2018 Prime Preferred Drug List The Universal Rx Prime Drug Formulary identifies commonly prescribed generic and brand drugs. While this document does not identify a specific copay tier for each medicine, drugs on this list are preferred for use and will generally be assigned lower copays defined by your drug benefit plan. If your prescription drug plan includes a three-tier copay structure, these drugs would go through at the preferred copayment tiers. Your plan documents may have coverage requirements or limitations that may exclude certain drugs or drug classes. Please review your benefit documents for information about specific medicines, and if you have questions please call the phone number printed on your member ID card. Also, when you are with your doctor and a prescribed medicine is going to be part of your treatment, please ask your doctor to prescribe a generic drug when it is appropriate. Please note that a brand name drug may move to nonpreferred status if a generic becomes available during the year. KEY: CAPITAL letters – Preferred BRAND drugs, lower case letters – generic drugs, [INJ] – Injectable medicines

A B C D E F G H I J K L M N O P Q R S T U V W X Z

aripiprazole ARISTADA [INJ] ARNUITY ELLIPTA ASACOL HD ASMANEX HFA ASMANEX TWISTHALER atenolol atenolol/chlorthalidone atorvastatin ATRIPLA ATROVENT HFA AVONEX [INJ] AZASITE azelastine nasal spray azithromycin

B

BYDUREON [INJ] BYDUREON BCISE [INJ]BYETTA [INJ] BYSTOLIC BYVALSON

C

doxycycline hyclate doxycycline monohydrate DUAVEE DULERA duloxetine delayed-release DUPIXET [INJ] DYMISTA

E EDARBI EDARBYCLOR EFFIENT ELIDEL ELIGARD ELIQUIS ELMIRON EMVERM enalapril ENBREL [INJ]ENBREL cartridge [INJ] enoxaparin [INJ] ENSTILAR ENTRESTO ENTYVIO EPCLUSA EPIDUO EPIDUO FORTE EPINEPHRINE AUTOINJECTOR(by Mylan) [INJ] EPIPEN EPIPEN JR [INJ] ergocalciferol erythromycin eye ointment ESBRIET escitalopram esomeprazole magnesium-delayed-release estradiol

Y

baclofen BANZEL benazeprilBENZNIDAZOLE benzonatate BEPREVE BETASERON [INJ] BETHKISBEVESPI AEROSPHERE BILTRICIDE bisoprolol/hctz BREO ELLIPTA BRILINTA BRISDELLE budesonide nebulization susp. bupropion bupropion ext-release buspirone butalbital/acetaminophen/ caffeine BUTRANS

CABOMEYTXCANASA CARAC carbidopa/levodopa carvedilol cefdinir cefuroxime axetil celecoxib CELONTIN cephalexin CERDELGA CETROTIDE [INJ] chlorhexidine gluconate chlorthalidone CHANTIX CIALIS CIPRODEX ciprofloxacin citalopram clarithromycin clindamycin hcl clindamycin phosphate clindamycin phosphate/benzoyl peroxide clobetasol propionate clomiphene citrate clonazepam clonidine clopidogrel clotrimazole/betamethasone dipropionate

doxazosin

Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in writing by an authorized representative of Universal Rx. v.2017-11 This document is in effect July 1, 2018.

A ABILIFY MAINTENA [INJ] ABSORICA ACANYA acetaminophen/codeine ACTEMRA [INJ] ACTHAR H.P. [INJ] acyclovir ADCIRCA ADEMPAS ADVAIR DISKUS ADVAIR HFA ADVATE AFSTYLA AKYNZEO ALBENZA albuterol nebulization solution alendronate ALINIAALIQOPA [INJ] allopurinol ALPHAGAN P 0.1% alprazolam ALREX amiodarone AMITIZA amitriptyline amlodipine amlodipine/benazepril amlodipine/valsartan amoxicillin amoxicillin/potassium clavulanate AMPYRA anastrozole ANDRODERM ANDROGEL 1.62% ANORO ELLIPTA apri ARANESP [INJ] ARCAPTA NEOHALER

diltiazem ext-release diphenoxylate/atropine divalproex delayed-release divalproex ext-release DIVIGEL donepezil

D DAKLINZA DALIRESP DAYTRANA DELZICOLDESCOVY desloratadine desonide dexamethasone dexmethylphenidate ext-release dextroamphetamine-amphetamine dextroamphetamine- amphetamine ext-release diazepam diclofenac sodium dicyclomine digoxin DILANTIN 30MG CAPSULE

COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA COPAXONE 40 MG (INJ ) CORLANOR CORTIFOAM COSENTYX [INJ] CREON CRINONE cyanocobalamin [INJ] cyclobenzaprine

2018 Prime Preferred Drug List

estradiol patch estradiol/norethindrone acetate ESTRING eszopiclone etodolac EUFLEXXA EVEKEO EXTAVIA ezetimibe ezetimibe / simvastatin

F famotidine FARESTON

G

gildess fe

GILENYA GILOTRIF glimepiride glipizide glipizide ext-release GLUCAGEN [INJ] GLUCAGON [INJ] glyburide GLYXAMBI GONAL-F GONAL-F RFF GONAL-F RFF REDI-JECT [INJ] GRALISE GRANIX [INJ] GRASTEK guanfacine ext-release

H

J JAKAFI JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR

M

FARXIGAFASENRA [INJ]

Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in writing by an authorized representative of Universal Rx. v.2017-11 This document is in effect July 1, 2018.

losartan/hctz LOTEMAX lovastatin LUMIGANLUXTURNA [INJ] LYRICA

MAKENA [INJ] meclizine medroxyprogesterone meloxicam MEPHYTON MEPSEVII [INJ] MENOPUR [INJ] MESTINON SYRUP metaxalone metformin metformin ext-release methimazole methocarbamol methotrexate methylphenidate methylphenidate ext-release methylprednisolone metoclopramide hcl metoprolol succinate ext-release metoprolol tartrate metronidazole metronidazole topical metronidazole vaginal gel microgestin fe MINIVELLE minocycline MIRENA mirtazapine MIRVASO MITIGARE moderiba mometasone mononessa MONOVISC [INJ] montelukast morphine sulfate ext-release MOVANTIK MOXEZA multivitamins/fluoride mupirocin MUSEMYLOTARG [INJ] MYRBETRIQ

N nabumetone NAMENDA XR NAMZARIC naproxen naproxen sodium NARCAN NASAL SPRAY NASCOBAL NATACYN NATAZIA neomycin/polymyxin/ HC ear drops NEULASTA [INJ] NEUPOGEN [INJ] NEVANAC NEXIUM PACKETS niacin ext-release nifedipine ext-release NINLARO nitrofurantoin mono/macrocrystal NORDITROPIN [INJ] nortriptyline NORVIR NOVOEIGHT NOVOLIN NOVOLOG [INJ] NOVOTWIST NEEDLES NOXAFIL [INJ] NUCYNTA NUCYNTA ER NUEDEXTA NUVARING nystatin oral susp. nystatin topical

O ODACTRAODEFSEY OFEV ofloxacin olanzapine olmesartan olmesartan/hctz omega-3 acid ethyl esters omeprazole delayed-release ondansetron ondansetron orally- disintegrating tablets ONETOUCH KITS/METERS; ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC

INVOKAMET INVOKAMET XR INVOKANA irbesartan IRESSA ISENTRESS isosorbide mononitrate ext-release

junel fe

K ketoconazole topical ketorolac KITABIS PAK KOGENATE KOVALTRY KYLEENA KYMRIAH [INJ]

L labetalol lamotrigine lansoprazole delayed-release LANTUS [INJ] latanoprost eye solution LATUDA LETAIRIS LEVEMIR [INJ] levetiracetam levocetirizine levofloxacin levothyroxine sodium lidocaine patches LINZESS liothyronine LIPOFEN lisinopril lisinopril/hctz LIVALO LO LOESTRIN FE lorazepamlosartan

ibandronate IBRANCE ibuprofen ILARIS ILEVRO IMBRUVICA INCRUSE ELLIPTA indomethacin INLYTA

I

HARVONI HEMLIBRA [INJ] HELIXATE FS [INJ] HIZENTRA HUMALOG [INJ] HUMATROPE [INJ] HUMIRA [INJ] HUMULIN [INJ] HUMULIN R U-500 KWIKPEN hydralazine hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/chlorpheniramine polistirex ext-release hydrocortisone topical hydromorphone hydroxychloroquine hydroxyzine hclhydroxyzine pamoate HYOPHEN HYSINGLA ER

gabapentin GELNIQUE gemfibrozil GENOTROPIN [INJ] GENVOYASP

fenofibrate fenofibrate micronized fenofibric acid delayed-release fentanyl patches FETZIMAFIASP [INJ] FINACEA finasteride FLECTOR FLOVENT DISKUS FLOVENT HFA fluconazole fluocinonide fluoxetine fluticasone nasal spray folic acid FORTEO [INJ] FRAGMIN [INJ] FREESTYLE KITS/METERS FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE LITE FREESTYLE TEST STRIPS furosemide FYCOMPA

2018 Prime Preferred Drug List

ONETOUCH TEST STRIPS; ULTRA, VERIO ONEXTON ONFI OPSUMIT ORACEA ORKAMBI ORTHOVISC [INJ] OTEZLA OTOVEL OTREXUP [INJ] oxcarbazepine oxybutynin ext-release oxycodone oxycodone/acetaminophen OXYCONTIN

P

S

T

U

X XALKORI XARELTO XELJANZ XELJANZ XR XIFAXAN XIGDUO XR XIIDRA XTANDI

XULTOPHY [INJ] XYREM

Y YESCARTA [INJ]

Z

VIBERZI VICTOZA [INJ] VIEKIRA PAK VIEKIRA XR VIIBRYD VIMPAT VIOKACE VOTRIENT VYVANSE

VENTOLIN HFA verapamil ext-release VERZENIOVESICARE

Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in writing by an authorized representative of Universal Rx. v.2017-11 This document is in effect July 1, 2018.

TACLONEX SUSP TAGRISSO tamoxifen tamsulosin ext-release TARCEVA TASIGNA TAYTULLA TAZORAC GEL TAZORAC 0.05% CREAM TECFIDERA TECHNIVIE TEKTURNA TEKTURNA-HCTtemazepam

SABRIL SAFYRAL SANCUSO SAVELLASEEBRI

pantoprazole delayed-release paroxetine PAZEO penicillin v potassium PENTASA PERFOROMIST PHOSLYRA PICATO pioglitazone PLEGRIDY [INJ] polymyxin/trimethoprim solution POMALYST potassium chloride ext-release POTIGA PRALUENT [INJ] pramipexole pravastatin prednisolone acetate eye suspension prednisolone sodium phos. prednisone PREMARIN CREAM PREMARIN TABS PREMPHASE PREMPRO PREPOPIKPREVYMIS [INJ] PREZISTA PROAIR HFA PROAIR RESPICLICK PROCRIT [INJ]

ZARXIO [INJ] ZELBORAF ZENPEP ZEPATIER zolpidem zolpidem ext-release ZOMIG NASAL ZONTIVITY ZORTRESS ZOVIRAX CREAM ZUBSOLV ZYLET ZYTIG

warfarin

WELCHOL

W

VARUBIVARUBI [INJ]VASCEPA

VELPHORO

VELTASSA

venlafaxine

venlafaxine ext-release

valacyclovir valsartan valsartan/hctz

V

UCERIS TABLETS ULORIC UPTRAVI UTIBRON

terazosin terconazole vaginal testosterone cypionate [INJ] timolol maleate eye solution TIVICAY tizanidine TOBI PODHALER TOBRADEX OINTMENT TOBRADEX ST tobramycin eye solution tobramycin/dexamethasone eye suspension topiramate TOUJEO SOLOSTAR [INJ] TOVIAZ TRACLEER TRADJENTA tramadol TRAVATAN Z trazodoneTRELEGY ELLIPTATREMFYA [INJ]TRESIBA [INJ] triamcinolone topical triamterene/hctz trinessa tri-sprintec TRIUMEQ TRUVADA TUDORZA PRESSAIRTRULICITY TYKERB TYMLOS [INJ]

SEREVENT DISKUS SEROSTIM [INJ] sertralineSHINGRIX [INJ] SIMPONI 100 MG [INJ] simvastatin SKYLA SOLIQUA [INJ] SOLODYN SOMATULINE DEPOT-[INJ] SOOLANTRA SOVALDI SPIRIVA HANDIHALER SPIRIVA RESPIMAT SPORANOX SOL spironolactone sprintec SPRYCEL STELARA [INJ] STIOLTO RESPIMAT STIVARGA STRENSIQ [INJ] STRIBILD STRIVERDI RESPIMAT SUBLOCADE [INJ]SUBOXONE SL FILM sulfamethoxazole/trimethoprim sumatriptan SUPREP SUTENT SYMBICORT SYMLINPEN [INJ] SYNAGIS [INJ] SYNJARDY

progesterone micronized PROLENSA promethazine promethazine/dextromethorphan propranolol propranolol ext-release PULMICORT FLEXHALER PULMOZYME PURIXAN PYLERA

Q QNASL QUDEXY quetiapine QUILLICHEW ER QUILLIVANT XR Quinapril QVARQVAR REDIHALER

R rabeprazole delayed-release RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RASUVO [INJ] REBIF [INJ] RECTIV REGRANEX GEL RELENZA RELISTOR [INJ] REMICADE [INJ] RENFLEXIS [INJ] REPATHA [INJ] RESTASIS REVLIMID REYATAZ risperidone rizatriptan ropinirole rosuvastatin ROZEREM