2019 Express Scripts National Preferred Formulary

1 The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list ( Formulary ) that is at the core of your prescription plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. 2019 Express Scripts PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by National Preferred Formulary all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan.

2 For specific questions about your coverage, please call the phone number printed on your member ID card. Only for Blue Cross 70%, 80% and 90% options KEY BARACLUDE SOLUTION clobetasol propionate EMVERM GILOTRIF. [INJ] - Injectable Drug BD AUTOSHIELD clomiphene citrate enalapril glimepiride Brand-name drugs are listed DUO NEEDLES clonazepam ENBREL [INJ] glipizide in CAPITAL letters. BD ULTRAFINE clonidine enoxaparin [INJ] glipizide ext-release Generic drugs are listed in INSULIN SYRINGES clopidogrel ENSTILAR GLUCAGEN [INJ]. lower case letters. BD ULTRAFINE clotrimazole/betamethasone ENTRESTO GLUCAGON [INJ].

3 PEN NEEDLES dipropionate EPCLUSA glyburide A BELBUCA COLCRYS EPIDUO FORTE GLYXAMBI. benazepril COMBIGAN EPINEPHRINE AUTO- GONAL-F, GONAL-F RFF, ABILIFY MAINTENA [INJ] benzonatate COMBIPATCH INJECTOR (by Mylan) [INJ] GONAL-F RFF. ABSORICA BEPREVE COMBIVENT RESPIMAT EPIPEN, EPIPEN JR [INJ] REDI-JECT [INJ]. ACANYA BETASERON [INJ] COPAXONE 40 MG [INJ] ergocalciferol GRALISE. acetaminophen/codeine BETHKIS CORLANOR ERIVEDGE GRANIX [INJ]. ACTEMRA [INJ] BEVESPI AEROSPHERE COSENTYX [INJ] ERLEADA GRASTEK. acyclovir BIKTARVY CREON erythromycin eye ointment guanfacine ext-release ADEMPAS bisoprolol/hctz CRINONE ESBRIET.

4 ADVAIR DISKUS blisovi fe cyanocobalamin [INJ] escitalopram H. ADVAIR HFA BOSULIF cyclobenzaprine esomeprazole magnesium AFSTYLA [INJ] BREO ELLIPTA delayed-release HARVONI. AIMOVIG [INJ] BRILINTA D estradiol HELIXATE FS [INJ]. AKYNZEO budesonide nebulization estradiol patches HUMALOG [INJ]. albuterol nebulization solution suspension DALIRESP estradiol/norethindrone acetate HUMIRA [INJ]. alendronate bupropion DARAPRIM ESTRING HUMULIN [INJ]. allopurinol bupropion ext-release DAYTRANA eszopiclone hydralazine ALPHAGAN P buspirone DESCOVY EUFLEXXA [INJ] hydrochlorothiazide alprazolam butalbital/acetaminophen/ desloratadine EVEKEO hydrocodone/acetaminophen ALREX caffeine desvenlafaxine succinate ezetimibe hydrocodone/chlorpheniramine amiodarone BYDUREON [INJ] ext-release ezetimibe/simvastatin polistirex ext-release AMITIZA BYETTA [INJ]

5 Dexamethasone hydrocortisone topical amitriptyline BYSTOLIC dexmethylphenidate F hydromorphone amlodipine BYVALSON ext-release hydroxychloroquine amlodipine/benazepril dextroamphetamine/ famotidine hydroxyzine hcl amlodipine/valsartan C amphetamine FARXIGA hydroxyzine pamoate amoxicillin dextroamphetamine/ fenofibrate HYSINGLA ER. amoxicillin/potassium CABOMETYX amphetamine ext-release fenofibrate micronized clavulanate CANASA diazepam fenofibric acid delayed-release I. AMPYRA CARAC diclofenac sodium fentanyl patches anastrozole CARAFATE SUSPENSION delayed-release FETZIMA ibandronate ANDRODERM carbidopa/levodopa dicyclomine FINACEA IBRANCE.

6 ANDROGEL carvedilol digoxin finasteride ibuprofen ANORO ELLIPTA cefdinir diltiazem ext-release FLECTOR ILEVRO. APRISO cefuroxime axetil diphenoxylate/atropine FLOVENT DISKUS INCRUSE ELLIPTA. ARCAPTA NEOHALER celecoxib divalproex delayed-release FLOVENT HFA indomethacin aripiprazole cephalexin divalproex ext-release fluconazole INLYTA. ARISTADA [INJ] CERDELGA DIVIGEL fluocinonide INVOKAMET. ARMONAIR RESPICLICK CEREZYME [INJ] donepezil fluoxetine INVOKAMET XR. ARNUITY ELLIPTA CETROTIDE [INJ] doxazosin fluticasone nasal spray INVOKANA. ASMANEX HFA CHANTIX doxycycline hyclate folic acid irbesartan ASMANEX TWISTHALER chlorhexidine gluconate doxycycline monohydrate FORTEO [INJ] IRESSA.

7 Atenolol chlorthalidone DUAVEE FRAGMIN [INJ] isosorbide mononitrate atenolol/chlorthalidone CIALIS DULERA furosemide ext-release atomoxetine CIMDUO duloxetine delayed-release FYCOMPA. atorvastatin CIPRODEX DUPIXENT [INJ] J. AVONEX [INJ] ciprofloxacin DYMISTA G. AZASITE citalopram JANUMET, JANUMET XR. azelastine nasal spray clarithromycin E gabapentin JANUVIA. azithromycin CLENPIQ GELNIQUE JARDIANCE. clindamycin hcl EDARBI gemfibrozil JENTADUETO. B clindamycin phosphate topical EDARBYCLOR GENOTROPIN [INJ] JENTADUETO XR. clindamycin phosphate/ ELIDEL GENVOYA junel baclofen benzoyl peroxide ELIQUIS GILENYA junel fe (continued).

8 Go to for a full list of Formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. 2018 Express Scripts THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. #1702 NP-A. All Rights Reserved You can find more information at PRMT22157-19 (09/05/18). K MOVANTIK P RUCONEST [INJ] triamcinolone topical MOXEZA triamterene/hctz ketoconazole topical moxifloxacin eye solution pantoprazole delayed-release S tri-lo-marzia ketorolac mupirocin paroxetine hcl trinessa KITABIS PAK MUSE PAZEO SANCUSO TRIPTODUR [INJ].

9 KOGENATE FS [INJ] MYDAYIS penicillin v potassium SAVELLA tri-sprintec KOVALTRY [INJ] MYRBETRIQ PENTASA SEGLUROMET TRULANCE. KYLEENA PERFOROMIST SEREVENT DISKUS TRULICITY [INJ]. N PHOSLYRA sertraline TUDORZA PRESSAIR. L PICATO sildenafil TYMLOS [INJ]. nabumetone pioglitazone SIMPONI 100 MG (for labetalol NAMZARIC PLEGRIDY [INJ] ulcerative colitis only) [INJ] U. lamotrigine naproxen, naproxen sodium polymyxin/trimethoprim simvastatin lansoprazole delayed-release NARCAN NASAL SPRAY eye solution SKYLA UCERIS FOAM. LANTUS [INJ] NASCOBAL POMALYST SOLIQUA [INJ] ULORIC.

10 Latanoprost eye solution neomycin/polymyxin/ potassium chloride ext-release SOLODYN UPTRAVI. LATUDA hydrocortisone ear solution PRALUENT [INJ] SOMATULINE DEPOT [INJ]. LETAIRIS NEXIUM PACKETS pramipexole SOOLANTRA V. LEVEMIR [INJ] niacin ext-release pravastatin SPIRIVA RESPIMAT. levetiracetam nifedipine ext-release prednisolone acetate spironolactone valacyclovir levocetirizine nitrofurantoin macrocrystal eye suspension sprintec valsartan levofloxacin NITYR prednisolone sodium SPRYCEL valsartan/hctz levothyroxine sodium NORDITROPIN [INJ] phosphate STEGLATRO VARUBI.