Express Scripts 2020 National Preferred Formulary Exclusions

2021 National Preferred Formulary Exclusions

The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.

Take action to avoid paying full price. 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. 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.

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

ANTIINFECTIVES Antibiotic Agents - Vancomycins (Oral) Antifungal Agents (Oral) Antivirals (Oral) Chagas Disease Agents AUTONOMIC & CENTRAL NERVOUS SYSTEM Alpha-2 Adrenergic Agonists (for Opioid Withdrawal)

Anticonvulsants

Antimigraine Agents

Antiparkinsonism Agents

Antipsychotics (Oral) Antispasmodic Agents Central Nervous System Stimulants

Duchenne Muscular Dystrophy (DMD) Agents Lambert-Eaton Myasthenic Syndrome Agents Long-Acting Opioid Oral Analgesics Multiple Sclerosis (Beta Interferons)

Narcotic Analgesics & Combinations

Excluded Medications

FIRVANQ TOLSURA SITAVIG LAMPIT LUCEMYRA

APTIOM FINTEPLA TOPIRAMATE ER CAPSULES VYEPTI GOCOVRI ER ONGENTYS XADAGO, ZELAPAR CAPLYTA OZOBAX

AMPHETAMINE ER SUSPENSION

EMFLAZA EXONDYS 51, VILTEPSO, VYONDYS 53 FIRDAPSE MORPHABOND ER, NUCYNTA ER, OXYCODONE ER, XTAMPZA ER EXTAVIA APADAZ, BENZHYDROCODONE/ACETAMINOPHEN NUCYNTA PRIMLEV

Preferred Alternatives

vancomycin capsules, vancomycin oral solution

itraconazole acyclovir oral or cream, famciclovir, valacyclovir BENZNIDAZOLE

clonidine

carbamazepine, oxcarbazepine, pregabalin, topiramate, VIMPAT DIACOMIT, EPIDIOLEX topiramate tablets, QUDEXY XR AIMOVIG, AJOVY, EMGALITY amantadine capsules, amantadine tablets, amantadine oral solution entacapone rasagiline, selegiline aripiprazole, asenapine, olanzapine, quetiapine er, quetiapine fumarate, risperidone, ziprasidone, LATUDA baclofen, tizanidine dexmethylphenidate er, dextroamphetamine er, dextroamphetamine/amphetamine er, methylphenidate cd, methylphenidate er, methylphenidate la, DYANAVEL XR, MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE prednisone solution, prednisone tablets No alternatives recommended RUZURGI hydromorphone er, morphine sulfate er, oxymorphone er, HYSINGLA ER, OXYCONTIN AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE hydrocodone/acetaminophen hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen oxycodone/acetaminophen

~ Medications will be excluded beginning 04/01/2021

? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Page 1

Continued

CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)

Drug Class

AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) Narcotic Antagonists

Neuropathic Agents Sedative-Hypnotic Agents Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants Tardive Dyskinesia Therapy

Transmucosal Fentanyl Analgesics

Miscellaneous Antidepressants

CARDIOVASCULAR ACE Inhibitors

Excluded Medications

BUNAVAIL EVZIO, NALOXONE AUTO-INJECTOR LYRICA CR DORAL, QUAZEPAM PEXEVA~, VIIBRYD~

DRIZALMA SPRINKLE INGREZZA FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA, SUBSYS

SPRAVATO

EPANED QBRELIS EDARBI~

Angiotensin Receptor Blockers (ARBs) and Combinations

EDARBYCLOR~

Anticoagulants

Beta Blockers & Combinations

Calcium Channel Blockers HMG & Cholesterol Inhibitor Combinations PCSK9 Inhibitors DERMATOLOGICAL Agents for Hyperhidrosis Oral Agents for Acne Rosacea Agents (Oral) Topical Acne Combinations Topical Acne/Antibiotic Combinations Topical Agents for Actinic Keratosis

~ Medications will be excluded beginning 04/01/2021

? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

PRADAXA, SAVAYSA BYSTOLIC~ DUTOPROL INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE KATERZIA ALTOPREV, EZALLOR SPRINKLE PRALUENT DRYSOL~ DORYX DR 80 MG, DOXYCYCLINE HYCLATE DR 80 MG MINOCYCLINE ER CAPSULES, XIMINO DOXYCYCLINE 40 MG CAPSULES EPIDUO FORTE VELTIN CARAC, FLUOROURACIL 0.5% CREAM, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA

Page 2

Preferred Alternatives

buprenorphine/naloxone, ZUBSOLV naloxone syringes, NARCAN NASAL SPRAY gabapentin, pregabalin estazolam, lorazepam citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA

AUSTEDO

fentanyl citrate lozenges

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

enalapril lisinopril candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, chlorthalidone plus valsartan ELIQUIS, XARELTO atenolol, carvedilol, metoprolol succinate metoprolol tartrate/hydrochlorothiazide, metoprolol succinate er plus hydrochlorothiazide propranolol er metoprolol succinate amlodipine atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO REPATHA

Over-the-Counter aluminum chloride containing products

doxycycline hyclate, doxycycline monohydrate minocycline er tablets doxycycline hyclate, doxycycline monohydrate adapalene/benzoyl peroxide clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream

Continued

CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)

Drug Class

DERMATOLOGICAL (continued) Topical Antibiotics for Acne Topical Antifungals

Topical Corticosteroids

Vitamin D Analogs (Topical) Miscellaneous Topical Dermatological Agents

Excluded Medications

CLINDAGEL, CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE) ECOZA, LULICONAZOLE, SULCONAZOLE, XOLEGEL

CLOCORTOLONE

VERDESO FOAM

CALCIPOTRIENE FOAM ALCORTIN A LIDOCAINE/TETRACAINE

DIABETES Blood Glucose Meters & Test Strips

ASCENSIA (CONTOUR) ROCHE (ACCU-CHEK) TRIVIDIA (TRUETEST, TRUETRACK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED

ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA

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

ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, KOMBIGLYZE XR

ALOGLIPTIN/PIOGLITAZONE

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

QTERN

Glucagon-Like Peptide-1 Agonists

ADLYXIN, VICTOZA

Insulins

ADMELOG, AFREZZA~, APIDRA, FIASP, INSULIN ASPART, INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG

NOVOLIN, RELION NOVOLIN

SEMGLEE

EAR/NOSE Nasal Steroids

BECONASE AQ, OMNARIS, ZETONNA

Otic Fluoroquinolone Antibiotics

CIPROFLOXACIN/FLUOCINOLONE OTIC

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

FENSOLVI

Growth Hormones

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZENPREP, ZOMACTON

Somatostatin Analogs

MYCAPSSA, SANDOSTATIN LAR DEPOT SIGNIFOR LAR

Testosterone Products Miscellaneous Endocrine Drugs

AVEED KORLYM

Preferred Alternatives

clindamycin phosphate gel, erythromycin gel, AMZEEQ

ciclopirox, econazole, ketoconazole, naftifine, oxiconazole betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment calcipotriene, calcitriol hydrocortisone, mupirocin lidocaine cream, lidocaine/prilocaine cream FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, VERIO FLEX ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS JANUVIA

JANUMET, JANUMET XR

pioglitazone plus JANUVIA

GLYXAMBI, STEGLUJAN

BYDUREON, BYETTA, OZEMPIC, TRULICITY

HUMALOG, LYUMJEV

HUMULIN LANTUS, LEVEMIR, TOUJEO, TRESIBA

budesonide, flunisolide, fluticasone, mometasone, QNASL

ciprofloxacin/dexamethasone otic, OTOVEL

LUPRON DEPOT-PED, TRIPTODUR

GENOTROPIN, NORDITROPIN FLEXPRO

SOMATULINE DEPOT For Acromegaly: SOMATULINE DEPOT For Cushing's Disease: SIGNIFOR testosterone cypionate, testosterone enanthate ketoconazole, LYSODREN, SIGNIFOR

~ Medications will be excluded beginning 04/01/2021

? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Page 3

Continued

CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)

Drug Class

GASTROINTESTINAL Antidiarrheal Agents

Antiemetics (Oral)

Bowel Evacuants Corticosteroids (Rectal Formulations) Gastroparesis Agents Helicobacter Pylori Agents Hemorrhoidal Preparations Inflammatory Bowel Agents Irritable Bowel Syndrome & Chronic Constipation Agents Pancreatic Enzymes

Proton Pump Inhibitors

HEMATOLOGICAL Antiplatelet Agents Erythropoiesis-Stimulating Agents Factor VIII Recombinant Products

Granulocyte Colony Stimulating Factors

Iron Replacement Agents

Sickle Cell Disease Agents

Thrombocytopenia Agents

HEPATITIS Hepatitis C

Excluded Medications

MYTESI

AKYNZEO CAPSULES EMEND POWDER PACKETS CLENPIQ~, GOLYTELY PACKETS~, OSMOPREP, PLENVU~, SUPREP~ CORTIFOAM GIMOTI HELIDAC, PYLERA PROCTOFOAM-HC

DIPENTUM

AMITIZA PERTZYE ACIPHEX SPRINKLE, ESOMEPRAZOLE STRONTIUM, NEXIUM PACKETS, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE

ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR

ARANESP, EPOGEN, MIRCERA

NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE

GRANIX, NEUPOGEN NEULASTA, UDENYCA MONOFERRIC OXBRYTA SIKLOS MULPLETA TAVALISSE LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI COMPLERA

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

~ Medications will be excluded beginning 04/01/2021

? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

DELSTRIGO

PIFELTRO PREZCOBIX RUKOBIA ER STRIBILD

Page 4

Preferred Alternatives

diphenoxylate/atropine, loperamide

granisetron, ondansetron, aprepitant, VARUBI TABLETS aprepitant, VARUBI TABLETS

peg-electrolyte solution

hydrocortisone enema, UCERIS FOAM No alternatives recommended lansoprazole/amoxicillin/clarithromycin, TALICIA pramoxine/hydrocortisone balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA LINZESS, TRULANCE CREON, PANCREAZE, ZENPEP

esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole, rabeprazole

aspirin plus omeprazole, esomeprazole, lansoprazole, pantoprazole or rabeprazole PROCRIT, RETACRIT ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT NIVESTYM, ZARXIO FULPHILA, ZIEXTENZO sodium ferric gluconate complex, VENOFER hydroxyurea, ADAKVEO, DROXIA DROXIA DOPTELET DOPTELET, PROMACTA, NPLATE

EPCLUSA, HARVONI, VOSEVI, ZEPATIER

ODEFSEY efavirenz/emtricitabine/tenofovir disoproxil fumarate, efavirenz/lamivudine/tenofovir disoproxil fumarate, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ efavirenz, EDURANT atazanavir, ritonavir, KALETRA TABLETS, PREZISTA Coverage may be approved for the treatment of human immunodeficiency virus-1 infection in heavily treatmentexperienced patients with multidrug-resistant infection. BIKTARVY, GENVOYA

Continued

CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)

Drug Class

MUSCULOSKELETAL & RHEUMATOLOGY Gout Therapy

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) OBSTETRICAL & GYNECOLOGICAL Combination Patches

Contraceptives

Estrogen & Estrogen Modifiers for Vaginal Symptoms

Estrogen/Progestin Combinations (Oral) Estrogens (Oral) Human Chorionic Gonadotropin Ovulatory Stimulants (Follitropins) Prenatal Vitamins Topical Estrogen Gels Vaginal Progesterones ONCOLOGY Acute Myeloid Leukemia (AML) Agents Bevacizumab-Containing Agents Breast Cancer Agents Chronic Lymphocytic Leukemia (CLL) Agents Multiple Myeloma Agents Myelodysplastic Syndrome Agents Myelofibrosis Agents Prostate Cancer Agents Rituximab-Containing Agents

Excluded Medications

Preferred Alternatives

COLCHICINE CAPSULES

colchicine tablets, MITIGARE

DICLOFENAC 35 MG CAPSULES, INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY, TIVORBEX, ZIPSOR, ZORVOLEX

diclofenac, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen, piroxicam

FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES

fenoprofen calcium tablets, diclofenac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen

RELAFEN DS

nabumetone, diclofenac, ibuprofen, indomethacin, meloxicam, naproxen, piroxicam

DICLOFENAC EPOLAMINE PATCHES, PENNSAID

diclofenac sodium topical, FLECTOR PATCHES, LICART PATCHES

CLIMARA PRO ANNOVERA~, BALCOLTRA~, LO LOESTRIN FE~, NATAZIA~, TWIRLA PHEXXI SLYND~ FEMRING INTRAROSA, OSPHENA~ PREMPHASE~, PREMPRO~ PREMARIN TABLETS~ CHORIONIC GONADOTROPIN, PREGNYL FOLLISTIM AQ PREGENNA, TRINAZ ELESTRIN, ESTROGEL CRINONE 4% CRINONE 8%

COMBIPATCH

generic oral and ring contraceptives, xulane patches

Barrier methods of contraception, such as condoms, diaphragms, spermicides or sponges. generic progestin-only oral contraceptives estradiol cream, estradiol patches, estradiol tablets, yuvafem, ESTRING, PREMARIN CREAM estradiol cream, yuvafem, ESTRING, PREMARIN CREAM amabelz, estradiol/norethindrone acetate, fyavolv, jinteli, mimvey, norethindrone/ethinyl estradiol estradiol tablets NOVAREL, OVIDREL GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT generic prenatal vitamins DIVIGEL medroxyprogesterone, megestrol, norethindrone, progesterone ENDOMETRIN

ONUREG AVASTIN KISQALI, KISQALI FEMARA CO-PACK, PIQRAY CALQUENCE BLENREP, XPOVIO INQOVI INREBIC TRELSTAR RITUXAN, RITUXAN HYCELA, TRUXIMA

azacitidine, decitabine

MVASI, ZIRABEV IBRANCE, VERZENIO IMBRUVICA, VENCLEXTA DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE decitabine JAKAFI ELIGARD, FIRMAGON RUXIENCE

~ Medications will be excluded beginning 04/01/2021

? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Page 5

Continued

CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)

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