October 2023

Preferred Drug List

The Preferred Drug List, administered by CVS Caremark® on behalf of Siemens, is a guide within select therapeutic categories for
clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic
available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help
identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational
purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase
Italics, and generic products in lowercase italics.

PLAN MEMBER HEALTH CARE PROVIDER

Your benefit plan provides you with prescription drug coverage
that is administered by CVS Caremark. Ask your doctor to consider
prescribing, when medically appropriate, a preferred medicine from
this list. Take this list the next time you or a covered family member
sees a doctor.
Your patient is covered under a prescription benefit plan administered
by CVS Caremark. As a way to help manage health care costs,
authorize generic substitution whenever possible. If you believe a
brand-name product is necessary, consider prescribing a brand name
on this list.

Please note: Please note:

• Your specific prescription benefit plan design may not cover
certain medications, products or categories, regardless of their
appearance in this document. Medications and products recently
approved by the U.S. Food and Drug Administration (FDA)
may not be covered upon release to the market.
• Your prescription benefit plan design may alter coverage of certain
products or vary copay1 amounts based on the condition being
treated.
• You may be responsible for the full cost of non-formulary products
that are not covered without a prior authorization for
medical necessity.
• For specific information regarding your prescription benefit
coverage and copay information, please visit Caremark.com
or contact a CVS Caremark Customer Care
representative at 1-866-478-5802.
• When a generic medication that is equivalent to a brand-name
drug is released to the market, in most instances, that brand-name
drug will be designated as a non-preferred option.
• Generics should be considered the first line of prescribing.
• 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 the market.
• The member's prescription benefit plan may have a different
copay for specific products on the list.
• Unless specifically indicated, drug list products will include all
dosage forms.

ANALGESICS § OPIOID ANALGESICS cephalexin § ANTIFUNGALS trimethoprim

buprenorphine transdermal SUPRAX fluconazole vancomycin capsule
§ COX-2 INHIBITORS EMVERM
codeine-acetaminophen itraconazole
celecoxib § ERYTHROMYCINS / XIFAXAN 550 MG
fentanyl transdermal terbinafine tablet
MACROLIDES
§ GOUT fentanyl transmucosal
lozenge azithromycin ANTIVIRALS ANTINEOPLASTIC
allopurinol hydrocodone ext-rel clarithromycin § CYTOMEGALOVIRUS AGENTS
colchicine tablet hydrocodone-acetaminophen clarithromycin ext-rel AGENTS
probenecid § ANTIMETABOLITES
hydromorphone erythromycins valganciclovir
MITIGARE DIFICID pemetrexed
hydromorphone ext-rel
methadone § HERPES AGENTS HORMONAL
§ NSAIDs § FLUOROQUINOLONES
morphine acyclovir capsule, tablet ANTINEOPLASTIC AGENTS
diclofenac sodium ciprofloxacin
morphine ext-rel valacyclovir § ANTIANDROGENS
ibuprofen levofloxacin
oxycodone
meloxicam tablet moxifloxacin § INFLUENZA AGENTS bicalutamide
oxycodone-acetaminophen
naproxen (except naproxen CR or oseltamivir
tramadol (except NDC* 52817019610) § PENICILLINS CARDIOVASCULAR
naproxen suspension) RELENZA
tramadol ext-rel tablet amoxicillin
§ NSAIDs, COMBINATIONS BELBUCA § ACE INHIBITORS
amoxicillin-clavulanate § MISCELLANEOUS
diclofenac sodium- XTAMPZA ER dicloxacillin enalapril
clindamycin fosinopril
misoprostol penicillin VK ivermectin tablet
ANTI-INFECTIVES lisinopril
§ NSAIDs, TOPICAL § TETRACYCLINES linezolid quinapril
ANTIBACTERIALS metronidazole
diclofenac sodium gel 1% doxycycline hyclate 20 mg ramipril
§ CEPHALOSPORINS nitrofurantoin (except NDC*
diclofenac sodium solution doxycycline hyclate capsule
cefdinir 16571074024) § ACE INHIBITOR /
1.5% minocycline
cefprozil pyrimethamine DIURETIC COMBINATIONS
tetracycline sulfamethoxazole-
cefuroxime axetil fosinopril-hydrochlorothiazide

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
lisinopril-hydrochlorothiazide ezetimibe-simvastatin isosorbide dinitrate 40 mg) pramipexole QELBREE
quinapril-hydrochlorothiazide fluvastatin isosorbide mononitrate pramipexole ext-rel
lovastatin nitroglycerin lingual spray rasagiline § FIBROMYALGIA
§ ALDOSTERONE pravastatin nitroglycerin sublingual ropinirole pregabalin
RECEPTOR ANTAGONISTS rosuvastatin ropinirole ext-rel
spironolactone § MISCELLANEOUS HYPNOTICS
simvastatin selegiline
midodrine NEUPRO § NONBENZODIAZEPINES
§ ANGIOTENSIN II § NIACINS ranolazine ext-rel eszopiclone
RYTARY
RECEPTOR ANTAGONISTS / niacin ext-rel ramelteon
DIURETIC COMBINATIONS CENTRAL NERVOUS ANTIPSYCHOTICS zolpidem
candesartan / candesartan- § OMEGA-3 FATTY ACIDS SYSTEM § ATYPICALS zolpidem ext-rel
hydrochlorothiazide omega-3 acid ethyl esters aripiprazole BELSOMRA
ANTIANXIETY
irbesartan / irbesartan- VASCEPA clozapine DAYVIGO
hydrochlorothiazide § BENZODIAZEPINES
§ BETA-BLOCKERS lurasidone
losartan / losartan- alprazolam § TRICYCLICS
olanzapine
hydrochlorothiazide atenolol clonazepam doxepin
quetiapine
olmesartan / olmesartan- carvedilol diazepam quetiapine ext-rel MIGRAINE
hydrochlorothiazide carvedilol phosphate ext-rel lorazepam risperidone
telmisartan / telmisartan- metoprolol succinate ext-rel oxazepam MONOCLONAL ANTIBODIES
ziprasidone
hydrochlorothiazide metoprolol tartrate AIMOVIG
§ ANTIDEMENTIA ABILIFY MAINTENA
valsartan / valsartan- nadolol AJOVY
PERSERIS
hydrochlorothiazide nebivolol donepezil EMGALITY
VRAYLAR
pindolol galantamine
§ ANGIOTENSIN II propranolol galantamine ext-rel § ANTISEIZURE AGENTS § TRIPTANS
RECEPTOR ANTAGONIST / propranolol ext-rel memantine eletriptan
carbamazepine
CALCIUM CHANNEL rivastigmine naratriptan
§ CALCIUM CHANNEL carbamazepine ext-rel
BLOCKER COMBINATIONS rivastigmine transdermal rizatriptan
BLOCKERS clobazam
amlodipine-olmesartan NAMZARIC diazepam rectal gel sumatriptan
amlodipine-telmisartan amlodipine zolmitriptan
ANTIDEPRESSANTS divalproex sodium
amlodipine-valsartan diltiazem ext-rel (except generics ONZETRA XSAIL
divalproex sodium ext-rel
for CARDIZEM LA) § SELECTIVE SEROTONIN ZEMBRACE SYMTOUCH
§ ANGIOTENSIN II ethosuximide
nifedipine ext-rel REUPTAKE INHIBITORS
RECEPTOR ANTAGONIST / gabapentin
verapamil ext-rel (SSRIs) MISCELLANEOUS ORAL
CALCIUM CHANNEL lacosamide
citalopram AGENTS
BLOCKER / DIURETIC § CALCIUM CHANNEL lamotrigine
escitalopram lamotrigine ext-rel NURTEC ODT
COMBINATIONS BLOCKER / ANTILIPEMIC
fluoxetine (except fluoxetine tablet 60 levetiracetam QULIPTA
amlodipine-valsartan- COMBINATIONS
mg, fluoxetine tablet [generics for
levetiracetam ext-rel UBRELVY
hydrochlorothiazide amlodipine-atorvastatin SARAFEM])
oxcarbazepine § MUSCULOSKELETAL
olmesartan-amlodipine- paroxetine HCl
§ DIGITALIS GLYCOSIDES phenobarbital THERAPY AGENTS
hydrochlorothiazide paroxetine HCl ext-rel (except
digoxin phenytoin
NDC* 60505367503) cyclobenzaprine (except
§ ANTIARRHYTHMICS phenytoin sodium extended
§ DIRECT RENIN sertraline primidone
cyclobenzaprine tablet 7.5 mg)
amiodarone TRINTELLIX
INHIBITORS / DIURETIC rufinamide § NARCOLEPSY
disopyramide
COMBINATIONS § SEROTONIN tiagabine
sotalol armodafinil
aliskiren NOREPINEPHRINE topiramate modafinil
ANTILIPEMICS TEKTURNA HCT REUPTAKE INHIBITORS valproic acid SUNOSI
ACL INHIBITORS / (SNRIs) zonisamide
§ DIURETICS APTIOM § POSTHERPETIC
COMBINATIONS desvenlafaxine ext-rel
amiloride FYCOMPA NEURALGIA (PHN)
NEXLETOL duloxetine
chlorthalidone NAYZILAM pregabalin ext-rel
NEXLIZET venlafaxine
ethacrynic acid OXTELLAR XR GRALISE
venlafaxine ext-rel capsule
§ BILE ACID RESINS furosemide TROKENDI XR
cholestyramine hydrochlorothiazide § MISCELLANEOUS VALTOCO PSYCHOTHERAPEUTIC -
colesevelam metolazone AGENTS XCOPRI MISCELLANEOUS
spironolactone- bupropion § OPIOID ANTAGONISTS
§ CHOLESTEROL hydrochlorothiazide § ATTENTION DEFICIT
bupropion ext-rel (except HYPERACTIVITY DISORDER naloxone
ABSORPTION INHIBITORS torsemide
bupropion ext-rel tablet 450 mg)
ezetimibe triamterene amphetamine- § PARTIAL OPIOID AGONIST
mirtazapine
triamterene- dextroamphetamine mixed / OPIOID ANTAGONIST
trazodone
§ FIBRATES hydrochlorothiazide salts COMBINATIONS
fenofibrate (except fenofibrate capsule § ANTIPARKINSONIAN amphetamine- buprenorphine-naloxone
HEART FAILURE AGENTS dextroamphetamine mixed
30 mg, 50 mg, 90 mg, 130 mg; sublingual
fenofibrate tablet 40 mg, 120 mg) BIDIL amantadine salts ext-rel ZUBSOLV
fenofibric acid delayed-rel CORLANOR carbidopa-levodopa atomoxetine
ENTRESTO carbidopa-levodopa ext-rel dexmethylphenidate ext-rel ENDOCRINE AND
§ HMG-CoA REDUCTASE VERQUVO guanfacine ext-rel METABOLIC
carbidopa-levodopa-
INHIBITORS / methylphenidate
§ NITRATES entacapone § ANDROGENS
COMBINATIONS methylphenidate ext-rel
entacapone
atorvastatin isosorbide dinitrate (except AZSTARYS testosterone gel (except authorized

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
 generics for TESTIM and VOGELXO) SODIUM-GLUCOSE ondansetron
testosterone solution CO-TRANSPORTER 2 CALCIUM REGULATORS MENOPAUSAL SYMPTOM prochlorperazine
NATESTO (SGLT2) INHIBITORS § BISPHOSPHONATES AGENTS promethazine
FARXIGA alendronate § ORAL scopolamine transdermal
ANTIDIABETICS ibandronate estradiol trimethobenzamide
JARDIANCE
AMYLIN ANALOGS risedronate estradiol-norethindrone SANCUSO
SYMLINPEN SODIUM-GLUCOSE DUAVEE
CO-TRANSPORTER 2 § CALCITONINS PREMPHASE § ANTISPASMODICS
§ BIGUANIDES (SGLT2) INHIBITOR / calcitonin-salmon PREMPRO dicyclomine
metformin BIGUANIDE COMBINATIONS
metformin ext-rel (except generics § CARNITINE DEFICIENCY § TRANSDERMAL § H2 RECEPTOR
SYNJARDY
AGENTS estradiol ANTAGONISTS
for FORTAMET and GLUMETZA) SYNJARDY XR
XIGDUO XR levocarnitine CLIMARA PRO famotidine
§ BIGUANIDE / COMBIPATCH
SULFONYLUREA SODIUM-GLUCOSE CONTRACEPTIVES INFLAMMATORY BOWEL
DIVIGEL
COMBINATIONS CO-TRANSPORTER 2 § MONOPHASIC DISEASE
EVAMIST
glipizide-metformin (SGLT2) INHIBITOR / ethinyl estradiol- § ORAL AGENTS
DIPEPTIDYL PEPTIDASE-4 drospirenone § VAGINAL balsalazide
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR ethinyl estradiol- estradiol vaginal cream budesonide delayed-rel
(DPP-4) INHIBITORS COMBINATIONS drospirenone-levomefolate IMVEXXY capsule
JANUVIA GLYXAMBI ethinyl estradiol- VAGIFEM mesalamine delayed-rel
norethindrone acetate mesalamine ext-rel
DIPEPTIDYL PEPTIDASE-4 SODIUM-GLUCOSE § PHOSPHATE BINDER
ethinyl estradiol- sulfasalazine
(DPP-4) INHIBITOR / CO-TRANSPORTER 2 AGENTS
norethindrone acetate-iron sulfasalazine delayed-rel
BIGUANIDE COMBINATIONS (SGLT2) INHIBITOR / calcium acetate
JANUMET DIPEPTIDYL PEPTIDASE-4 BIPHASIC sevelamer carbonate § RECTAL AGENTS
JANUMET XR (DPP-4) INHIBITOR / LO LOESTRIN FE AURYXIA hydrocortisone enema
BIGUANIDE COMBINATIONS VELPHORO mesalamine suppository
INCRETIN MIMETIC AGENTS § TRIPHASIC
TRIJARDY XR mesalamine suspension
MOUNJARO ethinyl estradiol-norgestimate POTASSIUM-REMOVING CORTIFOAM
OZEMPIC § SULFONYLUREAS AGENTS
RYBELSUS glimepiride FOUR PHASE VELTASSA § IRRITABLE BOWEL
TRULICITY glipizide NATAZIA SYNDROME
VICTOZA PROGESTINS alosetron
glipizide ext-rel
§ EXTENDED CYCLE § ORAL lubiprostone
INCRETIN MIMETIC AGENT / SUPPLIES ethinyl estradiol- medroxyprogesterone LINZESS
INSULIN COMBINATIONS levonorgestrel
ACCU-CHEK AVIVA PLUS megestrol acetate VIBERZI
SOLIQUA STRIPS AND KITS 2 progesterone, micronized
XULTOPHY § TRANSDERMAL § LAXATIVES
ACCU-CHEK GUIDE
STRIPS AND KITS 2 ethinyl estradiol- VAGINAL lactulose solution
INSULINS norelgestromin
ACCU-CHEK SMARTVIEW CRINONE peg 3350-electrolytes (except
BASAGLAR STRIPS AND KITS 2 ENDOMETRIN generics for MOVIPREP)
FIASP VAGINAL
BD ULTRAFINE INSULIN CLENPIQ
HUMULIN R U-500 ANNOVERA § SELECTIVE ESTROGEN
SYRINGES AND
LEVEMIR NUVARING RECEPTOR MODULATORS OPIOID-INDUCED
NEEDLES
NOVOLIN 70/30 raloxifene CONSTIPATION
DEXCOM CONTINUOUS DIABETIC KIDNEY DISEASE
NOVOLIN N GLUCOSE MONITORING SYMPROIC
NOVOLIN R KERENDIA § THYROID SUPPLEMENTS
SYSTEM PANCREATIC ENZYMES
NOVOLOG OMNIPOD 5 INSULIN levothyroxine
ENDOMETRIOSIS
NOVOLOG MIX 70/30 INFUSION PUMP liothyronine CREON
TOUJEO MYFEMBREE SYNTHROID VIOKACE
OMNIPOD DASH INSULIN ORILISSA
TRESIBA INFUSION PUMP ZENPEP
UTERINE FIBROIDS
§ INSULIN SENSITIZERS OMNIPOD INSULIN § GLUCOCORTICOIDS § PROTON PUMP
MYFEMBREE
INFUSION PUMP dexamethasone INHIBITORS
pioglitazone ORIAHNN
ONETOUCH ULTRA fludrocortisone esomeprazole delayed-rel
§ INSULIN SENSITIZER / STRIPS AND KITS 2 hydrocortisone GASTROINTESTINAL lansoprazole delayed-rel
BIGUANIDE COMBINATIONS ONETOUCH VERIO STRIPS methylprednisolone capsule
pioglitazone-metformin AND KITS 2 prednisolone solution (except § ANTIDIARRHEALS
omeprazole delayed-rel
V-GO INSULIN INFUSION prednisolone solution 10 mg/5 mL, 20 diphenoxylate-atropine pantoprazole delayed-rel
§ INSULIN SENSITIZER / PUMP mg/5 mL) loperamide tablet
SULFONYLUREA prednisone
COMBINATIONS ANTIOBESITY § ANTIEMETICS § STEROIDS, RECTAL
pioglitazone-glimepiride INJECTABLE § GLUCOSE ELEVATING aprepitant PROCTOFOAM-HC
SAXENDA AGENTS doxylamine-pyridoxine
§ MEGLITINIDES WEGOVY glucagon, human delayed-rel § ULCER THERAPY
nateglinide recombinant dronabinol COMBINATIONS
repaglinide § ORAL BAQSIMI granisetron PYLERA
orlistat GVOKE meclizine TALICIA
QSYMIA ZEGALOGUE metoclopramide

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
§ MISCELLANEOUS NUTRITIONAL / MOUTH / THROAT /
§ Nebulized Passive § ANTIFUNGALS DENTAL AGENTS
sucralfate tablet SUPPLEMENTS
Inhalation ciclopirox PROTECTANTS
GENITOURINARY § ELECTROLYTES formoterol inhalation solution clotrimazole
EPISIL
potassium chloride liquid econazole
§ BENIGN PROSTATIC § LEUKOTRIENE ketoconazole cream 2% OPHTHALMIC
HYPERPLASIA VITAMINS AND MINERALS MODULATORS nystatin § ANTIALLERGICS
alfuzosin ext-rel § FOLIC ACID / montelukast NAFTIN
doxazosin COMBINATIONS zafirlukast azelastine
dutasteride § ANTIPSORIATICS bepotastine
folic acid § NASAL ANTIHISTAMINES
dutasteride-tamsulosin acitretin cromolyn sodium
finasteride § MULTIVITAMINS 3 azelastine calcipotriene ointment, olopatadine
silodosin multivitamins olopatadine solution § ANTI-INFECTIVES
tamsulosin methoxsalen
§ PRENATAL VITAMINS § NASAL STEROIDS / ciprofloxacin
terazosin ENSTILAR
COMBINATIONS erythromycin
prenatal vitamins VTAMA
ERECTILE DYSFUNCTION azelastine-fluticasone ZORYVE gentamicin
ALPROSTADIL AGENTS RESPIRATORY flunisolide levofloxacin
fluticasone § ANTISEBORRHEICS moxifloxacin
MUSE § ANAPHYLAXIS mometasone ketoconazole shampoo 2% ofloxacin
§ PHOSPHODIESTERASE TREATMENT AGENTS sulfacetamide
selenium sulfide lotion 2.5%
INHIBITORS epinephrine § PHOSPHODIESTERASE-4 tobramycin
AUVI-Q INHIBITORS § ATOPIC DERMATITIS BESIVANCE
sildenafil
tadalafil EPIPEN roflumilast pimecrolimus
EPIPEN JR § ANTI-INFECTIVE /
tacrolimus
§ URINARY STEROID / BETA AGONIST ANTI-INFLAMMATORY
EUCRISA
ANTISPASMODICS § ANTICHOLINERGICS COMBINATIONS COMBINATIONS
ipratropium inhalation ADVAIR DISKUS CORTICOSTEROIDS neomycin-polymyxin B-
darifenacin ext-rel
fesoterodine ext-rel solution ADVAIR HFA ** § Low Potency bacitracin-hydrocortisone
oxybutynin SPIRIVA BREO ELLIPTA ** desonide (except desonide gel) neomycin-polymyxin B-
oxybutynin ext-rel YUPELRI SYMBICORT hydrocortisone dexamethasone
solifenacin tobramycin-dexamethasone
ANTICHOLINERGIC / BETA § STEROID INHALANTS § Medium Potency TOBRADEX OINTMENT
tolterodine AGONIST COMBINATIONS budesonide inhalation hydrocortisone butyrate
tolterodine ext-rel ANTI-INFLAMMATORIES
§ SHORT ACTING suspension cream, ointment, solution
trospium
ipratropium-albuterol PULMICORT FLEXHALER mometasone § Nonsteroidal
trospium ext-rel
GEMTESA inhalation solution triamcinolone cream, lotion, bromfenac
TOPICAL diclofenac
ointment (except triamcinolone
LONG ACTING ketorolac
HEMATOLOGIC DERMATOLOGY ointment 0.05%)
ANORO ELLIPTA ILEVRO
ANTICOAGULANTS ACNE § High Potency
STIOLTO RESPIMAT PROLENSA
§ INJECTABLE § Topical desoximetasone
ANTICHOLINERGIC / BETA adapalene (except adapalene pad) § Steroidal
enoxaparin fluocinonide (except fluocinonide
AGONIST / STEROID benzoyl peroxide dexamethasone
cream 0.1%)
§ ORAL INHALANT COMBINATIONS clindamycin gel (except NDC* difluprednate
BRYHALI
warfarin BREZTRI AEROSPHERE 68682046275) loteprednol
ELIQUIS TRELEGY ELLIPTA clindamycin solution § Very High Potency prednisolone acetate 1%
XARELTO clindamycin-benzoyl clobetasol cream, foam (except
§ ANTIHISTAMINES, peroxide § ANTIVIRALS
clobetasol emollient foam), gel,
§ SYNTHETIC HEPARINOID- LOW SEDATING dapsone trifluridine
lotion, ointment, shampoo
LIKE AGENTS levocetirizine erythromycin solution halobetasol cream, ointment
erythromycin-benzoyl BETA-BLOCKERS
fondaparinux § ANTITUSSIVES
peroxide § LOCAL ANALGESICS § Nonselective
§ PLATELET AGGREGATION benzonatate (except NDCs* tretinoin lidocaine patch timolol maleate solution
INHIBITORS 69336012615, 69499032915)
AKLIEF
clopidogrel ARAZLO § LOCAL ANESTHETICS Selective
BETA AGONISTS,
dipyridamole ext-rel-aspirin EPIDUO lidocaine-prilocaine BETOPTIC S
INHALANTS
prasugrel ONEXTON
§ SHORT ACTING § ROSACEA § CARBONIC ANHYDRASE
BRILINTA TWYNEO
albuterol inhalation solution azelaic acid gel INHIBITORS
WINLEVI
SICKLE CELL DISEASE albuterol sulfate CFC-free brimonidine gel brinzolamide
SIKLOS aerosol (except NDC* § ACTINIC KERATOSIS metronidazole dorzolamide
66993001968) fluorouracil cream 5% FINACEA FOAM
IMMUNOLOGIC levalbuterol tartrate CFC-free ORACEA § CARBONIC ANHYDRASE
fluorouracil solution
AGENTS aerosol RHOFADE INHIBITOR / BETA-
imiquimod
SOOLANTRA BLOCKER COMBINATIONS
ALLERGENIC EXTRACTS ZYCLARA
LONG ACTING dorzolamide-timolol
GRASTEK Hand-held Active Inhalation § ANTIBIOTICS
RAGWITEK CARBONIC ANHYDRASE
SEREVENT gentamicin
INHIBITOR /
STRIVERDI RESPIMAT mupirocin ointment

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
SYMPATHOMIMETIC § PROSTAGLANDINS ALPHAGAN P OTIC § ANTI-INFECTIVE /
COMBINATIONS bimatoprost § ANTI-INFECTIVES ANTI-INFLAMMATORY
§ SYMPATHOMIMETIC / COMBINATIONS
SIMBRINZA latanoprost acetic acid
BETA-BLOCKER
travoprost ofloxacin otic ciprofloxacin-dexamethasone
DRY EYE DISEASE COMBINATIONS
ZIOPTAN neomycin-polymyxin B-
RESTASIS brimonidine-timolol hydrocortisone
XIIDRA § SYMPATHOMIMETICS
brimonidine solution

QUICK REFERENCE DRUG LIST

A AURYXIA carbidopa-levodopa ext-rel dexmethylphenidate ext-rel erythromycin-benzoyl
ABILIFY MAINTENA AUVI-Q carbidopa-levodopa- diazepam peroxide
ACCU-CHEK AVIVA PLUS azelaic acid gel entacapone diazepam rectal gel erythromycins
STRIPS AND KITS 2 azelastine carvedilol diclofenac escitalopram
azelastine-fluticasone carvedilol phosphate ext-rel diclofenac sodium esomeprazole delayed-rel
ACCU-CHEK GUIDE
azithromycin cefdinir diclofenac sodium gel 1% estradiol
STRIPS AND KITS 2
AZSTARYS cefprozil diclofenac sodium solution estradiol vaginal cream
ACCU-CHEK SMARTVIEW
cefuroxime axetil 1.5% estradiol-norethindrone
STRIPS AND KITS 2 B celecoxib diclofenac sodium- eszopiclone
acetic acid
balsalazide cephalexin misoprostol ethacrynic acid
acitretin
BAQSIMI chlorthalidone dicloxacillin ethinyl estradiol-
acyclovir capsule, tablet
BASAGLAR cholestyramine dicyclomine drospirenone
adapalene (except adapalene pad)
BD ULTRAFINE INSULIN ciclopirox DIFICID ethinyl estradiol-
ADVAIR DISKUS
SYRINGES AND ciprofloxacin difluprednate drospirenone-levomefolate
ADVAIR HFA **
NEEDLES ciprofloxacin-dexamethasone digoxin ethinyl estradiol-
AIMOVIG
BELBUCA citalopram diltiazem ext-rel (except generics levonorgestrel
AJOVY
AKLIEF BELSOMRA clarithromycin for CARDIZEM LA) ethinyl estradiol-
albuterol inhalation solution benzonatate (except NDCs* clarithromycin ext-rel diphenoxylate-atropine norelgestromin
albuterol sulfate CFC-free 69336012615, 69499032915) CLENPIQ dipyridamole ext-rel-aspirin ethinyl estradiol-
aerosol (except NDC* benzoyl peroxide CLIMARA PRO disopyramide norethindrone acetate
bepotastine clindamycin divalproex sodium ethinyl estradiol-
66993001968)
BESIVANCE clindamycin gel (except NDC* divalproex sodium ext-rel norethindrone acetate-iron
alendronate
BETOPTIC S 68682046275) DIVIGEL ethinyl estradiol-norgestimate
alfuzosin ext-rel
bicalutamide clindamycin solution donepezil ethosuximide
aliskiren
BIDIL clindamycin-benzoyl dorzolamide EUCRISA
allopurinol
bimatoprost peroxide dorzolamide-timolol EVAMIST
alosetron
BREO ELLIPTA ** clobazam doxazosin ezetimibe
ALPHAGAN P
BREZTRI AEROSPHERE clobetasol cream, foam (except doxepin ezetimibe-simvastatin
alprazolam
BRILINTA clobetasol emollient foam), gel, doxycycline hyclate 20 mg
amantadine
brimonidine gel lotion, ointment, shampoo doxycycline hyclate capsule F
amiloride
brimonidine solution clonazepam doxylamine-pyridoxine
amiodarone famotidine
brimonidine-timolol clopidogrel delayed-rel
amlodipine FARXIGA
amlodipine-atorvastatin brinzolamide clotrimazole dronabinol
bromfenac clozapine DUAVEE fenofibrate (except fenofibrate capsule
amlodipine-olmesartan
amlodipine-telmisartan BRYHALI codeine-acetaminophen duloxetine 30 mg, 50 mg, 90 mg, 130 mg;

amlodipine-valsartan budesonide delayed-rel colchicine tablet dutasteride fenofibrate tablet 40 mg, 120 mg)

capsule colesevelam dutasteride-tamsulosin fenofibric acid delayed-rel

amlodipine-valsartan- fentanyl transdermal
hydrochlorothiazide budesonide inhalation COMBIPATCH
suspension CORLANOR E fentanyl transmucosal
amoxicillin lozenge
buprenorphine transdermal CORTIFOAM econazole
amoxicillin-clavulanate fesoterodine ext-rel
buprenorphine-naloxone CREON eletriptan
amphetamine- FIASP
sublingual CRINONE ELIQUIS
dextroamphetamine mixed FINACEA FOAM
bupropion cromolyn sodium EMGALITY
salts finasteride
bupropion ext-rel (except cyclobenzaprine (except EMVERM
amphetamine- fluconazole
dextroamphetamine mixed bupropion ext-rel tablet 450 mg) cyclobenzaprine tablet 7.5 mg) enalapril
ENDOMETRIN fludrocortisone
salts ext-rel D flunisolide
ANNOVERA
C enoxaparin
dapsone ENSTILAR fluocinonide (except fluocinonide
ANORO ELLIPTA calcipotriene ointment,
cream 0.1%)
aprepitant solution darifenacin ext-rel entacapone
DAYVIGO ENTRESTO fluorouracil cream 5%
APTIOM calcitonin-salmon
desonide (except desonide gel) EPIDUO fluorouracil solution
ARAZLO calcium acetate
desoximetasone epinephrine fluoxetine (except fluoxetine tablet 60
aripiprazole candesartan
mg, fluoxetine tablet [generics for
armodafinil candesartan- desvenlafaxine ext-rel EPIPEN
SARAFEM])
atenolol hydrochlorothiazide dexamethasone EPIPEN JR
DEXCOM CONTINUOUS EPISIL fluticasone
atomoxetine carbamazepine
GLUCOSE MONITORING erythromycin fluvastatin
atorvastatin carbamazepine ext-rel
SYSTEM erythromycin solution folic acid
carbidopa-levodopa

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Caremark.com or contact a CVS Caremark Customer Care representative.
fondaparinux ketorolac MOUNJARO ONZETRA XSAIL quinapril-hydrochlorothiazide
formoterol inhalation solution moxifloxacin ORACEA QULIPTA
fosinopril L multivitamins ORIAHNN
fosinopril-hydrochlorothiazide lacosamide mupirocin ointment ORILISSA R
furosemide lactulose solution MUSE orlistat RAGWITEK
FYCOMPA lamotrigine MYFEMBREE oseltamivir raloxifene
lamotrigine ext-rel oxazepam ramelteon
G lansoprazole delayed-rel N oxcarbazepine ramipril
gabapentin capsule nadolol OXTELLAR XR ranolazine ext-rel
galantamine latanoprost NAFTIN oxybutynin rasagiline
galantamine ext-rel levalbuterol tartrate CFC-free naloxone oxybutynin ext-rel RELENZA
GEMTESA aerosol NAMZARIC oxycodone repaglinide
gentamicin LEVEMIR naproxen (except naproxen CR or oxycodone-acetaminophen RESTASIS
glimepiride levetiracetam naproxen suspension) OZEMPIC RHOFADE
glipizide levetiracetam ext-rel naratriptan risedronate
glipizide ext-rel levocarnitine NATAZIA P risperidone
glipizide-metformin levocetirizine nateglinide pantoprazole delayed-rel rivastigmine
glucagon, human levofloxacin NATESTO tablet rivastigmine transdermal
recombinant levothyroxine NAYZILAM paroxetine HCl rizatriptan
GLYXAMBI lidocaine patch nebivolol paroxetine HCl ext-rel (except roflumilast
GRALISE lidocaine-prilocaine neomycin-polymyxin B- NDC* 60505367503) ropinirole
granisetron linezolid bacitracin-hydrocortisone peg 3350-electrolytes (except ropinirole ext-rel
GRASTEK LINZESS neomycin-polymyxin B- generics for MOVIPREP) rosuvastatin
guanfacine ext-rel liothyronine dexamethasone pemetrexed rufinamide
GVOKE lisinopril neomycin-polymyxin B- penicillin VK RYBELSUS
lisinopril-hydrochlorothiazide hydrocortisone PERSERIS RYTARY
H LO LOESTRIN FE NEUPRO phenobarbital
halobetasol cream, ointment loperamide NEXLETOL phenytoin S
HUMULIN R U-500 lorazepam NEXLIZET phenytoin sodium extended SANCUSO
hydrochlorothiazide losartan niacin ext-rel pimecrolimus SAXENDA
hydrocodone ext-rel losartan-hydrochlorothiazide nifedipine ext-rel pindolol scopolamine transdermal
hydrocodone-acetaminophen loteprednol nitrofurantoin (except NDC* pioglitazone selegiline
hydrocortisone lovastatin 16571074024) pioglitazone-glimepiride selenium sulfide lotion 2.5%
hydrocortisone butyrate lubiprostone nitroglycerin lingual spray pioglitazone-metformin SEREVENT
cream, ointment, solution lurasidone nitroglycerin sublingual potassium chloride liquid sertraline
hydrocortisone enema NOVOLIN 70/30 pramipexole sevelamer carbonate
hydromorphone M NOVOLIN N pramipexole ext-rel SIKLOS
hydromorphone ext-rel meclizine NOVOLIN R prasugrel sildenafil
medroxyprogesterone NOVOLOG pravastatin silodosin
I megestrol acetate NOVOLOG MIX 70/30 prednisolone acetate 1% SIMBRINZA
ibandronate meloxicam tablet NURTEC ODT prednisolone solution (except simvastatin
ibuprofen memantine NUVARING prednisolone solution 10 mg/5 mL, 20 solifenacin
ILEVRO mesalamine delayed-rel nystatin mg/5 mL) SOLIQUA
imiquimod mesalamine ext-rel prednisone SOOLANTRA
IMVEXXY mesalamine suppository O pregabalin sotalol
ipratropium inhalation mesalamine suspension ofloxacin pregabalin ext-rel SPIRIVA
solution metformin ofloxacin otic PREMPHASE spironolactone
ipratropium-albuterol metformin ext-rel (except generics olanzapine PREMPRO spironolactone-
inhalation solution for FORTAMET and GLUMETZA) olmesartan prenatal vitamins hydrochlorothiazide
irbesartan methadone olmesartan-amlodipine- primidone STIOLTO RESPIMAT
irbesartan- methoxsalen hydrochlorothiazide probenecid STRIVERDI RESPIMAT
hydrochlorothiazide methylphenidate olmesartan- prochlorperazine sucralfate tablet
isosorbide dinitrate (except methylphenidate ext-rel hydrochlorothiazide PROCTOFOAM-HC sulfacetamide
isosorbide dinitrate 40 mg) methylprednisolone olopatadine progesterone, micronized sulfamethoxazole-
isosorbide mononitrate metoclopramide omega-3 acid ethyl esters PROLENSA trimethoprim
itraconazole metolazone omeprazole delayed-rel promethazine sulfasalazine
ivermectin tablet metoprolol succinate ext-rel OMNIPOD 5 INSULIN propranolol sulfasalazine delayed-rel
metoprolol tartrate INFUSION PUMP propranolol ext-rel sumatriptan
J metronidazole OMNIPOD DASH INSULIN PULMICORT FLEXHALER SUNOSI
JANUMET midodrine INFUSION PUMP PYLERA SUPRAX
JANUMET XR minocycline OMNIPOD INSULIN pyrimethamine SYMBICORT
JANUVIA mirtazapine INFUSION PUMP SYMLINPEN
MITIGARE ondansetron Q SYMPROIC
JARDIANCE
modafinil ONETOUCH ULTRA QELBREE SYNJARDY
K mometasone STRIPS AND KITS 2 QSYMIA SYNJARDY XR
KERENDIA montelukast ONETOUCH VERIO STRIPS quetiapine SYNTHROID
ketoconazole cream 2% morphine AND KITS 2 quetiapine ext-rel
ketoconazole shampoo 2% morphine ext-rel ONEXTON quinapril

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Caremark.com or contact a CVS Caremark Customer Care representative.
T topiramate trospium ext-rel VERQUVO
torsemide TRULICITY V-GO INSULIN INFUSION Y
tacrolimus
TOUJEO TWYNEO PUMP YUPELRI
tadalafil
tramadol (except NDC* 52817019610) VIBERZI
TALICIA
tramadol ext-rel tablet U VICTOZA Z
tamsulosin
travoprost UBRELVY VIOKACE zafirlukast
TEKTURNA HCT
trazodone VRAYLAR ZEGALOGUE
telmisartan
TRELEGY ELLIPTA V VTAMA ZEMBRACE SYMTOUCH
telmisartan-
TRESIBA VAGIFEM ZENPEP
hydrochlorothiazide
tretinoin valacyclovir W ZIOPTAN
terazosin
triamcinolone cream, lotion, valganciclovir warfarin ziprasidone
terbinafine tablet
ointment (except triamcinolone valproic acid WEGOVY zolmitriptan
testosterone gel (except authorized
generics for TESTIM and VOGELXO)
ointment 0.05%) valsartan WINLEVI zolpidem
testosterone solution triamterene valsartan-hydrochlorothiazide zolpidem ext-rel
tetracycline triamterene- VALTOCO X zonisamide
tiagabine hydrochlorothiazide vancomycin capsule XARELTO ZORYVE
timolol maleate solution trifluridine VASCEPA XCOPRI ZUBSOLV
TRIJARDY XR VELPHORO XIFAXAN 550 MG ZYCLARA
TOBRADEX OINTMENT
trimethobenzamide VELTASSA XIGDUO XR
tobramycin
TRINTELLIX venlafaxine XIIDRA
tobramycin-dexamethasone
TROKENDI XR venlafaxine ext-rel capsule XTAMPZA ER
tolterodine
trospium verapamil ext-rel XULTOPHY
tolterodine ext-rel

PREFERRED OPTIONS LIST

DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
ABILIFY aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, methylphenidate ext-rel, AZSTARYS
quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR
albuterol sulfate CFC-free albuterol sulfate CFC-free aerosol
ACANYA adapalene (except adapalene pad), aerosol (except NDC* 66993001968), levalbuterol tartrate CFC-
benzoyl peroxide, clindamycin gel (except NDC* 68682046275), (NDC* 66993001968 only) free aerosol
clindamycin solution, clindamycin-benzoyl peroxide, dapsone,
erythromycin solution, erythromycin- ALEVICYN GEL, desonide (except desonide gel), hydrocortisone
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO, ALEVICYN SG,
ONEXTON, TWYNEO, WINLEVI ALEVICYN SOLUTION

ACIPHEX, ACIPHEX esomeprazole delayed-rel, lansoprazole delayed-rel capsule, ALIMTA pemetrexed

SPRINKLE omeprazole delayed-rel, pantoprazole delayed-rel tablet ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES
Activite 3 generic multivitamins INSULIN SYRINGES 4

ACTOS pioglitazone ALREX azelastine, bepotastine, cromolyn sodium, olopatadine

ACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin,
pravastatin, rosuvastatin, simvastatin
acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir
ALVESCO PULMICORT FLEXHALER
ACZONE adapalene (except adapalene pad),
benzoyl peroxide, clindamycin gel (except NDC* 68682046275), AMITIZA lubiprostone, LINZESS, SYMPROIC
clindamycin solution, clindamycin-benzoyl peroxide, dapsone, AMRIX cyclobenzaprine
erythromycin solution, erythromycin- (except cyclobenzaprine tablet 7.5 mg)
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO,
ONEXTON, TWYNEO, WINLEVI ANDROGEL testosterone gel (except authorized generics for TESTIM and
VOGELXO),
adapalene pad adapalene (except adapalene pad), benzoyl peroxide, testosterone solution, NATESTO
clindamycin gel (except NDC* 68682046275),
clindamycin solution, clindamycin-benzoyl peroxide, dapsone, APEXICON E desoximetasone (except
erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, desoximetasone ointment 0.05%), fluocinonide
AKLIEF, ARAZLO, EPIDUO, ONEXTON, TWYNEO, WINLEVI (except fluocinonide cream 0.1%), BRYHALI
ADDERALL amphetamine-dextroamphetamine mixed salts, methylphenidate APIDRA FIASP, NOVOLOG
ADDERALL XR amphetamine- APTENSIO XR amphetamine-
dextroamphetamine mixed salts ext-rel, dextroamphetamine mixed salts ext-rel,
dexmethylphenidate ext-rel, dexmethylphenidate ext-rel,
methylphenidate ext-rel, AZSTARYS methylphenidate ext-rel, AZSTARYS
ADRENALIN epinephrine, AUVI-Q, EPIPEN, EPIPEN JR ARNUITY ELLIPTA PULMICORT FLEXHALER
ADZENYS XR-ODT amphetamine- ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam tablet or
dextroamphetamine mixed salts ext-rel, naproxen (except naproxen CR or naproxen suspension) WITH
dexmethylphenidate ext-rel, esomeprazole delayed-rel, lansoprazole delayed-rel capsule,

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
omeprazole delayed-rel, or pantoprazole delayed-rel tablet BETAPACE AF
ASACOL HD balsalazide, mesalamine delayed-rel, mesalamine ext-rel, BETIMOL timolol maleate solution, BETOPTIC S
sulfasalazine, sulfasalazine delayed-rel
BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT
ASCENSIA STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK
KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW BEYAZ ethinyl estradiol-drospirenone,
STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, ethinyl estradiol-drospirenone-levomefolate,
ONETOUCH VERIO STRIPS AND KITS 2 ethinyl estradiol-levonorgestrel,
ethinyl estradiol-norethindrone acetate,
ASMANEX, ASMANEX PULMICORT FLEXHALER ethinyl estradiol-norethindrone acetate-iron,
HFA ethinyl estradiol-norgestimate,
LO LOESTRIN FE, NATAZIA
ATACAND, candesartan, candesartan-hydrochlorothiazide, irbesartan,
ATACAND HCT irbesartan-hydrochlorothiazide, losartan, losartan- BREEZE 2 STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK
hydrochlorothiazide, olmesartan, olmesartan- KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW
hydrochlorothiazide, telmisartan, telmisartan- STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2,
hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide ONETOUCH VERIO STRIPS AND KITS 2
ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam BROMSITE bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA
ATOPADERM desonide (except desonide gel), hydrocortisone budesonide ext-rel tablet balsalazide, mesalamine delayed-rel, mesalamine ext-rel,
sulfasalazine, sulfasalazine delayed-rel
AVENOVA Talk to your doctor
Bupap diclofenac sodium, ibuprofen,
AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, naproxen (except naproxen CR or
moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE naproxen suspension)
AZELEX adapalene (except adapalene pad), bupropion ext-rel tablet bupropion, bupropion ext-rel
benzoyl peroxide, clindamycin gel (except NDC* 68682046275), 450 mg (except bupropion ext-rel tablet 450 mg)
clindamycin solution, clindamycin-benzoyl peroxide, dapsone,
erythromycin solution, erythromycin- butalbital-acetaminophen diclofenac sodium, ibuprofen, naproxen (except naproxen CR or
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO, capsule, naproxen suspension)
ONEXTON, TWYNEO, WINLEVI butalbital-acetaminophen
tablet 25-325 mg,
AZESCO 6 generic prenatal vitamins butalbital-acetaminophen
AZOR amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- tablet 50-300 mg,
valsartan BUTALBITAL-
ACETAMINOPHEN
BALCOLTRA ethinyl estradiol-drospirenone, (NDC* 69499034230 only)
ethinyl estradiol-drospirenone-levomefolate,
ethinyl estradiol-levonorgestrel, butalbital-acetaminophen- diclofenac sodium, ibuprofen, naproxen (except naproxen CR or
ethinyl estradiol-norethindrone acetate, caffeine capsule naproxen suspension)
ethinyl estradiol-norethindrone acetate-iron, BUTRANS buprenorphine transdermal, BELBUCA
ethinyl estradiol-norgestimate,
LO LOESTRIN FE, NATAZIA BYDUREON BCISE MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
BANZEL clobazam, clonazepam, lamotrigine, rufinamide, topiramate, BYETTA MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
TROKENDI XR
BYSTOLIC atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol
BECONASE AQ azelastine-fluticasone, flunisolide, fluticasone, mometasone succinate ext-rel, metoprolol tartrate, nadolol, nebivolol, pindolol,
propranolol, propranolol ext-rel
BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan,
irbesartan-hydrochlorothiazide, losartan, losartan- CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan,
hydrochlorothiazide, olmesartan, olmesartan- NURTEC ODT, ONZETRA XSAIL, UBRELVY, ZEMBRACE
hydrochlorothiazide, telmisartan, telmisartan- SYMTOUCH
hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
calcipotriene cream, calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE
BENSAL HP desonide (except desonide gel), hydrocortisone calcipotriene foam,
CALCIPOTRIENE FOAM
benzonatate benzonatate
(NDCs* 69336012615, (except NDCs* 69336012615, 69499032915) calcipotriene- calcipotriene ointment or calcipotriene solution WITH
69499032915 only) betamethasone desoximetasone (except desoximetasone ointment 0.05%),
fluocinonide (except fluocinonide cream 0.1%) or BRYHALI;
BEPREVE azelastine, bepotastine, cromolyn sodium, olopatadine ENSTILAR, VTAMA, ZORYVE
BETAMETHASONE dexamethasone, hydrocortisone, methylprednisolone, calcitriol ointment calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE
ACETATE- prednisolone solution (except prednisolone solution 10 mg/5
BETAMETHASONE mL, CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or
SODIUM PHOSPHATE 20 mg/5 mL), prednisone naproxen suspension)
betamethasone desoximetasone (except desoximetasone ointment 0.05%), Capsinac diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium
dipropionate ointment fluocinonide (except fluocinonide cream 0.1%), BRYHALI solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except
0.05% naproxen CR or naproxen suspension)
BETAPACE, sotalol CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod,

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
ZYCLARA COLAZAL balsalazide, mesalamine delayed-rel, mesalamine ext-rel,
sulfasalazine, sulfasalazine delayed-rel
CARAFATE sucralfate tablet
colchicine capsule colchicine tablet, MITIGARE
CARBINOXAMINE levocetirizine
TABLET 6 MG COLCRYS colchicine tablet, MITIGARE
CARDIZEM, CARDIZEM diltiazem ext-rel COMBIGAN brimonidine-timolol
CD, (except generics for CARDIZEM LA)
CARDIZEM LA CONCERTA amphetamine-
dextroamphetamine mixed salts ext-rel,
carisoprodol 250 mg cyclobenzaprine dexmethylphenidate ext-rel,
(except cyclobenzaprine tablet 7.5 mg) methylphenidate ext-rel, AZSTARYS
CARNITOR, CARNITOR levocarnitine CONTOUR NEXT STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK
SF AND KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW
STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2,
CELEBREX celecoxib, diclofenac sodium, ibuprofen, ONETOUCH VERIO STRIPS AND KITS 2
meloxicam tablet, naproxen (except
naproxen CR or naproxen suspension) CONTOUR STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK
KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW
chlordiazepoxide-clidinium dicyclomine STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2,
(NDCs* 11534019701, ONETOUCH VERIO STRIPS AND KITS 2
42494040901,
51293069601, CONTRAVE orlistat, QSYMIA, SAXENDA, WEGOVY
51293069610,
67877073101, CORDRAN CREAM, desonide (except desonide gel), hydrocortisone
70700018501 only) CORDRAN LOTION

chlorzoxazone 250 mg, cyclobenzaprine

chlorzoxazone 375 mg, (except cyclobenzaprine tablet 7.5 mg) CORDRAN OINTMENT hydrocortisone butyrate cream, hydrocortisone butyrate
chlorzoxazone 500 mg ointment, hydrocortisone butyrate solution, mometasone,
(NDC* 73007001303 triamcinolone cream, triamcinolone lotion, triamcinolone
only), chlorzoxazone 750 ointment (except triamcinolone ointment 0.05%)
mg CORDRAN TAPE clobetasol cream, clobetasol foam (except clobetasol emollient
CIALIS sildenafil, tadalafil foam), clobetasol gel, clobetasol lotion, clobetasol ointment,
halobetasol cream, halobetasol ointment
CICATRACE Talk to your doctor
COREG CR atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol
CILOXAN ciprofloxacin, erythromycin, gentamicin, levofloxacin, succinate ext-rel,
moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol,
propranolol ext-rel
CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic
CoreMino doxycycline hyclate 20 mg, doxycycline hyclate capsule,
CIPRODEX ciprofloxacin-dexamethasone, ofloxacin otic minocycline, tetracycline
ciprofloxacin-fluocinolone ciprofloxacin-dexamethasone, ofloxacin otic COZAAR candesartan, irbesartan, losartan, olmesartan, telmisartan,
CITRANATAL 6 generic prenatal vitamins valsartan

CLIMARA (except estradiol, DIVIGEL, EVAMIST CRESEMBA itraconazole

CLIMARA PRO) CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin,
clindamycin gel (NDC* adapalene (except adapalene pad), pravastatin, rosuvastatin, simvastatin
68682046275 only) benzoyl peroxide, clindamycin gel (except NDC* 68682046275), cyclobenzaprine ext-rel cyclobenzaprine
clindamycin solution, clindamycin-benzoyl peroxide, dapsone, capsule, (except cyclobenzaprine tablet 7.5 mg)
erythromycin solution, erythromycin- cyclobenzaprine tablet 7.5
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO, mg
ONEXTON, TWYNEO, WINLEVI
CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-
clobetasol emollient foam clobetasol cream, clobetasol foam (except clobetasol emollient rel capsule
foam), clobetasol gel, clobetasol lotion, clobetasol ointment,
halobetasol cream, halobetasol ointment CYTOMEL levothyroxine, liothyronine, SYNTHROID
clobetasol spray clobetasol cream, clobetasol foam (except clobetasol emollient DALIRESP roflumilast
foam), clobetasol gel, clobetasol lotion, clobetasol ointment,
halobetasol cream, halobetasol ointment DARAPRIM pyrimethamine

CLOBEX SPRAY clobetasol cream, clobetasol foam (except clobetasol emollient DAYTRANA amphetamine-
foam), clobetasol gel, clobetasol lotion, clobetasol ointment, dextroamphetamine mixed salts ext-rel,
halobetasol cream, halobetasol ointment dexmethylphenidate ext-rel,
methylphenidate ext-rel, AZSTARYS
clocortolone cream hydrocortisone butyrate cream, hydrocortisone butyrate
ointment, hydrocortisone butyrate solution, mometasone, DELZICOL balsalazide, mesalamine delayed-rel, mesalamine ext-rel,
triamcinolone cream, triamcinolone lotion, triamcinolone sulfasalazine, sulfasalazine delayed-rel
ointment (except triamcinolone ointment 0.05%)

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
DEPAKOTE, DEPAKOTE carbamazepine, carbamazepine ext-rel, clonazepam, divalproex DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, irbesartan,
ER, DEPAKOTE sodium, divalproex sodium ext-rel, ethosuximide, gabapentin, irbesartan-hydrochlorothiazide, losartan, losartan-
SPRINKLE lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam, hydrochlorothiazide, olmesartan, olmesartan-
levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, hydrochlorothiazide, telmisartan, telmisartan-
phenytoin sodium extended, primidone, tiagabine, topiramate, hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR
XR, TROKENDI XR, XCOPRI Diphen Elixir levocetirizine

desonide gel desonide (except desonide gel), hydrocortisone DORYX, DORYX MPC doxycycline hyclate 20 mg, doxycycline hyclate capsule,
minocycline, tetracycline
desoximetasone ointment hydrocortisone butyrate cream, hydrocortisone butyrate
0.05% ointment, hydrocortisone butyrate solution, mometasone, doxepin cream desonide (except desonide gel), hydrocortisone, pimecrolimus,
triamcinolone cream, triamcinolone lotion, triamcinolone tacrolimus, EUCRISA
ointment (except triamcinolone ointment 0.05%) doxycycline hyclate doxycycline hyclate 20 mg, doxycycline hyclate capsule,
DesRx desonide (except desonide gel), hydrocortisone delayed-rel tablet minocycline, tetracycline

DETROL LA darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, doxycycline hyclate tablet doxycycline hyclate 20 mg, doxycycline hyclate capsule,
solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium 50 mg, minocycline, tetracycline
ext-rel, GEMTESA doxycycline hyclate tablet
75 mg,
dexchlorpheniramine levocetirizine doxycycline hyclate tablet
150 mg
Dexifol 3 generic multivitamins
doxycycline monohydrate doxycycline hyclate 20 mg, doxycycline hyclate capsule,
DEXILANT esomeprazole delayed-rel, lansoprazole delayed-rel capsule, capsule 75 mg, minocycline, tetracycline
omeprazole delayed-rel, pantoprazole delayed-rel tablet doxycycline monohydrate
dexlansoprazole delayed- esomeprazole delayed-rel, lansoprazole delayed-rel capsule, capsule 150 mg
rel omeprazole delayed-rel, pantoprazole delayed-rel tablet doxycycline monohydrate ORACEA
diclofenac potassium diclofenac sodium, ibuprofen, delayed-rel capsule
capsule 25 mg meloxicam tablet, naproxen (except DULERA ADVAIR DISKUS, ADVAIR HFA**,
diclofenac potassium naproxen CR or naproxen suspension) BREO ELLIPTA**, SYMBICORT
tablet 25 mg
DUOBRII calcipotriene ointment or
diclofenac potassium diclofenac sodium, ibuprofen, naproxen (except naproxen CR or calcipotriene solution WITH desoximetasone (except
powder naproxen suspension) desoximetasone ointment 0.05%), fluocinonide (except
diclofenac sodium solution diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium fluocinonide cream 0.1%) or BRYHALI; ENSTILAR, VTAMA,
2% solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except ZORYVE
naproxen CR or naproxen suspension) DYANAVEL XR amphetamine-
Diclofex DC diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium dextroamphetamine mixed salts ext-rel,
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except dexmethylphenidate ext-rel,
naproxen CR or naproxen suspension) methylphenidate ext-rel, AZSTARYS

Diclosaicin diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium DYMISTA azelastine-fluticasone, flunisolide, fluticasone, mometasone
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except DYRENIUM amiloride, triamterene
naproxen CR or naproxen suspension)
EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan,
DIFFERIN LOTION adapalene (except adapalene pad), irbesartan-hydrochlorothiazide, losartan, losartan-
benzoyl peroxide, clindamycin gel (except NDC* 68682046275), hydrochlorothiazide, olmesartan, olmesartan-
clindamycin solution, clindamycin-benzoyl peroxide, dapsone, hydrochlorothiazide, telmisartan, telmisartan-
erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
AKLIEF, ARAZLO, EPIDUO, ONEXTON, TWYNEO, WINLEVI
EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel,
diflorasone cream, desoximetasone (except BELSOMRA, DAYVIGO
diflorasone ointment desoximetasone ointment 0.05%), fluocinonide (except
fluocinonide cream 0.1%), BRYHALI E.E.S. GRANULES erythromycins
dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-
NURTEC ODT, ONZETRA XSAIL, UBRELVY, ZEMBRACE rel capsule
SYMTOUCH
ELIDEL pimecrolimus, tacrolimus, EUCRISA
DILANTIN carbamazepine, carbamazepine ext-rel, divalproex sodium,
divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, ELMIRON Talk to your doctor
lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, EluRyng ANNOVERA, NUVARING
oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium
extended, primidone, tiagabine, topiramate, valproic acid, ENLITE CONTINUOUS DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI GLUCOSE MONITORING
XR, XCOPRI SYSTEM
diltiazem ext-rel diltiazem ext-rel ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG
(generics for CARDIZEM (except generics for CARDIZEM LA)
LA only) EPANED enalapril, fosinopril, lisinopril, quinapril, ramipril

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
EPICERAM desonide (except desonide gel), hydrocortisone fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod,
ZYCLARA
ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan,
NURTEC ODT, ONZETRA XSAIL, UBRELVY, ZEMBRACE fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet
SYMTOUCH (generics for SARAFEM [generics for SARAFEM]), paroxetine HCl ext-rel (except NDC*
only) 60505367503), sertraline
ERYPED erythromycins
estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM
ESTRING estradiol vaginal cream, IMVEXXY, VAGIFEM fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60
mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
ethinyl estradiol- ANNOVERA, NUVARING paroxetine HCl ext-rel (except NDC* 60505367503), sertraline,
etonogestrel TRINTELLIX
EVEKEO amphetamine-dextroamphetamine mixed salts, methylphenidate flurandrenolide cream, desonide (except desonide gel), hydrocortisone
flurandrenolide lotion
EVERSENSE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
CONTINUOUS GLUCOSE flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate
MONITORING SYSTEM ointment, hydrocortisone butyrate solution, mometasone,
triamcinolone cream, triamcinolone lotion, triamcinolone
EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine- ointment (except triamcinolone ointment 0.05%)
valsartan
FML FORTE, FML dexamethasone, difluprednate, loteprednol, prednisolone
EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan- LIQUIFILM acetate 1%
amlodipine-hydrochlorothiazide
FOCALIN XR amphetamine-
FABIOR adapalene (except adapalene pad), dextroamphetamine mixed salts ext-rel,
benzoyl peroxide, clindamycin gel (except NDC* 68682046275), dexmethylphenidate ext-rel,
clindamycin solution, clindamycin-benzoyl peroxide, dapsone, methylphenidate ext-rel, AZSTARYS
erythromycin solution, erythromycin-
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO, Folvite-D 3 folic acid, generic multivitamins
ONEXTON, TWYNEO, WINLEVI
FORTAMET metformin, metformin ext-rel (except
FANAPT aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, generics for FORTAMET and GLUMETZA)
quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR
FORTESTA testosterone gel (except authorized generics for TESTIM and
FEMRING estradiol vaginal cream, IMVEXXY, VAGIFEM VOGELXO),
testosterone solution, NATESTO
fenofibrate capsule 30 mg, fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg,
50 mg, 90 mg, 130 mg; 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid FOSRENOL calcium acetate, sevelamer carbonate, AURYXIA, VELPHORO
fenofibrate tablet 40 mg, delayed-rel
120 mg FOSTEUM, FOSTEUM alendronate, ibandronate, risedronate
PLUS
FENOGLIDE TABLET 120 fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg,
MG 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid FREESTYLE LIBRE DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
delayed-rel CONTINUOUS GLUCOSE
MONITORING SYSTEM
fenoprofen, diclofenac sodium, ibuprofen,
FENOPROFEN CAPSULE meloxicam tablet, naproxen (except FREESTYLE STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK
naproxen CR or naproxen suspension) AND KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW
STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2,
FERIVA 21/7 3 generic multivitamins ONETOUCH VERIO STRIPS AND KITS 2
Fexmid cyclobenzaprine Genicin Vita-S 3 generic multivitamins
(except cyclobenzaprine tablet 7.5 mg)
GLUCAGEN HYPOKIT glucagon, human recombinant; BAQSIMI; GVOKE;
FINACEA GEL azelaic acid gel, brimonidine gel, metronidazole, ZEGALOGUE
FINACEA FOAM, RHOFADE, SOOLANTRA
GLUCAGON glucagon, human recombinant; BAQSIMI; GVOKE;
FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except naproxen CR or EMERGENCY KIT ZEGALOGUE
naproxen suspension)
GLUMETZA metformin, metformin ext-rel (except generics for FORTAMET
FLAREX dexamethasone, difluprednate, loteprednol, prednisolone and GLUMETZA)
acetate 1%
GLYCOPYRROLATE dicyclomine
FLORIVA, FLORIVA generic multivitamins TABLET 1.5 MG
PLUS 3
GOLYTELY peg 3350-electrolytes (except generics for MOVIPREP),
FLOVENT DISKUS, PULMICORT FLEXHALER CLENPIQ
FLOVENT HFA
GUARDIAN DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
flucytosine capsule 500 fluconazole CONNECT CONTINUOUS
mg GLUCOSE MONITORING
SYSTEM
fluocinonide cream 0.1% clobetasol cream, clobetasol foam (except clobetasol emollient
foam), clobetasol gel, clobetasol lotion, clobetasol ointment, GUARDIAN REAL-TIME DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
halobetasol cream, halobetasol ointment CONTINUOUS GLUCOSE

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
MONITORING SYSTEM succinate ext-rel,
metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol,
halcinonide cream desoximetasone (except propranolol ext-rel
desoximetasone ointment 0.05%), fluocinonide (except
fluocinonide cream 0.1%), BRYHALI INTRAROSA estradiol vaginal cream, IMVEXXY, VAGIFEM
HALOG desoximetasone (except INTUNIV amphetamine-
desoximetasone ointment 0.05%), fluocinonide (except dextroamphetamine mixed salts ext-rel, atomoxetine,
fluocinonide cream 0.1%), BRYHALI dexmethylphenidate ext-rel, guanfacine ext-rel, methylphenidate
ext-rel, AZSTARYS, QELBREE
HEPARIN SODIUM IN 5% enoxaparin, fondaparinux
DEXTROSE INVELTYS dexamethasone, difluprednate, loteprednol, prednisolone
acetate 1%
HORIZANT gabapentin, pregabalin, pregabalin ext-rel, GRALISE
INVOKAMET, SYNJARDY, SYNJARDY XR, XIGDUO XR
HUMALOG FIASP, NOVOLOG INVOKAMET XR
HUMALOG MIX 50/50 NOVOLOG MIX 70/30 INVOKANA FARXIGA, JARDIANCE
HUMALOG MIX 75/25 NOVOLOG MIX 70/30 isosorbide dinitrate 40 mg isosorbide dinitrate
HUMULIN 70/30 NOVOLIN 70/30 (except isosorbide dinitrate 40 mg), isosorbide mononitrate

HUMULIN N NOVOLIN N ivermectin cream azelaic acid gel, brimonidine gel, metronidazole,
FINACEA FOAM, RHOFADE, SOOLANTRA
HUMULIN R NOVOLIN R
JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH
hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin
lipophilic cream 0.1% ointment, hydrocortisone butyrate solution, mometasone,
triamcinolone cream, triamcinolone lotion, triamcinolone JENTADUETO, JANUMET, JANUMET XR
ointment (except triamcinolone ointment 0.05%) JENTADUETO XR

hydrocortisone butyrate hydrocortisone butyrate cream, hydrocortisone butyrate JORNAY PM amphetamine-

lotion ointment, hydrocortisone butyrate solution, mometasone, dextroamphetamine mixed salts ext-rel,
triamcinolone cream, triamcinolone lotion, triamcinolone dexmethylphenidate ext-rel,
ointment (except triamcinolone ointment 0.05%) methylphenidate ext-rel, AZSTARYS

HylaVite 3 generic multivitamins

KAMDOY desonide (except desonide gel), hydrocortisone
hyoscyamine sulfate ext- dicyclomine
rel Kapzin DC diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except
HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- naproxen CR or naproxen suspension)
rel, methadone, morphine ext-rel, XTAMPZA ER
KAZANO JANUMET, JANUMET XR
HYZAAR candesartan-hydrochlorothiazide,
irbesartan-hydrochlorothiazide, KEPPRA, KEPPRA XR carbamazepine, carbamazepine ext-rel, divalproex sodium,
losartan-hydrochlorothiazide, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine,
olmesartan-hydrochlorothiazide, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel,
telmisartan-hydrochlorothiazide, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium
valsartan-hydrochlorothiazide extended, primidone, tiagabine, topiramate, valproic acid,
zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI
Iclofenac CP diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium XR, XCOPRI
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except
naproxen CR or naproxen suspension) ketoconazole foam 2% ketoconazole shampoo 2%,
selenium sulfide lotion 2.5%
icosapent ethyl omega-3 acid ethyl esters, VASCEPA
Ketodan ketoconazole shampoo 2%,
INCRUSE ELLIPTA SPIRIVA selenium sulfide lotion 2.5%
INDERAL LA, INDERAL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol ketoprofen capsule 25 mg diclofenac sodium, ibuprofen,
XL succinate ext-rel, meloxicam tablet, naproxen (except
metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, naproxen CR or naproxen suspension)
propranolol ext-rel
ketoprofen ext-rel capsule diclofenac sodium, ibuprofen,
INDOCIN diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except
meloxicam tablet, naproxen (except naproxen CR or naproxen suspension)
naproxen CR or naproxen suspension)
KOMBIGLYZE XR JANUMET, JANUMET XR
indomethacin capsule 20 diclofenac sodium, ibuprofen,
mg meloxicam tablet, naproxen (except LACRISERT RESTASIS, XIIDRA
naproxen CR or naproxen suspension) LACTULOSE PAK lactulose solution
Inflammacin diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium LAMICTAL, LAMICTAL carbamazepine, carbamazepine ext-rel, clobazam, clonazepam,
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except ODT divalproex sodium,
naproxen CR or naproxen suspension) divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine,
INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel,

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
oxcarbazepine, phenobarbital, phenytoin, MACRODANTIN nitrofurantoin (except NDC* 16571074024)
phenytoin sodium extended, primidone, rufinamide, tiagabine,
topiramate, Matzim LA diltiazem ext-rel
valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR (except generics for CARDIZEM LA)
XR, TROKENDI XR, XCOPRI MAXALT, MAXALT-MLT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan,
LAMICTAL XR carbamazepine, carbamazepine ext-rel, divalproex sodium, NURTEC ODT, ONZETRA XSAIL, UBRELVY, ZEMBRACE
divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, SYMTOUCH
lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, MAXIDEX dexamethasone, difluprednate, loteprednol, prednisolone
oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium acetate 1%
extended, primidone, tiagabine, topiramate, valproic acid,
zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI mefenamic acid (NDC* diclofenac sodium, ibuprofen,
XR, XCOPRI 69336012830 only) meloxicam tablet, naproxen (except
naproxen CR or naproxen suspension)
LANOXIN TABLET digoxin
(125 MCG and 250 MCG meloxicam capsule diclofenac sodium, ibuprofen,
only) meloxicam tablet, naproxen (except
naproxen CR or naproxen suspension)
lansoprazole delayed-rel esomeprazole delayed-rel, lansoprazole delayed-rel capsule,
orally disintegrating tablet omeprazole delayed-rel, pantoprazole delayed-rel tablet MENEST estradiol
lanthanum carbonate calcium acetate, sevelamer carbonate, AURYXIA, VELPHORO metaxalone 400 mg cyclobenzaprine
(except cyclobenzaprine tablet 7.5 mg)
LANTUS 7 BASAGLAR, LEVEMIR
metformin ext-rel metformin, metformin ext-rel (except generics for FORTAMET
LASTACAFT azelastine, bepotastine, cromolyn sodium, olopatadine (generics for FORTAMET and GLUMETZA)
LATUDA aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, and GLUMETZA only)
quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR methocarbamol 500 mg cyclobenzaprine
LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, (NDC* 69036091010 (except cyclobenzaprine tablet 7.5 mg)
pravastatin, rosuvastatin, simvastatin only),
methocarbamol 750 mg
levorphanol fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext- (NDCs* 69036093090,
rel, methadone, 70868090190 only)
morphine ext-rel, XTAMPZA ER
MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate,
LEXAPRO citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 FORTEO, PROLIA, TYMLOS
mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
paroxetine HCl ext-rel (except NDC* 60505367503), sertraline, MICARDIS, candesartan, candesartan-hydrochlorothiazide, irbesartan,
TRINTELLIX MICARDIS HCT irbesartan-hydrochlorothiazide, losartan, losartan-
hydrochlorothiazide, olmesartan, olmesartan-
LIALDA balsalazide, mesalamine delayed-rel, mesalamine ext-rel, hydrochlorothiazide, telmisartan, telmisartan-
sulfasalazine, sulfasalazine delayed-rel hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
LIBRAX dicyclomine Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan,
NURTEC ODT, ONZETRA XSAIL, UBRELVY, ZEMBRACE
LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, SYMTOUCH
pravastatin, rosuvastatin, simvastatin
Millipred dexamethasone, hydrocortisone, methylprednisolone,
LITHOSTAT Talk to your doctor prednisolone solution (except prednisolone solution 10 mg/5
LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, mL,
pravastatin, rosuvastatin, simvastatin 20 mg/5 mL), prednisone

Lofena diclofenac sodium, ibuprofen, MINASTRIN 24 FE ethinyl estradiol-drospirenone,

meloxicam tablet, naproxen (except ethinyl estradiol-drospirenone-levomefolate,
naproxen CR or naproxen suspension) ethinyl estradiol-levonorgestrel,
ethinyl estradiol-norethindrone acetate,
LOKELMA VELTASSA ethinyl estradiol-norethindrone acetate-iron,
ethinyl estradiol-norgestimate,
Lorzone cyclobenzaprine LO LOESTRIN FE, NATAZIA
(except cyclobenzaprine tablet 7.5 mg)
MINIVELLE estradiol, DIVIGEL, EVAMIST
LOTEMAX, LOTEMAX SM dexamethasone, difluprednate, loteprednol, prednisolone
acetate 1% minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule,
minocycline, tetracycline
LOVAZA omega-3 acid ethyl esters, VASCEPA
MIRVASO azelaic acid gel, brimonidine gel, metronidazole,
luliconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, FINACEA FOAM, RHOFADE, SOOLANTRA
NAFTIN
Mondoxyne NL capsule 75 doxycycline hyclate 20 mg, doxycycline hyclate capsule,
LUMIGAN bimatoprost, latanoprost, travoprost, ZIOPTAN mg minocycline, tetracycline
LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, MOVANTIK lubiprostone, SYMPROIC
BELSOMRA, DAYVIGO
MOVIPREP peg 3350-electrolytes (except generics for MOVIPREP),
LYRICA duloxetine, pregabalin, pregabalin ext-rel

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
CLENPIQ ropinirole, ropinirole ext-rel, selegiline, NEUPRO
MULTAQ amiodarone NOVO NORDISK BD ULTRAFINE NEEDLES
NEEDLES 4
MultiPro 3 generic multivitamins
NOXAFIL fluconazole, itraconazole
mupirocin cream gentamicin, mupirocin ointment
NUCYNTA hydromorphone, morphine, oxycodone
MYDAYIS amphetamine-
dextroamphetamine mixed salts ext-rel, dexmethylphenidate NUCYNTA ER fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-
ext-rel, rel, methadone, morphine ext-rel, XTAMPZA ER
methylphenidate ext-rel, AZSTARYS
NuDiclo SoluPak, NuDiclo diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium
TabPak solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except
MYRBETRIQ darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, naproxen CR or naproxen suspension)
solifenacin, tolterodine, tolterodine ext-rel, trospium,
trospium ext-rel, GEMTESA NUEDEXTA Talk to your doctor

MYTESI diphenoxylate-atropine, loperamide NUVIGIL armodafinil, modafinil, SUNOSI

NAPRELAN diclofenac sodium, ibuprofen, OLUX-E clobetasol cream, clobetasol foam (except clobetasol emollient
meloxicam tablet, naproxen (except foam), clobetasol gel, clobetasol lotion, clobetasol ointment,
naproxen CR or naproxen suspension) halobetasol cream, halobetasol ointment

naproxen CR diclofenac sodium, ibuprofen, omeprazole-sodium esomeprazole delayed-rel, lansoprazole delayed-rel capsule,
meloxicam tablet, naproxen (except bicarbonate omeprazole delayed-rel, pantoprazole delayed-rel tablet
naproxen CR or naproxen suspension) OMNARIS azelastine-fluticasone, flunisolide, fluticasone, mometasone
naproxen suspension diclofenac sodium, ibuprofen, ONFI clobazam, clonazepam, lamotrigine, rufinamide, topiramate,
meloxicam tablet, naproxen (except TROKENDI XR
naproxen CR or naproxen suspension)
ONGLYZA JANUVIA
naproxen-esomeprazole diclofenac sodium, ibuprofen,
meloxicam tablet or naproxen (except naproxen CR or naproxen orphenadrine-aspirin- cyclobenzaprine
suspension) WITH esomeprazole delayed-rel, lansoprazole caffeine (except cyclobenzaprine tablet 7.5 mg)
delayed-rel capsule, omeprazole delayed-rel, or pantoprazole
delayed-rel tablet Orphengesic Forte cyclobenzaprine
(except cyclobenzaprine tablet 7.5 mg)
NEO-SYNALAR desonide (except desonide gel) or hydrocortisone WITH
gentamicin ORTHO D 3 folic acid, generic multivitamins

NESINA JANUVIA ORTHO DF 3 folic acid, generic multivitamins

NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone

NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel capsule, OSMOPREP peg 3350-electrolytes (except generics for MOVIPREP),
omeprazole delayed-rel, pantoprazole delayed-rel tablet CLENPIQ

NEXTERONE amiodarone OSPHENA estradiol

niacin tablet 500 mg niacin ext-rel OWEN MUMFORD BD ULTRAFINE NEEDLES

NEEDLES 4
Niacor niacin ext-rel
oxiconazole ciclopirox, clotrimazole, econazole, ketoconazole cream 2%,
NICADAN 3 generic multivitamins (NDCs* 00168035830, NAFTIN
51672135902 only)
NICAPRIN 3 generic multivitamins
OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-
NICAZEL, NICAZEL generic multivitamins rel, methadone,
FORTE 3 morphine ext-rel, XTAMPZA ER
NICOMIDE 3 generic multivitamins oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-
NILANDRON abiraterone, bicalutamide, ERLEADA, XTANDI, YONSA rel, methadone,
morphine ext-rel, XTAMPZA ER
nitrofurantoin (NDC* nitrofurantoin (except NDC* 16571074024)
16571074024 only) OXYTROL darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel,
solifenacin, tolterodine, tolterodine ext-rel, trospium,
NORGESIC FORTE cyclobenzaprine trospium ext-rel, GEMTESA
(except cyclobenzaprine tablet 7.5 mg)
pantoprazole delayed-rel esomeprazole delayed-rel, lansoprazole delayed-rel capsule,
NORITATE azelaic acid gel, brimonidine gel, metronidazole, suspension omeprazole delayed-rel, pantoprazole delayed-rel tablet
FINACEA FOAM, RHOFADE, SOOLANTRA
paroxetine HCl ext-rel citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60
NORPACE disopyramide (NDC* 60505367503 only) mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
paroxetine HCl ext-rel (except NDC* 60505367503), sertraline,
NORVASC amlodipine TRINTELLIX
NOURIANZ entacapone, pramipexole, pramipexole ext-rel, rasagiline, paroxetine mesylate paroxetine HCl

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Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
capsule 7.5 mg levalbuterol tartrate CFC-free aerosol
PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 PROMETRIUM medroxyprogesterone; progesterone, micronized
mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
paroxetine HCl ext-rel (except NDC* 60505367503), sertraline, PROTONIX esomeprazole delayed-rel, lansoprazole delayed-rel capsule,
TRINTELLIX omeprazole delayed-rel, pantoprazole delayed-rel tablet

peg 3350-electrolytes peg 3350-electrolytes (except generics for MOVIPREP), PROVENTIL HFA albuterol sulfate CFC-free aerosol
(generics for MOVIPREP CLENPIQ (except NDC* 66993001968), levalbuterol tartrate CFC-
only) free aerosol

Pennsaicin diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium PROVIGIL armodafinil, modafinil, SUNOSI
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60
naproxen CR or naproxen suspension) mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
PENNSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium paroxetine HCl ext-rel (except NDC* 60505367503), sertraline,
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except TRINTELLIX
naproxen CR or naproxen suspension) QNASL azelastine-fluticasone, flunisolide, fluticasone, mometasone
PENTASA balsalazide, mesalamine delayed-rel, mesalamine ext-rel, QTERN GLYXAMBI
sulfasalazine, sulfasalazine delayed-rel
quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel,
PERCOCET hydrocodone-acetaminophen, BELSOMRA, DAYVIGO
oxycodone-acetaminophen
QUILLICHEW ER amphetamine-
PERRIGO NEEDLES 4 BD ULTRAFINE NEEDLES dextroamphetamine mixed salts ext-rel, dexmethylphenidate
PEXEVA citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 ext-rel,
mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, methylphenidate ext-rel, AZSTARYS
paroxetine HCl ext-rel (except NDC* 60505367503), sertraline, QUILLIVANT XR amphetamine-
TRINTELLIX dextroamphetamine mixed salts ext-rel, dexmethylphenidate
PLAVIX clopidogrel, prasugrel, BRILINTA ext-rel,
methylphenidate ext-rel, AZSTARYS
POLYTOZA Talk to your doctor
QVAR REDIHALER 8 PULMICORT FLEXHALER
POLY-VI-FLOR 3 generic multivitamins
RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
POLY-VI-FLOR WITH generic multivitamins
IRON 3 RAYOS dexamethasone, hydrocortisone, methylprednisolone,
prednisolone solution (except prednisolone solution 10 mg/5
posaconazole delayed-rel fluconazole, itraconazole mL,
tablet 20 mg/5 mL), prednisone
PRADAXA warfarin, ELIQUIS, XARELTO RECEDO Talk to your doctor
PRECISION XTRA ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK RELION INSULIN NOVOLIN INSULIN
STRIPS AND KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW
STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, RENVELA calcium acetate, sevelamer carbonate, AURYXIA, VELPHORO
ONETOUCH VERIO STRIPS AND KITS 2 RHEUMATE 3 generic multivitamins
PRED FORTE, PRED dexamethasone, difluprednate, loteprednol, prednisolone RHOPRESSA bimatoprost, latanoprost, travoprost, ZIOPTAN
MILD acetate 1%
RIMSO-50 Talk to your doctor
prednisolone solution 10 dexamethasone, hydrocortisone, methylprednisolone,
mg/5 mL, prednisolone solution (except prednisolone solution 10 mg/5 RIOMET metformin, metformin ext-rel (except generics for FORTAMET
prednisolone solution 20 mL, and GLUMETZA)
mg/5 mL 20 mg/5 mL), prednisone
ROCKLATAN bimatoprost, latanoprost, travoprost, ZIOPTAN
PREMARIN estradiol
ROZEREM doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel,
PREMARIN CREAM estradiol vaginal cream, IMVEXXY, VAGIFEM BELSOMRA, DAYVIGO
PRENATAL PLUS 6 generic prenatal vitamins RyClora levocetirizine
PREVACID esomeprazole delayed-rel, lansoprazole delayed-rel capsule, SCARSILK PAD Talk to your doctor
omeprazole delayed-rel, pantoprazole delayed-rel tablet
SEASONIQUE ethinyl estradiol-drospirenone,
PREVIDENT Talk to your doctor ethinyl estradiol-drospirenone-levomefolate,
ethinyl estradiol-levonorgestrel,
PRILOSEC esomeprazole delayed-rel, lansoprazole delayed-rel capsule, ethinyl estradiol-norethindrone acetate,
omeprazole delayed-rel, pantoprazole delayed-rel tablet ethinyl estradiol-norethindrone acetate-iron,
PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- ethinyl estradiol-norgestimate,
rel capsule LO LOESTRIN FE, NATAZIA

PROAIR HFA, PROAIR albuterol sulfate CFC-free aerosol SEROQUEL XR aripiprazole, clozapine, lurasidone, olanzapine, quetiapine,
RESPICLICK (except NDC* 66993001968), quetiapine ext-rel, risperidone, ziprasidone, VRAYLAR

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
SILENOR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, TESTIM testosterone gel (except authorized generics for TESTIM and
BELSOMRA, DAYVIGO VOGELXO),
testosterone solution, NATESTO
SILIVEX Talk to your doctor
testosterone gel 1% testosterone gel (except authorized generics for TESTIM and
SILTREX Talk to your doctor (authorized generics for VOGELXO),
SINGULAIR montelukast, zafirlukast TESTIM and VOGELXO testosterone solution, NATESTO
only)
SORILUX calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE
THEO-24 formoterol inhalation solution, ipratropium inhalation solution,
SPRIX diclofenac sodium, ibuprofen, SEREVENT, SPIRIVA, STRIVERDI RESPIMAT, YUPELRI
meloxicam tablet, naproxen (except
naproxen CR or naproxen suspension) TIMOPTIC OCUDOSE timolol maleate solution, BETOPTIC S

STENDRA sildenafil, tadalafil TIROSINT levothyroxine, SYNTHROID

SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV TOBRADEX ST neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin-

polymyxin B-dexamethasone, tobramycin-dexamethasone,
SUBSYS fentanyl transmucosal lozenge TOBRADEX OINTMENT
sucralfate suspension sucralfate tablet topiramate ext-rel capsule carbamazepine, carbamazepine ext-rel, clobazam, clonazepam,
(generics for QUDEXY XR divalproex sodium, divalproex sodium ext-rel, gabapentin,
sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR only) lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam,
or naproxen suspension) WITH eletriptan, naratriptan, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin,
rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA phenytoin sodium extended, primidone, rufinamide, tiagabine,
XSAIL, UBRELVY or ZEMBRACE SYMTOUCH topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA,
OXTELLAR XR, TROKENDI XR, XCOPRI
SUPREP peg 3350-electrolytes (except generics for MOVIPREP), TOPROL-XL atenolol, carvedilol, carvedilol phosphate ext-rel,
CLENPIQ metoprolol succinate ext-rel, metoprolol tartrate, nadolol,
Sure Result DSS Premium diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium nebivolol, pindolol, propranolol, propranolol ext-rel
Pack solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except Tovet clobetasol cream, clobetasol foam (except clobetasol emollient
naproxen CR or naproxen suspension) foam), clobetasol gel, clobetasol lotion, clobetasol ointment,
SURE-TEST STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK halobetasol cream, halobetasol ointment
AND KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW TOVIAZ darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel,
STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium
ONETOUCH VERIO STRIPS AND KITS 2 ext-rel, GEMTESA
SYMJEPI epinephrine, AUVI-Q, EPIPEN, EPIPEN JR TRADJENTA JANUVIA
SYNERDERM desonide (except desonide gel), tramadol (NDC* tramadol (except NDC* 52817019610), tramadol ext-rel tablet
hydrocortisone 52817019610 only),
TALIVA 3 generic multivitamins tramadol ext-rel capsule

Targadox doxycycline hyclate 20 mg, doxycycline hyclate capsule,
minocycline, tetracycline
tavaborole terbinafine tablet
TAYTULLA ethinyl estradiol-drospirenone,
ethinyl estradiol-drospirenone-levomefolate,
ethinyl estradiol-levonorgestrel,
ethinyl estradiol-norethindrone acetate,
ethinyl estradiol-norethindrone acetate-iron,
ethinyl estradiol-norgestimate,
LO LOESTRIN FE, NATAZIA
TAZORAC adapalene (except adapalene pad),
benzoyl peroxide, clindamycin gel (except NDC* 68682046275),
clindamycin solution, clindamycin-benzoyl peroxide, dapsone,
erythromycin solution, erythromycin-
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO,
ONEXTON, TWYNEO, WINLEVI; calcipotriene ointment,
calcipotriene solution, VTAMA, ZORYVE
TEGRETOL, TEGRETOL carbamazepine, carbamazepine ext-rel, divalproex sodium,
XR divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine,
lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel,
oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium
extended, primidone, tiagabine, topiramate, valproic acid,
zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI
XR, XCOPRI
TRANSDERM SCOP meclizine, scopolamine transdermal
TRAVATAN Z bimatoprost, latanoprost, travoprost, ZIOPTAN
TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR
or naproxen suspension) WITH eletriptan, naratriptan,
rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA
XSAIL, UBRELVY or ZEMBRACE SYMTOUCH
triamcinolone aerosol hydrocortisone butyrate cream, hydrocortisone butyrate
0.2% ointment, hydrocortisone butyrate solution, mometasone,
triamcinolone cream, triamcinolone lotion, triamcinolone
ointment (except triamcinolone ointment 0.05%)
triamcinolone ointment hydrocortisone butyrate cream, hydrocortisone butyrate
0.05% ointment, hydrocortisone butyrate solution, mometasone,
triamcinolone cream, triamcinolone lotion, triamcinolone
ointment (except triamcinolone ointment 0.05%)
Trianex hydrocortisone butyrate cream, hydrocortisone butyrate
ointment, hydrocortisone butyrate solution, mometasone,
triamcinolone cream, triamcinolone lotion, triamcinolone
ointment (except triamcinolone ointment 0.05%)
TRICOR fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg,
130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid
delayed-rel
TRILEPTAL carbamazepine, carbamazepine ext-rel, divalproex sodium,

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, VIMPAT carbamazepine, carbamazepine ext-rel, divalproex sodium,
lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine,
oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel,
extended, primidone, tiagabine, topiramate, valproic acid, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium
zonisamide, APTIOM, FYCOMPA OXTELLAR XR, TROKENDI extended, primidone, tiagabine, topiramate, valproic acid,
XR, XCOPRI zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI
XR, XCOPRI
TRI-VI-FLOR 3 generic multivitamins
VITAFOL-ONE 6 generic prenatal vitamins
TRIVIDIA INSULIN BD ULTRAFINE INSULIN SYRINGES
SYRINGES 4 Vitasure 3 generic multivitamins
TronVite 3 generic multivitamins VIVELLE-DOT estradiol, DIVIGEL, EVAMIST
TRUETEST STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK VOGELXO testosterone gel (except authorized generics for TESTIM and
KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW VOGELXO),
STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, testosterone solution, NATESTO
ONETOUCH VERIO STRIPS AND KITS 2
VYZULTA bimatoprost, latanoprost, travoprost, ZIOPTAN
TRUETRACK STRIPS ACCU-CHEK AVIVA PLUS STRIPS AND KITS 2, ACCU-CHEK
AND KITS 5 GUIDE STRIPS AND KITS 2, ACCU-CHEK SMARTVIEW XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam
STRIPS AND KITS 2, ONETOUCH ULTRA STRIPS AND KITS 2, XENICAL orlistat, QSYMIA, SAXENDA, WEGOVY
ONETOUCH VERIO STRIPS AND KITS 2
XOPENEX HFA albuterol sulfate CFC-free aerosol
TUDORZA SPIRIVA (except NDC* 66993001968), levalbuterol tartrate CFC-
ULORIC allopurinol free aerosol

ULTIMED INSULIN BD ULTRAFINE INSULIN SYRINGES XYZBAC 3 generic multivitamins

SYRINGES 4 YASMIN ethinyl estradiol-drospirenone,
ULTIMED NEEDLES 4 BD ULTRAFINE NEEDLES ethinyl estradiol-drospirenone-levomefolate,
ethinyl estradiol-levonorgestrel,
ULTRAVATE clobetasol cream, clobetasol foam (except clobetasol emollient ethinyl estradiol-norethindrone acetate,
foam), clobetasol gel, clobetasol lotion, clobetasol ointment, ethinyl estradiol-norethindrone acetate-iron,
halobetasol cream, halobetasol ointment ethinyl estradiol-norgestimate,
LO LOESTRIN FE, NATAZIA
UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
YAZ ethinyl estradiol-drospirenone,
VALCYTE valganciclovir ethinyl estradiol-drospirenone-levomefolate,
VALTREX acyclovir capsule, acyclovir tablet, valacyclovir ethinyl estradiol-levonorgestrel,
ethinyl estradiol-norethindrone acetate,
Vanoxide-HC adapalene (except adapalene pad), ethinyl estradiol-norethindrone acetate-iron,
benzoyl peroxide, clindamycin gel (except NDC* 68682046275), ethinyl estradiol-norgestimate,
clindamycin solution, clindamycin-benzoyl peroxide, dapsone, LO LOESTRIN FE, NATAZIA
erythromycin solution, erythromycin-
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO, Yuvafem estradiol vaginal cream, IMVEXXY, VAGIFEM
ONEXTON, TWYNEO, WINLEVI ZALVIT 6 generic prenatal vitamins
VASCULERA Talk to your doctor ZEGERID esomeprazole delayed-rel, lansoprazole delayed-rel capsule,
VECTICAL calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE omeprazole delayed-rel, pantoprazole delayed-rel tablet

VELTIN adapalene (except adapalene pad), ZELAC Talk to your doctor

benzoyl peroxide, clindamycin gel (except NDC* 68682046275), ZERVIATE azelastine, bepotastine, cromolyn sodium, olopatadine
clindamycin solution, clindamycin-benzoyl peroxide, dapsone,
erythromycin solution, erythromycin- ZESTORETIC fosinopril-hydrochlorothiazide,
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO, lisinopril-hydrochlorothiazide,
ONEXTON, TWYNEO, WINLEVI quinapril-hydrochlorothiazide
venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext- ZETIA ezetimibe
(except 225 mg) rel capsule
ZETONNA azelastine-fluticasone, flunisolide, fluticasone, mometasone
VENTOLIN HFA albuterol sulfate CFC-free aerosol
(except NDC* 66993001968), levalbuterol tartrate CFC- ZIANA adapalene (except adapalene pad),
free aerosol benzoyl peroxide, clindamycin gel (except NDC* 68682046275),
clindamycin solution, clindamycin-benzoyl peroxide, dapsone,
VEREGEN imiquimod erythromycin solution, erythromycin-
benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO,
VIAGRA sildenafil, tadalafil ONEXTON, TWYNEO, WINLEVI
VIIBRYD citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 Ziclocin Pak diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium
mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except
paroxetine HCl ext-rel (except NDC* 60505367503), sertraline, naproxen CR or naproxen suspension)
TRINTELLIX
Ziclopro diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)† DRUG NAME(S) PREFERRED OPTION(S)†

REQUIRES MEDICAL REQUIRES MEDICAL

NECESSITY REVIEW OR NECESSITY REVIEW OR
USE PREFERRED USE PREFERRED
OPTION(S) OPTION(S)
solution 1.5%, ibuprofen, meloxicam tablet, naproxen (except phenytoin sodium extended, primidone, tiagabine, topiramate,
naproxen CR or naproxen suspension) valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR
XR, TROKENDI XR, XCOPRI
zileuton ext-rel montelukast, zafirlukast
ZONTIVITY Talk to your doctor
ZIRGAN trifluridine
ZORVOLEX diclofenac sodium, ibuprofen,
ZOLOFT citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 meloxicam tablet, naproxen (except
mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, naproxen CR or naproxen suspension)
paroxetine HCl ext-rel (except NDC* 60505367503), sertraline,
TRINTELLIX ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin-
polymyxin B-dexamethasone, tobramycin-dexamethasone,
zolpidem sublingual doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, TOBRADEX OINTMENT
BELSOMRA, DAYVIGO
ZOLPIMIST doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel,
BELSOMRA, DAYVIGO
ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium,
divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine,
lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel,
oxcarbazepine, phenobarbital, phenytoin,

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.
This is not an all-inclusive list of drugs that may require Prior Authorization. Certain plan restrictions may apply to all products, whether listed on this document or not. Plan restrictions may
include Utilization Management (UM) programs such as Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or Specialty Guideline Management (SGM).

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not
guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for
clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other
appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon
release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The
member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents
brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. 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 category and use where listed. Log in to
Caremark.com to check coverage and copay information for a specific medicine.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication. If your doctor believes you have a specific clinical need
for one of these products, he or she should contact the Prior Authorization department at: 1-855-240-0536.

§ Generics are available in this class and should be considered the first line of prescribing.
* Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package
size.
** Listing does not include certain NDCs*.
† The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.

1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the

prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.
2 An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or

ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746.
3 Generic multivitamins (except Activite, Dexifol, Folvite-D, Genicin Vita-S, HylaVite, Multipro, TronVite, Vitasure) are the only preferred options.

4 BD ULTRAFINE syringes and needles are the only preferred options.

5 ACCU-CHEK or ONETOUCH brand test strips are the only preferred options.

6 Generic prenatal vitamins are the only preferred options.

7 Long Acting Insulins - First Generation.

8 QVAR REDIHALER covered for members 5 years of age and under.

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.

©2023. All rights reserved. 1-100123 Caremark.com

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit
Caremark.com or contact a CVS Caremark Customer Care representative.