ABRIDGED STANDARD FORMULARY - envisionrx.com

1 ABRIDGED STANDARD 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. 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/ Selective Bile Acid Sequestrants DERMATOLOGICALS Peripheral Opioid ILEVRO [NP].

2 ANTI-OBESITY/ Phosphodiesterase WELCHOL Acne Products Receptor Antagonists PATADAY. ANOREXIANTS 4 (PDE4) Inhibitors PCSK9 Inhibitors EPIDUO MOVANTIK [NP] PAZEO. Amphetamines DALIRESP PRALUENT [SP] EPIDUO FORTE Phosphate Binder Agents PROLENSA. MYDAYIS ANTICOAGULANTS REPATHA [SP] RETIN-A AURYXIA [NP] XIIDRA. VYVANSE Direct Factor Xa Inhibitors Fibric Acid Derivatives Antipsoriatics VELPHORO [NP] Ophthalmic Anti-Obesity Agents ELIQUIS LIPOFEN COSENTYX Anti-infectives GENITOURINARY. CONTRAVE XARELTO Antihyperlipidemics - Misc. STELARA [SP] AGENTS - MISC. AZASITE. SAXENDA Thrombin Inhibitors VASCEPA Antineoplastic or Prostatic Hypertrophy BESIVANCE. AMINOGLYCOSIDES PRADAXA Premalignant Lesion Agents MOXEZA. ANTI-INFECTIVE AGENTS. Aminoglycosides Agents - Topical RAPAFLO VIGAMOX. ANTICONVULSANTS - MISC. BETHKIS [SP] Anti-infective Agents - Misc. PICATO [NP] Beta-blockers - AMPA Glutamate Receptor GOUT AGENTS. XIFAXAN TOLAK [NP] Ophthalmic ANALGESICS - Antagonists Gout Agents Antifungals - Topical BETIMOL.

3 ANTI-INFLAMMATORY FYCOMPA [NP] ANTINEOPLASTICS & ULORIC. JUBLIA COMBIGAN. Anti-TNF-alpha - Anticonvulsants - Misc. ADJUNCTIVE THERAPIES ZURAMPIC [NP]. Monoclonoal Antibodies LUZU COSOPT. BRIVIACT [NP] Antineoplastic - Hormonal Gout Agent Combinations HUMIRA [SP] & Related Agents NAFTIN Prostaglandins - LYRICA DUZALLO [NP]. Soluble Tumor Necrosis Rosacea Agents Ophthalmic VIMPAT [NP] ELIGARD [SP] HEMATOLOGICAL. Factor Receptor Agents Antineoplastic Enzyme RHOFADE [NP] LUMIGAN. ANTIDEPRESSANTS Corticosteroids - Topical AGENTS - MISC. TRAVATAN. ENBREL [SP] Inhibitors Modified Cyclics ENSTILAR [NP] Platelet Aggregation OTEZLA [SP] SPRYCEL [SP] VYZULTA [NP]. TRINTELLIX Inhibitors Antirheumatic - TASIGNA [SP] TACLONEX [NP] ZIOPTAN. VIIBRYD [NP] BRILINTA. Enzyme Inhibitors EUCRISA Ophthalmic Serotonin-Norepinephrine ANTIPARKINSON AGENTS Immunosuppressive HEMATOPOIETIC AGENTS Adrenergic Agents XELJANZ. Reuptake Inhibitors Antiparkinson Agents - Topical Hematopoietic Growth ALPHAGAN.

4 Antirheumatic (SNRIs) Dopaminergics Factors Antimetabolites ELIDEL SIMBRINZA. FETZIMA [NP] NEUPRO [NP] PROCRIT [SP]. OTREXUP [NP] DIAGNOSTIC PRODUCTS Ophthalmic RASUVO [NP] ANTIDIABETICS ANTIPSYCHOTICS/ ZARXIO [SP] Immunomodulators Diagnostic Tests Antidiabetic Combinations ANTIMANIC AGENTS HYPNOTICS RESTASIS. ANALGESICS - OPIOID Quinolinone Derivatives FREESTYLE. Opioid Partial Agonists INVOKAMET ONETOUCH Hypnotics - Tricyclic Agents OTIC AGENTS. JANUMET ABILIFY SILENOR. ZUBSOLV PRECISION Otic Combinations JENTADUETO REXULTI BELSOMRA. Opioid Agonists CIPRODEX. XIGDUO Antipsychotics - Misc. DIGESTIVE AIDS. MORPHABOND LAXATIVES OTOVEL [NP]. Dipeptidyl Peptidase-4 VRAYLAR [NP] Digestive Enzymes XTAMPZA CREON Laxative Combinations PROGESTINS. (DPP-4) Inhibitors ANTIVIRALS. ZOHYDRO ZENPEP CLENPIQ Progestins JANUVIA Hepatitis Agents ANDROGENS-ANABOLIC SUPREP MAKENA. TRADJENTA EPCLUSA [SP] ENDOCRINE & METABOLIC. Androgens Insulin AGENTS - MISC. MEDICAL DEVICES PSYCHOTHERAPEUTIC &.

5 HARVONI [SP]. ANDROGEL LANTUS Growth Hormones Diabetic Supplies NEUROLOGICAL AGENTS. MAVYRET [SP]. ANORECTAL AGENTS LEVEMIR GENOTROPIN [SP] FREESTYLE - MISC. VOSEVI [SP]. Intrarectal Steroids NOVOLIN NORDITROPIN [SP] ONETOUCH Multiple Sclerosis Agents ASSORTED CLASSES Bone Density Regulators PRECISION AVONEX [SP]. UCERIS [NP] NOVOLIN70/30. Potassium Removing Parenteral Therapy BETASERON [SP]. NOVOLOG TYMLOS [SP]. ANTIARRHYTHMICS Resins Supplies COPAXONE [SP]. TOUJEO Corticotropin Antiarrhythmics Type III VELTASSA [NP] GILENYA [SP]. TRESIBA ACTHAR [SP] BD. MULTAQ BETA BLOCKERS Control PLEGRIDY [SP]. Incretin Mimetic Agents Metabolic Modifiers ANTIASTHMATIC & (GLP-1 Receptor Agonists) Beta Blockers RAYALDEE [NP] Safety-Glide TECFIDERA [SP]. BRONCHODILATOR OZEMPIC. Cardio-Selective Syringe Movement Disorder AGENTS BYSTOLIC ESTROGENS Drug Therapy TRULICITY Estrogen Combinations Yale Sympathomimetics AUSTEDO [SP]. VICTOZA CARDIOVASCULAR DUAVEE MIGRAINE PRODUCTS.

6 ADVAIR AGENTS - MISC. Fibromyalgia Agents Sodium-Glucose PREMPHASE Serotonin Agonists ANORO Co-Transporter Pulmonary Hypertension - SAVELLA. ARCAPTA Endothelin Receptor PREMPRO ZEMBRACE [NP] Pseudobulbar Affect 2 (SGLT2) Inhibitors BREO Antagonists Estrogens MULTIVITAMINS (PBA) Agents FARXIGA. COMBIVENT LETAIRIS [SP] PREMARIN Prenatal Vitamins NUEDEXTA. INVOKANA. PROAIR Diabetic Other OPSUMIT [SP] FLUOROQUINOLONES CITRANATAL TETRACYCLINES. SEREVENT GLUCAGEN TRACLEER [SP] Fluoroquinolones NASAL AGENTS - Tetracyclines STIOLTO Cardiovascular Agents BAXDELA [SP] SYSTEMIC & TOPICAL XIMINO. ANTIDOTES Misc. - Combinations SYMBICORT Opioid Antagonists GASTROINTESTINAL Nasal Steroids ENTRESTO ULCER DRUGS. TRELEGY NARCAN AGENTS - MISC. QNASL. ADEMPAS [SP] Proton Pump Inhibitors VENTOLIN Inflammatory Bowel XHANCE [NP]. ANTIEMETICS CORLANOR DEXILANT. Bronchodilators - Agents Nasal Agent Combinations Anticholinergics Substance P/Neurokinin 1 APRISO DYMISTA URINARY. CONTRACEPTIVES.

7 INCRUSE (NK1) Receptor Antagonists ANTISPASMODICS. Combination STELARA [SP] OPHTHALMIC AGENTS. SPIRIVA VARUBI [SP] Contraceptives - Oral Gastrointestinal Chloride Urinary Antispasmodics Antiemetics - Misc. Ophthalmic Steroids MYRBETRIQ. Steroid Inhalants BEYAZ Channel Activators BONJESTA ALREX. ARNUITY NATAZIA AMITIZA VAGINAL PRODUCTS. DICLEGIS DUREZOL. ASMANEX YASMIN Irritable Bowel Vaginal Estrogens Syndrome (IBS) Agents LOTEMAX. FLOVENT ANTIHYPERLIPIDEMICS YAZ PREMARIN. LINZESS Ophthalmics - Misc. PULMICORT HMG CoA Reductase VASOPRESSORS. Inhibitors ACUVAIL. QVAR AZOPT Anaphylaxis Therapy LIVALO Agents BROMSITE. epinephrine (Mylan). KEY: [NP] = Non-Preferred [SP] = Specialty EXCLUDED MEDICATIONS WITH COVERED ALTERNATIVES. THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION. ANALGESICS. Nonsteroidal Anti-inflammatory Agents diclofenac, indomethacin, meloxicam Indocin, Tivorbex, Vivlodex, Zipsor, (NSAIDs) Zorvolex Opioid Agonists - Extended Release Xtampza, Zohydro ER, Morphabond ER Oxycontin, oxycodone ER, Kadian, Nucynta ER, Opana ER, Hysingla ER, Exalgo, Embeda, Butrans Opioid Agonists - Immediate Release Roxybond Nucynta, Oxaydo ANTIBIOTICS.

8 Antiprotozoals, Miscellaneous metronidazole Solosec ANTI-ADDICTION / SUBSTANCE ABUSE TREATMENT. Opioid Abuse Zubsolv Bunavail, buprenorphine/naloxone, Suboxone Film Opioid Antagonists Narcan, Naloxone Evzio ANTIVIRALS. Hepatitis C (All specialty brand drugs)[SP] Epclusa*, Harvoni*, Mavyret*, Vosevi* Olysio, Technivie*, Viekira*, Zepatier*, Daklinza*, Sovaldi*. AUTONOMIC & CENTRAL NERVOUS SYSTEM. Movement Disorders Austedo[SP] Ingrezza2. (All specialty brand drugs)[SP]. Transmucosal Fentanyl Analgesics fentanyl lozenge Abstral, Fentora, Lazanda, Subsys CONTRACEPTIVES. Oral Contraceptives Beyaz, Natazia, Safyral, Yasmin, generic Beyaz1, generic Safyral1, generic Yaz, Lo Loestrin Yasmin1, generic Yaz1. DERMATOLOGY. Acne (Oral Agents) Ximino, Zenatane, Myorisan, Claravis Absorica, Solodyn, minocycline ER. Acne (Topical) Epiduo Forte Gel, Epiduo, Acanya, Aczone, Clindagel, Onexton, clindamycin phosphate, Retin-A Tretin-X, Atralin, Tazorac, Ziana, adapal/ben P gel Actinic Keratosis Picato[NP], Tolak[NP], fluorouracil 5% cream, Carac, Zyclara, Ameluz, imiquimod 5% cream fluorouracil cream DIABETES.

9 Biguanides metformin (generic Glucophage Fortamet, generic Fortamet, or generic Glucophage XR) Glumetza, generic Glumetza Blood Glucose Meters & Test Strips Abbott (Freestyle, Precision), Ascencia (Breeze, Contour), Roche (Accu- Lifescan (Onetouch) Chek), all other test strips that are not Abbott (Freestyle, Precision) or Lifescan (Onetouch) brand Pen Needles & Syringes BD Products All Pen Needles and Syringes besides BD. products Glucagon-Like Peptide-1 Agonists (GLP-1) Victoza, Trulicity, Ozempic Adlyxin, Bydureon, Byetta, Tanzeum Long-Acting Insulin Levemir, Lantus Basaglar Rapid Acting Insulin Novolog, Novolin Afrezza, Apidra, Humalog, Humulin Sodium-Glucose Co-transporter 2 (SGLT-2) Farxiga, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR. Inhibitor & Combinations Xigduo XR. ENDOCRINE. Topical Testosterone Products Androgel , generic testosterones Androderm, Axiron, Fortesta, Testim Gonadotropin Releasing Hormone Agonists Eligard[SP] Lupron2.

10 HMG-CoA Reductase Inhibitors simvastatin, rosuvastatin, pravastatin, Zypitamag lovastatin, Livalo, fluvastatin, atorvastatin Osteoporosis (All specialty brand drugs)[SP] Tymlos Forteo ENVISIONRX 2019 STANDARD FORMULARY UPDATES | 2. EXCLUDED MEDICATIONS WITH COVERED ALTERNATIVES Continued THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION. GASTROINTESTINAL. Anti-Inflammatory/Anti-Ulcer Agents famotidine + ibuprofen or omeprazole + Duexis, Vimovo naproxen OPHTHALMIC AGENTS. Ophthalmic Steroids Alrex, Durezol Emu, Lotemax, Bromsite Blephamide, Flarex, FML, FML Forte, FMLE. Liquifilm, Maxidex, Maxitrol, Pred Forte, Pred Mild, Pred-G, Pred-G , Tobradex, Zylet, Pred Sod Phos, Dexameth UROLOGICAL. Urinary Antispasmodic Myrbetriq, oxybutynin, tolterodine, trospium Enablex, Toviaz, Vesicare VASOPRESSORS. Anaphylaxis Therapy Agents generic Epipen Epipen, Epipen-Jr, Auvi-Q, Adrenaclick, generic Adrenaclick WEIGHT LOSS. Weight Loss Agents Contrave*, Saxenda Belviq, Belviq XR, Qsymia*.