,
EPIDUO, TWYNEO, WINLEVI	ALORA	estradiol
ADCIRCA	sildenafil, tadalafil, TADLIQ	ALREX	azelastine, bepotastine,

ADDERALL

dexmethylphenidate,	cromolyn sodium, loteprednol,

dextroamphetamine,

olopatadine

methylphenidate	ALTOPREV	atorvastatin, ezetimibe-

ADDERALLXR		amphetamine- dextroamphetaminemixed salts ext-rel, dexmethylphenidate ext-rel,

simvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin

dextroamphetamineext-rel,	ALVESCO	ASMANEX HFA, PULMICORT
lisdexamfetamine,	FLEXHALER
methylphenidate ext-rel,
AZSTARYS	AMITIZA	lubiprostone, LINZESS, SYMPROIC
ADRENALIN	epinephrine (except NDCs
00093-XXXX-XX, 49502-	AMRIX	carisoprodol 350 mg,
XXXX-XX), AUVI-Q	chlorzoxazone 500 mg (except
NOC 73007001303),
ADVAIR DISKUS, ADVAIR HFA  budesonide-formoterol,	cyclobenzaprine (except
f/uticasone-salmeterol (except	cyclobenzaprine tablet 7.5
certain NDCs), Breyna, Wixe/a	mg), metaxa/one 800 mg,
lnhub, BREO ELLIPTA (except	methocarbamol (except NDCs
certain NDCs)	69036091010, 69036093090,

ADZENYS XR-ODT	amphetamine-

70868090190)

dextroamphetaminemixed	ANDROGEL	testosterone gel (except
salts ext-rel,	authorized generics for
dexmethylphenidateext-re/,	TESTIM and VOGELXO),
dextroamphetamineext-rel,	testosterone solution,
lisdexamfetamine,	NATESTO, XYOSTED
methylphenidate ext-rel,
AZSTARYS	ANGELIQ	estradio/-norethindrone,
BIJUVA

AFINITOR, AFINITOR DISPERZ  everolimus

AIMOVIG	AJOVY, EMGALITY, QULIPTA

ANZEMET	granisetron, ondansetron,
SANCUSO

AKYNZEO	aprepitant WITH granisetron,	APEXICON E	desoximetasone (except
ondansetron or SANCUSO	desoximetasone ointment
albuterol sulfate CFC-free	albuterol sulfate CFC-	0.05%), fluocinonide (except

aerosol (NDCs 00093317431,	free aerosol (except NDCs 66993001968 only)	 00093317431, 66993001968),
levalbuterol tartrate CFC-

fluocinonide cream 0.1%), BRYHALI

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)

APIDRA	FIASP, NOVOLOG	ATACAND, ATACAND HCT	candesartan,candesartan-
hydrochlorothiazide,
APLENZIN	bupropion, bupropion ext-rel	irbesartan, irbesartan-
(except bupropion ext-rel	hydrochlorothiazide, losartan,
tablet 450 mg)	losartan-hydrochlorothiazide,
olmesartan, olmesartan-
APOKYN	INBRIJA	hydrochlorothiazide,

APTENSIOXR		amphetamine- dextroamphetamine mixed salts ext-rel,

telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

dexmethylphenidate ext-rel,	ATIVAN	alprazolam, clonazepam,
dextroamphetamine ext-rel,	diazepam, lorazepam,
lisdexamfetamine,	oxazepam
methylphenidateext-rel,
AZSTARYS	ATRALIN	adapalene (except adapalene pad), benzoyl peroxide,
APTIVUS	Talk to your doctor	clindamycin gel (except NDC

ARALAST NP	PROLASTIN-C, ZEMAIRA

68682046275), clindamycin solution, clindamycin-benzoyl

ARAZLO	adapalene (except adapalene	peroxide, dapsone,

pad), benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl

erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, AKLIEF, EPIDUO, TWYNEO, WINLEVI

peroxide, dapsone,	ATROVENT HFA	SPIRIVA
erythromycin solution,
erythromycin-benzoyl	AUBAGIO	dimethyl fumarate delayed-rel,
peroxide, tretinoin, AKLIEF,	fingolimod, glatiramer,
EPIDUO, TWYNEO, WINLEVI	teriflunomide, AVONEX,

ARCALYST	Talk to your doctor

BAFIERTAM, BETASERON, COPAXONE 40 MG/ML,

ARNUITY ELLIPTA

ASMANEX HFA, PULMICORT	KESIMPTA, MAYZENT,

FLEXHALER

ARTHROTEC	celecoxib; diclofenac sodium, ibuprofen, meloxicam tablet or naproxen (except naproxen CR or naproxen suspension) WITH

OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
AVASTIN	ZIRABEV

AVENOVA	Talk to your doctor

esomeprazole delayed-rel,	AZASITE	ciprofloxacin, erythromycin,
lansoprazole delayed-rel	gentamicin, levofloxacin,
capsule, omeprazole delayed-	moxifloxacin, ofloxacin,
rel, or pantoprazole delayed-	sulfacetamide, tobramycin
rel tablet
AZELEX	adapalene (except adapalene
ASCENSIA STRIPS AND KITS	ACCU-CHEK AVIVA PLUS	pad), benzoyl peroxide,
STRIPS AND KITS, ACCU-	clindamycin gel (except NDC
CHEK GUIDE STRIPS AND	68682046275), c/indamycin
KITS,ACCU-	solution, clindamycin-benzoyl
CHEK SMARTVIEW STRIPS	peroxide, dapsone,
AND KITS, ONETOUCH ULTRA	erythromycin solution,
STRIPS AND KITS, ONETOUCH	erythromycin- benzoyl
VERIO STRIPS AND KITS	peroxide, tretinoin, AKLIEF,

ASMANEX	ASMANEX HFA, PULMICORT

EPIDUO, TWYNEO, WINLEVI

FLEXHALER	AZESCO	generic prenatal vitamins

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
AZOPT	brinzolamide, dorzolamide	prednisolone solution (except
prednisolone solution 10 mg/5

AZOR	am/odipine-o/mesartan, amlodipine-telmisartan,

mL,20 mg/5 mL), prednisone

BALCOLTRA

amlodipine-valsartan	betamethasone dipropionate	desoximetasone (except
ointment 0.05%	desoximetasone ointment
ethinyl estradiol-drospirenone,	0.05%), fluocinonide (except
ethinyl estradiol-drospirenone-	fluocinonide cream 0.1%),
levomefolate, ethinyl estradio/-	BRYHALI
/evonorgestrel, ethinyl
estradio/-/evonorgestrel-iron,	BETAPACE, BETAPACE AF	sotalol ethinyl estradiol-
norethindrone acetate-iron,	BETHKIS	tobramycin inhalation solution
ethinyl estradiol-norgestimate,

LO LOESTRIN FE, NATAZIA

BETIMOL

timolol maleate solution

BANZEL	c/obazam, c/onazepam,	BETOPTICS	 timolol maleate solution lamotrigine, rufinamide,	BEVESPIAEROSPHERE	ANORO ELLIPTA, STIOLTO
topiramate, topiramate ext-rel	RESPIMAT

BARACLUDE TABLET	entecavir, lamivudine, tenofovir disoproxil fumarate, VEMLIDY

BEYAZ	ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone- levomefolate, ethinyl estradio/-

BASAGLAR	INSULIN GLARGINE-YFGN,	levonorgestrel, ethinyl
LANTUS	estradio/-/evonorgestrel-iron,
ethinyl estradio/-norethindrone
BENICAR, BENICAR HCT	candesartan,candesartan-	acetate-iron, ethinyl estradiol- hydrochlorothiazide,	 norgestimate, LO LOESTRIN
irbesartan, irbesartan-	FE, NATAZIA
hydrochlorothiazide, losartan,

losartan-hydrochlorothiazide,

BORTEZOMIB

bortezomib, NINLARO

olmesartan, olmesartan-	BOTOX
hydrochlorothiazide,
telmisartan, telmisartan-

AJOVY, DAXXIFY, EMGALITY,
QULIPTA, XEOMIN

hydrochlorothiazide, valsartan,	BREEZE 2 STRIPS AND KITS	ACCU-CHEKAVIVA PLUS
valsartan-hydrochlorothiazide	STRIPS AND KITS, ACCU-
BENSAL HP	desonide (except desonide	CHEK GUIDE STRIPS AND
ge{), hydrocortisone	KITS,ACCU-
CHEK SMARTVIEW STRIPS
benzonatate (NDCs	benzonatate (except NDCs	AND KITS, ONETOUCH ULTRA
69336012615,69499032915	69336012615, 69499032915)	STRIPS AND KITS, ONETOUCH
only)	VERIO STRIPS AND KITS
BEPREVE	azelastine, bepotastine,	BROMSITE	bromfenac, diclofenac, cromolyn sodium, loteprednol,		ketorolac
olopatadine	BROVANA	arformoterol, formoterol
BERINERT	icatibant, RUCONEST	inhalation solution
BESIVANCE	ciprofloxacin, erythromycin,	budesonide ext-rel tablet	balsalazide, mesa/amine gentamicin, levofloxacin,		 delayed-rel, mesa/amine ext-
moxifloxacin, ofloxacin,	rel, sulfasalazine, sulfasa/azine
su/facetamide, tobramycin	delayed-rel
BETAMETHASONE ACETATE-  dexamethasone,	Bupap	diclofenac sodium, ibuprofen,
BETAMETHASONE SODIUM	hydrocortisone,	naproxen (except naproxen CR
PHOSPHATE	methylprednisolone,	or naproxen suspension)

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
BUPHENYL	sodium phenylbutyrate,	CANASA	budesonide foam,	
	PHEBURANE		hydrocortisone enema,	
			mesa/amine enema,	
bupropion ext-rel tablet 450	bupropion, bupropion ext-rel	mesa/amine suppository,	
mg	(except bupropion ext-rel	CORTIFOAM	
	tablet 450 mg)		
Capsinac	diclofenac sodium, diclofenac	
butalbital-acetaminophen	diclofenac sodium, ibuprofen,		sodium gel 1%, diclofenac	
capsule, butalbital-	naproxen (except naproxen CR		sodium solution 1.5%,	
acetaminophen tablet 25-325	or naproxen suspension}		ibuprofen, meloxicam tablet,	
mg, butalbital-acetaminophen			naproxen (except naproxen CR	
tablet 50-300 mg,			or naproxen suspension}	
BUTALBITAL-				
ACETAMINOPHEN (NDC		CARAC	f/uorouracil cream 5%,	
69499034230 only)			f/uorouracil solution,	

butalbital-acetaminophen-	diclofenac sodium, ibuprofen,

imiquimod

caffeine capsule	naproxen (except naproxen CR	CARAFATE	sucra/fate tablet
or naproxen suspension}
CARBAGLU	carglumic acid
BUTRANS	buprenorphine transdermal,
BELBUCA	CARBINOXAMINE TABLET 6	levocetirizine
MG
BYDUREON BCISE	liraglutide, MOUNJARO,
OZEMPIC, RYBELSUS,	CARDIZEM, CARDIZEM CD,	diltiazem ext-rel (except TRULICITY	CARDIZEM LA	 generics for CARDIZEM LA),
verapamil ext-rel
BYETTA	liraglutide, MOUNJARO,
OZEMPIC, RYBELSUS,	carisoprodo/ 250 mg	carisoprodol 350 mg,
TRULICITY	chlorzoxazone 500 mg (except
NDC 73007001303),
SYSTOLIC	acebutolol, atenolol, carvedilol,	cyclobenzaprine (except
carvedilol phosphate ext-rel,	cyclobenzaprine tablet 7.5
metoprolol succinate ext-rel,	mg), metaxalone BOO mg,
metoprolol tartrate, nadolol,	methocarbamol (except NDCs
nebivolol, propranolol,	69036091010, 69036093090,
propranolol ext-rel	70868090190}
calcipotriene cream,	calcipotriene ointment,	CARNITOR, CARNITOR SF	levocarnitine
CALCIPOTRIENE FOAM	calcipotriene solution, VTAMA,
ZORYVE CREAM	CAYSTON	tobramycin inhalation solution
calcipotriene-betamethasone	calcipotriene ointment or	CELEBREX	celecoxib, diclofenac sodium, calcipotriene solution WITH		 ibuprofen, meloxicam tablet,
desoximetasone (except	naproxen (except naproxen CR
desoximetasone ointment	or naproxen suspension}
0.05%), fluocinonide (except

fluocinonide cream 0.1%) or

CETROTIDE	cetrorelix acetate, GANIRELIX

BRYHALI; ENSTILAR,	ACETATE
TACLONEX, VTAMA, ZORYVE	chlordiazepoxide-clidinium	dicyclomine
CREAM	(NDCs 11534019701,
calcitriol ointment	calcipotriene ointment,	42494040901, 51293069601,
calcipotriene solution, VTAMA,	 51293069610, 67877073101, ZORYVE CREAM	70700018501 only)
CAMBIA	diclofenac sodium, ibuprofen,	chlorzoxazone 250 mg,	carisoprodol 350 mg, naproxen (except naproxen CR	chlorzoxazone 375 mg,	chlorzoxazone 500 mg (except or naproxen suspension}	chlorzoxazone 500 mg (NDC	 NDC 73007001303),

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
73007001303 only),	cyclobenzaprine (except		foam (except clobetasol	
chlorzoxazone 750 mg	cyclobenzaprine tablet 7.5		emollient foam), clobetasol gel,	
	mg), metaxalone 800 mg,		clobetasol lotion, clobetasol	
	methocarbamol (except NDCs		ointment, halobetasol cream,	
	69036091010, 69036093090,		halobetasol ointment	

70868090190)

clobetasol spray	clobetasol cream, clobetasol

CHORIONIC GONADOTROPIN  PREGNYL	foam (except c/obetasol
emollient foam), clobetaso/ gel,
CIALIS	sildenafil, tadalafil, vardenafil	clobetasol lotion, clobetasol
ointment, halobetasol cream,

CICATRACE	Talk to your doctor

halobetasol ointment

CILOXAN	ciprofloxacin, erythromycin,	CLOBEX SPRAY	clobetasol cream, clobetasol
gentamicin, levofloxacin,	foam (except clobetasol
moxifloxacin, ofloxacin,	emollient foam), clobetasol gel,
sulfacetamide, tobramycin	clobetasol lotion, clobetasol
CIMZIA LYOPHILIZED	AVSOLA, ILUMYA, REMICADE,	ointment, halobetasol cream,
POWDER	SIMPON! ARIA, SKYRIZI	halobetasol ointment
INTRAVENOUS, STELARA	clocortolone cream	hydrocortisone butyrate
INTRAVENOUS	cream, hydrocortisone
CINRYZE	ORLADEYO,TAKHZYRO	butyrate ointment, hydrocortisone butyrate
CIPRO HC OTIC	ciprofloxacin-dexamethasone,	 solution, mometasone, ofloxacin otic	triamcinolone cream,
triamcinolone lotion,
ciprofloxacin-fluocinolone	ciprofloxacin-dexamethasone,	triamcinolone ointment of/oxacin otic	 (except triamcinolone
ointment 0.05%)
CITRANATAL	generic prenatal vitamins
COLAZAL	balsalazide, mesa/amine
CLIMARA (except CLIMARA	estradiol	delayed-rel, mesa/amine ext-
PRO)	rel, sulfasalazine, sulfasalazine
delayed-rel
CLINDAGEL	adapa/ene (except adapa/ene
pad), benzoyl peroxide,	colchicine capsule	colchicine tablet, MITIGARE
clindamycin gel (except NDC
68682046275), clindamycin	COLCRYS	colchicine tablet, MITIGARE
solution, clindamycin-benzoy/

peroxide, dapsone,

COMBIGAN

brimonidine-timolol

erythromycin- benzoyl

erythromycin solution,	COMPLERA	efavirenz-emtricitabine-
peroxide, tretinoin, AKLIEF,	tenofovir disoproxil fumarate,
EPIDUO, TWYNEO, WINLEVI	efavirenz-lamivudine-tenofovir
disoproxil fumarate,
clindamycin gel (NOC	adapalene (except adapalene	BIKTARVY, CABENUVA,
68682046275 only)	pad), benzoyl peroxide,	DOVATO, GENVOYA,
clindamycin gel (except NOC	ODEFSEY, SYMTUZA,
68682046275), clindamycin	TRIUMEQ
solution, c/indamycin-benzoy/

peroxide, dapsone,

CONCERTA	amphetamine-

erythromycin solution,	dextroamphetamine mixed
erythromycin- benzoy/	salts ext-rel,
peroxide, tretinoin, AKLIEF,	dexmethylphenidate ext-rel,
EPIDUO, TWYNEO, WINLEVI	dextroamphetamine ext-rel, lisdexamfetamine,
clobetasol emollient foam	c/obetasol cream, clobetasol	methylphenidate ext-rel,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	AZSTARYS		propranolol ext-rel	
CONTOUR NEXT STRIPS AND	ACCU-CHEK AVIVA PLUS	COSOPTPF	dorzolamide-timolol	
KITS	STRIPS AND KITS, ACCU-
CHEK GUIDE STRIPS AND	
COZAAR	candesartan, irbesartan,	
	KITS,ACCU-
CHEK SMARTVIEW STRIPS		/osartan, o/mesartan,
telmisartan, valsartan	

AND KITS, ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH

CRESEMBA

itraconazole

VERIO STRIPS AND KITS	CRESTOR	atorvastatin, ezetimibe-
CONTOUR STRIPS AND KITS	ACCU-CHEK AVIVA PLUS	simvastatin, fluvastatin,
STRIPS AND KITS, ACCU-	lovastatin, pitavastatin,
CHEK GUIDE STRIPS AND	pravastatin, rosuvastatin,
KITS,ACCU-	simvastatin
CHEK SMARTVIEW STRIPS	CRINONE	ENDOMETRIN
AND KITS, ONETOUCH ULTRA
STRIPS AND KITS, ONETOUCH	CUPRIMINE	penicillamine
VERIO STRIPS AND KITS

CONTRAVE	orlistat, QSYMIA, SAXENDA,

cyclobenzaprine ext-rel	carisoprodol 350 mg,
capsule, cyclobenzaprine	chlorzoxazone 500 mg (except

WEGOVY, ZEPBOUND	tablet 7.5 mg	NDC 73007001303),
COPAXONE 20 MG/ML	dimethyl fumarate delayed-re/,	cyclobenzaprine (except
fingolimod, glatiramer,	cyclobenzaprine tablet 7.5
teriflunomide, AVONEX,	mg), metaxalone 800 mg,
BAFIERTAM, BETASERON,	methocarbamol (except NDCs
COPAXONE 40 MG/ML,	69036091010,69036093090,
KESIMPTA, MAVZENT,	70868090190)
OCREVUS, REBIF, TYSABRI,	CYCLOSET	Talk to your doctor VUMERITY, ZEPOSIA
CYMBALTA	desvenlafaxineext-rel,
CORDRAN CREAM,	desonide (except desonide	duloxetine, venlafaxine,
CORDRAN LOTION	gel), hydrocortisone	venlafaxine ext-rel capsule
CORDRAN OINTMENT	hydrocortisone butyrate	CYSTADANE	betaine cream, hydrocortisone
butyrate ointment,	CYTOMEL	levothyroxine, liothyronine hydrocortisone butyrate
solution, mometasone,	DALIRESP	roflumi/ast triamcinolone cream,
triamcinolone lotion,	DARAPRIM	pyrimethamine
triamcinolone ointment
(except triamcinolone	DAYTRANA	amphetamine-
ointment 0.05%)	dextroamphetamine mixed
salts ext-rel,
CORDRAN TAPE	c/obetasol cream, c/obetasol	dexmethylphenidateext-rel, foam (except clobetasol	 dextroamphetamine ext-rel,
emollient foam), clobetaso/ gel,	lisdexamfetamine,
clobetasol lotion, clobetasol	methylphenidate ext-rel,
ointment, halobetaso/ cream,	AZSTARYS
halobetasol ointment
DELZICOL	balsalazide, mesa/amine
COREGCR	acebutolol, atenolo/, carvedilol,	delayed-rel, mesa/amine ext-
carvedilol phosphate ext-rel,	rel, sulfasalazine, su/fasalazine
metopro/ol succinate ext-rel,	delayed-rel
metoprolol tartrate, nado/o/,

nebivolo/, proprano/o/,

DENAVIR	acyclovir (except acyclovir

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	cream), penciclovir,	DEXILANT	esomeprazole delayed-rel,	
	valacyclovir		lansoprazole delayed-rel	
capsule, omeprazole delayed-	
DEPAKOTE, DEPAKOTE ER,	carbamazepine,		rel, pantoprazo/e delayed-rel	
DEPAKOTE SPRINKLE	carbamazepine ext-rel,		tablet	
	c/onazepam, divalproex			
	sodium, divalproex sodium	dexlansoprazole de/ayed-rel	esomeprazole delayed-rel,	
	ext-rel, ethosuximide,		lansoprazole delayed-rel	
	gabapentin, lacosamide,		capsule, omeprazo/e delayed-	
	lamotrigine, lamotrigine ext-		rel, pantoprazole delayed-rel	
	rel, levetiracetam,		tablet	
	levetiracetam ext-rel,			
	oxcarbazepine,phenobarbital,	DIACOMIT	Talk to your doctor	

phenytoin, phenytoin sodium extended, pregabalin,

diclofenac potassium capsule	diclofenac sodium, ibuprofen,

primidone, tiagabine,	25 mg, dic/ofenac potassium	meloxicam tablet, naproxen
topiramate, topiramate ext-re/,	tablet25 mg	(except naproxen CR or
valproic acid, zonisamide,	naproxen suspension)
APTIOM, BRIVIACT,	dic/ofenac potassium powder	diclofenac sodium, ibuprofen,

FYCOMPA, OXTELLAR XR, XCOPRI

naproxen (except naproxen CR
or naproxen suspension)

DEPO-SUBQ PROVERA 104		medroxyprogesteroneacetate	diclofenac sodium solution 2% diclofenac sodium, diclofenac 15DmglmL		sodium gel 1%, dic/ofenac
DESFERAL	deferasirox, deferiprone,	sodium solution 1.5%, deferoxamine	 ibuprofen, meloxicam tablet,
naproxen (except naproxen CR
desonide gel		desonide (except desonide	or naproxen suspension) ge{), hydrocortisone
DiclofexDC	diclofenac sodium, diclofenac
desoximetasone ointment	hydrocortisone butyrate	sodium gel 1%, diclofenac
0.05%	cream,hydrocortisone	sodium solution 1.5%, butyrate ointment,	 ibuprofen, meloxicam tablet,
hydrocortisonebutyrate	naproxen (except naproxen CR
solution, mometasone,	or naproxen suspension)
triamcinolone cream,

triamcinolone lotion,

Dic/osaicin

diclofenac sodium, diclofenac

triamcinolone ointment	sodium gel 1%, diclofenac
(except triamcinolone	sodium solution 1.5%,
ointment 0.05%)	ibuprofen, meloxicam tablet,
naproxen (except naproxen CR
DESVENLAFAXINE ER	desven/afaxine ext-rel,	or naproxen suspension) duloxetine, venlafaxine,

venlafaxine ext-rel capsule

DIFFERIN LOTION	adapalene (except adapalene
pad), benzoyl peroxide,

DETROL LA	darifenacin ext-rel,	clindamycin gel (except NDC
fesoterodine ext-rel,	68682046275), clindamycin
oxybutynin ext-rel, solifenacin,	solution, clindamycin-benzoyl
tolterodine, tolterodine ext-rel,	peroxide, dapsone,
trospium, trospium ext-rel,	erythromycin solution,
GEMTESA	erythromycin- benzoy/
peroxide, tretinoin, AKLIEF,
dexchlorpheniramine	clemastine 2.68 mg,	EPIDUO, TWYNEO, WINLEVI
cyproheptadine, levocetirizine
diflorasone cream, diflorasone  desoximetasone (except
Dexifol	generic multivitamins	ointment	desoximetasone ointment
0.05%), fluocinonide (except

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	fluocinonide cream 0.1%),		minocycline, tetracycline	
	BRYHALI	doxycycline hyclate tablet 50	doxycycline hyclate capsule,	
dihydroergotaminespray	eletriptan, naratriptan,	mg, doxycycline hyclate tablet	doxycycline hyclate tablet	
	rizatriptan, sumatriptan,	75 mg, doxycycline hyclate	(except doxycycline hyclate	
	zolmitriptan, NURTEC ODT,	tablet 150 mg	tablet 50 mg, 75 mg, 150 mg),	
	UBRELVY		minocycline, tetracycline	
DILANTIN	carbamazepine,	doxycycline monohydrate	doxycycline hyclate capsule,	
	carbamazepine ext-rel,	capsule 75 mg, doxycycline	doxycycline hyclate tablet	
	divalproex sodium, divalproex	monohydrate capsule 150 mg	(except doxycycline hyclate	
	sodium ext-rel, gabapentin,		tablet 50 mg, 75 mg, 150 mg),	
	lacosamide, lamotrigine,		minocycline, tetracycline	
	/amotrigine ext-rel,
levetiracetam, levetiracetam	doxycycline monohydrate	
ORACEA	
	ext-rel, oxcarbazepine,	delayed-rel capsule		

phenobarbital, phenytoin, phenytoin sodium extended,

DUAVEE	estradiol-norethindrone,

pregabalin, primidone,	raloxifene, BIJUVA
tiagabine, topiramate,	DULERA	budesonide-formoterol,
topiramate ext-rel, valproic	fluticasone-salmeterol (except

acid, zonisamide, APTIOM, BRIVIACT, FYCOMPA, OXTELLAR XR, XCOPRI

certain NDCs), Breyna, Wixela lnhub, BREO ELLIPTA (except certain NDCs)

diltiazem ext-rel (generics for	diltiazem ext-rel (except	DUOBRII	calcipotriene ointment or CARDIZEM LA only)	 generics for CARDIZEM LA),		 calcipotriene solution WITH
verapamil ext-rel	desoximetasone (except
DIOVAN, DIOVAN HCT	candesartan, candesartan-	desoximetasone ointment hydrochlorothiazide,	 0.05%), fluocinonide (except
irbesartan, irbesartan-	fluocinonide cream 0.1%) or
hydrochlorothiazide, losartan,	BRYHALI; ENSTILAR,
losartan-hydrochlorothiazide,	TACLONEX, VTAMA, ZORYVE
olmesartan, olmesartan-	CREAM
hydrochlorothiazide,	DYANAVELXR	amphetamine-
telmisartan, telmisartan-	dextroamphetamine mixed
hydrochlorothiazide, valsartan,	salts ext-rel,
valsartan-hydrochlorothiazide	dexmethylphenidate ext-rel,
Diphen Elixir	clemastine 2.68 mg,	dextroamphetamine ext-rel, cyproheptadine, levocetirizine	 lisdexamfetamine,
methylphenidate ext-rel,
DORYXMPC	doxycycline hyclate capsule,	AZSTARYS
doxycycline hyclate tablet

(except doxycycline hyclate

DYMISTA	azelastine-fluticasone,

tablet 50 mg, 75 mg, 150 mg),	flunisolide, fluticasone,
minocycline, tetracycline	mometasone
doxepin cream		desonide (except desonide	 DYRENIUM	amiloride, triamterene gel), hydrocortisone,	DYSPORT	 DAXXIFY, XEOMIN
pimecrolimus, tacrolimus,
EUCRISA, OPZELURA	ECOZA	ciclopirox, clotrimazole,
doxycycline hyclate delayed-	doxycycline hyc/ate capsule,	econazole, ketoconazole

rel tablet	doxycycline hyc/ate tablet (except doxycycline hyclate tablet 50 mg, 75 mg, 150 mg),

cream 2%, oxiconazole
(except NDCs 00168035830,
51672135902)

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
EDARBI, EDARBYCLOR	candesartan, candesartan-		RETACRIT	
	hydrochlorothiazide,			
irbesartan, irbesartan-	ergotamine-caffeine	eletriptan, naratriptan,	
hydrochlorothiazide, losartan,		rizatriptan, sumatriptan,	
losartan-hydrochlorothiazide,		zolmitriptan, NURTEC ODT,	
olmesartan, olmesartan-		UBRELVY	

hydrochlorothiazide, telmisartan, telmisartan-

ERTACZO	ciclopirox, clotrimazole,

hydrochlorothiazide, valsartan,	econazole, ketoconazole
valsartan-hydrochlorothiazide	cream 2%, oxiconazole
(except NDCs 00168035830,
EDLUAR	doxepin, ramelteon,	51672135902)
temazepam, zolpidem,

zo/pidem ext-rel

ERYPED	erythromycins

EDURANT	efavirenz	ESBRIET	pirfenidone, OFEV
E.E.S. GRANULES	erythromycins	estradiol vaginal tablet	estradiol vaginal cream,
IMVEXXY, VAGIFEM

EFFEXORXR	desvenlafaxineext-rel, duloxetine, venlafaxine,

ESTRING	estradiol vaginal cream,

venlafaxine ext-rel capsule	IMVEXXY, VAGIFEM
ELELYSO	CERDELGA, CEREZYME	ESTROGEL	estradio/
ELESTRIN	estradiol	EVEKEO	dexmethylphenidate, dextroamphetamine,
ELIDEL	pimecrolimus, tacrolimus,	methylphenidate
EUCRISA, OPZELURA
EVERSENSE CONTINUOUS	DEXCOM CONTINUOUS
ELMIRON	Talk to your doctor	GLUCOSE MONITORING	GLUCOSE MONITORING
SYSTEM	SYSTEM

EMEND	aprepitant

EXFORGE	amlodipine-olmesartan,

ENLITE CONTINUOUS	DEXCOM CONTINUOUS	amlodipine-telmisartan,
GLUCOSE MONITORING	GLUCOSE MONITORING	amlodipine-valsartan
SYSTEM	SYSTEM
EXFORGE HCT	amlodipine-valsartan-
ENTERAGAM	alosetron, VIBERZI, XIFAXAN	hydrochlorothiazide,
550MG	olmesartan-amlodipine-
hydrochlorothiazide
ENTYVIO INTRAVENOUS (For	AVSOLA, REMICADE, SKYRIZI
Crohn's Disease Only)	INTRAVENOUS, STELARA	EXJADE	deferasirox, deferiprone,
INTRAVENOUS	deferoxamine
EPANED	enalapril, fosinopril, lisinopril,	EXTAVIA	dimethyl fumarate delayed-rel, quinapril, ramipril		 fingolimod, glatiramer,
teriflunomide, AVONEX,
EPICERAM	desonide (except desonide	BAFIERTAM, BETASERON,
gel), hydrocortisone	COPAXONE 40 MG/ML,
KESIMPTA, MAYZENT,

epinephrine (NDCs 00093-	epinephrine (except NDCs

OCREVUS, REBIF, TYSABRI,

XXXX-XX, 49502-XXXX-XX	00093-XXXX-XX, 49502-	VUMERITY, ZEPOSIA only)	 XXXX-XX), AUVI-Q

EPIPEN, EPIPEN JR	epinephrine (except NDCs

EYLEA	BYOOVIZ, CIMERLI

00093-XXXX-XX, 49502-	FABIOR	adapalene (except adapalene
XXXX-XX), AUVI-Q	pad), benzoyl peroxide,
c/indamycin gel (except NDC
EPOGEN	ARANESP, PROCRIT,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
68682046275), clindamycin	topiramate, topiramate ext-rel solution, clindamycin-benzoyl
peroxide, dapsone,	FIORICET CAPSULE	diclofenac sodium, ibuprofen,
erythromycin solution,	naproxen (except naproxen CR
erythromycin- benzoy/	or naproxen suspension)
peroxide, tretinoin, AKLIEF,

EPIOUO, TWYNEO, WINLEVI

FIRAZYR

icatibant, RUCONEST

FANAPT	aripiprazole, asenapine,	FIRMAGON	ELIGARO
clozapine, lurasidone,	FLAREX	dexamethasone, difluprednate,

olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR

loteprednol, prednisolone acetate 1%

sodium gel 1%, diclofenac

FEIBA	NOVOSEVEN RT, SEVENFACT	FLECTOR	dic/ofenac sodium, dic/ofenac
FEMRING	estradiol vaginal cream,	sodium solution 1.5%,
IMVEXXY, VAGIFEM	ibuprofen, meloxicam tablet,
naproxen (except naproxen CR
fenofibrate capsule 30 mg, 50	 fenofibrate (except fenofibrate	or naproxen suspension) mg, 90 mg, 130 mg;	capsule 30 mg, 50 mg, 90 mg,
fenofibrate tablet 40 mg, 120	130 mg; fenofibrate tablet 40	FLORIVA, FLORIVA PLUS	generic multivitamins
mg	mg, 120 mg), fenofibric acid	FLOVENT OISKUS, FLOVENT	ASMANEX HFA, PULMICORT
delayed-rel	HFA	FLEXHALER

FENOGLIOE TABLET 120 MG		fenofibrate (except fenofibrate	flucytosine capsule 500 mg capsule 30 mg, 50 mg, 90 mg,

fluconazole

130 mg; fenofibrate tablet 40	fluocinonide cream 0.1%	clobetasol cream, clobetasol
mg, 120 mg), fenofibric acid	foam (except clobetasol
delayed-rel	emollient foam), clobetasol gel,
fenoprofen, FENOPROFEN	diclofenac sodium, ibuprofen,	clobetasol lotion, clobetasol
CAPSULE	meloxicam tablet,	ointment, halobetasol cream,
naproxen (except naproxen CR	halobetasol ointment
or naproxen suspension)	f/uorouracil cream 0.5%	fluorouracil cream 5%,
fluorouracil solution,

FENTORA	fentanyl transmucosal

imiquimod

FERIVA21/7	generic multivitamins	f/uoxetine tablet (generics for	fluoxetine (except f/uoxetine
FERRIPROX	deferasirox, deferiprone,	SARAFEM only)	 tablet 60 mg, f/uoxetine tablet deferoxamine		[generics tor SARAFEM]),
paroxetine HCI ext-rel (except
FETZIMA	desvenlafaxine ext-rel,	NOC 60505367503),
duloxetine, venlafaxine,	sertraline, vilazodone
venlafaxine ext-rel capsule
f/uoxetine tablet 60 mg,	citalopram, escitalopram,
Fexmid	carisoprodol 350 mg,	FLUOXETINE 60 MG	 f/uoxetine (except f/uoxetine chlorzoxazone 500 mg (except		tablet 60 mg, f/uoxetine tablet
NOC 73007001303),	[generics for SARAFEM]),
cyclobenzaprine (except	paroxetine HCl, paroxetine HCI
cyclobenzaprinetablet 7.5	ext-rel (except NOC
mg), metaxalone 800 mg,	60505367503), sertra/ine,
methocarbamol (except NOCs	vilazodone, TRINTELLIX 69036091010,69036093090,

70868090190)

flurandrenolide cream,

desonide (except desonide

FINTEPLA	clobazam, clonazepam, lamotrigine, rufinamide,

flurandrenolide lotion	gel), hydrocortisone flurandrenolide ointment	 hydrocortisone butyrate

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
cream, hydrocortisone	GELNIQUE	darifenacin ext-rel,
butyrate ointment,	fesoterodine ext-rel,
hydrocortisone butyrate	oxybutynin ext-rel, solifenacin,
solution, mometasone,	tolterodine, tolterodine ext-rel,
triamcinolone cream,	trospium, trospium ext-rel,
triamcinolone lotion,	GEMTESA
triamcinolone ointment
(except triamcinolone	GENOTROPIN	HUMATROPE, NORDITROPIN,
ointment 0.05%)	SOGROYA
FML FORTE, FML LIQUIFILM	dexamethasone, difluprednate,	GEODON CAPSULE	 aripiprazole, asenapine, loteprednol, prednisolone		clozapine, lurasidone,
acetate 1%	olanzapine, quetiapine,
quetiapine ext-rel, risperidone,
FOCALIN XR	amphetamine-	ziprasidone, VRAYLAR
dextroamphetaminemixed
salts ext-rel,	GEODON INTRAMUSCULAR	haloperidol, ziprasidone

dexmethylphenidate ext-rel, dextroamphetamine ext-rel,	GILENYA
/isdexamfetamine, methylphenidate ext-rel,

dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX,

AZSTARYS	BAFIERTAM, BETASERON,
COPAXONE 40 MG/ML,
FORTAMET	metformin, metformin ext-rel	 KESIMPTA, MAYZENT, (except generics	OCREVUS, REBIF, TYSABRI,
for FORTAMET and	VUMERITY, ZEPOSIA
GLUMETZA)	GLASSIA	PROLASTIN-C, ZEMAIRA

FOSRENOL	calcium acetate, sevelamer
carbonate, AURYXIA

FOSTEUM, FOSTEUM PLUS	alendronate, ibandronate,
risedronate

GLEEVEC	imatinib mesylate, BOSULIF, SPRYCEL
GLUMETZA	metformin, metformin ext-rel
(except generics

FRAGMIN	enoxaparin, fondaparinux	for FORTAMET and GLUMETZA)
FREESTYLE LIBRE	DEXCOM CONTINUOUS
CONTINUOUS GLUCOSE	GLUCOSE MONITORING	GLYCOPYRROLATETABLET	dicyclomine
MONITORING SYSTEM	SYSTEM	1.5 MG
FREESTYLE STRIPS AND KITS		ACCU-CHEK AVIVA PLUS	GOLYTELY	peg 3350-electrolytes (except STRIPS AND KITS, ACCU-		 generics for MOVIPREP),
CHEK GUIDE STRIPS AND	sodium sulfate-potassium
KITS,ACCU-	sulfate-magnesium sulfate,
CHEK SMARTVIEW STRIPS	CLENPIQ
AND KITS, ONETOUCH ULTRA
STRIPS AND KITS, ONETOUCH	GONAL-F	FOLLISTIM AQ
VERIO STRIPS AND KITS	GRANIX	NIVESTYM
FULPHILA	FYLNETRA, NYVEPRIA	GUARDIAN	DEXCOM CONTINUOUS
Fyremadel	cetrorelix acetate, GANIRELIX	 CONNECT CONTINUOUS	GLUCOSE MONITORING ACETATE	GLUCOSE MONITORING	 SYSTEM
SYSTEM

ganirelix acetate	cetrorelix acetate, GANIRELIX	GUARDIAN REAL-TIME

DEXCOM CONTINUOUS

ACETATE

CONTINUOUS GLUCOSE	GLUCOSE MONITORING

GEL-ONE		DUROLANE, EUFLEXXA,	MONITORING SYSTEM	SYSTEM GELSYN-3, SUPARTZ FX

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
halcinonide cream	desoximetasone (except	HVZAAR	candesartan-	
	desoximetasone ointment		hydrochlorothiazide,	
	0.05%), fluocinonide (except		irbesartan-	
	ftuocinonide cream 0.1%),		hydrochlorothiazide, losartan-	
	BRYHALI		hydrochlorothiazide,	

HALOG	desoximetasone (except		olmesartan- hydrochlorothiazide,	
	desoximetasone ointment		telmisartan-	
	0.05%), fluocinonide (except		hydrochlorothiazide, valsartan-	
	fluocinonide cream 0.1%),		hydrochlorothiazide	
	BRYHALI			
		lclofenac CP	diclofenac sodium, diclofenac	
HEPARIN SODIUM IN 5%	enoxaparin, fondaparinux		sodium gel 1%, diclofenac	
DEXTROSE			sodium solution 1.5%,	

HERCEPTIN, HERCEPTIN	KANJINTI, TRAZIMERA

ibuprofen, meloxicam tablet, naproxen (except naproxen CR

HYLECTA	or naproxen suspension)
HERZUMA	KANJINTI, TRAZIMERA	ICLUSIG	imatinib mesylate, BOSULIF,
HORIZANT	gabapentin, pregabalin,	SPRYCEL
GRALISE	ILEVRO	bromfenac, diclofenac,
HUMALOG	FIASP, NOVOLOG	ketorolac
HUMALOG MIX 50/50	NOVOLOG MIX 70/30	IMBRUVICA	BRUKINSA, CALQUENCE HUMALOG MIX 75/25	NOVOLOG MIX 70/30	INCRUSE ELLIPTA	 SPIRIVA
HUMULIN 70/30	NOVOLIN 70/30	INDERAL LA, INDERAL XL	acebutolol, ateno/o/, carvedilol,
carvedilo/ phosphate ext-rel,
HUMULIN N	NOVOLIN N	metoprolol succinate ext-rel, metoprolol tartrate, nadolol,
HUMULIN R	NOVOLIN R	nebivolol, propranolol, proprano/ol ext-rel
HYALGAN	DUROLANE, EUFLEXXA,
GELSYN-3, SUPARTZ FX	lndocin, INDOCIN	diclofenac sodium, ibuprofen,
meloxicam tablet,
hydrocortisone butyrate lotion hydrocortisonebutyrate	naproxen (except naproxen CR cream, hydrocortisone	or naproxen suspension) butyrate ointment,
hydrocortisonebutyrate	lnflammacin	dic/ofenac sodium, diclofenac
solution, mometasone,	sodium gel 1%, diclofenac
triamcinolone cream,	sodium solution 1.5%,
triamcinolone lotion,	ibuprofen, meloxicam tablet,
triamcinolone ointment	naproxen (except naproxen CR
(except triamcinolone	or naproxen suspension)
ointment 0.05%)

INFLECTRA

AVSOLA, ILUMYA, REMICADE,

	INTRAVENOUS, STELARA	
hyoscyamine sulfate ext-rel	dicyclomine		INTRAVENOUS	
HYQVIA

HYSINGLA ER	CUTAQUIG

fentanyl transdermal,	INNOPRANXL	acebutolol, atenolol, carvedilol,
carvedilol phosphate ext-rel, metoprolol succinate ext-rel,	
	hydrocodone ext-rel,
methadone, morphine ext-rel,
oxycodone ext-rel		metoprolol tartrate, nadolol,
nebivolol, propranolol, propranolol ext-rel	

HylaVite	generic multivitamins	SIMPON! ARIA, SKYRIZI

EXCLUDED DRUG NAME($)	PREFERRED OPTION($)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION($)	
INTELENCE	etravirine		dextroamphetamine mixed	

INTRAROSA	estradiol vaginal cream,		salts ext-rel,
dexmethy/phenidateext-rel,	
	IMVEXXY, VAGIFEM		dextroamphetamine ext-rel,	

INTUNIV

amphetamine-

lisdexamfetamine, methylphenidate ext-rel,

dextroamphetaminemixed	AZSTARYS
salts ext-rel, atomoxetine,
dexmethylphenidateext-rel,	JUXTAPID	REPATHA
dextroamphetamineext-re/,
guanfacine ext-rel,	JYNARQUE	Talk to your doctor
lisdexamfetamine,
methylphenidate ext-rel,	KALETRA	atazanavir, darunavir,
AZSTARYS, QELBREE	lopinavir-ritonavir
INVELTYS	dexamethasone, difluprednate,	KAMDOY	desonide {except desonide
/oteprednol, prednisolone	gel), hydrocortisone acetate 1%
KapzinDC	diclofenac sodium, diclofenac
INVOKAMET, INVOKAMET XR   SYNJARDY, SYNJARDY XR,	sodium gel 1%, diclofenac
XIGDUOXR	sodium solution 1.5%,
ibuprofen, meloxicam tablet,
INVOKANA	FARXIGA, JARDIANCE	naproxen {except naproxen CR
or naproxen suspension)
IRESSA	erlotinib, gefitinib
KAZANO	saxagliptin-metformin ext-rel,
ISORDIL	isosorbide dinitrate {except	ZITUVIMET, ZITUVIMET XR
isosorbide dinitrate 40 mg),
isosorbide mononitrate	KENALOG		hydrocortisone butyrate cream, hydrocortisone
isosorbide dinitrate 40 mg	isosorbide dinitrate {except	butyrate ointment,
isosorbide dinitrate 40 mg),	hydrocortisone butyrate
isosorbide mononitrate	solution, mometasone,
triamcinolone cream,

isotretinoin capsule 25 mg, 35

isotretinoin capsule20 mg,30

triamcinolone lotion,

mg	mg,40mg	triamcinolone ointment
ISTALOL	timolol maleate solution		{except triamcinolone ointment 0.05%)
ivermectin cream	azelaic acid gel, brimonidine	KEPPRA, KEPPRA XR	carbamazepine,
gel, metronidazo/e,	carbamazepine ext-rel,
FINACEA FOAM, SOOLANTRA	divalproex sodium, divalproex
IXINITY	ALPROLIX, BENEFIX, REBINYN	sodium ext-rel, gabapentin, lacosamide, /amotrigine,
JADENU	deferasirox, deferiprone,	lamotrigine ext-rel, deferoxamine	levetiracetam, levetiracetam
ext-rel, oxcarbazepine,
JAKAFI (For Polycythemia	BESREMI	phenobarbital, phenytoin,
Vera Only)	phenytoin sodium extended,
pregabalin, primidone,
JANUMET, JANUMET XR	saxagliptin-metformin ext-rel,	tiagabine, topiramate,
ZITUVIMET, ZITUVIMET XR		topiramate ext-rel, valproic acid, zonisamide, APTIOM,

JANUVIA

saxag/iptin, ZITUVIO

BRIVIACT, FYCOMPA,

JENTADUETO,JENTADUETO	saxagliptin-metformin ext-rel,	OXTELLAR XR, XCOPRI
XR	ZITUVIMET, ZITUVIMET XR	KETO-DIASTIX	Talk to your doctor
JORNAYPM	amphetamine-

EXCLUDED DRUG NAME(S)

ketoconazole foam 2%

Ketodan

ketoprofen capsule 25 mg

ketoprofen ext-rel capsule

KET0STIX KITABIS PAK K0RLYM KUVAN KYPR0LIS LACRISERT
LACTUL0SE PAK LAMICTAL, LAMICTAL 0DT

LAMICTALXR

PREFERRED OPTION(S)

ketoconazole shampoo 2%, selenium sulfide lotion 2.5%, Z0RYVEF0AM
ketoconazole shampoo 2%, selenium sulfide lotion 2.5%,
Z0RYVEF0AM

diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
Talk to your doctor tobramycin inhalation solution mifepristone
sapropterin bortezomib, NINLARO RESTASIS, XIIDRA
lactulose solution
carbamazepine, carbamazepine ext-rel, clobazam, clonazepam, divalproex sodium, divalproex sodium ext-rel, 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, APTI0M, BRIVIACT, FYC0MPA, 0XTELLAR XR,
XCOPRI

carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine,

EXCLUDED DRUG NAME(S)

LAN0XIN TABLET (125 MCG
and 250 MCG only)

lansoprazole delayed-rel orally disintegrating tablet

lanthanum carbonate

LATUDA

LEMTRADA

LESC0LXL

LETAIRIS

LEUKINE LEVEMIR

levorphanol

LEXAPR0

PREFERRED OPTION(S)

phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, topiramate ext-rel, valproic acid, zonisamide, APTI0M, BRIVIACT, FYC0MPA, 0XTELLAR XR, XC0PRI
digoxin

esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole de/ayed­ rel, pantoprazole delayed-rel tablet
calcium acetate, sevelamer carbonate, AURYXIA
aripiprazole, asenapine, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR
dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AV0NEX, BAFIERTAM, BETASER0N, C0PAX0NE 40 MG/ML, KESIMPTA, MAYZENT, 0CREVUS, REBIF, TYSABRI, VUMERITY, ZEP0SIA
atorvastatin, ezetimibe­ simvastatin, f/uvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin
ambrisentan, bosentan,
0PSUMIT NIVESTYM
INSULIN GLARGINE-YFGN, LANTUS
fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, oxycodone ext-rel
citalopram, escitalopram, ftuoxetine (except f/uoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]),

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	paroxetine HCI, paroxetine HCI	LUMIGAN	bimatoprost, latanoprost,	
	ext-rel(except NOC		travoprost	
	60505367503), sertraline,
vilazodone, TRINTELLIX	
LUNESTA	
doxepin, ramelteon,	
			temazepam, zo/pidem,	
LIALDA	ba/sa/azide, mesa/amine		zolpidem ext-rel	
	delayed-rel, mesa/amine ext- rel, sulfasalazine, sulfasalazine	
LUPRON DEPOT 7.5 MG, 22.5	
ELIGARD	
	delayed-re/	MG, 30 MG, 45 MG		
LIBRAX	dicyclomine	LUZU	ciclopirox, clotrimazole,
econazo/e, ketoconazole	
LILETTA	KYLEENA, MIRENA, SKYLA		cream2%, oxiconazole	

LIPITOR	atorvastatin, ezetimibe-		(except NDCs 00168035830,
51672135902)	
	simvastatin, fluvastatin,			
	lovastatin, pitavastatin,	LYRICA	duloxetine, pregabalin	
pravastatin, rosuvastatin,
simvastatin	MACROOANTIN		nitrofurantoin (except NOC 16571074024)

LITHOSTAT	Talk to your doctor

MatzimLA	diltiazem ext-rel (except

LIVALO	atorvastatin, ezetimibe-	generics for CARDIZEM LA),
simvastatin, fluvastatin,	verapamil ext-rel
lovastatin, pitavastatin,
pravastatin, rosuvastatin,	MAVYRET	EPCLUSA (genotypes 1, 2, 3, 4,
simvastatin	5, 6), HARVONI (genotypes 1,
4, 5, 6), VOSEVI
Lofena	diclofenac sodium, ibuprofen,
meloxicam tablet, naproxen	MAXALT, MAXALT-MLT	eletriptan, naratriptan,
(except naproxen CR or	rizatriptan, sumatriptan,
naproxen suspension)		zolmitriptan, NURTEC ODT, UBRELVY

LOKELMA	VELTASSA

MAXIOEX	dexamethasone, difluprednate,

Lorzone	carisoprodol 350 mg,	loteprednol, prednisolone
chlorzoxazone 500 mg (except	acetate 1%
NOC 73007001303),
cyclobenzaprine (except	mefenamic acid (NOC	 diclofenac sodium, ibuprofen, cyc/obenzaprine tablet 7.5	 69336012830 only)	me/oxicam tablet,
mg),metaxalone 800 mg,	naproxen (except naproxen CR
methocarbamol (except NDCs	or naproxen suspension) 69036091010, 69036093090,
70868090190)	MEKINIST TABLET	COTELLIC, MEKTOVI
LOTEMAX, LOTEMAX SM	dexamethasone, difluprednate,	meloxicam capsule	 diclofenac sodium, ibuprofen, loteprednol, predniso/one		meloxicam tablet,
acetate 1%	naproxen (except naproxen CR
or naproxen suspension)
LOVAZA	icosapent ethyl, omega-3 acid
ethyl esters	MENEST	estradiol
LUCENTIS	BYOOVIZ, CIMERLI	MENOSTAR	estradiol
luliconazole	ciclopirox, clotrimazole,	meperidine	 hydromorphone, morphine, econazo/e, ketoconazole		oxycodone
cream 2%, oxiconazole	MESTINON	pyridostigmine,

(except NDCs 00168035830,
51672135902)

pyridostigmine ext-rel

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)

metaxalone 400 mg	carisoprodol 350 mg,	 (except doxycycline hyclate chlorzoxazone 500 mg (except	tablet 50 mg,75 mg, 150 mg),
NDC 73007001303),	minocycline, tetracycline
cyclobenzaprine (except
cyclobenzaprine tablet 7.5	MINOLIRA	doxycycline hyclate capsule,
mg), metaxalone 800 mg,	doxycycline hyc/ate tablet
methocarbamol (except NDCs	(except doxycycline hyclate
69036091010,69036093090,	tablet 50 mg,75 mg, 150 mg),
70868090190)	minocycline, tetracycline
metformin ext-rel (generics for  metformin, metformin ext-rel	MIRVASO	azelaic acid gel, brimonidine
FORTAM ET and GLUMETZA	(except generics for	gel, metronidazole, FINACEA
only)	FORTAMET and GLUMETZA)	FOAM, SOOLANTRA
methocarbamol 500 mg (NDC carisoprodol 350 mg,	Mondoxyne NL capsule 75 mg  doxycycline hyclate capsule,
69036091010 only),	chlorzoxazone 500 mg (except	doxycycline hyclate tablet
methocarbamol 750 mg	NDC 73007001303),	(except doxycycline hyclate
(NDCs 69036093090,	cyclobenzaprine(except	tablet 50 mg,75 mg, 150 mg),
70868090190 only)	cyclobenzaprinetablet 7.5	minocycline, tetracycline
mg), metaxalone 800 mg,

methocarbamol (except NDCs

MONOVISC	DUROLANE, EUFLEXXA,

69036091010,69036093090,	GELSYN-3, SUPARTZ FX
70868090190)	MOVANTIK	lubiprostone, SYMPROIC
METROGEL	azelaic acid gel, brimonidine	MOVIPREP	peg 3350-electrolytes (except

gel, metronidazole, FINACEA FOAM, SOOLANTRA

generics for MOVIPREP),
sodium sulfate-potassium

MIACALCIN INJECTION	alendronate, calcitonin-	sulfate-magnesium sulfate, salmon, ibandronate,	 CLENPIQ
risedronate, teriparatide,	MULPLETA	DOPTELET PROLIA, TYMLOS
MICARDIS, MICARDIS HCT	candesartan, candesartan-	MultiPro	generic multivitamins
hydrochlorothiazide,	mupirocin cream	gentamicin, mupirocin irbesartan, irbesartan-		 ointment
hydrochlorothiazide, losartan,
losartan-hydrochlorothiazide,	MYDAYIS	amphetamine-
olmesartan, olmesartan-	dextroamphetaminemixed
hydrochlorothiazide,	salts ext-rel,
telmisartan, telmisartan-	dexmethylphenidateext-rel,
hydrochlorothiazide, valsartan,	dextroamphetamineext-rel,
valsartan-hydrochlorothiazide	lisdexamfetamine, methylphenidate ext-rel,

Migergot	eletriptan, naratriptan,
rizatriptan, sumatriptan,

AZSTARYS

zolmitriptan, NURTEC ODT,	MYOBLOC	DAXXIFY, XEOMIN
UBRELVY
MYRBETRIQ	darifenacin ext-rel,
MIGRANAL	eletriptan, naratriptan,	 fesoterodine ext-rel, rizatriptan, sumatriptan,	oxybutynin ext-rel, solifenacin,
zolmitriptan, NURTEC ODT,	tolterodine, tolterodine ext-rel,
UBRELVY	trospium, trospium ext-rel,
GEMTESA
MINIVELLE	estradiol
MYTESI	diphenoxylate-atropine,
minocycline ext-rel	doxycycline hyclate capsule,	loperamide doxycycline hyclate tablet

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
NAFTIN	ciclopirox, clotrimazole,	niacin tablet 500 mg	niacin ext-rel	
econazole, ketoconazole
cream 2%, oxiconazole	Niacor	niacin ext-rel
(except NDCs 00168035830,

51672135902)

NICADAN	generic multivitamins

NAMENDAXR	memantine	NICAPRIN	generic multivitamins
NAPRELAN	diclofenac sodium, ibuprofen,	NICAZEL, NICAZEL FORTE	generic multivitamins meloxicam tablet,	 NILANDRON	 abiraterone, bicalutamide,
naproxen (except naproxen CR	ERLEADA, NUBEQA, XTANDI,
or naproxen suspension)	YONSA
naproxen CR	diclofenac sodium, ibuprofen,	nitrofurantoin (NOC	nitrofurantoin (except NOC
meloxicam tablet,	16571074024 only)	16571074024)
naproxen (except naproxen CR
or naproxen suspension)	NITYR	ORFADIN
naproxen suspension	diclofenac sodium, ibuprofen,	NORGESIC FORTE	carisoprodol 350 mg,
meloxicam tablet,	chlorzoxazone 500 mg (except
naproxen (except naproxen CR	NOC 73007001303),
or naproxen suspension)	cyc/obenzaprine (except
naproxen-esomeprazole	diclofenac sodium, ibuprofen,	cyclobenzaprinetablet 7.5

meloxicam tablet or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel,

mg), metaxalone 800 mg, methocarbamol (except NDCs 69036091010, 69036093090,
70868090190)

lansoprazole delayed-rel	NORITATE	azelaic acid gel, brimonidine
capsule, omeprazole delayed-	gel, metronidazole, FINACEA
rel, or pantoprazole delayed-	FOAM, SOOLANTRA
rel tablet

NEO-SYNALAR	desonide (except desonide

NORPACE	disopyramide

gel) or hydrocortisone WITH	NORTHERA	midodrine gentamicin

NESINA	saxagliptin, ZITUVIO

NEULASTA,NEULASTA	FYLNETRA, NYVEPRIA

NORVASC	amlodipine, nifedipine ext-rel
NORVIR	ritonavir

ONPRO	NOURIANZ	entacapone, pramipexole, pramipexole ext-rel, rasagiline,
NEUPOGEN	NIVESTYM	ropinirole, ropinirole ext-rel, selegiline, NEUPRO

NEVANAC

bromfenac, diclofenac,
ketorolac	NOVAREL	PREGNYL

NEXAVAR	pazopanib, sorafenib, sunitinib,	NOVO NORDISK NEEDLES	BD ULTRAFINE NEEDLES
CABOMETYX, INLYTA,
LENVIMA	NOXAFIL	f/uconazole, itraconazole

NEXIUM	esomeprazole delayed-rel,	NPLATE	ALVAIZ, DOPTELET
lansoprazole delayed-rel

capsule, omeprazole delayed-	NUCALA LYOPHILIZED

DUPIXENT, FASENRA,

rel, pantoprazole delayed-rel	POWDER	NUCALA (except lyophilized
tablet	powder), TEZSPIRE, XOLAIR
NEXTERONE	amiodarone	NUCYNTA	hydromorphone, morphine,
oxycodone

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
NUCYNTAER	fentanyl transdermal,		69036091010, 69036093090,	
	hydrocodone ext-rel,		70868090190)	
methadone, morphine ext-rel,
oxycodone ext-rel	Orphengesic Forte	carisoprodol 350 mg, chlorzoxazone 500 mg (except
NuDiclo TabPak	dic/ofenac sodium, diclofenac	NDC 73007001303),
sodium gel 1%, diclofenac	cyclobenzaprine (except
sodium solution 1.5%,	cyclobenzaprine tablet 7.5
ibuprofen, meloxicam tablet,	mg), metaxalone 800 mg,
naproxen (except naproxen CR	methocarbamol (except NDCs
or naproxen suspension)		69036091010,69036093090, 70868090190)
NUEDEXTA	Talk to your doctor
ORTHO D	folic acid, generic
NUTROPINAQ	HUMATROPE, NORDITROPIN,	multivitamins
SOGROYA
ORTHODF	folic acid, generic
NUVARING	ethinyl estradiol-etonogestrel,	multivitamins
ANNOVERA
ORTHOVISC	DUROLANE, EUFLEXXA,
NUVESSA	clindamycin, metronidazole	GELSYN-3, SUPARTZ FX
NUVIGIL	armodafinil, modafinil,	OSENI	saxagliptin-metformin ext-rel,
LUMRY2, SUNOSI, WAKIX,	ZITUVIMET, ZITUVIMET XR;
XYWAV	saxagliptin or ZITUVIO WITH
pioglitazone
OCTAGAM	Talk to your doctor
OSMOPREP	peg 3350-electrolytes (except
OGIVRI	KANJINTI, TRAZIMERA	generics for MOVIPREP),
omeprazole-sodium	esomeprazole delayed-rel,	sodium sulfate-potassium
bicarbonate		lansoprazole delayed-rel	sulfate-magnesium sulfate, capsule, omeprazole delayed-	 CLENPIQ
rel, pantoprazole delayed-rel	OSPHENA	estradiol tablet
OTOVEL	ciprofloxacin-dexamethasone,
OMNARIS	azelastine-fluticasone,	ofloxacin otic
fluniso/ide, f/uticasone,
mometasone	OTREXUP	RASUVO
OMNITROPE	HUMATROPE, NORDITROPIN,	OVIDREL	PREGNYL
SOGROYA

ONFI	clobazam, clonazepam,

OWEN MUMFORD NEEDLES	BD ULTRAFINE NEEDLES

lamotrigine, rufinamide,	oxiconazole (NDCs	ciclopirox, clotrimazole, topiramate, topiramate ext-rel	 00168035830, 51672135902	 econazo/e, ketoconazo/e
only)	cream 2%, oxiconazole
ONGLYZA	saxagliptin, ZITUVIO	(except NDCs 00168035830,
51672135902)
ORENCIA INTRAVENOUS	AVSOLA, REMICADE, SIMPON!
ARIA	OXISTAT	ciclopirox, clotrimazo/e, econazole, ketoconazole

orphenadrine-aspirin-caffeine  carisoprodo/ 350 mg,

cream 2%, oxiconazole

NDC 73007001303),
cyclobenzaprine (except		51672135902)	
cyclobenzaprinetablet 7.5 mg), metaxalone BOO mg, methocarbamol (except NDCs	OXYCONTIN	fentanyl transdermal, hydrocodone ext-rel,
methadone, morphine ext-rel,	

chlorzoxazone 500 mg (except	(except NDCs 00168035830,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	oxycodone ext-rel		delayed-rel, mesa/amine ext-	
oxymorphone ext-rel	fentanyl transdermal,		rel, sulfasalazine, sulfasalazine
delayed-rel	
	hydrocodone ext-rel,			
	methadone, morphine ext-re/,	PERCOCET	hydrocodone-acetaminophen,	
	oxycodone ext-rel		oxycodone-acetaminophen	
OXYTROL	darifenacin ext-rel,	PERRIGO NEEDLES	BO ULTRAFINE NEEDLES	
	fesoterodine ext-rel,
oxybutynin ext-rel, so/ifenacin,	
PERTZYE	
CREON, VIOKACE, ZENPEP	

tolterodine, tolterodine ext-rel, trospium, trospium ext-rel,

PLAVIX	clopidogrel, dipyridamole ext-

GEMTESA	rel-aspirin, prasugrel,
BRILINTA

PANCREAZE	CREON, VIOKACE, ZENPEP

PLENVU	peg 3350-e/ectro/ytes (except

pantoprazole delayed-rel	esomeprazo/e delayed-rel,	generics for MOVIPREP),
suspension		lansoprazole delayed-rel	sodium sulfate-potassium capsule, omeprazole delayed-	sulfate-magnesium sulfate,
rel, pantoprazole delayed-rel	CLENPIQ
tablet

paroxetine HCI ext-rel (NOC	citalopram, escitalopram,
60505367503 only)	fluoxetine (except fluoxetine

POLYTOZA	Talk to your doctor

POLY-VI-FLOR	generic multivitamins

tablet 60 mg, fluoxetine tablet	POLY-VI-FLOR WITH IRON	generic multivitamins
[generics for SARAFEM]),
paroxetine HG/, paroxetine HCI	posaconazo/e delayed-rel	fluconazole, itraconazole
ext-rel(except NOC	tablet
60505367503), sertraline,
vilazodone, TRINTELLIX	PRADAXA	warfarin, ELIQUIS, XARELTO
paroxetine mesylate capsule	paroxetine HG/	PRALUENT	REPATHA
7.5mg
PRECISION XTRA STRIPS AND ACCU-CHEK AVIVA PLUS
PAXIL, PAXIL CR	citalopram, escitalopram,	KITS	STRIPS AND KITS, ACCU-
fluoxetine (except f/uoxetine	CHEK GUIDE STRIPS AND
tablet 60 mg, fluoxetine tablet	KITS,ACCU-
[generics for SARAFEM]),	CHEK SMARTVIEW STRIPS
paroxetine HCI, paroxetine HCI	AND KITS, ONETOUCH ULTRA
ext-rel (except NOC	STRIPS AND KITS, ONETOUCH
60505367503), sertraline,	VERIO STRIPS AND KITS
vilazodone, TRINTELLIX
PRED FORTE, PRED MILD	dexamethasone, difluprednate,
peg 3350-electrolytes	peg 3350-electrolytes (except	loteprednol, prednisolone
(generics for MOVIPREP only)	generics for MOVIPREP),	acetate 1% sodium sulfate-potassium
sulfate-magnesium sulfate,	prednisolone solution 10 mg/5  dexamethasone,
CLENPIQ	ml, predniso/one solution 20	hydrocortisone, mg/Sml	methylprednisolone,
PEGASYS	Talk to your doctor	predniso/one solution (except
prednisolone solution 10 mg/5

PENNSAID

diclofenac sodium, diclofenac sodium gel 1%, diclofenac

ml, 20mg/5 ml), prednisone

sodium solution 1.5%,	PREMARIN	estradiol ibuprofen, meloxicam tablet,
naproxen (except naproxen CR	PREMARIN CREAM	estradiol vaginal
or naproxen suspension)	cream, IMVEXXY, VAGIFEM
PENTASA	balsalazide, mesa/amine	PREMPHASE	estradiol-norethindrone,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)

BIJUVA	00093317431, 66993001968),
levalbuterol tartrate CFC-
PREMPRO		estradiol-norethindrone,	free aerosol BIJUVA
PROVIGIL	armodafinil, modafinil,
PRENATAL PLUS	generic prenatal vitamins	LUMRYZ, SUNOSI, WAKIX,
XYWAV
PREVACID	esomeprazole delayed-rel,
lansoprazole delayed-rel	PROZAC	citalopram, escitalopram,
capsule, omeprazole delayed-	fluoxetine (except fluoxetine
rel, pantoprazole delayed-rel	tablet 60 mg, fluoxetine tablet
tablet	[generics for SARAFEM]),
paroxetine HCI, paroxetine HCI

PREVIDENT	Talk to your doctor

ext-rel (except NDC

PREZISTA	atazanavir, darunavir	60505367503), sertraline, vilazodone, TRINTELLIX
PRILOSEC	esomeprazole delayed-rel,	PULMICORT RESPULES	budesonide inhalation
lansoprazole delayed-rel	suspension, ASMANEX HFA,

capsule, omeprazole delayed-
rel, pantoprazole delayed-rel

PULMICORT FLEXHALER

tablet	QNASL	aze/astine-fluticasone,
PRISTIQ	desvenlafaxineext-rel,	 flunisolide, fluticasone, duloxetine, venlafaxine,	mometasone
venlafaxine ext-relcapsule	QTERN	GLYXAMBI
PROAIR RESPICLICK	albuterol sulfate CFC-free	quazepam	doxepin, ramelteon,
aerosol (except NDCs	temazepam, zolpidem,
00093317431, 66993001968),	zolpidem ext-rel
levalbuterol tartrate CFC-
free aerosol	QUILLICHEW ER	amphetamine- dextroamphetamine mixed

PROCORT	hydrocortisone

salts ext-rel,

Proctocort, PROCTOCORT	budesonide foam,	dexmethylphenidate ext-rel, hydrocortisone enema,	dextroamphetamineext-rel,
mesa/amine enema,	lisdexamfetamine,
mesa/amine suppository,	methylphenidate ext-rel,
CORTIFOAM	AZSTARYS
PROCYSBI	CYSTAGON	QUILLIVANT XR	amphetamine-
dextroamphetaminemixed
PROLENSA	bromfenac, diclofenac,	salts ext-rel,
ketorolac	dexmethylphenidate ext-rel,
dextroamphetamineext-rel,
PROMACTA	ALVAIZ, DOPTELET	lisdexamfetamine, methylphenidate ext-rel,
PROMETRIUM	medroxyprogesterone;	AZSTARYS
progesterone, micronized
QVAR REDIHALER	ASMANEX HFA, PULMICORT
PROTONIX	esomeprazole delayed-rel,	FLEXHALER
lansoprazole delayed-rel
capsule, omeprazo/e delayed-	RAPAFLO	alfuzosin ext-rel, doxazosin,
rel, pantoprazole delayed-rel	silodosin, tamsu/osin, terazosin
tablet
RAVICTI	sodium phenylbutyrate,
PROVENTIL HFA	albuterol sulfate CFC-free	PHEBURANE aerosol (except NDCs
RAYOS	dexamethasone,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
hydrocortisone,	RITUXAN	RUXIENCE	
methylprednisolone,
prednisolone solution (except	RIXUBIS	ALPROLIX, BENEFIX, REBINYN	

prednisolone solution 10 mg/5 mL, 20 mg/5 mL), prednisone

ROCKLATAN	bimatoprost, brimonidine solution, brimonidine-timolol,

RECEDO	Talk to your doctor	brinzolamide, dorzolamide, dorzo/amide-timolol,
RELION INSULIN	NOVOLIN INSULIN	/atanoprost, timo/ol ma/eate
solution, travoprost,
RELISTOR	lubiprostone, SYMPROIC	ALPHAGAN P, SIMBRINZA
REMODULIN	treprostinil	ROWASA	mesa/amine enema
RENFLEXIS	AVSOLA, ILUMYA, REMICADE,	ROZEREM	doxepin, ramelteon,
SIMPONI ARIA, SKYRIZI	temazepam, zolpidem,
INTRAVENOUS, STELARA	zo/pidem ext-rel
INTRAVENOUS
RUBRACA	LYNPARZA, ZEJULA
RENVELA	calcium acetate, sevelamer
carbonate, AURYXIA	RyC/ora	clemastine 2.68 mg, cyproheptadine, levocetirizine
RETIN-A MICRO	adapalene (except adapalene
pad), benzoyl peroxide,	SABRIL	vigabatrin clindamycin gel (except NOC
68682046275), clindamycin	SAIZEN	HUMATROPE, NORDITROPIN,
solution, clindamycin-benzoyl	SOGROYA
peroxide, dapsone,

erythromycin solution,

SANDOSTATIN LAR	SOMATULINE DEPOT

erythromycin-benzoyl	SCARSILK PAD	Talk to your doctor
peroxide, tretinoin, AKLIEF,
EPIDUO, TWYNEO, WINLEVI	SELZENTRY	maraviroc
REVATIO	sildenafil, tadalafil, TADLIQ	SEREVENT	STRIVERDI RESPIMAT
REYATAZ	atazanavir, darunavir	SEROQUELXR	aripiprazole, asenapine,

olanzapine, quetiapine,

RHEUMATE	generic multivitamins	clozapine, lurasidone,
RHOFADE	azelaic acid gel, brimonidine	 quetiapine ext-rel, risperidone, gel, metronidazole, FINACEA	ziprasidone, VRAYLAR
FOAM, SOOLANTRA	SEYSARA	doxycycline hyclate capsule,
RHOPRESSA	bimatoprost, brimonidine	doxycycline hyclate tablet solution, brimonidine-timo/o/,	 (except doxycycline hyclate
brinzolamide, dorzolamide,	tablet 50 mg,75 mg, 150 mg),
dorzolamide-timo/ol,	minocycline, tetracycline
/atanoprost, timolol maleate	SFROWASA	mesa/amine enema solution, travoprost,
ALPHAGAN P, SIMBRINZA	SIGNIFOR LAR	SOMATULINE DEPOT
RIABNI	RUXIENCE	SILENOR	doxepin, ramelteon, temazepam, zolpidem,

RIMSO-50	Talk to your doctor

zolpidem ext-rel

RIOMET	metformin, metformin ext-rel	SILIVEX	Talk to your doctor (except generics for
FORTAMET and GLUMETZA)	SILTREX	Talk to your doctor

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
SINGULAIR	montelukast, zafirlukast	Sure Result DSS Premium	diclofenac sodium, diclofenac	

SOURIS (For Myasthenia	
VYVGART, VYVGART	Pack	sodium gel 1%, diclofenac
sodium solution 1.5%,	
Gravis Only)	HYTRULO		ibuprofen, meloxicam tablet,	

SOLODYN	doxycycline hyclate capsule, doxycycline hyclate tablet

naproxen (except naproxen CR
or naproxen suspension)

(except doxycyc/ine hyclate	SUTENT	pazopanib, sunitinib,
tablet 50 mg, 75 mg, 150mg),	CABOMETYX, INLYTA,
minocycline, tetracycline	LENVIMA
SOLOSEC	clindamycin, metronidazole	SYMBICORT	budesonide-formoterol,
f/uticasone-salmeterol (except

SOMAVERT	SOMATULINE DEPOT

certain NDCs), Breyna, Wixela

SORILUX	calcipotriene ointment,	lnhub, BREO ELLIPTA (except
calcipotriene solution, VTAMA,	certain NDCs)
ZORYVE CREAM	SYNDROS	dronabinol
SPORANOX CAPSULE	itraconazole, terbinafine tablet	SYNERDERM	desonide (except desonide
SPORANOX SOLUTION	f/uconazole	gel), hydrocortisone
SPRIX	diclofenac sodium, ibuprofen,	SYNVISC, SYNVISC-ONE	DUROLANE, EUFLEXXA,
meloxicam tablet,	GELSYN-3, SUPARTZ FX
naproxen (except naproxen CR	SYPRINE	trientine
or naproxen suspension)

STENDRA	sildenafil, tadalafil, vardenafil
STRIBILD	efavirenz-emtricitabine-

TAFINLAR CAPSULE	BRAFTOVI, ZELBORAF

TALIVA	generic multivitamins

tenofovir disoproxil fumarate,	Targadox	doxycycline hyclate capsule,
efavirenz-lamivudine-tenofovir	doxycycline hyclate tablet
disoproxil fumarate,	(except doxycycline hyclate
BIKTARVY, CABENUVA,	tablet 50 mg, 75 mg, 150 mg),
DOVATO, GENVOYA,	minocycline, tetracycline
ODEFSEY, SYMTUZA,
TRIUMEQ	TARGRETIN	bexarotene
SUBOXONE	buprenorphine-naloxone	TASIGNA	imatinib mesylate, BOSULIF,
sublingual, ZUBSOLV	SPRYCEL

SUBSYS	 fentanyl transmucosal	 tavaborole	terbinafine tablet sucralfate suspension	sucralfate tablet	TAVALISSE	 ALVAIZ, DOPTELET
sumatriptan-naproxen	diclofenac sodium, ibuprofen	TAYTULLA	ethinyl estradiol-drospirenone, ornaproxen(exceptnaproxen		ethinyl estradiol-drospirenone-
CR or naproxen suspension)	levomefolate, ethinyl estradiol-
WITH eletriptan, naratriptan,	levonorgestrel, ethinyl
rizatriptan, sumatriptan,	estradiol-levonorgestrel-iron,
zolmitriptan, NURTEC ODT or	ethinyl estradiol-norethindrone
UBRELVY	acetate-iron, ethinyl estradiol-
norgestimate, LO LOESTRIN
SUPREP	peg 3350-electrolytes (except	FE, NATAZIA generics for MOVIPREP),
sodium sulfate-potassium	TAZORAC	adapalene (except adapalene
sulfate-magnesium sulfate,	pad), benzoyl peroxide,
CLENPIQ	clindamycin gel (except NOC

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
68682046275), clindamycin	TIMOPTIC OCUDOSE	timolol maleate solution solution, clindamycin-benzoyl

peroxide, dapsone,

tiotropium bromide	SPIRIVA

erythromycin solution,	TIROSINT	levothyroxine erythromycin- benzoyl
peroxide, tretinoin, AKLIEF,	TOBI, TOBI PODHALER	tobramycin inhalation solution
EPIDUO, TWYNEO, WINLEVI;
calcipotriene ointment,	TOBRADEX, TOBRADEX ST	neomycin-polymyxin 8- calcipotriene solution, VTAMA,		bacitracin-hydrocortisone,
ZORYVE CREAM	neomycin-polymyxin 8-
dexamethasone, tobramycin-
TECFIDERA	dimethyl fumarate delayed-rel,	dexamethasone fingolimod, glatiramer,
teriflunomide, AVONEX,	topiramate ext-rel capsule	 carbamazepine, BAFIERTAM, BETASERON,	 (generics for QUDEXY XR	carbamazepine ext-rel, COPAXONE 40 MG/ML,	 only)	 clobazam, clonazepam,
KESIMPTA, MAYlENT,	divalproex sodium, divalproex
OCREVUS, REBIF, TYSABRI,	sodium ext-rel, gabapentin,
VUMERITY, ZEPOSIA	lacosamide, lamotrigine,
lamotrigine ext-rel,
TEGRETOL, TEGRETOL XR	carbamazepine,	 levetiracetam, levetiracetam carbamazepine ext-rel,	ext-rel, oxcarbazepine,
divalproex sodium, divalproex	phenobarbital, phenytoin,
sodium ext-rel, gabapentin,	phenytoin sodium extended,
lacosamide, lamotrigine,	pregabalin, primidone,
lamotrigine ext-rel,	rufinamide, tiagabine,
levetiracetam, levetiracetam	topiramate, topiramate ext-rel,
ext-rel, oxcarbazepine,	valproic acid, zonisamide,
phenobarbital, phenytoin,	APTIOM, BRIVIACT,
phenytoin sodium extended,	FYCOMPA, OXTELLAR XR,

tiagabine, topiramate,
topiramate ext-rel, valproic	
TOPROL-XL	acebutolol, atenolol, carvedilol,	
acid, zonisamide, APTIOM,		carvedilol phosphate ext-rel,	
BRIVIACT, FYCOMPA,		metoprolol succinate ext-rel,	
OXTELLAR XR, XCOPRI		metoprolol tartrate, nadolol,	
		nebivolol, propranolol,	

pregabalin, primidone,	XCOPRI

TESTIM	testosterone gel (except
authorized generics for		propranolol ext-rel	
TESTIM and VOGELXO),
testosterone solution,	Tovet	clobetasol cream, clobetasol foam (except clobetasol	
NATESTO, XYOSTED		emollient foam), clobetasol gel,	
clobetasol lotion, clobetasol
testosterone gel 1%	testosterone gel (except	ointment, halobetasol cream,
(authorized generics for	authorized generics for	halobetasol ointment
TESTIM and VOGELXO only)	TESTIM and VOGELXO),
testosterone solution,	TOVIAZ	darifenacin ext-rel,
NATESTO, XYOSTED	fesoterodine ext-rel,
oxybutynin ext-rel, solifenacin,
THEO-24	arformoterol, formoterol	tolterodine, tolterodine ext-rel, inhalation solution, ipratropium	trospium, trospium ext-rel,
inhalation solution, SPIRIVA,	GEMTESA
STRIVERDI RESPIMAT,
YUPELRI	TRACLEER	ambrisentan, bosentan,
OPSUMIT

THIOLA	tiopronin
THIOLAEC	tiopronin delayed-rel

TRADJENTA	saxagliptin, ZITUVIO

EXCLUDED DRUG NAME(S)

tramadol tablet 100 mg, tramadol ext-rel capsule

TRANSDERM SCOP

PREFERRED OPTION(S)

tramadol (except tramadol tablet 100 mg), tramadol ext­ rel tablet
meclizine, scopolamine transdermal

EXCLUDED DRUG NAME(S)

PREFERRED OPTION(S)

pregabalin, primidone, tiagabine, topiramate, topiramate ext-rel, valproic acid, zonisamide, APTIOM, BRIVIACT, FYCOMPA, OXTELLAR XR, XCOPRI

TRAVATANZ

TRELSTAR MIXJECT TREXIMET

bimatoprost, latanoprost, travoprost
ELIGARD
diclofenac sodium, ibuprofen ornaproxen(exceptnaproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT or UBRELVY

TRI-VI-FLOR	generic multivitamins

TRIVIDIA INSULIN SYRINGES	BD ULTRAFINE INSULIN
SYRINGES

TronVite	generic multivitamins

TRUDHESA		eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY

triamcinolone aerosol 0.2%

hydrocortisonebutyrate cream, hydrocortisone butyrate ointment, hydrocortisonebutyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%)

TRUVADA

TRUXIMA TUDORZA
UCERISFOAM

abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate, lamivudine-zidovudine, APRETUDE, CIMDUO, DESCOVY
RUXIENCE SPIRIVA
budesonide foam,

triamcinolone ointment 0.05% hydrocortisonebutyrate
cream, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%)

hydrocortisone enema, mesa/amine enema, mesa/amine suppository, CORTIFOAM
UDENYCA	FYLNETRA, NYVEPRIA

ULORIC	a/lopurinol

ULTIMED INSULIN SYRINGES	BD ULTRAFINE INSULIN
SYRINGES

TRICOR

TRILEPTAL

fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg,
130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital phenytoin, phenytoin sodium extended,

ULTIMED NEEDLES

ULTOMIRIS (For Myasthenia Gravis Only)
ULTRAVATE

UROXATRAL

V-GO INSULIN INFUSION

BD ULTRAFINE NEEDLES

VYVGART, VYVGART HYTRULO
c/obetasol cream, clobetasol foam (except c/obetasol emollient foam), clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment
alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
OMNIPOD 5 INSULIN

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
PUMP	INFUSION PUMP, OMNIPOD	VESICARE	darifenacin ext-rel,	
	DASH INSULIN INFUSION		fesoterodine ext-rel,	
	PUMP, OMNIPOD INSULIN		oxybutynin ext-rel, solifenacin,	
	INFUSION PUMP, TWIIST		tolterodine, tolterodine ext-rel,	
	INSULIN INFUSION PUMP AND		trospium, trospium ext-rel,	
	SUPPLIES		GEMTESA	
VALCYTE	valganciclovir	VIAGRA	sildenafil, tadalafil, vardenafil	
VALTREX	acyclovir (except acyclovir	VICTOZA	/iraglutide, MOUNJARO,	
	cream, ointment), valacyclovir		OZEMPIC, RYBELSUS,	

VANOS	clobetasol cream, clobetasol		TRULICITY	
	foam (except clobetasol	VIIBRYD	citalopram, escitalopram,	
	emollient foam), clobetasol gel,		fluoxetine (except fluoxetine	
	c/obetasol lotion, clobetasol		tablet 60 mg, fluoxetine tablet	
	ointment, halobetasol cream,		[generics for SARAFEM]),	
	halobetasol ointment		paroxetine HCI, paroxetine HCl	

Vanoxide-HC	adapalene (except adapalene		ext-rel (except NOC
60505367503), sertraline,	
	pad), benzoyl peroxide,
clindamycin gel (except NOC		vilazodone, TRINTELLIX	
	68682046275), clindamycin	VIMPAT	carbamazepine,	
	solution, clindamycin-benzoyl		carbamazepine ext-rel,	
	peroxide, dapsone,		divalproex sodium, divalproex	
	erythromycin solution,		sodium ext-rel, gabapentin,	
	erythromycin- benzoyl		lacosamide, lamotrigine,	
	peroxide, tretinoin, AKLIEF,		lamotrigine ext-rel,	
	EPIDUO, TWYNEO, WINLEVI		levetiracetam, levetiracetam	

VARUBI	aprepitant		ext-rel, oxcarbazepine,
phenobarbital, phenytoin,	

VASCEPA

icosapent ethy omega-3 acid

phenytoin sodium extended, pregabalin, primidone,

ethyl esters	tiagabine, topiramate,
VASCULERA	Talk to your doctor	topiramate ext-rel, valproic acid, zonisamide, APTIOM,
VECTICAL	calcipotriene ointment,	BRIVIACT, FYCOMPA,
calcipotriene solution, VTAMA,	OXTELLAR XR, XCOPRI
ZORYVE CREAM	VIRACEPT	atazanavir, darunavir,
VELPHORO	calcium acetate, sevelamer		 lopinavir-ritonavir carbonate, AURYXIA	VISC0-3	DUROLANE, EUFLEXXA,
venlafaxine ext-rel tablet	desvenlafaxine ext-rel,	GELSYN-3, SUPARTZ FX
(except 225 mg)	duloxetine, venlafaxine,	VITAFOL-ONE	generic prenatal vitamins venlafaxine ext-rel capsule
VENTOLIN HFA	albuterol sulfate CFC-free	Vitasure	 generic multivitamins aerosol (except NDCs	VIVELLE-DOT	estradiol 00093317431, 66993001968),
levalbuterol tartrate CFC-	VOGELXO	testosterone gel (except
free aerosol	authorized generics for
TESTIM and VOGELXO),
VERDESO	desonide (except desonide	 testosterone solution, gel), hydrocortisone	NATESTO,XYOSTED
VEREGEN	imiquimod, podofi/ox	VOTRIENT	pazopanib, sunitinib,
CABOMETYX, INL YTA,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)

LENVIMA	norgestimate, LO LOESTRIN
FE, NATAZIA

VPRIV	CERDELGA, CEREZYME

YAZ

ethinyl estradiol-drospirenone,

VUSION	nystatin	ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-
WELLBUTRIN XL	bupropion, bupropion ext-rel	levonorgestrel, ethinyl
(except bupropion ext-rel	estradiol-levonorgestrel-iron,
tablet 450 mg)	ethinyl estradiol-norethindrone

XALKORI CAPSULE	ALECENSA, ALUNBRIG, AUGTYRO, ZVKADIA

acetate-iron, ethinyl estradiol-
norgestimate, LO LOESTRIN FE, NATAZIA

XANAX, XANAX XR	alprazolam, clonazepam,	Yuvafem	estradiol vaginal cream, diazepam, lorazepam,

oxazepam

IMVEXXY, VAGIFEM

XENAZINE

tetrabenazine, AUSTEDO,	ZALVIT	generic prenatal vitamins
AUSTEDO XR, INGREZZA	ZARXIO	NIVESTYM

XENICAL	orlistat, QSYMIA, SAXENDA,	ZEGERID	esomeprazole delayed-rel,
WEGOVY, ZEPBOUND	/ansoprazole delayed-rel

XERESE

acyclovir (except acyclovir	capsule, omeprazole delayed-

cream, ointment), valacyclovir

rel,pantoprazole delayed-rel tablet

XIFAXAN 200 MG	sulfamethoxazole-	ZELAC	Talk to your doctor
trimethoprim

XOLEGEL COREPAK

XOLEGELDUO

ciclopirox, ketoconazole cream	ZELAPAR	rasagiline, selegiline
2%	ZEPATIER	EPCLUSA (genotypes 1, 2, 3, 4,
ciclopirox, ketoconazole cream	5, 6), HARVONI (genotypes 1,

2%, ketoconazole shampoo

4, 5, 6}

XOPENEX HFA

2%, selenium sulfide lotion	ZESTORETIC	 fosinopril-hydrochlorothiazide, 2.5%, ZORYVE FOAM		lisinopril-hydrochlorothiazide,
albuterol sulfate CFC-free	quinapril-hydrochlorothiazide
aerosol (except NDCs	ZETIA	ezetimibe
00093317431, 66993001968},
levalbuterol tartrate CFC-	ZETONNA	azelastine-fluticasone,
free aerosol	flunisolide, fluticasone,
mometasone

XTAMPZAER	fentanyl transdermal,
hydrocodone ext-rel,	ZIANA	adapalene (except adapalene
methadone, morphine ext-rel,	pad}, benzoyl peroxide,
oxycodone ext-rel	clindamycin gel (except NOC
68682046275), clindamycin
XYREM	LUMRVZ, WAKIX, XYWAV	solution, clindamycin-benzoyl

XYZBAC

YASMIN

generic multivitamins	peroxide, dapsone,
erythromycin solution,
ethinyl estradiol-drospirenone,	erythromycin- benzoyl

ethinyl estradiol-drospirenone- levomefolate, ethinyl estradiol-

peroxide, tretinoin, AKLIEF, EPIDUO, TWYNEO, WINLEVI

levonorgestrel, ethinyl	Ziclopro	diclofenac sodium, diclofenac
estradiol-levonorgestrel-iron,	sodium gel 1%, diclofenac
ethinyl estradiol-norethindrone	sodium solution 1.5%,
acetate-iron, ethinyl estradiol-	ibuprofen, meloxicam tablet,

EXCLUDED DRUG NAME{S)	PREFERRED OPTION{S)	EXCLUDED DRUG NAME{S)	PREFERRED OPTION(S)
naproxen (except naproxen CR	ext-rel, oxcarbazepine,
or naproxen suspension)	phenobarbital, phenytoin, phenytoin sodium extended,
ZIEXTENZO	FYLNETRA, NYVEPRIA	pregabalin, primidone,
tiagabine, topiramate,
zileuton ext-rel	montelukast, zafirlukast	topiramate ext-rel, valproic

ZIPSOR

diclofenac sodium, ibuprofen,	acid, zonisamide, APTIOM,

meloxicam tablet, naproxen
(except naproxen CR or

BRIVIACT, FYCOMPA, OXTELLAR XR, XCOPRI

naproxen suspension)	ZONTIVITY	Talk to your doctor
ZIRGAN	trifluridine	ZOVIRAX	acyclovir {except acyclovir

ZOLADEX

ELIGARD, MYFEMBREE,	cream), penciclovir,

ORILISSA

ZOLOFT	citalopram, escitalopram, f/uoxetine (except f/uoxetine tablet 60 mg, fluoxetine tablet

valacyclovir

ZYCLARA	f/uorouracil 5% cream, fluorouracil solution, imiquimod

[generics for SARAFEM]).	ZYLET	neomycin-polymyxin 8-
paroxetine HCI, paroxetine HCI	bacitracin-hydrocortisone,
ext-rel (except NOC	neomycin-polymyxin 8-
60505367503), sertraline,	dexamethasone, tobramycin-
vilazodone, TRINTELLIX	dexamethasone
zolpidem sublingual	doxepin, ramelteon,	ZYMAXID	ciprofloxacin, erythromycin, temazepam, zolpidem,		 gentamicin, levof/oxacin,
zolpidem ext-rel	moxifloxacin, ofloxacin,

ZONEGRAN	carbamazepine,

sulfacetamide, tobramycin

carbamazepine ext-rel,	ZYTIGA	abiraterone, bicalutamide,
divalproex sodium, divalproex	ERLEADA, NUBEQA, XTANDI,
sodium ext-rel, gabapentin,	YONSA
lacosamide, lamotrigine,
lamotrigine ext-rel,	ZYVOX	linezolid levetiracetam, levetiracetam

TABLE 1- PREFERRED OPTIONS FOR INDICATION BASED SELF-ADMINISTERED

AUTOIMMUNE EXCLUDED MEDICATIONS

		ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ RINVOQ	
		ADALIMUMAB-ADAZ HYRIMOZ
RINVOQ
SKYRIZI SUBCUTANEOUS STELARASUBCUTANEOUS	
		CIMZIA PREFILLED SYRINGE COSENTYX
RINVOQ	
		ADALIMUMAB-ADAZ BIMZELX
HYRIMOZ OTEZLA
SKYRIZI SUBCUTANEOUS SOTYKTU STELARASUBCUTANEOUS TREMFYA	
AMJEVITA HUMIRA
ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS SIMPONI

XELJANZXR	ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ OTEZLA RINVOQ
SKYRIZI SUBCUTANEOUS STELARASUBCUTANEOUS TREMFYA	
ACTEMRA ACTPEN ACTEMRASUBCUTANEOUS AMJEVITA
HUMIRA KINERET SIMPONI	ADALIMUMAB-ADAZ ENBREL
HYRIMOZ KEVZARA
ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS	

		RINVOQ	
		XELJANZ	
		XELJANZXR	
..
••		ADALIMUMAB-ADAZ HYRIMOZ
RINVOQ	
		SKYRIZI SUBCUTANEOUS	
		STELARA SUBCUTANEOUS	
		TREMFYA	
		VELSIPITY	
		XELJANZ	
		XELJANZXR	
		ZEPOSIA	
ACTEMRA ACTPEN	ADALIMUMAB-ADAZ	
ACTEMRASUBCUTANEOUS	ENBREL	
AMJEVITA	HYRIMOZ	
HUMIRA		
KINERET		
ORENCIA CLICKJECT		
ORENCIA SUBCUTANEOUS		

CONDITION	EXCLUDED DRUG NAME(S)	PREFERRED OPTION($)

ULCERATIVE COLITIS

ALL OTHER CONDITIONS

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.

Drug products are identified by unique numerical product identifiers, called National Drug Codes (NOC), which identify the manufacturer, strength, dosage form, formulation and package size.
Some listings do not include certain NDCs as noted above.

For VOSEVI listing above: For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).
An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746.
BO ULTRAFINE syringes and needles are the only preferred options.

ACCU-CHEK or ONETOUCH brand test strips 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.

An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication. For more information, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers 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.
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