2018 National Formulary - Southern Scripts, LLC

1 2018 National Formulary Effective 01/01/2018 The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing. For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available.

2 It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider. Tier Definitions 1 Generics 2 Preferred Brands 3 Non-Preferred Brands (ST) Step Therapy (PA) Prior Authorization (SP) Specialty Drugs Major Drug Class Overview Non-Preferred and Excluded* Drugs With Preferred Options 2018 Preferred Non-Preferred / Excluded * Drug Class ANALGESICS EUFLEXXA, GEL-ONE, HYALGAN, MONOVISC, ORTHOVISC GELSYN-3, SUPARTZ FX, SYNVISC, SYNVISC-ONE ANTIARTHRITICS ABSTRAL, EMBEDA, KADIAN, ZOHYDRO ER fentanyl, fentanyl citrate, morphine sulfate er, oxycodone hcl, FENTORA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN NARCOTICS ANTI-INFECTIVES REBETOL moderiba, ribapak, ribavirin, ribavirin ANTIVIRALS DAKLINZA*, EPCLUSA*.

3 HARVONI*, SOVALDI*, TECHNIVIE*, VIEKIRA PAK* MAVYRET, ZEPATIER HEPATITIS C DOXYCYCLINE IR-DR ORACEA TETRACYCLINES CARDIAC BENICAR HCT, EDARBI, EDARBYCLOR candesartan-hydrochlorothiazid, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide ANGIOTENSIN RECEPTOR BLOCKER PRADAXA clopidogrel, ELIQUIS, XARELTO ANTICOAGULANTS LIVALO, VYTORIN atorvastatin calcium, rosuvastatin calcium, simvastatin STATINS CNS ADDERALL XR dextroamphetamine-amphet er, dextroamphetamine-amphetamine ADHD PEXEVA, SARAFEM citalopram hbr, escitalopram oxalate, escitalopram oxalate, fluoxetine hcl, fluvoxamine maleate, paroxetine er, paroxetine hcl, sertraline hcl, trazodone hcl, VIIBRYD ANTIDEPRESSANTS FANAPT, INVEGA, REXULTI aripiprazole, olanzapine, olanzapine odt, quetiapine fumarate, quetiapine fumarate er, LATUDA, SAPHRIS ANTI-PSYCHOTIC ZOLPIMIST eszopiclone, zaleplon, zolpidem tartrate er, BELSOMRA, ROZEREM SLEEP DIABETES ALOGLIPTIN, KAZANO, KOMBIGLYZE XR, NESINA, ONGLYZA.

4 OSENI JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA DPP-4 BYDUREON PEN, BYETTA, TANZEUM TRULICITY, VICTOZA INCRETINS AFREZZA, APIDRA HUMALOG, HUMALOG MIX 50-50, HUMALOG MIX 75-25, HUMULIN 70-30, HUMULIN N, HUMULIN R, NOVOLIN 70-30, NOVOLIN N, NOVOLIN R, NOVOLOG, NOVOLOG FLEXPEN, NOVOLOG MIX 70-30 INSULIN BASAGLAR KWIKPEN U-100 LANTUS, LANTUS SOLOSTAR, LEVEMIR, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-200 INSULIN: LONG ACTING GLUMETZA, RIOMET metformin hcl OTHER INVOKAMET, INVOKANA FARXIGA, JARDIANCE, SYNJARDY, XIGDUO XR SGLT-2 Preferred Non-Preferred / Excluded * Drug Class DIABETES ACCU-CHEK AVIVA CONNECT, ACCU-CHEK AVIVA PLUS, ADVOCATE BLOOD GLUCOSE MONITOR, ASCENSIA BREEZE 2, CONTOUR, EMBRACE, PRODIGY, TRUETEST TEST STRIPS, TRUETRACK SMART SYSTEM, UNISTRIP1 FREESTYLE TEST STRIPS, ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO TESTING ENDOCRINE ESTRING estradiol, DIVIGEL, PREMARIN ESTROGENS GANIRELIX ACETATE.

5 PREGNYL CETROTIDE, NOVAREL GONADOTROPIN BRAVELLE clomiphene citrate, FOLLISTIM AQ, FOLLISTIM AQ, GONAL-F, MENOPUR OVULATORY STIMULANTS CRINONE, ENDOMETRIN PROGESTINS FORTESTA, NATESTO, STRIANT, TESTIM, VOGELXO ANDROGEL, AXIRON TESTOSTERONE GASTROINTESTINAL PANCREAZE, PERTZYE CREON, VIOKACE, ZENPEP DIGESTIVE ENZYMES DIPENTUM, LIALDA balsalazide disodium, AMITIZA, APRISO, ASACOL HD, DELZICOL, LINZESS, PENTASA OTHER DEXILANT, ZEGERID RX lansoprazole, omeprazole, pantoprazole sodium PROTON PUMP INHIBITORS GROWTH HORMONES GENOTROPIN, HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, ZOMACTON, ZORBTIVE NORDITROPIN FLEXPRO HEMATOLOGY ARANESP, EPOGEN, MIRCERA PROCRIT MUSCULOSKELETAL ACTEMRA, CIMZIA, OTEZLA, REMICADE, SIMPONI, STELARA, TALTZ AUTOINJECTOR, TALTZ SYRINGE, XELJANZ COSENTYX 150MG, COSENTYX 300MG, ENBREL, ENTYVIO, HUMIRA, ORENCIA, SILIQ ANTI-INFLAMMATORY ** ** Trial of ONE First Line Product and ONE Second Line Product is Required before any Non-Preferred Products.

6 Required Second Line Required First Line Indication HUMIRA or ORENCIA HUMIRA or ORENCIA Rheumatoid Arthritis Juvenille Idiopathic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA COSENTYX or HUMIRA or ORENCIA HUMIRA or ORENCIA Ankylosing Spondylitis Psoriatic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA COSENTYX or SILIQ COSENTYX or HUMIRA Plaque Psoriasis ENBREL Pediatric Plaque Psoriasis ENTYVIO HUMIRA Crohn's Disease HUMIRA Pediatric Crohn's ENTYVIO HUMIRA Ulcerative Colitis HUMIRA Hidradentis Supperativa HUMIRA Uvelitis OPHTHALMIC COSOPT PF, SIMBRINZA, ZIOPTAN dorzolamide hcl, latanoprost, AZOPT, COMBIGAN, TRAVATAN Z GLAUCOMA ACUVAIL bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA NSAIDS Preferred Non-Preferred / Excluded * Drug Class OTIC CETRAXAL ciprofloxacin hcl MISCELLANEOUS RESPIRATORY DULERA, INCRUSE ELLIPTA ADVAIR DISKUS, ANORO ELLIPTA, BREO ELLIPTA, SPIRIVA, STIOLTO RESPIMAT, SYMBICORT, TUDORZA PRESSAIR ARCAPTA NEOHALER, FORADIL.

7 PROVENTIL HFA, XOPENEX HFA PERFOROMIST, PROAIR HFA, SEREVENT DISKUS, VENTOLIN HFA BETA AGONISTS ALVESCO, ASMANEX ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR INHALED STEROIDS BECONASE AQ, NASONEX, OMNARIS, QNASL, ZETONNA flunisolide, DYMISTA NASAL STEROIDS TOPICAL ATRALIN, AVAGE, AZELEX, BENZACLIN, VELTIN adapalene, clindamycin phos-tretinoin, clindamycin-benzoyl peroxide, erythromycin, metronidazole, tretinoin, ACANYA, EPIDUO, FINACEA, TAZORAC ACNE ALDARA, FLUOROURACIL, ZYCLARA fluorouracil, imiquimod, PICATO MISCELLANEOUS UROLOGICAL ENABLEX, GELNIQUE, TOVIAZ oxybutynin chloride, tolterodine tartrate, MYRBETRIQ, VESICARE ANTISPASMODICS LEVITRA, STAXYN, STENDRA, VIAGRA sildenafil citrate, CIALIS ERECTILE DYSFUNCTION Please Note.

8 Drugs Marked with * are Excluded CARDIAC ACE INHIBITORS CAPSULE amlodipine besylate-benazepril 1 TABLET benazepril hcl 1 TABLET benazepril hcl-hctz 1 TABLET captopril 1 TABLET captopril/hydrochlorothiazide 1 TABLET enalapril maleate 1 TABLET fosinopril sodium 1 TABLET fosinopril-hydrochlorothiazide 1 TABLET lisinopril 1 TABLET lisinopril-hctz 1 TABLET moexipril hcl 1 TABLET moexipril-hydrochlorothiazide 1 TABLET perindopril erbumine 1 TABLET quinapril 1 TABLET quinapril-hydrochlorothiazide 1 CAPSULE ramipril 1 TABLET trandolapril 1 TABLET ACCUPRIL 3 CAPSULE ALTACE 3 SOLUTION, ORAL EPANED 3 TABLET LOTENSIN 3 TABLET MAVIK 3 TABLET PRINIVIL 3 SOLUTION, ORAL QBRELIS 3 TABLET,IMMED AND EXTEND REL BIPHASE 24HR TARKA 3 TABLET VASOTEC 3 TABLET ZESTRIL 3 ANTICOAGULANTS TABLET cilostazol 1 TABLET clopidogrel 1 TABLET dipyridamole 1 SYRINGE (ML) enoxaparin sodium SP 1 SYRINGE (ML) fondaparinux sodium SP 1 VIAL (ML)

9 Heparin sodium 1 TABLET jantoven 1 TABLET, EXTENDED RELEASE pentoxifylline 1 TABLET ticlopidine hcl 1 TABLET warfarin sodium 1 TABLET BRILINTA 2 TABLET COUMADIN 2 TABLET EFFIENT 2 TABLET ELIQUIS 2 SYRINGE (ML) FRAGMIN SP 2 TABLET MEPHYTON 2 TABLET XARELTO SP 2 CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR AGGRENOX 3 CAPSULE PRADAXA 3 ANTIARRHYTHMIC TABLET amiodarone hcl 1 SOLUTION, ORAL digoxin 1 TABLET digoxin 1 CAPSULE disopyramide phosphate 1 TABLET flecainide acetate 1 CAPSULE mexiletine hcl 1 TABLET pacerone 1 VIAL (ML) procainamide hcl 1 TABLET propafenone hcl 1 Printed Date:11/1/2017 Page 5 | 2018 National Formulary Data Last Updated:10/30/2017 B4G Participant.

10 N CARDIAC ANTIARRHYTHMIC VIAL (ML) quinidine gluconate 1 TABLET, EXTENDED RELEASE quinidine sulfate 1 TABLET quinidine sulfate 1 TA