The following is a list of the most commonly prescribed drugs. It representsan abbreviated version of the drug list (formulary) that is at the core of yourprescription-drug benefit plan. The list is not all-inclusive and does notguarantee coverage. In addition to using this list, you are encouraged to askyour doctor to prescribe generic drugs whenever appropriate.

OPEN ACCESS (2020)

PLEASE NOTE: Brand-name drugs may move to nonformulary status if ageneric version becomes available during the year. Not all the drugslisted are covered by all prescription-drug benefit programs; check yourbenefit materials for the specific drugs covered and the copayments foryour prescription-drug benefit program. For specific questions aboutyour coverage, please call the phone number printed on your member IDcard.

A .acetaminophen-codeineacycloviradapalene-benzoylperoxideAE

ADVAIR DISKUSQL

ADVAIR HFAQL

AFSTYLA†

AIMOVIGQL, PA, †

AJOVYQL, PA, †

albuterol sulfatealendronate sodiumalfuzosin hcl erallopurinolALPHAGAN PalprazolamambrisentanQL, PA, †

amiodarone hclAMITIZAQL, PA

amitriptyline hclamlodipine besy-benazepril hclST

amlodipine besylateamoxicillin-potclavulanateamoxicillinamphetamine sulfateQL,

AE

amphetamine-dextroamphetamineAE

anastrozoleANORO ELLIPTAQL

aprepitantQL

aripiprazoleQL

armodafinilQL, PA

ARMOUR THYROIDARNUITY ELLIPTAQL

ASMANEX HFAQL

atenolol-chlorthalidoneatenololatorvastatin calciumATRIPLAQL, †

ATROVENT HFAQL

AUBAGIOQL, PA, †

azathioprineazelaic acidAE

azelastine hclazithromycin

B .baclofenbenazepril hclbenazepril-hydrochlorothiazideBESIVANCEST

BETASERONQL, PA, †

bisoprolol-hydrochlorothiazidebosentanQL, PA, †

BREO ELLIPTAQL

BREVICON (28)BRILINTAQL

brimonidine tartratebudesonideQL

buprenorphine hcl-naloxone hclQL

bupropion hcl er(smoking det)QL

bupropion hcl er (sr)bupropion hcl er (xl)bupropion hclbuspirone hclbutalbital-apap-caffeineQL

butalbital-asa-caffeineQL

BYSTOLICQL, ST

C .cabergolinecalcitriolcarbamazepinecarbidopa-levodopacarvedilolcefadroxilcefdinircefuroxime axetilcelecoxibQL

cephalexinCETROTIDEPA, †

CHANTIXQL

chlorhexidine gluconateciclopiroxcinacalcet hclPA, †

CIPRODEXciprofloxacincitalopramhydrobromideQL

clarithromycinclindamycin hclclindamycin phos-benzoyl peroxAE

clindamycin phosphateclobetasol propionateclonazepamclonidine hclclopidogrel bisulfateclotrimazole-betamethasoneclotrimazolecolestipol hclCOMBIGANCOMBIPATCHQL

COMBIVENTRESPIMATQL

COSENTYXPA, †

CREONcyanocobalamin [INJ]cyclobenzaprine hclcyproheptadine hcl

D .dalfampridine erQL, PA, †

DESCOVYQL, †

desloratadineQL

dexamethasonediazepamdiclofenac sodiumdicyclomine hcldigoxindiltiazem hcl erdiphenoxylate-atropinedivalproex sodium erdivalproex sodiumdorzolamide hcl-timololmaldoxazosin mesylatedoxepin hcldoxycycline hyclatedoxycyclinemonohydrateDUAVEEQL

duloxetine hclQL

DUPIXENTQL, PA, †

dutasterideQL

DYMISTAQL

E .econazole nitrateELIQUISQL

ELMIRONEMGALITYQL, PA, †, AE

enalapril maleateenalapril-hydrochlorothiazideENBRELQL, PA, †

EPIDUO FORTEAE

epinephrineQL [INJ]EPIPEN 2-PAKQL [INJ]EPIPEN JR 2-PAKQL

[INJ]erythromycinescitalopram oxalateesomeprazolemagnesiumQL, ST

estradiolESTROSTEP FEeszopicloneQL, ST

etodolac

EUFLEXXAQL, PA, †

exemestaneezetimibeQL, ST

F .FARXIGAQL

febuxostatfenofibrate micronizedQL

finasterideFLOVENT DISKUSQL

FLOVENT HFAQL

fluconazolefludrocortisone acetatefluorometholonefluorouracil†

fluoxetine hclfluticasone-salmeterolQL

fluvoxamine maleatefolic acidFORTEOQL, PA, †

furosemide

G .gabapentingemfibrozilGENERESS FEGENOTROPINPA, †

gentamicin sulfateGENVOYAQL, †

glatiramer acetateQL, PA, †

glimepirideglipizide erglipizide xlglipizideGLUCAGONEMERGENCYQL [INJ]glyburideGLYXAMBIQL

guanfacine hcl erQL

guanfacine hcl

H .HUMIRAPA, †

hydralazine hclhydrochlorothiazidehydrocodone-acetaminophenhydrocodone-ibuprofenhydrocortisonehydromorphone hclhydroxychloroquinesulfatehydroxyzine hclhyoscyamine sulfate

I .ibandronate sodiumQL, PA,

†

imatinib mesylateQL, PA, †

indomethacinipratropium bromideipratropium-albuterolirbesartanisosorbide mononitrateerisotretinoinAE

J .JANUMET XRQL

JANUMETQL

JANUVIAQL

JARDIANCEQL

K .ketoconazoleketorolac tromethamineKOVALTRY†

L .labetalol hcllactuloselamotriginelansoprazoleLANTUSlatanoprostLATUDAQL

leflunomideletrozoleLEVEMIRlevetiracetamlevocetirizinedihydrochloridelevofloxacinlevothyroxine sodiumlidocaine viscous hclLINZESSQL, PA

liothyronine sodiumlisinoprillithium carbonate erlithium carbonateLIVALOQL, ST

LO LOESTRIN FElorazepamlosartan potassium-hctzlosartan potassiumloteprednol etabonatelovastatinLUMIGANST

M .MAVYRETQL, PA, †

meclizine hclmedroxyprogesteroneacetateQL

meloxicammemantine hclQL

mercaptopurinemesalamineQL

metformin hcl erQL

metformin hclmethadone hclmethimazolemethocarbamolmethotrexatemethylphenidate hclerQL, AE

methylphenidate hclQL, AE

methylprednisolonemetoclopramide hclmetoprolol succinate ermetoprolol tartratemetronidazoleMINIVELLEQL

minocycline hclmirtazapinemisoprostolmodafinilQL, PA

mometasone furoateMONOVISCQL, PA, †

montelukast sodiummorphine sulfate erQL

morphine sulfateMOVANTIKQL, PA

mupirocinmycophenolate mofetilMYRBETRIQQL, ST

N .nabumetonenaltrexone hclQL

naproxennaratriptan hclQL

neomycin-polymyxin-hcNEULASTAPA, †

NEUPOGENPA, † [INJ]nifedipine ernitrofurantoinnitroglycerinnortriptyline hclNOVOEIGHT†

NOVOLIN 70/30NOVOLIN NNOVOLIN R [INJ]NOVOLOG FLEXPENNOVOLOGNUCALAPA, †

NUCYNTA ERQL

www.WellDyneRx.com

UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved

NUVARINGQL

nystatin

O .olmesartan medoxomil-hctzQL, ST

olmesartanmedoxomilQL, ST

olopatadine hclomega-3-acid ethylestersQL

ondansetronONETOUCH ULTRABLUEQL

ONETOUCH VERIOQL

OPDIVOPA, †

ORTHOVISCQL, PA, †

oseltamivir phosphateQL

OTEZLAQL, PA, †

oxcarbazepineoxybutynin chloride eroxybutynin chlorideoxycodone hcloxycodone-acetaminophenQL

OXYCONTINQL

OZEMPICQL, PA

P .pantoprazole sodiumparoxetine hclPAZEOpeg 3350/electrolytespenicillin v potassiumPENTASApermethrinphenazopyridine hclphenytoinpimecrolimuspioglitazone hclpolymyxin b-trimethoprimposaconazolePA

potassium chloride erpotassium citrate erpravastatin sodiumprazosin hclprednisoloneprednisonepregabalinQL, ST

PREMARINQL

PREMPROQL

PREPOPIKPROAIR HFAQL

PROAIR RESPICLICKQL

prochlorperazineprogesteronePROLENSApromethazine hclpromethazine-codeinepromethazine-dmpropranolol hcl erpropranolol hclPULMICORTFLEXHALERQL

Q .quetiapine fumarate erQL

quetiapine fumarateQL

quinapril hclQVAR REDIHALERQL

R .ramiprilranolazine erQL

REBIFQL, PA, †

REMICADEPA, †

REPATHAQL, PA, †

RESTASISQL, PA

REVLIMIDQL, PA, †

risperidoneritonavirQL, †

rizatriptan benzoateQL

ropinirole hcl erQL

ropinirole hclrosuvastatin calciumQL, ST

S .sertraline hclsevelamer carbonatesilodosinsimvastatinsodium fluoridesodium sulfacetamidesolifenacin succinateQL,

ST

sotalol hclSPIRIVA HANDIHALERQL

SPIRIVA RESPIMATQL

spironolactoneSPRYCELQL, PA, †

STELARAPA, †

STIOLTO RESPIMATQL

STRIBILDQL, †

SUBOXONEQL

sucralfatesulfamethoxazole-trimethoprimsulfasalazinesumatriptanQL

SYMBICORTQL

SYNJARDYQL

SYNTHROID

T .tacrolimustadalafil (pah)QL, PA, †

tadalafilQL

tamoxifen citratetamsulosin hclTECFIDERAQL, PA, †

temazepamtenofovir disoproxilfumarateQL, †

terbinafine hclterconazoletestosterone cypionatetestosteronePA

timolol maleateTIVICAYQL, †

tizanidine hclQL

tobramycin-dexamethasone

tobramycintolterodine tartratetopiramateTOUJEO SOLOSTARtramadol hcltramadol-acetaminophenTRAVATAN ZST

trazodone hclTRESIBA FLEXTOUCHtriamcinolone acetonidetriamterene-hctztriazolamTRIUMEQQL, †

TRULICITYQL, PA

TRUVADAQL, †

V .valacyclovir hclvalsartan-hydrochlorothiazidevalsartanvenlafaxine hcl ervenlafaxine hclverapamil hcl erVICTOZAQL, PA

VIIBRYDQL, ST

VIMPATQL

VIREADQL, †

VIVITROLPA, †

VYVANSEQL, AE

W .warfarin sodiumwixela inhubQL

X .XARELTOQL

XIFAXANQL, PA

XIGDUO XRQL

XIIDRAQL, PA

XOLAIRPA, †

XULTOPHYQL

Z .zaleplonZENPEPzolpidem tartrate erQL, ST

zolpidem tartrateQL

zonisamide

www.WellDyneRx.com

UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved

(Continued)

Non-Preferred Medication(s) Selected Preferred Alternative(s) ACANYAPA and ONEXTONPA (clindamycin phosphate-benzoyl peroxide)

clindamycin and benzoyl peroxide (separate agents)

ADMELOGPA (insulin lispro) NOVOLOG

AEROSPANPA (flunisolide) ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL

AIRDUOPA QL(fluticasone-salmeterol 55-14 mcg, 113-14 mcg, 232-14 mcg)

fluticasone-salmeterolQL (100-50 mcg, 250-50 mcg, 500-50 mcg), wixelaQL, ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL

ALLZITALPA QL (butalbital-acetaminophen 25-325 mg) and butalbital-acetaminophen 50-300 mgPA QL

butalbital-acetaminophen 50-325 mgQL

ALVESCOPA (ciclesonide) ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL

AMRIXPA QL (cyclobenzaprine ER) cyclobenzaprine 5 mg, cyclobenzaprine 10 mg

APIDRAPA (insulin glulisine) NOVOLOG

APIDRA SOLOSTARPA (insulin glulisine) NOVOLOG

AUVI-QPA QL (epinephrine solution) epinephrine 0.15 mgQL, epinephrine 0.3 mgQL, EPIPENQL, EPIPEN JRQL

BASAGLARPA (insulin glargine) LANTUS, LEVEMIR, TOUJEO, TRESIBA

BELSOMRAPA QL (suvorexant) zolpidem IRQL, zaleplon

BONJESTAPA QL and DICLEGISPA QL (doxylamine-pyridoxine) OTC doxylamine and OTC pyridoxine

BRAVELLE† PA (urofollitropin) GONAL-F†, GONAL-F RFF†

BYETTAPA QL (exenatide) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL

BYDUREONPA QL (exenatide extended-release) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL

CETRAXALPA QL (ciprofloxacin 0.2% otic soln) ofloxacin otic soln

DENAVIRPA (penciclovir) acyclovir ointment

DEXILANTQL (dexlansoprazole) lansoprazole, omeprazole, pantoprazole

DIABETES TEST STRIPSPA QL (e.g., Accu-Chek, Ascensia, Breeze, Contour, etc.)

ONETOUCHQL

DUEXISPA QL (famotidine-ibuprofen) OTC famotidine and OTC ibuprofen (separate agents)

DULERAPA QL (mometasone-formoterol) fluticasone-salmeterolQL (100-50 mcg, 250-50 mcg, 500-50 mcg), wixelaQL, ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL

DUREZOLPA (difluprednate) prednisolone acetate ophth solution

EXTAVIA† PA QL BETASERON† PA QL, REBIF† PA QL

FOLLISTIM AQ† PA (follitropin beta) GONAL-F†, GONAL-F RFF†

FORFIVO XLPA QL (bupropion ER) bupropion ER

GLUMETZAPA QL and FORTAMETPA QL (metformin ER modified/osmotic)

metformin ER (generic Glucophage XR)

GRALISEPA QL (gabapentin) gabapentin

HORIZANTPA QL (gabapentin ER) gabapentin

HUMALOGPA (insulin lispro) NOVOLOG

HUMULIN NPA (insulin isophane), HUMULIN RPA (insulin regular), HUMULIN 70/30PA (insulin NPH and regular)

NOVOLIN N, NOVOLIN R, NOVOLIN 70/30

INCRUSE ELLIPTAPA (umeclidinium) SPIRIVAQL

INVOKANAPA QL (canagliflozin) FARXIGAQL, JARDIANCEQL

INVOKAMETPA QL (canagliflozin-metformin), INVOKAMET XRPA QL (canagliflozin-metformin ER)

SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL

JENTADUETOPA QL,JENTADUETO XRPA QL (linagliptin and metformin) JANUMETQL, JANUMET XRQL

JUBLIAPA (eficonazole) ciclopirox

KAZANOPA QL (alogliptin-metformin) JANUMETQL, JANUMET XRQL

Examples of Non-Preferred Medications with Selected Formulary Alternatives The following is a list of some non-preferred brand-name medications with examples of selected covered formulary alternatives. This is not an all-inclusive list.

www.WellDyneRx.com

UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved

Non-Preferred Medication(s) Selected Preferred Alternative(s) KOMBIGLYZE XRPA QL (saxagliptin-metformin ER) JANUMETQL, JANUMET XRQL

LASTACAFTPA QL (alcaftadine eye soln) OTC ketotifen eye soln

NASCOBALPA (cyanocobalamin nasal) OTC vitamin B12

NESINAPA QL (alogliptin) JANUVIAQL

NORDITROPIN†, PA (somatropin) GENOTROPIN†, PA

ONGLYZAPA QL (saxagliptin) JANUVIAQL

OSENIPA QL (alogliptin-pioglitazone) JANUVIAQL and pioglitazone

PANCREAZEPA (pancrelipase DR) CREON, ZENPEP

PERTZYEPA (pancrelipase DR) CREON, ZENPEP

PROVENTIL HFAPA QL (albuterol) PROAIR HFAQL

QTERNPA QL (dapagliflozin-saxagliptin) GLYXAMBIQL

SEGLUROMETPA QL (ertugliflozin-metformin) SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL

STEGLATROPA QL (ertugliflozin) FARXIGAQL, JARDIANCEQL

STEGLUJANPA QL (ertugliflozin-sitagliptin) GLYXAMBIQL

SOLARAZEPA (diclofenac 3% gel) Fluorouracil 5% cream

SOLIQUAPA QL (insulin glargine-lixisenatide) XULTOPHYPA QL

SOLODYNPA QL (minocycline ER) minocycline

SOOLANTRAPA (ivermectin cream) metronidazole cream

TIROSINTPA QL (levothyroxine) levothyroxine, SYNTHROID

TRADJENTAPA QL (linagliptin) JANUVIAQL

TREXIMETPA QL (sumatriptan-naproxen) sumatriptanQL and naproxen (separate agents)

TUDORZA PRESSAIRPA QL (aclidinium) SPIRIVAQL

VENTOLIN HFAPA QL (albuterol sulfate) PROAIR HFAQL

VIMOVOPA QL (esomeprazole-naproxen) OTC esomeprazole and OTC naproxen

XOPENEX HFAPA QL (levalbuterol) PROAIR HFAQL

ZEGERIDPA QL (omeprazole-sodium bicarbonate) OTC omeprazole-sodium bicarbonate

ZIANAPA and VELTINPA (clindamycin phosphate-tretinoin) clindamycin and tretinoinAE (separate agents)

ZIOPTANPA QL (tafluprost) latanoprost

ZORVOLEXPA QL (diclofenac) diclofenac sodium DR

ZOVIRAX CREAMPA acyclovir ointment

ZYFLOPA QL (zileuton) and ZYFLO CRPA QL (zileuton ER) montelukast, zafirlukast

For the member: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the US Food and Drug Administration (FDA) may not be covered upon release to market.

WellDyneRx may contact your provider after receiving a prescription to request consideration of a drug list product or generic equivalent. This may result in your provider prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of the original prescription. Generic medications contain the same active ingredi- ents as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards.

In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-pre- ferred or excluded option upon release of the generic product to the market.

For the physician: Generics should be considered the first-line of prescribing. Please prescribe preferred products and allow generic substitutions when medically appropriate. Brand-name drugs are listed in CAPITAL letters; generic drugs are listed in lower case letters.

This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to market.

[INJ] = Injectable Drug

ER = Extended-Release

DR = Delayed Release

AE = Age Edit

LD = Limited Distribution

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

† Indicates specialty

medications

KEY

www.WellDyneRx.com

UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved