Express Scripts 2019 Walmart Preferred Drug List Exclusions

1 2019 Walmart Preferred drug List Exclusions The excluded medications shown below are not covered on the Walmart drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you're currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following Preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. For more information contact Express Scripts Customer Service at or visit the My Benefits tab on or on the WIRE.

2 Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. drug Class Excluded Medications Preferred Alternatives AUTONOMIC & CENTRAL NERVOUS SYSTEM. LUCEMYRA clonidine Alpha-2 Adrenergic Agonists (for Opioid Withdrawal). Anti-Migraine Therapy SUMAVEL DOSEPRO, TREXIMET, ZOMIG NASAL rizatriptan, sumatriptan tablets, zolmitriptan amantadine capsules, amantadine tablets, GOCOVRI ER, OSMOLEX ER. amantadine oral solution Antiparkinsonism Agents XADAGO rasagiline, selegiline AVONEX ADMINISTRATION PACK, AVONEX PEN, PLEGRIDY, Beta Interferons for Multiple Sclerosis BETASERON, EXTAVIA. REBIF, REBIF REBIDOSE. EMFLAZA prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51 No alternatives recommended EMBEDA, HYSINGLA ER, KADIAN, NUCYNTA/NUCYNTA ER, Long-Acting Opioid Oral Analgesics hydromorphone ER, tramadol OXYCODONE ER, OXYCONTIN, ZOHYDRO ER.

3 Narcotic Analgesics BUPRENORPHINE PATCHES, BUTRANS fentanyl patches, hydromorphone ER. Narcotic Antagonists EVZIO naloxone syringe, NARCAN NASAL SPRAY. Neuropathic Agents LYRICA CR gabapentin, GRALISE, LYRICA. Transmucosal Fentanyl Analgesics ABSTRAL, FENTORA, LAZANDA fentanyl citrate lozenges CARDIOVASCULAR. PRADAXA, SAVAYSA ELIQUIS, XARELTO. Anticoagulants HMG & Cholesterol Inhibitor Combinations ALTOPREV, LIVALO, ZYPITAMAG atorvastatin, lovastatin, rosuvastatin, simvastatin DERMATOLOGICAL. DOXYCYCLINE 40 MG CAPSULES ORACEA. Oral Agents For Rosacea clindamycin/benzoyl peroxide, clindamycin/tretinoin, Topical Acne/Antibiotic Combinations AKTIPAK, VELTIN. erythromycin/benzoyl peroxide, ACANYA, ONEXTON. FLUOROURACIL CREAM, diclofenac 3% gel, fluorouracil 5% cream, Topical Agents for Actinic Keratosis IMIQUIMOD CREAM PUMP imiquimod 5% cream, CARAC, PICATO.

4 Topical Antifungals LULICONAZOLE ciclopirox, econazole, ketoconazole, naftifine, oxiconazole acyclovir capsules, acyclovir tablets, famciclovir tablets, Topical Antiviral Agents XERESE CREAM. valacyclovir tablets, ZOVIRAX CREAM. desonide cream/lotion/ointment, Topical Corticosteroids TOPICORT SPRAY, VERDESO FOAM. desoximetasone cream/ointment Miscellaneous Topical Dermatological Agents ALCORTIN A hydrocortisone, mupirocin Continued 2018 Express Scripts . All Rights Reserved. 340120. All trademarks are the property of their respective owners. Page 1 DL44109Q-WM-19 (11/01/2018). drug Class Excluded Medications Preferred Alternatives ABBOTT (FREESTYLE, PRECISION), BAYER (BREEZE, CONTOUR), NATIONAL MEDICAL (ADVOCATE), OMNIS. DIABETES HEALTH (EMBRACE, VICTORY), ROCHE (ACCU-CHEK), LIFESCAN (ONETOUCH), RELION METERS/STRIPS.

5 Blood Glucose Meters & Test Strips TRIVIDIA (TRUETEST, TRUETRACK), UNISTRIP. ALL OTHER METERS & STRIPS THAT ARE NOT. LIFESCAN OR RELION BRAND. ALOGLIPTIN, NESINA, ONGLYZA JANUVIA, TRADJENTA. Dipeptidyl Peptidase-4 Inhibitors & Combinations ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR. Glucagon-Like Peptide-1 Agonists ADLYXIN, TANZEUM, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY. NOVOLIN HUMULIN, RELION INSULIN. Insulins ADMELOG, APIDRA, FIASP, NOVOLOG HUMALOG. EAR/NOSE. BECONASE AQ, NASONEX, OMNARIS, QNASL, ZETONNA budesonide, fluticasone, mometasone Nasal Steroids Otic Fluoroquinolone Antibiotics CETRAXAL ofloxacin ear solution, CIPRODEX, OTOVEL. ENDOCRINE (OTHER). CLIMARA PRO COMBIPATCH. Combination Patches estradiol patches, estradiol tablets, yuvafem, Estrogen and Estrogen Modifiers for Vaginal Symptoms FEMRING.

6 ESTRING, PREMARIN CREAM, PREMARIN TABLETS. Gonadotropin Releasing Hormone (GnRH) Agonists LUPRON DEPOT-PED TRIPTODUR. (for Central Precocious Puberty). GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO, Growth Hormones OMNITROPE. NUTROPIN AQ NUSPIN, SAIZEN, SAIZENPREP, ZOMACTON. Topical Estrogen Gels ESTROGEL DIVIGEL. GASTROINTESTINAL. CORTIFOAM hydrocortisone enema, UCERIS FOAM. Corticosteroids (Rectal Formulations). balsalazide disodium, mesalamine gm delayed-release, Inflammatory Bowel Agents DELZICOL, DIPENTUM. sulfasalazine, APRISO, PENTASA. Pancreatic Enzymes PANCREAZE, PERTZYE CREON, ZENPEP. HEMATOLOGICAL. ARANESP, EPOGEN, MIRCERA PROCRIT. Erythropoiesis-Stimulating Agents ADVATE, ADYNOVATE, AFSTYLA, HELIXATE FS, KOGENATE FS, Factor VIII Recombinant Products ELOCTATE, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE. KOVALTRY, NOVOEIGHT, NUWIQ.

7 Granulocyte Colony Stimulating Factors NEUPOGEN GRANIX, ZARXIO. HEPATITIS EPCLUSA, HARVONI, MAVYRET, TECHNIVIE, DAKLINZA, OLYSIO, SOVALDI, ZEPATIER. Hepatitis C VIEKIRA PAK, VIEKIRA XR, VOSEVI. HIV BIKTARVY, GENVOYA, ODEFSEY, STRIBILD, SYMFI, SYMFI LO, ATRIPLA. Antiretrovirals TRIUMEQ. MUSCULOSKELETAL & RHEUMATOLOGY. DUZALLO, ZURAMPIC allopurinol, probenecid Gout Therapy fenoprofen calcium tablets, diclofenac, ibuprofen, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES. indomethacin, meloxicam, nabumetone, naproxen Osteoporosis Therapy FORTEO TYMLOS. Continued 2018 Express Scripts . All Rights Reserved. 340120. All trademarks are the property of their respective owners. Page 2 DL44109Q-WM-19 (11/01/2018). drug Class Excluded Medications Preferred Alternatives OBSTETRICAL & GYNECOLOGICAL.

8 Gonadotropin-Releasing Hormone (GnRH) ORILISSA LUPRON DEPOT, SYNAREL, ZOLADEX. Receptor Antagonists (for Endometriosis). Vaginal Progesterones ENDOMETRIN CRINONE 8% GEL. OPHTHALMIC betaxolol drops, levobunolol drops, TIMOPTIC OCUDOSE. Antiglaucoma Drugs (Beta-Adrenergic Blockers) ALPHAGAN P , COMBIGAN. Antiglaucoma Drugs (Ophthalmic Prostaglandins) ZIOPTAN latanoprost drops, LUMIGAN, TRAVATAN Z. azelastine drops, cromolyn drops, olopatadine drops, Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, EMADINE. ALREX, BEPREVE, PAZEO. dexamethasone drops, fluorometholone drops, Ophthalmic Anti-Inflammatory FLAREX, FML FORTE, FML , MAXIDEX, PRED MILD. prednisolone drops, LOTEMAX. Ophthalmic Non-Steroidal Anti-Inflammatory Drugs ACUVAIL, NEVANAC diclofenac drops, ketorolac drops, ILEVRO, PROLENSA. (NSAIDs). DUROLANE, EUFLEXXA, GEL-ONE, GELSYN-3, GENVISC 850, OSTEOARTHRITIS.

9 HYALGAN, HYMOVIS, SUPARTZ FX, SYNVISC, SYNVISC-ONE, MONOVISC, ORTHOVISC. Hyaluronic Acid Derivatives VISCO-3. RESPIRATORY EPINEPHRINE AUTO-INJECTOR (BY MYLAN), AUVI-Q. Epinephrine Auto-Injector Systems EPIPEN, EPIPEN JR. Long-Acting Beta Agonist Nebulized BROVANA PERFOROMIST. ALVESCO, ARMONAIR RESPICLICK, ARNUITY ELLIPTA, Pulmonary Anti-Inflammatory Inhalers ASMANEX HFA/TWISTHALER, PULMICORT FLEXHALER, QVAR. FLOVENT DISKUS/HFA. Pulmonary Anti-Inflammatory/. ADVAIR DISKUS/HFA, BREO ELLIPTA DULERA, SYMBICORT. Beta Agonist Combination Inhalers Short-Acting Beta2-Agonist Inhalers LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA. ENDARI Over-the-Counter glutamine powder or tablets HYDROXYPROGESTERONE 1,250 MG/5 ML hydroxyprogesterone caproate 250 mg/ml (single dose vial). MISCELLANEOUS AGENTS SIKLOS DROXIA.

10 MEBOLIC, OMNIVEX, XYZBAC, ZYVIT Over-the-Counter multivitamin combination plus folic acid NOCTIVA desmopressin tablets Hereditary Angioedema BERINERT RUCONEST. Indication Based Management drug Class Nonpreferred Medications Preferred Alternatives All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted ACTEMRA, COSENTYX, ENBREL, HUMIRA, INFLECTRA, following a coverage review. A trial of one or more Preferred OTEZLA, REMICADE, RENFLEXIS, SIMPONI 100 MG (FOR. INFLAMMATORY CONDITIONS medications is required prior to initiating therapy with a ULCERATIVE COLITIS ONLY), STELARA SC, TREMFYA*, Nonpreferred medication. A formulary exception may be XELJANZ, XELJANZ XR. granted for patients already established on therapy with a Nonpreferred medication. Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.