2020 MaxorPlusAdvantage Drug Formulary

(formerly known as Essential Formulary)

www.maxorplus.com

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription plan. The list is notall-inclusive and does not guarantee coverage. In addition to using this list, you areencouraged to ask your doctor to prescribe generic drugs whenever appropriate.

KEY[INJ] - Injectable DrugBrand-name drugs are listed in CAPITAL letters.Generic drugs are listed in lower case letters.

ABILIFY MAINTENA [INJ]acetaminophen/codeineACTEMRA [INJ]acyclovirADEMPASADVAIR HFAADYNOVATE [INJ]AFSTYLA [INJ]AIMOVIG [INJ]AJOVY [INJ]albuterol nebulization solutionalendronateallopurinolALPHAGAN P 0.1%alprazolamALREXamiodaroneamitriptylineamlodipineamlodipine/benazeprilamlodipine/valsartanamoxicillinamoxicillin/potassium clavulanateanastrozoleANDRODERMANORO ELLIPTAAPRISOARALAST NP [INJ]ARIKAYCEaripiprazoleARISTADA [INJ]ARMONAIR RESPICLICKARNUITY ELLIPTAASMANEX HFAASMANEX TWISTHALERatenololatenolol/chlorthalidoneatomoxetineatorvastatinAUSTEDOAVONEX [INJ]AZASITEazelastine nasal sprayazithromycin

A

B

CABOMETYXCARACCARAFATE SUSPENSIONcarbidopa/levodopacarvedilolcefdinircefuroxime axetilcelecoxibcephalexinCERDELGACEREZYME [INJ]CETROTIDE [INJ]CHANTIXchlorhexidine gluconatechlorthalidoneCIMDUOCIPRODEXciprofloxacincitalopramclarithromycinCLENPIQclindamycin hclclindamycin phosphate topicalclindamycin phosphate/ benzoyl peroxideclobetasol propionateclomiphene citrateclonazepamclonidineclopidogrelclotrimazole/betamethasone dipropionateCOLCRYSCOMBIGANCOMBIPATCHCOMBIVENT RESPIMATCOMETRIQCOPAXONE 40 MG [INJ]CORLANORCOSENTYX [INJ]CREONCRINONE

C

cyanocobalamin [INJ]cyclobenzaprine

DALIRESPDARAPRIMDAYTRANADESCOVYdesloratadinedesvenlafaxine succinatedexamethasoneDEXCOM RECEIVER, SENSOR, TRANSMITTERdexmethylphenidate ext-releasedextroamphetamine/ amphetaminedextroamphetamine/ amphetamine ext-releasediazepamdiclofenac sodium delayed-releasedicyclominedigoxindiltiazem ext-releasediphenoxylate/atropinedivalproex delayed-releasedivalproex ext-releaseDIVIGELdonepezildoxazosindoxycycline hyclatedoxycycline monohydrateDUAVEEDULERAduloxetine delayed-releaseDUPIXENT [INJ]DYANAVEL XRDYMISTA

D

EDARBIEDARBYCLORELIQUISELOCTATE [INJ]EMGALITY [INJ]EMVERMenalaprilENBREL [INJ]enoxaparin [INJ]ENSTILARENTRESTOEPCLUSAEPIDIOLEXEPIDUO FORTEepinephrine auto-injector (by Mylan) [INJ]EPIPEN, EPIPEN JR [INJ]ergocalciferolERIVEDGEERLEADAerythromycin eye ointmentESBRIETescitalopram

E

esomeprazole magnesium delayed-releaseestradiolestradiol patchestradiol/norethindrone acetateESTRINGeszopicloneEUFLEXXA [INJ]ezetimibeezetimibe/simvastatin

famotidineFARXIGAfenofibratefenofibrate micronizedfenofibric acid delayed-releasefentanyl patchFETZIMAFINACEA FOAMfinasterideFLECTORFLOVENT DISKUSFLOVENT HFAfluconazolefluocinonidefluoxetinefluticasone nasal sprayfolic acidFORTEO [INJ]FRAGMIN [INJ]FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE, FREESTYLE LIBRE READER, SENSORFREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITEfurosemideFYCOMPA

F

gabapentin GELNIQUEgemfibrozilGENOTROPIN [INJ]GENVOYAGILENYAGILOTRIFGLASSIA [INJ]glimepirideglipizideglipizide ext-releaseGLUCAGEN [INJ]GLUCAGON [INJ]glyburideGLYXAMBI

G

HARVONIHUMALOG [INJ]HUMIRA [INJ]HUMULIN [INJ]hydralazinehydrochlorothiazidehydrocodone/ acetaminophenhydrocodone/ chlorpheniramine polistirex ext-releasehydrocortisone topicalhydromorphonehydroxychloroquinehydroxyzine hclhydroxyzine pamoateHYSINGLA ER

H

ibandronateIBRANCEibuprofenILEVROINBRIJAINCRUSE ELLIPTAindomethacinINLYTAINVELTYSINVOKAMETINVOKAMET XRINVOKANAirbesartanIRESSAisosorbide mononitrate ext-release

I

JANUMET, JANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRJIVI [INJ]JULUCAjuneljunel fe

J

ketoconazole topicalketorolacKITABIS PAKKOGENATE FS [INJ]KOVALTRY [INJ]KYLEENA

K

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE.

PLEASE NOTE: Brand-name drugs may move to nonformulary status if a genericversion becomes available during the year. Not all the drugs listed are covered byall prescription plans; check your benefit materials for the specific drugs coveredand the copayments for your prescription plan. For specific questions about yourcoverage, please call the phone number printed on your member ID card.

GONAL-F [INJ]GRASTEKguanfacine ext-release

baclofenBARACLUDE SOLUTIONBD AUTOSHIELD DUO NEEDLESBD ULTRAFINE INSULIN SYRINGESBD ULTRAFINE PEN NEEDLESBELBUCAbenazepril

benzonatateBEPREVEBETASERON [INJ]BETHKISBEVESPI AEROSPHEREBIKTARVYbisoprolol/hctzblisovi feBOSULIFBREO ELLIPTABRILINTAbudesonide nebulization suspensionbupropionbupropion ext-releasebuspironebutalbital/acetaminophen/ caffeineBYDUREON [INJ]BYETTA [INJ]BYSTOLIC

Cost for covered alternatives may vary.(continued)

© 2020 All Rights Reserved.Other trademarks are the propertyof their respective owners.

ketoconazole topicalketorolacKITABIS PAKKOGENATE FS [INJ]KOVALTRY [INJ]KYLEENA

Llabetalollamotriginelansoprazole delayed-releaseLANTUS [INJ]latanoprost eye solutionLATUDALEVEMIR [INJ]levetiracetamlevocetirizinelevofloxacinlevothyroxine sodiumlidocaine patchesLINZESSliothyronineLIPOFENlisinoprillisinopril/hctzLIVALOLO LOESTRIN FELOKELMAlorazepamLORBRENAlosartanlosartan/hctzLOTEMAXLOTEMAX SMlovastatinLUMIGANLUPANETA [INJ]LUPRON DEPOT 3.75 MG, 11.25 MG [INJ]LUPRON DEPOT-PED [INJ]

MAYZENTmeclizinemedroxyprogesteronemeloxicammetaxalonemetforminmetformin ext-releasemethimazolemethocarbamolmethotrexatemethylphenidatemethylphenidate ext-releasemethylprednisolonemetoclopramide hclmetoprolol succinate ext-releasemetoprolol tartratemetronidazolemetronidazole topicalmetronidazole vaginalmicrogestin feminocyclineMIRENAmirtazapineMIRVASOMITIGAREmoderibamometasoneMONOVISC [INJ]montelukastmorphine sulfate ext-releaseMOVANTIKmoxifloxacin eye solutionmupirocinMUSEMYDAYISMYRBETRIQ

M

nabumetoneNAMZARICnaproxen, naproxen sodiumNARCAN NASAL SPRAYNASCOBALneomycin/polymyxin/ hydrocortisone ear solutionNEXIUM PACKETSniacin ext-releasenifedipine ext-releasenitrofurantoin macrocrystalNITYRNIVESTYM [INJ]NORDITROPIN [INJ]nortriptylineNOVAREL [INJ]NOVOEIGHT [INJ]NOVOFINE AUTOSHIELD NEEDLESNOVOFINE NEEDLESNOVOTWIST NEEDLESNUCALA [INJ]NUCYNTA, NUCYNTA ERNUEDEXTAnystatinnystatin topical

N

ODACTRAOFEVofloxacinolanzapineolmesartanolmesartan/hctzolopatadine eye solutionomega-3 acid ethyl estersomeprazole delayed-releaseondansetronondansetron orally disintegrating tabletsONETOUCH KITS/METERS: ULTRA 2, ULTRAMINI, VERIO, VERIO FLEXONETOUCH TEST STRIPS: ULTRA, VERIOONEXTONOPSUMITORACEAORALAIRORILISSAORTHOVISC [INJ]oseltamivirOTEZLAOTOVELOTREXUP [INJ]OVIDREL [INJ]oxcarbazepineoxybutynin ext-releaseoxycodoneoxycodone/acetaminophenOXYCONTINOZEMPIC [INJ]

O

pantoprazole delayed-releaseparoxetinePAZEOpenicillin v potassiumPENTASAPERFOROMISTPHOSLYRAPICATOpioglitazone

P

QBREXZAQNASLQUDEXY XRquetiapineQUILLICHEW ERQUILLIVANT XRquinaprilQVARQVAR REDIHALER

Q

rabeprazole delayed-releaseRAGWITEKraloxifeneramiprilranitidineRASUVO [INJ]REBIF [INJ]RECTIVRELISTOR [INJ]RELISTOR TABLETSREMICADE [INJ]REPATHA (NDCs starting with 55513)[INJ]RESTASISRETACRIT [INJ]REVLIMIDRHOPRESSArisperidonerizatriptanropinirolerosuvastatinRUBRACARUCONEST [INJ]

R

SAVELLASEGLUROMETSEREVENT DISKUSsertralinesildenafilSIMPONI 100 MG (for ulcerative colitis only) [INJ]simvastatinSKYLASKYRIZI [INJ]SOLIQUA [INJ]SOMATULINE DEPOT [INJ]SOOLANTRASOVALDIspironolactonesprintecSPRYCELSTEGLATROSTELARA SC [INJ]STRENSIQ [INJ]sulfamethoxazole/ trimethoprimsumatriptanSUNOSISUPREPSUTENTSYMBICORTSYMFISYMFI LOSYMJEPI [INJ]SYMLINPEN [INJ]SYMPROICSYNJARDYSYNJARDY XR

S

TACLONEX SUSPENSIONtacrolimus topicaltadalafilTALZENNAtamoxifentamsulosin ext-releaseTASIGNATAYTULLATAZORAC GELTAZORAC 0.05% CREAMTECFIDERATEKTURNA HCTterazosinterconazole vaginaltestosterone cypionate [INJ]THALOMIDtimolol maleate eye solutiontizanidineTOBI PODHALERTOBRADEX OINTMENTTOBRADEX STtobramycin eye solutiontobramycin/dexamethasone eye suspensiontopiramateTOUJEO [INJ]TOVIAZTRADJENTAtramadolTRAVATAN ZtrazodoneTRELEGY ELLIPTATREMFYA [INJ]TRESIBA [INJ]triamcinolone topicaltriamterene/hctztri-lo-marzia

T

trinessaTRIPTODUR [INJ]tri-sprintecTRIUMEQTRULANCETRULICITY [INJ]TYMLOS [INJ]

UCERIS FOAMUDENYCA [INJ]UPTRAVI

U

valacyclovirvalsartanvalsartan/hctzVARUBIVASCEPAVELPHOROvenlafaxinevenlafaxine ext-releaseVENTOLIN HFAverapamil ext-releaseVERZENIOVIBERZIVIIBRYDVIMPATVIOKACEVIZIMPROVOSEVIVYVANSE

V

warfarin

W

XALKORIXARELTOXELJANZ, XELJANZ XRXIFAXANXIGDUO XRXIIDRAXOLAIR [INJ]XTANDIXULTOPHY [INJ]XYREM

X

ZARXIOZENPEPzolpidemzolpidem ext-releaseZOMIG NASALZTLIDOZUBSOLVZYLETZYTIGA 500 MG

Z

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE.

Cost for covered alternatives may vary.

YONSAYUPELRI yuvafem

Y

© 2020 All Rights Reserved.Other trademarks are the propertyof their respective owners.

PLEGRIDY [INJ]polymyxin/trimethoprim eye solutionPOMALYSTpotassium chloride ext-releasePRALUENT (NDCs starting with 00024) [INJ]pramipexolepravastatinPRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPSprednisolone acetate eye suspensionprednisolone sodium phosphateprednisonepregabalinPREMARIN CREAMPREMARIN TABLETSPREMPHASEPREMPROPREPOPIKPROAIR HFAPROAIR RESPICLICKPROCRIT [INJ]progesterone micronizedPROLASTIN C [INJ]PROLENSApromethazinepromethazine/ dextromethorphanpropranololpropranolol ext-releasePULMICORT FLEXHALERPYLERA

2020 Advantage Formulary Exclusions

Effective 1/1/2020

*Current 2019 exclusion in this class**Grandfathering for current utilizers permitted

EXCLUDED DRUGS ALTERNATIVES

This document contains a list of medica�ons that are excluded (not covered) on the Advantage Formulary. Here are some important items to note. A) This is not a complete list of medica�ons excluded under your pharmacy benefit plan. B) Some drugs or drug categories listed may not be covered by your specific pharmacy benefit plan. C) Some drugs may have certain restric�ons (ex. prior authoriza�on requirements, quan�ty limits) or special copays. D) In some cases, MaxorPlus may offer Brand drugs at the generic copay, but exclude the equivalent generic products. The drugs in the list may change over �me due to changes in drug pricing. For drugs in the program, members will always have access to either the brand or generic equivalent at a generic copay. E) Addi�onal alterna�ves other than what is included in the table may be available. For specific ques�ons about coverage or copay informa�on, please visit www.maxorplus.com and log in or call 1-800-687-0707.

ABSTRAL*, FENTANYL CITRATE BUCCAL ABLETS*, FENTORA* AKYNZEO CAPSULE

ALBUTEROL SULFATE HFAAMBIEN, AMBIEN CRAMRIXAUBAGIOBAYER (BREEZE, CONTOUR)*, NATIONAL MEDICAL (ADVOCATE)*, OMNIS HEALTH (EMBRACE,VICTORY)*, ROCHE (ACCU-CHEK)*, TRIVIDIA (TRUETEST, TRUETRACK)*, UNISTRIP*ALL OTHER METERS & STRIPSTHAT ARE NOT LISTED AS PREFERRED*CIALISCOLCHICINECUPRIMINEELIDELEMEND CAPSULE, POWDER PACKET, TRIFOLD PACKEPANEDEXJADEFOCALIN, FOCALIN XRGRANIX, NEUPOGEN*JADENU, JADENU SPRINKLELYRICAMULPLETANOVOLIN*, RELION NOVOLINNUWIQ**, RECOMBINATE*, XYNTHA*,XYNTHA SOLOFUSE*ONZETRA XSAILORFADINPENNSAIDQBRELISRAPAFLORHOFADESITAVIG

SPIRIVA HANDIHALER*, SPIRIVA RESPIMAT*, TUDORZA PRESSAIRSTRIVERDI RESPIMATSUBSYSTIVORBEX, VIVLODEX, ZORVOLEX*

TUDORZA PRESSAIRVIVLODEXXATMEPZIPSOR

fentanyl citrate lozenges (generic for Ac�q)

granisetron (generic for Kytril), ondansetron (generic for Zofran), aprepitant (generic for Emend),VARUBI TABLETSPROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFAzolpidem (generic for Ambien), zolpidem ER (generic for Ambien CR)cyclobenzaprine ER (generic for Amrix)GILENYA, MAYZENT, TECFIDERAFREESTYLE KITS/METERS: FREESTYLE FREEDOM*, FREESTYLE FREEDOM LITE*, FREESTYLE INSULINX*, FREESTYLE LITE*FREESTYLE STRIPS: FREESTYLE*, FREESTYLE INSULINX*, FREESTYLE LITE*ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, VERIO FLEXONETOUCH STRIPS: ULTRA, VERIO PRECISION XTRA METER*, TEST STRIPS*, B-KETONE STRIPS

tadalafil (generic for Cialis)COLCRYS, MITIGAREpenicillamine (generic for Cuprimine)pimecrolimus (generic for Elidel)aprepitant (generic for Emend), VARUBI TABLETS

enalapril (generic for Vasotec)deferasirox (generic for Exjade)dexmethylphenidate (generic for Focalin, Focalin XR)NIVESTYM*, ZARXIOdeferasirox (generic for Exjade)pregabalin (generic for Lyrica)DOPTELETHUMULINADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT

sumatriptan nasal spray (generic for Imitrex nasal spray), ZOMIG NASAL SPRAYni�sinone (generic for ORFADIN), NITYRdiclofenac sodium topical (generic for Voltaren), FLECTOR PATCHlisinopril (generic for Zestril)silodosin (generic for Rapaflo)MIRVASOacyclovir (generic for Zovirax, oral or cream), famciclovir (generic for Famvir),valacyclovir (generic for Valtrex)INCRUSE ELLIPTA

SEREVENT DISKUSfentanyl citrate lozenges (generic for Ac�q)diclofenac sodium (generic for Voltaren), etodolac (generic for Lodine), ibuprofen (generic for Motrin), indomethacin (generic for Indocin), meloxicam (generic for Mobic), nabumetone (generic for Relafen), naproxen (generic for Naprosyn), piroxicam (generic for Feldene)INCRUSE ELLIPTAdiclofenac sodium (generic for Voltaren), meloxicam (generic for Mobic), nabumetone (generic for Relafen)methotrexate (generic for Trexall)diclofenac (generic for Voltaren tablet)