October 2023

Medications Requiring Prior Authorization for

Medical Necessity for Standard Option, High Option
and High Deductible Health Plan (HDHP) Members -
Chart
Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. If you continue
using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost.

If you are currently using one of the drugs requiring prior authorization for medical necessity, ask your doctor to choose one of the
generic or brand formulary options listed below.

Category Drugs Requiring Prior Formulary Options

Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Acromegaly SANDOSTATIN LAR SOMATULINE DEPOT
SIGNIFOR LAR
SOMAVERT

Allergies dexchlorpheniramine levocetirizine

Diphen Elixir
Antihistamines RyClora
CARBINOXAMINE TABLET 6 MG

Allergies BECONASE AQ azelastine-fluticasone, flunisolide, fluticasone, mometasone

Nasal Steroids / Combinations OMNARIS
QNASL
ZETONNA

Anti-infectives, Antibacterials E.E.S. GRANULES erythromycins

ERYPED
Erythromycins / Macrolides
Anti-infectives, Antibacterials doxycycline hyclate delayed-rel tablet doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline,
Tetracyclines doxycycline hyclate tablet 50 mg tetracycline
doxycycline hyclate tablet 75 mg
doxycycline hyclate tablet 150 mg
doxycycline monohydrate capsule 75 mg
doxycycline monohydrate capsule 150 mg
minocycline ext-rel
CoreMino
Mondoxyne NL capsule 75 mg
Targadox
DORYX
DORYX MPC

Anti-infectives, Antibacterials nitrofurantoin (NDC* 16571074024 only) nitrofurantoin (except NDC* 16571074024)
MACRODANTIN
Miscellaneous
Anti-infectives, Antifungals flucytosine capsule 500 mg fluconazole

posaconazole delayed-rel tablet fluconazole, itraconazole

NOXAFIL

CRESEMBA itraconazole

tavaborole terbinafine tablet

Anti-infectives, Antiretroviral Agents COMPLERA efavirenz-emtricitabine-tenofovir disoproxil fumarate,

STRIBILD efavirenz-lamivudine-tenofovir disoproxil fumarate, BIKTARVY, DOVATO,
Combination Agents GENVOYA, ODEFSEY, SYMTUZA
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
TRUVADA abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate,
lamivudine-zidovudine, CIMDUO, DESCOVY

Anti-infectives, Antiretroviral Agents APTIVUS Talk to your doctor

Protease Inhibitors LEXIVA atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA
VIRACEPT

Anti-infectives, Antivirals VALCYTE valganciclovir

Cytomegalovirus †
Anti-infectives, Antivirals BARACLUDE TABLET entecavir, lamivudine, tenofovir disoproxil fumarate,
EPIVIR HBV BARACLUDE SOLUTION, VEMLIDY
Hepatitis B †

Anti-infectives, Antivirals MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI
2
Hepatitis C †
VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
ZEPATIER

Anti-infectives, Antivirals acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir

VALTREX
Herpes †
Anti-infectives DARAPRIM pyrimethamine
Miscellaneous
Antiobesity CONTRAVE orlistat, QSYMIA, SAXENDA, WEGOVY
XENICAL

Antiseizure Agents topiramate ext-rel capsule carbamazepine, carbamazepine ext-rel, clobazam, clonazepam, divalproex sodium,
(generics for QUDEXY XR only) divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-
rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital,
phenytoin, phenytoin sodium extended, primidone, rufinamide, tiagabine,
topiramate,
valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR,
XCOPRI

BANZEL SUSPENSION clobazam, clonazepam, lamotrigine, rufinamide, topiramate, TROKENDI XR

ONFI

SABRIL vigabatrin

ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium,

divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-
rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital,
phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate,
valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR,
XCOPRI

Anxiety † ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam

XANAX
Benzodiazepines
XANAX XR

Asthma † albuterol sulfate CFC-free aerosol albuterol sulfate CFC-free aerosol (except NDC* 66993001968),
(NDC* 66993001968 only) levalbuterol tartrate CFC-free aerosol
Beta Agonists, Short-Acting PROAIR RESPICLICK
PROVENTIL HFA
VENTOLIN HFA
XOPENEX HFA

Asthma † zileuton ext-rel montelukast, zafirlukast

Leukotriene Modulators SINGULAIR

Asthma † ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA,

Steroid Inhalants ASMANEX PULMICORT FLEXHALER, QVAR REDIHALER
ASMANEX HFA
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Asthma † or Chronic Obstructive DULERA ADVAIR DISKUS, ADVAIR HFA**, BREO ELLIPTA**, SYMBICORT
Pulmonary Disease (COPD) †
Steroid / Beta Agonist Combinations
Attention Deficit Hyperactivity ADDERALL amphetamine-dextroamphetamine mixed salts, methylphenidate
EVEKEO
Disorder †
ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel,
ADZENYS XR-ODT dexmethylphenidate ext-rel, methylphenidate ext-rel, AZSTARYS, MYDAYIS,
APTENSIO XR VYVANSE
CONCERTA
DAYTRANA
FOCALIN XR

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine,

dexmethylphenidate ext-rel, guanfacine ext-rel, methylphenidate ext-rel,
AZSTARYS, MYDAYIS, VYVANSE

Autoimmune Agents ACTEMRA INTRAVENOUS REMICADE, SIMPONI ARIA

ORENCIA INTRAVENOUS
Physician-Administered Agents
AVSOLA REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS,
CIMZIA LYOPHILIZED POWDER STELARA INTRAVENOUS
INFLECTRA
RENFLEXIS

ENTYVIO (For Crohn's Disease Only) REMICADE, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS

ILUMYA REMICADE

Autoimmune Agents CIMZIA PREFILLED SYRINGE COSENTYX, ENBREL, HUMIRA, RINVOQ

SIMPONI
Self-Administered Agents TALTZ
Ankylosing Spondylitis † XELJANZ
XELJANZ XR

Autoimmune Agents CIMZIA PREFILLED SYRINGE HUMIRA, RINVOQ, SKYRIZI SUBCUTANEOUS, STELARA SUBCUTANEOUS
Self-Administered Agents
Crohn's Disease †
Autoimmune Agents CIMZIA PREFILLED SYRINGE HUMIRA, OTEZLA, SKYRIZI SUBCUTANEOUS, STELARA SUBCUTANEOUS,
Self-Administered Agents COSENTYX TALTZ, TREMFYA
ENBREL
Psoriasis †
Autoimmune Agents CIMZIA PREFILLED SYRINGE COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ,
ORENCIA CLICKJECT SKYRIZI SUBCUTANEOUS
Self-Administered Agents
ORENCIA SUBCUTANEOUS
Psoriatic Arthritis † SIMPONI
STELARA SUBCUTANEOUS
TALTZ
TREMFYA
XELJANZ
XELJANZ XR

Autoimmune Agents ACTEMRA ACTPEN ENBREL, HUMIRA, KEVZARA, ORENCIA CLICKJECT,

ACTEMRA SUBCUTANEOUS ORENCIA SUBCUTANEOUS, RINVOQ, XELJANZ, XELJANZ XR
Self-Administered Agents CIMZIA PREFILLED SYRINGE
Rheumatoid Arthritis † KINERET
SIMPONI

Autoimmune Agents SIMPONI HUMIRA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ,

XELJANZ XR
Self-Administered Agents
Ulcerative Colitis †
Autoimmune Agents ACTEMRA ACTPEN ENBREL, HUMIRA
ACTEMRA SUBCUTANEOUS
Self-Administered Agents KINERET
All Other Conditions †
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS

Cancer RIABNI RUXIENCE

TRUXIMA
Biosimilars

Cancer GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL

TASIGNA
Chronic Myelogenous
Leukemia †
Kinase Inhibitors
Cancer ALIQOPA Talk to your doctor
Follicular Lymphoma † ZYDELIG COPIKTRA
PI3K Inhibitors
Cancer AVASTIN ZIRABEV
Monoclonal Antibodies HERCEPTIN KANJINTI, TRAZIMERA
HERCEPTIN HYLECTA

RITUXAN RUXIENCE

Cancer BORTEZOMIB NINLARO, VELCADE

KYPROLIS
Multiple Myeloma †
Proteasome Inhibitors
Cancer NILANDRON abiraterone, bicalutamide, ERLEADA, XTANDI, YONSA
Prostate † ZYTIGA
Antiandrogens

Cancer LUPRON DEPOT ELIGARD, FIRMAGON

Prostate † TRELSTAR MIXJECT
ZOLADEX
Luteinizing Hormone-Releasing
Hormone (LHRH) Agonists

Cardiovascular BETAPACE sotalol

BETAPACE AF
Antiarrhythmics
NORPACE disopyramide

Cardiovascular ZETIA ezetimibe

Antilipemics
Cholesterol Absorption Inhibitors

Cardiovascular fenofibrate capsule 30 mg fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg;
fenofibrate capsule 50 mg fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel
Antilipemics fenofibrate capsule 90 mg
Fibrates fenofibrate capsule 130 mg
fenofibrate tablet 40 mg
fenofibrate tablet 120 mg
FENOGLIDE TABLET 120 MG
TRICOR

Cardiovascular ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin,

Antilipemics CRESTOR pravastatin, rosuvastatin, simvastatin
LESCOL XL
HMG-CoA Reductase Inhibitors LIPITOR
(HMGs or Statins) / Combinations 3 LIVALO

Cardiovascular niacin tablet 500 mg niacin ext-rel

Niacor
Antilipemics
Niacins
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Cardiovascular icosapent ethyl omega-3 acid ethyl esters, VASCEPA
Antilipemics
Omega-3 Fatty Acids
Cardiovascular PRALUENT REPATHA
Antilipemics
PCSK9 Inhibitors
Cardiovascular LANOXIN TABLET digoxin
(125 MCG and 250 MCG only)
Digitalis Glycosides
Cardiovascular DYRENIUM amiloride, triamterene
Diuretics
Cardiovascular isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate
Nitrates

Cardiovascular LETAIRIS ambrisentan, bosentan, OPSUMIT

TRACLEER
Pulmonary Arterial Hypertension
Endothelin Receptor Antagonists
Cardiovascular ADCIRCA sildenafil, tadalafil
REVATIO
Pulmonary Arterial Hypertension
Phosphodiesterase Inhibitors
Cardiovascular REMODULIN treprostinil
Pulmonary Arterial Hypertension
Prostaglandin Vasodilators
Carnitine Deficiency CARNITOR levocarnitine
CARNITOR SF

Central Precocious Puberty LUPRON DEPOT-PED SUPPRELIN LA, TRIPTODUR

Chronic Obstructive Pulmonary INCRUSE ELLIPTA SPIRIVA

Disease (COPD) † TUDORZA
Anticholinergics

Chronic Obstructive Pulmonary BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT

Disease (COPD) †
Anticholinergic / Beta Agonist
Combinations
Long Acting
Contraceptives BALCOLTRA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate,
BEYAZ ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate,
Oral MINASTRIN 24 FE ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,
NATAZIA LO LOESTRIN FE
SEASONIQUE
TAYTULLA
YASMIN
YAZ

Contraceptives LILETTA KYLEENA, MIRENA, SKYLA

Progestin Intrauterine Devices
Contraceptives NUVARING ethinyl estradiol-etonogestrel, ANNOVERA
Vaginal
Cystic Fibrosis † TOBI tobramycin inhalation solution
Inhaled Antibiotics TOBI PODHALER
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Dental PREVIDENT Talk to your doctor
Cavity/Caries Prevention
Depression † fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg,
paroxetine HCl ext-rel fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
Antidepressants, Selective Serotonin (NDC* 60505367503 only) paroxetine HCl ext-rel (except NDC* 60505367503), sertraline
Reuptake Inhibitors (SSRIs) LEXAPRO
PAXIL
PAXIL CR
PEXEVA
PROZAC
TRINTELLIX
VIIBRYD
ZOLOFT

Depression † venlafaxine ext-rel tablet (except 225 mg) desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
CYMBALTA
Antidepressants, Serotonin
EFFEXOR XR
Norepinephrine Reuptake Inhibitors PRISTIQ
(SNRIs)
Depression † bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)
APLENZIN
Antidepressants,
WELLBUTRIN XL
Miscellaneous Agents

Depression and/or Schizophrenia † ABILIFY aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel,
FANAPT risperidone, ziprasidone, VRAYLAR
Antipsychotics, Atypicals LATUDA
SEROQUEL XR

Dermatology adapalene pad adapalene (except adapalene pad), adapalene-benzoyl peroxide,

clindamycin gel (NDC* 68682046275 only) benzoyl peroxide, clindamycin gel (except NDC* 68682046275),
Acne †
Vanoxide-HC clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution,
ACANYA erythromycin-benzoyl peroxide, tretinoin, ONEXTON
AZELEX
DIFFERIN LOTION
FABIOR
TAZORAC
VELTIN
ZIANA

Dermatology fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, ZYCLARA
CARAC
Actinic Keratosis †
Dermatology NEO-SYNALAR desonide (except desonide gel) or hydrocortisone WITH gentamicin
Anti-infective / Anti-inflammatory

Dermatology mupirocin cream gentamicin, mupirocin ointment

Antibiotics
Dermatology calcipotriene cream calcipotriene ointment, calcipotriene solution
calcipotriene foam
Antipsoriatics calcitriol ointment
CALCIPOTRIENE FOAM
SORILUX
TAZORAC
VECTICAL

calcipotriene-betamethasone calcipotriene ointment or calcipotriene solution WITH

desoximetasone (except desoximetasone ointment 0.05%),
fluocinonide (except fluocinonide cream 0.1%) or BRYHALI

Dermatology doxepin cream desonide (except desonide gel), hydrocortisone, pimecrolimus, tacrolimus,
EUCRISA
Atopic Dermatitis †
ELIDEL pimecrolimus, tacrolimus, EUCRISA

doxycycline monohydrate delayed-rel capsule ORACEA

Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Dermatology FINACEA GEL azelaic acid gel, brimonidine gel, ivermectin cream, metronidazole,
Rosacea † MIRVASO FINACEA FOAM, SOOLANTRA
NORITATE

Dermatology CICATRACE Talk to your doctor

POLYTOZA
Scars RECEDO
SCARSILK PAD
SILIVEX
SILTREX

Dermatology ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
Ketodan
Seborrheic Dermatitis †
Dermatology desonide gel desonide (except desonide gel), hydrocortisone
DesRx
Skin Inflammation and Hives † flurandrenolide cream
Low Potency Corticosteroids flurandrenolide lotion
CORDRAN CREAM
CORDRAN LOTION

Dermatology clocortolone cream hydrocortisone butyrate cream, hydrocortisone butyrate ointment,

desoximetasone ointment 0.05% hydrocortisone butyrate solution, mometasone, triamcinolone cream,
Skin Inflammation and Hives †
flurandrenolide ointment triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%)
Medium Potency Corticosteroids hydrocortisone butyrate lipophilic cream 0.1%
hydrocortisone butyrate lotion
triamcinolone aerosol 0.2%
triamcinolone ointment 0.05%
Trianex
CORDRAN OINTMENT

Dermatology betamethasone dipropionate ointment 0.05% desoximetasone (except desoximetasone ointment 0.05%),
diflorasone cream fluocinonide (except fluocinonide cream 0.1%), BRYHALI
Skin Inflammation and Hives † diflorasone ointment
High Potency Corticosteroids halcinonide cream
APEXICON E
HALOG

Dermatology clobetasol emollient foam clobetasol cream, clobetasol foam (except clobetasol emollient foam),
Skin Inflammation and Hives † clobetasol spray clobetasol gel, clobetasol lotion, clobetasol ointment, halobetasol cream,
fluocinonide cream 0.1% halobetasol ointment
Very High Potency Corticosteroids Tovet
CLOBEX SPRAY
CORDRAN TAPE
OLUX-E
ULTRAVATE

Dermatology VEREGEN imiquimod

Warts
Dermatology ALEVICYN GEL desonide (except desonide gel), hydrocortisone
ALEVICYN SG
Wound Care Products ALEVICYN SOLUTION

Dermatology ATOPADERM desonide (except desonide gel), hydrocortisone

BENSAL HP
Miscellaneous Skin Conditions
EPICERAM
KAMDOY
SYNERDERM

luliconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, NAFTIN

oxiconazole
(NDCs* 00168035830, 51672135902 only)

Diabetes † metformin ext-rel (generics for FORTAMET metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)
and GLUMETZA only)
Biguanides FORTAMET
GLUMETZA
RIOMET
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Diabetes † NESINA JANUVIA
Dipeptidyl Peptidase-4 ONGLYZA
TRADJENTA
(DPP-4) Inhibitors
Diabetes † JENTADUETO JANUMET, JANUMET XR
JENTADUETO XR
Dipeptidyl Peptidase-4 KAZANO
(DPP-4) Inhibitor Combinations KOMBIGLYZE XR

OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone

Diabetes † BYDUREON BCISE OZEMPIC, RYBELSUS, TRULICITY, VICTOZA

Injectable Incretin Mimetics BYETTA

Diabetes † APIDRA FIASP, NOVOLOG

HUMALOG
Insulins
HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 4 NOVOLIN 70/30 4

HUMULIN N 4 NOVOLIN N 4

HUMULIN R 4 NOVOLIN R 4

NOTE: Humulin R U-500 concentrate will not

be subject to prior authorization and will
continue to be covered.

Diabetes † LANTUS BASAGLAR, LEVEMIR

Long Acting Insulins 5
Diabetes † TOUJEO TRESIBA
Long Acting Insulins 6

Diabetes † ACTOS pioglitazone

Insulin Sensitizers

Diabetes † INVOKANA FARXIGA, JARDIANCE

Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitors
Diabetes † INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR
INVOKAMET XR
Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitor /
Biguanide Combinations
Diabetes † QTERN GLYXAMBI
Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitor /
Dipeptidyl Peptidase-4 (DPP-4)
Inhibitor Combinations
Diabetes † NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES
OWEN MUMFORD NEEDLES
Supplies, Needles 7 PERRIGO NEEDLES
ULTIMED NEEDLES
All other insulin needles that are not
BD ULTRAFINE brand

Diabetes † ALLISON MEDICAL INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES

Supplies, Syringes 7 TRIVIDIA INSULIN SYRINGES
ULTIMED INSULIN SYRINGES
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
All other insulin syringes that are not
BD ULTRAFINE brand

Diabetes † BREEZE 2 STRIPS AND KITS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 8,
CONTOUR NEXT STRIPS AND KITS ACCU-CHEK GUIDE STRIPS AND KITS 8,
Supplies, Test Strips and Kits 8, 9 CONTOUR STRIPS AND KITS ACCU-CHEK SMARTVIEW STRIPS AND KITS 8,
FREESTYLE STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS 8,
All other test strips that are not ONETOUCH VERIO STRIPS AND KITS 8
ACCU-CHEK or ONETOUCH brand

ENLITE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

GLUCOSE MONITORING SYSTEM
EVERSENSE CONTINUOUS
GLUCOSE MONITORING SYSTEM
FREESTYLE LIBRE CONTINUOUS
GLUCOSE MONITORING SYSTEM
GUARDIAN CONNECT CONTINUOUS
GLUCOSE MONITORING SYSTEM
GUARDIAN REAL-TIME CONTINUOUS
GLUCOSE MONITORING SYSTEM
All other continuous glucose monitoring
systems that are not DEXCOM brand

Endocrine and Metabolic prednisolone solution 10 mg/5 mL dexamethasone, hydrocortisone, methylprednisolone,

prednisolone solution 20 mg/5 mL prednisolone solution (except prednisolone solution 10 mg/5 mL, 20 mg/5 mL),
Corticosteroids
Millipred prednisone
BETAMETHASONE ACETATE-
BETAMETHASONE SODIUM
PHOSPHATE
RAYOS

Endocrine and Metabolic PROMETRIUM medroxyprogesterone; progesterone, micronized

Progestins
Endometriosis † LUPRON DEPOT ORILISSA
ZOLADEX

Gastrointestinal chlordiazepoxide-clidinium dicyclomine

Anticholinergics (NDCs* 11534019701, 42494040901,
51293069601, 51293069610,
67877073101,
70700018501 only)
hyoscyamine sulfate ext-rel
GLYCOPYRROLATE TABLET 1.5 MG
LIBRAX

Gastrointestinal ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG

Antidiarrheals MYTESI diphenoxylate-atropine, loperamide

Gastrointestinal TRANSDERM SCOP meclizine, scopolamine transdermal

Antiemetics
Gastrointestinal AMITIZA lubiprostone, LINZESS, MOVANTIK, SYMPROIC
Irritable Bowel Syndrome † lubiprostone, LINZESS, MOTEGRITY
TRULANCE

Gastrointestinal LACTULOSE PAK lactulose solution

Laxatives peg 3350-electrolytes peg 3350-electrolytes (except generics for MOVIPREP),
(generics for MOVIPREP only) sodium sulfate-potassium sulfate-magnesium sulfate, CLENPIQ
GOLYTELY
MOVIPREP
OSMOPREP
SUPREP

Gastrointestinal PANCREAZE CREON, VIOKACE, ZENPEP

PERTZYE
Pancreatic Enzymes
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Gastrointestinal lansoprazole delayed-rel dexlansoprazole delayed-rel, esomeprazole delayed-rel,
Proton Pump Inhibitors (PPIs) orally disintegrating tablet lansoprazole delayed-rel capsule, omeprazole delayed-rel,
omeprazole-sodium bicarbonate pantoprazole delayed-rel tablet
ACIPHEX
ACIPHEX SPRINKLE
NEXIUM
PREVACID
PROTONIX
ZEGERID

Gastrointestinal sucralfate suspension sucralfate tablet

CARAFATE
Ulcer Treatment
Gaucher Disease ELELYSO CERDELGA, CEREZYME

Genitourinary ELMIRON Talk to your doctor

RIMSO-50
Interstitial Cystitis
Genitourinary LITHOSTAT Talk to your doctor
Miscellaneous THIOLA tiopronin
THIOLA EC

Gout † colchicine capsule colchicine tablet, MITIGARE

COLCRYS

ULORIC allopurinol

Growth Hormones HUMATROPE GENOTROPIN, NORDITROPIN

NUTROPIN AQ
OMNITROPE
SAIZEN

Hematologic HEPARIN SODIUM IN 5% DEXTROSE enoxaparin, fondaparinux

Anticoagulants
Injectable
Hematologic PRADAXA warfarin, ELIQUIS, XARELTO
Anticoagulants
Oral

Hematologic CUPRIMINE penicillamine

Chelating Agents DESFERAL deferasirox, deferiprone, deferoxamine
EXJADE
FERRIPROX
JADENU

SYPRINE trientine

Hematologic EPOGEN ARANESP, RETACRIT

PROCRIT
Erythropoiesis-Stimulating Agents
Hematologic ALPROLIX REBINYN
Hemophilia B
Hematologic FULPHILA ZIEXTENZO
NEULASTA
Neutropenia Colony Stimulating
NEULASTA ONPRO
Factors UDENYCA

GRANIX NIVESTYM
NEUPOGEN
ZARXIO

PLAVIX clopidogrel, prasugrel, BRILINTA

Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Hematologic ZONTIVITY Talk to your doctor
Platelet Aggregation Inhibitors
Hematologic PROMACTA DOPTELET, TAVALISSE
Thrombocytopenia Agents
High Blood Pressure † ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide,
quinapril-hydrochlorothiazide
ACE Inhibitor / Diuretic
Combinations
High Blood Pressure † ATACAND candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan
Angiotensin II Receptor Antagonists BENICAR
COZAAR
DIOVAN
EDARBI
MICARDIS

High Blood Pressure † ATACAND HCT candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide,

BENICAR HCT losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide,
Angiotensin II Receptor Antagonist / DIOVAN HCT telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide
Diuretic Combinations EDARBYCLOR
HYZAAR
MICARDIS HCT

High Blood Pressure † AZOR amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan

Angiotensin II Receptor Antagonist / EXFORGE
Calcium Channel Blocker
Combinations
High Blood Pressure † EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide,
Angiotensin II Receptor Antagonist / olmesartan-amlodipine-hydrochlorothiazide
Calcium Channel Blocker / Diuretic
Combinations

High Blood Pressure † COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel,
Beta-blockers INDERAL LA metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, propranolol ext-rel
INDERAL XL
INNOPRAN XL
TOPROL-XL

High Blood Pressure † NORVASC amlodipine

Calcium Channel Blockers diltiazem ext-rel diltiazem ext-rel (except generics for CARDIZEM LA)
(generics for CARDIZEM LA only)
Matzim LA
CARDIZEM
CARDIZEM CD
CARDIZEM LA

Huntington's Disease XENAZINE tetrabenazine, AUSTEDO, AUSTEDO XR

Immunology OTREXUP methotrexate

RASUVO
Disease Modifying Antirheumatic
Agents
Immunology BERINERT icatibant, RUCONEST
Hereditary Angioedema TAKHZYRO Talk to your doctor

Immunology CUVITRU CUTAQUIG

GAMMAGARD
Immune Globulins HYQVIA
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Inflammatory Bowel Disease (IBD) ASACOL HD balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine,
Ulcerative Colitis † COLAZAL sulfasalazine delayed-rel, PENTASA
DELZICOL
LIALDA

Interferons † PEGASYS Talk to your doctor

Kidney Disease † lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO
FOSRENOL
Phosphate Binders
Menopausal Symptom Agents paroxetine mesylate capsule 7.5 mg paroxetine HCl
Oral MENEST estradiol
OSPHENA
PREMARIN

Menopausal Symptom Agents MINIVELLE estradiol, DIVIGEL, EVAMIST

VIVELLE-DOT
Transdermal
Menopausal Symptom Agents estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM
Yuvafem
Vaginal ESTRING
FEMRING
INTRAROSA
PREMARIN CREAM

Multiple Sclerosis AUBAGIO dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide,

AVONEX BETASERON, COPAXONE, KESIMPTA, MAYZENT, OCREVUS, REBIF,
EXTAVIA TYSABRI, VUMERITY, ZEPOSIA
GILENYA
PLEGRIDY
TECFIDERA

Musculoskeletal carisoprodol 250 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)

chlorzoxazone 250 mg
chlorzoxazone 375 mg
chlorzoxazone 500 mg
(NDC* 73007001303 only)
chlorzoxazone 750 mg
cyclobenzaprine ext-rel capsule
cyclobenzaprine tablet 7.5 mg
metaxalone 400 mg
methocarbamol 500 mg
(NDC* 69036091010 only)
methocarbamol 750 mg
(NDCs* 69036093090, 70868090190 only)
orphenadrine-aspirin-caffeine
Fexmid
Lorzone
Orphengesic Forte
AMRIX
NORGESIC FORTE

Narcolepsy NUVIGIL armodafinil, modafinil, SUNOSI

PROVIGIL

XYREM SODIUM OXYBATE

Nephropathic Cystinosis PROCYSBI CYSTAGON

Ophthalmic ALREX azelastine, bepotastine, cromolyn sodium, olopatadine

BEPREVE
Allergies LASTACAFT
ZERVIATE

Ophthalmic AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin,

CILOXAN sulfacetamide, tobramycin, BESIVANCE
Anti-infectives
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
Ophthalmic TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone,
Anti-infective / Anti-inflammatory ZYLET neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone,
TOBRADEX OINTMENT

Ophthalmic ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA

BROMSITE
Anti-inflammatory, Nonsteroidal NEVANAC

Ophthalmic FLAREX dexamethasone, difluprednate, loteprednol, prednisolone acetate 1%

FML FORTE
Anti-inflammatory, Steroidal FML LIQUIFILM
INVELTYS
LOTEMAX
LOTEMAX SM
MAXIDEX
PRED FORTE
PRED MILD

Ophthalmic ZIRGAN trifluridine

Antivirals

Ophthalmic LACRISERT RESTASIS SINGLE DOSE, RESTASIS MULTIDOSE, XIIDRA

Artificial Tears
Ophthalmic TRAVATAN Z bimatoprost, latanoprost, tafluprost, travoprost, LUMIGAN, ZIOPTAN
Glaucoma BETIMOL timolol maleate solution, BETOPTIC S
TIMOPTIC OCUDOSE

Ophthalmic AVENOVA Talk to your doctor

Miscellaneous
Opioid Dependency SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV

Osteoarthritis † GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

HYALGAN
Viscosupplements
MONOVISC
ORTHOVISC
SYNVISC
SYNVISC-ONE
VISCO-3

Osteoporosis † MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA,

TYMLOS
Calcium Regulators
Otic ciprofloxacin-fluocinolone ciprofloxacin-dexamethasone, ofloxacin otic
Anti-infective / Anti-inflammatory CIPRO HC
CIPRODEX

Overactive Bladder / Incontinence † DETROL LA darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin,
Urinary Antispasmodics OXYTROL tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ
TOVIAZ

Pain butalbital-acetaminophen capsule diclofenac sodium, ibuprofen,

butalbital-acetaminophen tablet 25-325 mg naproxen (except naproxen CR or naproxen suspension)
Headache † butalbital-acetaminophen tablet 50-300 mg
butalbital-acetaminophen-caffeine capsule
diclofenac potassium powder
Bupap
BUTALBITAL-ACETAMINOPHEN
(NDC* 69499034230 only)
CAMBIA
FIORICET CAPSULE

dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT,

ergotamine-caffeine ONZETRA XSAIL, UBRELVY, ZEMBRACE SYMTOUCH
Migergot
CAFERGOT
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
MAXALT
MAXALT-MLT

sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR or

TREXIMET naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan,
zolmitriptan, NURTEC ODT, ONZETRA XSAIL, UBRELVY or
ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY

Pain AIMOVIG AJOVY, EMGALITY, QULIPTA

Migraine
CGRP Inhibitors
Pain LYRICA duloxetine, pregabalin, pregabalin ext-rel
Neuropathic Pain †
Pain BUTRANS buprenorphine transdermal, BELBUCA
Opioid Analgesics SUBSYS fentanyl transmucosal lozenge

levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone,

oxymorphone ext-rel morphine ext-rel, NUCYNTA ER, XTAMPZA ER
HYSINGLA ER
OXYCONTIN

PERCOCET hydrocodone-acetaminophen, oxycodone-acetaminophen

tramadol (NDC* 52817019610 only) tramadol (except NDC* 52817019610), tramadol ext-rel tablet
tramadol ext-rel capsule

Pain and Inflammation † ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam tablet
or naproxen (except naproxen CR or naproxen suspension) WITH
Nonsteroidal Anti-inflammatory dexlansoprazole delayed-rel, esomeprazole delayed-rel, lansoprazole
Drugs (NSAIDs) / Combinations delayed-rel capsule, omeprazole delayed-rel, or pantoprazole delayed-rel tablet

CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam tablet,

naproxen (except naproxen CR or naproxen suspension)

diclofenac sodium solution 2% diclofenac sodium, diclofenac sodium solution 1.5%, ibuprofen, meloxicam tablet,
Capsinac naproxen (except naproxen CR or naproxen suspension)
Diclofex DC
Diclosaicin
Iclofenac CP
Inflammacin
Kapzin DC
NuDiclo SoluPak
NuDiclo TabPak
Pennsaicin
Sure Result DSS Premium Pack
Ziclocin Pak
Ziclopro

diclofenac potassium capsule 25 mg diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR
diclofenac potassium tablet 25 mg or naproxen suspension)
fenoprofen
indomethacin capsule 20 mg
ketoprofen capsule 25 mg
ketoprofen ext-rel capsule
mefenamic acid (NDC* 69336012830 only)
meloxicam capsule
naproxen CR
naproxen suspension
Lofena
FENOPROFEN CAPSULE
INDOCIN
NAPRELAN
SPRIX
ZORVOLEX
Category Drugs Requiring Prior Formulary Options
Drug Class Authorization for (May Require Prior Authorization)
Medical Necessity 1
naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam tablet or naproxen (except naproxen
CR or naproxen suspension) WITH dexlansoprazole delayed-rel, esomeprazole
delayed-rel, lansoprazole delayed-rel capsule, omeprazole delayed-rel, or
pantoprazole delayed-rel tablet

Parkinson's Disease APOKYN INBRIJA, KYNMOBI

NOURIANZ entacapone, pramipexole, pramipexole ext-rel, rasagiline, ropinirole,

ropinirole ext-rel, selegiline, NEUPRO

RYTARY carbidopa-levodopa, carbidopa-levodopa ext-rel

Phenylketonuria KUVAN sapropterin

Postherpetic Neuralgia HORIZANT gabapentin, pregabalin, pregabalin ext-rel, GRALISE

Premenstrual Dysphoric Disorder fluoxetine tablet (generics for SARAFEM fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for
only) SARAFEM]), paroxetine HCl ext-rel (except NDC* 60505367503), sertraline
(PMDD)

Prenatal Vitamins 10 AZESCO generic prenatal vitamins, CITRANATAL

PRENATAL PLUS
VITAFOL-ONE
ZALVIT
All other brand prenatal vitamins that are not
CITRANATAL

Prostate Condition JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel,

Benign Prostatic Hyperplasia † doxazosin, silodosin, tamsulosin or terazosin

RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

UROXATRAL

Respiratory ARALAST NP PROLASTIN-C

Alpha-1 Antitrypsin Deficiency GLASSIA
ZEMAIRA

Respiratory benzonatate (NDCs* 69336012615, benzonatate (except NDCs* 69336012615, 69499032915)

69499032915 only)
Cough
Respiratory THEO-24 formoterol inhalation solution, ipratropium inhalation solution, PERFOROMIST,
Xanthines SEREVENT, SPIRIVA, STRIVERDI RESPIMAT, YUPELRI

Sleep Disorder quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA
Hypnotics, Non-benzodiazepines zolpidem sublingual
LUNESTA
ROZEREM
SILENOR
ZOLPIMIST

Testosterone Replacement † testosterone gel 1% (authorized generics for testosterone gel (except authorized generics for TESTIM and VOGELXO),
TESTIM and VOGELXO only) testosterone solution, ANDRODERM, NATESTO
Androgens ANDROGEL
FORTESTA
TESTIM
VOGELXO

Thyroid Supplements CYTOMEL levothyroxine, liothyronine, SYNTHROID

TIROSINT levothyroxine, SYNTHROID

Urea Cycle Disorders BUPHENYL sodium phenylbutyrate

RAVICTI

Uterine Fibroids † LUPRON DEPOT ORIAHNN

 Category Other Considerations
Drug Class
All Drugs On a quarterly basis, new and existing products - including limited source generics, products with significant cost inflation, and
specialty and non-specialty products - may be re-evaluated to determine appropriate formulary placement. These evaluations will
assess whether clinically appropriate and cost-effective options remain available on the formulary and may result in additional
products not covered without a medical exception, addition or deletion of a product.

Atopic Dermatitis † As new atopic dermatitis products launch, all existing products in the class will be re-evaluated to determine appropriate formulary
placement. These evaluations will assess whether clinically appropriate and cost-effective options are available on the formulary
and may result in additional products not covered without a medical exception, addition or deletion of a product on the first day of
any calendar month.

Autoimmune and Hepatitis C † For some clients, an Indication-Based Formulary will be utilized for products in these classes and may result in additional
products not covered for certain conditions without a medical exception.

Drugs for Infusion Into Spaces Other A drug that must be infused into a space other than the blood will generally not be covered under the prescription drug benefit.
Than the Blood
New-to-Market Agents 1 New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately.
Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will
be presented to the CVS Caremark® National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for
review and approval.

The listed formulary options are subject to change.

List of Drugs Requiring Prior Authorization for Medical Necessity

ABILIFY ATOPADERM calcipotriene cream
ACANYA AUBAGIO calcipotriene foam
ACIPHEX AVASTIN CALCIPOTRIENE FOAM
ACIPHEX SPRINKLE AVENOVA calcipotriene-betamethasone
ACTEMRA ACTPEN AVONEX calcitriol ointment
ACTEMRA INTRAVENOUS AVSOLA CAMBIA
ACTEMRA SUBCUTANEOUS AZASITE Capsinac
ACTOS AZELEX CARAC
ACUVAIL AZESCO CARAFATE
acyclovir cream AZOR CARBINOXAMINE TABLET 6 MG
adapalene pad BALCOLTRA CARDIZEM
ADCIRCA BANZEL SUSPENSION CARDIZEM CD
ADDERALL BARACLUDE TABLET CARDIZEM LA
ADDERALL XR BECONASE AQ carisoprodol 250 mg
ADZENYS XR-ODT BENICAR CARNITOR
AIMOVIG BENICAR HCT CARNITOR SF
albuterol sulfate CFC-free aerosol BENSAL HP CELEBREX
(NDC* 66993001968 only) benzonatate (NDCs* 69336012615, 69499032915 only) chlordiazepoxide-clidinium (NDCs* 11534019701,
ALEVICYN GEL BEPREVE 42494040901, 51293069601, 51293069610,
ALEVICYN SG BERINERT 67877073101, 70700018501 only)
ALEVICYN SOLUTION BETAMETHASONE ACETATE- chlorzoxazone 250 mg
ALIQOPA BETAMETHASONE SODIUM PHOSPHATE chlorzoxazone 375 mg
ALLISON MEDICAL INSULIN SYRINGES 7 betamethasone dipropionate ointment 0.05% chlorzoxazone 500 mg (NDC* 73007001303 only)
ALPROLIX BETAPACE chlorzoxazone 750 mg
ALREX BETAPACE AF CICATRACE
ALTOPREV BETIMOL CILOXAN
ALVESCO BEVESPI AEROSPHERE CIMZIA LYOPHILIZED POWDER
AMITIZA BEYAZ CIMZIA PREFILLED SYRINGE
AMRIX BORTEZOMIB CIPRO HC
ANDROGEL BREEZE 2 STRIPS AND KITS 9 CIPRODEX
APEXICON E BROMSITE ciprofloxacin-fluocinolone
APIDRA Bupap clindamycin gel (NDC* 68682046275 only)
APLENZIN BUPHENYL clobetasol emollient foam
APOKYN bupropion ext-rel tablet 450 mg clobetasol spray
APTENSIO XR butalbital-acetaminophen capsule CLOBEX SPRAY
APTIVUS butalbital-acetaminophen tablet 25-325 mg clocortolone cream
ARALAST NP butalbital-acetaminophen tablet 50-300 mg COLAZAL
ARTHROTEC BUTALBITAL-ACETAMINOPHEN colchicine capsule
ASACOL HD (NDC* 69499034230 only) COLCRYS
ASMANEX butalbital-acetaminophen-caffeine capsule COMPLERA
ASMANEX HFA BUTRANS CONCERTA
ATACAND BYDUREON BCISE CONTOUR NEXT STRIPS AND KITS 9
ATACAND HCT BYETTA CONTOUR STRIPS AND KITS 9
ATIVAN CAFERGOT CONTRAVE
CORDRAN CREAM FEMRING INTRAROSA
CORDRAN LOTION fenofibrate capsule 30 mg INTUNIV
CORDRAN OINTMENT fenofibrate capsule 50 mg INVELTYS
CORDRAN TAPE fenofibrate capsule 90 mg INVOKAMET
COREG CR fenofibrate capsule 130 mg INVOKAMET XR
CoreMino fenofibrate tablet 40 mg INVOKANA
COZAAR fenofibrate tablet 120 mg isosorbide dinitrate 40 mg
CRESEMBA FENOGLIDE TABLET 120 MG JADENU
CRESTOR fenoprofen JALYN
CUPRIMINE FENOPROFEN CAPSULE JENTADUETO
CUVITRU FERRIPROX JENTADUETO XR
cyclobenzaprine ext-rel capsule Fexmid KAMDOY
cyclobenzaprine tablet 7.5 mg FINACEA GEL Kapzin DC
CYMBALTA FIORICET CAPSULE KAZANO
CYTOMEL FLAREX ketoconazole foam 2%
DARAPRIM flucytosine capsule 500 mg Ketodan
DAYTRANA fluocinonide cream 0.1% ketoprofen capsule 25 mg
DELZICOL fluorouracil cream 0.5% ketoprofen ext-rel capsule
DESFERAL fluoxetine tablet (generics for SARAFEM only) KINERET
desonide gel fluoxetine tablet 60 mg KOMBIGLYZE XR
desoximetasone ointment 0.05% flurandrenolide cream KUVAN
DesRx flurandrenolide lotion KYPROLIS
DETROL LA flurandrenolide ointment LACRISERT
dexchlorpheniramine FML FORTE LACTULOSE PAK
diclofenac potassium capsule 25 mg FML LIQUIFILM LANOXIN TABLET (125 MCG and 250 MCG only)
diclofenac potassium powder FOCALIN XR lansoprazole delayed-rel orally disintegrating tablet
diclofenac potassium tablet 25 mg FORTAMET lanthanum carbonate
diclofenac sodium solution 2% FORTESTA LANTUS
Diclofex DC FOSRENOL LASTACAFT
Diclosaicin FREESTYLE LIBRE CONTINUOUS LATUDA
DIFFERIN LOTION GLUCOSE MONITORING SYSTEM LESCOL XL
diflorasone cream FREESTYLE STRIPS AND KITS 9 LETAIRIS
diflorasone ointment FULPHILA levorphanol
dihydroergotamine spray GAMMAGARD LEXAPRO
diltiazem ext-rel (generics for CARDIZEM LA only) GEL-ONE LEXIVA
DIOVAN GILENYA LIALDA
DIOVAN HCT GLASSIA LIBRAX
Diphen Elixir GLEEVEC LILETTA
DORYX GLUMETZA LIPITOR
DORYX MPC GLYCOPYRROLATE TABLET 1.5 MG LITHOSTAT
doxepin cream GOLYTELY LIVALO
doxycycline hyclate delayed-rel tablet GRANIX Lofena
doxycycline hyclate tablet 50 mg GUARDIAN CONNECT CONTINUOUS Lorzone
doxycycline hyclate tablet 75 mg GLUCOSE MONITORING SYSTEM LOTEMAX
doxycycline hyclate tablet 150 mg GUARDIAN REAL-TIME CONTINUOUS LOTEMAX SM
doxycycline monohydrate capsule 75 mg GLUCOSE MONITORING SYSTEM luliconazole
doxycycline monohydrate capsule 150 mg halcinonide cream LUNESTA
doxycycline monohydrate delayed-rel capsule HALOG LUPRON DEPOT
DULERA HEPARIN SODIUM IN 5% DEXTROSE LUPRON DEPOT-PED
DYRENIUM HERCEPTIN LYRICA
EDARBI HERCEPTIN HYLECTA MACRODANTIN
EDARBYCLOR HORIZANT Matzim LA
E.E.S. GRANULES HUMALOG MAVYRET
EFFEXOR XR HUMALOG MIX 50/50 MAXALT
ELELYSO HUMALOG MIX 75/25 MAXALT-MLT
ELIDEL HUMATROPE MAXIDEX
ELMIRON HUMULIN 70/30 4 mefenamic acid (NDC* 69336012830 only)
ENLITE CONTINUOUS HUMULIN N 4 meloxicam capsule
GLUCOSE MONITORING SYSTEM HUMULIN R 4 MENEST
ENTERAGAM HYALGAN metaxalone 400 mg
ENTYVIO (For Crohn's Disease Only) hydrocortisone butyrate lipophilic cream 0.1% metformin ext-rel
EPICERAM hydrocortisone butyrate lotion (generics for FORTAMET and GLUMETZA only)
EPIVIR HBV hyoscyamine sulfate ext-rel methocarbamol 500 mg (NDC* 69036091010 only)
EPOGEN HYQVIA methocarbamol 750 mg
ergotamine-caffeine HYSINGLA ER (NDCs* 69036093090, 70868090190 only)
ERYPED HYZAAR MIACALCIN INJECTION
estradiol vaginal tablet Iclofenac CP MICARDIS
ESTRING icosapent ethyl MICARDIS HCT
EVEKEO ILUMYA Migergot
EVERSENSE CONTINUOUS INCRUSE ELLIPTA Millipred
GLUCOSE MONITORING SYSTEM INDERAL LA MINASTRIN 24 FE
EXFORGE INDERAL XL MINIVELLE
EXFORGE HCT INDOCIN minocycline ext-rel
EXJADE indomethacin capsule 20 mg MIRVASO
EXTAVIA Inflammacin Mondoxyne NL capsule 75 mg
FABIOR INFLECTRA MONOVISC
FANAPT INNOPRAN XL MOTEGRITY
MOVIPREP PREVIDENT TOVIAZ
mupirocin cream PRISTIQ TRACLEER
MYTESI PROAIR RESPICLICK TRADJENTA
NAPRELAN PROCRIT tramadol (NDC* 52817019610 only)
naproxen CR PROCYSBI tramadol ext-rel capsule
naproxen suspension PROMACTA TRANSDERM SCOP
naproxen-esomeprazole PROMETRIUM TRAVATAN Z
NATAZIA PROTONIX TRELSTAR MIXJECT
NEO-SYNALAR PROVENTIL HFA TREXIMET
NESINA PROVIGIL triamcinolone aerosol 0.2%
NEULASTA PROZAC triamcinolone ointment 0.05%
NEULASTA ONPRO QNASL Trianex
NEUPOGEN QTERN TRICOR
NEVANAC quazepam TRINTELLIX
NEXIUM RAPAFLO TRIVIDIA INSULIN SYRINGES 7
niacin tablet 500 mg RASUVO TRULANCE
Niacor RAVICTI TRUVADA
NILANDRON RECEDO TRUXIMA
nitrofurantoin (NDC* 16571074024 only) REMODULIN TUDORZA
NORGESIC FORTE RENFLEXIS UDENYCA
NORITATE REVATIO ULORIC
NORPACE RIABNI ULTIMED INSULIN SYRINGES 7
NORVASC RIMSO-50 ULTIMED NEEDLES 7
NOURIANZ RIOMET ULTRAVATE
NOVO NORDISK NEEDLES 7 RITUXAN UROXATRAL
NOXAFIL ROZEREM VALCYTE
NuDiclo SoluPak RyClora VALTREX
NuDiclo TabPak RYTARY Vanoxide-HC
NUTROPIN AQ SABRIL VECTICAL
NUVARING SAIZEN VELTIN
NUVIGIL SANDOSTATIN LAR venlafaxine ext-rel tablet (except 225 mg)
OLUX-E SCARSILK PAD VENTOLIN HFA
omeprazole-sodium bicarbonate SEASONIQUE VEREGEN
OMNARIS SEROQUEL XR VIEKIRA PAK
OMNITROPE SIGNIFOR LAR VIIBRYD
ONFI SILENOR VIRACEPT
ONGLYZA SILIVEX VISCO-3
ORENCIA INTRAVENOUS SILTREX VITAFOL-ONE
orphenadrine-aspirin-caffeine SIMPONI VIVELLE-DOT
Orphengesic Forte SINGULAIR VOGELXO
ORTHOVISC SOMAVERT WELLBUTRIN XL
OSENI SORILUX XANAX
OSMOPREP SPRIX XANAX XR
OSPHENA STRIBILD XENAZINE
OTREXUP SUBOXONE XENICAL
OWEN MUMFORD NEEDLES 7 SUBSYS XOPENEX HFA
oxiconazole (NDCs* 00168035830, 51672135902 only) sucralfate suspension XYREM
OXYCONTIN sumatriptan-naproxen YASMIN
oxymorphone ext-rel SUPREP YAZ
OXYTROL Sure Result DSS Premium Pack Yuvafem
PANCREAZE SYNERDERM ZALVIT
paroxetine HCl ext-rel (NDC* 60505367503 only) SYNVISC ZARXIO
paroxetine mesylate capsule 7.5 mg SYNVISC-ONE ZEGERID
PAXIL SYPRINE ZEMAIRA
PAXIL CR TAKHZYRO ZEPATIER
peg 3350-electrolytes (generics for MOVIPREP only) Targadox ZERVIATE
PEGASYS TASIGNA ZESTORETIC
Pennsaicin tavaborole ZETIA
PERCOCET TAYTULLA ZETONNA
PERRIGO NEEDLES 7 TAZORAC ZIANA
PERTZYE TECFIDERA Ziclocin Pak
PEXEVA TESTIM Ziclopro
PLAVIX testosterone gel 1% zileuton ext-rel
PLEGRIDY (authorized generics for TESTIM and VOGELXO only) ZIRGAN
POLYTOZA THEO-24 ZOLADEX
posaconazole delayed-rel tablet THIOLA ZOLOFT
PRADAXA THIOLA EC zolpidem sublingual
PRALUENT TIMOPTIC OCUDOSE ZOLPIMIST
PRED FORTE TIROSINT ZONEGRAN
PRED MILD TOBI ZONTIVITY
prednisolone solution 10 mg/5 mL TOBI PODHALER ZORVOLEX
prednisolone solution 20 mg/5 mL TOBRADEX ST ZYDELIG
PREMARIN topiramate ext-rel capsule (generics for QUDEXY XR only) ZYLET
PREMARIN CREAM TOPROL-XL ZYTIGA
PRENATAL PLUS TOUJEO
PREVACID Tovet
There may be additional drugs subject to prior authorization or other plan design restrictions. Please consult your plan for further information.

This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available drug
options. Log in to Caremark.com to check coverage and copay information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a
substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CVS Caremark assumes no
liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change.

Subject to applicable laws and regulations.

† This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.
* Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and
package size.
** Listing does not include certain NDCs*.
1 If your doctor believes you have a specific clinical need for one of these products, they should contact the Prior Authorization department at: 1-855-240-0536.
2 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).
3 If approved for coverage and prescribed for primary prevention of cardiovascular disease, may be covered without cost sharing through an exceptions process.
4 Rebranded or private label formulations are not covered without a prior authorization for medical necessity (i.e., RELION).
5 Long Acting Insulins - First Generation.
6 Long Acting Insulins - Second Generation.
7 BD ULTRAFINE syringes and needles are the only preferred options.
8 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or
ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746.
9 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options.
10 Generic prenatal vitamins and CITRANATAL are the only preferred options.

This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark.
Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.

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