2021 Express Scripts National Preferred Formulary

1 KEY[INJ] - Injectable DrugBrand-name drugs are listedin CAPITAL drugs are listed in lower case MAINTENA [INJ]acetaminophen/codeineACTEMRA [INJ]acyclovirADEMPASADVAIR HFAADVATE [INJ]ADYNOVATE [INJ]AFSTYLA [INJ]AIMOVIG [INJ]AJOVY [INJ]albuterol nebulizationsolutionalbuterol sulfate hfa (byCipla, Lupin, Par, Perrigo,Proficient Rx & Teva)ALECENSA alendronateallopurinolALPHAGAN P ELLIPTAARALAST NP [INJ]ARIKAYCE aripiprazoleARISTADA [INJ]ARNUITY ELLIPTAASMANEX HFAASMANEX TWISTHALER atenololatenolol/chlorthalidoneatomoxeti neatorvastatinAUSTEDOAVONEX [INJ]AZASITE azelastine nasal sprayazithromycinAZOPTB baclofenBAFIERTAMBAQSIMIBARACLUDE SOLUTIONBAXDELABD AUTOSHIELD DUO NEEDLESBD ULTRAFINE INSULIN SYRINGESBD ULTRAFINE PEN NEEDLESBELBUCA benazeprilbenzonatateBETASERON [INJ]BEVESPI AEROSPHEREBIKTARVY bisoprolol/hctzblisovi feBOSULIFBREO ELLIPTABREZTRI AEROSPHEREBRILINTA budesonide nebulizationsuspensionbupropionbupropion ext-releasebuspironebutalbital/acetamino phen/caffeineBYDUREON [INJ]BYETTA [INJ]BYSTOLICCCABOMETYX carbidopa/levodopacarvedilolcefdinircefu roxime axetilcelecoxibcephalexinCERDELGACEREZYM E [INJ]CETROTIDE [INJ]

2 CHANTIX chlorhexidine gluconatechlorthalidoneCIMDUO ciprofloxacincitalopramclarithromycinCLE NPIQ clindamycin hclclindamycin phosphatetopicalclindamycin phosphate/benzoyl peroxideclobetasol propionateclomiphene citrateclonazepamclonidineclopidogrelclo trimazole/betamethasonedipropionatecolch icine tabletsCOMBIGANCOMBIPATCHCOMBIVENT RESPIMATCOMETRIQCORLANORCREON cyanocobalamin [INJ]cyclobenzaprineDDALIRESPDAYTRANADES COVY desloratadinedesvenlafaxine succinate ext-releasedexamethasoneDEXCOM RECEIVER, SENSOR,TRANSMITTER dexmethylphenidate ext-releasedextroamphetamine/amphetamine dextroamphetamine/amphetamine ext-releasediazepamdiclofenac sodium delayed-releasedicyclominedigoxindiltiaz em ext-releasedimethyl fumaratediphenoxylate/atropinedivalproex delayed-releasedivalproex ext-releaseDIVIGEL donepezildoxazosindoxycycline hyclatedoxycycline monohydrateDUAVEEDULERA duloxetine delayed-releaseDUPIXENT [INJ]DYANAVEL XREEDARBIEDARBYCLORELIQUISELOCTATE [INJ]EMGALITY [INJ]EMVERM enalaprilENBREL [INJ]ENDOMETRIN enoxaparin [INJ]ENSTILARENTRESTOEPCLUSAEPIDIOLEX epinephrine auto-injector (by Mylan, Teva)

3 [INJ]EPIPEN, EPIPEN JR [INJ]ergocalciferolERIVEDGEERLEADA erythromycin eye ointmentESBRIET escitalopramesomeprazole magnesiumdelayed-releaseESPEROCT [INJ]estradiolestradiol patchesestradiol/norethindroneacetateEST RING eszopicloneetonogestrel-ee vaginal ringEUFLEXXA [INJ]ezetimibeezetimibe/simvastatinFfamo tidineFARXIGAFASENRA [INJ]fenofibratefenofibrate micronizedfenofibric acid delayed-releasefentanyl patchesFETZIMAFINACEA FOAM finasterideFLECTORFLOVENT DISKUSFLOVENT HFAfluconazolefluocinonidefluoxetineflut icasone nasal sprayfolic acidFORTEO [INJ]FRAGMIN [INJ]FREESTYLE KITS/METERS:FREESTYLE FREEDOM,FREESTYLE FREEDOM LITE,FREESTYLE INSULINX,FREESTYLE LITEFREESTYLE LIBRE & LIBRE 2 READER, SENSORFREESTYLE TEST STRIPS:FREESTYLE, FREESTYLE INSULINX,FREESTYLE LITEFULPHILA furosemideFYCOMPAG gabapentinGAMMACOREGELNIQUE gemfibrozilGENOTROPIN [INJ]GENVOYAGILENYAGLASSIA [INJ]glimepirideglipizideglipizide ext-releaseGLUCAGEN [INJ]GLUCAGON [INJ]glyburideGLYXAMBIGONAL-F, GONAL-F RFF,GONAL-F RFF REDI-JECT [INJ]GRASTEK guanfacine ext-releaseGVOKE [INJ]HHARVONIHUMALOG [INJ]HUMIRA [INJ]HUMULIN [INJ]hydralazinehydrochlorothiazidehydro codone/acetaminophenhydrocodone/chlorphe niramine polistirexext-releasehydrocortisone topicalhydromorphonehydroxychloroquinehy droxyzine hclhydroxyzine pamoateHYSINGLA ERIibandronateIBRANCE ibuprofenINBRIJAINCRUSE ELLIPTA indomethacinINLYTAINVELTYSINVOKAMETINVOK AMET XRINVOKANA irbesartanIRESSA isosorbide mononitrate ext-releaseJJANUMET, JANUMET XRJANUVIAJARDIANCEJIVI [INJ]

4 JULUCA juneljunel fe2021 Express ScriptsNational Preferred FormularyThe following is a list of the most commonly prescribed drugs. It represents anabbreviated version of the drug list ( Formulary ) that is at the core of your prescriptionplan. The list is not all-inclusive and does not guarantee coverage. In addition tousing this list, you are encouraged to ask your doctor to prescribe generic drugswhenever NOTE: Brand-name drugs may move to nonformulary status if a genericversion becomes available during the year. Not all the drugs listed are covered byall prescription plans; check your benefit materials for the specific drugs coveredand the copayments for your prescription plan. For specific questions about yourcoverage, please call the phone number printed on your member ID 1(continued) 2020 Express Scripts . All Rights trademarks are the property of their respective #1702 NP-APRMT22157-21 (01/01/21)Go to for a full list of Formulary exclusions with their covered alternatives or log on to compare drug prices.

5 Costs for covered alternatives may DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at [INJ]ketoconazole topicalketorolacKITABIS PAKKOGENATE FS [INJ]KOVALTRY [INJ]KYLEENAKYNMOBIL labetalollamotriginelansoprazole delayed-releaseLANTUS [INJ]latanoprost eye solutionLATUDALEVEMIR [INJ]levetiracetamlevocetirizinelevoflox acinlevothyroxine sodiumLICART lidocaine patchesLINZESS liothyronineLIPOFEN lisinoprillisinopril/hctzLIVALOLO LOESTRIN FELOKELMA lorazepamLORBRENA losartanlosartan/hctzLOTEMAX GEL, OINTMENTLOTEMAX SMloteprednol eye suspensionlovastatinLUMIGANLUPANETA PACK [INJ]LUPRON DEPOT MG, MG [INJ]LUPRON DEPOT-PED [INJ]LYNPARZALYUMJEV [INJ]MMAYZENT meclizinemedroxyprogesteronemeloxicammet axalonemetforminmetformin ext-releasemethimazolemethocarbamolmetho trexatemethylphenidatemethylphenidate ext-releasemethylprednisolonemetoclopram idemetoprolol succinate ext-releasemetoprolol tartratemetronidazolemetronidazole topicalmetronidazole vaginalmicrogestin feminocyclineMIRENA mirtazapineMIRVASOMITIGARE mometasoneMONOVISC [INJ]montelukastmorphine sulfate ext-releaseMOVANTIK moxifloxacin eye solutionmupirocinMUSEMVASI [INJ]MYDAYISMYRBETRIQN nabumetoneNAMZARIC naproxen, naproxen sodiumNARCAN NASAL SPRAYNASCOBALNATESTONAYZILAM neomycin/polymyxin/hydrocortisone ear solutionNEXLETOLNEXLIZET niacin ext-releasenifedipine ext-releaseNINLARO nitrofurantoin macrocrystalNITYRNIVESTYM [INJ]NORDITROPIN [INJ]nortriptylineNOVAREL [INJ]NOVOEIGHT [INJ]NOVOFINE AUTOSHIELDNEEDLESNOVOFINE NEEDLESNOVOTWIST NEEDLESNUBEQANUCALA [INJ]

6 NUEDEXTA nystatinnystatin topicalOODACTRAODEFSEYODOMZOOFEV ofloxacinolanzapineolmesartanolmesartan/ hctzomega-3 acid ethyl estersomeprazole delayed-releaseondansetronondansetron orallydisintegrating tabletsONETOUCH KITS/METERS:ULTRA 2, ULTRAMINI,VERIO, VERIO FLEXONETOUCH TEST STRIPS:ULTRA, VERIOONEXTONOPSUMITORALAIRORIAHNNORILISS AORTHOVISC [INJ]oseltamivirOTEZLAOTOVELOVIDREL [INJ]oxcarbazepineoxybutynin ext-releaseoxycodoneoxycodone/acetaminop henOXYCONTINOZEMPIC [INJ]PPANCREAZE pantoprazole delayed-releaseparoxetine hclpenicillin v potassiumPENTASAPERFOROMISTPHOSLYRA pioglitazonePLEGRIDY [INJ]polymyxin/trimethoprim eye solutionPOMALYST potassium chloride ext-releasepramipexolepravastatinPRECISI ON XTRA METERS,TEST STRIPS, B-KETONE STRIPS prednisolone acetate eye suspensionprednisolone sodiumphosphateprednisonepregabalinPREMA RIN CREAMPREMARIN TABLETSPREMPHASEPREMPROPROCRIT [INJ]progesterone micronizedPROLASTIN C [INJ]promethazinepromethazine/dextrometh orphanpropranololpropranolol ext-releasePULMICORT FLEXHALERQQNASLQUDEXY XRquetiapineQUILLICHEW ERQUILLIVANT XRquinaprilQVAR REDIHALERR rabeprazole delayed-releaseRAGWITEK raloxifeneramiprilRASUVO [INJ]

7 REBIF [INJ]RECTIVRELISTOR [INJ]RELISTOR TABLETSREMICADE [INJ]REPATHA [INJ]RESTASISRETACRIT [INJ]REVLIMIDRHOPRESSARINVOQ ERrisperidonerizatriptanropinirolerosuva statinRUBRACARUCONEST [INJ]RUXIENCE [INJ]RYBELSUSSSAVELLASEGLUROMETSEREVENT DISKUS sertralinesildenafilSIMPONI 100 MG (forulcerative colitis only) [INJ]simvastatinSKYLASKYRIZI [INJ]SOLIQUA [INJ]SOLOSECSOMATULINE DEPOT [INJ]SPIRIVA HANDIHALERSPIRIVA RESPIMAT spironolactonesprintecSPRYCELSTEGLATROST EGLUJANSTELARA SC [INJ]STIOLTO RESPIMATSTRENSIQ [INJ]SUBLOCADE [INJ]sulfamethoxazole/trimethoprimsumatr iptanSUNOSISUPREPSUTENTSYMBICORTSYMFISYM FI LOSYMJEPI [INJ]SYMLINPEN [INJ]SYMPROICSYMTUZASYNJARDY, SYNJARDY XRTtacrolimus topicaltadalafilTAKHZYRO [INJ]TALICIATALTZ [INJ]TALZENNA tamoxifentamsulosin ext-releaseTASIGNATAYTULLATAZORAC GELTAZORAC CREAMTEGSEDI [INJ]TEKTURNA HCTTEMIXYS terazosinterconazole vaginaltestosterone cypionate [INJ]THALOMID timolol maleate eye solutiontizanidineTOBI PODHALERTOBRADEX OINTMENTTOBRADEX STtobramycin eye solutiontobramycin/dexamethasoneeye suspensiontopiramateTOUJEO [INJ]TOVIAZTRACLEER SUSPENSION tramadoltravoprost eye solutionTRAZIMERA [INJ]trazodoneTRELEGY ELLIPTATREMFYA [INJ]

8 TRESIBA [INJ]triamcinolone topicaltriamterene/hctzTRIJARDY XRtri-lo-marziaTRIPTODUR [INJ]tri-sprintecTRIUMEQTRULANCETRULICIT Y [INJ]TYMLOS [INJ]UUCERIS FOAMUPTRAVIV valacyclovirvalsartanvalsartan/hctzVARUB IVASCEPAVELPHORO venlafaxinevenlafaxine ext-releaseverapamil ext-releaseVERZENIOVIBERZIVIIBRYDVIMPATV IOKACEVIZIMPROVOSEVIVUMERITYVYVANSEW warfarinXXALKORIXARELTOXELJANZ, XELJANZ XRXIFAXANXIGDUO XRXIIDRAXOLAIR [INJ]XTANDIXULTOPHY [INJ]XYREMXYWAVYYONSAYUPELRI yuvafemZZARXIO [INJ]ZEJULAZENPEPZEPATIERZEPOSIAZERVIATE ZIEXTENZO [INJ]ZIOPTANZIRABEV [INJ]zolpidemzolpidem ext-releaseZOMIG NASALZTLIDOZUBSOLVZYLETZYTIGA 500 MGPage 2 2020 Express Scripts . All Rights trademarks are the property of their respective #1702 NP-APRMT22157-21 (01/01/21)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 DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021.

9 THIS LIST IS SUBJECT TO CHANGE. You can find more information at