Express Scripts 2021 National Preferred Formulary List

1 Page 1(continued) 2020 Express Scripts . All Rights trademarks are the property of their respective #1702 NP-ACOMP1702A-21 (11/01/20)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. THIS LIST IS SUBJECT TO CHANGE. You can find more information at [SP]abacavir/lamivudine [SP]abacavir/lamivudine/zidovudine [SP]ABELCET [INJ]ABILIFY MAINTENA [INJ]abiraterone acetate [SP]ABRAXANE [INJ] [SP]acamprosate delayed-releaseacarboseACCU- chek FASTCLIX LANCETS [OTC]ACCU- chek MULTICLIX LANCET KIT [OTC]ACCU- chek MULTICLIX LANCETS [OTC]ACCU- chek SOFTCLIX LANCET KIT [OTC]ACCU- chek SOFTCLIX LANCETS [OTC]acebutololacetaminophen/codeineacet azolamideacetazolamide ext-releaseacetazolamide sodium [INJ]acetic acid ear solutionacetic acid irrigation solutionacetic acid/hydrocortisone ear solutionacetic acid/oxyquinoline vaginalacetylcysteine [INJ]acetylcysteine inhalation solutionacitretinACTEMRA [INJ] [SP]ACTHIB [INJ]

2 ACTHREL [INJ]ACTIMMUNE [INJ] [SP]ACTIVASE [INJ]acycloviracyclovir ointmentacyclovir sodium [INJ]ADACEL [INJ]ADAKVEO [INJ] [SP]adapaleneadapalene/benzoyl peroxideADCETRIS [INJ] [SP]ADDAMEL N [INJ]adefovirADEMPAS [SP]adenosine [INJ]ADVAIR HFAADVATE [INJ] [SP]ADYNOVATE [INJ] [SP]AFINITOR 10 MG TABLETS [SP]AFINITOR DISPERZ [SP]afirmelleAFLURIA QUAD [INJ]AFSTYLA [INJ] [SP]AIMOVIG [INJ]AJOVY [INJ]albendazolealbumin human [INJ]albuterolalbuterol ext-releasealbuterol nebulization solutionalbuterol sulfate hfa (by Cipla, Lupin, Par, Perrigo, Proficient Rx & Teva)alclometasoneALDURAZYME [INJ] [SP]ALECENSA [SP]alendronatealfentanil [INJ]ALFERON N [INJ]alfuzosin ext-releaseALIMTA [INJ]ALINIAALIQOPA [INJ] [SP]aliskirenallopurinolallopurinol sodium [INJ]almotriptanalosetronALPHAGAN P [INJ] [SP]ALPHANINE SD [INJ] [SP]alprazolamalprazolam ext-releasealprazolam orally disintegrating tabletsALPROLIX [INJ] [SP]alprostadil [INJ]altaveraALUNBRIG [SP]alyacenamabelzamantadineAMBISOME [INJ]ambrisentan [SP]amcinonideamethiaamethia loamethystamifostine [INJ]amikacin [INJ]amilorideamiloride/hydrochlorothiaz ideaminocaproic acidaminocaproic acid [INJ]aminophylline [INJ]AMINOSYN [INJ]amiodaroneamiodarone [INJ]

3 Amitriptylineamitriptyline/chlordiazepox ideamlodipineamlodipine/atorvastatinamlo dipine/benazeprilamlodipine/olmesartanam lodipine/valsartanamlodipine/valsartan/h ydrochlorothiazideammonium lactate 12% topicalamoxapineamoxicillinamoxicillin/p otassium clavulanateamoxicillin/potassium clavulanate ext-releaseamphetamine sulfateamphotericin [INJ]ampicillinampicillin sodium [INJ]ampicillin sodium/sulbactam [INJ]AMYTAL [INJ]AMZEEQ anagrelideanastrozoleANDRODERMANORO ELLIPTAAPLISOL [INJ]APOKYN [INJ] [SP]apraclonidine eye solutionaprepitantapriAPTIVUS [SP]AQUASOL A [INJ]ARALAST NP [INJ] [SP]aranelleARIKAYCE [SP]aripiprazolearipiprazole orally disintegrating tabletsARISTADA [INJ]ARISTOSPAN [INJ]armodafinilARMOUR THYROIDARNUITY ELLIPTAARRANON [INJ] [SP]arsenic trioxide [INJ]ascorbic acid [INJ]ashlynaASMANEX HFAASMANEX TWISTHALER aspirin/dipyridamole ext-releaseatazanavir [SP]atenololatenolol/chlorthalidoneATGAM [INJ]atomoxetineatorvastatinatovaquoneat ovaquone/proguanilatropine [INJ]atropine sulfate eye ointmentatropine sulfate eye solutionaubraaubra eqAUGMENTIN MG/5 MLaurovelaaurovela 24 feaurovela fe2021 Express Scripts National Preferred Formulary ListThe 2021 National Preferred Formulary drug list is shown below.

4 The Formulary is the list of drugs included in your prescription plan. Inclusion on the list does not following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the Formulary . The only OTC products andprescription medical supplies that appear on the list are in contracted 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 allprescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about yourcoverage, please call the phone number printed on your member ID [INJ] Injectable Drug[OTC] Over-the-counter Product[SP] Specialty DrugBrand-name drugs are listed in CAPITAL letters.

5 Example: ABILIFY MAINTENAG eneric drugs are listed in lower-case letters. Example: ibuprofenFor the member:FDA-approved generic medications meet strict standards andcontain the same active ingredients as their corresponding brand-name medications,although they may have a different the physician:Please prescribe Preferred products and allow genericsubstitutions when medically 2(continued) 2020 Express Scripts . All Rights trademarks are the property of their respective #1702 NP-ACOMP1702A-21 (11/01/20)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.

6 THIS LIST IS SUBJECT TO CHANGE. You can find more information at [SP]avianeAVONEX [INJ] [SP]AVYCAZ [INJ]ayunaazacitidine [INJ] [SP]AZASITE azathioprine [SP]azathioprine sodium [INJ] [SP]AZEDRA [INJ] [SP]azelaic acidazelastine eye solutionazelastine nasal sprayazelastine/fluticasoneazithromycina zithromycin [INJ]AZOPT aztreonam [INJ]azuretteBbacitracin [INJ]bacitracin eye ointmentbacitracin/polymyxin eye ointmentbaclofenbaclofen [INJ]BAL IN OIL [INJ]balanced salt eye irrigation solutionbal-care dha prenatal vitaminsbalsalazideBALVERSA [SP]balzivaBANZELBAQSIMIBARACLUDE SOLUTIONBAVENCIO [INJ] [SP]BAXDELABAXDELA [INJ]b-complex [INJ]BD AUTOSHIELD DUO NEEDLES [OTC]BD NANO 2ND GEN PEN NEEDLESBD ULTRAFINE INSULIN SYRINGES [OTC]BD ULTRAFINE PEN NEEDLES [OTC]bekyreeBELBUCA benazeprilbenazepril/hydrochlorothiazide BENDEKA [INJ] [SP]BENEFIX [INJ] [SP]BENLYSTA [INJ] [SP]BENZNIDAZOLE benzonatatebenzoyl peroxidebenzphetaminebenztropinebenztrop ine [INJ]BESPONSA [INJ] [SP]betamethasone acetate/betamethasonesodium phosphate [INJ]betamethasone dipropionatebetamethasone dipropionate augmentedbetamethasone valerateBETASERON [INJ] [SP]betaxololbetaxolol eye solutionbethanecholBEVESPI AEROSPHERE bexarotene [SP]BEXSERO [INJ]bicalutamideBICILLIN C-R [INJ]BICILLIN L-A [INJ]BIKTARVY [SP]bimatoprost eye solutionbiolon [INJ]BIOTHRAX [INJ]

7 Bisoprololbisoprolol/hydrochlorothiazide bivalirudin [INJ]blanchebleomycin [INJ]BLINCYTO [INJ] [SP]blisovi 24 feblisovi feBOOSTRIX [INJ]bosentan [SP]BOSULIF [SP]BOTOX [INJ] [SP]BREO ELLIPTA bretylium tosylate [INJ]BREVITAL [INJ]BREZTRI AEROSPHERE briellynBRILINTA brimonidine eye solutionBRINEURA [INJ] [SP]bromfenac eye solutionbromocriptinebrompheniramine/pse udoephedrine/codeinebrompheniramine/pseu doephedrine/dextromethorphanbudesonide ext-releasebudesonide nebulization suspensionbumetanidebumetanide [INJ]bupivacaine [INJ]bupivacaine/dextrose [INJ]bupivacaine/epinephrine [INJ]buprenorphinebuprenorphine [INJ]buprenorphine patchesbuprenorphine/naloxonebupropionbu propion ext-releasebupropion ext-release (smoking deterrent)

8 Buspironebusulfan [INJ]butalbital/acetaminophenbutalbital/ acetaminophen/caffeinebutalbital/acetami nophen/caffeine/codeinebutalbital/aspiri n/caffeinebutalbital/aspirin/caffeine/co deinebutorphanol [INJ]butorphanol nasalBYDUREON [INJ]BYETTA [INJ]BYSTOLICC cabergolineCABLIVI [INJ] [SP]CABOMETYX [SP]caffeine citratedcaffeine citrated [INJ]caffeine/sodium benzoate [INJ]calcipotrienecalcipotriene/betameth asone dipropionatecalcitonin salmon nasalcalcitriolcalcitriol [INJ]calcitriol ointmentcalcium acetatecalcium chloride [INJ]CALCIUM DISODIUM VERSENATE [INJ]calcium gluconate [INJ]CALDOLOR VIALS [INJ]camilacamresecamrese locandesartancandesartan/hydrochlorothia zideCAPASTAT SULFATE [INJ]capecitabine [SP]CAPRELSA [SP]captoprilcaptopril/hydrochlorothiazi decarbachol [INJ]CARBAGLU [SP]carbamazepinecarbamazepine ext-releasecarbidopacarbidopa/levodopaca rbidopa/levodopa ext-releasecarbidopa/levodopa orally disintegrating tabletscarbidopa/levodopa/entacaponecarb inoxaminecarboplatin [INJ]carmustine [INJ]carteolol eye solutioncarvedilolcarvedilol phosphate ext-releasecaspofungin [INJ]CATHFLO ACTIVASE [INJ]CAVERJECT [INJ]CAYSTON [SP]caziantcefaclorcefaclor ext-releasecefadroxilcefazolin [INJ]cefdinircefditorencefepime [INJ]cefepime/dextrose [INJ]cefiximecefotaxime [INJ]cefotetan [INJ]cefoxitin [INJ]cefoxitin/dextrose [INJ]cefpodoximecefprozilceftazidime [INJ]

9 CEFTAZIDIME/DEXTROSE [INJ]ceftriaxone [INJ]ceftriaxone/dextrose [INJ]cefuroxime axetilcefuroxime sodium [INJ]celecoxibCELONTIN cephalexinCEPROTIN [INJ] [SP]CERDELGA [SP]CEREZYME [INJ] [SP]cetirizine syrupCETROTIDE [INJ] [SP]cevimelineCHANTIX charlotte 24 fechatealchateal eqCHEMETCHENODAL [SP]chloramphenicol [INJ]chlordiazepoxidechlordiazepoxide/cl idiniumchlorhexidine gluconatechloroprocaine hcl [INJ]chloroquinechlorothiazidechlorothia zide sodium [INJ]chlorpromazinechlorpromazine [INJ]chlorthalidonechlorzoxazoneCHOLBAM [SP]cholestyraminecholestyramine lightcholine salicylate/magnesium salicylatechromium chloride [INJ]ciclopiroxciclopirox shampoocidofovir [INJ]cilostazolCIMDUO [SP]cimetidinecinacalcetCINRYZE [INJ] [SP]CINVANTI [INJ]ciprofloxacinciprofloxacin ear solutionciprofloxacin eye solutionciprofloxacin lactate/dextrose [INJ]ciprofloxacin/dexamethasone ear suspensioncisplatin [INJ]citalopramcladribine [INJ]clarithromycinclarithromycin ext-releaseclemastineCLENPIQ clindamycin hclclindamycin palmitateclindamycin phosphate [INJ]clindamycin phosphate topicalclindamycin phosphate vaginalclindamycin phosphate/benzoyl peroxideclindamycin phosphate/dextrose [INJ]clindamycin phosphate/tretinoinCLINIMIX [INJ]CLINIMIX E [INJ]clobazamclobetasol propionateclobetasol propionate shampooclobetasol propionate/emollientclofarabine [INJ]

10 Clomiphene citrateclomipramineclonazepamclonazepam orally disintegrating tabletsclonidineclonidine [INJ]clonidine ext-releaseclonidine patchesclopidogrelclorazepateclotrimazol e topicalclotrimazole trochePage 3(continued) 2020 Express Scripts . All Rights trademarks are the property of their respective #1702 NP-ACOMP1702A-21 (11/01/20)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. T