ABRIDGED SELECT FORMULARY - envisionrx.com

1 ABRIDGED SELECT FORMULARY . visibly different The following is a list of the most commonly prescribed brand medications. It represents an abbreviated version of the drug list ( FORMULARY ) that is at the core of your prescription-drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to drugs on this list, the majority of generic medications are covered under your plan and you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. Search complete FORMULARY drug information at PLEASE NOTE: Preferred brand drugs may move to non-preferred status if a generic version becomes available during the year.

2 Any medication approved to enter the market will not be covered until reviewed by the EnvisionRx Pharmacy and Therapeutics Committee. Not all drugs listed are covered by all prescription-drug benefit programs. For specific questions about your coverage, please call the phone number printed on your member ID card or visit ADHD/ANTI NARCOLEPSY/ ANTICOAGULANTS ANTI-INFECTIVE AGENTS Antineoplastic or GOUT AGENTS Ophthalmic ANTI-OBESITY/ Direct Factor Xa Inhibitors - MISC. Premalignant Lesion Gout Agents Anti-infectives ANOREXIANTS ELIQUIS Anti-infective Agents - Agents - Topical ULORIC AZASITE.

3 Amphetamines XARELTO Misc. PICATO [NP] ZURAMPIC [NP] BESIVANCE. MYDAYIS XIFAXAN TOLAK [NP] Gout Agent Combinations MOXEZA. VYVANSE ANTICONVULSANTS Antifungals - Topical ANTINEOPLASTICS & DUZALLO [NP] VIGAMOX. Anti-Obesity Agents AMPA Glutamate Receptor JUBLIA. Antagonists ADJUNCTIVE THERAPIES Beta-blockers - CONTRAVE LUZU HEMATOLOGICAL Ophthalmic FYCOMPA [NP] Antineoplastic - Hormonal AGENTS - MISC. SAXENDA & Related Agents NAFTIN BETIMOL. Anticonvulsants - Misc. Platelet Aggregation ELIGARD [SP] Dermatologicals - Misc. Inhibitors COMBIGAN. AMINOGLYCOSIDES BRIVIACT [NP].

4 Aminoglycosides ZYTIGA [SP] EUCRISA BRILINTA COSOPT. LYRICA. Antineoplastic Enzyme Rosacea Agents Prostaglandins - BETHKIS [SP] HEMATOPOIETIC AGENTS. ANTIDEPRESSANTS Inhibitors RHOFADE [NP] Ophthalmic ANALGESICS - Modified Cyclics SPRYCEL [SP] Corticosteroids - Topical Hematopoietic Growth LUMIGAN. ANTI-INFLAMMATORY TRINTELLIX TASIGNA [SP] ENSTILAR [NP] Factors TRAVATAN. Anti-TNF-alpha - VIIBRYD [NP] TACLONEX [NP] PROCRIT [SP] VYZULTA [NP]. Monoclonoal Antibodies ANTIPARKINSON AGENTS ZARXIO [SP]. Serotonin-Norepinephrine Immunosuppressive ZIOPTAN.

5 HUMIRA [SP] Antiparkinson Reuptake Inhibitors Agents - Topical HYPNOTICS Ophthalmic Soluble Tumor Necrosis Dopaminergics (SNRIs) ELIDEL Hypnotics - Tricyclic Agents Adrenergic Agents Factor Receptor Agents FETZIMA [NP] NEUPRO [NP]. SILENOR ALPHAGAN. ENBREL [SP] ANTIPSYCHOTICS/ DIAGNOSTIC PRODUCTS. ANTIDIABETICS Diagnostic Tests BELSOMRA SIMBRINZA. OTEZLA [SP] ANTIMANIC AGENTS. Antidiabetic Combinations Ophthalmic Antirheumatic - Quinolinone Derivatives ONETOUCH LAXATIVES. INVOKAMET Immunomodulators Enzyme Inhibitors ABILIFY Laxative Combinations DIGESTIVE AIDS RESTASIS.

6 XELJANZ [SP] JANUMET CLENPIQ. REXULTI Digestive Enzymes Antirheumatic SYNJARDY SUPREP OTIC AGENTS. Antimetabolites ANTIVIRALS CREON. Dipeptidyl Peptidase-4 Otic Combinations OTREXUP [NP] (DPP-4) Inhibitors Hepatitis Agents ZENPEP MEDICAL DEVICES CIPRODEX. RASUVO [NP] JANUVIA EPCLUSA [SP] ENDOCRINE & METABOLIC Diabetic Supplies OTOVEL [NP]. Insulin HARVONI [SP] AGENTS - MISC. ONETOUCH. ANALGESICS - OPIOID LANTUS Growth Hormones Parenteral Therapy PROGESTINS. MAVYRET [SP]. Opioid Partial Agonists Supplies Progestins LEVEMIR VOSEVI [SP] GENOTROPIN [SP].

7 ZUBSOLV Bone Density Regulators BD PEN NEEDLES & MAKENA. NOVOLIN. Opioid Agonists ASSORTED CLASSES SYRINGES. NOVOLIN70/30 TYMLOS [SP] PSYCHOTHERAPEUTIC &. MORPHABOND Potassium Removing NOVOLOG Corticotropin MIGRAINE PRODUCTS NEUROLOGICAL AGENTS. XTAMPZA Resins TOUJEO ACTHAR [SP] - MISC. ZOHYDRO VELTASSA [NP] Serotonin Agonists Multiple Sclerosis Agents TRESIBA ESTROGENS ZEMBRACE [NP]. ANDROGENS-ANABOLIC Incretin Mimetic Agents BETA BLOCKERS AVONEX [SP]. Beta Blockers Estrogen Combinations MULTIVITAMINS. Androgens (GLP-1 Receptor Agonists) BETASERON [SP].

8 Cardio-Selective DUAVEE Prenatal Vitamins ANDROGEL OZEMPIC COPAXONE [SP]. BYSTOLIC PREMPHASE CITRANATAL. TRULICITY GILENYA [SP]. ANORECTAL AGENTS PREMPRO. VICTOZA CARDIOVASCULAR MUSCULOSKELETAL PLEGRIDY [SP]. Intrarectal Steroids Estrogens Sodium-Glucose AGENTS - MISC. THERAPY AGENTS TECFIDERA [SP]. UCERIS [NP] PREMARIN. Co-Transporter Cardiovascular Agents Viscosupplements Movement Disorder ANTIARRHYTHMICS 2 (SGLT2) Inhibitors Misc. FLUOROQUINOLONES EUFLEXXA [SP] Drug Therapy Antiarrhythmics Type III INVOKANA ADEMPAS [SP] Fluoroquinolones SYNVISC [SP] AUSTEDO [SP].

9 MULTAQ JARDIANCE CORLANOR BAXDELA [SP] Fibromyalgia Agents Diabetic Other Pulmonary Hypertension - NASAL AGENTS - SAVELLA. ANTIASTHMATIC & Endothelin Receptor GASTROINTESTINAL SYSTEMIC & TOPICAL. GLUCAGEN Pseudobulbar Affect BRONCHODILATOR Antagonists AGENTS - MISC. Nasal Steroids (PBA) Agents AGENTS ANTIDOTES Inflammatory Bowel QNASL. LETAIRIS [SP] NUEDEXTA. Sympathomimetics Opioid Antagonists Agents XHANCE [NP]. OPSUMIT [SP]. ADVAIR NARCAN APRISO Nasal Agent Combinations TETRACYCLINES. TRACLEER [SP] Tetracyclines ANORO STELARA [SP] DYMISTA. ANTIEMETICS Cardiovascular Agents ARCAPTA Gastrointestinal Chloride XIMINO.

10 Substance P/Neurokinin 1 Misc. - Combinations OPHTHALMIC AGENTS. BREO Channel Activators (NK1) Receptor Antagonists ENTRESTO Ophthalmic Steroids ULCER DRUGS. COMBIVENT AMITIZA. VARUBI [SP] ALREX Proton Pump Inhibitors SEREVENT CONTRACEPTIVES Irritable Bowel Antiemetics - Misc. Combination Syndrome (IBS) Agents DUREZOL DEXILANT. STIOLTO BONJESTA Contraceptives - Oral LINZESS LOTEMAX URINARY. TRELEGY DICLEGIS BEYAZ Peripheral Opioid Ophthalmics - Misc. ANTISPASMODICS. VENTOLIN Receptor Antagonists ANTIHYPERLIPIDEMICS NATAZIA ACUVAIL Urinary Antispasmodics Bronchodilators - HMG CoA Reductase YASMIN MOVANTIK [NP] AZOPT MYRBETRIQ.