CalPERS Basic Plan Drug List

Transcription

1 July 2016 CalPERS Basic Plan Drug List The CalPERS Basic Plan Drug List contains non-specialty generic and preferred brand drugs for the outpatient prescription drug benefit program administered by CVS Caremark. The Drug List, which is updated quarterly, is presented in two ways: categorized by therapeutic class, and alphabetical. In the Drug List: Generics should be considered the first line of prescribing and have the lowest cost-sharing 1 ; they are shown in lowercase italics 2. Not all covered generics are listed. Those listed are examples of what may be prescribed. If a drug class contains a generic, it is marked with the symbol " ". If no generic is available in a drug class, there may be more than one brand-name drug in that class to treat a condition. 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 FDA-approved labeling and use where listed. Preferred brand drugs are in CAPS. These are the member's most cost-effective brand-name drugs, but have higher cost-sharing than generic drugs. The Drug List may not include: Products recently approved by the U.S. Food and Drug Administration (FDA). New-to-market products and new variations of products already in the marketplace may not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS Caremark Pharmacy and Therapeutics Committee (consisting of medical experts who are not CVS Caremark employees) or other appropriate reviewing body. The Drug List does not include: Excluded drugs. Please refer to "Preferred Options For Excluded And Non-Preferred Drugs" toward the end of this document. Please see the separate "Medications Requiring Prior Authorization" document for the complete list of non-specialty excluded drugs. Non-preferred brand drugs, many of which are covered but will have higher cost-sharing. Please refer to "Preferred Options For Excluded And Non-Preferred Drugs" toward the end of this document. In most instances, a brandname drug will be designated as a non-preferred option when an equivalent generic product is released to the market. Specialty drugs for complex health conditions. For specialty drugs, please see the separate "Advanced Control Specialty Formulary" document. Please note that the Drug List is not all-inclusive and does not guarantee coverage. Prescription drugs with over-thecounter equivalents may not be covered by the plan. Drugs listed may be subject to utilization management, such as prior authorization, step therapy, and quantity limits. For specific information regarding prescription coverage and cost-sharing, please visit or contact a CVS Caremark Customer Care representative for CalPERS members at PLAN MEMBER Please take this list with you when you or a covered family member sees a doctor or other health care provider. Please ask your provider to consider prescribing, when medically appropriate, a generic or preferred medicine from this list. After receiving your prescription, CVS Caremark may contact your provider to request consideration of a preferred brand product or a generic alternative. This may result in your doctor prescribing, when medically appropriate, a different product in place of your original prescription. HEALTH CARE PROVIDER As a way to help manage health care costs while maintaining quality, please prescribe generic drugs or authorize generic substitution whenever possible. If you believe a brand-name product is necessary, please consider prescribing a preferred brand from this list. Unless specifically indicated, drug list products will include all dosage forms.

2 DRUG LIST BY THERAPEUTIC CLASS ANALGESICS NSAIDs diclofenac sodium meloxicam naproxen NSAIDs, diclofenac sodiummisoprostol NSAIDs, TOPICAL diclofenac sodium solution VOLTAREN GEL COX-2 INHIBITORS celecoxib GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel ABSTRAL BUTRANS FENTORA HYSINGLA ER NUCYNTA NUCYNTA ER OPANA ER OXYCONTIN SUBSYS ANTI-INFECTIVES ANTIBACTERIALS CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX ERYTHROMYCINS / MACROLIDES azithromycin clarithromycin clarithromycin ext-rel erythromycins DIFICID FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel levofloxacin moxifloxacin PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK TETRACYCLINES doxycycline hyclate minocycline tetracycline ANTIFUNGALS fluconazole itraconazole terbinafine tablet ANTIVIRALS CYTOMEGALOVIRUS valganciclovir HERPES acyclovir valacyclovir INFLUENZA RELENZA TAMIFLU MISCELLANEOUS clindamycin ivermectin metronidazole nitrofurantoin sulfamethoxazoletrimethoprim ALBENZA SIVEXTRO XIFAXAN 550 MG CARDIOVASCULAR ACE INHIBITORS fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC candesartan / candesartanhydrochlorothiazide eprosartan irbesartan / irbesartanhydrochlorothiazide losartan / losartanhydrochlorothiazide telmisartan / telmisartanhydrochlorothiazide valsartan / valsartanhydrochlorothiazide BENICAR / BENICAR HCT ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER amlodipine-telmisartan amlodipine-valsartan AZOR ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC amlodipine-valsartanhydrochlorothiazide TRIBENZOR ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION INHIBITORS ZETIA FIBRATES fenofibrate fenofibric acid HMG-CoA REDUCTASE INHIBITORS / atorvastatin fluvastatin lovastatin pravastatin simvastatin CRESTOR VYTORIN NIACINS niacin ext-rel OMEGA-3 FATTY ACIDS omega-3 acid ethyl esters BETA-BLOCKERS atenolol carvedilol metoprolol succinate ext-rel metoprolol tartrate nadolol propranolol propranolol ext-rel BYSTOLIC COREG CR CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel 3 nifedipine ext-rel verapamil ext-rel CALCIUM CHANNEL BLOCKER / ANTILIPEMIC amlodipine-atorvastatin DIGITALIS GLYCOSIDES digoxin DIRECT RENIN INHIBITORS / DIURETIC TEKTURNA / TEKTURNA HCT DIURETICS furosemide hydrochlorothiazide metolazone spironolactonehydrochlorothiazide torsemide triamterenehydrochlorothiazide NITRATES nitroglycerin lingual spray NITROLINGUAL NITROSTAT NITRATE / VASODILATOR BIDIL MISCELLANEOUS RANEXA CENTRAL NERVOUS SYSTEM ANTICONVULSANTS carbamazepine carbamazepine ext-rel diazepam rectal gel divalproex sodium divalproex sodium ext-rel ethosuximide gabapentin lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone tiagabine topiramate valproic acid zonisamide FYCOMPA OXTELLAR XR QUDEXY XR TROKENDI XR VIMPAT ANTIDEMENTIA donepezil galantamine galantamine ext-rel memantine rivastigmine rivastigmine transdermal NAMENDA XR ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline BRINTELLIX FLUOXETINE 60 MG VIIBRYD SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) duloxetine venlafaxine venlafaxine ext-rel KHEDEZLA PRISTIQ MISCELLANEOUS bupropion bupropion ext-rel mirtazapine trazodone ANTIPARKINSONIAN amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO ANTIPSYCHOTICS ATYPICALS aripiprazole clozapine olanzapine quetiapine risperidone

3 ziprasidone LATUDA SEROQUEL XR ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel guanfacine ext-rel methylphenidate methylphenidate ext-rel QUILLIVANT XR STRATTERA VYVANSE FIBROMYALGIA LYRICA SAVELLA HYPNOTICS NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel TRICYCLICS SILENOR MIGRAINE SELECTIVE SEROTONIN AGONISTS naratriptan rizatriptan sumatriptan zolmitriptan RELPAX ZOMIG NASAL SPRAY SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET MUSCULOSKELETAL THERAPY cyclobenzaprine NARCOLEPSY NUVIGIL POSTHERPETIC NEURALGIA GRALISE PSYCHOTHERAPEUTIC - MISCELLANEOUS OPIOID ANTAGONISTS NARCAN NASAL SPRAY PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet SUBOXONE FILM VASOMOTOR SYMPTOM BRISDELLE ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM AXIRON ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR JANUMET JANUMET XR JENTADUETO INCRETIN MIMETIC TRULICITY VICTOZA INSULINS HUMULIN R U-500 VIAL LANTUS LEVEMIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 TOUJEO TRESIBA INSULIN SENSITIZERS pioglitazone INSULIN SENSITIZER / BIGUANIDE pioglitazone-metformin INSULIN SENSITIZER / SULFONYLUREA pioglitazone-glimepiride MEGLITINIDES nateglinide repaglinide SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA JARDIANCE SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE XIGDUO XR SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD INSULIN SYRINGES AND NEEDLES ONETOUCH ULTRA STRIPS ONETOUCH VERIO STRIPS CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate risedronate ATELVIA CALCITONINS calcitonin-salmon CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone ethinyl estradiolnorethindrone acetate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE SAFYRAL TRIPHASIC ethinyl estradiol-norgestimate ORTHO TRI-CYCLEN LO FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiollevonorgestrel TRANSDERMAL ethinyl estradiolnorelgestromin VAGINAL NUVARING ESTROGENS ORAL estradiol estropipate PREMARIN TRANSDERMAL estradiol DIVIGEL EVAMIST MINIVELLE VAGINAL ESTRACE CREAM PREMARIN CREAM VAGIFEM ESTROGEN / PROGESTINS ORAL estradiol-norethindrone PREMPHASE PREMPRO TRANSDERMAL COMBIPATCH ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR DUAVEE GLUCOCORTICOIDS methylprednisolone prednisone GLUCOSE ELEVATING GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT PHOSPHATE BINDER calcium acetate PHOSLYRA RENVELA VELPHORO PROGESTINS ORAL medroxyprogesterone progesterone, micronized MEGACE ES VAGINAL CRINONE SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene OSPHENA THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine trimethobenzamide DICLEGIS SANCUSO VARUBI H2 RECEPTOR ANTAGONISTS ranitidine INFLAMMATORY BOWEL DISEASE ORAL balsalazide budesonide capsule sulfasalazine sulfasalazine delayed-rel APRISO LIALDA PENTASA UCERIS RECTAL hydrocortisone enema mesalamine rectal suspension CANASA CORTIFOAM IRRITABLE BOWEL SYNDROME LINZESS LOTRONEX VIBERZI LAXATIVES lactulose peg 3350-electrolytes MOVIPREP SUPREP OPIOID-INDUCED CONSTIPATION MOVANTIK PANCREATIC ENZYMES CREON ULTRESA VIOKACE ZENPEP PROTON PUMP INHIBITORS esomeprazole lansoprazole omeprazole omeprazole-sodium bicarbonate capsule pantoprazole DEXILANT STEROIDS, RECTAL PROCTOFOAM-HC ULCER THERAPY PYLERA

4 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin dutasteride finasteride tamsulosin terazosin RAPAFLO URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel GELNIQUE MYRBETRIQ HEMATOLOGIC ANTICOAGULANTS warfarin ELIQUIS PRADAXA XARELTO PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole ext-rel-aspirin BRILINTA EFFIENT IMMUNOLOGIC ALLERGENIC EXTRACTS GRASTEK RAGWITEK RESPIRATORY ANAPHYLAXIS TREATMENT AUVI-Q EPIPEN EPIPEN JR ANTICHOLINERGICS ANTICHOLINERGIC / BETA AGONIST SHORT ACTING ipratropium-albuterol inhalation solution COMBIVENT RESPIMAT LONG ACTING ANORO ELLIPTA BETA AGONISTS, INHALANTS SHORT ACTING albuterol inhalation solution PROAIR HFA PROVENTIL HFA VENTOLIN HFA LONG ACTING Hand-held Active Inhalation ARCAPTA SEREVENT Nebulized Passive Inhalation PERFOROMIST LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast NASAL ANTIHISTAMINES azelastine olopatadine NASAL STEROIDS flunisolide fluticasone triamcinolone NASONEX PHOSPHODIESTERASE-4 INHIBITORS DALIRESP STEROID / BETA AGONIST ADVAIR DULERA STEROID INHALANTS budesonide inhalation suspension ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR TOPICAL DERMATOLOGY ACNE adapalene benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin ACANYA ATRALIN BENZACLIN DIFFERIN EPIDUO RETIN-A MICRO TAZORAC ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod PICATO ZYCLARA ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin JUBLIA LUZU NAFTIN ANTIPSORIATICS acitretin calcipotriene methoxsalen SORILUX CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency hydrocortisone butyrate mometasone triamcinolone CLODERM LOCOID LOTION High Potency desoximetasone fluocinonide Very High Potency clobetasol cream, foam, gel, lotion, ointment, shampoo IMMUNOMODULATORS tacrolimus ELIDEL ROSACEA metronidazole sulfacetamide-sulfur FINACEA ORACEA SOOLANTRA MISCELLANEOUS SKIN AND MUCOUS MEMBRANE DENAVIR MOUTH / THROAT / DENTAL PROTECTANTS EPISIL OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium olopatadine PATADAY PAZEO ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin ofloxacin sulfacetamide tobramycin BESIVANCE MOXEZA VIGAMOX ANTI-INFECTIVE / ANTI-INFLAMMATORY neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- tobramycin- TOBRADEX OINTMENT TOBRADEX ST ZYLET ANTI-INFLAMMATORIES Nonsteroidal bromfenac diclofenac ketorolac PROLENSA Steroidal ALREX DUREZOL LOTEMAX BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE INHIBITORS dorzolamide AZOPT CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol COSOPT PF CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC SIMBRINZA IMMUNOMODULATORS RESTASIS PROSTAGLANDINS latanoprost travoprost TRAVATAN Z ZIOPTAN SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX ALPHABETICAL DRUG LIST A ABSTRAL ACANYA acitretin acyclovir adapalene ADVAIR ALBENZA albuterol inhalation solution alendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine amlodipine amlodipine-atorvastatin amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartanhydrochlorothiazide amoxicillin amoxicillin-clavulanate amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel ANDRODERM ANORO ELLIPTA APRISO ARCAPTA

5 aripiprazole ASMANEX ATELVIA atenolol atorvastatin ATRALIN AUVI-Q AXIRON azelastine AZILECT azithromycin AZOPT AZOR B balsalazide BD INSULIN SYRINGES AND NEEDLES BENICAR BENICAR HCT BENZACLIN benzoyl peroxide BESIVANCE BETIMOL BETOPTIC S BEYAZ BIDIL BRILINTA brimonidine BRINTELLIX BRISDELLE bromfenac budesonide capsule budesonide inhalation suspension buprenorphine-naloxone sublingual tablet bupropion bupropion ext-rel BUTRANS BYSTOLIC C calcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartanhydrochlorothiazide carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone carvedilol cefdinir cefprozil cefuroxime axetil celecoxib cephalexin cholestyramine ciclopirox CIPRODEX ciprofloxacin ciprofloxacin ext-rel citalopram clarithromycin clarithromycin ext-rel clindamycin clindamycin solution clindamycin-benzoyl peroxide clobetasol cream, foam, gel, lotion, ointment, shampoo CLODERM clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine tablet COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COREG CR CORTIFOAM COSOPT PF CREON CRESTOR CRINONE cromolyn sodium cyclobenzaprine D DALIRESP DENAVIR desonide desoximetasone DEXILANT diazepam rectal gel DICLEGIS diclofenac diclofenac sodium diclofenac sodium solution diclofenac sodiummisoprostol dicloxacillin DIFFERIN DIFICID digoxin diltiazem ext-rel 3 dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DUAVEE DULERA duloxetine DUREZOL dutasteride E econazole EFFIENT ELIDEL ELIQUIS entacapone EPIDUO EPIPEN EPIPEN JR EPISIL eprosartan erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins escitalopram esomeprazole ESTRACE CREAM estradiol estradiol-norethindrone estropipate eszopiclone ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiolnorelgestromin ethinyl estradiolnorethindrone acetate ethinyl estradiol-norgestimate ethosuximide EVAMIST F FARXIGA fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge FENTORA FINACEA finasteride FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil cream 5% fluorouracil solution fluoxetine FLUOXETINE 60 MG fluticasone fluvastatin fosinopril fosinopril-hydrochlorothiazide furosemide FYCOMPA G gabapentin galantamine galantamine ext-rel GELNIQUE gentamicin glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GRALISE granisetron GRASTEK guanfacine ext-rel H HUMULIN R U-500 VIAL hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate hydrocortisone enema hydromorphone hydromorphone ext-rel HYSINGLA ER I ibandronate imiquimod ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorothiazide itraconazole ivermectin J JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JUBLIA K ketoconazole ketorolac KHEDEZLA L lactulose lamotrigine lamotrigine ext-rel lansoprazole LANTUS latanoprost LATUDA LEVEMIR levetiracetam levetiracetam ext-rel levofloxacin levothyroxine LIALDA LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LOTION losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX lovastatin LUZU LYRICA M meclizine medroxyprogesterone MEGACE ES meloxicam memantine mesalamine rectal suspension metformin metformin ext-rel methadone methoxsalen methylphenidate methylphenidate ext-rel methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole MINASTRIN 24 FE MINIVELLE minocycline MIRAPEX ER mirtazapine mometasone montelukast morphine morphine ext-rel morphine suppository MOVANTIK MOVIPREP MOXEZA moxifloxacin MYRBETRIQ N nadolol NAFTIN NAMENDA XR naproxen naratriptan NARCAN NASAL SPRAY NASONEX NATAZIA nateglinide neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- NEUPRO niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin lingual spray NITROLINGUAL NITROSTAT NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING NUVIGIL nystatin O ofloxacin olanzapine olopatadine omega-3 acid ethyl esters omeprazole

6 omeprazole-sodium bicarbonate capsule ondansetron ONETOUCH ULTRA STRIPS ONETOUCH VERIO STRIPS OPANA ER ORACEA ORTHO TRI-CYCLEN LO OSPHENA oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN P pantoprazole paroxetine paroxetine ext-rel PATADAY PAZEO peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pioglitazone pioglitazone-glimepiride pioglitazone-metformin PRADAXA pramipexole pravastatin prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO primidone PRISTIQ PROAIR HFA probenecid prochlorperazine PROCTOFOAM-HC progesterone, micronized PROLENSA promethazine propranolol propranolol ext-rel PROVENTIL HFA PULMICORT FLEXHALER PYLERA Q QUDEXY XR quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide QVAR R RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RELENZA RELPAX RENVELA repaglinide RESTASIS RETIN-A MICRO risedronate risperidone rivastigmine rivastigmine transdermal rizatriptan ropinirole ropinirole ext-rel S SAFYRAL SANCUSO SAVELLA selegiline SEREVENT SEROQUEL XR sertraline SILENOR SIMBRINZA simvastatin SIVEXTRO SOOLANTRA SORILUX spironolactonehydrochlorothiazide STRATTERA SUBOXONE FILM SUBSYS sulfacetamide sulfacetamide-sulfur sulfamethoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan SUPRAX SUPREP SYMLINPEN SYNTHROID T tacrolimus TAMIFLU tamsulosin TAZORAC TEKTURNA TEKTURNA HCT telmisartan telmisartanhydrochlorothiazide terazosin terbinafine tablet tetracycline tiagabine timolol maleate solution TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin- tolterodine tolterodine ext-rel topiramate torsemide TOUJEO TRADJENTA tramadol tramadol ext-rel TRAVATAN Z travoprost trazodone TRESIBA tretinoin TREXIMET triamcinolone triamterenehydrochlorothiazide TRIBENZOR trimethobenzamide TROKENDI XR trospium trospium ext-rel TRULICITY U UCERIS ULORIC ULTRESA V VAGIFEM valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothiazide VARUBI VELPHORO venlafaxine venlafaxine ext-rel VENTOLIN HFA verapamil ext-rel VIBERZI VICTOZA VIGAMOX VIIBRYD VIMPAT VIOKACE VOLTAREN GEL VYTORIN VYVANSE W warfarin WELCHOL X XARELTO XIFAXAN 550 MG XIGDUO XR Z zafirlukast ZENPEP ZETIA ZIOPTAN ziprasidone zolmitriptan zolpidem zolpidem ext-rel ZOMIG NASAL SPRAY zonisamide ZYCLARA ZYLET PREFERRED OPTIONS FOR EXCLUDED AND NON-PREFERRED DRUGS ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ACCU-CHEK STRIPS ONETOUCH ULTRA STRIPS, ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALORA ALTOPREV pioglitazone amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, QUILLIVANT XR, STRATTERA, VYVANSE AUVI-Q, EPIPEN, EPIPEN JR ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR estradiol, DIVIGEL, EVAMIST, MINIVELLE AMITIZA AMRIX ANDROGEL ANGELIQ ANTARA APEXICON E APIDRA ARMOUR THYROID ARTHROTEC ASACOL HD LINZESS cyclobenzaprine estradiol-norethindrone, PREMPHASE, PREMPRO fenofibrate, fenofibric acid desoximetasone, fluocinonide NOVOLOG levothyroxine, SYNTHROID celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS

7 ASCENSIA STRIPS ONETOUCH ULTRA STRIPS, ATACAND, ATACAND HCT ATROVENT HFA AXERT AZELEX BECONASE AQ BENZAC AC, BENZAC W BENZIQ naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC BREEZE 2 STRIPS ONETOUCH ULTRA STRIPS, BREO ELLIPTA BYDUREON BYETTA CARAC CARDIZEM CARDIZEM CD CARDIZEM LA (including generic form) CARDURA XL CLIMARA PRO CLINDAGEL clobetasol spray CLOBEX SPRAY CONTOUR NEXT STRIPS ADVAIR TRULICITY, VICTOZA TRULICITY, VICTOZA fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA diltiazem ext-rel (not generic CARDIZEM LA) diltiazem ext-rel (not generic CARDIZEM LA) diltiazem ext-rel (not generic CARDIZEM LA) alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO COMBIPATCH erythromycin solution clobetasol foam clobetasol foam ONETOUCH ULTRA STRIPS, CONTOUR STRIPS ONETOUCH ULTRA STRIPS, CYMBALTA DELZICOL DETROL LA duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, DIOVAN, DIOVAN HCT DORAL DUEXIS DYMISTA EDARBI, EDARBYCLOR EDLUAR ENABLEX ENJUVIA ESTRING EXFORGE EXFORGE HCT FEMRING FETZIMA FIRST TESTOSTERONE fluorouracil cream 0.5% FORTAMET FORTESTA FOSAMAX PLUS D FOSRENOL celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT flunisolide, fluticasone, triamcinolone or NASONEX WITH azelastine or olopatadine oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, estradiol, estropipate, PREMARIN ESTRACE CREAM, PREMARIN CREAM, VAGIFEM amlodipine-telmisartan, amlodipine-valsartan, AZOR amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR ESTRACE CREAM, PREMARIN CREAM, VAGIFEM duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA metformin, metformin ext-rel alendronate, ibandronate, risedronate, ATELVIA calcium acetate, PHOSLYRA, RENVELA, VELPHORO FREESTYLE STRIPS ONETOUCH ULTRA STRIPS, FROVA GLUMETZA HUMALOG naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY metformin, metformin ext-rel NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN INCRUSE ELLIPTA INNOPRAN XL INTERMEZZO NOVOLIN atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR

8 INTUNIV INVOKAMET INVOKANA ISTALOL JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA Matzim LA MENEST MENOSTAR MICARDIS, MICARDIS HCT NAPRELAN NATESTO NESINA NITROMIST NORITATE NORVASC OLEPTRO OLUX-E OMNARIS ONGLYZA OSENI OXYTROL PANCREAZE PENNSAID PERTZYE amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, QUILLIVANT XR, STRATTERA, VYVANSE XIGDUO XR FARXIGA, JARDIANCE timolol maleate solution, BETIMOL dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO JANUMET, JANUMET XR, JENTADUETO JANUMET, JANUMET XR, JENTADUETO azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO latanoprost, travoprost, TRAVATAN Z, ZIOPTAN diltiazem ext-rel (not generic CARDIZEM LA) estradiol, estropipate, PREMARIN estradiol celecoxib, diclofenac sodium, meloxicam, naproxen JANUVIA, TRADJENTA nitroglycerin lingual spray, NITROLINGUAL, NITROSTAT metronidazole, sulfacetamide-sulfur, FINACEA, SOOLANTRA amlodipine trazodone clobetasol foam JANUVIA, TRADJENTA JANUMET, JANUMET XR, JENTADUETO oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, CREON, ULTRESA, VIOKACE, ZENPEP diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL CREON, ULTRESA, VIOKACE, ZENPEP PEXEVA PLAVIX PRECISION XTRA STRIPS PRED MILD PREFEST PREVACID PROTONIX PROTOPIC QNASL RAYOS RELION INSULIN RELISTOR RHINOCORT AQUA RIOMET ROZEREM STRIANT citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, BRINTELLIX, FLUOXETINE 60 MG, VIIBRYD clopidogrel, BRILINTA, EFFIENT ONETOUCH ULTRA STRIPS,, DUREZOL, LOTEMAX estradiol-norethindrone, PREMPHASE, PREMPRO esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT tacrolimus, ELIDEL, methylprednisolone, prednisone NOVOLIN INSULIN MOVANTIK metformin, metformin ext-rel SURE-TEST STRIPS ONETOUCH ULTRA STRIPS, SYMBICORT TANZEUM TESTIM testosterone gel 1% 6 TEVETEN, TEVETEN HCT TOVIAZ TRICOR TRIGLIDE TRILIPIX ADVAIR, DULERA TRULICITY, VICTOZA oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, fenofibrate, fenofibric acid fenofibrate, fenofibric acid fenofibrate, fenofibric acid TRUETEST STRIPS ONETOUCH ULTRA STRIPS, TRUETRACK STRIPS TUDORZA VALCYTE VALTREX VASCEPA VERAMYST VIMOVO ONETOUCH ULTRA STRIPS, valganciclovir acyclovir, valacyclovir omega-3 acid ethyl esters celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT

9 VOGELXO XOPENEX HFA PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA ZETONNA ZUBSOLV ZYFLO, ZYFLO CR buprenorphine-naloxone sublingual tablet, SUBOXONE FILM montelukast, zafirlukast 1 Cost-sharing is the share of costs covered by your insurance that you pay out of your own pocket. This term includes copayments (a fixed amount which CalPERS members pay for many drugs) and coinsurance (a percentage of the cost, which CalPERS members pay for certain drugs). 2 A "branded generic" drug is a brand name drug that has the lower cost-sharing of a generic drug. Any such "branded generic" drug will be listed in lowercase italics but with the first letter capitalized. 3 The Drug List does not include generic CARDIZEM LA. 4 ONETOUCH brand test strips are the only preferred test strips for blood glucose testing in members with diabetes. The manufacturer may provide a ONETOUCH blood glucose meter at no charge to individuals who are currently using a meter other than ONETOUCH. For more information on how to obtain a free ONETOUCH meter, call The preferred options in the right column include available treatments that have been determined to be clinically appropriate, cost-effective, and approved by the CVS Caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body). The preferred options are not necessarily clinically equivalent to the excluded and non-preferred drugs in the left column. 6 The Drug List includes the authorized generics for TESTIM and VOGELXO. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. 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 All rights reserved