Your 2021 Select Standard Formulary

1 Your 2021 Select Standard FormularyEffective January 1, 2021 For the most current list of covered medications or if you have questions:Call the number on your member ID your plan s website on your member ID card to: Find a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and your formularyWhat is a Formulary ?A Formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription create the list, OptumRx is guided by the Pharmacy and Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

2 About this Formulary Where differences between this Formulary and your benefit plan exist, the benefit plan documents rule. This may not be a complete list of medications that are covered by your plan. Please review your benefit plan for full do I use my Formulary ?You and your doctor can use the Formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan s member website or call the number on your member ID are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. This is how much you will pay when you fill a does the Formulary change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a generic equal becomes available.

3 Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each a medication changes tiers, you may have to pay a different amount for that are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) if I don t agree with a decision about an excluded medication?You or your authorized representative and your doctor can ask for a coverage request by calling the number on your member ID tipsWhat is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. What if my doctor writes a brand-name prescription?

4 If your doctor gives you a prescription for a brand-name medication, ask if a generic or lower-cost option could be right for you. Generic medications are usually your lowest-cost medicationsAn over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription if I am taking a specialty medication?Specialty medications are used to treat complex conditions. These high-cost medications may be injected, infused or taken by mouth. Please note, not all specialty medications are listed in the Formulary . Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Reading your formularyThe Formulary gives you choices so you and your doctor can decide your best course of treatment. In this Formulary , brand-name medications are shown in UPPERCASE (for example, CLOBEX).

5 Generic medications are shown in lowercase (for example, clobetasol).Tier informationUsing lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your Tier IncludesHelpful TipsTier 1 $ Lower-cost generics and some brand-nameUse Tier 1 drugs for the lowest out-of-pocket 2 $$ Mid-range cost preferred brand-nameUse Tier 2 drugs instead of Tier 3 to help reduce your out-of-pocket 3 $$$ Highest-cost non-preferredMany Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

6 SP Specialty Medication Medication is designated as specialty. 3P Tier 3 preferred4 Table of ContentsAnalgesics - Drugs for - Drugs for Pain and / Substance Abuse Treatment - Drugs for Agents - Drugs for Alzheimer's Disease and - Drugs for Nausea and - Drugs for - Drugs for Mood - Drugs for Agents - Drugs for Mood Products / Modifiers / Volume Expanders - Drugs for Bleeding Agents - Drugs for Heart and Circulation Nervous System Agents - Drugs for Attention Deficit Nervous System Agents - Drugs for Multiple Nervous System Agents - and Oral Agents - Drugs for Mouth and Throat Agents - Drugs for Skin - Antidiabetic - Glucose - Glycemic - / Minerals / Metals / Agents - Drugs for Acid Reflux and Agents - Drugs for Bowel, Intestine and Stomach or Enzyme Disorder - Drugs for Replacement, Modification, Agents - Drugs for Bladder, Genital and Kidney Agents - Drugs for Prostate Agents - Agents - Men's Agents - Agents - Agents - Sex Hormones and Birth Agents - Agents - Drugs for Immune System Stimulation or Bowel Disease Bone Disease Agents - Drugs for Bone Disease Agents - Therapeutic Agents - Drugs for Eye Allergy, Infection and Agents - Drugs for Agents - Drugs for Miscellaneous Eye Agents - Drugs for Ear Tract / Pulmonary Agents - Drugs for Allergies, Cough, Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Tract / Pulmonary Agents - Drugs for Cystic Tract / Pulmonary Agents - Drugs for Pulmonary Muscle Relaxants - Drugs for Muscle Pain and Disorder NameDrug TierNotesAnalgesics - Drugs for Painacetaminophen-codeine #21acetaminophen-codeine #31acetaminophen-codeine #41acetaminophen-codeine oral tablet 300-15 mg.

7 300-60 mg1apap-caff-dihydrocodeine oral capsule1 BELBUCA2butalbital-apap-caffeine1fentany l1hydrocodone-acetaminophen oral tablet1hydromorphone hcl oral tablet1 HYSINGLA ER2morphine sulfate er oral tablet extended release1 NUCYNTA3oxycodone hcl oral tablet1oxycodone-acetaminophen1 OXYCONTIN2tramadol hcl oral tablet 50 mg1 TREZIX3 XTAMPZA ER2 Analgesics - Drugs for Pain and Inflammationcelecoxib oral1 drug NameDrug TierNotesdiclofenac sodium oral1diclofenac sodium transdermal gel 1 %1etodolac oral tablet1ibuprofen oral tablet1 INDOMETHACIN ORAL CAPSULE 20 MG3indomethacin oral capsule 25 mg, 50 mg1ketorolac tromethamine oral1meloxicam oral1nabumetone oral1 NAPRELAN3naproxen oral tablet1 Anestheticslidocaine external patch1lidocaine-prilocaine external cream1 Anti-Addiction / Substance Abuse Treatment AgentsBUNAVAIL3buprenorphine hcl sublingual1buprenorphine hcl-naloxone hcl1 CHANTIX3 CHANTIX CONTINUING MONTH PAK3 CHANTIX STARTING MONTH PAK3naltrexone hcl oral1 NARCAN2 ZUBSOLV2 For more information regarding the tiers and designations in this drug list.

8 Please see the Reading your Formulary section of this NameDrug TierNotesAntibacterialsamoxicillin oral capsule1amoxicillin oral suspension reconstituted1amoxicillin oral tablet1amoxicillin-potassium clavulanate oral suspension reconstituted1amoxicillin-potassium clavulanate oral tablet1azithromycin oral suspension reconstituted1azithromycin oral tablet1cefdinir1cefuroxime axetil1cephalexin oral capsule1cephalexin oral suspension reconstituted1ciprofloxacin hcl oral tablet 250 mg, 500 mg1clarithromycin oral tablet1clindamycin hcl oral1 CLINDESSE3 DIFICID3doxycycline hyclate oral capsule1doxycycline hyclate oral tablet1doxycycline monohydrate oral capsule1doxycycline monohydrate oral tablet1levofloxacin oral tablet1 drug NameDrug TierNotesmetronidazole oral tablet1metronidazole vaginal1minocycline hcl oral capsule1mupirocin external1nitrofurantoin macrocrystal oral1nitrofurantoin monohydrate macrocrystals1 NUZYRA ORAL3penicillin v potassium oral tablet1 SEYSARA3 SOLOSEC3sulfamethoxazole-trimethoprim oral tablet1 XENLETA3 XEPI3 XIMINO3 AnticoagulantsELIQUIS2 ELIQUIS DVT/PE STARTER PACK2enoxaparin sodium1 SPPRADAXA2warfarin sodium oral1 XARELTO2 XARELTO STARTER PACK2 Anticonvulsants - Drugs for SeizuresBRIVIACT3carbamazepine oral tablet1divalproex sodium er1 For more information regarding the tiers and designations in this drug list.

9 Please see the Reading your Formulary section of this NameDrug TierNotesdivalproex sodium oral tablet delayed release1 EPIDIOLEX3 SPFYCOMPA3gabapentin oral capsule1gabapentin oral tablet1lamotrigine er1lamotrigine oral tablet1levetiracetam oral tablet1 NAYZILAM3oxcarbazepine oral tablet1 SYMPAZAN3topiramate oral tablet1 TROKENDI XR3 VALTOCO 10 MG DOSE3 VALTOCO 15 MG DOSE3 VALTOCO 20 MG DOSE3 VALTOCO 5 MG DOSE3 VIMPAT3 XCOPRI3 XCOPRI (250 MG DAILY DOSE)3 XCOPRI (350 MG DAILY DOSE)3zonisamide oral1 Antidementia Agents - Drugs for Alzheimer's Disease and Dementiadonepezil hcl oral tablet 10 mg, 23 mg1 drug NameDrug TierNotesmemantine hcl oral tablet 10 mg, 5 mg1 NAMZARIC2 Antidepressantsamitriptyline hcl oral1bupropion hcl er (sr)1bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg1 BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG3bupropion hcl oral1citalopram hydrobromide oral tablet1desvenlafaxine succinate er1doxepin hcl oral capsule1duloxetine hcl oral1escitalopram oxalate oral tablet1fluoxetine hcl oral capsule1fluoxetine hcl oral tablet1fluvoxamine maleate1 FORFIVO XL3mirtazapine oral tablet1nortriptyline hcl oral capsule1paroxetine hcl1sertraline hcl oral tablet1trazodone hcl oral1 TRINTELLIX3venlafaxine hcl1 For more information regarding the tiers and designations in this drug list, please see the Reading your Formulary section of this NameDrug TierNotesvenlafaxine hcl er1 VIIBRYD3 VIIBRYD STARTER PACK3 Antiemetics - Drugs for Nausea and Vomitingmeclizine hcl oral tablet1metoclopramide hcl oral tablet 10 mg1ondansetron hcl oral tablet 4 mg, 8 mg1ondansetron odt1prochlorperazine maleate oral1scopolamine1 VARUBI (180 MG DOSE)

10 3 Antifungalsciclopirox external solution1clotrimazole external cream1clotrimazole-betamethasone external cream1 CRESEMBA ORAL3fluconazole oral tablet1 GYNAZOLE-13 KERYDIN3ketoconazole external cream1ketoconazole external shampoo1nystatin external cream1nystatin mouth/throat1terbinafine hcl oral1 drug NameDrug TierNotesterconazole vaginal cream1 Antigout Agentsallopurinol oral1colchicine oral tablet1febuxostat1 Antimigraine AgentsAIMOVIG2eletriptan hydrobromide1 EMGALITY2 EMGALITY (300 MG DOSE)2 NURTEC2rizatriptan benzoate1sumatriptan succinate oral1 UBRELVY2 Antineoplastics - Drugs for Canceranastrozole oral1 CABOMETYX2 SPcapecitabine1 SPIBRANCE ORAL CAPSULE3 SPIDHIFA3 SPimatinib mesylate1 SPIMBRUVICA ORAL TABLET3 SPKANJINTI2 SPletrozole oral1 LYNPARZA2 SPMVASI2 SPNUBEQA3 SPREVLIMID2 SPRUBRACA2 SPRUXIENCE2 SPFor more information regarding the tiers and designations in this drug list, please see the Reading your Formulary section of this NameDrug TierNotesSPRYCEL2 SPtamoxifen citrate oral1 TARGRETIN EXTERNAL3 SPtemozolomide1 SPTRAZIMERA2 SPXTANDI3 SPZEJULA2 SPZIRABEV2 SPAntiparasiticsARAKODA3 EMVERM2hydroxychloroquine sulfate oral1 Antiparkinson Agentsbenztropine mesylate oral1carbidopa-levodopa oral tablet1 INBRIJA3 SPNOURIANZ3pramipexole dihydrochloride1ropinirole hcl1 RYTARY3 AntiplateletsBRILINTA2clopidogrel bisulfate oral1prasugrel hcl1 Antipsychotics - Drugs for Mood Disordersaripiprazole oral tablet1 ARISTADA3 ARISTADA INITIO3 INVEGA SUSTENNA3 drug NameDrug TierNotesINVEGA TRINZA3 LATUDA3olanzapine oral tablet1 PERSERIS3quetiapine fumarate1quetiapine fumarate er1 REXULTI3risperidone oral tablet1 SAPHRIS2 VRAYLAR3ziprasidone hcl1 Antiviralsacyclovir oral capsule1acyclovir oral tablet1 BIKTARVY3 CIMDUO2 DESCOVY3 DOVATO2entecavir1 SPEPCLUSA2 SPGENVOYA3 HARVONI2 SPJULUCA2 MAVYRET2