October 2024
•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 listed in therapeutic categories are for representational purposes only. This is not an all­ inclusive list and does not guarantee coverage. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
PLAN MEMBER
Your benefit plan provides you with prescription drug coverage that is administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list the next time you or a covered family member sees a doctor.
•		Your specific prescription benefit plan design may not cover certain medications, products or categories, regardless of their appearance in this document. Medications and products recently
approved by the U.S. Food and Drug Administration (FDA) may not be covered immediately upon release to the market.
•		Your prescription benefit plan design may alter coverage of certain products or vary cost sharing amounts based on the condition being treated.
•	You may be responsible for the full cost of medications and products that are removed from coverage.
•	For specific information regarding your prescription benefit coverage and cost sharing, or if you have additional questions, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu.
•		When a generic medication that is equivalent to a brand-name drug is released to the market, in most instances, that brand-name drug will be designated as a non-preferred option.
HEALTH CARE PROVIDER
Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is medically necessary, consider prescribing a brand name on this list.
•	The member's prescription benefit plan design may alter coverage of certain products or vary cost sharing amounts based on the condition being treated.
•		This drug list represents a summary of prescription coverage. The member's specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered immediately upon release to the market.
•	The member's prescription benefit plan may have different cost sharing for specific products on the list.
•	Unless specifically indicated, drug list products will include all dosage forms.
•	
•	Log in to Caremark.com to check coverage and cost sharing information for a specific medicine.

ANALGESICS

COX-2 INHIBITORS
celecoxib
GOUT
a/lopurinol colchicine tablet probenecid MITIGARE
NSAIDS
diclofenac sodium diclofenac sodium solution
1.5%
ibuprofen meloxicam tablet
napr0X6n (except ""f"OXen CRor naproxensuspension)
NSAIDS, COMBINATIONS
diclofenac sodium-misoprosto/ 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 tramadot tablet 100 mg)
tramadol ext-rel tablet
OPIOID PARTIAL AGONISTS
buprenorphine transdermal
BELBUCA
VISCOSUPPLEMENTS
DUROLANE EUFLEXXA GELSYN-3 SUPARTZFX

ANTI-INFECTIVE$

ANTHELMINTICS
ivermectin tablet
EMVERM
ANTI-BACTERIALS -
MISCELLANEOUS
sulfamethoxazole- trimethoprim
ANTIFUNGALS
fluconazo/e itraconazo/e terbinafine tablet
ANTIRETROVIRAL AGENTS
abacavir atazanavir darunavir efavirenz emtricitabine etravirine lamivudine maraviroc nevirapine nevirapine ext-rel ritonavir zidovudine 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 va/acyc/ovir valganciclovir PAXLOVID
RELENZA
CEPHALOSPORINS
cefdinir cefprozil
cefuroxime axetil cephalexin
ERYTHROMYCINS/MACROLI DES
azithromycin c/arithromycin clarithromycin ext-re/ erythromycins DIFICID
FLUOROQUINOLONES
ciprofloxacin levofloxacin moxifloxacin
HEPATITISB
entecavir lamivudine
tenofovir disoproxil fumarate
VEMLIDY
HEPATITISC
ribavirin
EPCLUSA (genotypes1.2. 3, 4, 5, 6)
HARVONI (genotypes 1. 4, 5, 6)
VOSEVI
MISCELLANEOUS
clindamycin linezo/id metronidazole
nitrofurantoin(except NOC
16571074024)
pyrimethamine vancomycin capsule MEPRON
XIFAXAN 550 MG

NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS
tenofovir disoproxil fumarate
PENICILLINS
amoxicillin
amoxicillin-clavulanate dicloxacillin
penicillin vk
TETRACYCLINES
doxycycline hyclate capsule doxycycline hyclate tablet
(except doxycycline hyctate tablet 50 mg. 75 mg, 150 mg)
minocycline
tetracycline

ANTINEOPLASTIC

AGENTS ALKYLATING AGENTS
cyc/ophosphamide melphalan temozolomide
ANTIMETABOLITES
capecitabine mercaptopurine pemetrexed LONSURF
BIOLOGIC RESPONSE MODIFIERS
BESREMI ERIVEDGE REVLIMID THALOMID
BIOSIMILARS
HERZUMA OGIVRI RUXIENCE ZIRABEV
HORMONAL ANTINEOPLASTIC AGENTS
abiraterone anastrozole bicalutamide exemestane fulvestrant

letrozole leuprolide acetate megestrol acetate tamoxifen toremifene ELIGARD ERLEADA
NUBEQA
><TANDI 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 ZVDELIG 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
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-va/sartan-
hydrochlorothiazide candesartan-
hydrochlorothiazide irbesartan-hydrochlorothiazide losartan-hydrochlorothiazide olmesartan-amlodipine-
hydrochlorothiazide o/mesartan­
hydrochlorothiazide telmisartan-
hydrochlorothiazide valsartan-hydrochlorothiazide
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan irbesartan losartan olmesartan

telmisartan valsartan
ANTIARRHYTHMICS
amiodarone disopyramide sota/o/ MULTAQ
ANTILIPEMICS, ACL INHIBITORS/COMBINATION
s
NEXLETOL NEXLIZET
ANTILIPEMICS, BILE ACID RESINS
chofestyramine cofesevefam
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR
ezetimibe
ANTILIPEMICS, FIBRATES
fenofibrate (except tenofi>rate capsule 30 mg, 50 mg, 90 mg, 130 mg; fenofobrate
tablet 40 mg, 120 mg)
fenofibric acid delayed-rel
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS
atorvastatin ffuvastatin lovastatin pitavastatin pravastatin rosuvastatin simvastatin
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATION
s
ezetimibe-simvastatin
ANTILIPEMICS, MISCELLANEOUS
niacin ext-ref
ANTILIPEMICS, OMEGA-3 FATTY ACIDS
icosapent ethyl
omega-3 acid ethyl esters
ANTILIPEMICS, PCSK9 INHIBITORS
REPATHA

BETA-BLOCKER/DIURETIC COMBINATIONS
atenofof-chlorthalidone bisoprolol-hydrochforothiazide metoprolof-
hydrochforothiazide
BETA-BLOCKERS
acebutofof atenolof carvedifo/
carvedilo/ phosphate ext-rel metoprofof succinate ext-rel metoprofof tartrate
nadofof nebivofol propranofof
propranofof ext-ref
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amfodipine-atorvastatin
CALCIUM CHANNEL BLOCKERS
amlodipine
diftiazem ext-ref cexcept generics tor CARDIZEM LA)
nifedipine ext-ref verapamil ext-rel
DIGITALIS GLYCOSIDES
digoxin
DIRECT RENIN INHIBITORS/COMBINATION
s
aliskiren
DIURETICS
amiloride chforthalidone ethacrynic acid furosemide hydrochlorothiazide metolazone spirono/actone-
hydrochlorothiazide torsemide triamterene triamterene-
hydrochforothiazide
HEART FAILURE
isosorbide dinitrate- hydralazine
CORLANOR ENTRESTO VERQUVO

MISCELLANEOUS
clonidine
clonidine transdermal

doxepin	carbamazepine ext-re/	zolpidem
duloxetine	clobazam	zolpidem ext-rel
escitalopram	clonazepam	MIGRAINE

guanfacine midodrine ranolazine ext-re/

f/uoxetine (except fluoxetine tablet 60	diazepam
mg, fluoxetine tablet [generics for	diazepam rectal gel
SARAFEM])	divalproex sodium
imipramine he/	divalproex sodium ext-re/

eletriptan naratriptan rizatriptan

NITRATES
isosorbide dinitrate (except isosorbide dinitrate 40 mg)
isosorbide mononitrate nitroglycerin lingual spray nitroglycerin sublingual
PULMONARY ARTERIAL HYPERTENSION

mirtazapine	ethosuximide	sumatriptan
nortriptyline	gabapentin	zolmitriptan
paroxetine he/	lacosamide	AJOVY
paroxetine he/ ext-re/ (except NOC	lamotrigine	EMGALITY
60505367503)	/amotrigine ext-rel	NURTECODT
sertraline	levetiracetam	QULIPTA
trazodone	/evetiracetam ext-rel	UBRELVY
venlafaxine	oxcarbazepine	MISCELLANEOUS
venlafaxine ext-re/ capsule	phenobarbital

ambrisentan

vilazodone	phenytoin

lithium carbonate

bosentan sildenafil tada/afil treprostinil ADEMPAS OPSUMIT ORENITRAM TADLIQ UPTRAVI

CENTRAL NERVOUS SYSTEM

ALCOHOL DETERRENTS
acamprosate calcium disulfiram

TRINTELLIX		phenytoin sodium extended	lithium carbonate ext-re/ tablet pregabalin		300mg
ANTIPARKINSONIAN	primidone	lithium carbonate ext-re/ tablet
AGENTS	rufinamide	450mg
amantadine	tiagabine	pyridostigmine
carbidopa-levodopa	topiramate	pyridostigmine ext-rel
carbidopa-levodopa ext-re/	topiramate ext-re/	RADICAVA ORS
carbidopa-levodopa-	valproic acid	MOVEMENT DISORDERS
entacapone	 vigabatrin	tetrabenazine entacapone	zonisamide	 AUSTEDO
pramipexole	APTIOM	AUSTEDOXR
pramipexole ext-rel	FYCOMPA	INGREZZA
rasagiline	NAYllLAM
ropinirole	OXTELLARXR	MULTIPLE SCLEROSIS
ropinirole ext-re/	VALTOCO	AGENTS
se/egiline	XCOPRI	dimethyl fumarate delayed-rel

ANTIANXIETY

INBRIJA
NEUPRO

ATTENTION DEFICIT

fingolimod
glatiramer

alprazolam

RYTARY	HYPERACTIVITY DISORDER

teriflunomide

buspirone

ANTIPSYCHOTICS	amphetamine-	AVONEX

clomipramine f/uvoxamine lorazepam
oxazepam

aripiprazole asenapine chlorpromazine

dextroamphetamine mixed	BETASERON
salts ext-rel	COPAXONE 40 MG/ML
atomoxetine	KESIMPTA
dexmethy/phenidate	MAYZENT

ANTIDEMENTIA
donepezil galantamine galantamine ext-rel memantine rivastigmine
rivastigmine transdermal
NAMZARIC

c/ozapine	dexmethy/phenidateext-rel	OCREVUS
f/uphenazine	dextroamphetamine	REBIF
haloperidol	dextroamphetamine ext-rel	TYSABRI
lurasidone	guanfacine ext-re/	VUMERITY
olanzapine	lisdexamfetamine	ZEPOSIA
perphenazine	methylphenidate
quetiapine	methylphenidateext-rel	MUSCULOSKELETAL
quetiapine ext-rel	AZSTARYS	THERAPY AGENTS
risperidone	QELBREE	baclofen

ANTIDEPRESSANTS

thiothixene
trifluoperazine

BOTULINUM TOXINS

carisoprodol 350 mg ch/orzoxazone 500 mg (except

amitriptyline
bupropion
bupropion ext-rel (except 1,up,op;on

ziprasidone	DYSPORT	NOC73007001303)
ABILIFY MAINTENA	XEOMIN	cyclobenzaprine (except
PERSERIS	HYPNOTICS	cyclobenzaprine tablet 7.5 mg)

ext·rel tablet 450 mg)

VRAYLAR

doxepin

dantrolene

citalopram desipramine desvenlafaxine ext-rel

ANTISEIZURE AGENTS	ramelteon
carbamazepine	temazepam

metaxalone 800 mg

methocarbamol (except Noes
69036091010, 69036093090,
70868090190)
tizanidine
LYVISPAH
NARCOLEPSY/CATAPLEXY
armodafinil modafinil LUMRYZ SUNOSI WAKIX XYWAV
OPIOID AGONIST/ANTAGONIST
buprenorphine-naloxone sublingual
ZUBSOLV
OPIOID ANTAGONIST
naloxone naltrexone
POSTHERPETIC NEURALGIA (PHN)
GRAUSE

ANTIDIABETICS,	 ANTIDIABETICS,	CARNITINE DEFICIENCY DIPEPTIDYL PEPTIDASE-4	MISCELLANEOUS	AGENTS
(DPP-4) INHIBITOR	mifepristone	levocarnitine
COMBINATIONS
saxagliptin-metformin ext-rel	ANTIDIABETICS, SODIUM-	CENTRAL PRECOCIOUS
JANUMET	GLUCOSE	PUBERTY
JANUMETXR	COTRANSPORTER-2(SGLT2)	FENSOLVI
TRIJARDYXR	INHIBITOR COMBINATIONS	LUPRON DEPOT-PED
SYNJARDY	SUPPRELIN LA
ANTIDIABETICS,	SYNJARDYXR
DIPEPTIDYL PEPTIDASE-4	XIGDUOXR	CHELATING AGENTS
(DPP-4) INHIBITORS	deferasirox
saxagliptin	ANTIDIABETICS, SODIUM-	deferiprone
JANUVIA	GLUCOSE	deferoxamine
COTRANSPORTER-2 (SGLT2)	penicillamine
ANTIDIABETICS, INCRETIN	INHIBITOR/DPP-4	trientine
MIMETIC AGENTS	INHIBITOR COMBINATIONS
MOUNJARO	GLYXAMBI	CONTRACEPTIVES
OZEMPIC	ethinyl estradiol-drospirenone
RYBELSUS	ANTIDIABETICS, SODIUM-	ethinyl estradiol-drospirenone-
TRULICITY	GLUCOSE	levomefolate
VICTOZA	COTRANSPORTER-2 (SGLT2)	ethinyl estradiol-etonogestrel
INHIBITORS	ethinyl estradiol-levonorgestrel
ANTIDIABETICS, INCRETIN	FARXIGA	ethinyl estradiol-
MIMETIC COMBINATION	JARDIANCE	levonorgestrel-iron
AGENTS	ethinyl estradiol-
SOLIQUA	ANTIDIABETICS,	norelgestromin
XULTOPHY	SULFONYLUREA	ethinyl estradiol-norethindrone
glimepiride	acetate-iron

ENDOCRINE AND METABOLIC

ANTIDIABETICS, INSULIN

glipizide	ethinyl estradiol-norgestimate

ACROMEGALY
SOMATULINE DEPOT
ANDROGENS
testosterone gel (except authorized genencs for TESTIM andVOGELXO)
testosterone solution
NATESTO XYOSTED

FIASP	glipizide ext-rel	medroxyprogesterone acetate
HUMULIN R U-500	ANTIOBESITY	150mglml
LANTUS	norethindrone
NOVOLIN 70/30	orlistat	ANNOVERA
NOVOLIN N	QSYMIA	KYLEENA
NOVOLIN R	SAXENDA	LO LOESTRIN FE
NOVOLOG	WEGOVY	MIRENA
NOVOLOG MIX 70/30	ZEPBOUND	NATAZIA
TOUJEO	CALCIUM RECEPTOR	SKYLA
TRESIBA	AGONISTS

ANTIDIABETICS, ALPHA­ GLUCOSIDASE INHIBITORS

ANTIDIABETICS, INSULIN	cinacalcet
SENSITIZER

DIABETIC SUPPLIES
ACCU-CHEK AVIVA PLUS

acarbose

pioglitazone

CALCIUM REGULATORS,	STRIPS AND KITS
BISPHOSPHONATES	ACCU-CHEK GUIDE STRIPS

ANTIDIABETICS, AMYLIN ANALOGS
SYMUNPEN

ANTIDIABETICS, INSULIN	alendronate	AND KITS
SENSITIZER/BIGUANIDE	ibandronate	ACCU-CHEK SMARTVIEW
COMBINATION	risedronate	STRIPS AND KITS

ANTIDIABETICS,BIGUANIDE

pioglitazone-metformin

CALCIUM REGULATORS,

BD ULTRAFINE INSULIN SYRINGES AND NEEDLES

metformin
metformin ext-rel (except for FORTAMETand GLUMETZA)
ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS
glipizide-metformin

ANTIDIABETICS, INSULIN	MISCELLANEOUS	DEXCOM CONTINUOUS
SENSITIZER/SULFONYLURE	calcitonin-salmon	GLUCOSE MONITORING
A COMBINATION	PROLIA	SYSTEM

INFUSION PUMP

pioglitazone-glimepiride	CALCIUM REGULATORS,	OMNIPOD 5 INSULIN
ANTIDIABETICS,	PARATHYROID HORMONES	OMNIPOD DASH INSULIN
MEGLITINIDE	teriparatide	INFUSION PUMP
nateglinide	TYMLOS	OMNIPOD INSULIN INFUSION
repaglinide	PUMP

ONETOUCH LANCETS/ LANCING DEVICE
ONETOUCH ULTRA STRIPS AND KITS
ONETOUCH VERIO STRIPS AND KITS
V-GO INSULIN INFUSION PUMP
ENDOMETRIOSIS
ORILISSA
ENZYME REPLACEMENTS
betaine cargtumic acid sapropterin
sodium phenylbutyrate ELFABRIO FABRAZYME GALAFOLD PHEBURANE
ESTROGENS
estradiot
estradiot vaginal cream estradiot-norethindrone BIJUVA
CLIMARAPRO COMBIPATCH IMVEXXY VAGIFEM
FERTILITY REGULATORS
clomiphene FOLLISTIM AQ GANIRELIX ACETATE MENOPUR
OVIDREL
GAUCHER DISEASE
CERDELGA CEREZYME
GLUCOCORTICOIDS
dexamethasone ftudrocortisone hydrocortisone methytprednisotone prednisolone solution (except
prednisolone solution 10 mg/5ml, 20 mg/5ml)
prednisone
GLUCOSE ELEVATING AGENTS
glucagon, human recombinant
BAQSIMI GVOKE ZEGALOGUE

HEREDITARY TYROSINEMIA TYPE1AGENTS
ORFADIN
HUMAN GROWTH HORMONES
HUMATROPE NORDITROPIN SOGROYA
MINERALOCORTICOID RECEPTOR ANTAGONISTS
KERENDIA
MISCELLANEOUS
cabergoline ratoxifene CYSTAGON
PHOSPHATE BINDER AGENTS
calcium acetate sevelamer carbonate AURYXIA
POLYNEUROPATHY
TEGSEDI
POTASSIUM-REMOVING AGENTS
VELTASSA
PROGESTINS
medroxyprogesterone megestrol acetate progesterone, micronized ENDOMETRIN
THYROID AGENTS
tevothyroxine
/iothyronine methimazole propy/thiouracil
UTERINE FIBROIDS
MYFEMBREE ORIAHNN
VASOPRESSINS
desmopressin spray, tablet
GASTROINTESTINAL ANTICHOLINERGICS
dicyctomine
ANTIDIARRHEALS
diphenoxylate-atropine loperamide

ANTIEMETICS
aprepitant
doxylamine-pyridoxine delayed-rel
dronabinot granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine
scopolamine transdermat trimethobenzamide SANCUSO
H2-RECEPTOR ANTAGONISTS
famotidine
INFLAMMATORY BOWEL DISEASE
balsalazide
budesonide delayed-rel capsule
budesonide foam hydrocortisone enema mesa/amine delayed-re/ mesa/amine ext-rel mesa/amine suppository mesa/amine suspension sulfasalazine sulfasalazine delayed-rel CORTIFOAM
IRRITABLE BOWEL SYNDROME WITH CONSTIPATION
/ubiprostone
LINZESS
IRRITABLE BOWEL SYNDROME WITH DIARRHEA
alosetron
VIBERZI
LAXATIVES
lactulose solution
peg 3350-electrolytes (except
for MOVIPREP)
sodium sulfate-potassium sulfate-magnesium sulfate
CLENPIQ
MISCELLANEOUS
misoprostol sucralfate tablet ursodiot SYMPROIC

PANCREATIC ENZYMES
CREON VIOKACE ZENPEP
PROTON PUMP INHIBITORS
esomeprazote delayed-rel lansoprazole delayed-rel
capsule
omeprazo/e delayed-rel pantoprazole delayed-rel
tablet
RECTAL, CORTICOSTEROIDS
PROCTOFOAM-HC
ULCER THERAPY COMBINATIONS
bismuth-metronidazole- tetracyc/ine
lansoprazote + amoxicillin + clarithromycin
TALICIA

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA
alfuzosin ext-rel doxazosin dutasteride
dutasteride-tamsutosin finasteride
si/odosin tamsulosin terazosin
ERECTILE DYSFUNCTION
sildenafil tada/afil vardenafil MUSE
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-INFECTIVES
clindamycin 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 ELOCTATE ESPEROCT JIVI KOGENATE FS KOVALTRY NOVOEIGHT NUWIQ XYNTHA
HEMOPHILIA B AGENTS
ALPROLIX 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
DOPTELET PROMACTA TAVALISSE
IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS
GRASTEK ORALAIR RAGWITEK
AUTOIMMUNE AGENTS (PHYSICIAN­ ADMINISTERED)
AVSOLA ILUMYA REMICADE SIMPON! 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-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS
CIMZIA PREFILLED SYRINGE COSENTYX
RINVOQ

AUTOIMMUNE AGENTS (SELF-ADMINISTERED), PSORIASIS
ADALIMUMAB-ADAZ HYRIMOZ
OTEZLA
SKYRIZI SUBCUTANEOUS SOTYKTU
STELARA SUBCUTANEOUS TALTZ
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 XELJANZ
XELJANZXR ZEPOSIA
DISEASE-MODIFYING ANTI­ RHEUMATIC DRUGS (DMARDS)
hydroxychloroquine leflunomide methotrexate RASUVO

HEREDITARYANGIOEDEMA
icatibant ORLADEYO RUCONEST TAKHZVRO
IMMUNOGLOBULIN
CUTAQUIG
IMMUNOSUPPRESSANTS
azathioprine cyclosporine cyclosporine modified everolimus mycophenolate mofetil mycophenolate sodium sirolimus
tacrolimus
ENSPRYNG

NUTRITIONAL/SUPPLEM ENTS

ELECTROLYTES
potassium chloride ext-rel potassium chloride liquid
PRENATAL VITAMINS
prenatal vitamins
VITAMINS
calcitriol (1, 25-d3) doxercalciferol fo/ic acid
folic acid-vitamin b6-vitamin b12
multivitamins paricalcitol

OPHTHALMIC

ANTI-INFECTIVE/ANTI­ INFLAMMATORY
neomycin-polymyxin b- bacitracin-hydrocortisone
neomycin-polymyxin b- dexamethasone
tobramycin-dexamethasone
ANTI-INFECTIVES
ciprofloxacin erythromycin gentamicin levofloxacin moxifloxacin ofloxacin sulfacetamide tobramycin trifluridine

ANTI-INFLAMMATORIES
bromfenac dexamethasone diclofenac dif/uprednate ketorolac loteprednol
prednisolone acetate 1%
ANTIALLERGICS
azelastine bepotastine cromolyn sodium loteprednol olopatadine
ANTIGLAUCOMA
bimatoprost brimonidine solution brimonidine-timolol brinzolamide dorzolamide dorzolamide-timolol latanoprost
timolol maleate solution travoprost
ALPHAGAN P
SIMBRINZA
ORY EYE DISEASE
RESTASIS XIIDRA
RETINAL DISORDERS
BYOOVIZ CIMERLI

RESPIRATORY

ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS
PROLASTIN-C ZEMAIRA
ANAPHYLAXIS TREATMENT AGENTS
epinephrine (e><cepl NDCs 00093-
xxxx-xx.49502-XXXX-XX)
AUVI-Q
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ipratropium-albuterol inhalation solution
ANORO ELLIPTA STIOLTO RESPIMAT

ANTICHOLINERGIC/BETA AGONIST/STEROID COMBINATIONS
BREZTRIAEROSPHERE TRELEGY ELLIPTA
ANTICHOLINERGICS
ipratropium inhalation solution
SPIRIVA YUPELRI
ANTIHISTAMINE COMBINATIONS
azelastine-fluticasone
ANTIHISTAMINES
azelastine clemastine 2.68 mg cyproheptadine levocetirizine olopatadine
BETA AGONISTS
albuterol inhalation solution albuterol sulfate etc-free
aerosol(except NDCs 00093317431.
66993001968)
arformoterol
formoterol inhalation solution levalbuterol tartrate etc-free
aerosol
STRIVERDI RESPIMAT
COLD/COUGH
benzonatate (except NDCs
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 lyophilizedpowder)
TEZSPIRE XOLAIR
STEROID INHALANTS
budesonide inhalation suspension
PULMICORT FLEXHALER
STEROIO/BETA-AGONIST COMBINATIONS
fluticasone-salmeterol(except certain NDCs)
Wixela lnhub
AIRSUPRA
BREO ELLIPTA (except certainNDCs)

TOPICAL

DERMATOLOGY, ACNE
adapalene (except ac1apa1ene pad) benzoyl peroxide c/indamycin 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 su/fadiazine
DERMATOLOGY, ANTIFUNGALS
ciclopirox clotrimazole econazole
ketoconazole cream 2% nystatin
oxiconazole (except NDCs 00166035830, 51672135902)
DERMATOLOGY, ANTIPSORIATICS
acitretin
calcipotriene ointment, solution
methoxsalen ENSTILAR TACLONEX VTAMA ZORYVE CREAM
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo 2% selenium sulfide lotion 2.5% ZORYVEFOAM
DERMATOLOGY, ATOPIC DERMATITIS
pimecrolimus tacrolimus ADBRY
CIBINQO DUPIXENT EUCRISA OPZELURA RINVOQ
DERMATOLOGY, CORTICOSTEROIDS
c/obetasol cream, foam, gel, lotion, ointment, shampoo
(except clobetesolemollient foam)
desonide (exceptdesonidegel)
desoximetasone
fluocinonide (except ttuocinonide cream 0.1%)
halobetasol cream, ointment hydrocortisone hydrocortisone butyrate
cream, ointment, solution mometasone

triamcinolone cream, lotion, ointment (except triamcinoCone ointment0.05%)
BRYHALI
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine patch lidocaine-prilocaine

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
acyclovir ointment ammonium lactate 12% diclofenac sodium gel 1% penciclovir
podofilox
DERMATOLOGY,ROSACEA
azelaic acid gel brimonidine gel metronidazole

FINACEA FOAM ORACEA SOOLANTRA
DERMATOLOGY, SCABICIDES AND PEDICULICIDES
malathion permethrin 5%
MOUTH/THROAT /DENTAL AGENTS
cevimeline

pi/ocarpine tablet
EPISIL MUGARD
OTIC
acetic acid
ciprofloxacin-dexamethasone neomycin-polymyxin b-
hydrocortisone ofloxacin otic

QUICK REFERENCE DRUG LIST

A	ALPROLIX
ALUNBRIG	AVONEX
AVSOLA	brimonidine gel
brimonidine solution	
abacavir	amantadine	azathioprine	brimonidine-timolol	
abacavir-lamivudine	ambrisentan	azelaic acid gel	brinzolamide	
ABILIFY MAINTENA	amiloride	azelastine	bromfenac	
abiraterone	amiodarone	azelastine	BRUKINSA	
acamprosate calcium	amitriptyline	azelastine-fluticasone	BRYHALI	
acarbose	amlodipine	azithromycin	budesonide delayed-rel	
ACCU-CHEK AVIVA PLUS	amlodipine-atorvastatin	AZSTARYS	capsule
STRIPS AND KITS	amlodipine-olmesartan			budesonide foam
ACCU-CHEK GUIDE STRIPS	amlodipine-telmisartan	B	budesonide inhalation
AND KITS	amlodipine-valsartan	baclofen	suspension
ACCU-CHEK SMARTVIEW	amlodipine-valsartan-	balsalazide	buprenorphine transdermal
STRIPS AND KITS		hydrochlorothiazide	 BAQSIMI	buprenorphine-naloxone acebutolol	ammonium lactate 12%	BO ULTRAFINE INSULIN		sublingual
acetic acid	amoxicillin	SYRINGES AND NEEDLES	bupropion
acitretin	amoxicillin-c/avulanate	BELBUCA	bupropion ext-rel(except
acyclovir	amphetamine-	 benzonatate (exceptNDCs		bupropionext-reltablet 450 mg) acyclovir ointment		 dextroamphetaminemixed		69336012615. 69499032915)	 buspirone ADALIMUMAB-ADAZ		salts ext-rel	benzoyl peroxide	BYOOVIZ
adapalene (exceptadapalene pad)	anagrelide	bepotastine
ADBRY	anastrozole	BESREMI	C
ADEMPAS	ANNOVERA	betaine	CABENUVA
ADVATE	ANORO ELLIPTA	BETASERON	cabergoline
ADYNOVATE	aprepitant	bexarotene	CABOMETYX
AFSTYLA	APTIOM	bicalutamide	calcipotriene ointment,
AIRSUPRA	ARANESP	BIJUVA	solution
AJOVY	arformoterol	BIKTARVY	calcitonin-salmon
AKLIEF	aripiprazole	bimatoprost	calcitriol (1, 25-d3} albuterol inhalation solution	armodafinil	bismuth-metronidazole-	calcium acetate albuterol sulfate cfc-free	asenapine		tetracycline	 CALQUENCE
aerosol (except NOCs 00093317431,	atazanavir	bisoprolol-	candesartan
66993001968)	atenolol	hydrochlorothiazide	candesartan-
ALECENSA	atenolol-chlorthalidone	bortezomib	hydrochlorothiazide
alendronate	atomoxetine	bosentan	capecitabine
alfuzosin ext-rel	atorvastatin	BOSULIF	carbamazepine aliskiren	 AUGTYRO	 BRAFTOVI	carbamazepine ext-rel al/opurinol	 AURYXIA	BREO ELLIPTAcexceptcertain	carbidopa-levodopa
alosetron	AUSTEDO	NDCs)	carbidopa-levodopa ext-rel
ALPHAGAN P	AUSTEDOXR	BREZTRIAEROSPHERE	carbidopa-levodopa- alprazolam	AUVI-Q	BRILINTA		entacapone

carglumic acid	COMBIPATCH	DIFICID	ENBREL	
carisoprodol 350 mg	COPAXONE 40 MG/ML	difluprednate	ENDARI	
carvedilol	COPIKTRA	digoxin	ENDOMETRIN	
carvedilol phosphate ext-rel	CORLANOR	diltiazem ext-rel (except ger>«ics tor	enoxaparin	
cefdinir	CORTIFOAM	CARDIZEM LA)	ENSPRYNG
cefprozil	COSENTYX	dimethyl fumarate delayed-	ENSTILAR

chlorthalidone
chlorzoxazone 500 mg (except	cyclophosphamide
cyclosporine	donepezil
DOPTELET	EPISIL
eplerenone	
NOC73007001303)	cyclosporine modified	dorzolamide	ERIVEDGE	
cholestyramine	cyproheptadine	dorzolamide-timolol	ERLEADA	
CIBINQO	CYSTAGON	DOVATO	erlotinib	
ciclopirox	doxazosin	erythromycin	

cefuroxime axetil	COTELLIC	rel	entacapone
celecoxib
cephalexin	CREON
cromolyn sodium	diphenoxylate-atropine
dipyridamole ext-rel-aspirin	entecavir
ENTRESTO	
CERDELGA	cromolyn solution	disopyramide	EPCLUSA (genotypes1,2.3,4,5,s>	
CEREZYME	CUTAQUIG	disulfiram	EPIDUO	
cevimeline chlorpromazine	cyclobenzaprine(except
cyciobenzaprine tablet7.5mg)	divalproex sodium
divalproex sodium ext-rel	epinephrine (exceptNOCs00093·
XXXX·XX, 49502-XXXX-XX)	

cilostazol	D	doxepin	erythromycin solution	
CIMDUO	dantrolene	doxepin	erythromycin-benzoyl	
CIMERLI	dapsone	doxercalciferol	peroxide	
CIMZIA PREFILLED SYRINGE	darifenacin ext-rel	doxycycline hyclate capsule	erythromycins	
cinacalcet	darunavir	doxycycline hyclate tablet	escitalopram	
ciprofloxacin	deferasirox	 (except doxycyctine hyclatetablet50	esomeprazole delayed-rel ciprofloxacin	deferiprone	mg.75mg.150mg)	 ESPEROCT
ciprofloxacin-dexamethasone   deferoxamine	doxylamine-pyridoxine	estradiol
citalopram	 DESCOVY		delayed-rel	 estradiol vaginal cream clarithromycin	 desipramine	 dronabinol	 estradiol-norethindrone clarithromycin ext-rel	desmopressin spray, tablet	duloxetine	ethacrynic acid
clemastine 2.68 mg	 desonide (exceptclesonide ge1J	 DUPIXENT	 ethambutol CLENPIQ	desoximetasone	DUPIXENT	ethinyl estradiol- CLIMARAPRO	 desvenlafaxine ext-rel	 DUROLANE		drospirenone clindamycin	 dexamethasone	 dutasteride	 ethinyl estradiol-
clindamycin	dexamethasone	dutasteride-tamsulosin		drospirenone-levomefolate clindamycin gel (exceptNOC	 DEXCOM CONTINUOUS	 DYSPORT	ethinyl estradiol-etonogestrel
68682046275)	GLUCOSE MONITORING	ethinyl estradiol-
clindamycin solution	SYSTEM	E	levonorgestrel
clindamycin-benzoyl	dexmethytphenidate	econazole	ethinyl estradiol-
peroxide	dexmethylphenidate ext-rel	efavirenz		 levonorgestrel-iron clobazam	dextroamphetamine	 efavirenz-emtricitabine-	ethinyl estradiol- clobetasol cream, foam, gel,	dextroamphetamine ext-rel		tenofovir disoproxil		norelgestromin
lotion, ointment, shampoo	dextromethorphan-	fumarate	ethinyl estradiol-

clomiphene
clomipramine	pseudoephedrine
dextromethorphan-	tenofovir disoproxil
fumarate	ethinyl estradiol- norgestimate	
clonazepam	promethazine	eletriptan	ethosuximide	

(exceptctobetesol emollientfoam)	brompheniramine-	efavirenz-lamivudine-	norethindrone acetate-iron

clonidine	diazepam	ELFABRIO	etoposide	
clonidine transdermal	diazepam rectal gel	ELIGARD	etravirine	
clopidogrel	diclofenac	ELIQUIS	EUCRISA	
clotrimazole	diclofenac sodium	ELOCTATE	EUFLEXXA	
clozapine	diclofenac sodium gel 1%	EMGALITY	everolimus	
codeine-acetaminophen	diclofenac sodium solution	EMPAVELI	everolimus	

codeine-promethazine codeine-promethazine-
phenylephrine	1.5%
diclofenac sodium- misoprostol	emtricitabine emtricitabine-tenofovir
disoproxil fumarate	
colchicine tablet	dicloxacillin	EMVERM	
colesevelam	dicyclomine	enalapril	

exemestane ezetimibe
ezetimibe-simvastatin

F	gentamicin	irbesartan-	levocarnitine
FABRAZYME	GENVOYA	hydrochlorothiazide	levocetirizine
famotidine	glatiramer	ISENTRESS	/evofloxacin
FARXIGA	glimepiride	isoniazid	levofloxacin
FASENRA	glipizide	isosorbide dinitrate (except	 /evothyroxine fenofibrate (except tenofibrate capsu1e	g/ipizide ext-rel		isoso<bide dinitrate 40 mg)	lidocaine patch
30 mg, 50 mg. 90 mg, 130 mg;	glipizide-metformin	isosorbide dinitrate-	lidocaine-prilocaine
fenofibrate teblet 40 mg, 120 mg)	glucagon, human		hydralazine	 linezolid fenofibric acid delayed-rel		recombinant	isosorbide mononitrate	LINZESS FENSOLVI	 GLYXAMBI	 isotretinoin capsule 10 mg, 20	 liothyronine
fentanyl transdermal	GRALISE		mg, 30 mg, 40 mg	 lisdexamfetamine fentanyl transmucosal	 granisetron	itraconazole	lisinopril
fesoterodine ext-rel	GRASTEK	ivermectin tablet	lisinopril-hydrochlorothiazide
FIASP	guanfacine		 lithium carbonate
FINACEA FOAM	guanfacine ext-rel	J	lithium carbonate ext-rel
finasteride	GVOKE	JANUMET	tablet 300 mg
fingolimod	JANUMETXR	lithium carbonate ext-rel
fluconazo/e	H	JANUVIA	tablet 450 mg
f/udrocortisone	halobetaso/ cream, ointment	JARDIANCE	LO LOESTRIN FE
flunisolide	ha/operidol	JIVI	LONSURF

fluocinonide (except fluocinonide	HARVONI (genotypes 1, 4, s.6)
cream0.1%)	HERZUMA	K

loperamide lopinavir-ritonavir

fluorouraci/ cream 5%	HUMATROPE	KERENDIA	lorazepam

hydrochlorothiazide	ketoconazole cream 2%	losartan-hydrochlorothiazide	
hydrocodone ext-rel	ketoconazole shampoo 2%	loteprednol	
hydrocodone-acetaminophen	ketorolac	loteprednol	

fluorouracil solution	HUMULIN R U-50O	KESIMPTA	losartan fluoxetine (except ftuoxetine tablet 60
mg, fluoxetina tablet [generics for
SARAFEM))
fluphenazine	hydrocodone-homatropine	KEVZARA	lovastatin
fluticasone		hydrocortisone		KISQALI		 lubiprostone f/uticasone-salmeterol (except		hydrocortisone		KISQALI FEMARA CO-PACK		LUMAKRAS certain NOCs)	hydrocortisone butyrate	KOGENATE FS	LUMRVZ
fluvastatin	cream, ointment, solution	KOSELUGO	LUPRON DEPOT-PED
fluvoxamine	hydrocortisone enema	KOVALTRY	lurasidone
folic acid	hydromorphone	KRAZATI	LYNPARZA
folic acid-vitamin b6-vitamin	hydroxychloroquine	KYLEENA	LYVISPAH
b12	hydroxyurea
FOLLISTIM AQ	HYRIMOZ	L	M
fondaparinux	/acosamide	malathion
formoterol inhalation solution		/actu/ose solution	maraviroc fosinopril	ibandronate	/amivudine	 MAYZENT
fosinopril-	IBRANCE	/amivudine	meclizine

FYLNETRA
 		ILUMYA
imatinib mesylate	clarithromycin
lansoprazole delayed-rel	megestrol acetate
MEKTOVI	
G	imipramine he/	capsule	meloxicam tablet	

hydrochlorothiazide	 ibuprofen	 /amivudine-zidovudine	 medroxyprogesterone fulvestrant	 ibuprofen-famotidine	 lamotrigine	 medroxyprogesterone furosemide	icatibant	lamotrigine ext-rel		acetate 150 mg/ml FYCOMPA	 icosapent ethyl	 lansoprazo/e + amoxicillin +	megestrol acetate

gabapentin	imiquimod	LANTUS	melphalan	
GALAFOLD	IMVEXXY	lapatinib	memantine	
galantamine	INBRIJA	latanoprost	MENOPUR	
galantamine ext-rel	INGREZZA	leflunomide	MEPRON	
GANIRELIX ACETATE	INLYTA	LENVIMA	mercaptopurine	
GAVRETO	 ipratropium inhalation	 letrozole	 mesa/amine delayed-rel gefitinib		 solution	 leuprolide acetate	 mesa/amine ext-re/ GELSYN-3	ipratropium-albuterol	levalbuterol tartrate etc-free	 mesa/amine suppository GEMTESA		inhalation solution		aerosol	 mesa/amine suspension gentamicin	 irbesartan	 levetiracetam	metaxalone 800 mg
/evetiracetam ext-rel

metformin	NAY2ILAM	OMNIPOD DASH INSULIN	phenytoin
metformin ext-rel (except ger,.;cs	nebivolol	INFUSION PUMP	phenytoin sodium extended
for FORTAMET and GLUMETZA)	neomycin-polymyxin b-	 OMNIPOD INSULIN	 PHESGO methadone		 bacitracin-hydrocortisone		INFUSION PUMP	pi/ocarpine tablet methimazole	 neomycin-po/ymyxin b-	ondansetron	pimecrolimus methocarbamol (except NOCs		dexamethasone	 ONETOUCH LANCETS/	pioglitazone
69036091010, 69036093090,	neomycin-polymyxin b-	LANCING DEVICE	pioglitazone-glimepiride
70868090190)		hydrocortisone	ONETOUCH ULTRA STRIPS	 piog/itazone-metformin methotrexate	NEUPRO		AND KITS	pirfenidone
methoxsalen	nevirapine	ONETOUCH VERIO STRIPS	pitavastatin methylphenidate	nevirapine ext-rel		AND KITS	podofilox methylphenidate ext-rel	 NEXLETOL	 OPSUMIT	potassium chloride ext-rel methylprednisolone	 NEXLIZET	OPZELURA	potassium chloride liquid metoclopramide	niacin ext-rel	 ORACEA	pramipexole
metolazone	nifedipine ext-rel	 ORALAIR	pramipexole ext-rel metoprolol succinate ext-rel	 NINLARO	ORENCIA CLICKJECT	prasugrel metopro/o/ tartrate	nitrofurantoin(except NOC	ORENCIA SUBCUTANEOUS	pravastatin
metopro/o/-		16571074024)	 ORENITRAM	prednisolone acetate 1% hydrochlorothiazide	nitroglycerin lingual spray	ORFADIN	prednisolone solution (except
metronidazole	nitroglycerin sublingual	ORIAHNN	prednisolone solution 10 mg/5ml, 20
metronidazole	 NIVESTYM	 ORILISSA		mg/5ml) metronidazo/e	 NORDITROPIN	 ORLADEYO	 prednisone midodrine	norethindrone	orlistat	 pregaba/in mifepristone	nortriptyline	ose/tamivir	 prenatal vitamins minocyc/ine	 NOVOEIGHT	 OTEZLA	primidone
MIRENA	NOVOLIN 70/30	OVIDREL	probenecid
mirtazapine	 NOVOLIN N	 oxazepam	prochlorperazine misoprostol	 NOVOLIN R	 oxcarbazepine	 PROCRIT MITIGARE	NOVOLOG	oxiconazole (except NOCs	 PROCTOFOAM-HC
modafini/	NOVOLOG MIX 70/30		00168035830, 51672135902)	progesterone, micronized mometasone	NOVOSEVEN RT	OXTELLARXR	 PROLASTIN-C
mometasone	NUBEQA	oxybutynin ext-rel	 PROLIA montelukast	NUCALA (except lyophilized powder)	oxycodone	 PROMACTA morphine	NURTECODT	oxycodone ext-rel	promethazine morphine ext-rel	NUWIQ	oxycodone-acetaminophen	propranolo/
MOUNJARO	nystatin	OZEMPIC	propranolo/ ext-rel

moxifloxacin	NYVEPRIA
moxifloxacin			p

propylthiouraci/
PULMICORT FLEXHALER

MUGARD	0	pantoprazo/e delayed-rel	pyrazinamide
MULTAQ	 OCREVUS		tablet	 pyridostigmine multivitamins	 ODEFSEY	 paricalcitol	 pyridostigmine ext-rel mupirocin ointment	ODOMZO	paroxetine he/	pyrimethamine
MUSE	OFEV	paroxetine he/ ext-rel (except
mycophenolate mofetil	ofloxacin	NOC60505367503)	Q
mycophenolate sodium	of/oxacin otic	PAXLOVID	QELBREE
MYFEMBREE	OGIVRI	pazopanib	QSYMIA
olanzapine	peg 3350-electrolytes(except	quetiapine

N	olmesartan

generics for MOVIPREP)

quetiapine ext-rel

nadolol	o/mesartan-amlodipine-	pemetrexed	quinapril
naloxone	hydrochlorothiazide	pencic/ovir	quinapril-hydrochlorothiazide
naltrexone	olmesartan-	penici/lamine	QULIPTA
NAMZARIC		hydrochlorothiazide	 penicillin vk			 naproxen (except naproxenCR or	o/opatadine	PERJETA	R
naproxen suspension)	olopatadine	permethrin 5%	RADICAVA ORS
naratriptan	omega-3 acid ethyl esters	perphenazine	RAGWITEK	
NATAZIA	omeprazo/e delayed-rel	PERSERIS	raloxifene	
nateglinide	OMNIPOD 5 INSULIN	PHEBURANE	ramelteon	
NATESTO	INFUSION PUMP	phenobarbital	ramipril	

ranolazine ext-rel	SKYRIZI SUBCUTANEOUS	temazepam	TRULICITY
rasagiline	SKYRIZI SUBCUTANEOUS	temozolomide	TWYNEO
RASUVO	sodium phenylbutyrate	tenofovir disoproxil fumarate	TYMLOS
REBIF	sodium sulfate-potassium	terazosin	TYSABRI
REBINYN	sulfate-magnesium sulfate	terbinafine tablet		
RELENZA	SOGROYA	terif/unomide	u
REMICADE	solifenacin	teriparatide	UBRELVY
repaglinide	SOUQUA	testosterone gel(except authorized	UPTRAVI
REPATHA	SOMATULINE DEPOT	generics for TESTIMand VOGELXO)	ursodiol
RESTASIS	SOOLANTRA	testosterone solution		
RETACRIT	sorafenib	tetrabenazine	V
RETEVMO	sotalol	tetracycline	V-GO INSULIN INFUSION
REVLIMID	SOTYKTU	TEZSPIRE	PUMP
ribavirin	SPIRIVA	THALOMID	VAGIFEM
rifampin	spironolactone	thiothixene	valacyc/ovir
RINVOQ	spironolactone-	tiagabine	valganciclovir
risedronate	hydrochlorothiazide	timolol maleate solution	valproic acid
risperidone	SPRYCEL	tiopronin	valsartan
ritonavir	STELARAINTRAVENOUS	tiopronin delayed-rel	valsartan-hydrochlorothiazide rivastigmine	STELARA SUBCUTANEOUS	 TIVICAY	 VALTOCO
rivastigmine transdermal	STIOLTO RESPIMAT	tizanidine	vancomycin capsule
rizatriptan	STIVARGA	tobramycin	vardenafil
roflumilast	STRIVERDI RESPIMAT	tobramycin inhalation	VELTASSA
ropinirole	sucralfate tablet	solution	VEMLIDY
ropinirole ext-rel	sulfacetamide	tobramycin-dexamethasone	venlafaxine
rosuvastatin	sulfamethoxazole-	tolterodine	ven/afaxine ext-rel capsule
ROZLYTREK	trimethoprim	tolterodine ext-rel	verapamil ext-rel
RUCONEST	su/fasalazine	topiramate	VERQUVO
rufinamide	sulfasalazine delayed-rel	topiramate ext-rel	VIBERZI
RUXIENCE	sumatriptan	toremifene	VICTOZA
RYBELSUS	sunitinib	torsemide	vigabatrin
RYDAPT	SUNOSI	TOUJEO	vi/azodone
RYTARY	SUPARTZFX	tramadol (except tramadol tablet 100	VIOKACE
SUPPRELIN LA	mg)	VISTOGARD

s

SYMLINPEN	tramadol ext-rel tablet	VITRAKVI
SANCUSO	SYMPROIC	travoprost	VOSEVI
sapropterin	SYMTUZA	trazodone	VRAYLAR
saxagliptin	SYNJARDY	TRELEGY ELLIPTA	VTAMA
saxagliptin-metformin ext-rel	  SYNJARDYXR		TREMFYA	VUMERITY

SAXENDA
scopolamine transdermal	T

treprostinil

w

TRESIBA

selegiline	TACLONEX	tretinoin	WAKIX
selenium sulfide lotion 2.5%	tacrolimus	tretinoin capsule	warfarin
sertraline	tacrolimus	triamcinolone cream, lotion,	WEGOVY
sevelamer carbonate	tadalafil	ointment (except triamcinolone	WINLEVI
SEVENFACT	tadalafil	ointment 0.05%)	Wixela lnhub
SIKLOS	TADLIQ	triamterene
sildenafil	TAGRISSO	triamterene-	X
sildenafil	TAKHZVRO	hydrochlorothiazide	XARELTO
silodosin	TALICIA	trientine	XCOPRI
silver su/fadiazine	TALTZ	trifluoperazine	XELJANZ
SIMBRINZA	tamoxifen	trifluridine	XELJANZXR
SIMPONI ARIA	tamsulosin	TRIJARDYXR	XEOMIN
simvastatin	TAVALISSE	trimethobenzamide	XIFAXAN 550 MG
sirolimus	TEGSEDI	TRINTELLIX	XIGDUOXR
SKYLA	telmisartan	TRIUMEQ	XIIDRA
SKYRIZI INTRAVENOUS	telmisartan-	trospium	XOLAIR SKYRIZI SUBCUTANEOUS		hydrochlorothiazide	trospium ext-re/	XOSPATA
XTANDI

z

XULTOPHY
XYNTHA

ZEPBOUND	zolpidem ext-rel
ZEPOSIA	zonisamide

XYOSTED	zafirlukast	zidovudine	ZORYVE CREAM
XYWAV	ZEGALOGUE	ziprasidone	ZORYVEFOAM
y	ZEJULA	ZIRABEV	ZUBSOLV
ZELBORAF	zolmitriptan	ZVDELIG
YONSA	ZEMAIRA	zolpidem	ZVKADIA
YUPELRI	ZENPEP

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)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION($)	
ABILIFY	aripiprazole, asenapine, c/ozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel, risperidone,
ziprasidone, VRAYLAR		pad), benzoyl peroxide, clindamycin gel (except NOC 68682046275), c/indamycin solution, clindamycin-benzoyl
peroxide, dapsone,	
			erythromycin solution,	
ACANYA	adapalene (except adapalene	erythromycin- benzoyl pad), benzoyl peroxide,	 peroxide, tretinoin, AKLIEF,
clindamycin gel (except NOC	EPIOUO, TWYNEO, WINLEVI
68682046275), clindamycin
solution, clindamycin-benzoyl	adapalene pad	adapalene (except adapalene peroxide, dapsone,		 pad), benzoyl peroxide,
erythromycin solution,	clindamycin gel (except NOC
erythromycin- benzoyl	68682046275), clindamycin
peroxide, tretinoin, AKLIEF,	solution, c/indamycin-benzoyl
EPIDUO, TWYNEO, WINLEVI	peroxide, dapsone,
erythromycin solution,
ACIPHEX, ACIPHEX SPRINKLE esomeprazole delayed-rel,	erythromycin- benzoyl lansoprazole delayed-rel	 peroxide, tretinoin, AKLIEF,
capsule, omeprazole delayed-	EPIDUO, TWYNEO, WINLEVI
rel, pantoprazole delayed-rel
tablet	ADCIRCA	sildenafil, tadalafil, TADLIQ

ACTEMRAINTRAVENOUS	AVSOLA, REMICAOE, SIMPONI	ADOERALL	dexmethylphenidate,
ARIA	dextroamphetamine,
methylphenidate
Activite	generic multivitamins
AODERALLXR	amphetamine-
ACTOS	pioglitazone	dextroamphetaminemixed
salts ext-rel,

ACUVAIL

bromfenac, diclofenac,

dexmethylphenidateext-rel,

ketorolac	dextroamphetamine ext-rel,
acyclovir cream	acyclovir (except acyclovir	lisdexamfetamine,

cream), penciclovir, valacyclovir

methylphenidate ext-rel,
AZSTARYS

ACZONE

adapalene (except adapalene	ADRENALIN	epinephrine (except NDCs

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	00093-XXXX-XX, 49502-		NOC 73007001303),	
	XXXX-XX), AUVI-Q		cyclobenzaprine (except	
cyclobenzaprine tablet 7.5	
ADVAIR DISKUS, ADVAIR HFA	fluticasone-sa/meterol (except	mg), metaxalone 800 mg,	
	certain NDCs), Wixela lnhub,	methocarbamol (except NDCs	
	BREO ELLIPTA (except certain	69036091010,69036093090,	
	NDCs)	70868090190)	
ADZENYS XR-ODT	amphetamine-	ANDROGEL	testosterone gel (except
dextroamphetamine mixed	authorized generics for
salts ext-rel,	TESTIM and VOGELXO),
dexmethylphenidateext-rel,	testosterone solution,
dextroamphetamineext-rel,	NATESTO, XYOSTED
lisdexamfetamine,
methylphenidate ext-rel,	ANGELIQ	estradio/-norethindrone,
AZSTARYS	BIJUVA

AFINITOR, AFINITOR DISPERZ everolimus	ANZEMET	granisetron, ondansetron,
SANCUSO
AIMOVIG	AJOVY, EMGALITY, QULIPTA
APEXICON E	desoximetasone (except
AKYNZEO	aprepitant WITH granisetron,	desoximetasone ointment ondansetron or SANCUSO	 0.05%), f/uocinonide (except

albuterol sulfate CFC-free	albuterol sulfate CFC- aerosol (NDCs 00093317431,	 free aerosol (except NDCs

fluocinonide cream 0.1%), BRYHALI

66993001968 only)	00093317431, 66993001968),	APIDRA	FIASP, NOVOLOG
levalbuterol tartrate CFC-
free aerosol	APLENZIN	bupropion, bupropion ext-re/
(except bupropion ext-rel
ALEVICYN GEL,	desonide (except desonide	tablet 450 mg)
ALEVICYN SG, ALEVICYN
SOLUTION	gel), hydrocortisone	
APOKYN	
INBRIJA	
ALIMTA	pemetrexed	APTENSIO XR	amphetamine-	
dextroamphetamine mixed
ALIQOPA	Talk to your doctor	salts ext-rel,

ALLISON MEDICAL INSULIN

dexmethylphenidate ext-rel,
8D ULTRAFINE INSULIN	dextroamphetamine ext-rel,

SYRINGES	SYRINGES	/isdexamfetamine,
ALORA	estradiol	methylphenidate ext-rel,
AZSTARYS

ALREX	aze/astine, bepotastine, cromolyn sodium, /oteprednol,

APTIVUS	Talk to your doctor

o/opatadine	ARALASTNP	PROLASTIN-C, ZEMAIRA
ALTOPREV	atorvastatin, ezetimibe-	ARAZLO	adapalene (except adapalene simvastatin, fluvastatin,		 pad), benzoy/ peroxide,
lovastatin, pitavastatin,	clindamycin gel (except NDC
pravastatin, rosuvastatin,	68682046275), clindamycin
simvastatin	solution, c/indamycin-benzoy/
ALVESCO	PULMICORT FLEXHALER		peroxide, dapsone, erythromycin solution,
AMITIZA	lubiprostone, LINZESS,	erythromycin-benzoyl
SYMPROIC	peroxide, tretinoin, AKLIEF,
EPIDUO, TWYNEO, WINLEVI
AMRIX	carisoprodol 350 mg,
chlorzoxazone 500 mg (except	ARCALYST	Talk to your doctor

EXCLUDED DRUG NAME(S)

ARNUITY ELLIPTA	PREFERRED OPTION(S)

PULMICORT FLEXHALER	EXCLUDED DRUG NAME(S)

AVASTIN	PREFERRED OPTION(S)

ZIRABEV	
ARTHROTEC	celecoxib; diclofenac sodium,	AVENOVA	Talk to your doctor	
	ibuprofen, meloxicam tablet or
naproxen (except naproxen CR	
AZASITE	ciprofloxacin, erythromycin,	
	or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel		gentamicin, levofloxacin,
moxifloxacin, ofloxacin, sulfacetamide, tobramycin	

capsule, omeprazole delayed- rel, or pantoprazole delayed-

AZELEX	adapalene (except adapalene

rel tablet	pad), benzoyl peroxide,
clindamycin gel (except NOC
ASCENSIA STRIPS AND KITS	ACCU-CHEK AVIVA PLUS	68682046275), clindamycin
STRIPS AND KITS, ACCU-	solution, clindamycin-benzoy/
CHEK GUIDE STRIPS AND	peroxide, dapsone,
KITS,ACCU-	erythromycin solution,
CHEK SMARTVIEW STRIPS	erythromycin- benzoyl
AND KITS, ONETOUCH ULTRA	peroxide, tretinoin, AKLIEF,
STRIPS AND KITS, ONETOUCH	EPIDUO, TWYNEO, WINLEVI VERIO STRIPS AND KITS

ASMANEX, ASMANEX HFA	PULMICORT FLEXHALER

ATACAND, ATACAND HCT	candesartan, candesartan-

AZESCO	generic prenatal vitamins
AZOPT	brinzolamide, dorzolamide

hydrochlorothiazide,	AZOR	amlodipine-olmesartan,
irbesartan, irbesartan-	amlodipine-telmisartan,
hydrochlorothiazide, /osartan,	amlodipine-va/sartan
losartan-hydrochlorothiazide,	BALCOLTRA	ethinyl estradiol-drospirenone,

o/mesartan, olmesartan- hydrochlorothiazide, telmisartan, telmisartan- hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

ethinyl estradiol-drospirenone- levomefolate, ethinyl estradio/- levonorgestrel, ethinyl estradiol-levonorgestrel-iron, ethinyl estradiol-

ATIVAN	alprazolam, clonazepam,	 norethindrone acetate-iron, diazepam, lorazepam,	ethinyl estradiol-norgestimate,
oxazepam	LO LOESTRIN FE, NATAZIA
ATRALIN	adapalene (except adapalene	BANZEL	clobazam, clonazepam, pad), benzoyl peroxide,		 lamotrigine, rufinamide,
c/indamycin gel (except NOC	topiramate, topiramate ext-rel
68682046275), clindamycin	BARACLUDE TABLET	entecavir, /amivudine,

solution, clindamycin-benzoy/
peroxide, dapsone,

tenofovir disoproxil fumarate,

erythromycin solution,	VEMLIDY
erythromycin- benzoyl	BASAGLAR	LANTUS
peroxide, tretinoin, AKLIEF,
EPIDUO, TWYNEO, WINLEVI	BENEFIX	ALPROLIX, REBINYN
ATROVENT HFA	SPIRIVA	BENICAR, BENICAR HCT	candesartan, candesartan-
AUBAGIO	dimethyl fumarate delayed-re/,	hydrochlorothiazide,

fingolimod, glatiramer, teriflunomide, AVONEX, BETASERON, COPAXONE 40

irbesartan, irbesartan- hydrochlorothiazide, losartan, losartan-hydrochlorothiazide,
o/mesartan, olmesartan-

MG/ML, KESIMPTA,	hydroch/orothiazide,
MAYZENT, OCREVUS, REBIF,	telmisartan, telmisartan-
TYSABRI, VUMERITY, ZEPOSIA	hydrochlorothiazide, valsartan,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
valsartan-hydrochlorothiazide	STRIPS AND KITS, ACCU- CHEK GUIDE STRIPS AND
BENSALHP	desonide (except desonide	KITS,ACCU-
ge(), hydrocortisone	CHEK SMARTVIEW STRIPS

benzonatate (NDCs	benzonatate (except NDCs

AND KITS, ONETOUCH ULTRA
STRIPS AND KITS, ONETOUCH

69336012615,69499032915	69336012615, 69499032915)	VERIO STRIPS AND KITS
only)
BROMSITE	bromfenac, diclofenac,
BEPREVE	azelastine, bepotastine,	ketorolac
cromolyn sodium, loteprednol,
olopatadine	BROVANA	arformoterol, formoterol

BERINERT	icatibant, RUCONEST

BESIVANCE	ciprof/oxacin,erythromycin,

inhalation solution
budesonide ext-rel tablet	balsalazide, mesa/amine
delayed-rel, mesa/amine ext-

gentamicin, levof/oxacin,	rel, su/fasalazine, sulfasalazine
moxifloxacin, ofloxacin,	delayed-rel
sulfacetamide, tobramycin
Bupap	diclofenac sodium, ibuprofen,
BETAMETHASONE ACETATE-  dexamethasone,	naproxen (except naproxen CR
BETAMETHASONE SODIUM	hydrocortisone,	or naproxen suspension)
PHOSPHATE	methylprednisolone,
prednisolone solution (except	BUPHENYL	sodium phenylbutyrate,
prednisolone solution 10 mg/5	PHEBURANE
mL, 20 mg/5 mL), prednisone
bupropion ext-rel tablet 450	bupropion, bupropion ext-rel betamethasone dipropionate	desoximetasone (except	mg	 (except bupropion ext-rel
ointment 0.05%	desoximetasone ointment	tablet 450 mg)
0.05%), fluocinonide (except
f/uocinonide cream 0.1%),	buta/bital-acetaminophen	diclofenac sodium, ibuprofen,
BRYHALI		capsule, butalbital-	naproxen (except naproxen CR acetaminophen tablet 25-325	 or naproxen suspension)
BETAPACE, BETAPACE AF	sotalol	mg, butalbital-acetaminophen
tablet 50-300 mg,

BETHKIS

tobramycin inhalation solution

BUTALBITAL-

BETIMOL	timolol maleate solution		ACETAMINOPHEN (NDC 69499034230 only)
BETOPTICS	timolol maleate solution	butalbital-acetaminophen-	diclofenac sodium, ibuprofen,
BEVESPIAEROSPHERE	ANORO ELLIPTA, STIOLTO	caffeine capsule	naproxen (except naproxen CR
RESPIMAT	or naproxen suspension)
BEYAZ	ethinyl estradiol-drospirenone,	BUTRANS	buprenorphine transdermal, ethinyl estradiol-drospirenone-		 BELBUCA
levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-levonorgestrel-iron, ethinyl estradiol-norethindrone

BYDUREON BCISE		MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, VICTOZA

acetate-iron, ethinyl estradiol-	BYETTA	MOUNJARO, OZEMPIC,
norgestimate, LO LOESTRIN	RYBELSUS, TRULICITY,
FE, NATAZIA	VICTOZA
BORTEZOMIB	bortezomib, NINLARO	SYSTOLIC	acebutolol, atenolol, carvedilol,
BOTOX	AJOVY, DYSPORT, EMGALITY,	carvedilol phosphate ext-rel,

QULIPTA, XEOMIN

metoprolol succinate ext-rel, metoprolol tartrate, nadolol,

BREEZE 2 STRIPS AND KITS	ACCU-CHEK AVIVA PLUS	nebivolol, propranolol,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)
proprano/ol ext-re/	cyc/obenzaprine (except

calcipotriene cream, CALCIPOTRIENE FOAM	ca/cipotriene ointment, calcipotriene solution, VTAMA,		
	ZORYVE CREAM		
calcipotriene-betamethasone	ca/cipotriene ointment or
calcipotriene solution WITH	

CARNITOR, CARNITOR SF	

cyclobenzaprine tablet 7.5 mg), metaxa/one 800 mg, methocarbamo/ (except NDCs 69036091010, 69036093090,
70868090190)

levocarnitine
desoximetasone (except
desoximetasone ointment	CAYSTON	tobramycin inhalation solution
0.05%), f/uocinonide (except
f/uocinonide cream 0.1%) or	CELEBREX	celecoxib, diclofenac sodium,
BRYHALI; ENSTILAR,	ibuprofen, me/oxicam tablet,
TACLONEX,VT AMA, ZORYVE	naproxen (except naproxen CR
CREAM	or naproxen suspension)
ca/citrio/ ointment	ca/cipotriene ointment,	CETROTIDE	GANIRELIX ACETATE
calcipotriene solution, VT AMA,

ZORYVE CREAM

chlordiazepoxide-clidinium	dicyclomine
(NDCs11534019701,

CAMBIA	diclofenac sodium, ibuprofen,	42494040901, 51293069601,
naproxen (except naproxen CR	 51293069610, 67877073101, or naproxen suspension)	70700018501 only)
CANASA		budesonide foam,	 chlorzoxazone 250 mg,	 carisoprodol 350 mg, hydrocortisone enema,	chlorzoxazone 375 mg,	chlorzoxazone 500 mg (except mesa/amine suppository,	 chlorzoxazone 500 mg {NOC	 NOC 73007001303), mesa/amine suspension,	 73007001303 only),	 cyc/obenzaprine {except CORTIFOAM	 chlorzoxazone 750 mg	 cyclobenzaprine tablet 7.5
mg), metaxa/one 800 mg,
CAPEX	ketoconazole shampoo 2%,	methocarbamo/ {except NDCs
selenium sulfide lotion 2.5%,	69036091010, 69036093090,
ZORYVEFOAM	70868090190)
Capsinac	diclofenac sodium, diclofenac	CHORIONIC GONADOTROPIN  OVIDREL
sodium gel 1%, diclofenac
sodium solution 1.5%,	CIALIS	sildenafil, tadalafil, vardenafil
ibuprofen, me/oxicam tablet,

naproxen {except naproxen CR

CICATRACE	Talk to your doctor

or naproxen suspension)	CILOXAN	ciprofloxacin, erythromycin,
CARAC	fluorouracil cream 5%,	 gentamicin, levofloxacin, fluorouracil solution,	moxifloxacin, ofloxacin,
imiquimod	sulfacetamide, tobramycin
CARAFATE	sucralfate tablet	CIMZIA L YOPHILIZED	AVSOLA, ILUMYA, REMICADE,
POWDER	SIMPONI ARIA, SKYRIZI
CARBAGLU	carglumic acid	INTRAVENOUS, STELARA INTRAVENOUS
CARBINOXAMINE TABLET 6	levocetirizine
MG	CINRYZE	ORLADEYO,TAKHZYRO

CARDIZEM, CARDIZEM CD,	diltiazem ext-re/ {except	CIPRO HC OTIC	ciprofloxacin-dexamethasone,
CARDIZEM LA	generics for CARDIZEM LA),	ofloxacin otic verapami/ ext-re/
ciprofloxacin-f/uocinolone	ciprofloxacin-dexamethasone,
carisoprodol 250 mg	carisoprodol 350 mg,	ofloxacin otic ch/orzoxazone 500 mg {except

NOC 73007001303),

CITRANATAL

generic prenatal vitamins

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

CLIMARA {except CLIMARA	estradiol	delayed-rel, mesa/amine ext-
PRO)	rel, sulfasalazine, sulfasa/azine
delayed-rel
CLINDAGEL	adapalene (except adapa/ene
pad), benzoyl peroxide,	colchicine capsule	colchicine tablet, MITIGARE
clindamycin gel (except NOC
68682046275), clindamycin	COLCRYS	colchicine tablet, MITIGARE
solution, clindamycin-benzoy/

peroxide, dapsone,

COMBIGAN

brimonidine-timolol

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

efavirenz-emtricitabine- tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil fumarate,

clindamycin gel (NOC	adapalene (except adapalene	BIKTARVY, CABENUVA,
68682046275 only)	pad), benzoyl peroxide,	DOVATO, GENVOYA,
clindamycin gel (except NDC	ODEFSEY, SYMTUZA,
68682046275), clindamycin	TRIUMEQ
solution, clindamycin-benzoy/	CONCERTA	amphetamine-

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

dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, lisdexamfetamine,

clobetasol emollient foam	clobetasol cream, clobetasol	methylphenidate ext-rel, foam (except c/obetasol	 AZSTARYS
emollient foam), c/obetasol gel,	CONTOUR NEXT STRIPS AND  ACCU-CHEK AVIVA PLUS

c/obetasol lotion, c/obetasol ointment, halobetasol cream, ha/obetaso/ ointment

KITS	STRIPS AND KITS, ACCU- CHEK GUIDE STRIPS AND KITS,ACCU-

clobetasol spray	clobetasol cream, clobetasol	CHEK SMARTVIEW STRIPS
foam (except clobetasol	AND KITS, ONETOUCH ULTRA
emollient foam), clobetaso/ gel,	STRIPS AND KITS, ONETOUCH
c/obetasol lotion, clobetasol	VERIO STRIPS AND KITS

ointment, halobetasol cream,	CONTOUR STRIPS AND KITS
halobetasol ointment

ACCU-CHEK AVIVA PLUS STRIPS AND KITS, ACCU-

CLOBEX SPRAY	clobetasol cream, clobetasol	CHEK GUIDE STRIPS AND
foam (except clobetasol	KITS,ACCU-
emollient foam), c/obetasol gel,	CHEK SMARTVIEW STRIPS
clobetasol lotion, clobetasol	AND KITS, ONETOUCH ULTRA
ointment, halobetasol cream,	STRIPS AND KITS, ONETOUCH
halobetasol ointment	VERIO STRIPS AND KITS
c/ocortolone cream	hydrocortisone butyrate	CONTRAVE	orlistat, QSYMIA, SAXENDA,
cream, hydrocortisone	WEGOVY, ZEPBOUND

butyrate ointment,	COPAXONE 20 MG/ML
hydrocortisonebutyrate
solution, mometasone, triamcinolone cream,

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

triamcinolone lotion,	BETASERON, COPAXONE40
triamcinolone ointment	MG/ML, KESIMPTA,
(except triamcinolone	MAYZENT, OCREVUS, REBIF,
ointment 0.05%)	TYSABRI, VUMERITY, ZEPOSIA
COLAZAL	balsalazide, mesa/amine	CORDRAN CREAM,	desonide {except desonide

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

triamcinolone cream,	DARAPRIM	pyrimethamine triamcinolone lotion,
triamcinolone ointment	DAYTRANA	amphetamine-
(except triamcinolone	dextroamphetamine mixed
ointment 0.05%)	salts ext-rel,
CORDRAN TAPE	clobetasol cream, clobetasol	dexmethylphenidate ext-rel,

foam (except c/obetasol emollient foam), clobetasol gel, clobetasol lotion, clobetaso/ ointment, ha/obetaso/ cream,

dextroamphetamine ext-rel,
/isdexamfetamine, methylphenidate ext-rel, AZSTARYS

halobetasol ointment	DELZICOL	ba/salazide, mesa/amine
COREGCR	acebutolol, atenolol, carvedilol,	delayed-re/, mesa/amine ext-

carvedilol phosphate ext-re/, metoprolol succinate ext-rel,

rel, sulfasa/azine,sulfasa/azine delayed-rel

metoprolol tartrate, nado/o/,	DENAVIR	acyclovir (except acyclovir
nebivolol, propranolol,	cream), penciclovir,
proprano/o/ ext-rel	va/acyc/ovir
COSOPTPF	dorzolamide-timo/o/	DEPAKOTE, DEPAKOTE ER,	carbamazepine,

COZAAR

candesartan, irbesartan,	DEPAKOTE SPRINKLE	carbamazepine ext-rel,

/osartan, o/mesartan, telmisartan, valsartan

clonazepam, divalproex sodium, divalproex sodium ext-rel, ethosuximide,

CRESEMBA	itraconazo/e	gabapentin, /acosamide, lamotrigine, lamotrigine ext-
CRESTOR		atorvastatin, ezetimibe-	rel, /evetiracetam, simvastatin, f/uvastatin,	 levetiracetam ext-rel,
/ovastatin, pitavastatin,	oxcarbazepine, phenobarbital,
pravastatin, rosuvastatin,	phenytoin, phenytoin sodium
simvastatin	extended, pregabalin,
primidone, tiagabine,
CRINONE	ENDOMETRIN		topiramate, topiramate ext-rel, valproic acid, zonisamide,
CUPRIMINE	penicillamine	APTIOM, FYCOMPA,

cyc/obenzaprine ext-rel

carisoprodol 350 mg,	OXTELLAR XR, XCOPRI

	cyclobenzaprine (except		
	cyclobenzaprinetablet 7.5	DESFERAL	deferasirox, deferiprone,	
	mg), metaxalone 800 mg,		deferoxamine	
	methocarbamol (except NDCs
69036091010,69036093090,	desonide gel	
desonide (except desonide	
	70868090190)		gel), hydrocortisone	
CYCLOSET	Talk to your doctor	desoximetasone ointment	hydrocortisone butyrate	

CYMBALTA	desvenlafaxine ext-rel,	0.05%	cream, hydrocortisone
butyrate ointment,	
	duloxetine, venlafaxine,		hydrocortisone butyrate	

capsule, cyc/obenzaprine	chlorzoxazone 500 mg (except	DEPO-SUBQ PROVERA 104	 medroxyprogesterone acetate tablet 7.5 mg	 NDC 73007001303),		150mglmL

EXCLUDED DRUG NAME(S)

DESVENLAFAXINE ER

DETROLLA

dexchlorpheniramine

Dexifol

DEXILANT

dexlansoprazole delayed-rel

DIACOMIT

diclofenac potassium capsule 25 mg, diclofenac potassium tablet25mg

diclofenac potassium powder

dic/ofenac sodium solution 2%

Dic/ofex DC

PREFERRED OPTION(S)

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%)
desvenlafaxine ext-rel, duloxetine, venlafaxine, ven/afaxine ext-rel capsule
darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-re/, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GEMTESA
clemastine 2.68 mg, cyproheptadine, levocetirizine
generic multivitamins

esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed­ rel, pantoprazole delayed-rel tablet
esomeprazole delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed­ rel, pantoprazole delayed-rel tablet
Talk to your doctor

diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
dic/ofenac sodium, diclofenac sodium gel 1%, dic/ofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)

EXCLUDED DRUG NAME(S)

Diclosaicin

DIFFERIN LOTION

diflorasone cream, diflorasone ointment

dihydroergotamine spray

DILANTIN

diltiazem ext-rel (generics for
CARDIZEM LA only)

DIOVAN, DIOVAN HCT

PREFERRED OPTION(S)

diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
adapalene (except adapalene pad), benzoy/ peroxide, clindamycin gel (except NOC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, dapsone, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, AKLIEF, EPIDUO, TWYNEO, WINLEVI
desoximetasone (except desoximetasone ointment 0.05%), fluocinonide (except
fluocinonide cream 0.1%),
BRYHALI

e/etriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-re/, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, topiramate ext-rel, valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, XCOPRI
diltiazem ext-rel (except generics for CARDIZEM LA), verapamil ext-re/
candesartan,candesartan­ hydrochlorothiazide, irbesartan, irbesartan­ hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, o/mesartan, olmesartan­ hydrochlorothiazide, telmisartan, telmisartan-

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)

hydrochlorothiazide, valsartan,	EXCLUDED DRUG NAME(S)	PREFERRED OPTION{S)

AZSTARYS	
	valsartan-hydrochlorothiazide			
		DYMISTA	azelastine-fluticasone,	
Diphen Elixir	clemastine 2.68 mg,		flunisolide, fluticasone,	
	cyproheptadine, levocetirizine		mometasone	
DORYXMPC	doxycycline hyclate capsule,	DYRENIUM	amiloride, triamterene	
	doxycycline hyclate tablet			
	(except doxycycline hyclate	ECOZA	ciclopirox, clotrimazole,	
	tablet 50 mg, 75 mg, 150 mg),		econazole, ketoconazole	
	minocycline, tetracycline		cream 2%, oxiconazole	
			(except NDCs 00168035830,	
doxepin cream	desonide (except desonide		51672135902)	
	gel), hydrocortisone,			
	pimecrolimus, tacrolimus,	EDARBI, EDARBYCLOR	candesartan,candesartan-	
	EUCRISA, OPZELURA		hydrochlorothiazide,	
			irbesartan, irbesartan-	
doxycycline hyclate delayed-	doxycycline hyclate capsule,		hydrochlorothiazide, losartan,	
rel tablet	doxycycline hyclate tablet		losartan-hydrochlorothiazide,	
	(except doxycycline hyclate		o/mesartan, olmesartan-	
	tablet 50 mg, 75 mg, 150 mg),		hydrochlorothiazide,	
	minocycline, tetracycline		telmisartan, telmisartan-	
doxycycline hyclate tablet 50	doxycycline hyclate capsule,		hydrochlorothiazide, valsartan,
va/sartan-hydrochlorothiazide	

mg, doxycycline hyclate tablet
75 mg, doxycycline hyclate	doxycycline hyclate tablet
(except doxycycline hyclate	
EDLUAR	
doxepin, ramelteon,	
tablet 150 mg	tablet 50 mg, 75 mg, 150 mg),		temazepam, zolpidem,	
	minocyc/ine, tetracycline		zolpidem ext-rel	
doxycycline monohydrate	doxycycline hyclate capsule,	EDURANT	efavirenz	
capsule 75 mg, doxycycline
monohydrate capsule 150 mg	doxycycline hyclate tablet
(except doxycycline hyclate	
E.E.S. GRANULES	erythromycins	

tablet 50 mg, 75 mg, 150 mg),
minocycline, tetracycline

EFFEXORXR	desvenlafaxine ext-rel, duloxetine, venlafaxine,

doxycycline monohydrate	ORACEA	venlafaxine ext-rel capsule delayed-rel capsule
ELELYSO	CERDELGA, CEREZYME
DUAVEE	estradiol-norethindrone,
raloxifene, BIJUVA	ELESTRIN	estradio/
DUOBRII	calcipotriene ointment or	ELIDEL	pimecrolimus, tacrolimus, calcipotriene solution WITH		EUCRISA, OPZELURA
desoximetasone (except	ELMIRON	Talk to your doctor
desoximetasone ointment

BRYHALI; ENSTILAR,	ENLITE CONTINUOUS	DEXCOM CONTINUOUS	
TACLONEX, VTAMA, ZORYVE	GLUCOSE MONITORING	GLUCOSE MONITORING	
CREAM	SYSTEM	SYSTEM	
amphetamine-	ENTERAGAM	alosetron, VIBERZI, XIFAXAN	
dextroamphetamine mixed		550MG	
salts ext-rel,			
dexmethylphenidate ext-rel,	ENTYVIO INTRAVENOUS (For	AVSOLA, REMICADE, SKYRIZI	
dextroamphetamine ext-rel,	Crohn's Disease Only)	INTRAVENOUS, STELARA	
lisdexamfetamine,		INTRAVENOUS	
methylphenidate ext-rel,			
	EPANED	enalapril, fosinopril, lisinopril,	

0.05%), fluocinonide (except	EMEND	aprepitant fluocinonide cream 0.1%) or

DYANAVELXR

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

quinapril, ramipril	fingolimod, glatiramer,
teriflunomide, AVONEX,
EPICERAM	desonide (except desonide	BETASERON,COPAXONE40
geQ,hydrocortisone	MG/ML, KESIMPTA,

TYSABRI, VUMERITY, ZEPOSIA

epinephrine (NDCs 00093-	epinephrine (except NDCs	MAYZENT, OCREVUS, REBIF,
XXXX-XX, 49502-XXXX-XX	00093-XXXX-XX, 49502-
only)	XXXX-XX), AUVI-Q	EYLEA	BYOOVIZ, CIMERLI
EPIPEN, EPIPEN JR	epinephrine (except NDCs	FABIOR	adapalene (except adapalene
00093-XXXX-XX, 49502-	pad), benzoyl peroxide,
XXXX-XX), AUVI-Q	clindamycin gel (except NOC

EPOGEN	ARANESP, PROCRIT,

68682046275), clindamycin solution, clindamycin-benzoyl
RETACRIT	peroxide, dapsone,
ergotamine-caffeine	eletriptan, naratriptan,	erythromycin solution,
rizatriptan, sumatriptan,	erythromycin- benzoyl
zolmitriptan, NURTEC ODT,	peroxide, tretinoin, AKLIEF,
UBRELVY	EPIDUO, TWYNEO, WINLEVI
ERTACZO	ciclopirox, clotrimazole,	FANAPT	aripiprazole, asenapine, econazole, ketoconazole		 c/ozapine, lurasidone,
cream 2%, oxiconazole	olanzapine, quetiapine,
(except NDCs 00168035830,	quetiapine ext-rel, risperidone,
51672135902)	ziprasidone, VRAYLAR
ERYPED	erythromycins	FEIBA	NOVOSEVEN RT, SEVENFACT
ESBRIET	pirfenidone, OFEV	FEMRING	estradiol vaginal cream,
IMVEXXY, VAGIFEM
estradiol vaginal tablet	estradiol vaginal cream,	fenofibrate capsule 30 mg, 50	fenofibrate (except fenofibrate
IMVEXXY, VAGIFEM	mg, 90 mg, 130 mg;	capsule 30 mg, 50 mg, 90 mg,
ESTRING	estradiol vaginal cream,	fenofibrate tablet 40 mg, 120	130 mg; fenofibrate tablet 40
IMVEXXY, VAGIFEM	mg		mg, 120 mg), fenofibric acid delayed-rel

ESTROGEL	estradiol

FENOGLIDE TABLET 120 MG	fenofibrate (except fenofibrate

EVEKEO	dexmethylphenidate,	capsule 30 mg, 50 mg, 90 mg,
dextroamphetamine,	130 mg; fenofibrate tablet 40
methylphenidate	mg, 120 mg), fenofibric acid
delayed-rel
EVERSENSE CONTINUOUS	DEXCOM CONTINUOUS
GLUCOSE MONITORING	GLUCOSE MONITORING	fenoprofen, FENOPROFEN	diclofenac sodium, ibuprofen,
SYSTEM	SYSTEM	CAPSULE	meloxicam tablet,
naproxen (except naproxen CR
EXFORGE	amlodipine-olmesartan,	or naproxen suspension) amlodipine-telmisartan,
amlodipine-va/sartan	FENTORA	fentanyl transmucosal
EXFORGE HCT	amlodipine-valsartan-	FERIVA21n	generic multivitamins hydrochlorothiazide,
olmesartan-amlodipine-	FERRIPROX	deferasirox, deferiprone,
hydrochlorothiazide	deferoxamine
EXJADE	deferasirox, deferiprone,	FETZIMA	desvenlafaxine ext-rel, deferoxamine		duloxetine, ven/afaxine,
venlafaxine ext-re/ capsule
EXTAVIA	dimethyl fumarate delayed-rel,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
Fexmid	carisoprodol 350 mg,	FLUOXETINE 60 MG	f/uoxetine (except f/uoxetine	
	chlorzoxazone 500 mg (except		tablet 60 mg, fluoxetine tablet	
	NOC 73007001303),		[generics for SARAFEM]),	
	cyclobenzaprine (except		paroxetine HCI, paroxetine HCI	
	cyclobenzaprine tablet 7.5		ext-rel (except NOC	
	mg), metaxalone 800 mg,		60505367503), sertraline,	
	methocarbamol (except NDCs		vi/azodone, TRINTELLIX	
	69036091010,69036093090,			
	70868090190)	flurandrenolide cream,
f/urandrenolide lotion	desonide (except desonide
gel), hydrocortisone	
FINTEPLA	clobazam, clonazepam,
lamotrigine, rufinamide,	flurandrenolide ointment	hydrocortisone butyrate	
	topiramate, topiramate ext-rel		cream, hydrocortisone
butyrate ointment,	
FIORICET CAPSULE	diclofenac sodium, ibuprofen,		hydrocortisone butyrate	
	naproxen (except naproxen CR		solution, mometasone,	
	or naproxen suspension)		triamcinolone cream,	

FIRAZYR	icatibant, RUCONEST		triamcinolone lotion,
triamcinolone ointment	

FIRMAGON	ELIGARD

(except triamcinolone ointment 0.05%)

FLAREX	dexamethasone,difluprednate,	FML FORTE, FML LIQUIFILM	dexamethasone,difluprednate, loteprednol, prednisolone		 loteprednol, prednisolone
acetate 1%	acetate 1%
FLECTOR	diclofenac sodium, diclofenac	FOCALIN XR	amphetamine-
sodium gel 1%, diclofenac	dextroamphetamine mixed
sodium solution 1.5%,	salts ext-rel,
ibuprofen, meloxicam tablet,	dexmethylphenidate ext-rel,
naproxen (except naproxen CR	dextroamphetamine ext-rel,
or naproxen suspension)	lisdexamfetamine,
FLORIVA, FLORIVA PLUS	generic multivitamins	methylphenidateext-rel,
AZSTARYS
FLOVENT DISKUS, FLOVENT	PULMICORT FLEXHALER	FORTAMET	metformin, metformin ext-rel
HFA
(except generics
f/ucytosine capsule 500 mg	fluconazole	for FORTAMET and GLUMETZA)
fluocinonide cream 0.1%	clobetasol cream, clobetasol
foam (except clobetasot	FORTESTA	testosterone gel (except
emollient foam), clobetaso/ gel,	authorized generics for
clobetasol lotion, clobetasol	TESTIM and VOGELXO),
ointment, halobetasol cream,	testosterone solution,
halobetasol ointment	NATESTO, XYOSTED
fluorouracil cream 0.5%	fluorouracil cream 5%,	FOSRENOL	calcium acetate, sevelamer fluorouracil solution,		carbonate, AURYXIA
imiquimod
FOSTEUM, FOSTEUM PLUS	alendronate, ibandronate,
fluoxetine tablet (generics for	fluoxetine (except fluoxetine	risedronate
SARAFEM only)	tablet 60 mg, fluoxetine tablet

[generics for SARAFEM]),

FRAGMIN	enoxaparin, fondaparinux

paroxetine HCI ext-rel (except	 FREESTYLE LIBRE	 DEXCOM CONTINUOUS NOC 60505367503),	CONTINUOUS GLUCOSE	GLUCOSE MONITORING
sertraline, vilazodone	MONITORING SYSTEM	SYSTEM
fluoxetine tablet 60 mg,	citalopram, escitalopram,	FREESTYLE STRIPS AND KITS	ACCU-CHEK AVIVA PLUS

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	STRIPS AND KITS, ACCU-	GOLYTELY	peg 3350-electrolytes (except	
	CHEK GUIDE STRIPS AND		generics for MOVIPREP),	
	KITS,ACCU-		sodium sulfate-potassium	
	CHEK SMARTVIEW STRIPS		sulfate-magnesium sulfate,	
	AND KITS, ONETOUCH ULTRA		CLENPIQ	
	STRIPS AND KITS, ONETOUCH			
	VERIO STRIPS AND KITS	GONAL-F	FOLLISTIM AQ	
FULPHILA	FYLNETRA, NYVEPRIA	GRANIX	NIVESTYM	
Fyremadel	GANIRELIX ACETATE	GUARDIAN	DEXCOM CONTINUOUS	
		CONNECT CONTINUOUS	GLUCOSE MONITORING	
ganirelix acetate	GANIRELIX ACETATE	GLUCOSE MONITORING	SYSTEM	
		SYSTEM		
GEL-ONE	DUROLANE, EUFLEXXA,			
	GELSYN-3, SUPARTZ FX	GUARDIAN REAL-TIME	DEXCOM CONTINUOUS	

GELNIQUE	darifenacin ext-rel,	CONTINUOUS GLUCOSE MONITORING SYSTEM	GLUCOSE MONITORING SYSTEM	
fesoterodine ext-rel,			
oxybutynin ext-rel, solifenacin,	halcinonide cream	desoximetasone (except	
tolterodine, tolterodine ext-rel,		desoximetasone ointment	
trospium, trospium ext-rel,		0.05%), f/uocinonide (except	
GEMTESA		fluocinonide cream 0.1%),	
		BRYHALI	
GENOTROPIN	HUMATROPE, NORDITROPIN,			
SOGROYA	HALOG	desoximetasone (except	
desoximetasone ointment
GEODON CAPSULE	aripiprazole, asenapine,	0.05%), fluocinonide (except
clozapine, lurasidone,	fluocinonide cream 0.1%),
olanzapine, quetiapine,	BRYHALI
quetiapine ext-rel, risperidone,
ziprasidone, VRAYLAR	HEPARIN SODIUM IN 5%	enoxaparin, fondaparinux
DEXTROSE
GEODON INTRAMUSCULAR	haloperidol, ziprasidone
HERCEPTIN, HERCEPTIN	HERZUMA, OGIVRI
GILENYA	dimethyl fumarate delayed-rel,	HYLECTA
fingo/imod, glatiramer,
teriflunomide, AVONEX,	HORIZANT	gabapentin, pregabalin,
BETASERON, COPAXONE 40	GRALISE
MG/ML, KESIMPTA,
MAVZENT, OCREVUS, REBIF,	HUMALOG	FIASP, NOVOLOG TYSABRI, VUMERITY, ZEPOSIA

GLASSIA	PROLASTIN-C, ZEMAIRA

GLEEVEC	imatinib mesylate, BOSULIF,

HUMALOG MIX 50/50	NOVOLOG MIX 70/30

HUMALOG MIX 75/25	NOVOLOG MIX 70/30

SPRYCEL	HUMULIN 70/30	NOVOLIN 70/30

NOVOLIN R

GLUCAGEN HYPOKIT	glucagon, human recombinant;	HUMULIN N	NOVOLIN N BAQSIMI; GVOKE;	HUMULIN R
ZEGALOGUE
GLUMETZA	metformin, metformin ext-rel	HYALGAN	 DUROLANE, EUFLEXXA, (except generics		GELSYN-3, SUPARTZ FX
for FORTAMETand	hydrocortisone butyrate lotion hydrocortisone butyrate
GLUMETZA)	cream, hydrocortisone
GLYCOPYRROLA TE TABLET	dicyclomine	butyrate ointment,
1.5MG	hydrocortisone butyrate
solution, mometasone,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	triamcinolone cream,	lndocin, INOOCIN	dic/ofenac sodium, ibuprofen,	
	triamcinolone lotion,		meloxicam tablet,	
	triamcinolone ointment		naproxen (except naproxen CR	
	(except triamcinolone		or naproxen suspension)	
	ointment 0.05%)	lnflammacin	diclofenac sodium, diclofenac	
Hy/aVite	generic multivitamins		sodium gel 1%, diclofenac	
sodium solution 1.5%,
hyoscyamine sulfate ext-rel	dicyclomine	ibuprofen, meloxicam tablet,
naproxen (except naproxen CR

HYQVIA

CUTAQUIG

or naproxen suspension)

HYSINGLA ER	fentanyl transdermal,	INFLECTRA	AVSOLA, ILUMYA, REMICADE,
hydrocodone ext-rel,	SIMPONI ARIA, SKYRIZI
methadone, morphine ext-rel,	INTRAVENOUS, STELARA
oxycodone ext-rel	INTRAVENOUS

HYZAAR	candesartan-
hydrochlorothiazide, irbesartan- hydrochlorothiazide, losartan- hydrochlorothiazide, olmesartan- hydroch/orothiazide,
telmisartan-	INNOPRANXL

INTELENCE	acebutolo/, ateno/o/, carvedilol, carvedi/o/ phosphate ext-rel, metoprolo/ succinate ext-rel, metoprolol tartrate, nadolo/, nebivolol, propranolol, propranolol ext-rel
etravirine	
hydrochlorothiazide, valsartan-			
hydrochlorothiazide	INTRAROSA	estradiol vaginal cream,	
lc/ofenac GP	diclofenac sodium, diclofenac		IMVEXXY, VAGIFEM	
sodium gel 1%, diclofenac	INTUNIV	amphetamine-	
sodium solution 1.5%,		dextroamphetaminemixed	
ibuprofen, meloxicam tablet,		salts ext-rel, atomoxetine,	
naproxen (except naproxen CR		dexmethylphenidate ext-rel,	
or naproxen suspension)		dextroamphetamineext-re/,	
		guanfacine ext-rel,	
ICLUSIG	imatinib mesylate, BOSULIF,	lisdexamfetamine,
SPRYCEL	methylphenidate ext-rel,
AZSTARYS,QELBREE
ILET INSULIN INFUSION	OMNIPOO 5 INSULIN
PUMP ANO SUPPLIES	INFUSION PUMP, OMNIPOO	INVELTYS	dexamethasone, dif/uprednate,
DASH INSULIN INFUSION	loteprednol, prednisolone
PUMP, OMNIPOD INSULIN	acetate 1%
INFUSION PUMP, V-GO
INSULIN INFUSION PUMP	INVOKAMET, INVOKAMET XR  SYNJARDY, SYNJAROY XR,

ILEVRO	bromfenac, diclofenac,		
	ketorolac	INVOKANA	FARXIGA, JARDIANCE	
IMBRUVICA	BRUKINSA, CALQUENCE	IRESSA	erlotinib, gefitinib	
INCRUSE ELLIPTA	SPIRIVA	ISOROIL	isosorbide dinitrate (except	

INDERAL LA, INDERAL XL	
acebutolol, atenolol, carvedilol,		isosorbide dinitrate 40 mg},
isosorbide mononitrate	
	carvedilol phosphate ext-rel,
metoprolo/ succinate ext-rel,	isosorbide dinitrate 40 mg	
isosorbide dinitrate (except	
	metoprolo/ tartrate, nado/o/,		isosorbide dinitrate 40 mg),	
	nebivo/o/, proprano/o/,		isosorbide mononitrate	
	propranolol ext-rel	isotretinoin capsule25 mg, 35	isotretinoin capsule20 mg, 30	

XIGOUOXR

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

mg	mg,40mg	solution, mometasone, triamcinolone cream,
ISTALOL	timolo/ maleate solution	triamcinolone lotion,
triamcinolone ointment
ivermectin cream	azelaic acid gel, brimonidine	(except triamcinolone
gel, metronidazo/e,	ointment 0.05%)
FINACEA FOAM, SOOLANTRA

IXINITY	ALPROLIX, REBINYN

KEPPRA, KEPPRA XR	carbamazepine, carbamazepine ext-rel,

JADENU	deferasirox, deferiprone,	divalproex sodium, divalproex deferoxamine	 sodium ext-rel, gabapentin,
lacosamide, lamotrigine,
JAKAFI (For Polycythemia	BESREMI	lamotrigine ext-rel,
Vera Only)	levetiracetam, levetiracetam
ext-rel, oxcarbazepine,
JALYN	dutasteride-tamsu/osin;	phenobarbital, phenytoin, dutasteride or finasteride	phenytoin sodium extended,
WITHa/fuzosin ext-rel,	pregabalin, primidone,
doxazosin, si/odosin,	tiagabine, topiramate,
tamsulosin or terazosin		topiramate ext-rel, valproic acid, zonisamide, APTIOM,
JENTADUETO, JENTADUETO	saxagliptin-metformin ext-rel,	FYCOMPA, OXTELLAR XR,
XR	JANUMET, JANUMET XR	XCOPRI
JORNAYPM	amphetamine-	KETO-DIASTIX	Talk to your doctor
dextroamphetaminemixed
salts ext-re/,	ketoconazole foam 2%	 ketoconazole shampoo 2%, dexmethylphenidateext-rel,		selenium sulfide lotion 2.5%,
dextroamphetamine ext-rel,	ZORYVEFOAM
lisdexamfetamine,

methylphenidate ext-rel,	Ketodan

ketoconazole shampoo 2%,

AZSTARYS	selenium sulfide lotion 2.5%,
ZORYVEFOAM

JUXTAPID	REPATHA

ketoprofen capsule 25 mg	diclofenac sodium, ibuprofen,

JYNARQUE	Talk to your doctor	meloxicam tablet, naproxen
(except naproxen CR or
KALETRA	atazanavir, darunavir,	naproxen suspension) lopinavir-ritonavir
ketoprofen ext-rel capsule	diclofenac sodium, ibuprofen,
KAMDOY	desonide (except desonide	meloxicam tablet, naproxen
gel), hydrocortisone	(except naproxen CR or
naproxen suspension)

KANJINTI	HERZUMA, OGIVRI

KapzinDC	diclofenac sodium, diclofenac

KETOSTIX	Talk to your doctor

sodium gel 1%, diclofenac	KITABISPAK	tobramycin inhalation solution sodium solution 1.5%,
ibuprofen, meloxicam tablet,	KORLYM	mifepristone naproxen (except naproxen CR

or naproxen suspension)

KUVAN

sapropterin

KAZANO	saxagliptin-metformin ext-rel,	KYPROLIS	bortezomib, NINLARO
JANUMET, JANUMET XR
LACRISERT	RESTASIS, XIIDRA
KENALOG	hydrocortisone butyrate
cream, hydrocortisone	LACTULOSE PAK	lactulose solution
butyrate ointment,	LAMICTAL, LAMICTAL ODT	carbamazepine, hydrocortisone butyrate

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
carbamazepine ext-rel,		teriflunomide, AVONEX,	
clobazam, clonazepam,		BETASERON, COPAXONE 40	
divalproex sodium, diva/proex		MG/ML, KESIMPTA,	
sodium ext-rel, gabapentin,		MAYZENT, OCREVUS, REBIF,	
lacosamide, lamotrigine,		TYSABRI, VUMERITY, ZEPOSIA	
lamotrigine ext-rel,
/evetiracetam, /evetiracetam	
LESCOLXL	
atorvastatin, ezetimibe-	
ext-rel, oxcarbazepine, phenobarbital, phenytoin,		simvastatin, fluvastatin,
lovastatin, pitavastatin,	
phenytoin sodium extended,		pravastatin, rosuvastatin,	
pregabalin, primidone,		simvastatin	

rufinamide, tiagabine, topiramate, topiramate ext-rel,

LETAIRIS	ambrisentan, bosentan,

valproic acid, zonisamide,	OPSUMIT
APTIOM, FYCOMPA,	LEUKINE	NIVESTYM OXTELLAR XR, XCOPRI
LAMICTALXR	carbamazepine,	LEVEMIR	LANTUS

divalproex sodium, divalproex sodium ext-re/, gabapentin, lacosamide, /amotrigine, lamotrigine ext-rel,
/evetiracetam, levetiracetam	

LEXAPRO	hydrocodone ext-rel, methadone, morphine ext-rel, oxycodone ext-rel
cita/opram, escitalopram,	
ext-rel, oxcarbazepine,
phenobarbital, phenytoin, phenytoin sodium extended, pregabalin, primidone, tiagabine, topiramate, topiramate ext-re/, valproic acid, zonisamide, APTIOM,
FYCOMPA, OXTELLAR XR,		fluoxetine (except f/uoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCI, paroxetine HCI ext-rel (except NDC 60505367503), sertraline, vilazodone, TRINTELLIX	
XCOPRI	LIALDA	balsalazide, mesa/amine	
		delayed-rel, mesa/amine ext-	

carbamazepine ext-rel,	levorphanol	fentanyl transdermal,

LANOXIN TABLET (125 MCG
and 250 MCG only)	digoxin		rel, sulfasa/azine, su/fasalazine delayed-rel	
lansoprazole delayed-rel orally	esomeprazole delayed-rel,	LIBRAX	dicyclomine	
disintegrating tablet	lansoprazo/e delayed-rel			
	capsule, omeprazole delayed-	LILETTA	KYLEENA, MIRENA, SKYLA	
	rel, pantoprazole delayed-rel			
	tablet	LIPITOR	atorvastatin, ezetimibe-	
			simvastatin, f/uvastatin,	
lanthanum carbonate	calcium acetate, sevelamer		lovastatin, pitavastatin,	
	carbonate, AURYXIA		pravastatin, rosuvastatin,	
LASTACAFT	aze/astine, bepotastine,		simvastatin	
	cromolyn sodium, lotepredno/,	LITHOSTAT	Talk to your doctor	
	olopatadine			
		LIVALO	atorvastatin, ezetimibe-	
LATUDA	aripiprazole, asenapine,		simvastatin, f/uvastatin,	
	clozapine, lurasidone,		lovastatin, pitavastatin,	
	o/anzapine, quetiapine,		pravastatin, rosuvastatin,	
	quetiapine ext-rel, risperidone,		simvastatin	
	ziprasidone, VRAYLAR			
		Lofena	diclofenac sodium, ibuprofen,	
LEMTRADA	dimethyl fumarate delayed-re/,	meloxicam tablet, naproxen	
	fingolimod, glatiramer,	(except naproxen CR or	

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	naproxen suspension)	MAXALT,  MAXALT-MLT	eletriptan, naratriptan,	

LOKELMA	
VELTASSA		rizatriptan, sumatriptan,
zolmitriptan, NURTEC ODT,	

LORBRENA	ALECENSA, ALUNBRIG

UBRELVY

MAXIDEX	dexamethasone, dif/uprednate,

Lorzone	carisoprodol 350 mg,	 loteprednol, prednisolone chlorzoxazone 500 mg (except	acetate 1%
NOC 73007001303),
cyclobenzaprine (except	mefenamic acid (NOC	diclofenac sodium, ibuprofen, cyclobenzaprine tablet 7.5	69336012830 only)	 meloxicam 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, prednisolone		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, econazole, ketoconazole		oxycodone
cream 2%, oxiconazole
(except NDCs 00168035830,	MESTINON	pyridostigmine,
51672135902)	pyridostigmine ext-rel
LUMIGAN	bimatoprost, latanoprost,	metaxalone 400 mg	carisoprodol 350 mg, travoprost		chlorzoxazone 500 mg (except
NOC 73007001303),
LUNESTA	doxepin, ramelteon,	cyc/obenzaprine (except
temazepam, zolpidem,	cyclobenzaprine tablet 7.5
zolpidem ext-rel	mg), metaxalone 800 mg,
methocarbamol (except NDCs
LUPRON DEPOT 7.5 MG, 22.5	ELIGARD	69036091010, 69036093090,
MG, 30 MG, 45 MG	70868090190)
LUZU	ciclopirox, clotrimazole,	metformin ext-rel (generics for metformin, metformin ext-rel econazole, ketoconazole	FORTAMET and GLUMETZA	(except generics for
cream 2%, oxiconazole	only)	FORTAM ET and GLUMETZA)
(except NDCs 00168035830,
51672135902)	methocarbamol 500 mg (NOC carisoprodol 350 mg,
69036091010 only),	chlorzoxazone 500 mg (except
LYRICA	duloxetine, pregabalin	methocarbamol 750 mg	 NOC 73007001303), (NDCs 69036093090,	cyclobenzaprine (except

MACRODANTIN	nitrofurantoin (except NOC

70868090190 only)	cyclobenzaprine tablet 7.5

16571074024)	mg), metaxalone 800 mg,
MatzimLA	diltiazem ext-rel (except	methocarbamol (except NDCs generics for CARDIZEM LA),	 69036091010,69036093090,
verapamil ext-rel	70868090190)
MAVYRET	EPCLUSA (genotypes 1, 2, 3, 4,	METROGEL	azelaic acid gel, brimonidine
5, 6), HARVONI (genotypes 1,	gel, metronidazole, FINACEA
4, 5, 6), VOSEVI	FOAM, SOOLANTRA

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

MIACALCIN INJECTION	alendronate, ca/citonin-	CLENPIQ
salmon, ibandronate,
risedronate, teriparatide,	MultiPro	generic multivitamins
PROLIA, TYMLOS
mupirocin cream	gentamicin, mupirocin
MICARDIS, MICARDIS HCT	candesartan, candesartan-	ointment hydrochlorothiazide,
irbesartan, irbesartan-	MYDAYIS	amphetamine-
hydrochlorothiazide, /osartan,	dextroamphetaminemixed
losartan-hydrochlorothiazide,	salts ext-rel,
o/mesartan, olmesartan-	dexmethylphenidate ext-rel,
hydroch/orothiazide,	dextroamphetamineext-rel,
telmisartan, telmisartan-	lisdexamfetamine,
hydrochlorothiazide, valsartan,	methylphenidate ext-rel,
valsartan-hydrochlorothiazide	AZSTARYS
Migergot	e/etriptan, naratriptan,	MYOBLOC	DYSPORT, XEOMIN
rizatriptan, sumatriptan,	MYRBETRIQ	darifenacin ext-rel,

zolmitriptan, NURTEC ODT, UBRELVY

fesoterodine ext-rel, oxybutynin ext-rel, solifenacin,

MIGRANAL		eletriptan, naratriptan,	tolterodine, tolterodine ext-rel, rizatriptan, sumatriptan,	trospium, trospium ext-rel,
zolmitriptan, NURTEC ODT,	GEMTESA
UBRELVY	MYTESI	diphenoxylate-atropine,
MINIVELLE	estradiol	loperamide
minocycline ext-rel	doxycycline hyclate capsule,	NAFTIN	ciclopirox, c/otrimazole, doxycyc/ine hyclate tablet		 econazole, ketoconazo/e
(except doxycycline hyclate	cream 2%, oxiconazo/e
tablet 50 mg, 75 mg,150 mg),	(except NDCs 00168035830,
minocycline, tetracycline	51672135902)
MINOLIRA	doxycycline hyclate capsule,	NAMENDAXR	memantine
doxycycline hyclate tablet	NAPRELAN	diclofenac sodium, ibuprofen,

(except doxycycline hyclate tablet 50 mg, 75mg, 150 mg), minocycline, tetracycline
MIRVASO	azelaic acid gel, brimonidine gel, metronidazole, FINACEA FOAM, SOOLANTRA

meloxicam tablet,
naproxen (except naproxen CR
or naproxen suspension)
naproxenCR	diclofenac sodium, ibuprofen, meloxicam tablet,
naproxen {except naproxen CR

Mondoxyne NL capsule 75 mg  doxycycline hyclate capsule,	or naproxen suspension)
doxycycline hyclate tablet	naproxen suspension	diclofenac sodium, ibuprofen,

{except doxycycline hyclate tablet 50 mg, 75 mg, 150 mg), minocycline, tetracycline
MONOVISC		DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

meloxicam tablet,
naproxen {except naproxen CR
or naproxen suspension)
naproxen-esomeprazole	diclofenac sodium, ibuprofen,
meloxicam tablet or naproxen

MOVANTIK	lubiprostone, SYMPROIC	{except naproxen CR or
naproxen suspension) WITH

MOVIPREP

peg 3350-electrolytes {except	esomeprazole delayed-rel,
generics for MOVIPREP),	lansoprazole delayed-rel
sodium sulfate-potassium	capsule, omeprazole delayed-
sulfate-magnesium sulfate,	rel, or pantoprazole delayed-

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

rel tablet	NORPACE	disopyramide
NEO-SYNALAR		desonide (except desonide	NORTHERA	midodrine ge{) or hydrocortisone WITH
gentamicin	NORVASC	amlodipine, nifedipine ext-rel
NESINA	saxagliptin, JANUVIA	NORVIR	ritonavir
NEULASTA,NEULASTA	FYLNETRA, NYVEPRIA	NOURIANZ	entacapone, pramipexole,
ONPRO	pramipexole ext-rel, rasagiline,
ropinirole, ropinirole ext-rel,
NEUPOGEN	NIVESTYM	selegiline, NEUPRO
NEVANAC	bromfenac, diclofenac,	NOVAREL	OVIDREL
ketorolac
NOVO NORDISK NEEDLES	8D ULTRAFINE NEEDLES
NEXAVAR	pazopanib, sorafenib, sunitinib,
CABOMETYX, INL YTA,	NOXAFIL	fluconazole, itraconazole
LENVIMA
NPLATE	DOPTELET, PROMACTA,
NEXIUM	esomeprazole delayed-rel,	TAVALISSE
/ansoprazole 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

niacin tablet 500 mg	niacin ext-rel

NUCYNTAER	fentanyl transdermal,

Niacor	niacin ext-rel	hydrocodone ext-rel, methadone, morphine ext-rel,
NICADAN	generic multivitamins	oxycodone ext-rel
NICAPRIN	generic multivitamins	NuDiclo TabPak	diclofenac sodium, diclofenac
sodium gel 1%, diclofenac
NICAZEL, NICAZEL FORTE	generic multivitamins	sodium solution 1.5%,
ibuprofen, meloxicam tablet,

NILANDRON	abiraterone, bicalutamide,

naproxen (except naproxen CR

ERLEADA, NUBEQA, XTANDI,	or naproxen suspension)
YONSA

nitrofurantoin (NOC	nitrofurantoin (except NOC

NUEDEXTA	Talk to your doctor

16571074024 only)	16571074024)	NUTROPINAQ	HUMATROPE, NORDITROPIN,

NITYR	ORFADIN

NORGESIC FORTE	carisoprodol 350 mg, chlorzoxazone 500 mg (except

SOGROYA

NUVARING	ethinyl estradiol-etonogestrel,
ANNOVERA

cyclobenzaprine (except
cyclobenzaprine tablet 7.5	
NUVIGIL	
armodafinil, modafinil,	
mg), metaxalone BOO mg,
methocarbamol (except NDCs		LUMRYZ, SUNOSI, WAKIX, XYWAV	
69036091010,69036093090,			
70868090190)	OCTAGAM	Talk to your doctor	
NORITATE	azelaic acid gel, brimonidine	omeprazole-sodium	esomeprazole delayed-rel,	
gel, metronidazole, FINACEA	bicarbonate	lansoprazole delayed-rel	
FOAM, SOOLANTRA		capsule, omeprazole delayed-	

NOC 73007001303),	NUVESSA	clindamycin, metronidazole

EXCLUDED DRUG NAME(S)	PREFERRED OPTION($)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	rel, pantoprazole delayed-re/	OSPHENA	estradiol	
	tablet	OTOVEL	ciprofloxacin-dexamethasone,	
OMNARIS	azelastine-fluticasone,		of/oxacin otic	
	flunisolide, fluticasone, mometasone	
OTREXUP	
RASUVO	
OMNITROPE	HUMATROPE, NORDITROPIN,	OWEN MUMFORD NEEDLES	BD ULTRAFINE NEEDLES	

SOGROYA

oxiconazole (N DCs	ciclopirox, clotrimazole,

ONFI	clobazam, clonazepam,	00168035830, 51672135902	 econazo/e, ketoconazole lamotrigine, rufinamide,	 only)	cream 2%, oxiconazo/e
topiramate, topiramate ext-rel		(except NDCs 00168035830, 51672135902)
ONGLYZA	saxag/iptin, JANUVIA
OXISTAT	cic/opirox, c/otrimazole,
ORENCIA INTRAVENOUS	AVSOLA, REMICADE, SIMPONI	econazole, ketoconazole
ARIA	cream2%, oxiconazole
(except NDCs 00168035830,
orphenadrine-aspirin-caffeine  carisoprodol 350 mg,	51672135902)
ch/orzoxazone 500 mg (except
NOC 73007001303),	OXYCONTIN	fentanyl transderma/,
cyclobenzaprine (except	hydrocodone ext-rel,
cyclobenzaprinetablet 7.5	methadone, morphine ext-rel,
mg), metaxalone 800 mg,	oxycodone ext-rel methocarbamol (except NDCs
69036091010, 69036093090,	oxymorphone ext-rel	fentanyl transdermal,
70868090190)	hydrocodone ext-rel,
methadone, morphine ext-rel,
Orphengesic Forte	carisoprodol 350 mg,	oxycodone ext-rel chlorzoxazone 500 mg (except
NOC 73007001303),	OXYTROL	darifenacin ext-rel,
cyc/obenzaprine (except	fesoterodine ext-rel,
cyc/obenzaprine tablet 7.5	oxybutynin ext-rel, solifenacin,
mg), metaxalone 800 mg,	tolterodine, tolterodine ext-rel,
methocarbamo/ (except NDCs	trospium, trospium ext-rel,
69036091010,69036093090,	GEMTESA
70868090190)
PANCREAZE	CREON, VIOKACE, ZENPEP
ORTHOD	folic acid, generic

ORTHODF	
folic acid, generic	suspension	lansoprazole delayed-rel
capsule, omeprazole delayed-	
	multivitamins		rel,pantoprazole delayed-rel	
			tablet	
ORTHOVISC	DUROLANE, EUFLEXXA,
GELSYN-3, SUPARTZ FX	paroxetine HCI ext-rel (NDC	citalopram, escitalopram,	

OSENI	saxagliptin-metformin ext-rel,	60505367503 only)	fluoxetine (except fluoxetine
tablet 60 mg, f/uoxetine tablet	
	JANUMET, JANUMET XR;
saxagliptin or JANUVIA WITH		[generics for SARAFEM]),
paroxetine HCI, paroxetine HCI	
	pioglitazone		ext-re/ (except NDC	
OSMOPREP	peg 3350-electrolytes (except		60505367503), sertraline, vilazodone, TRINTELLIX	

multivitamins	pantoprazole delayed-rel	esomeprazole delayed-re/,

generics for MOVIPREP),
sodium sulfate-potassium	
paroxetine mesylate capsule	
paroxetine HCI	
sulfate-magnesium sulfate,	7.5mg		
CLENPIQ			
	PAXIL, PAXIL CR	citalopram, escitalopram,	

EXCLUDED DRUG NAME(S)

peg 3350-electrolytes
(generics for MOVIPREP only)

PEGASYS PENNSAID

PENTASA

PERCOCET

PERRIGO NEEDLES PERTZVE
PLAVIX

PLENVU

POLYTOZA POLY-VI-FLOR
POLY-VI-FLOR WITH IRON

posaconazole delayed-rel tablet
PRADAXA PRALUENT

PREFERRED OPTION(S)

fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCI, paroxetine HCl ext-re/ (except NOC 60505367503), sertraline, vilazodone, TRINTELLIX
peg 3350-e/ectro/ytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate-magnesium sulfate, CLENPIQ
Talk to your doctor

diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
balsalazide, mesa/amine delayed-rel, mesa/amine ext­ rel, sulfasalazine, sulfasalazine delayed-rel
hydrocodone-acetaminophen, oxycodone-acetaminophen
BD ULTRAFINE NEEDLES CREON, VIOKACE, ZENPEP
clopidogrel, dipyridamole ext­ re/-aspirin, prasugrel, BRILINTA
peg 3350-electrolytes (except generics for MOVIPREP), sodium sulfate-potassium sulfate-magnesium sulfate, CLENPIQ
Talk to your doctor generic multivitamins generic multivitamins fluconazo/e, itraconazo/e
warfarin, ELIQUIS, XARELTO REPATHA

EXCLUDED DRUG NAME(S)

PRED FORTE, PRED MILD

prednisolone solution 10 mg/5 ml, prednisolone solution 20 mgl5ml

PREGNYL PREMARIN PREMARIN CREAM

PREMPHASE

PREMPRO

PRENATAL PLUS PREVACID

PREVIDENT PREZISTA PRILOSEC

PRISTIQ

PROAIR RESPICLICK

PREFERRED OPTION(S)

CHEK GUIDE STRIPS AND KITS,ACCU-
CHEK SMARTVIEW STRIPS AND KITS, ONETOUCH ULTRA STRIPS AND KITS, ONETOUCH VERIO STRIPS AND KITS
dexamethasone, difluprednate, loteprednol, prednisolone acetate 1%
dexamethasone, hydrocortisone, methylpredniso/one, prednisolone solution {except prednisolone solution 10 mg/5 ml, 20mg/5 ml), prednisone
OVIDREL
estradio/ estradiol vaginal
cream, IMVEXXY, VAGIFEM

estradio/-norethindrone,
BIJUVA

estradiol-norethindrone,
BIJUVA

generic prenatal vitamins
esomeprazole delayed-rel, lansoprazo/e delayed-re/ capsule, omeprazole delayed­ rel, pantoprazole delayed-rel tablet
Talk to your doctor atazanavir, darunavir esomeprazo/e delayed-rel,
lansoprazole delayed-rel
capsule, omeprazole de/ayed­ rel, pantoprazole delayed-rel tablet
desvenlafaxineext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
albuterol sulfate CFC-free aerosol (except NDCs 00093317431, 66993001968),
leva/buterol tartrate CFC-

PRECISION XTRA STRIPS AND ACCU-CHEK AVIVA PLUS KITS	STRIPS AND KITS, ACCU-

free aerosol

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
PROCORT	hydrocortisone		dextroamphetamine ext-rel,	
Proctocort, PROCTOCORT	budesonide foam,		lisdexamfetamine,
methylphenidate ext-rel,	
	hydrocortisone enema,
mesa/amine suppository,		AZSTARYS	
	mesa/amine suspension,	QUILLIVANT XR	amphetamine-	
	CORTIFOAM		dextroamphetamine mixed	
PROCYSBI	CYSTAGON		salts ext-rel,
dexmethylphenidate ext-rel,	

PROLENSA

bromfenac, diclofenac,

dextroamphetamineext-rel, lisdexamfetamine,

PROMETRIUM

ketorolac	methylphenidate ext-rel,
medroxyprogesterone;	AZSTARYS
progesterone, micronized	QVAR REDIHALER	PULMICORT FLEXHALER

PROTONIX	esomeprazo/e delayed-rel,	RAPAFLO	alfuzosin ext-re/, doxazosin,
/ansoprazo/e delayed-rel	silodosin, tamsu/osin, terazosin capsule, omeprazole delayed-
rel, pantoprazole delayed-re/	RAVICTI	sodium phenylbutyrate,
tablet	PHEBURANE
PROVENTIL HFA	albutero/ sulfate CFC-free	RAYOS	dexamethasone, aerosol (except NDCs		 hydrocortisone,
00093317431, 66993001968),	methylprednisolone,
/evalbuterol tartrate CFC-	predniso/one solution (except
free aerosol	prednisolone solution 10 mg/5
mL, 20 mg/5 mL), prednisone

PROVIGIL

armodafinil, modafinil,
LUMRYZ, SUNOSI, WAKIX,	RECEDO	Talk to your doctor
XYWAV

PROZAC	citalopram, escitalopram,

RELION INSULIN	NOVOLIN INSULIN

f/uoxetine (except fluoxetine	RELISTOR	lubiprostone, SYMPROIC
tablet 60 mg, fluoxetine tablet

[generics for SARAFEM]),	REMODULIN
paroxetine HCI, paroxetine HCI

treprostinil

ext-rel (except NDC

RENFLEXIS	AVSOLA, ILUMYA, REMICADE,

60505367503), sertraline,	SIMPONI ARIA, SKYRIZI
vi/azodone, TRINTELLIX	INTRAVENOUS, STELARA INTRAVENOUS

PULMICORT RESPULES	budesonide inhalation
suspension, PULMICORT	RENVELA

calcium acetate, sevelamer

FLEXHALER	carbonate, AURYXIA
QNASL	azelastine-fluticasone,	RETIN-A MICRO	adapalene (except adapalene
flunisolide, fluticasone,	pad), benzoyl peroxide,

	68682046275), clindamycin	
QTERN	GLYXAMBI	solution, clindamycin-benzoyl	
		peroxide, dapsone,	
quazepam	doxepin, ramelteon,	erythromycin solution,	
	temazepam, zolpidem,	erythromycin-benzoyl	
	zolpidem ext-rel	peroxide, tretinoin, AKLIEF,	
		EPIDUO, TWYNEO, WINLEVI	
QUILLICHEW ER	amphetamine-			
dextroamphetamine mixed	REVATIO	sildenafil, tadalafi/, TADLIQ	
salts ext-rel,			
dexmethylphenidate ext-rel,	REYATAZ	atazanavir, darunavir	

mometasone	clindamycin gel (except NDC

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

RHEUMATE	generic multivitamins	olanzapine, quetiapine, quetiapine ext-rel, risperidone,
RHOFADE	azelaic acid gel, brimonidine	ziprasidone, VRAYLAR
gel, metronidazo/e, FINACEA
FOAM, SOOLANTRA	SEYSARA	doxycycline hyclate capsule, doxycycline hyclate tablet
RHOPRESSA	bimatoprost, brimonidine	{except doxycycline hyclate
solution, brimonidine-timolol,	tablet 50 mg, 75 mg, 150 mg),
brinzolamide, dorzolamide,	minocycline, tetracycline dorzolamide-timolol,
latanoprost, timolol maleate	SFROWASA	mesa/amine suspension 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 RITUXAN	RUXIENCE	 SINGULAIR	montelukast, zafirlukast
RIXUBIS	ALPROLIX, REBINYN	SOLODYN	doxycycline hyclate capsule,
doxycycline hyc/ate tablet
ROCKLATAN	bimatoprost, brimonidine	 {except doxycycline hyclate solution, brimonidine-timolol,	tablet 50 mg,75 mg, 150 mg),
brinzolamide, dorzolamide,	minocycline, tetracycline dorzolamide-timolol,
latanoprost, timolol maleate	SOLOSEC	c/indamycin, metronidazole
solution, travoprost,

ALPHAGAN P, SIMBRINZA

SOMAVERT	SOMATULINE DEPOT

ROWASA	mesalamine suspension	SORILUX	calcipotriene ointment,
calcipotriene solution, VTAMA,
ROZEREM	doxepin, ramelteon,	ZORYVE CREAM
temazepam, zolpidem,

zolpidem ext-rel

SPORANOX CAPSULE	itraconazole, terbinafine tablet

RUBRACA	LYNPARZA, ZEJULA	SPORANOX SOLUTION	fluconazole
RyClora	clemastine 2.68 mg,	SPRIX	diclofenac sodium, ibuprofen, cyproheptadine, levocetirizine		 meloxicam tablet,
naproxen {except naproxen CR
SABRIL	vigabatrin	or naproxen suspension)
SAIZEN	HUMATROPE, NORDITROPIN,	STENDRA	sildenafi/, tadalafi/, vardenafil
SOGROYA
STRIBILD	efavirenz-emtricitabine-
SANDOSTATIN LAR	SOMATULINE DEPOT	tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir
SCARSILK PAD	Talk to your doctor	disoproxil fumarate,
BIKTARVY, CABENUVA,
SELZENTRY	maraviroc	DOVATO, GENVOYA,
SEREVENT	STRIVERDI RESPIMAT	ODEFSEY, SYMTUZA, TRIUMEQ
SEROQUELXR	aripiprazole, asenapine,	SUBOXONE	 buprenorphine-naloxone clozapine, lurasidone,		sublingual, ZUBSOLV

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
SUBSYS	fentanyl transmucosal	TAYTULLA	ethinyl estradiol-drospirenone,	
sucralfate suspension	sucralfate tablet		ethinyl estradiol-drospirenone-
levomefolate, ethinyl estradiol-	

sumatriptan-naproxen	diclofenac sodium, ibuprofen

levonorgestrel, ethinyl estradiol-levonorgestrel-iron,

ornaproxen(exceptnaproxen	ethinyl estradiol-norethindrone
CR or naproxen suspension)	acetate-iron, ethinyl estradiol-
WITH eletriptan, naratriptan,	norgestimate, LO LOESTRIN
rizatriptan, sumatriptan,	FE, NATAZIA
zolmitriptan, NURTEC ODT or
UBRELVY	TAZORAC	adapalene (except adapalene pad), benzoyl peroxide,

SUPREP	peg 3350-electrolytes (except

clindamycin gel (except NOC

generics for MOVIPREP),	68682046275), clindamycin
sodium sulfate-potassium	solution, clindamycin-benzoyl
sulfate-magnesium sulfate,	peroxide, dapsone,
CLENPIQ	erythromycin solution,
Sure Result DSS Premium	diclofenac sodium, diclofenac	erythromycin- benzoyl
Pack	sodium gel 1%, diclofenac	peroxide, tretinoin, AKLIEF,
sodium solution 1.5%,	EPIDUO, TWYNEO, WINLEVI;
ibuprofen, meloxicam tablet,	calcipotriene ointment,
naproxen (except naproxen CR	calcipotriene solution, VTAMA,
or naproxen suspension)	ZORYVE CREAM
SUTENT	pazopanib, sunitinib,	TECFIDERA	dimethyl fumarate delayed-rel,
CABOMETYX, INLYTA,	fingolimod, glatiramer,
LENVIMA	teriflunomide, AVONEX,
BETASERON, COPAXONE 40
SYMBICORT	fluticasone-salmeterol (except	MG/ML, KESIMPTA,
certain NDCs), Wixela lnhub,	MAYZENT, OCREVUS, REBIF,
BREO ELLIPTA (except certain	TYSABRI, VUMERITY, ZEPOSIA
NDCs)	TEGRETOL, TEGRETOL XR	carbamazepine,
SYNDROS	dronabinol	carbamazepine ext-rel, divalproex sodium, divalproex
SYNERDERM		desonide (except desonide	sodium ext-rel, gabapentin, gel), hydrocortisone	 lacosamide, lamotrigine,
lamotrigine ext-rel,
SYNVISC, SYNVISC-ONE	DUROLANE, EUFLEXXA,	levetiracetam, levetiracetam
GELSYN-3, SUPARTZ FX	ext-rel, oxcarbazepine, phenobarbital, phenytoin,
SYPRINE	trientine	phenytoin sodium extended,
TAFINLAR CAPSULE	BRAFTOVI, ZELBORAF	pregabalin, primidone, tiagabine, topiramate,
TALIVA	generic multivitamins		topiramate ext-rel, valproic acid, zonisamide, APTIOM,
Targadox	doxycycline hyclate capsule,	FYCOMPA, OXTELLAR XR,
doxycycline hyclate tablet	XCOPRI
(except doxycycline hyclate

tablet 50 mg, 75 mg,150 mg),

TESTIM	testosterone gel (except

minocycline, tetracycline	authorized generics for TESTIM and VOGELXO),
TARGRETIN	bexarotene	testosterone solution,
NATESTO,XYOSTED

	SPRYCEL	testosterone gel 1%
(authorized generics for	testosterone gel (except
authorized generics for	
tavaborole	terbinafine tablet	TESTIM and VOGELXO only)	TESTIM and VOGELXO),	

TASIGNA	imatinib mesylate, BOSULIF,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	testosterone solution,
NATESTO,XYOSTED		oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel,	
trospium, trospium ext-rel,
THEO-24	arformoterol, formoterol	GEMTESA
inhalation solution, ipratropium
inhalation solution, SPIRIVA,	TRACLEER	ambrisentan, bosentan,
STRIVERDI RESPIMAT,	OPSUMIT
YUPELRI

THIOLA	tiopronin

TRADJENTA	saxagliptin, JANUVIA

tramadol tablet 100 mg,	tramadol (except tramadol

THIOLA EC	tiopronin delayed-rel	tramadol ext-rel capsule	tablet 100 mg), tramadol ext-
rel tablet
TIMOPTIC OCUDOSE	timolol maleate solution
TRANSDERM SCOP	meclizine, scopolamine
TIROSINT	levothyroxine	transdermal
TOBI, TOBI PODHALER	tobramycin inhalation solution	TRAVATANZ	bimatoprost, latanoprost,
TOBRADEX, TOBRADEX ST	neomycin-polymyxin 8-		 travoprost bacitracin-hydrocortisone,	TRAZIMERA	HERZUMA, OGIVRI
neomycin-polymyxin8-
dexamethasone, tobramycin-	TRELSTAR MIXJECT	ELIGARD
dexamethasone
TREXIMET	diclofenac sodium, ibuprofen
topiramate ext-rel capsule	carbamazepine,	ornaproxen(exceptnaproxen
(generics for QUDEXY XR	carbamazepine ext-rel,	CR or naproxen suspension)
only)		clobazam, clonazepam,	 WITH eletriptan, naratriptan, divalproex sodium, divalproex	rizatriptan, sumatriptan,
sodium ext-rel, gabapentin,	zolmitriptan, NURTEC ODT or
lacosamide, lamotrigine,	UBRELVY
lamotrigine ext-rel,
levetiracetam, levetiracetam	triamcinolone aerosol 0.2%	 hydrocortisone butyrate ext-rel, oxcarbazepine,		cream, hydrocortisone
phenobarbital, phenytoin,	butyrate ointment,
phenytoin sodium extended,	hydrocortisone butyrate
pregabalin, primidone,	solution, mometasone,
rufinamide, tiagabine,	triamcinolone cream,
topiramate, topiramate ext-rel,	triamcinolone lotion,
valproic acid, zonisamide,	triamcinolone ointment
APTIOM, FYCOMPA,	(except triamcinolone
OXTELLAR XR, XCOPRI	ointment 0.05%)
TOPROL-XL	acebutolol, atenolol, carvedilol,	triamcinolone ointment 0.05% hydrocortisone butyrate carvedilol phosphate ext-rel,		cream, hydrocortisone
metoprolol succinate ext-rel,	butyrate ointment,
metoprolol tartrate, nadolol,	hydrocortisonebutyrate
nebivolol, propranolol,	solution, mometasone,
propranolol ext-rel	triamcinolone cream,
triamcinolone lotion,
Tovet	clobetasol cream, c/obetasol	 triamcinolone ointment foam (except clobetasol	(except triamcinolone
emollient foam), clobetasol gel,	ointment 0.05%)
clobetasol lotion, clobetasol
ointment, ha/obetasot cream,	TRICOR	fenofibrate (except fenofibrate
halobetasol ointment	capsule 30 mg, 50 mg, 90 mg,
130 mg; fenofibrate tablet 40
TOVIAZ	darifenacin ext-rel,	mg, 120 mg), fenofibric acid fesoterodine ext-rel,	 delayed-rel

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION($)	
TRILEPTAL	carbamazepine,	ULTRAVATE	clobetasol cream, clobetasol	
	carbamazepine ext-rel,		foam (except clobetasol	
	divalproex sodium, divalproex		emollient foam), clobetasol gel,	
	sodium ext-rel, gabapentin,		clobetasol lotion, clobetasol	
	lacosamide, lamotrigine,		ointment, halobetasol cream,	
	lamotrigine ext-rel,		halobetasol ointment	
	levetiracetam, levetiracetam
ext-rel, oxcarbazepine,	
UROXATRAL	alfuzosin ext-rel, doxazosin,	
	phenobarbital, phenytoin,		silodosin, tamsulosin, terazosin	

phenytoin sodium extended, pregabalin, primidone,

VALCYTE	valganciclovir

tiagabine, topiramate,	VALTREX	acyclovir (except acyclovir

topiramate ext-rel, valproic acid, zonisamide, APTIOM,

cream, ointment), valacyclovir

FYCOMPA, OXTELLAR XR,	VANOS	clobetasol cream, clobetasol
XCOPRI	foam (except clobetasol
TRIPTODUR	FENSOLVI, LUPRON DEPOT-	emollient foam), clobetasol gel,
PED, SUPPREUN LA	clobetaso/ lotion, clobetasol
ointment, halobetasol cream,
TRI-VI-FLOR	generic multivitamins	halobetasol ointment
TRIVIDIA INSULIN SYRINGES	8D ULTRAFINE INSULIN	Vanoxide-HC	adapalene (except adapalene
SYRINGES	pad), benzoyl peroxide,
clindamycin gel (except NOC
TronVite	generic multivitamins		68682046275), clindamycin solution, clindamycin-benzoyl
TRUDHESA		eletriptan, naratriptan,	peroxide, dapsone, rizatriptan, sumatriptan,	 erythromycin solution,
zolmitriptan, NURTEC ODT,	erythromycin- benzoyl
UBRELVY	peroxide, tretinoin, AKLIEF,
EPIDUO, TWYNEO, WINLEVI
TRUVADA	abacavir-/amivudine,
emtricitabine-tenofovir	VARUBI	aprepitant disoproxil fumarate,
lamivudine-zidovudine,	VASCEPA	icosapent ethyl, omega-3 acid
CIMDUO, DESCOVY	ethyl esters
TRUXIMA	RUXIENCE	VASCULERA	Talk to your doctor
TUDORZA	SPIRIVA	VECTICAL	calcipotriene ointment, calcipotriene solution, VTAMA,
TYVASO DPI	Talk to your doctor	ZORYVE CREAM

UCERISFOAM	budesonide foam,	VELPHORO	calcium acetate, sevelamer hydrocortisone enema,		carbonate, AURYXIA
mesa/amine suppository,
mesa/amine suspension,	VELTIN	adapalene (except adapalene
CORTIFOAM	pad), benzoyl peroxide,
clindamycin gel (except NOC

UDENYCA	FYLNETRA, NYVEPRIA

68682046275), clindamycin

ULORIC	al/opurinol	solution, clindamycin-benzoyl peroxide, dapsone,
ULTIMED INSULIN SYRINGES		8D ULTRAFINE INSULIN	erythromycin solution,
SYRINGES	erythromycin- benzoyl
peroxide, tretinoin, AKLIEF,
ULTIMED NEEDLES	8D ULTRAFINE NEEDLES	EPIDUO, TWYNEO, WINLEVI
venlafaxine ext-rel tablet	desvenlafaxine ext-rel,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
(except 225 mg)	duloxetine, venlafaxine,	VIVELLE-DOT	estradiol	
	venlafaxine ext-rel capsule			
		VOGELXO	testosterone gel (except	
VENTOLIN HFA	albuterol sulfate CFC-free		authorized generics for	
	aerosol (except NDCs		TESTIM and VOGELXO),	
	00093317431, 66993001968),		testosterone solution,	
	levalbuterol tartrate CFC-		NATESTO, XYOSTED	
	free aerosol			
		VOTRIENT	pazopanib, sunitinib,	
VERDESO	desonide (except desonide		CABOMETYX, INLYTA,	
	ge0, hydrocortisone		LENVIMA	
VEREGEN	imiquimod, podofilox	VPRIV	CERDELGA, CEREZYME	
VESICARE	darifenacin ext-rel,	VUSION	nystatin	
	fesoterodine ext-rel,			
	oxybutynin ext-rel, solifenacin,	WELLBUTRIN XL	bupropion, bupropion ext-rel	
	tolterodine, tolterodine ext-rel,		(except bupropion ext-rel	
	trospium, trospium ext-rel,		tablet 450 mg)	
	GEMTESA	XALKORI CAPSULE	ALECENSA, ALUNBRIG,	
VIAGRA	sildenafil, tadalafil, vardenafil		AUGTYRO, ZYKADIA	
VIIBRYD	citalopram, escitalopram,	XANAX, XANAX XR	alprazolam, clonazepam,	
	f/uoxetine (except f/uoxetine		diazepam, lorazepam,	
	tablet 60 mg, fluoxetine tablet		oxazepam	

[generics for SARAFEM]),
paroxetine HCI, paroxetine HCI

XENAZINE	tetrabenazine, AUSTEDO,

ext-rel (except NOC	AUSTEDO XR. INGREZZA
60505367503), sertraline,	XENICAL	orlistat, QSYMIA, SAXENDA,
vilazodone, TRINTELLIX	WEGOVY, ZEPBOUND
VIMPAT	carbamazepine,	XERESE	acyclovir (except acyclovir

carbamazepine ext-rel, divalproex sodium, divalproex

cream, ointment), valacyclovir

sodium ext-rel, gabapentin,	XIFAXAN 200 MG	sulfamethoxazole- lacosamide, lamotrigine,		 trimethoprim
lamotrigine ext-rel,
levetiracetam, levetiracetam	XIMINO	doxycycline hyclate capsule,
ext-rel, oxcarbazepine,	doxycycline hyclate tablet
phenobarbital, phenytoin,	(except doxycycline hyclate
phenytoin sodium extended,	tablet 50 mg, 75 mg, 150 mg),
pregabalin, primidone,	minocycline, tetracycline tiagabine, topiramate,
topiramate ext-rel, valproic	XOLEGEL COREPAK	 ciclopirox, ketoconazole cream acid, zonisamide, APTIOM,		2%
FYCOMPA, OXTELLAR XR,
XCOPRI	XOLEGELDUO		ciclopirox, ketoconazole cream 2%, ketoconazole shampoo
VIRACEPT	atazanavir, darunavir,	2%, selenium sulfide lotion lopinavir-ritonavir	2.5%, ZORYVE FOAM
VISCO-3	DUROLANE, EUFLEXXA,	XOPENEXHFA	albuterol sulfate CFC-free
GELSYN-3, SUPARTZ FX	aerosol (except NDCs 00093317431, 66993001968),
VITAFOL-ONE	generic prenatal vitamins	levalbuterol tartrate CFC-
Vitasure	generic multivitamins	free aerosol
XTAMPZAER	fentanyl transdermal,

EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	EXCLUDED DRUG NAME(S)	PREFERRED OPTION(S)	
	hydrocodone ext-rel,	ZIANA	adapalene (except adapalene	
	methadone, morphine ext-rel,		pad), benzoy/ peroxide,	
	oxycodone ext-rel		clindamycin gel (except NDC	

XYREM	
LUMRVZ, WAKIX, XYWAV		68682046275), clindamycin
solution, clindamycin-benzoyl	
peroxide, dapsone,
XVZBAC	generic multivitamins	erythromycin solution,
YASMIN	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 estradio/-norethindrone	sodium solution 1.5%,
acetate-iron, ethinyl estradiol-	ibuprofen, meloxicam tablet,
norgestimate, LO LOESTRIN	naproxen (except naproxen CR
FE, NATAZIA	or naproxen suspension)
YAZ	ethinyl estradio/-drospirenone,	ZIEXTENZO	FYLNETRA, NYVEPRIA
ethinyl estradiol-drospirenone-
levomefolate, ethinyl estradio/-	zileuton ext-rel	montelukast, zafirlukast
/evonorgestrel, ethinyl
estradiol-levonorgestrel-iron,	ZIPSOR	dic/ofenac sodium, ibuprofen,
ethinyl estradio/-norethindrone	meloxicam tablet, naproxen
acetate-iron, ethinyl estradiol-	(except naproxen CR or
norgestimate, LO LOESTRIN	naproxen suspension)
FE, NATAZIA
ZIRGAN	trifluridine
Yuvafem	estradio/ vaginal cream,
IMVEXXY, VAGIFEM	ZOLADEX		ELIGARD, MYFEMBREE, ORILISSA
ZALVIT	generic prenatal vitamins
ZOLOFT	citalopram, escitalopram,
ZARXIO	NIVESTYM		f/uoxetine (except fluoxetine tablet 60 mg, f/uoxetine tablet
ZEGERID	esomeprazole delayed-rel,	[generics for SARAFEM]),
lansoprazole delayed-rel	paroxetine HCI, paroxetine HCI
capsule, omeprazole delayed-	ext-re/ (except NDC
rel,pantoprazole delayed-rel	60505367503), sertraline,
tablet	vilazodone, TRINTELLIX
ZELAC	Talk to your doctor	zolpidem sublingual	doxepin, ramelteon,

ZELAPAR

rasagi/ine, se/egiline	temazepam, zolpidem,

zolpidem ext-rel

ZEPATIER	EPCLUSA (genotypes 1, 2, 3, 4,	ZONEGRAN	carbamazepine,
5, 6), HARVONI (genotypes 1,	carbamazepine ext-rel,
4, 5,6)	divalproex sodium, diva/proex
ZESTORETIC	fosinopril-hydrochlorothiazide,	sodium ext-rel, gabapentin,

lisinopril-hydrochlorothiazide, quinapril-hydrochlorothiazide

/acosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam

ZETIA	ezetimibe	ext-rel, oxcarbazepine, phenobarbital, phenytoin,
ZETONNA	azelastine-fluticasone,	phenytoin sodium extended, fluniso/ide, fluticasone,	 pregaba/in, primidone,
mometasone	tiagabine, topiramate,
topiramate ext-rel, valproic

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

acid, zonisamide, APTIOM,	bacitracin-hydrocortisone,
FYCOMPA, OXTELLAR XR,	neomycin-polymyxin 8-
XCOPRI	dexamethasone, tobramycin-
dexamethasone
ZONTIVITY	Talk to your doctor
ZVMAXID	ciprofloxacin, erythromycin,
ZOVIRAX	acyclovir (except acyclovir	gentamicin, levof/oxacin,
cream), penciclovir,	moxifloxacin, of/oxacin,
valacyclovir	sulfacetamide, tobramycin
ZYCLARA	f/uorouracil 5% cream,	ZVTIGA	abiraterone, bicalutamide, fluorouracil solution,		 ERLEADA, NUBEQA, XTANDI,
imiquimod	YONSA
ZVLET	neomycin-polymyxin 8-	ZYVOX	linezolid

TABLE 1- PREFERRED OPTIONS FOR INDICATION BASED SELF-ADMINISTERED

AUTOIMMUNE EXCLUDED MEDICATIONS

XELJANZXR	ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ RINVOQ	
		ADALIMUMAB-ADAZ HYRIMOZ
RINVOQ
SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS	
		CIMZIA PREFILLED SYRINGE COSENTYX
RINVOQ	
		ADALIMUMAB-ADAZ HYRIMOZ
OTEZLA
SKYRIZI SUBCUTANEOUS SOTYKTU
STELARA SUBCUTANEOUS TALTZ
TREMFYA	
AMJEVITA HUMIRA
ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS SIMPONI
TALTZ XELJANZ XELJANZXR	ADALIMUMAB-ADAZ COSENTYX
ENBREL HYRIMOZ OTEZLA RINVOQ
SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA	
ACTEMRA ACTPEN ACTEMRA SUBCUTANEOUS AMJEVITA
HUMIRA	ADALIMUMAB-ADAZ ENBREL
HYRIMOZ KEVZARA
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS	

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

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

.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 (NDC), 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.
BD 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.
QVAR REDIHALER and fluticasone HFA are covered for members 6 years of age and under.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.
The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.
©2024 CVS Health and/or one of its affiliates. All rights reserved.	106-30478A 100124