2026 Express Scripts National Preferred Formulary

The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY [INJ] - Injectable Drug [OTC] - Over-the-counter Product [SP] - Specialty Drug Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters. A ABILIFY ASIMTUFII [INJ] ABILIFY MAINTENA [INJ] ACCU-CHEK: FASTCLIX, SOFTCLIX LANCETS [OTC] acetaminophen/codeine acyclovir ADALIMUMAB-ADAZ [INJ] [SP] ADALIMUMAB-ADBM (by Boehringer Ingelheim & Quallent) [INJ] [SP] ADALIMUMAB-RYVK (by Quallent) [INJ] [SP] ADBRY [INJ] [SP] ADEMPAS [SP] ADVAIR HFA ADVATE [INJ] [SP] ADYNOVATE [INJ] [SP] AFSTYLA [INJ] [SP] AIMOVIG [INJ] AIRSUPRA AJOVY [INJ] albuterol nebulization solution albuterol sulfate hfa (all manufacturers covered except Prasco) ALECENSA [SP] alendronate alfuzosin ext-release ALHEMO PEN [INJ] [SP]

ASMANEX HFA ASMANEX TWISTHALER atenolol

CERDELGA [SP] CEREZYME [INJ] [SP] CETROTIDE [INJ] [SP] chlorhexidine gluconate chlorthalidone CIBINQO [SP] CIMDUO [SP] CIMERLI [INJ] [SP] CINRYZE [INJ] [SP] ciprofloxacin citalopram

divalproex ext-release donepezil DOPTELET [SP] dorzolamide/timolol eye solution DOVATO [SP] doxazosin doxepin capsules, solution, tablets doxycycline hyclate doxycycline monohydrate DROPLET: LANCETS, GENTEEL LANCING DEVICE [OTC] DUAVEE DULERA duloxetine delayed-release DUPIXENT [INJ] [SP] DYSPORT [INJ] [SP] E EBGLYSS [INJ] [SP] eletriptan ELFABRIO [INJ] [SP] ELIQUIS ELOCTATE [INJ] [SP] EMBECTA PEN NEEDLES [OTC] EMBECTA SYRINGES [OTC] EMGALITY [INJ]

atomoxetine atorvastatin AUVI-Q [INJ]

AVONEX [INJ] [SP] AVSOLA [INJ] [SP] AZASITE azathioprine [SP] azelaic acid azelastine nasal spray azithromycin AZSTARYS B baclofen BAFIERTAM [SP] BAQSIMI BARACLUDE SOLUTION BAXDELA BELBUCA benazepril BENEFIX [INJ] [SP] benzonatate betamethasone dipropionate BETASERON [INJ] [SP]

clarithromycin clindamycin hcl clindamycin phosphate topical clindamycin phosphate/ benzoyl peroxide clobetasol propionate clomiphene citrate clonazepam clonidine clopidogrel clotrimazole/betamethasone dipropionate colchicine COMBIPATCH COMBIVENT RESPIMAT COTELLIC [SP] CREON CRINONE 8% [SP] cyanocobalamin [INJ] cyclobenzaprine cyclosporine eye solution D DANZITEN [SP] dasatinib [SP] deferiprone [SP] DELSTRIGO [SP] DESCOVY [SP] desloratadine desonide desvenlafaxine succinate ext-release dexamethasone DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR dexmethylphenidate ext-release dextroamphetamine/amphetamine dextroamphetamine/amphetamine ext-release diazepam diclofenac sodium delayed-release dicyclomine digoxin diltiazem ext-release dimethyl fumarate [SP] diphenoxylate/atropine divalproex delayed-release

EMPAVELI [INJ] [SP] emtricitabine/tenofovir

BIKTARVY [SP] bisoprolol/hctz BOSULIF [SP] BRAFTOVI [SP] BREO ELLIPTA

disoproxil fumarate [SP]

EMVERM enalapril

ENBREL [INJ] [SP] ENDOMETRIN [SP] enoxaparin [INJ] [SP] ENSACOVE [SP] ENSTILAR ENTRESTO ENTYVIO IV [INJ] [SP] EPCLUSA [SP] EPIDIOLEX [SP] epinephrine auto-injector (by Mylan, Teva) [INJ] EPIPEN, EPIPEN JR [INJ] EPYSQLI [INJ] [SP] ergocalciferol ERIVEDGE [SP] ERLEADA [SP] erythromycin eye ointment ERZOFRI [INJ] escitalopram esomeprazole magnesium delayed-release ESPEROCT [INJ] [SP] estradiol estradiol patches estradiol vaginal inserts estradiol/norethindrone acetate eszopiclone ethinyl estradiol/desogestrel ethinyl estradiol/drospirenone

BREZTRI AEROSPHERE brimonidine eye solution BRIXADI [INJ] [SP] BRUKINSA [SP] budesonide nebulization suspension budesonide/formoterol inhaler buprenorphine/naloxone bupropion bupropion ext-release buspirone butalbital/acetaminophen/caffeine BYDUREON BCISE [INJ] BYETTA [INJ] BYOOVIZ [INJ] [SP] C CABENUVA [INJ] [SP]

allopurinol alprazolam

ALPROLIX [INJ] [SP] ALTUVIIIO [INJ] [SP] ALUNBRIG [SP] ALYFTREK [SP]

amiodarone amitriptyline amlodipine

amlodipine/benazepril amlodipine/valsartan amoxicillin amoxicillin/potassium clavulanate anastrozole ANORO ELLIPTA

CABOMETYX [SP] CALQUENCE [SP] CARBAGLU [SP] carbidopa/levodopa carvedilol cefdinir cefuroxime axetil celecoxib cephalexin CEQUR SIMPLICITY

APRETUDE [INJ] [SP] ARALAST NP [INJ] [SP] ARIKAYCE [SP] aripiprazole ARISTADA [INJ] ARMOUR THYROID

(continued) Go to express-scripts.com/2026drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2026, THROUGH DECEMBER 31, 2026. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. For Stelara, see Exclusion Document for more information.

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ethinyl estradiol/drospirenone/ levomefolate ethinyl estradiol/ethynodiol ethinyl estradiol/etonogestrel vaginal ring ethinyl estradiol/levonorgestrel ethinyl estradiol/levonorgestrel/iron ethinyl estradiol/ norelgestromin patches ethinyl estradiol/norethindrone ethinyl estradiol/ norethindrone acetate ethinyl estradiol/norethindrone/iron ethinyl estradiol/norgestimate ethinyl estradiol/norgestrel EUCRISA EXKIVITY [SP] famotidine FARXIGA FASENRA [INJ] [SP] fenofibrate fenofibric acid delayed-release FENSOLVI [INJ] [SP] fentanyl patches FETZIMA FILSPARI [SP] FINACEA FOAM finasteride fingolimod [SP] fluticasone nasal spray fluticasone/salmeterol inhalation powder folic acid FRAGMIN [INJ] [SP] FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE [OTC] FREESTYLE LIBRE: READER, SENSOR FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE, FREESTYLE PRECISION NEO [OTC] FRUZAQLA [SP] FULPHILA [INJ] [SP] EYSUVIS ezetimibe ezetimibe/simvastatin F FABHALTA [SP] FABRAZYME [INJ] [SP] FLECTOR fluconazole fluocinolone fluocinonide fluoxetine

GLASSIA [INJ] [SP] glatopa [INJ] [SP] glimepiride glipizide glipizide ext-release glucagon emergency kit [INJ] glyburide GLYXAMBI GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT [INJ] [SP] GRASTEK guanfacine ext-release GVOKE [INJ] H HAEGARDA [INJ] [SP] HARVONI [SP] HEMANGEOL [SP] HERCESSI [INJ] [SP] HUMALOG CARTRIDGE, U-100 KWIKPEN, U-200 KWIKPEN, JUNIOR KWIKPEN [INJ] HUMALOG MIX [INJ] HUMALOG TEMPO [INJ] HUMULIN [INJ] HUMULIN MIX [INJ] hydralazine hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/chlorpheniramine polistirex ext-release hydrocortisone topical hydromorphone hydroxychloroquine hydroxyzine hcl hydroxyzine pamoate HYMPAVZI PEN [INJ] [SP] HYSINGLA ER I ibandronate IBRANCE [SP] ibuprofen icosapent ethyl IDELVION [INJ] [SP] ILET: PUMP, SUPPLIES IMBRUVICA [SP] IMKELDI [SP] INBRIJA [SP] INCRUSE ELLIPTA indomethacin INFLIXIMAB [INJ] [SP] INGREZZA, INGREZZA SPRINKLE [SP] INLYTA [SP] INSULIN GLARGINE-YFGN [INJ] INSULIN LISPRO [INJ] INSULIN LISPRO PROTAMINE MIX [INJ] ipratropium bromide nasal spray ipratropium/albuterol sulfate nebulization solution IQIRVO [SP] irbesartan isosorbide mononitrate ext-release isotretinoin J JAKAFI [SP] JANUMET, JANUMET XR JANUVIA

JARDIANCE JIVI [INJ] [SP] JULUCA [SP] K KERENDIA

methylprednisolone metoclopramide metoprolol succinate ext-release metoprolol tartrate metronidazole metronidazole topical metronidazole vaginal MICROLET: LANCETS, NEXT LANCING DEVICE [OTC] MIEBO MINIMED: INSULIN PUMP, PUMP INFUSION SETS, PARADIGM RESERVOIR minocycline mirabegron ext-release MIRENA [SP] mirtazapine MIRVASO MITIGARE modafinil mometasone MONOVISC [INJ] [SP] montelukast morphine sulfate ext-release MOUNJARO [INJ] MOVANTIK moxifloxacin eye solution MULTAQ mupirocin MYFEMBREE MYHIBBIN [SP] MYRBETRIQ N nabumetone naloxone nasal spray NAMZARIC naproxen naproxen sodium NASCOBAL NAYZILAM nebivolol NEFFY NEMLUVIO [INJ] [SP] neomycin/polymyxin/hydrocortisone ear solution NGENLA [INJ] [SP] niacin ext-release nifedipine ext-release NINLARO [SP] nitrofurantoin macrocrystal NITYR [SP] NIVESTYM [INJ] [SP] norethindrone nortriptyline NOVOEIGHT [INJ] [SP] NUBEQA [SP] NUCALA [INJ] [SP] NUEDEXTA NURTEC ODT nystatin nystatin topical O OCALIVA [SP] OCREVUS, OCREVUS ZUNOVO [INJ] [SP] ODACTRA NEXLETOL NEXLIZET

KESIMPTA [INJ] [SP] ketoconazole topical ketorolac KISQALI [SP] KITABIS PAK [SP] KLOXXADO KOVALTRY [INJ] [SP] KYLEENA [SP] L labetalol lacosamide LAGEVRIO (EUA) lamotrigine lansoprazole delayed-release latanoprost eye solution LENVIMA [SP] letrozole

levetiracetam levocetirizine levofloxacin levothyroxine sodium levoxyl LICART lidocaine patches LINZESS liothyronine liraglutide [INJ] lisdexamfetamine lisinopril lisinopril/hctz lithium carbonate LIVDELZI [SP]

LOKELMA lorazepam LORBRENA [SP] losartan losartan/hctz loteprednol eye suspension lovastatin LUMRYZ ER [SP] LUPKYNIS [SP] LUPRON DEPOT [INJ] [SP] lurasidone LYNPARZA [SP] LYUMJEV [INJ] LYUMJEV TEMPO [INJ] M magnesium sulfate/potassium sulfate/sodium sulfate solution MAYZENT [SP] meclizine medroxyprogesterone MEKINIST [SP] MEKTOVI [SP] meloxicam mesalamine delayed-release metaxalone metformin metformin ext-release methimazole methocarbamol methotrexate methylphenidate methylphenidate ext-release

furosemide FYCOMPA fyremadel [INJ] [SP] G gabapentin GAMMACORE GAVRETO [SP] GELNIQUE gemfibrozil GENOTROPIN [INJ] [SP] GENVOYA [SP]

ODEFSEY [SP] ODOMZO [SP] OFEV [SP]

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R rabeprazole delayed-release RADICAVA ORS [SP] RAGWITEK raloxifene ramipril REBIF [INJ] [SP] RECTIV RELISTOR [INJ] REPATHA [INJ] RESTASIS MULTIDOSE RETACRIT [INJ] [SP] REZDIFFRA [SP] RINVOQ ER, RINVOQ LQ [SP] risperidone RUCONEST [INJ] [SP] RUXIENCE [INJ] [SP] RYBELSUS RYDAPT [SP] RYKINDO [INJ] S SAVELLA SCEMBLIX [SP] SELARSDI [INJ] [SP] SEMGLEE (YFGN) [INJ] sertraline SEVENFACT [INJ] [SP] sildenafil SIMLANDI [INJ] [SP] SIMPONI 100MG (for Ulcerative Colitis only) [INJ] [SP] rizatriptan roflumilast ropinirole rosuvastatin ROZLYTREK [SP] simvastatin SKYLA [SP] SKYRIZI [INJ] [SP] SODIUM OXYBATE (by Hikma) [SP] solifenacin SOLIQUA [INJ] SOLOSEC SOMATULINE DEPOT [INJ] [SP] SOMAVERT [INJ] [SP] SOTYKTU [SP] SPIRIVA RESPIMAT spironolactone STIOLTO RESPIMAT STIVARGA [SP] STRENSIQ [INJ] [SP] STRIVERDI RESPIMAT SUBLOCADE [INJ] [SP] sucralfate sulfamethoxazole/trimethoprim sumatriptan SUNOSI SUPPRELIN LA [SP] SYMFI, SYMFI LO [SP] SYMJEPI [INJ] SYMLINPEN [INJ] SYMPROIC SYMTUZA [SP] SYNJARDY, SYNJARDY XR T

ofloxacin OGIVRI [INJ] [SP] olanzapine olmesartan olmesartan/hctz omega-3 acid ethyl esters omeprazole delayed-release OMNIPOD 5: KITS, PODS OMNIPOD DASH: KITS, PODS OMNIPOD GO: PODS OMNITROPE [INJ] [SP] OMVOH [INJ] [SP] ondansetron ondansetron orally disintegrating tablets ORIAHNN ORILISSA ORTHOVISC [INJ] [SP] oseltamivir OTEZLA [SP] OVIDREL [INJ] [SP] oxcarbazepine oxybutynin ext-release oxycodone oxycodone/acetaminophen OZEMPIC [INJ] P PANCREAZE pantoprazole delayed-release paroxetine hcl PAXLOVID penicillin v potassium PENTASA 250MG CAPSULES pioglitazone PIQRAY [SP] PLEGRIDY [INJ] [SP] polymyxin/trimethoprim eye solution POMALYST [SP] potassium chloride ext-release pramipexole pravastatin PRECISION XTRA: METERS, TEST STRIPS, B-KETONE STRIPS [OTC] prednisolone acetate eye suspension prednisolone sodium phosphate OPSUMIT [SP] OPSYNVI [SP] ORALAIR [SP] PHEBURANE [SP] PHESGO [INJ] [SP] PIFELTRO [SP] progesterone micronized PROLASTIN C [INJ] [SP] promethazine promethazine/dextromethorphan propranolol propranolol ext-release Q quetiapine quinapril QULIPTA QVAR REDIHALER prednisone pregabalin PREGNYL [INJ] [SP] PREMARIN CREAM prenatal vitamins PROCRIT [INJ] [SP]

TAKHZYRO [INJ] [SP] TALICIA TALTZ [INJ] [SP] TALZENNA [SP] tamoxifen tamsulosin ext-release TANDEM MOBI CARTRIDGE, KIT, SYSTEM TAVALISSE [SP] TECHLITE LANCETS [OTC] telmisartan terazosin terconazole vaginal teriflunomide [SP] testosterone cypionate [INJ] TEZSPIRE [INJ] [SP] thyroid timolol maleate eye solution tiotropium powder inhaler tizanidine TOBI PODHALER [SP] tobramycin eye solution tobramycin/dexamethasone eye suspension topiramate topiramate ext-release torsemide TOUJEO [INJ] TRACLEER SUSPENSION [SP] tramadol trazodone triamterene/hctz TRIJARDY XR TRIPTODUR [INJ] [SP] TRIUMEQ [SP] TRIVIDIA METERS: TRUE METRIX AIR, TRUE METRIX, TRUE METRIX GO [OTC] TRIVIDIA TEST STRIPS: TRUE METRIX, TRUETRACK [OTC] TRULANCE TRULICITY [INJ] TRELEGY ELLIPTA TREMFYA [INJ] [SP] treprostinil [INJ] [SP] TRESIBA [INJ] tretinoin topical triamcinolone topical

VELTASSA VEMLIDY venlafaxine

venlafaxine ext-release verapamil ext-release VERQUVO VERZENIO [SP] VGO VIBERZI vilazodone VIOKACE VITRAKVI [SP] VIVITROL [INJ] [SP] VIZIMPRO [SP] VOSEVI [SP] VOYDEYA [SP] VTAMA

VUMERITY [SP] VYNDAMAX [SP] VYNDAQEL [SP] W warfarin WEGOVY [INJ] X XACIATO XALKORI [SP] XARELTO XDEMVY [SP] XELJANZ, XELJANZ SOLUTION, XELJANZ XR [SP] XHANCE XIFAXAN XIGDUO XR XIIDRA XOLAIR [INJ] [SP] XTANDI [SP] XYNTHA, XYNTHA SOLOFUSE [INJ] [SP] XYOSTED [INJ] XYWAV [SP] Y

YESINTEK [INJ] [SP] YEZTUGO [INJ] [SP] YEZTUGO [SP] YONSA [SP] YUPELRI Z ZELBORAF [SP] ZEMAIRA [INJ] [SP] ZENPEP ZEPATIER [SP] ZEPBOUND PEN [INJ] ZEPOSIA [SP] ZIEXTENZO [INJ] [SP] ZIRABEV [INJ] [SP] zolpidem zolpidem ext-release ZOMIG 2.5MG NASAL ZORYVE 0.15% CREAM ZTLIDO ZUBSOLV ZURZUVAE [SP] ZYKADIA [SP] ZYMFENTRA [INJ] [SP]

TRUQAP [SP] TWIIST: KITS TYENNE [INJ] [SP] TYMLOS [INJ] [SP] TYVASO DPI [SP] U UBRELVY

UPTRAVI TABLETS [SP] USTEKINUMAB-TTWE (by Quallent) [INJ] [SP] UZEDY [INJ] V valacyclovir valsartan valsartan/hctz VALTOCO VANRAFIA [SP] varenicline VARUBI VASCEPA VELSIPITY [SP]

TABRECTA [SP] tacrolimus topical tadalafil TAFINLAR [SP] TAGRISSO [SP]

For Stelara, see Exclusion Document for more information.

Go to express-scripts.com/2026drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2026, THROUGH DECEMBER 31, 2026. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com.

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2026 National Preferred Formulary Exclusions

The excluded medications shown below are not covered on the Express Scripts drug list. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. If there is a clinical reason, identified by your doctor, that requires you to continue taking your current medication, your doctor can request a coverage review by visiting the Express Scripts online portal at esrx.com/PA. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans. Drug Class Excluded Medications Preferred Alternatives

vancomycin capsules, vancomycin 50mg/ml oral solution

FIRVANQ, VANCOMYCIN 25MG/ML SOLUTION

ANTIINFECTIVES Antibiotic Agents (Oral)

FULVICIN P/G griseofulvin ultra 125mg or 250mg tablets LIKMEZ, METRONIDAZOLE 125MG TABLETS metronidazole 250mg or 500mg tablets SIVEXTRO linezolid tablets or suspension

nitrofurantoin macro, nitrofurantoin mono/macro, sulfamethoxazole/trimethoprim, trimethoprim

fosfomycin

Antibiotic Agents for Urinary Tract Infections

NITROFURANTOIN 50MG/5ML SUSPENSION nitrofurantoin 25mg/5ml suspension

Antifungal Agents (Oral)

TOLSURA

itraconazole

Antivirals

penciclovir cream, DENAVIR, XERESE

acyclovir oral or cream, famciclovir, valacyclovir

Chagas Disease Agents

LAMPIT

BENZNIDAZOLE

KISUNLA, LEQEMBI

No alternatives recommended

AUTONOMIC & CENTRAL NERVOUS SYSTEM Alzheimer’s Agents Amyotrophic Lateral Sclerosis (ALS) Agents

donepezil, galantamine tablets, galantamine er, rivastigmine

ZUNVEYL

QALSODY

No alternatives recommended

EPRONTIA, TOPIRAMATE 50MG SPRINKLE CAPSULES

topiramate 25mg sprinkle capsules

FINTEPLA GABARONE LIBERVANT MOTPOLY XR

DIACOMIT, EPIDIOLEX

gabapentin

diazepam rectal gel, NAYZILAM, VALTOCO

Anticonvulsants

lacosamide

PRIMIDONE 125MG TABLETS

primidone 50mg or 250mg tablets

VIGAFYDE ZONISADE

vigabatrin powder packets

zonisamide

ONZETRA XSAIL

sumatriptan nasal spray, zolmitriptan nasal spray etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen or oxaprozin plus almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan or zolmitriptan

sumatriptan/naproxen sodium, SYMBRAVO, TREXIMET

Antimigraine Agents

TRUDHESA

dihydroergotamine nasal spray

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

VYEPTI

AIMOVIG, AJOVY, EMGALITY

AUTONOMIC & CENTRAL NERVOUS SYSTEM Antimigraine Agents (continued)

eletriptan, naratriptan, rizatriptan, sumatriptan, NURTEC ODT, UBRELVY Coverage may be approved for the treatment of Parkinson’s Disease under certain conditions.

ZAVZPRET

APOKYN

DHIVY

carbidopa/levodopa

GOCOVRI ER

amantadine

Antiparkinsonism Agents

cabergoline, entacapone, pramipexole, rasagiline, ropinirole

NOURIANZ

ONAPGO, VYALEV XADAGO, ZELAPAR

carbidopa/levodopa er rasagiline, selegiline

risperidone er, ABILIFY ASIMTUFII, ABILIFY MAINTENA, ARISTADA, ARISTADA INITIO, ERZOFRI, RYKINDO ER, UZEDY ER aripiprazole, asenapine, lurasidone, olanzapine, paliperidone er, quetiapine tablets (except 150mg), risperidone, ziprasidone

INVEGA HAFYERA, INVEGA SUSTENNA, INVEGA TRINZA

Antipsychotics (Injectable)

COBENFY, FANAPT

Antipsychotics (Oral)

OPIPZA

aripiprazole odt or oral solution quetiapine 50mg or 100mg tablets baclofen solution, suspension or tablets metaxalone 400mg or 800mg tablets

QUETIAPINE 150MG TABLETS LYVISPAH, OZOBAX, OZOBAX DS METAXALONE 640MG TABLETS

Antispasmodic Agents

BUCAPSOL LOREEV XR

buspirone

Anxiolytic Agents

lorazepam tablets

LUMRYZ ER, SODIUM OXYBATE (by Hikma), XYWAV dextroamphetamine er, dextroamphetamine/ amphetamine er, lisdexamfetamine dexmethylphenidate er, methylphenidate cd, methylphenidate er, methylphenidate la, AZSTARYS

Cataplexy Treatment

SODIUM OXYBATE (by Amneal), XYREM

DYANAVEL XR, XELSTRYM

Central Nervous System Stimulants

METHYLPHENIDATE ER 45MG, 63MG & 72MG, QUILLICHEW ER, QUILLIVANT XR, RELEXXII ER

ONYDA XR

clonidine er tablets

prednisolone solution/syrup, prednisolone tablets, prednisone solution, prednisone tablets

AGAMREE

AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53

Duchenne Muscular Dystrophy (DMD) Agents

No alternatives recommended

Coverage may be approved for the treatment of Duchenne Muscular Dystrophy under certain conditions.

DUVYZAT

Movement Disorders Therapy

AUSTEDO, AUSTEDO XR

INGREZZA, INGREZZA SPRINKLE

BRIUMVI

KESIMPTA, OCREVUS, OCREVUS ZUNOVO dimethyl fumarate, fingolimod, teriflunomide, BAFIERTAM, MAYZENT, VUMERITY, ZEPOSIA (for Multiple Sclerosis only)

Multiple Sclerosis Agents

GILENYA, PONVORY, TASCENSO ODT

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

CONZIP, QDOLO, TRAMADOL 25MG & 75MG TABLETS, TRAMADOL ER CAPSULES, TRAMADOL SOLUTION

tramadol 50mg & 100mg tablets, tramadol er tablets

hydromorphone tablets, morphine tablets, oxycodone tablets, oxymorphone tablets hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen hydrocodone bitartrate er, hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER

levorphanol

AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) Narcotic Analgesics & Combinations

NUCYNTA

NUCYNTA ER, OXYCODONE ER, OXYCONTIN, XTAMPZA ER OXAYDO, OXYCODONE COATED TABLETS, ROXYBOND

oxycodone uncoated tablets

PRIMLEV, PROLATE SOLUTION

oxycodone/acetaminophen

SEGLENTIS

tramadol 50mg tablets plus celecoxib

Narcotic Antagonists Niemann-Pick Disease Type C Agents Rett Syndrome Agents

ZIMHI

naloxone syringes

MIPLYFFA

AQNEURSA

DAYBUE

No alternatives recommended

DORAL, QUAZEPAM

estazolam, lorazepam

Sedative-Hypnotic Agents

ZOLPIDEM 7.5MG CAPSULES

eszopiclone, zaleplon, zolpidem tablets citalopram tablets, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone desvenlafaxine er, duloxetine, venlafaxine hcl er, FETZIMA

Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants

CITALOPRAM CAPSULES

DRIZALMA SPRINKLE, VENLAFAXINE BESYLATE ER

FENTANYL CITRATE BUCCAL TABLETS, FENTORA

Transmucosal Fentanyl Analgesics

fentanyl citrate lozenges

APLENZIN, BUPROPION XL 450MG, FORFIVO XL bupropion xl 150mg or 300mg RALDESY trazodone tablets

Miscellaneous Antidepressants

olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline tablets

SPRAVATO

CARDIOVASCULAR ACE Inhibitors

QBRELIS

lisinopril

Alpha-Adrenergic Agonists

CLONIDINE ER 0.17MG, NEXICLON XR

clonidine patches, clonidine tablets

candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

EDARBI

candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, chlorthalidone plus valsartan

Angiotensin Receptor Blockers (ARBs) & Combinations

EDARBYCLOR

(continued)

CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)

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Drug Class

Excluded Medications

Preferred Alternatives

CARDIOVASCULAR Angiotensin Receptor Blockers (ARBs) & Combinations (continued)

telmisartan/amlodipine

amlodipine/olmesartan, amlodipine/valsartan

VALSARTAN SOLUTION

valsartan tablets

Anticoagulants

PRADAXA, SAVAYSA

dabigatran, ELIQUIS, XARELTO

BISOPROLOL FUMARATE 2.5MG TABLETS

bisoprolol 5mg or 10mg

INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE LABETALOL 400MG TABLETS CONJUPRI, LEVAMLODIPINE

propranolol er

Beta Blockers & Combinations

metoprolol succinate

labetalol 100mg, 200mg or 300mg tablets amlodipine, felodipine er, nifedipine er, nisoldipine

Calcium Channel Blockers

KATERZIA, NORLIQVA FUROSCIX, SOAANZ HEMICLOR, THALITONE

amlodipine

bumetanide, furosemide, torsemide

chlorthalidone

Diuretics

INZIRQO

hydrochlorothiazide capsules or tablets amiloride hcl, eplerenone, spironolactone

triamterene, DYRENIUM

Generic Anti-Hypertensive Agents (Categories include: ACE Inhibitors, Alpha-Adrenergic Blockers, Angiotensin Receptor Blockers [ARBs], Beta Blockers, Calcium Channel Blockers, Central Alpha-Adrenergic Agonists, Direct Renin Inhibitors, Direct Vasodilators and Diuretics) fenofibrate capsules (43mg, 67mg, 130mg, 134mg, 200mg), fenofibrate tablets, fenofibric acid atorvastatin, fluvastatin er, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin ezetimibe plus atorvastatin or rosuvastatin

Endothelin Receptor Antagonists

TRYVIO

FENOFIBRATE CAPSULES (30MG, 50MG, 90MG, 150MG), LIPOFEN

Fenofibrates

ALTOPREV, ATORVALIQ, EZALLOR SPRINKLE

HMG & Cholesterol Inhibitor Combinations

ROSUVASTATIN/EZETIMIBE

PCSK9 & siRNA Inhibitors

LEQVIO, PRALUENT

REPATHA

Pulmonary Arterial Hypertension (PAH) Agents Sodium Glucose Co-Transporter-1 & 2 Inhibitors

sildenafil oral suspension, sildenafil 20mg tablets, tadalafil 20mg tablets

LIQREV, TADLIQ

INPEFA

FARXIGA, JARDIANCE

ASPRUZYO SPRINKLE ER

ranolazine er

ivabradine tablets, atenolol, bisoprolol 5mg or 10mg, carvedilol, metoprolol succinate, metoprolol tartrate, propranolol

CORLANOR SOLUTION, CORLANOR TABLETS

Miscellaneous Cardiovascular Agents

LODOCO

colchicine

NORPACE CR

amiodarone, quinidine sulfate, sotalol Over-the-Counter aluminum chloride containing products

DERMATOLOGICAL Agents for Hyperhidrosis

DRYSOL, QBREXZA, SOFDRA

Coverage may be approved for the treatment of molluscum contagiosum.

Molluscum Contagiosum Agents

ZELSUVMI

Oral Agents for Acne

ABSORICA LD

isotretinoin capsules

(continued)

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Page 7

Drug Class

Excluded Medications

Preferred Alternatives

DORYX DR 80MG, DORYX MPC, DOXYCYCLINE HYCLATE DR 80MG MINOCYCLINE BIPHASIC TABLETS, MINOCYCLINE ER CAPSULES, XIMINO

doxycycline hyclate, doxycycline monohydrate

DERMATOLOGICAL Oral Agents for Acne (continued)

minocycline 24 hour er tablets

Oral: minocycline Topical: azelaic acid, ivermectin, metronidazole azelaic acid, ivermectin topical, metronidazole topical, sodium sulfacetamide/sulfur, FINACEA FOAM

Rosacea Agents (Oral)

EMROSI

EPSOLAY, ZILXI

Rosacea Agents (Topical)

NORITATE

metronidazole topical

adapalene, adapalene/benzoyl peroxide, benzoyl peroxide gel, clindamycin topical, clindamycin/ benzoyl peroxide, tretinoin, tretinoin micro

CABTREO, TWYNEO

CLENIA PLUS, SULFACETAMIDE/SULFUR 8%-4% CLEANSER, SULFACETAMIDE/SULFUR 9%-4.25% SUSPENSION, ZMA CLEAR

sulfacetamide/sulfur 9%-4% cleanser, sulfacetamide/sulfur 8%-4% suspension

Topical Agents for Acne

azelaic acid, dapsone 5% (tube) or 7.5% gel (pump), clindamycin topical, erythromycin topical, FINACEA FOAM

DAPSONE 7.5% GEL (TUBE)

FABIOR, TAZAROTENE FOAM

tazarotene cream or gel, tretinoin

azelaic acid, clindamycin phosphate gel, clindamycin/tretinoin, dapsone, erythromycin gel, tretinoin diclofenac 3% gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod

WINLEVI

CARAC, FLUOROURACIL 0.5% CREAM, KLISYRI, ZYCLARA

Topical Agents for Actinic Keratosis

ciclopirox 8% topical solution, tavaborole topical solution

ciclopirox 8% treatment kit

MICONAZOLE/ZINC OXIDE/PETROLATUM, VUSION naftifine, oxiconazole, ECOZA, ERTACZO, LULICONAZOLE, LUZU, NAFTIN, OXISTAT LOTION, SULCONAZOLE, XOLEGEL clocortolone, diflorasone, diflorasone/emollient, flurandrenolide, halcinonide, CLOBETASOL 0.025%, IMPOYZ, SERNIVO, ULTRAVATE, VERDESO

clotrimazole, ketoconazole, miconazole, nystatin

Topical Antifungals

ciclopirox, clotrimazole, econazole, ketoconazole

generic topical corticosteroids except those listed in the exclusion column

Topical Corticosteroids

Vitamin D Analogs (Topical)

CALCIPOTRIENE FOAM, SORILUX

calcipotriene cream, ointment or solution

generic topical corticosteroids except those listed in the exclusion column for Topical Corticosteroids plus mupirocin

ALCORTIN A

crotamiton

permethrin

Miscellaneous Topical Dermatological Agents

alclometasone cream and ointment; desonide cream and ointment; fluocinolone body oil, cream, ointment and solution; hydrocortisone 1% cream and ointment, 2.5% cream, lotion, ointment and solution; hydrocortisone valerate cream and ointment

doxepin cream

LIDOCAINE/TETRACAINE, PLIAGLIS

lidocaine cream, lidocaine/prilocaine cream

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

DERMATOLOGICAL Miscellaneous Topical Dermatological Agents (continued)

TRI-LUMA

fluocinolone, hydroquinone, tretinoin

VEREGEN

imiquimod 5% cream, podofilox gel or solution

DIABETES Biguanidine Agents

METFORMIN 625MG TABLETS

metformin 500mg, 850mg or 1,000mg tablets

ABBOTT FREESTYLE KITS/METERS (FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE) ABBOTT FREESTYLE TEST STRIPS (FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE, FREESTYLE PRECISION NEO) ABBOTT PRECISION XTRA METERS, TEST STRIPS TRIVIDIA METERS (TRUE METRIX AIR, TRUE METRIX, TRUE METRIX GO) TRIVIDIA TEST STRIPS (TRUE METRIX, TRUETRACK)

ASCENSIA (CONTOUR) ELI LILLY (TEMPO) LIFESCAN (ONETOUCH SOLUTIONS STARTER, ULTRA, ULTRA2, VERIO, VERIO FLEX) ROCHE (ACCU-CHEK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED

Blood Glucose Meters & Test Strips

DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR

Continuous Glucose Monitoring Systems

EVERSENSE 365: SENSOR, TRANSMITTER

PEN NEEDLES & SYRINGES BY: ARKRAY HOME AIDE DIAGNOSTICS HTL-STREFA NOVO NORDISK OWEN MUMFORD PRODIGY DIABETES CARE SIMPLE DIAGNOSTICS TRIVIDIA (NIPRO DIAGNOSTICS) ULTIMED ALL OTHER DIABETIC PEN NEEDLES & SYRINGES THAT ARE NOT LISTED AS PREFERRED

EMBECTA PEN NEEDLES EMBECTA SYRINGES

Diabetic Pen Needles & Syringes

DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR

Diabetic Supply Kits

BIGFOOT UNITY PROGRAM KIT

ALOGLIPTIN, NESINA, SITAGLIPTIN, TRADJENTA, ZITUVIO ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, SITAGLIPTIN/METFORMIN, SITAGLIPTIN/METFORMIN ER, ZITUVIMET, ZITUVIMET XR

saxagliptin, JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations

saxagliptin/metformin, JANUMET, JANUMET XR

ALOGLIPTIN/PIOGLITAZONE

pioglitazone plus saxagliptin or JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations

QTERN, STEGLUJAN

GLYXAMBI

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

DIABETES (continued) Glucose-Elevating Drugs

GLUCAGEN HYPOKIT, GLUCAGON EMERGENCY KIT (by Fresenius), ZEGALOGUE

glucagon emergency kit (by Amphastar), BAQSIMI, GVOKE

Insulin (Basal) & Glucagon-Like Peptide-1 (GLP-1) Agonist Combinations

XULTOPHY

SOLIQUA

U-100: HUMALOG (CARTRIDGE, KWIKPEN, JUNIOR KWIKPEN), HUMALOG TEMPO, INSULIN LISPRO, LYUMJEV KWIKPEN & VIAL, LYUMJEV TEMPO U-200: HUMALOG KWIKPEN, LYUMJEV KWIKPEN

U-100: ADMELOG, APIDRA, FIASP, HUMALOG VIAL, INSULIN ASPART, NOVOLOG, RELION NOVOLOG Inhalation: AFREZZA

U-100: BASAGLAR, BASAGLAR TEMPO, INSULIN DEGLUDEC, INSULIN GLARGINE, LANTUS, LEVEMIR, REZVOGLAR

U-100: INSULIN GLARGINE-YFGN, SEMGLEE (YFGN), TRESIBA

Insulins

U-200: TRESIBA U-300: TOUJEO

U-200: INSULIN DEGLUDEC U-300: INSULIN GLARGINE

INSULIN ASPART PROTAMINE, NOVOLOG MIX, RELION NOVOLOG MIX NOVOLIN, NOVOLIN MIX, RELION NOVOLIN, RELION NOVOLIN MIX BRENZAVVY, DAPAGLIFLOZIN, INVOKANA, STEGLATRO DAPAGLIFLOZIN/METFORMIN ER, INVOKAMET, INVOKAMET XR, SEGLUROMET

HUMALOG MIX, INSULIN LISPRO PROTAMINE MIX

HUMULIN, HUMULIN MIX

FARXIGA, JARDIANCE

Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors & Combinations

SYNJARDY, SYNJARDY XR, XIGDUO XR

GLIMEPIRIDE 3MG TABLETS GLIPIZIDE 2.5MG TABLETS

glimepiride 1mg, 2mg or 4mg tablets

Sulfonylurea Agents

glipizide 5mg tablets

EAR/NOSE Nasal Antihistamines & Combination Products

azelastine/fluticasone, DYMISTA

azelastine nasal plus fluticasone nasal

Nasal Steroids

BECONASE AQ, OMNARIS, QNASL, ZETONNA flunisolide, fluticasone, mometasone, XHANCE

CETRAXAL

ciprofloxacin otic, ofloxacin otic

Otic Antibiotics & Combination Products

CIPRO HC, CIPROFLOXACIN/FLUOCINOLONE OTIC

ciprofloxacin/dexamethasone otic

ketoconazole tablets, mifepristone 300mg, SIGNIFOR

ISTURISA

ENDOCRINE Cushing’s Agents

RECORLEV

ketoconazole tablets

Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty)

LUPRON DEPOT-PED

FENSOLVI, SUPPRELIN LA, TRIPTODUR

HUMATROPE, NORDITROPIN FLEXPRO, NUTROPIN AQ NUSPIN, SAIZEN, SAIZENPREP, ZOMACTON

GENOTROPIN, OMNITROPE

Growth Hormones

SKYTROFA, SOGROYA

GENOTROPIN, OMNITROPE, NGENLA

LANREOTIDE, SANDOSTATIN LAR DEPOT

SOMATULINE DEPOT

Somatostatin Analogs

For Acromegaly: SOMATULINE DEPOT For Cushing’s Disease: SIGNIFOR

SIGNIFOR LAR

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

testosterone cypionate, testosterone enanthate, XYOSTED

AVEED, AZMIRO

ENDOCRINE (continued) Testosterone Products

KYZATREX, NATESTO, TLANDO, UNDECATREX ADTHYZA 16.25MG, 32.5MG, 65MG, 97.5MG, 130MG LEVOTHYROXINE CAPSULES, THYQUIDITY, TIROSINT, TIROSINT-SOL

testosterone gel, testosterone solution levothyroxine tablets, thyroid pork, ARMOUR THYROID

Thyroid Replacement Therapy

levothyroxine tablets

Miscellaneous Endocrine Agents

CORTROPHIN GEL

No alternatives recommended

GASTROINTESTINAL Antidiarrheal Agents Antiemetics (Injectable)

opium tincture, MYTESI

diphenoxylate/atropine, loperamide

CINVANTI, FOCINVEZ

fosaprepitant injection

granisetron, ondansetron, aprepitant, VARUBI TABLETS

AKYNZEO CAPSULES

ANTIVERT, MECLIZINE 50MG TABLETS

meclizine 25mg tablets granisetron, ondansetron doxylamine/pyridoxine hcl aprepitant, VARUBI TABLETS

ANZEMET BONJESTA

Antiemetics (Oral)

EMEND POWDER PACKETS

ONDANSETRON ODT 16MG TABLETS

ondansetron odt 4mg or 8mg tablets

magnesium sulfate/potassium sulfate/sodium sulfate solution, peg 3350/ascorbic acid powder packets

Bowel Evacuants

CLENPIQ, PLENVU, SUFLAVE, SUTAB

Constipation Agents Corticosteroids (Rectal Formulations)

RELISTOR TABLETS

lubiprostone, MOVANTIK, SYMPROIC

CORTIFOAM

budesonide foam, hydrocortisone enema

Gallstone Dissolution Agents

RELTONE

ursodiol

Gastroparesis Agents

GIMOTI

No alternatives recommended hydrocortisone ac suppositories, pramoxine/hydrocortisone cream pramoxine/hydrocortisone cream

HYDROCORTISONE/PRAMOXINE 25-18MG SUPPOSITORIES

Hemorrhoidal Preparations

PROCTOFOAM-HC

balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA 250MG CAPSULES

Inflammatory Bowel Agents

DIPENTUM

Irritable Bowel Syndrome & Chronic Constipation Agents

IBSRELA

lubiprostone, prucalopride, LINZESS, TRULANCE

Pancreatic Enzymes

PERTZYE

CREON, PANCREAZE, ZENPEP

esomeprazole magnesium capsules, lansoprazole capsules, omeprazole capsules, pantoprazole tablets, rabeprazole tablets esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole, rabeprazole

dexlansoprazole, DEXILANT

Proton Pump Inhibitors

KONVOMEP, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE

Miscellaneous Gastrointestinal Agents

DARTISLA ODT

glycopyrrolate tablets

HEMATOLOGICAL Antiplatelet Agents

aspirin plus omeprazole, esomeprazole magnesium, lansoprazole, pantoprazole or rabeprazole

YOSPRALA DR

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

HEMATOLOGICAL (continued) Erythropoiesis-Stimulating Agents

ARANESP, EPOGEN, MIRCERA

PROCRIT, RETACRIT

IXINITY, RIXUBIS NOVOSEVEN RT

BENEFIX

SEVENFACT

ADVATE, ADYNOVATE, AFSTYLA, ALTUVIIIO, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, XYNTHA, XYNTHA SOLOFUSE

Factor Deficiency Agents & Related Products

NUWIQ, RECOMBINATE

REBINYN

ALPROLIX, IDELVION

FYLNETRA, NEULASTA, NYVEPRIA, ROLVEDON, RYZNEUTA, STIMUFEND, UDENYCA GRANIX, NEUPOGEN, NYPOZI, RELEUKO, ZARXIO

FULPHILA, ZIEXTENZO

Granulocyte Colony Stimulating Factors

NIVESTYM

Hematopoietic & Thrombopoietic Agents

APHEXDA

plerixafor

For Hemophilia A with inhibitors: ALHEMO, HEMLIBRA

For Hemophilia A without inhibitors: ALHEMO, HEMLIBRA, HYMPAVZI For Hemophilia B with inhibitors: ALHEMO For Hemophilia B without inhibitors: ALHEMO, HYMPAVZI

Hemophilia Agents

QFITLIA

Hemophilia Gene Therapy Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors Iron Replacement Agents Sickle Cell Disease Agents

BEQVEZ

HEMGENIX

VAFSEO

PROCRIT, RETACRIT

MONOFERRIC SIKLOS, XROMI

sodium ferric gluconate complex, VENOFER

hydroxyurea, DROXIA eltrombopag, NPLATE

ALVAIZ

Thrombocytopenia Agents

MULPLETA

DOPTELET

Coverage may be approved for the treatment of Myelodysplastic Syndrome with Transfusion- Dependent Anemia under certain conditions.

Miscellaneous Hematology Agents RYTELO

HEPATITIS Hepatitis C

LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI

EPCLUSA, HARVONI, VOSEVI, ZEPATIER

atazanavir, darunavir, fosamprenavir, lopinavir/ritonavir, ritonavir, PREZISTA

PREZCOBIX

HIV Antiretrovirals

Coverage may be approved for the treatment of human immunodeficiency virus-1 infection in heavily treatment-experienced patients with multidrug-resistant infection.

Note: Current patients established on therapy are allowed to continue therapy.

RUKOBIA ER

STRIBILD

BIKTARVY, GENVOYA

MUSCULOSKELETAL & RHEUMATOLOGY Muscle Relaxants & Antispasmodic Agents

METHOCARBAMOL 1,000MG TABLETS

methocarbamol 500mg tablets

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

COMBOGESIC

ibuprofen plus acetaminophen

COXANTO, DICLOFENAC 35MG CAPSULES, DOLOBID, FENOPROFEN 200MG CAPSULES, FENOPRON, KETOROLAC NASAL SPRAY, OXAPROZIN 300MG CAPSULES, RELAFEN DS, SPRIX, ZORVOLEX

MUSCULOSKELETAL & RHEUMATOLOGY (continued) Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

generic oral nonsteroidal anti-inflammatory drugs

ELYXYB

celecoxib

MELOXICAM SUSPENSION

ibuprofen suspension, naproxen suspension

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

DICLOFENAC EPOLAMINE PATCHES

FLECTOR, LICART

OBSTETRICAL & GYNECOLOGICAL Combination Patches

CLIMARA PRO

COMBIPATCH

FEMLYV, LO LOESTRIN FE, NATAZIA, NEXTSTELLIS, TWIRLA, TYBLUME

generic oral, patch and ring contraceptives

Contraceptives

Barrier methods of contraception, such as condoms, diaphragms or spermicides.

PHEXXI

SLYND

generic progestin-only oral contraceptives estradiol cream, estradiol vaginal inserts, PREMARIN CREAM

ESTRING, IMVEXXY, INTRAROSA, OSPHENA

Estrogen & Estrogen Modifiers for Vaginal Symptoms

estradiol cream, estradiol patches, estradiol tablets, estradiol vaginal inserts, PREMARIN CREAM

FEMRING

Estrogen/Progestin Combinations (Oral)

estradiol/norethindrone acetate, ethinyl estradiol/norethindrone acetate

BIJUVA, PREMPHASE, PREMPRO

Estrogens (Oral)

MENEST, PREMARIN TABLETS

estradiol tablets

CHORIONIC GONADOTROPIN 10,000 UNITS, NOVAREL

Human Chorionic Gonadotropin

OVIDREL, PREGNYL

GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT generic prenatal vitamins

Ovulatory Stimulants (Follitropins)

FOLLISTIM AQ

Prenatal Vitamins

CITRANATAL, NATAL PNV, PREGENNA, TRINAZ

Topical Estrogen Agents

ELESTRIN

estradiol gel, gel pump or patches

medroxyprogesterone, megestrol, norethindrone, progesterone paroxetine hcl, paroxetine hcl ext-release Coverage may be approved for the treatment of Acute Myeloid Leukemia under certain conditions.

Vaginal Progesterones

CRINONE 4%

Miscellaneous Gynecological Agents paroxetine mesylate

ONUREG

ONCOLOGY Acute Myeloid Leukemia (AML) Agents

REZLIDHIA VANFLYTA GRAFAPEX

TIBSOVO RYDAPT

Alkylating Agents

busulfan, cyclophosphamide, etoposide, fludarabine Coverage may be approved for the treatment of Diffuse Large B-cell Lymphoma under certain conditions.

B-Cell Lymphoma Agents

COLUMVI

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

Coverage may be approved for the treatment of Diffuse Large B-cell Lymphoma under certain conditions. For Follicular Lymphoma: LUNSUMIO

ONCOLOGY B-Cell Lymphoma Agents (continued)

EPKINLY

Bendamustine Agents

VIVIMUSTA

bendamustine, BENDEKA

Bevacizumab-Containing Agents Bispecific Human Epidermal Growth Factor Receptor 2 (HER2)-Directed Antibody

ALYMSYS, AVASTIN, VEGZELMA

ZIRABEV

ZIIHERA

PERJETA plus HERCESSI or OGIVRI

Bortezomib Agents

BORUZU

bortezomib

For Mantle Cell Lymphoma: BRUKINSA, CALQUENCE For Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma: BRUKINSA, CALQUENCE, IMBRUVICA, VENCLEXTA

Bruton Tyrosine Kinase Inhibitors JAYPIRCA

Docetaxel Agents

DOCIVYX BESREMI

docetaxel

Interferons

hydroxyurea

Coverage may be approved for the treatment of Breast Cancer under certain conditions.

Kinase Inhibitors

ITOVEBI

Melphalan Agents (Injectable)

IVRA

melphalan injection

bortezomib, DARZALEX, KYPROLIS, POMALYST, REVLIMID, THALOMID

Multiple Myeloma Agents

XPOVIO

Myelodysplastic Syndrome Agents

INQOVI

decitabine

Myelofibrosis Agents

INREBIC, OJJAARA

JAKAFI

Coverage may be approved for the treatment of KRAS G12C-mutated non-small cell lung cancer.

KRAZATI

Non-Small Cell Lung Cancer Agents

TEPMETKO

TABRECTA LYNPARZA

PARP Inhibitors

RUBRACA, ZEJULA

Pemetrexed Agents

AXTLE

pemetrexed disodium

abiraterone plus LYNPARZA, TALZENNA plus XTANDI

AKEEGA

Prostate Cancer Agents

ELIGARD, FIRMAGON, LUPRON DEPOT, LUTRATE DEPOT

CAMCEVI, LEUPROLIDE DEPOT, TRELSTAR

Renal Cell Cancer Agents Rituximab-Containing Agents Thiotepa Injectable Agents

FOTIVDA

CABOMETYX, INLYTA, LENVIMA

RIABNI, RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE

TEPYLUTE

thiotepa

HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, KANJINTI, ONTRUZANT, TRAZIMERA

Trastuzumab-Containing Agents

HERCESSI, OGIVRI

dasatinib, imatinib, nilotinib, pazopanib, sorafenib, sunitinib, IMKELDI, STIVARGA timolol drops, betaxolol drops, carteolol drops, levobunolol drops

Tyrosine Kinase Inhibitors

QINLOCK

OPHTHALMIC Antiglaucoma Agents (Beta-Adrenergic Blockers)

BETIMOL, TIMOPTIC OCUDOSE

(continued)

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Drug Class

Excluded Medications

Preferred Alternatives

OPHTHALMIC (continued) Antiglaucoma Agents (Ophthalmic Prostaglandins)

tafluprost drops, travoprost drops, DURYSTA, IDOSE TR, IYUZEH, LUMIGAN, TRAVATAN Z, VYZULTA, XELPROS, ZIOPTAN

bimatoprost drops, latanoprost drops

Blepharoptosis Agents

UPNEEQ

No alternatives recommended

Ophthalmic Agents (Complement Protein C5 Inhibitors)

Coverage may be approved for the treatment of Geographic Atrophy under certain conditions.

IZERVAY

EYLEA, EYLEA HD, VABYSMO

PAVBLU

Ophthalmic Agents (Vascular Endothelial Growth Inhibitors)

LUCENTIS SUSVIMO

BYOOVIZ, CIMERLI

No alternatives recommended

ATROPINE (PRESERVATIVE FREE) 1% EYE SINGLE USE DROPPERETTE

atropine 1% drops

CYSTADROPS QLOSI, VUITY

CYSTARAN

Ophthalmic Agents (Other)

No alternatives recommended

azelastine drops, bepotastine drops, cromolyn drops, epinsatine drops, olopatadine drops azelastine drops, bepotastine drops, cromolyn drops, epinastine drops, olopatadine drops dexamethasone drops, difluprednate drops, fluorometholone drops, loteprednol 0.5% drops, prednisolone drops

VERKAZIA

Ophthalmic Anti-Allergic

ALOMIDE, ALREX, ZERVIATE

CLOBETASOL DROPS, FLAREX, FML FORTE, MAXIDEX, PRED MILD

Ophthalmic Anti-Inflammatory

Ophthalmic Combinations

TOBRADEX ST, ZYLET

tobramycin/dexamethasone drops

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

ACUVAIL, NEVANAC

bromfenac drops, diclofenac drops, ketorolac drops

ciprofloxacin drops, gatifloxacin drops, levofloxacin drops, moxifloxacin drops, ofloxacin drops

Ophthalmic Quinolone Antibiotics BESIVANCE, CILOXAN OINTMENT

DUROLANE, EUFLEXXA, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, HYMOVIS, SUPARTZ FX, SYNOJOYNT, SYNVISC, SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3

OSTEOARTHRITIS Hyaluronic Acid Derivatives

MONOVISC, ORTHOVISC

RENAL Nephropathic Cystinosis Agents

PROCYSBI

CYSTAGON

OXYBUTYNIN 2.5MG

oxybutynin solution or syrup, oxybutynin 5mg tablets

Overactive Bladder Agents

oxybutynin solution or syrup, MYRBETRIQ ER SUSPENSION

VESICARE LS

FERRIC CITRATE, FOSRENOL POWDER PACKETS, VELPHORO, XPHOZAH URIMAR-T CAPSULES, URNEVA

calcium acetate, lanthanum, sevelamer carbonate, sevelamer hcl

Phosphate Binders

Miscellaneous Urologicals

uro mp, uro sp

carbinoxamine liquid and 4mg tablets; cetirizine solution and syrup; desloratidine tablets; hydroxyzine solution, syrup and tablets; levocetirizine solution and tablets epinephrine auto-injector (by Mylan, Teva), AUVI-Q, EPIPEN, EPIPEN JR

RESPIRATORY Antihistamines (Oral)

clemastine, CARBINOXAMINE ER 4MG/5ML SUSPENSION, KARBINAL ER SUSPENSION

EPINEPHRINE AUTO-INJECTOR (by Amneal Pharma, Avkare)

Epinephrine Auto-Injector Systems

(continued)

CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)

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