2020 FOURTH QUARTER Quick Reference Preferred Drug List - … · 2020. 9. 14. · AMRIX ANDROGEL 1% ANGELIQ ANTARA APEXICON E APIDRA APLENZIN ARMOUR THYROID ARTHROTEC ASACOL HD ASCENSIA

QUICK REFERENCE DRUG LIST

A

abacavir tabletabacavir-lamivudine ABILIFY MAINTENA**

abirateroneACCU-CHEK AVIVA PLUS

STRIPS AND KITS 11

ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11

ACCU-CHEK GUIDE STRIPS AND KITS 11

ACCU-CHEK SMARTVIEW STRIPS AND KITS 11

acitretin

ACUVAILacyclovir capsule, tabletadapaleneADEMPASADVAIR DISKUS

ADVAIR HFAADYNOVATE

AFINITOR

AIMOVIGAJOVY

albuterol inhalation solutionalbuterol sulfate CFC-free

aerosolalendronatealfuzosin ext-relaliskiren

allopurinolalosetronALPHAGAN P

alprazolamamantadineambrisentanamilorideAMITIZA

2020 FOURTH QUARTERQuick Reference Preferred Drug List - Tiers 1&2

The 2020 Quick Reference Preferred Drug List is an alphabetical listing of preferred and generic drugs. Generics should be considered the first line of prescribing. The preferred medicines are listed to help identify products that are clinically appropriate and cost effective. This is not an all-inclusive list and is subject to change. This list represents brand products in CAPS and generic products in lowercase.

The Preferred Alternatives Drug List, lists non-preferred brand-name drugs with their preferred and/or generic alternatives.

Please note that specific prescription benefit plan designs may not cover certain medicines, regardless of their appearance in this document. Please read the prescription drug section of your Group Plan Booklet- certificate. Also please note that some of the drugs listed may be on one of the pharmacy programs; Dose Optimization, Prior Authorization or Quantity limits - those drugs are identified with an asterisk (*).

We encourage you to register and use the Caremark website that is linked to the www.nipponlifebenefits.com website. Use the “Check Drug Coverage and Cost” tool on the CVS Caremark website for the most up to date information. If you do not have access to the website, or would prefer to talk to a customer service representative, have your ID card available and call CVS Caremark customer service at 866-644-7527.

We Cover family planning services which consist of FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage section of your Nippon Life Insurance Company of America Booklet-Certificate, counseling on use of contraceptives and related topics, and sterilization procedures for women. Such services are not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF and when provided by a Participating Provider. Please see page 11-12 for the additional information.

NOTHING HEREIN IS A GUARANTEE OF BENEFITS OR ELIGIBILITY. ALL TERMS, PROVISIONS, CONDITIONS, LIMITITATIONS AND EXCLUSIONS SHOWN IN YOUR NIPPON LIFE INSURANCE COMPANY OF AMERICA CERTIFICATE AND MASTER POLICY WILL GOVERN.

NC2019-38 (10/20)

amlodipineamlodipine-atorvastatinamlodipine-olmesartanamlodipine-telmisartanamlodipine-valsartanamlodipine-valsartan-

hydrochlorothiazide

amoxicillinamoxicillin-clavulanateamphetamine-

dextroamphetamine mixed salts

amphetamine-dextroamphetamine mixed salts ext-rel †

ANDRODERM* ANORO ELLIPTA

ARANESP aripiprazole ARISTADA ARISTADA INITIO armodafinil* ARNUITY ELLIPTA

atazanavir atenolol atomoxetine atorvastatin ATRIPLA AUBAGIO AUSTEDO azelaic acid gel azelastine azithromycin

AZOPT

B

balsalazideBAQSIMIBASAGLARBD ULTRAFINE INSULIN

SYRINGES AND NEEDLES

BELBUCA* BELSOMRA

benzonatate (except NDCs^

69336012615, 69499032915)

benzoyl peroxide BESIVANCE BETASERON BETHKISBETIMOLBETOPTIC S BEVESPI AEROSPHERE

bicalutamideBIDILBIKTARVY

bosentanBOSULIFBREO ELLIPTA BRILINTAbrimonidinebromfenacBRYHALI*budesonide capsule budesonide ext-rel budesonide inhalation

suspension

buprenorphine transdermal buprenorphine-naloxone

sublingualbupropionbupropion ext-rel 7

BYSTOLIC*

C

CABOMETYX calcipotriene ointment,

solutioncalcitonin-salmoncalcium acetate candesartan candesartan-

hydrochlorothiazide

carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-

entacaponecarvedilolcarvedilol phosphate ext-rel cefdinircefprozilcefuroxime axetil celecoxibcephalexinCERDELGACEREZYME CETROTIDE cholestyramineciclopirox*CILOXAN OINTMENT

CIMDUOcinacalcetCIPRODEXciprofloxacincitalopramCITRANATAL

clarithromycin clarithromycin ext-rel CLIMARA PRO clindamycinclindamycin gel (except NDC^

68682046275)

clindamycin solution clindamycin-benzoyl

peroxideclobazamclobetasol cream, foam, gel,

lotion, ointment, shampoo clonazepamclopidogrelclotrimazoleclozapinecodeine-acetaminophen* colchicine tablet colesevelamCOMBIGAN COMBIPATCH

COMPLERA COPAXONE

COPIKTRACORLANOR CORTIFOAM

COSENTYX

CREON

CRINONE

cromolyn sodiumcyclobenzaprine 8

D

DALIRESPdarifenacin ext-rel DESCOVY

desonide desoximetasone desvenlafaxine ext-rel* dexamethasone DEXCOM CONTINUOUS

GLUCOSE MONITORING SYSTEMDEXILANT* diazepamdiazepam rectal gel diclofenacdiclofenac sodium diclofenac sodium gel 1%

(except NDC^ 69499031866)

diclofenac sodium solution diclofenac sodium-

misoprostoldicloxacillindicyclomineDIFICIDdigoxindiltiazem ext-rel 5

dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGELdonepezildorzolamidedorzolamide-timolol DOVATOdoxazosindoxepindoxycycline hyclate 20 mg doxycycline hyclate capsule doxycycline monohydrate

delayed-rel capsule doxylamine-pyridoxine

delayed-reldronabinolDUAVEEduloxetineDUPIXENT

DUREZOLDUROLANE

dutasteridedutasteride-tamsulosin DYMISTA

E

econazoleeletriptanELIGARDELIQUIS

EMGALITYEMVERM*ENBREL

ENDOMETRINentacapone

entecavirENTRESTOEPCLUSA

EPIDUOepinephrine auto-injector EPIPENEPIPEN JR

EPISILERLEADAerythromycinerythromycin solution erythromycin-benzoyl

peroxideerythromycinsESBRIETescitalopram esomeprazoleestradiolestradiol-norethindrone ESTRINGeszopicloneethinyl estradiol-

drospirenoneethinyl estradiol-

drospirenone-levomefolate ethinyl estradiol-etonogestrel ethinyl estradiol-

levonorgestrel ethinyl estradiol-

norelgestromin ethinyl estradiol-

norethindrone acetate ethinyl estradiol-

norethindrone acetate-iron ethinyl estradiol-norgestimate ethosuximideEUCRISA* EVAMISTeverolimusEVOTAZ

EYLEAezetimibeezetimibe-simvastatin

F

famotidine FARXIGA* FASENRA

fenofibrate 4

fenofibric acid delayed-relfentanyl transdermalfentanyl transmucosal

lozengeFIASPFINACEA FOAMfinasterideFIRAZYRFLOVENT DISKUS

FLOVENT HFA

fluconazolefludrocortisoneflunisolidefluocinonide 12

fluorouracil cream 5%

fluorouracil solution

fluoxetine 6

fluticasonefluvastatin

FML FORTEFML S.O.P.folic acidFORTEOfosinoprilfosinopril-hydrochlorothiazidefurosemideFYCOMPA

G

gabapentingalantaminegalantamine ext-rel GEL-ONEGELSYN-3GENOTROPIN

gentamicinGENVOYA

GILENYAglatiramerglimepirideglipizideglipizide ext-relglipizide-metforminGLUCAGEN HYPOKITGLUCAGON EMERGENCY

KITGLYXAMBIGONAL-F

GRALISEgranisetronGRASTEKguanfacine ext-relGVOKE

H

HARVONIHUMATROPE

HUMIRAHUMULIN R U-500 hydrochlorothiazide hydrocodone ext-rel hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate

cream, lotion, ointment, solution

hydrocortisone enema hydromorphone* hydromorphone ext-rel*

I

ibandronate IBRANCE

ibuprofenILEVROimatinib mesylate imiquimod INCRUSE ELLIPTA

INGREZZA* ipratropium inhalation

solution ipratropium-albuterol

inhalation solution irbesartan irbesartan-

hydrochlorothiazide

NC2019-38 (10/20)

IRESSA

ISENTRESS

itraconazole*ivermectin

J

JANUMET

JANUMET XRJANUVIA*JARDIANCE

JIVI

K

ketoconazole cream 2%ketoconazole shampoo 2%

ketorolacKISQALIKISQALI FEMARA CO-

PACKKOGENATE FSKOVALTRY

KYLEENA

L

lactulose solution lamivudinelamotriginelamotrigine ext-rel lansoprazoleLASTACAFTlatanoprostLATUDA*levalbuterol tartrate CFC-free

aerosolLEVEMIRlevetiracetam levetiracetam ext-rel levocarnitinelevocetirizinelevofloxacinlevothyroxinelidocaine-prilocainelinezolidLINZESS*liothyroninelisinoprillisinopril-hydrochlorothiazide LO LOESTRIN FE LOKELMAlorazepamlosartanlosartan-hydrochlorothiazide loteprednollovastatinLUCENTISluliconazoleLUMIGANLUPRON DEPOT

LYNPARZA

M

MAXIDEXMAYZENTmeclizinemedroxyprogesteronemegestrol acetatemeloxicam

memantinemesalamine delayed-rel mesalamine ext-rel mesalamine suppository mesalamine suspension metforminmetformin ext-rel 10

methadone*methoxsalen methylphenidate methylphenidate ext-rel †methylprednisolone

metoclopramide metolazonemetoprolol succinate ext-rel metoprolol tartrate metronidazole minocyclineMIRENAmirtazapine mometasone montelukastmorphine*morphine ext-rel* morphine suppository MOVANTIK*moxifloxacinMUGARDMULPLETAMULTAQmupirocin ointment MUSE*MYDAYISMYRBETRIQ

N

nadololNAFTINnaloxone injectionNAMZARICnaproxen 2

naratriptanNARCAN NASAL SPRAY

nateglinideneomycin-polymyxin B-

bacitracin-hydrocortisone neomycin-polymyxin B-

dexamethasone NEULASTANEUPRONEVANACniacin ext-relnifedipine ext-rel nitrofurantoin nitroglycerin lingual spray nitroglycerin sublingual NIVESTYMNORVIRNOVOEIGHTNOVOLIN 70/30 NOVOLIN NNOVOLIN RNOVOLOGNOVOLOG MIX 70/30 NUBEQANUCALANUCYNTA*NUCYNTA ER*

NUEDEXTA

NURTEC ODT

NUWIQnystatin

O

ODEFSEY

ODOMZOOFEVofloxacinolanzapineolmesartanolmesartan-amlodipine-

hydrochlorothiazide

olmesartan-hydrochlorothiazide

olopatadineomega-3 acid ethyl estersomeprazoleOMNIPOD INSULIN

INFUSION PUMPondansetronONEXTONONZETRA XSAIL

OPSUMIT

ORALAIRORENITRAM

ORFADIN* ORILISSA oseltamivir OSPHENA

OTEZLAOVIDRELoxazepam oxcarbazepine OXTELLAR XR oxybutyninoxybutynin ext-rel oxycodone*oxycodone-acetaminophen* OZEMPIC

P

pantoprazoleparoxetine HClparoxetine HCl ext-relparoxetine mesylatePAZEOpeg 3350-electrolytespenicillin VKPENTASAPERFOROMIST

phenobarbitalphenytoinphenytoin sodium extendedPHOSLYRA

PICATOpimecrolimuspindololpioglitazonepioglitazone-glimepiridepioglitazone-metforminpotassium chloride liquidPRALUENTpramipexolepramipexole ext-rel prasugrel

pravastatinPRED MILDprednisolone acetate 1%

prednisolone solutionprednisonepregabalinPREMARINPREMARIN CREAM

PREMPHASE

PREMPROprenatal vitaminsPREZCOBIX

PREZISTA

primidoneprobenecidprochlorperazinePROCTOFOAM-HCprogesterone, micronizedPROLASTIN-CPROLIApromethazinepropranololpropranolol ext-relPULMICORT FLEXHALERPYLERA

Q

quetiapinequetiapine ext-relquinaprilquinapril-hydrochlorothiazideQVAR REDIHALER

R

RAGWITEK

raloxifeneramelteonramiprilranolazine ext-rel rasagilineRASUVO

REBIFREBINYN*RELENZA*repaglinide RESTASIS RETACRIT

REYVOW RHOPRESSA ribavirinRINVOQrisedronate risperidone rivastigmine rivastigmine transdermal rizatriptan ROCKLATAN ropiniroleropinirole ext-rel rosuvastatin RUBRACA RUCONEST RYBELSUS*

RYDAPT

S

SANCUSO

SAXENDAscopolamine transdermal selegilineselenium sulfide lotion 2.5%

SEREVENTsertralinesevelamer carbonate sildenafilsilodosinSIMBRINZAsimvastatinSKYLASKYRIZIsolifenacinSOLIQUASOMATULINE DEPOTSOMAVERT SOOLANTRAsotalolSPIRIVAspironolactone-

hydrochlorothiazide

SPRYCELSTELARA

SUBCUTANEOUS STIOLTO RESPIMAT STRIBILDSTRIVERDI RESPIMAT SUBSYS*sucralfate tablet sulfacetamide sulfamethoxazole-

trimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptanSUNOSISUPARTZ FXSUPRAX

SUPREPSYMBICORT

SYMFISYMFI LOSYMJEPISYMLINPEN SYMPROICSYMTUZASYNJARDYSYNJARDY XRSYNTHROID

T

tacrolimustadalafil TAKHZYRO tamsulosin TAZORAC* TECFIDERATEGSEDI TEKTURNA HCT* telmisartan telmisartan-

hydrochlorothiazideTEMIXYS terazosin terbinafine tablet* testosterone gel 9testosterone solution

NC2019-38 (10/20)

tetrabenazinetetracyclinetiagabinetimolol maleate solution TIVICAYTOBRADEX OINTMENT

TOBRADEX STtobramycintobramycin inhalation

solutiontobramycin-dexamethasone TOLAKtolterodinetolterodine ext-rel topiramatetorsemideTOVIAZ*tramadol* (except NDC^ 52817019610)

tramadol ext-rel*travoprosttrazodoneTRELEGY ELLIPTATREMFYA

TRESIBAtretinoin*triamcinolone cream, lotion,

ointmenttriamterenetriamterene-

hydrochlorothiazide

TRIJARDY XR trimethobenzamide TRINTELLIX*TRIUMEQTROKENDI XR

trospiumtrospium ext-rel TRULICITY

TRUVADATYMLOSTYSABRI

U

UBRELVY

UDENYCA

UPTRAVI

V

valacyclovirvalganciclovirvalproic acidvalsartanvalsartan-hydrochlorothiazide vancomycin capsuleVARUBIVASCEPAVELPHOROVELTASSAVEMLIDYvenlafaxinevenlafaxine ext-rel capsule verapamil ext-relV-GO INSULIN INFUSION

PUMPVIBERZI VICTOZA

vigabatrinVIIBRYD*VIMPAT

VIOKACE

VISCO-3

VISTOGARD

VOSEVI 3

VRAYLAR*VUMERITY

VYVANSE

W

warfarin

X

XARELTOXELJANZ

XELJANZ XRXIFAXAN 550 MGXIGDUO XR* XIIDRA

XOLAIRXTAMPZA ER*XTANDI XULTOPHY

Y

YONSA

YUPELRI

Z

zafirlukastZEJULAZEMBRACE SYMTOUCHZENPEPzileuton ext-rel ziprasidonezolmitriptanzolpidemzolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY* zonisamideZUBSOLVZYCLARA

PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)*

ABILIFY

ACANYA

ACIPHEX, ACIPHEX SPRINKLE

ACTEMRA

ACTICLATE

Activite

ACTOS

acyclovir cream

aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA*, VRAYLAR*

adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin* , EPIDUO, ONEXTON, TAZORAC*

esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT*

ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR

doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline

folic acid

pioglitazone

acyclovir capsule, acyclovir tablet, valacyclovir

ALCORTIN A desonide, hydrocortisone

ALEVICYN GEL, ALEVICYN SG, ALEVICYN SOLUTION

desonide, hydrocortisone

ALIQOPA COPIKTRA

ALLISON MEDICAL INSULIN SYRINGES 13 BD ULTRAFINE INSULIN SYRINGES

ALORA estradiol, DIVIGEL, EVAMIST

ALPROLIX Consult doctor

ALREX azelastine, cromolyn sodium, olopatadine, LASTACAFT, PAZEO

ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

DRUG NAME(S) PREFERRED OPTION(S)*

ALVESCO

AMRIX

ANDROGEL 1%

ANGELIQ

ANTARA

APEXICON E

APIDRA

APLENZIN

ARMOUR THYROID

ARTHROTEC

ASACOL HD

ASCENSIA STRIPS AND KITS 14

ASMANEX, ASMANEX HFA

ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER

cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)

testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*

estradiol-norethindrone, PREMPHASE, PREMPRO

fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel

desoximetasone, fluocinonide (except fluocinonide cream 0.1%), BRYHALI*

FIASP, NOVOLOG

bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)

levothyroxine, liothyronine, SYNTHROID

celecoxib; diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT*

balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA

ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11

ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER

NC2019-38 (10/20)


ATACAND, ATACAND HCT

ATOPADERM

ATROVENT HFA

AVENOVA

AVONEX

AZELEX

BARACLUDE TABLET

BEAU RX

BECONASE AQ

BENICAR, BENICAR HCT

BENSAL HP

BENZAC AC

BENZACLIN

BENZIQ

benzonatate (NDCs^ 69336012615, 69499032915 only)

BERINERT

BETAPACE, BETAPACE AF

BEYAZ

candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide


ipratropium inhalation solution, INCRUSE ELLIPTA, SPIRIVA, YUPELRI

Consult doctor

glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY

adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*

entecavir, lamivudine, VEMLIDY

Consult doctor

flunisolide, fluticasone, mometasone, DYMISTA






benzonatate (except NDCs^ 69336012615, 69499032915)

FIRAZYR, RUCONEST

sotalol

ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron


bimatoprost solution 0.03%

BREEZE 2 STRIPS AND KITS 14

Bupap

bupropion ext-rel tablet 450 mg

butalbital-acetaminophen tablet 50-300 mg, BUTALBITAL-ACETAMINOPHEN (NDC^ 69499034230 only)

butalbital-acetaminophen-caffeine capsule

BUTRANS

BYDUREON

BYETTA

CAFERGOT

calcipotriene cream

calcitriol ointment

CAMBIA

CARAC

CARAFATE

CARBINOXAMINE TABLET 6 MG

CARDIZEM, CARDIZEM CD, CARDIZEM LA

CARNITOR, CARNITOR SF

chlordiazepoxide-clidinium (NDC^ 42494040901 only)

chlorzoxazone 375 mg, chlorzoxazone 500 mg (NDC^ 73007001303 only), chlorzoxazone 750 mg, CHLORZOXAZONE 250 MG

CIALIS

CICATRACE

CIMZIA

CLINDAGEL

clindamycin gel (NDC^ 68682046275 only)

latanoprost, travoprost, LUMIGAN


diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)

bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)



buprenorphine transdermal, BELBUCA

OZEMPIC, RYBELSUS*, TRULICITY, VICTOZA

OZEMPIC, RYBELSUS*, TRULICITY, VICTOZA

eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY*

calcipotriene ointment, calcipotriene solution



fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA

sucralfate tablet

levocetirizine

diltiazem ext-rel (except generics for CARDIZEM LA)

levocarnitine

dicyclomine


sildenafil, tadalafil

Consult doctor

COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR

erythromycin solution

adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-

NC2019-38 (10/20)


clobetasol spray

CLOBEX SPRAY

COLAZAL

COLCRYS

CONSENSI

CONTOUR NEXT STRIPS AND KITS 14

CONTOUR STRIPS AND KITS 14

CONTRAVE

CORDRAN OINTMENT

CoreMino

COUMADIN

CRESTOR

cyclobenzaprine ext-rel capsule, cyclobenzaprine tablet 7.5 mg

CYMBALTA

DaVite

DELZICOL

DETROL LA

dexchlorpheniramine

Dexifol

Dexpak

diclofenac sodium gel 1% (NDC^ 69499031866 only)

benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*

clobetasol foam

clobetasol foam

balsalazide

colchicine tablet

amlodipine WITH celecoxib



SAXENDA

hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment


warfarin

atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin


desvenlafaxine ext-rel*, duloxetine, venlafaxine, venlafaxine ext-rel capsule

folic acid


darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ*

levocetirizine

folic acid

dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone

diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)


Diclofex DC (NDC^ 51021037201 only)

Diclosaicin

diflorasone cream, diflorasone ointment

dihydroergotamine spray

diltiazem ext-rel (generics for CARDIZEM LA only)

DIOVAN, DIOVAN HCT

Diphen Elixir

DORAL

DORYX, DORYX MPC

doxepin cream







levocetirizine

doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA


desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA*

doxycycline hyclate delayed-rel tablet 200 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline

doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only), doxycycline hyclate tablet 75 mg, doxycycline hyclate tablet 150 mg


doxycycline monohydrate capsule 75 mg, doxycycline monohydrate capsule 150 mg


DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT

DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide

DYRENIUM amiloride, triamterene

EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA

E.E.S. GRANULES erythromycins

NC2019-38 (10/20)


EFFEXOR XR

ELELYSO

ELOCTATE

ENABLEX

ENLITE CONTINUOUS GLUCOSE MONITORING SYSTEM

ENTERAGAM

ENTYVIO

EPICERAM

EPOGEN

ergotamine-caffeine

ERYPED

EUFLEXXA

EVEKEO

EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM

EVZIO

EXFORGE

EXFORGE HCT

EXTAVIA

FANAPT

FEMRING

fenofibrate tablet 120 mg

FENOGLIDE TABLET 120 MG

fenoprofen, FENOPROFEN CAPSULE

FERIVA 21/7

FETZIMA

Fexmid

desvenlafaxine ext-rel* , duloxetine, venlafaxine, venlafaxine ext-rel capsule

CERDELGA, CEREZYME

ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ


DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

alosetron, VIBERZI, XIFAXAN 550 MG

HUMIRA, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR


ARANESP, RETACRIT


erythromycins

DUROLANE, GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3

amphetamine-dextroamphetamine mixed salts, methylphenidate


naloxone injection, NARCAN NASAL SPRAY

amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan

amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide



estradiol, ESTRING, PREMARIN CREAM



diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

folic acid



FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA

FIORICET CAPSULE diclofenac sodium, ibuprofen,


naproxen (except naproxen CR or naproxen suspension)

FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

flucytosine capsule 500 mg fluconazole

fluocinonide cream 0.1% clobetasol cream

fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA

fluoxetine tablet (generics for SARAFEM only) fluoxetine (except fluoxetine tablet 60 mg,

fluoxetine tablet 60 mg

flurandrenolide lotion (NDC^ 24470092112 only)

flurandrenolide ointment

FML LIQUIFILM

FOLIC-K

FOLLISTIM AQ

Folvik-D

Folvite-D

FORTAMET

FORTESTA

FOSAMAX PLUS D

FOSRENOL

FOSTEUM, FOSTEUM PLUS

FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING SYSTEM

FREESTYLE STRIPS AND KITS 14

FROVA

FULPHILA

fluoxetine tablet [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline

citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX*, VIIBRYD*



dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

folic acid

GONAL-F

folic acid

folic acid

metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)


alendronate, ibandronate, risedronate

calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO

alendronate, ibandronate, risedronate




NEULASTA, UDENYCA

NC2019-38 (10/20)


Genicin Vita-S folic acid

GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL

GLUMETZA metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)

GLYCOPYRROLATE TABLET 1.5 MG dicyclomine

GRANIX NIVESTYM

GUARDIAN CONNECT CONTINUOUS GLUCOSE MONITORING SYSTEM


HORIZANT gabapentin, GRALISE

HUMALOG FIASP, NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 NOVOLIN 70/30

HUMULIN N NOVOLIN N

HUMULIN R NOVOLIN R

HYALGAN DUROLANE, GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3

hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate

HylaVite

HYSINGLA ER

INDERAL LA, INDERAL XL

INDOCIN

indomethacin capsule 20 mg

Inflammacin

INNOPRAN XL

INTERMEZZO

INTUNIV

INVOKAMET, INVOKAMET XR

cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment

folic acid

fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel*, methadone*, morphine ext-rel*, NUCYNTA ER*, XTAMPZA ER

atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC*






amphetamine-dextroamphetamine mixed salts ext-rel †, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE

SYNJARDY, SYNJARDY XR, XIGDUO XR*


INVOKANA

ISTALOL

JALYN

FARXIGA*, JARDIANCE

timolol maleate solution, BETIMOL, BETOPTIC S

dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin

JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR

KAMDOY desonide, hydrocortisone

KAZANO JANUMET, JANUMET XR

ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5%

Ketodan ketoconazole shampoo 2%, selenium sulfide lotion 2.5%

ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

KINERET ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR

KOMBIGLYZE XR JANUMET, JANUMET XR

LACTULOSE PAK lactulose solution

LAMICTAL, LAMICTAL ODT, LAMICTAL XR carbamazepine, carbamazepine ext-rel,

LANOXIN TABLET (125 MCG and 250 MCG only)

lanthanum carbonate

LANTUS

LAZANDA

LESCOL XL

LETAIRIS

levorphanol

LEXAPRO

LIALDA

LIDOCAINE-TETRACAINE CREAM (NDC^ 71800063115 only)

LIDOTREX

divalproex sodium, divalproex sodium ext-rel, gabapentin, 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, VIMPAT

digoxin

calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO

BASAGLAR, LEVEMIR

fentanyl transmucosal lozenge, SUBSYS*


ambrisentan, bosentan, OPSUMIT

fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel* , methadone* , morphine ext-rel* , NUCYNTA ER*, XTAMPZA ER*



lidocaine-prilocaine

lidocaine-prilocaine

NC2019-38 (10/20)


LIPITOR

LIVALO

Lorid

Lorzone

LOTEMAX, LOTEMAX SM

LUNESTA

MACRODANTIN

Matzim LA

MAVYRET

mefenamic acid (NDC^ 69336012830 only)

MENEST

MENOSTAR

metformin ext-rel (generics for FORTAMET and GLUMETZA only)

methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only)

MIACALCIN INJECTION

MIACALCIN NASAL SPRAY

MICARDIS, MICARDIS HCT

Migergot

MILLIPRED

MINASTRIN 24 FE

MINIVELLE

MINOCIN

minocycline ext-rel



folic acid




nitrofurantoin


EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 3


estradiol, PREMARIN

estradiol



alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, TYMLOS

calcitonin-salmon





estradiol, DIVIGEL, EVAMIST


doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline,


Mondoxyne NL capsule 75 mg

MONOVISC

MOVIPREP

MultiPro

mupirocin cream

MYTESI

NAPRELAN

naproxen-esomeprazole

naproxen CR

naproxen suspension

NATAZIA

NATESTO

NESINA

NEUPOGEN

NEXIUM

tetracycline



peg 3350-electrolytes, SUPREP

Consult doctor

gentamicin, mupirocin ointment

Consult doctor


diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT*



ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE


JANUVIA*

NIVESTYM


niacin tablet 500 mg niacin ext-rel

Niacor niacin ext-rel

NICADAN folic acid

NICAPRIN folic acid

NICAZEL, NICAZEL FORTE folic acid

NICOMIDE folic acid

NILANDRON abiraterone, bicalutamide, XTANDI, YONSA

NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual

NORDITROPIN GENOTROPIN, HUMATROPE

NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)

NORITATE azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA

NORVASC amlodipine

NOVACORT desonide, hydrocortisone

NOVO NORDISK NEEDLES 13 BD ULTRAFINE NEEDLES

NC2019-38 (10/20)


NuDiclo SoluPak, NuDiclo TabPak

NUTROPIN AQ

NUVIGIL

Okebo

OLEPTRO

OLUX-E

omeprazole-sodium bicarbonate

OMNARIS

OMNITROPE

OMNIVEX

ONETOUCH ULTRA STRIPS AND KITS 14

ONETOUCH VERIO STRIPS AND KITS 14

ONFI

ONGLYZA

ORENCIA CLICKJECT, ORENCIA INTRAVENOUS, ORENCIA SUBCUTANEOUS

orphenadrine-aspirin-caffeine

Orphengesic Forte

ORTHO D

ORTHO DF

ORTHO TRI-CYCLEN LO

ORTHOVISC

OSENI

OSMOPREP

OWEN MUMFORD NEEDLES 13

oxiconazole (NDCs^ 00168035830, 51672135902 only)

OXYCONTIN


GENOTROPIN, HUMATROPE

armodafinil, SUNOSI


trazodone

clobetasol foam




folic acid



clobazam, lamotrigine, topiramate, TROKENDI XR

JANUVIA*

COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR



folic acid

folic acid

ethinyl estradiol-norgestimate


JANUMET, JANUMET XR; JANUVIA* WITH pioglitazone

peg 3350-electrolytes, SUPREP

BD ULTRAFINE NEEDLES

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

fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel*, methadone*, morphine ext-rel*, NUCYNTA ER*, XTAMPZA ER*


OXYTROL

PANCREAZE

PENNSAID

PERCOCET

PERRIGO NEEDLES 13

PERTZYE

PEXEVA

PLAVIX

PLEGRIDY

POLYTOZA

posaconazole delayed-rel tablet

PRADAXA

PRECISION XTRA STRIPS AND KITS 14

PRED FORTE

PREFEST

PRENATAL PLUS

PREVACID

PREVIDENT

PRIMLEV

PRISTIQ

PROAIR HFA, PROAIR RESPICLICK

PROCRIT

PRODIGEN

PROTONIX

PROTOPIC

PROVENTIL HFA


CREON, VIOKACE, ZENPEP


hydrocodone-acetaminophen, hydromorphone* , morphine* , oxycodone-acetaminophen, NUCYNTA*


CREON, VIOKACE, ZENPEP


clopidogrel, prasugrel, BRILINTA


Consult doctor

fluconazole, itraconazole*

warfarin, ELIQUIS, XARELTO



estradiol-norethindrone, PREMPHASE, PREMPRO

generic prenatal vitamins, CITRANATAL


Consult doctor

hydrocodone-acetaminophen, hydromorphone* , morphine* , oxycodone-acetaminophen, NUCYNTA*


albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

ARANESP, RETACRIT

Consult doctor


pimecrolimus, tacrolimus, EUCRISA*

albuterol sulfate CFC-free aerosol,

NC2019-38 (10/20)


PROZAC

PSORCON

QNASL

QSYMIA

QTERN

quazepam

RAPAFLO

RAYOS

RECEDO

RELION INSULIN

REPATHA

RHEUMATE

RIBOZEL

RIMSO-50

RIOMET

ROZEREM

RyClora

SABRIL

SAIZEN

SCARSILK PAD

SEROQUEL XR

SIL-K PAD

SILIVEX

SILTREX

SIMPONI

SINGULAIR

SORILUX

SPRIX

STENDRA

STRIANT

levalbuterol tartrate CFC-free aerosol




SAXENDA

GLYXAMBI


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


Consult doctor

NOVOLIN INSULIN

PRALUENT

folic acid

folic acid

Consult doctor



levocetirizine

vigabatrin


Consult doctor


Consult doctor

Consult doctor

Consult doctor

COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR

montelukast, zafirlukast, zileuton ext-rel






SUBOXONE

sucralfate suspension

sumatriptan-naproxen

SURE-TEST STRIPS AND KITS 14

SYNERDERM

SYNVISC, SYNVISC-ONE

TALIVA

TALTZ

TARGADOX

TASIGNA

TAYTULLA

TESTIM

testosterone gel 1% (authorized generics for TESTIM and VOGELXO only)

TIMOPTIC OCUDOSE

TIROSINT

TOBI, TOBI PODHALER

TOPROL-XL

TOUJEO

TRADJENTA

tramadol* (NDC^ 52817019610 only)

TRANSDERM SCOP

TREXIMET

buprenorphine-naloxone sublingual, ZUBSOLV

sucralfate tablet

diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY*




folic acid

COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR


imatinib mesylate, BOSULIF, SPRYCEL




timolol maleate solution, BETIMOL, BETOPTIC S

levothyroxine, SYNTHROID

tobramycin inhalation solution, BETHKIS


TRESIBA

JANUVIA*

tramadol* (except NDC^ 52817019610), tramadol ext-rel*

meclizine, scopolamine transdermal

diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY*

NC2019-38 (10/20)


triamcinolone acetonide aerosol 0.2%

TRICOR

TRIGLIDE

TRILIPIX

TRIVIDIA INSULIN SYRINGES 13

TronVite

TRUETEST STRIPS AND KITS 14

TRUETRACK STRIPS AND KITS 14

TUDORZA

ULTIMED INSULIN SYRINGES 13

ULTIMED NEEDLES 13

UROXATRAL

VALCYTE

VALTREX

Vanatol LQ, Vanatol S

Vanoxide-HC

VASCULERA

VECTICAL

VELTIN

venlafaxine ext-rel tablet (except 225 mg)

VENTOLIN HFA





BD ULTRAFINE INSULIN SYRINGES

folic acid



ELLIPTA,INCRUSE SPIRIVA, YUPELRI

BD ULTRAFINE INSULIN SYRINGES


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

valganciclovir

acyclovir capsule, acyclovir tablet, valacyclovir



Consult doctor



desvenlafaxine ext-rel*, duloxetine, venlafaxine, venlafaxine ext-rel capsule



VEREGEN

VIAGRA

VIEKIRA PAK

VITAFOL-ONE

Vitasure

VIVELLE-DOT

VOGELXO

XANAX, XANAX XR

XENAZINE

XOLEGEL

XOPENEX HFA

Xvite

XYZBAC

YAZ

ZARXIO

ZEGERID

ZEMAIRA

ZEPATIER

ZETIA

ZETONNA

ZIANA

ZOHYDRO ER

ZOLPIMIST

ZONEGRAN

ZONTIVITY

ZORTRESS

imiquimod


EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

generic prenatal vitamins, CITRANATAL

folic acid

estradiol, DIVIGEL, EVAMIST


alprazolam, clonazepam, diazepam, lorazepam, oxazepam

tetrabenazine, AUSTEDO

ciclopirox*, ketoconazole cream 2%


folic acid

folic acid


NIVESTYM


PROLASTIN-C

EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

ezetimibe



fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel*, methadone*, morphine ext-rel*, NUCYNTA ER*, XTAMPZA ER*


carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, 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, VIMPAT

Consult doctor

everolimus

NC2019-38 (10/20)


ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)

ZUPLENZ granisetron, ondansetron, SANCUSO

ZYDELIG COPIKTRA

ZYFLO montelukast, zafirlukast, zileuton ext-rel

ZYLET neomycin-polymyxin B-bacitracin-


hydrocortisone, neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST

ZYTIGA abiraterone, bicalutamide, XTANDI, YONSA

ZYVIT folic acid

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. 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. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay1 information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

§ Generics are available in this class and should be considered the first line of prescribing. ^ 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^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription

price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Listing does not include naproxen CR or naproxen suspension. 3 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). 4 Listing does not include fenofibrate tablet 120 mg. 5 Listing does not include generics for CARDIZEM LA. 6 Listing does not include fluoxetine tablet 60 mg, fluoxetine tablet (generics for SARAFEM). 7 Listing does not include bupropion ext-rel tablet 450 mg. 8 Listing does not include cyclobenzaprine tablet 7.5 mg. 9 Listing does not include the authorized generics for TESTIM and VOGELXO. 10 Listing does not include generics for FORTAMET and GLUMETZA. 11 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on

how to obtain a blood glucose meter, call: 1-877-418-4746. 12 Listing does not include fluocinonide cream 0.1%. 13 BD ULTRAFINE syringes and needles are the only preferred options. 14 ACCU-CHEK brand test strips are the only preferred options.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.

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NC2019-38 (10/20)

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2020 FOURTH QUARTER Quick Reference Preferred Drug List - … · 2020. 9. 14. · AMRIX ANDROGEL 1% ANGELIQ ANTARA APEXICON E APIDRA APLENZIN ARMOUR THYROID ARTHROTEC ASACOL HD ASCENSIA