January 2022 2022 EMPIRE PLAN FLEXIBLE FORMULARY …

1 January 2022. 2022 EMPIRE plan FLEXIBLE . FORMULARY PREFERRED. DRUG LIST. Administered by CVS Caremark . The EMPIRE plan FLEXIBLE FORMULARY Preferred Drug List is a guide within select therapeutic categories for enrollees and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name drug to treat a condition. These preferred brand-name drugs are listed to help identify products that are clinically appropriate and cost-effective. This is not an all-inclusive list. This FORMULARY includes a list of commonly prescribed covered drugs by therapeutic class, a Quick Reference Drug List with commonly prescribed covered drugs in alphabetic order, a listing of commonly prescribed non-preferred (Level 3) covered drugs and covered preferred drug alternatives, and a listing of excluded drugs along with covered alternatives.

2 This list represents brand-name drugs in CAPS and generic drugs in lowercase italics. Generally generics are subject to a Level 1 copayment, or the lowest copayment; preferred brand drugs are subject to a Level 2. copayment, and non-preferred brand drugs are subject to a Level 3 copayment, or the highest copayment. Refer to your plan materials for specific information regarding copayment amounts. ENROLLEE HEALTH CARE PROVIDER. Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider by CVS Caremark.

3 As a way to help manage health care costs, prescribing, when medically appropriate, a preferred generic or a authorize generic substitution whenever possible. If you believe a preferred brand-name drug from this list. Take this list along when brand-name drug is necessary, consider prescribing a brand-name you or a covered family member sees a doctor. drug on this list. Please note: Please note: You will be responsible for the full cost of non- FORMULARY products Generics should be considered the first line of prescribing. that are excluded from coverage unless a request for a This drug list represents a summary of prescription coverage.

4 Medical exception is approved. New prescription drug products It is not all-inclusive and does not guarantee coverage. may be subject to exclusion upon release to the market. The enrollee's prescription benefit plan may have a different For specific information regarding your prescription benefit copay for specific products on the list. coverage and copay information, please visit Unless specifically indicated, drug list products will include all or dosage forms. call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 Log in to to check for the EMPIRE plan Prescription Drug Program. coverage and copay information for a specific medicine.

5 Any brand-name drug for which a generic drug becomes available will be designated as a non-preferred drug. When a generic version is available, mandatory generic substitution will apply. In this case, use of a non-preferred product will result in the member paying the applicable non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug (Ancillary Charge). ANALGESICS NSAIDs NSAIDs, COMBINATIONS fentanyl citrate (generic hydromorphone QL/PA. diclofenac sodium diclofenac sodium- FENTORA) PA/QL hydromorphone ext-rel COX-2 INHIBITORS fentanyl transdermal QL/PA QL/PA.

6 Diflunisal misoprostol celecoxib (generic etodolac fentanyl transmucosal methadone QL/PA. CELEBREX) ibuprofen NSAIDs, TOPICAL lozenge PA/QL morphine QL/PA. meloxicam tablet diclofenac sodium gel 1% hydrocodone ext-rel (generic morphine ext-rel QL/PA. GOUT HYSINGLA ER) QL/PA morphine suppository QL/PA. nabumetone (generic VOLTAREN GEL). allopurinol naproxen (except naproxen CR or hydrocodone ext-rel (generic oxycodone QL/PA. colchicine tablet (generic OPIOID ANALGESICS ZOHYDRO ER) QL/PA oxycodone ext-rel QL/PA. naproxen suspension). COLCRYS) naproxen sodium buprenorphine transdermal hydrocodone-acetaminophen oxycodone-acetaminophen febuxostat (generic ULORIC) oxaprozin (generic BUTRANS) (except hydrocodone-acetaminophen QL/PA.)

7 Probenecid sulindac QL/PA tablet mg or hydrocodone- tramadol QL/PA. COLCRYS codeine-acetaminophen QL acetaminophen tablet 10-300 mg) tramadol ext-rel QL/PA. QL/PA BELBUCA QL/PA. Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the EMPIRE plan Prescription Drug Program. 1. NUCYNTA QL/PA ANTIMALARIALS HERPES AGENTS VERZENIO SGM ANGIOTENSIN II. NUCYNTA ER QL/PA atovaquone-proguanil acyclovir VITRAKVI SGM RECEPTOR ANTAGONISTS /. SUBSYS PA/QL chloroquine famciclovir DIURETIC COMBINATIONS.

8 XTAMPZA ER QL/PA MONOCLONAL ANTIBODIES. mefloquine valacyclovir candesartan pyrimethamine (generic RITUXAN SGM candesartan- NON-OPIOID ANALGESICS INFLUENZA AGENTS. DARAPRIM) MULTIPLE MYELOMA hydrochlorothiazide butalbital-acetaminophen- COARTEM oseltamivir (generic irbesartan caffeine TAMIFLU) QL/PA IMMUNOMODULATORS. irbesartan- butalbital-aspirin-caffeine ANTIRETROVIRAL AGENTS RELENZA QL/PA REVLIMID SGM hydrochlorothiazide Generally, single-source brand losartan VISCOSUPPLEMENTS drugs (products for which a MISCELLANEOUS PROTEASOME INHIBITORS. generic is not available) and losartan-hydrochlorothiazide DUROLANE albendazole (generic NINLARO SGM.)

9 Generic drugs indicated for the olmesartan (generic GELSYN-3 treatment of HIV and its ALBENZA) QL/PA VELCADE SGM BENICAR). HYALGAN opportunistic infections are atovaquone PROSTATE CANCER olmesartan- SUPARTZ FX FORMULARY . clindamycin hydrochlorothiazide ANTIRETROVIRAL dapsone LUTEINIZING HORMONE- ANTI-INFECTIVES (generic BENICAR HCT). COMBINATIONS ivermectin (generic RELEASING HORMONE. telmisartan efavirenz-lamivudine- STROMECTOL) (LHRH) AGONISTS. ANTIBACTERIALS telmisartan- tenofovir disoproxil metronidazole ELIGARD SGM hydrochlorothiazide CEPHALOSPORINS. fumarate (generic SYMFI, nitazoxanide (generic lupron depot SGM valsartan cefadroxil SYMFI LO) ALINIA).

10 Cefdinir MISCELLANEOUS valsartan-hydrochlorothiazide emtricitabine-tenofovir nitrofurantoin cefixime (generic SUPRAX) disoproxil fumarate nitrofurantoin ext-rel AVASTIN SGM ANGIOTENSIN II. cefprozil (generic TRUVADA) pentamidine (generic ERIVEDGE SGM RECEPTOR ANTAGONIST /. cefuroxime axetil BIKTARVY NEBUPENT) LYNPARZA SGM CALCIUM CHANNEL. cephalexin CIMDUO praziquantel (generic RUBRACA SGM BLOCKER COMBINATIONS. SUPRAX SUSPENSION 500 DESCOVY BILTRICIDE) QL/PA ZEJULA SGM amlodipine-olmesartan MG/5 ML, TABLET DOVATO sulfamethoxazole- (generic AZOR). EVOTAZ trimethoprim CARDIOVASCULAR. ERYTHROMYCINS /. GENVOYA tinidazole ACE INHIBITORS ANGIOTENSIN II.