2021 I l l i n o i s Prior Authorization and

Specialty RX Management Guidelines This form contains information regarding Nippon Life Benefits’ Prior Authorization program, which includes drugs that have dispensing limitations, dose limitations, and prior authorization requirements including the Prior Authorization Process on Formulary Drugs with Clinically Effective Alternatives as well as the Specialty Drug Management program.

The following drugs have a Dispensing Limitation (quantity limit per 30 days unless otherwise specified) and please note that the quantity limit may include other prescript ion drugs if they treat the same condit ion:

Quantity Limits

Prescription Drug Albenza (336 tabs per 365 days)

Hysingla ER** Relenza cap(40) (1 fill of either Releza or Tamiflu every 90 days)

Albuterol inhaler 30DS (2) Imitrex 25mg, 50mg, 100mg Tab (12)

Relpaz 20mg & 40 mg Tab (12)

Alsuma Injection (12 ea) Imitrex Injection (12 ea) Rozerem (30)

Ambien 5/10 (30) Imitrex Inj Vial (12vl) Sonata 5/10 mg (30)

Ambien CR (30) Imitrex 5mg Nasal Spray (24); Imitrex 20mg Nasal Spray (12 ea)

Sprix (5 bottles per 25 days)

Amerge 1mg & 2.5 mg Tab (12) Intermezzo (30) Stadol Nasal Spray (5 ml)

Arymo** Levitra 2.5/5/10/20 mg (6) Stayxn (6)

Axert 6.5mg & 12.5 mg Tab (12) Levorphanol** Stendra (6)

Belbuca** Lidocaine (Emla (30 gm), Lidocaine 2% gel (30 gm), Lidocaine 4% gel (30gm), Lidocaine 5% oint (50gm), Lidocaine 4% soln (50ml), Pliaglis 7-7% cream (30gm), Synera 70-70mg patch(2))

Sumavel Dosepro 4mg (18ea), Sumavel Dosepro 6mg (12ea)

Biltricide (24 tab per 365 days) Lunesta 1/2/3 mg (30) Tamiflu 75mg Cap (14 tabs), Tamiflu 45mg (14 tabs), Tamiflu 30mg (28 tabs), Tamiflu 30mg/5ml Oral Susp, (180ml), (1 fill of either Relenza or Tamiflu every 90 days)

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Butrans** Maxalt/Maxalt MLT 5mg & 10mg Tab (18)

Tapentadol**

Caverject (6) Meperidine** Targiniq ER**

Cialis 10/20 mg (6), Cialis 2.5/5mg (30)

Methadone** Toradol 10 mg (20)

chloroquine 250mg tab 10DS (40tabs every 60 days) chloroquine 500mg tab 10DS (20tabs every 60 days)

Methadose** Tramadol**

Codeine** Migranal Nasal Spray – (1 x8ml) Treximet 10-60mg, 85-500mg Tab (9) Conzip** Monurol (1) Troxyca ER**

Diflucan 150mg (2) Morphabond** Vantrella**

Dolophine** Morphine** Ventolin inhaler 30DS (2) Ventolin inhaler 90DS (6)

Edex (6) Muse (6) Viagra 25/50/100 mg (6)

Edluar (30) Nucynta** Xtampza ER**

Embeda** OxyContin**

Zohydro**

Emverm (12 tabs per 365 days) Oxycodone** Zohydro ER**

Exalgo** Oxymorphone** Zomig Nasal Spray (12 ea)

Frova 2.5 mg Tab (18) Pentazocine/naloxone** Zomig/Zomig ZMT 2.5mg & 5mg (12)

Hydromorphone** Proventil inhaler 30DS (2)

Proventil inhaler 90DS (6)

hydroxychloroquine 10DS (22 tablets every 60 days)

**Opioids - Plans implementing morphine milligram equivalent (MME) based quantity limits on opioids are providing

coverage for an initial amount of 90 MME or less per day. - This program requires a post limit review to provide coverage for additional quantities of the prescribed

opioids of 200 MME or less per day. - Neither initial quantities nor post limit quantities will be set up for patients with cancer, a terminal condition,

or pain being managed through hospice or palliative care.

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Dos e Opt i m i z a t i o n A cost-savings program that identifies medications where a different dosage or quantity would be more efficient. The pharmacy works with the physician to recommend such options. Dose optimization Quantity Limit – 30 tablets. Drug Dose (mg) Drug Dose (mg) Abilify 5/10/15 Movantik 12.5 Actos 15 Namenda XR 7 Adalat CC 30 Nesina 6.25/12.5 Altoprev 20 Niaspan 500 Amaryl 1 Norvasc 2.5/5 Aplenzin 174 Nourianz 20 mg Arava 10 Oleptro 150 Aricept 5 Onglyza 2.5 Aricept ODT 5 Oseni 12.5/15 Avapro 75/150 Paxil 10/20 Azilect 0.5 Paxil CR 12.5 Azor 5-20 Pexeva 10/20 Benicar 5/20 Plendil 2.5/5 Benicar HCT 20-12.5 Pravachol 10/20/40 Bevyxxa 40 Prestalia 3.5/2.5 Bystolic 2.5/5/10 Prestalia 7/5 Caduet 2.5-10, 2.5-20, 2.5-

40, 5-10, 5-20, 5-40

Prinivil 5/10/20

Cardura 1/2/4 Pristiq 25/50 Cardura XL 4 Procardia XL 30 Celexa 10/20 Provera 2.5/5 Coreg Cr 10/20/40 Rapflo 4 Corgard 20/40 Razadyne ER 8 Crestor 5/10/20 Remeron 7.5/15 Depakote ER 250 Remeron Rapid Disolve 15 Detrol LA 2 Requip XL 2/4/6 Desvenlafaxine ER 50 mg Rexulti 0.25/0.5/1/2 Dexilant 30 Rybelsus 7 mg Diflucan 100 Savaysa 15/30 Diovan HCT 80-12.5 / 160-12.5 Seroquel XR 50/150/200 Ditropan XL 5 Silenor 3 Drizalma DR Capsule 20 mg/30 mg Stelatro 5 Edarbi 40 Sular 8.5/17/20 Effexor XR 37.5/75 Symbyax 3/25 – 6/25 Enablex 7.5 Tekturna 150 Exforge 5-160 Tekturna HCT 150-12.5

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Exforge HCT 5-160-12.5 Toprol XL 25/50/100 Ezallor Sprinkle 5/10/20 Toviaz 4 Farxiga 5 Tribenzor 20.5-12.5 Fetzima 20/40 Trintellix 5/10 Fosamax 5 Twynsta 40-5 Inderal LA 60/80 Vaseretic 5-12.5 Ingrezza 40 Venlafazine HCI ER 37.5/75 Intuniv 1/2 Verelan PM 100 Invega 1.5/3 Veralan SR 120/180 Invokana 100 Vesicare 5 Januvia 25/50 Viibryd 10/20 Kerlone 10 Vivlodex 5 Khedezla ER 50 Vraylar 1.5/3 Latuda 20/40/60 Xadago 50 Levaquin 250 Xigduo XR 5/500 Lexapro 5/10 Zaroxlyn 2.5/5 Linzess 145 Zebeta 5 Lipitor 10/20/40 Zestoretic 10-12.5 Livalo 1 / 2 Zestril 5/10/20 Lotrel 2.5-10, 5-10, 5-20 Zocor 5/10/20 Lozol 1.25 Zoloft 25/50 Luvox 25/50 Zypitamag 1/2 Micardis HCT 40-12.5 Zyprexa 2.5/7.5 Micardis 20/40 mg Zyprexa Zydis 5/10 Mirapex ER 0.375/

0.75/1.5/2.25

Mobic 7.5

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Pri o r Aut h o r i z a t i o n Dru g s Your physician will have to provide additional information to indicate medical necessity to CVS Caremark for the following drugs to be filled:

Acne Agents: Topical tretinoins (Atralin, Avita, Retin-A, Retin-A Micro, Tretin-X, Tretinoin) and Differin for ages 35 and older and all ages for Fabior and Tazorac. Anabolic Steroids: Anadrol-50, Oxandrin Antifungals: Ciclodan, ciclopirox topical solutions, CNL8, Jublia, Kerydin, Lamisil/terabinafine, Onmel/itraconazole, Pedipirox, Penlac/ciclopirox Sporanox/itraconazole, terbinafine, Terbinex Anti-viral: Sitavig Compounds: All Compounds* Dental products: Arestin Dermatological: Amcinonide Ointment, Ala Scalp, Bryhali, Capex, Clobex lotion, Clobex Shampoo, Cloderm, Cordran, Cutivate, Cyclocort, Derma-Smooth, Dermatop Ointment, Desonate, Desowen Cream, Diprolene Augmented Ointment, Diprolene AF Augmented Cream, Elocon, Halobetasol Aerosol Foam, Halog, Impoyz, Kenalog Aerosol Spray, Lexette, Locoid, Luxiq Aerosol Foam, Micort-HC, Olux Aerosol Foam, Pandel Cream, Santyl, Sernivo Spray, Solaraze, Synalar, Temovate, Texacort, Topicort, Tridesilon, Trianex, Ultravate, Vanos, Verdeso, Westcort Ointment Dermatological Medical Products Eczema: Eucrisa Infant Formulas: New Jersey Only Erectile Dysfunction: Caverject, Edex, Lavitra, Muse, Stayxn, through age 49 GI Motility: Lotronex Narcolepsy: armodafanil, Provigil, Xyrem Narcotic Analgesics: Abtral, Actiq, Fentora, Onsolis, Subsys Pain Management: Duexis, Vimovo Peanut Allergy: Palforzia Saliva Substitutes Testosterones: Enanthate injection, Cypionate injection, topical gel, topical cream, topical ointment, topical solution, transdermal patch, nasal gel, mucoadhesive buccal system, propionate implant pellets, powder/crystals for compounding ( Androderm, Axiron, Fortesta, Striant, Testosterone Ointment, Testosterone Cream, Methyltestosterone, Oral Fluoxymesterone, Testopel) Topical Analgesics: Pain Patches *A compound medication is one that is made by combining, mixing or altering ingredients, in response to a prescription, to create a customized medication that is not otherwise commercially available.

Pri o r A uthor i z a t i o n Pro c ess

For the medications above that indicate a prior authorization is required, please follow the process below. 1. Bring your prescription to a pharmacist. 2. If drugs require prior authorization, the pharmacist will receive a message stating that the physician must call

CVS Caremark at 800-294-5979. 3. Your pharmacist should advise you as well as your physician of the Prior Authorization process and number to call. 4. This means that your physician will have to call the number or FAX a letter of medical necessity to CVS Caremark.

Physician prior authorization number is 800-294-5979. Physician prior authorization FAX number is 888-836-0730. 5. CVS Caremark will evaluate the information received based on internally developed clinical criteria. The decision

will be an approval, denial, or review for more information.

App r ova l

After a claim is approved, an override is applied so that the claim will process electronically at the pharmacy and a letter will be sent to you and your physician indicating the approval and the time period of the approval.

Den i a l

If the medication is denied, then a letter is sent to both you and your physician. The denial letter will outline directions on how to appeal the decision.

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Mis s i n g I n f o r m a t i o n

If more information is required, the physician’s office will be contacted. Once the physician’s office provides CVS Caremark with the required information then a review will be completed within 24 – 48 hours.

Additional drugs may be added to the Prior Authorization or Quantity Limit list throughout the year. Your specific benefit design may not cover certain drugs, even though they appear on this list. This document is a summary reference and may not necessarily reflect all coverage and exclusions of the plan benefit system.

Prior Authorization Process on Formulary Drugs and Supplies

with Clinically Effective Alternatives

The following drugs and supplies are included:

Supply Name Supply Usage Available Alternatives

All other insulin needles that are not BD Ultrafine brand needles (Examples include, but are not limited to: Novo Nordisk Needles, Owen Mumford Needles, Perrigo Needles, Ultimed Needles)

Diabetes Supplies, Needles BD Ultrafine Needles

All other insulin syringes that are not BD Ultrafine brand syringes (Examples include, but are not limited to: Allison Medical Insulin Syringes, Trividia Insulin Syringes, Ultimed Insulin Syringes)

Diabetes Supplies, Syringes BD Ultrafine Insulin Syringes

All other strips and kits that are not Onetouch brand (Examples include, but are not limited to: (Accu-check Aviva Plus, Accu-check Compact Plus, Accu-chek Guide, Accu-Chek Smartview, Breeze 2 Strips and Kits, Contour Next Strips and Kits, Contour Strips and Kits, Freestyle Strips and Kits

Diabetes Supplies, Strips and Kits Onetouch Ultra Strips and Kits, Onetouch Verio Strips and Kits

Enlite Continuous Glucose Monitoring System, Eversense Continuous Glucose Monitoring System, Freestyle Libre Continuous Glucose Monitoring System, Guardian Connect Continuous Glucose Monitoring System

Diabetes Supplies Dexcom Continuous Glucose Monitoring System

Drug Name Medication Usage Available Alternatives

Abilify Depression aripiprazole, clozapine, olanzapine,quetiapine, quetiapine ext-rel, risperidone, ziprasidone, Latuda, Vraylar

Acanya Topical Derm Acne adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

Aciphex/Aciphex Sprinkle Gastrointestinal Agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

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Acticlate Anti-Infective doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

Actemra Rheumatoid Arthritis Enbrel, Humira, Rinvoq, Xelijanz, Xelijanz XR

Actos Diabetes pioglitazone acyclovir cream 5% Antiviral acyclovir capsule, acyclovir tablet,

valacyclovir

Adzenys ER/XR-ODT ADHD amphetamine-dextroamphetamine mixed-salts ext-rel, methylphenidate ext-rel, Mydayis, Vyvanse

Alcortin A Dermatology desonide, hydrocortisone

Alevicyn Gel, Alevicyn SG, Alevicyn solution Dermatology desonide, hydrocortisone

Aliquopa Cancer Copiktra

Alprolix Hemophilia IX Consult Doctor Alrex Ophthalmic azelastine, cromolyn

sodium, olopatadine, Lastacaft, Pazeo

Altoprev Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Alvesco Asthma Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Qvar Redihaler

Amitza Irritable Bowel Syndrome Linzess, Movantik, Symproic

Amrix Musculoskeletal cyclobenzaprine (except cyclobenzaprine tablet 7.5mg)

Androgel 1% Testosterone Relacement testosterone gel (except authorized generics for Testim and Vogelxo), testosterone solution, Androderm

Apexicon E Dermatology desoximetasone, fluocinonide (except fluocinonide cream 0.1%), Bryhali Apidra Diabetes Fiasp, Novolog

Aplenzin Depression bupropion, bupropion ext-rel (except buproprion ext-rel tablet 450mg)

Apokyn Parkinson’s Disease Inbrija

Aptensio XR ADHD amphetamine-dextroamphetamine mixed-salts ext-rel, methylphenidate ext-rel, Mydayis, Vyvanse

Aralast NP Respiratory Prolastin-C

Arthrotec Anti-inflammatory celecoxib, diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or Dexilant

Asacol HD Inflammatory bowel disease balsalazide, mesalamine del-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine del-rel, Pentasa

Asmanex/Asmanex HFA Asthma Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Qvar Redihaler

Atacand High blood pressure candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

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Atacand HCT High blood pressure candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide

Atopaderm Dermatology desonide, hydrocortisone

Avenova Ophthalmic Consult Doctor

Avonex Multiple Sclerosis dimethyl fumarate del-rel, glatiramer, Aubagio, Betaseron, Copaxone, Gilenya, Kesimpta, Mayzent, Ocrevus, Rebif, Tysabri, Vumerity, Zeposia

Azelex Dermatology adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

Baraclude Tab Anti-infectives, Antivirals, Hepatitis B entecavir, lamivudine, Vemlidy

Beau Rx Dermalogy Consult Doctor

Beconase AQ Allergies flunisolide spray, fluticasone spray, mometasone spray, Dymista

Benicar/Benicar HCT High Blood Pressure candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan—hydrochlorothiazide

Bensal HP Dermatology/Misc. Skin Conditions desonide, hydrocortisone

Benzaclin Topical Derm Acne adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

benzonatate (NDC 69336012615, 69499032915 only)

Respiratory Cough benzonatate (except NDC 69336012615, 69499032915)

Bepreve Allergies azelastine, cromolyn sodium, olopatadine, Lastracraft, Pazeo

Berinert Hematologic Firazry, Ruconest

Betapace Tab/Betapace AF Tab Ventricula Arrhythmias sotalol

Bevsepi Aeroshere COPD Anoro Ellipta, Stiolto Respimat

Beyaz Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

bimatoprost solution 0.03% Ophthalmic latanoprost, travoprost, Lumigan, Zioptan

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Bortezomib Cancer Ninlaro, Velcade

Bupap Pain diclofenac sodium,ibuprofen, naproxen (except naproxen CR or suspension)

bupropion ext-rel tablet 450mg Depression bupropion, bupropion ext-rel (except buproprion ext-rel tablet 450mg)

Butalbital-Acetaminophen (NDC 69499034230 only)

Pain diclofenac sodium,ibuprofen, naproxen (except naproxen CR or suspension)

butalbital-acetaminophen-caffeine capsule Pain diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

butalbital/apap 50mg-300mg tabs Pain diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

Butrans Pain buprenorphine transdermal, Belbuca

Bydureon Diabetes Ozempic, Rybelsus, Trulicity, Victoza

Byetta Diabetes (injectable) Ozempic,Rybelsus, Trulicity, Victoza Cafergot Migraines eletriptan, naratriptan, rizatriptan,

sumatriptan, zolmitriptan, Nurtec ODT, Onzetra Xsail, Reyvow, Ubrelvy, Zembrace Symtouch, Zomig Nasal Spray

calcipotrien cre 0.005% Topical Dermatology calcipotriene ointment, calcipotriene solution

calcipotriene/betamethasone Dermatology calcipotriene ointment, calcipotriene solution with desoximetasone, fluocinonide (except fluocinonide cream 0.1%) or Bryhali

calcitriol oin 3mcg/gm Topical Dermatology calcipotriene ointment, calcipotriene solution

Cambia Migraine NSAID diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

Carac Dermatology fluorouracil cream 5%, fluorouracil soln, imiquimod, Picato, Tolac, Zyclara

Carafate Gastrointestinal sucralfate tablet

Carbinoxamine Tab Antihistamine levocetirizine

Cardizem/ Cardizem CD High Blood Pressure diltiazem ext-rel (except generic of Cardizem LA)

Cardizem LA High Blood Pressure diltiazem ext-rel (except generic of Cardizem LA)

Carnitor/Carnitor SF Carnitine Deficiency levocarnitine

chlordiazepoxide/clidinium(NDC 42494040901 only)

Gastrointestinal dicyclomine

chlorzoxazone 375mg, 500 mg (NDC 73007001303 only), 750mg

Muscle Relaxer cyclobenzaprine (except cyclobenzaprine table 7.5mg)

Chlorzoxazone 250mg Musculoskeletal cyclobenzaprine (except cyclobenzaprine table 7.5mg)

Cialis Erectile Dysfunction silendafil, tadalafil

Cicatrace Dermatology Consult Doctor

Cimzia Crohn’s Disease Cosentyx, Enbrel, Humira, Otezla, Rinvoq, Skyrizi, Stelara Subcutaneous, Tremfya, Xelijanz, Xelijanz XR

Cipro HC Otic, Anti-infective/Anti-inflammatory Combinations

ciprofloxacin-dexamethasone, ofloxacin otic

Ciprodex Otic, Anti-infective/Anti-inflammatory Combinations

ciprofloxacin-dexamethasone, ofloxacin otic

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clindamycin gel (NDC 68682046275 only) Acne adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

clobetasol spray Dermatology clobetasol foam

Clobex Spray Dermatology clobetasol foam

Colazal Gastrointestinal/Inflammatory Bowel Disease balsalazide

Colcrys Gout colchincine tablet

Consensi High Blood Pressure amlodipine with celecoxib

Contrave Anti-Obesity Oral Saxenda

Cordran Oin 0.05% Topical Dermatology hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment

CoreMino Tablet Anti-infectives, Antibacterials doxycycline hyclate 20mg, doxycycline hyclate

capsule, minocycline, tetracycline Crestor Cardiovascular Antilipemics atorvastatin, ezetimibe-simvastatin,

fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

cyclobenzaprine ext-rel capsule Musculoskeletal cyclobenzaprine (except cyclobenzaprine 7.5mg)

cyclobenzaprine tab 7.5mg Musculoskeletal agents cyclobenzaprine (except cyclobenzaprine 7.5mg)

Cymbalta Depression desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

Daraprim Anti-infectives, Antimalarial pyrimethamine

Daytrana ADHD amphetamine-dextroamphetamine mixed-salts ext-rel, methylphenidate ext-rel, Mydayis, Vyvanse

Delzicol Inflammatory bowel disease balsalazide, mesalamine del-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine del-rel, Pentasa

Detrol LA Overactive bladder darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, Myrbetriq, Toviaz

dexchlorpheniramine syrup Allergies levocetirizine

Diclofex DC (NDC 51021037201 only) Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Diclosaicin Mis Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Differin Lotion Dermatology adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

diflorasone cre 0.05% Topical dermatology desoximetasone, fluocinonide (except fluocinonide cream 0.1%), Bryhali

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diflorasone oin 0.05% Topical dermatology desoximetasone, fluocinonide (except fluocinonide cream 0.1%), Bryhali

dihydroergotamine mesylate nasal spray Migraines eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Nurtec ODT, Onzetra Xsail, Reyvow, Ubrelvy, Zembrace Symtouch, Zomig Nasal Spray

diltiazem ext-rel (generic Cardizem LA only) High Blood Pressure diltiazem ext-rel (except generic Cardizem LA)

Diovan High Blood Pressure candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

Diovan HCT High blood pressure candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide

Diphen Elixir Allergies levocetirizine

Doryx/Doryx MPC Anti-Infectives, Antibacterials doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

doxepin cream Moderate pruritis desonide, hydrocortisone, pimecrolimus, tacrolimus, Eucrisa

doxycycline hyclate del-rel tablet 200mg Anti-Infectives, Antibacterials doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

doxycycline hyclate tablet 50mg (NDC 72143021160 only), doxycycline hyclate tablet 75mg, 150mg

Anti-Infectives, Antibacterials doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

doxycycline monohydrate capsule 75mg, 150mg

Anti-Infectives, Antibacterials doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

doxycycline monohydrate del-rel capsule Dermatology Oracea

Dulera Asthma Advair Diskus, Advair HFA, Breo Ellipta, Symbicort

Dutoprol High Blood Pressure metoprolol succinate ext-rel with hydrochlorothiazide

Dyrenium Cap Edema amiloride, triamterene

Edarbi High blood pressure candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

Edarbyclor High blood pressure candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide

E.E.S. Granules Infections erythromycins

Effexor XR Antidepressent desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

Elelyso Type 1 Gaucher Disease Cerdelga, Cerezyme

Eloctate Hemophilia VIII Adynovate, Jivi, Kogenate FS, Kovaltry, Novoeight, Nuwiq

Enablex Overactive Bladder darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, Myrbetriq, Toviaz

Enteragam Gastrointestinal alosetron, Viberzi, Xifaxan 550mg

Entyvio Ulcerative Colitis or Crohn’s Disease Humira, Stelara Subcutaneous, Xeljanz, Xeljanz XR

Epiceram Dermatologic desonide, hydrocortisone

Epogen Anemia Aranesp, Retacrit

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ergotamine-caffeine tablet Headache eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Nurtec ODT, Onzetra Xsail, Reyvow, Ubrelvy, Zembrace Symtouch, Zomig Nasal Spray

Eryped Infections erythromycins

Estring Menopausal Symptom Agents estradiol, Imvexxy

Evekeo ADHD amphetamine–dextroamphetamine mixed salts, methylphenidate

Evzio Opiod Reversal Agents naloxone injection, Narcan Nasal Spray

Exforge High Blood Pressure amlodipine-olmesartan, amlodipine-telmisartan, amlopdipine-valsartan

Exforge HCT High Blood Pressure amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide

Fabior Dermatology adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

Extavia Multiple Sclerosis dimethyl fumarate del-rel, glatiramer, Aubagio, Betaseron, Copaxone, Gilenya, Kesimpta, Mayzent, Ocrevus, Rebif, Tysabri, Vumerity, Zeposia

Fanapt Antipsychotics aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, Latuda, Vraylar

Femring Menopausal Symptom Agents estradiol, Imvexxy

fenofibrate tab 120mg Cardiovascular fenofibrate (except 120mg tablet), fenofibric acid del-rel

Fenoglide Tab 120mg Cardiovascular fenofibrate (except 120mg tablet), fenofibric acid del-rel

Fenoprofen Capsule Nonsteroidal, anti-infammatory (NSAID) diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Fenoprofen 600mg Tabs Nonsteroidal, anti-infammatory (NSAID) diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Fexmid Tab Musculoskeletal cyclobenzaprine (except cyclobenzaprine tablet 7.5mg)

Finacea Gel Rosacea azelaic acid gel, metronidazole, Finacea Foam, Soolantra

Fioricet Capsule Pain diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

flucytosine 500mg capsule Anti-infectives/Antifungals fluconazole

fluocinonide cream 0.1% Topical steroid clobetasol cream

fluorouracil cream 0.5% Dermatology fluorouracil cream 5%, fluorouracil soln, imiquimod, Picato, Tolak, Zyclara

fluoxetine tablet 60mg Depression citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60mg), fluoxetine tablet (generics for Sarafem), paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix

fluoxetine tablet (generics for Sarafem only) Premenstrual Dysporic Disorder fluoxetine (except fluoxetine tablet 60mg, fluoxetine tablet (generics for Sarafem), paroxetine HCI ext-rel, sertraline

flurandrenolide lotion (NDC 24470092112 only)

Dermatology desonide, hydrocortisone

NC20262-2 (1/21)12

flurandrenolide ointment Dermatology hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment

FML Liquifilm Anti-inflammatory dexamethasone, loteprednol, prednisolone acetate 1%, Durezol, FML Forte, FML S.O.P., Maxidex, Pred Mild

Follistim AQ Infertility Gonal-F

Fortamet Diabetes (oral medication) metformin, metformin ext-rel (except generic Fortamet or Glumetza)

Fortesta Testosterone Relacement testosterone gel (except authorized generics for Testim and Vogelxo), testosterone solution, Androderm

Fosrenol Kidney Disease calcium acetate, sevelamer carbonate, Phoslyra, Velphoro

Fulphila Hematologic Ziextenzo

Gel-One Osteoarthritis Durolane, Euflexxa, Gelsyn-3, Supartz FX

Glassia Respiratory Prolastin-C

Gleevec Cancer imatinib mesylate, Bosulif, Sprycel

Glumetza Diabetes (oral medication) metformin, metformin ext-rel (except generic Fortamet or Glumetza)

Glycopyrrolate Tab 1.5mg Anticholinergic dicyclomine

Golytely Laxatives Peg 3350-electrolytes, Clenpio

Granix Hematologic Nivestym

Horizant Restless Leg Syndrome gabapentin, Gralise

Humalog Diabetes (insulin) Fiasp, Novolog Humalog Mix 50/50 Diabetes (insulin) Novalog Mix 70/30

Humalog Mix 75/25 Diabetes (insulin) Novalog Mix 70/30

Humatrope Growth Hormones Genotropin, Norditropin

Humulin 70/30 Diabetes (insulin) Novolin 70/30

Humulin N Diabetes (insulin) Novolin N

Humulin R Diabetes (insulin) Novolin R

NOTE: Humulin R U-500 concentrate will not be subject to review.

Hyalgan Osteoarthritis Durolane, Euflexxa, Gelsyn-3, Supartz FX

hydrocortisone butyrate lipophilic cream 0.1%

Dermatology hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment

Hysingla ER Pain fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel., Nucynta ER, Xtampza ER

Incruse Ellipta COPD Spiriva, Yupelri

NC20262-2 (1/21)13

Inderal LA/XL Caps High Blood Pressure atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, Bystolic

Indocin Analgesics/NSAIDS diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

indomethacin Nonsteroidal, anti-infammatory (NSAID) diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Inflammacin Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR

Innopran XL High Blood Pressure atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, Bystolic

Intermezzo Hypnotics doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra

Intrarosa Menopausal Symptom Agents estradiol, Imvexxy

Intuniv Attention deficit hyperactivity amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel, Mydayis, Vyvanse

Invokamet/Invokamet XR Diabetes Synjardy, Synjardy XR, Xigduo XR

Invokana Diabetes Farxiga, Jardiance

isosorbide dinitrate 40mg Cardiovascular Isosorbide dinitrate (except isosorbide dinitrate (40mg), isosorbide mononitrate

Jalyn Prostate condition dutasteride-tamsulosin; dutasteride or finasteride with alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin

Jentadueto/Jentadueto XR Diabetes Janumet, Janumet XR

Kamdoy Dermatologic desonide, hydrocortisone

Kazano Diabetes Janumet, Janumet XR,

ketoconazole aerosol foam 2% Dermatology ketoconazole shampoo 2%, selenium sulfide lotion 2.5%

Ketodan Dermatology ketoconazole shampoo 2%, selenium sulfide lotion 2.5%

ketoprofen cap 25mg Pain and Inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

ketoprofen ext-rel capsule Pain and Inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Kineret Rheumatoid Arthritis Enbrel, Humira, Rinvoq, Xelijanz, Xelijanz XR

Kombiglyze XR Diabetes Janumet, Janumet XR

Kyprolis Cancer Ninlaro, Velcade

Lacrisert Dry Eye Disease Restatsis, Xiidra

Lactulose pak 10gm Constipation lactulose solution

Lanoxin Tab (125 mcg and 250 mcg only) Heart failure digoxin

lanthanum carbonate Kidney Disease calcium acetate, sevelamer carbonate, Phoslyra, Velphoro

NC20262-2 (1/21)14

Lantus Diabetes Basaglar, Levemir

Lazanda Pain fentanyl transdermal lozenge, Subsys

Lescol XL Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Letairis Cardiovascular ambrisentan, bosentan, Opsumit

levorphanol Pain fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel., Nucynta ER, Xtampza ER

Lexapro Depression citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60mg, fluoxetine tablet [generics for Sarafem]), paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix

Lialda Inflammatory Bowel Disease balsalazide, mesalamine del-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine del-rel, Pentasa

Lidocaine-Tetracaine Cream (NDC 710800063115 only)

Topical/Dermatology lidocaine/prilocaine

Lidotrex Topical/Dermatology lidocaine/prilocaine

Lipitor Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Livalo Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lorzone Tablet Musculoskeletal cyclobenzaprine (except cyclobenzaprine tablet 7.5mg)

Lotemax/Lotemax SM Ophthalmic dexamethasone, loteprednol, prednisolone acetate 1%, Durezol, FML Forte, FML S.O.P., Maxidex, Pred Mild

Lunesta Hypnotics doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra

Macrodantin Urinary Tract Infection nitrofurantoin

Matzim LA High blood pressure diltiazem ext-rel (except generic of Cardizem LA)

Mavyret Hepatitis C Epclusa, Harvoni, Vosevi

mefenamic acid (NDC 69336012830 only) Pain diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Menest Menopausal Symptom Agents estradiol

metaxalone 400mg Musculoskeletal cyclobenzaprine (except cyclobenzaprine 7.5mg)

metformin ext-rel (generics for Fortamet and Glumetza only)

Diabetes metformin, metformin ext-rel (except generics for Fortamet and Glumetza)

methocarbamol 500mg (NDC 69036091010 only), methocarbamol 750mg (NDC 69036093090, 70868090190 only)

Musculoskeletal cyclobenzaprine (except cyclobenzaprine 7.5mg)

Miacalcin Inj Postmenopausal osteoporosis alendronate, calcitonin-salmon, ibandronate, risedronate, Forteo, Prolia, Tymlos

Miacalcin Nasal Spray Postmenopausal osteoporosis calcitonin-salmon

NC20262-2 (1/21)15

Migergot Migraines eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Nurtec ODT, Onzetra Xsail, Reyvow, Ubrelvy, Zembrace Symtouch, Zomig Nasal Spray

Millipred Pain and Inflammation dexamethasone, hydrocortisone, methylprednisolone, prednisone solution, prednisone

Minastrin 24 FE Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Minivelle Estrogen replacement estradiol, Divigel, Evamist

Minocin Anti-infectives/Antibacterials/Tetracyclines doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

minocycline ext-rel tablet Anti-infectives/Antibacterials/Tetracyclines doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

Mirvaso Dermatology azelaic acid gel, metronidazole, Finacea Foam, Soolantra

Mondoxyne NL 75mg Capsule Anti-infectives/Antibacterials/Tetracyclines doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

Monovisc Osteoarthritis Durolane, Euflexxa, Gelsyn-3, Supartz FX

MoviPrep Laxative Peg 3350-electrolytes,Clenpiq

mupirocin cream Dermatology antibiotics gentamicin, mupirocin ointment

Mytesi Gastrointestinal diphenoxylate-atropine, loperamide

Naprelan Pain and inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

naproxen CR Pain and Inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

naproxen-esomeprazole Pain and Inflammation diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) With esomeprazole, lansoprazole, omeprazole, pantoprazole or Dexilant

naproxen suspension Pain and inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Natazia Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, Lo Loestrin Fe

Natesto Testosterone replacement testosterone gel (except authorized generics for Testim and Vogelxo), testosterone solution, Androderm

Nesina Diabetes Januvia

Neulasta/Neulasta Onpro Hematologic Ziextenzo

Neupogen Hematologic Nivestym

Nexium Gastrointestinal Agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

niacin 500mg Cardiovascular niacin ext-rel

NC20262-2 (1/21)16

Niacor 500mg Cardiovascular niacin ext-rel

Nilandron Cancer abiraterone, bicalutamide, Xtandi, Yonsa

Norgesic Forte Musculoskeletal cyclobenzaprine (except cyclobenzaprine tablet 7.5mg)

Noritate Dermatology azelaic aicd gel, metronidazole, Finacea Foam, Soolantra

Norvasc High blood pressure amlodipine

Novacort Dermatology desonide, hydrocortisone

NuDiclo SoluPak Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

NuDiclo TabPak Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Neulasta/Neulasta Onpro Hematologic Ziextenzo

Nutropin AQ Growth hormones Genotropin,Norditropin Nuvaring Contraceptive ethinyl estradiol-etonogesterel, Annovera

Nuvigil Sleep apnea, Narcolepsy armodafinil, Sunosi

Oleptro Depression trazodone

Olux-E Dermatology clobetasol foam

omeprazole sodium bicarbonate (generic Zegerid)

Gastrointestinal agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Omnaris Allergies flunisolide spray, fluticasone spray, mometasone spray, Dymista

Omnitrope Growth hormones Genotropin, Norditropin

Onfi Anticonvulsant clobazam, lamotrigine, topiramate, Trokendi XR

Onglyza Diabetes Januvia

Orencia Clickjet, Orencia Intravenous, Orencia Subcutaneous

Rheumatoid Arthritis Cosentyx, Enbrel, Humira, Otezla, Rinvoq, Stelara Subcutaneous, Xelijanz, Xelijanz XR

ophendarine-aspirin-caffeine tablet Musculoskeletal cyclobenzaprine (except cyclobenzaprine tabet 7.5mg)

Orphengesic Forte Tablet Musculoskeletal cyclobenzaprine (except cyclobenzaprine tabet 7.5mg)

Orthovisc Osteoarthritis Durolane, Euflexxa, Gelsyn-3, Supartz FX

Oseni Diabetes Janumet, Janumet XR, Januvia with pioglitazone

Osmoprep Laxative peg 3350-electrolytes, Clenpiq

Osphena Menopausal Symptom Agents estradiol

oxiconazle (NDCs 00168035830, 51672135902 only)

Dermatology ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, luliconazole

Oxycontin Pain fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel., Nucynta ER, Xtampza ER

NC20262-2 (1/21)17

oxymorphone ext-rel Opioid Analgesic fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel, Nucynta ER, Xtampza ER

Oxytrol Overactive bladder darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, Myrbetriq, Toviaz

Paxil/Paxil CR Antidepressant citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60mg, fluoxetine tablet [generics for Sarafem]), paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix

Pennsaid Pain and inflammation diclofenac sodium, diclofenac sodium solution, diclofenac sodium 1% gel, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Percocet Pain hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, Nucynta

Pexeva Antidepressant citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60mg, fluoxetine tablet [generics for Sarafem]), paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix

Plavix Hematologic clopidogrel, prasugrel, Brilinta Plegridy Multiple Sclerosis dimethyl fumarate del-rel, glatiramer,

Aubagio, Betaseron, Copaxone, Gilenya, Kesimpta, Mayzent, Ocrevus, Rebif, Tysabri, Vumerity, Zeposia

Polytoza Dermatology Consult Doctor

posaconazole del-rel tablet Anti-infectives/Antifunglas fluconazole, itraconazole

Pradaxa Hemotologic warfarin, Eliquis, Xarelto

Pred Forte Ophthalmic/Anti-inflammatories/Steroidal dexamethasone, loteprednol, prednisolone acetate 1%, Durezol, FML Forte, FML S.O.P., Maxidex, Pred Mild

Premarin Menopausal Symptom Agents estradiol

Premarin Cream Menopausal Symptom Agents estradiol, Imvexxy

Prevacid Gastrointestinal agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Prevident Dental Consult Doctor

Primlev Pain hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, Nucynta

Pristiq Depression desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

Proair HFA/Proair Respiclick Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Procrit Anemia Aranesp, Retacrit

Prodigen Anti-diarrheal/Probiotic Consult Doctor

Prolensa Ophthalmic bromfenac, diclofenac, ketorolac, Acuvail, Ilevro, Nevanac

Protonix Gastrointestinal agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

NC20262-2 (1/21)18

Provad Gastrointestinal Probiotic Consult Doctor

Proventil HFA Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Prozac Depression citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60mg, fluoxetine tablet [generics for Sarafem]), paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix

Psorcon Cre 0.05% Topical Dermatology desoximetasone, fluocinonide (except fluocinonide creat 0.1%), Bryhali

Qnasl Allergies flunisolide spray, fluticasone spray, mometasone spray, Dymista

Qsymia Anti-Obesity Saxenda

Qtern Diabetes Glyxambi

quazepam Sleep Disorder doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra

Rapaflo Benign Prostatic hyperplasia alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

Rayos Pain and inflammation dexamethasone, hydrocortisone, methylprednisolone solution, prednisone solution, prednisone Recedo Scar Treatment Consult Doctor

Repatha Cardiovascular PCSK9 Inhibitors Praluent

Rimso-50 Interstitial cystitis Consult Doctor

Riomet Diabetes (oral medication) metformin, metformin ext-rel (except generic Fortamet or Glumetza)

Rozerem Hypnotics doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra

Ryclora Allergies levocetirizine

Sabril Anticonvulsant vigabatrin

Saizen Growth hormones Genotropin, Norditropin

Sandostatin LAR Depot Acromegaly Somatuline Depot

Scarsilk Pad Dermatology Consult Doctor

Seroquel XR Antipsychotic aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, Latuda, Vraylar

Signifor LAR Acromegaly Somatuline Depot

Sil-K Pad Scar Treatment Consult Doctor

Silivex Dermatology Consult Doctor

Siltrex Dermatology Consult Doctor

Simponi Rheumatoid Arthritis Cosentyx, Enbrel, Humira, Otezla, Rinvoq, Stelara subcutaneous, Xelijanz, Xelijanz XR

Singular Asthma montelukast, zafirlukast, zileuton ext-rel

Somavert Acromegaly Somatuline Depot

Sorilux Antipsoriatics calcipotriene ointment, calcipotriene solution

Sprix Pain diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

NC20262-2 (1/21)19

Stendra Erectile Dysfunction sildenafil, tadalafil

Suboxone Opioid Dependency buprenorphine-naloxone sublingual, Zubsolv

sucralfate Suspension Ulcers sucralfate tablet

sumatriptan-naproxen tablet Headache diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) with eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Nurtec ODT, Onzetra Xsail, Reyvow, Ubrelvy Zembrace Symtouch or Zomig Nasal Spray

Suprep Laxatives Peg 3350-electrolytes, Clenpio

Synerderm Emulsion Dermatology desonide, hydrocortisone

Synvisc/Synvisc One Osteoarthritis Durolane, Gel-One, Gelsyn-3, Supartz FX, Visco-3

Taltz Plaque Psoriasis Cosentyx, Enbrel, Humira, Otezla, Skyrizi, Stelara Subcutaneous, Tremfya, Xelijanz, Xelijanz XR

Targadox Anti-infective doxycycline hyclate 20mg, doxycycline hyclate capsule, minocycline, tetracycline

Tasigna Cancer imatinib mesylate, Bosulif, Sprycel

Taytulla Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Tazorac Dermatology adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

Tecfidera Multiple Sclerosis dimethyl fumarate del-rel, glatiramer, Aubagio, Betaseron, Copaxone, Gilenya, Kesimpta, Mayzent, Ocrevus, Rebif, Tysabri, Vumerity, Zeposia

Testim Testosterone Replacement testosterone gel (except authorized generics for Testim and Vogelxo), testosterone solution, Androderm

testosterone gel 1%(authorized generics for Testim and Vogelxo only)

Testosterone Replacement testosterone gel (except authorized generics for Testim and Vogelxo), testosterone solution, Androderm

Timoptic Ocudose Ophthalmic timolol maleate solution, Betimol, Betoptic S

Tirosint Thyroid Agents levothyroxine, Synthroid

Tobi / Tobi Podhaler Cystic Fibrosis tobramycin inhalation solution, Bethkis

Toprol XL High blood pressure atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, Bystolic

Tracleer Cardiovascular ambrisentan, bosentan, Opsumit

Tradjenta Diabetes Januvia

tramadol (NDC 52817019610) Pain tramadol (except NDC 52817019610, tramadol ext -rel

Transderm-Scop Antiemetic meclizine, scopolamine transdermal

NC20262-2 (1/21)20

Treximet Tablet Headache diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) with eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Nurtec ODT, Onzetra Xsail, Reyvow, Ubrelvy Zembrace Symtouch or Zomig Nasal Spray

triamcinolone acetonide aerosol 0.2% Dermatology hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment

Tricor Cardiovascular fenofibrate (except fenofibrate tablet 120mg), fenofibric acid del-rel

Trulance Irritable Bowel Syndrome Linzess

Tudorza Chronic obstructive pulmonary disease (COPD)

Spiriva, Yupelri

Udenyca Hematologic Ziextenzo

Uroxatral Benign Prostatic hyperplasia alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

Valcyte Anti-Infective, Antivirals valganciclovir

Valtrex Anti-infective, Antivirals acyclovir capsule, acyclovir tablet, valacyclovir

Vanatol LQ/Vanatol S Pain diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

Vanoxide-HC Acne vulgaris adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

Vectical Oin 3mcg/gm Topical Dermatology calcipotriene ointment, calcipotriene solution

Veltin Topical Derm Acne adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

venlafaxine ext-rel tablet (except 225 mg) Depression desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule,

Ventolin HFA Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Veregen Dermatology imiquimod

Viagra Erectile Dysfunction sildenafil, tadalafil

Viibryd Antidepressant citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60mg, fluoxetine tablet [generics for Sarafem]), paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix

Viekira Pak Hepatitis Epclusa, Harvoni

Visco-3 Osteoarthritis Durolane, Euflexxa, Gelzyn-3, Supartz FX

Vivelle-Dot Estrogen replacement estradiol, Divigel, Evamist

Vogelxo Testosterone replacement testosterone gel (except authorized generics for Testim and Vogelxo), testosterone solution, Androderm

NC20262-2 (1/21)21

Xanax, Xanax XR Anxiety alprazolam, clonazepam, diazepam, lorazepam, oxazepam

Xenazine Huntington’s Disease Agents tetrabenazine, Austedo

Xolegel Topical Dermatology ciclopirox, ketoconazole cream 2%

Xopenex HFA Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Yaz Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Zarxio Hematologic Nivestym

Zemaira Pulmonary Enzyme Deficiency Prolastin-C

Zegerid Gastrointestinal Agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Zelac Gastrointestinal Probiotic Consult Doctor Zepatier Anti-infectives, Antivirals Epclusa, Harvoni

Zetia High Cholesterol ezetimibe

Zetonna Allergies flunisolide spray, fluticasone spray, mometasone spray, Dymista

Ziana Topical Derm Acne adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Onexton

Zirgan Antivirals trifluridine

Zohydro ER Pain fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel., Nucynta ER, Xtampza ER

Zolpimist Sleep disorders doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra

Zonegran Epilepsy carbamazepine, carbamazepine ext–rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext. rel, levetiracetam, levetiracelam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, Oxtellar XR, Trokendi XR, Vimpat, Xcopri

Zontivity Hematologic Consult Doctor

Zortress Rapamycin Derivatives everolimus

Zorvolex Pain diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Zydelig Cancer Copiktra

Zuplenz Antiemetic granisetron, ondansetron, Sancuso

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Zylet Ophthalmic neomycin-polymyxin B-bacitracin-hyrocortisone, neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, Tobradex Ointment, Tobradex St

Zytiga Prostate cancer abiraterone, bicalutamide, Xtandi, Yonsa

*Lowercase alternative drugs indicate generic. Initial capitalized drugs indicate brand Prior Authorizat ion Process on Formulary Drugs and supp l ies with Clinically Effect ive Alternatives

Aut h o r i z a t i o n P r o c e s

1. Upon receipt of a prescription for one of the above listed drugs or supplies, the pharmacist will be provided a list of available alternatives.

2. The pharmacist will call your physician to discuss changing the prescription to an alternative. 3. If there is a medical reason that you cannot take an available alternative, your physician must call CVS Caremark at

855-240-0536. 4. CVS Caremark will evaluate the information received based on clinical criteria.

App r o v a l After approval is received, the claim will process electronically at the pharmacy and a letter will be sent to you and your physician indicating the approval and the time period for the approval.

Den i a l If denied, a letter is sent to both you and your physician. The denial letter will outline directions on how to appeal the decision.

Specialty Guideline Management

Specialty Guideline Management is a program that supports safe, clinically appropriate and cost-effective use of specialty medications. The following specialty medications require prior authorization.

Specialty Drug Class Drug Names

Acromegaly Bynfezia, Mycapssa, octreotide (Sandostatin), Sandostatin LAR Depot, Signifor LAR Somatuline Depot, Somavert

Allergic Asthma Cinquair, Fasenra, Nucala, Xolair Alpha-1 Antitrypsin (AAT) Deficiency Aralast NP, Glassia, Prolastin-C Zemaira Amyloidosis Onpattro, Tegsedi, Vyndamax, Vyndaqel

Anemia Aranesp, Epogen, Mircera, Procrit, Reblozyl, Retacrit Atopic Dermatitis Dupixent

Bone Disorders Strensiq

Botulinum Toxins Botox, Dysport, Myobloc, Xeomin Cardiac Disorders Tikosyn

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Central Precocious Puberty (CPP) Fensolvi, leuprolid, Lupron Depot-PED, Supprelin LA Cryopyrin-Associated Periodic Syndromes (CAPS) Arcalyst, Ilaris, Kineret Cushing’s Syndrome Isturisa, Korlym, Signifor Cystic Fibrosis (CF) Bethkis, Cayston, Kalydeco, Kitabis Pak, Orkambi, Pulmozyme, TOBI

Podhaler, Symdeko, tobramycin inhalation solution (TOBI), Trikafta

Dupuytren’s Contracture Xiaflex

Electrolyte Disorders Keveyis, Samsca Gastrointestinal Disorders - Other Cholbam, Gattex, Ocaliva, Zorbtive Gout Krystexxa Growth Hormone (GH) and Related Disorders Genotropin, Humatrope, Increlex, Norditopin,

Nutropin/Nutropin AQ, Omnitrope, Saizen, Zomacton Hematopoietics Mozobil, Neumega

Hemophagocytic Lymphohistiocytosis Gamifant

Hemophilia and Related Bleeding Disorders Advate, Adynovate, Afstyla, Alphanate, AlphaNine SD, Alproloix, Bebulin VH, BeneFIX, Coagadex, Corifact, Eloctate, Esperoct, Feiba NF, Fibryga, Helixate FS, Hemlibra,Hemofil M, Humate-P, I d e l v i o n , I x i n i t y , J i v i , Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Mononine, Novoeight, NovoSeven, Nuwiq, Obizur, Profilnine SD, Recombinate, Riastap, Rixubis, Sevenfact, Stimate Nasal Spray, Tretten, Vonvendi, Wilate, Xyntha

Hepatitis C Daklinza, Epclusa, Harvoni, Mavyret, Olysio, Pegasys, Ribavirin (ribavirin capsules/tablets), Copegus, Moderiba, Rebetol, Ribasphere, Ribasphere Ribatab, Sovaldi, Technivie, Viekira Pak, Viekira XR, Vosevi, Zepatier

Hereditary Angioedema (HAE) Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro Hormonal Therapies Aveed, Eligard, Fensolvi, Firmagon, leuprolide, Lupaneta Pack,

Lupron Depot, Natpara, Trelstar, Triptodur, Vantas, Zoladez Human Immunodeficiency Virus (HIV) Arikayce, Egrifta, Fuzeon, Serostim

Immune Deficiencies and related disorders Cutaquig, Panzyga

Immune Therapies Asceniv, Bivigam, Carimune NF, Cuvitru, GamaSTAN S/D, Gammagard, Gammaked, Gammaplex, Gamunex, Hizentra, HyQvia, Octagam, Privigen, Xembify

Immune (Idiopathic) Thrombocytopenia (ITP Nplate, Promacta, Tavalisse

Infectious Disease Actimmune, Arikayce

Infertility Bravelle, Cetrotide, chorionic gonadotropin (Novarel, Ovidrel, Pregnyl), Follistim AQ, ganirelix acetate, Gonal-F, leuprolide, Menopur, Repronex

Inflammatory Bowel Disease (IBD) Avsola, Cimzia, Entyvio, Humira, Inflectra, Remicade, Renflexis, Simponi, Stelara, Tysabri

Iron Overload deferoxamine (Desferal), Exjade, Ferriprox, Jadenu Lambert-Eaton myasthenic syndrome Firdapse Lipid Disorders Juxtapid, Kynamro,Repatha Lipodystrophy Myalept Lysosomal Storage Disorders (LSD) and Related Disorders

Adagen, Aldurazyme, Cerdelga, Cerezyme, Cystadane, Cystagon, Cystaran, Elaprase, Elelyso, Fabrazyme, Galafold, Kanuma, Lumizyme, Mepsevii, Naglazyme, Nityr, Orfadin, Procysbi, Vimzim, VPRIV, Zavesca

Mental Health Spravato, Zulresso Movement Disorders Apokyn, Austedo, Duopa, Inbrija, Ingrezza, Kynmobi, Northera,

Nuplazid, Radicava, Soliris, Xenazine Multiple Sclerosis (MS) Ampyra, Aubagio, Avonex, Bafiertam, Betaseron, Copaxone,

Extavia, Gilenya, Glatopa, Lemtrada, Mavenclad, Mayzent, mitoxantrone, Ocrevus, Plegridy, Rebif, Tecfidera, Tysabri, Vumerity, Zeposia

Muscular Dystrophy Emflamza, Exondys 51, Vyondys 53

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Neutropenia Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestyn, Udenyca, Zarxio, Ziextenzo

Ocular Disorders Beovu, Jetrea, Macugen, Oxervate, Tepezza, Visudyne Oncology Adcetris, Afinitor, Alecensa. Aliqopa, Alunbrig, Arzerra, Asparlas,

Avastin, Ayvakit, azacitidine (Vidaza), Balversa, Bavencio, Beleodaq, Belrapzo, Bendeka, Bendomustine, Blincyto, Bosulif, Brukinsa, capecitabine (Xeloda), Braftovi, Caprelsa, Cabometyx, Calquence, Cometriq, Copiktra, Cotellic Cyramza, Darzalex, Daurismo, decitabine (Dacogen), Elzonris, Empliciti, Enhertu, Erbitux, Erivedge, Erleada, Farydak, Faslodex, Folotyn, Fusilev, Gazyva, Gilotrif, Gleevec, Halaven, Herceptin, Herzuma, Hycamtin Capsules, Ibrance, Iclusig, Idhifa, Imbruvica, Imfinzi, Imlygic, Inlyta, Inrebic, Intron-A, Inqovi, Iressa, Istodax, Ixempra, Jakafi, Jevtana, Kadcyla, Kanjinti, Keytruda, Khapzory, Kisquali, Koselugo, Kyprolis, Lartruvo, Lenvima, Libatyo, Lonsurf, Lorbrena, Lumoxiti, Lynparza, Mekinist, Mektovi, mitroxantrone, Mvasi, Mylotarg, Nerlynx, Nexavar, Ninlaro, Nubeqa, Odomzo, Ogivri, Oncaspar, Ontruzent, Opdivo, Padcev, Pemazyre, Perjeta, Phesgo, Piqray, Polivy, Pomalyst, Portrazza, Poteligeo, Proleukin, Purixan, Qinlok, Retevmo, Revlimid, Rituxin, Rituxin Hycela, Rozlytrek, Rubraca, Ruxience, Rydapt, Sarclisa, Sprycel, Stivarga, Sutent, Sylatron, Sylvant, Synribo, Tabrecta, Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin, Tasigna, Tazverik, Tecentriq, temozolomide (Temodar), Thalomid, Tibsovo, Torisel, Trazimera, Treanda, Trodelvy, Truxima, Tukysa, Turalio, Tykerb, Valchlor, Vectibix, Velcade, Venclexta, Verzenio, Vitrakvi, Vizimpro, Votrient, Xalkori, Xermelo, Xospata, Xgeva, Xtandi, Yervoy, Yonsa, Zaltrap, Zejula, Zelboraf, Zirabev, zoledronic acid (Zometa), Zolinza, Zydelig, Zykadia, Zytiga

Osteoarthritis (OA) Euflexxa, Gel-One, Gelsyn-3, Genvisc-850, Hyalgan, Hymovis, Monovisc, Orthovisc, Sodium Hyaluronate, Supartz, Synvisc/Synvisc One, Triluron, Visco-3

Osteoporosis Evenity, Forteo, Prolia, Tymlos, zoledronic acid (Reclast)

Paroxysmal Nocturnal Hemoglobinuria (PNH) Soliris Phenylketonuria (PKU) Kuvan, Palynziq, Ultomiris Pre-term Birth Makena Psoriasis Avsola, Cosentyx, Enbrel, Humira, Ilumya, Inflectra, Otezla,

Otrexup, Rasuvo, Remicade, Renflexis, Siliq, Skyrizi, Stelara, Taltz, Tremfya

Pulmonary Arterial Hypertension (PAH) Adcirca, Adempas, Alyq, epoprostenol (Flolan), Letairis, Opsumit, Orenitram, Remoudlin, sildenafil (Revatio), Tracleer, Tyvaso, Uptravi, Veletri, Ventavis

Pulmonary Disorders - Other Esbriet, Ofev Rare Disorders Dojolvi, Givlaari, Ruzurgi, Uplinza

Renal Disorders Jynarque, Parsabiv, Sensipar

Respiratory Syncytial Virus (RSV) Synagis Retinal Disorders Avastin, Eylea, Lucentis,

Rheumatoid Arthritis (RA) Actemra, Avsola, Cimzia, Enbrel, Humira, Inflectra, Kevzara, Kineret, Olumaiant, Orencia, Otrexup, Rasuvo, Remicade, Renflexis, Rinvoq, Rituxan, Simponi, Simponi Aria, Xelijanz, Xelijanz XR

Seizure Disorders Acthar, Epilodex, Fintelpa, Sabril

Sickle Cell Disease Adakveo, Endari, Oxbry

Sleep Disorders Hetlioz, Wakik

Systemic Lupus Erythamatosus Benlysta

Thrombocytopenia Cablivi, Doptelet, Mulpleta

Urea Cycle Disorders Buphenyl, Carbaglu, Ravicti

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