empire-plan-flexible-formulary-july-2020.pdf - Johnson, Kimberly

Please enable JavaScript to view the full PDF

July 2020 2020 EMPIRE PLAN FLEXIBLE FORMULARY DRUG LIST Administered by CVS Caremark® The Empire Plan Flexible Formulary is a guide within select therapeutic categories for enrollees 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 drug to treat a condition. These preferred brand-name drugs are listed to help identify products that are clinically appropriate and cost-effective. This is not an all-inclusive list. This formulary includes a list of commonly prescribed covered drugs by therapeutic class, a Quick Reference Drug List with commonly prescribed covered drugs in alphabetic order, a listing of commonly prescribed non-preferred (Level 3) covered drugs and covered preferred drug alternatives, and a listing of excluded drugs along with covered alternatives. This list represents brand-name drugs in CAPS and generic drugs in lowercase italics. Generally generics are subject to a Level 1 copayment, or the lowest copayment; preferred brand drugs are subject to a Level 2 copayment, and non-preferred brand drugs are subject to a Level 3 copayment, or the highest copayment. Refer to your plan materials for specific information regarding copayment amounts. ENROLLEE HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by CVS Caremark. Ask your doctor to consider administered by CVS Caremark. As a way to help manage health prescribing, when medically appropriate, a preferred generic or a care costs, authorize generic substitution whenever possible. If you preferred brand-name drug from this list. Take this list along when believe a brand-name drug is necessary, consider prescribing a you or a covered family member sees a doctor. brand-name drug on this list. Please note: Please note: • You will be responsible for the full cost of non-formulary • Generics should be considered the first line of prescribing. products that are excluded from coverage unless a request for a medical exception is approved. New prescription drug products • This drug list represents a summary of prescription coverage. may be subject to exclusion upon release to the market. It is not all-inclusive and does not guarantee coverage. • For specific information regarding your prescription benefit • The enrollee's prescription benefit plan may have a different coverage and copay information, please visit copay for specific products on the list. https://www.empireplanrxprogram.com or call 1-877-7- • Unless specifically indicated, drug list products will include all NYSHIP dosage forms. (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. • Log in to https://www.empireplanrxprogram.com to check coverage and copay information for a specific medicine. • Any brand-name drug for which a generic drug becomes available will be designated as a non-preferred drug. When a generic version is available, mandatory generic substitution will apply. In this case, use of a non-preferred product will result in the member paying the applicable non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug (Ancillary Charge). ANALGESICS § NSAIDs, COMBINATIONS colchicine tablet (generic fentanyl transmucosal oxycodone-acetaminophen diclofenac sodium- COLCRYS) lozenge PA/QL QL § NSAIDs febuxostat (generic ULORIC) hydrocodone ext-rel (generic tramadol QL/PA misoprostol diclofenac sodium probenecid ZOHYDRO ER) QL/PA tramadol ext-rel QL/PA diflunisal § NSAIDs, TOPICAL COLCRYS hydrocodone-acetaminophen ABSTRAL PA/QL etodolac diclofenac sodium gel 1% QL BELBUCA QL/PA ibuprofen (generic VOLTAREN GEL) § OPIOID ANALGESICS hydromorphone QL/PA HYSINGLA ER QL/PA meloxicam buprenorphine transdermal hydromorphone ext-rel NUCYNTA QL/PA nabumetone § COX-2 INHIBITORS (generic BUTRANS) QL/PA NUCYNTA ER QL/PA naproxen celecoxib (generic QL/PA methadone QL/PA OXYCONTIN QL/PA naproxen sodium CELEBREX) codeine-acetaminophen QL morphine QL/PA SUBSYS PA/QL oxaprozin fentanyl citrate (generic morphine ext-rel QL/PA XTAMPZA ER QL/PA sulindac § GOUT FENTORA) PA/QL morphine suppository QL/PA allopurinol fentanyl transdermal QL/PA oxycodone QL/PA Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 1 § NON-OPIOID ANALGESICS COARTEM § MISCELLANEOUS CARDIOVASCULAR § ANGIOTENSIN II butalbital-acetaminophen- DARAPRIM albendazole (generic RECEPTOR ANTAGONIST / § ACE INHIBITORS CALCIUM CHANNEL caffeine ALBENZA) QL/PA ANTIRETROVIRAL AGENTS benazepril BLOCKER / DIURETIC butalbital-aspirin-caffeine atovaquone Generally, single-source brand clindamycin captopril COMBINATIONS VISCOSUPPLEMENTS drugs (products for which a generic is not available) and dapsone enalapril olmesartan-amlodipine- GEL-ONE generic drugs indicated for the ivermectin (generic fosinopril hydrochlorothiazide HYALGAN treatment of HIV and its STROMECTOL) lisinopril (generic TRIBENZOR) SUPARTZ FX opportunistic infections are metronidazole perindopril formulary. nitrofurantoin quinapril § ANTIARRHYTHMICS ANTI-INFECTIVES § ANTIRETROVIRAL nitrofurantoin ext-rel ramipril amiodarone COMBINATIONS pentamidine (generic trandolapril disopyramide ANTIBACTERIALS BIKTARVY NEBUPENT) dofetilide (generic TIKOSYN) § CEPHALOSPORINS § ACE INHIBITOR / CALCIUM CIMDUO praziquantel (generic SGM cefadroxil CHANNEL BLOCKER DESCOVY BILTRICIDE) QL/PA flecainide cefdinir COMBINATIONS EVOTAZ sulfamethoxazole- propafenone cefixime (generic SUPRAX) GENVOYA trimethoprim amlodipine-benazepril propafenone ext-rel cefprozil ODEFSEY tinidazole trandolapril-verapamil ext-rel sotalol cefuroxime axetil SYMFI trimethoprim (generic TARKA) MULTAQ cephalexin SYMFI LO vancomycin SUPRAX SUSPENSION 500 § ACE INHIBITOR / ANTILIPEMICS SYMTUZA ALINIA DIURETIC COMBINATIONS MG/5 ML, TABLET EMVERM § BILE ACID RESINS § ANTITUBERCULAR benazepril- § ERYTHROMYCINS / SIVEXTRO cholestyramine AGENTS hydrochlorothiazide MACROLIDES XIFAXAN 550 MG colesevelam (generic ethambutol captopril-hydrochlorothiazide WELCHOL) azithromycin isoniazid enalapril-hydrochlorothiazide ANTINEOPLASTIC colestipol clarithromycin pyrazinamide AGENTS fosinopril-hydrochlorothiazide clarithromycin ext-rel rifampin lisinopril-hydrochlorothiazide § CHOLESTEROL erythromycin delayed-rel PRIFTIN Generally, single-source brand quinapril-hydrochlorothiazide ABSORPTION INHIBITORS drugs (products for which a erythromycin ethylsuccinate RIFATER ezetimibe (generic ZETIA) erythromycin stearate generic is not available) and § ADRENOLYTICS, TRECATOR generic drugs indicated for the CENTRAL DIFICID treatment of cancer are § FIBRATES ANTIVIRALS formulary. clonidine fenofibrate § FLUOROQUINOLONES clonidine transdermal § CYTOMEGALOVIRUS HORMONAL fenofibric acid ciprofloxacin AGENTS ANTINEOPLASTIC AGENTS guanfacine gemfibrozil levofloxacin valganciclovir (generic § ANTIANDROGENS § ALDOSTERONE § HMG-CoA REDUCTASE moxifloxacin VALCYTE) abiraterone (generic RECEPTOR ANTAGONISTS INHIBITORS / § PENICILLINS ZYTIGA) SGM eplerenone COMBINATIONS HEPATITIS AGENTS amoxicillin ERLEADA SGM spironolactone atorvastatin Generally, single-source brand amoxicillin-clavulanate XTANDI SGM ezetimibe-simvastatin § ANGIOTENSIN II drugs (products for which a amoxicillin-clavulanate ext-rel generic is not available) and YONSA SGM (generic VYTORIN) ampicillin generic drugs indicated for the ZYTIGA 500 MG SGM RECEPTOR ANTAGONISTS / treatment of Hepatitis B and DIURETIC COMBINATIONS fluvastatin dicloxacillin lovastatin penicillin VK Hepatitis C are formulary. § LUTEINIZING HORMONE- candesartan RELEASING HORMONE pravastatin § HEPATITIS B AGENTS candesartan- § TETRACYCLINES (LHRH) AGONISTS rosuvastatin (generic entecavir tablet hydrochlorothiazide CRESTOR) doxycycline hyclate lamivudine tablet ELIGARD SGM irbesartan simvastatin minocycline BARACLUDE SOLUTION LUPRON DEPOT SGM irbesartan- tetracycline EPIVIR-HBV SOLUTION hydrochlorothiazide § NIACINS VIBRAMYCIN SYRUP KINASE INHIBITORS losartan VEMLIDY niacin ext-rel BOSULIF SGM losartan-hydrochlorothiazide § ANTIFUNGALS § HEPATITIS C AGENTS CABOMETYX SGM olmesartan (generic § OMEGA-3 FATTY ACIDS clotrimazole troches ribavirin SGM IBRANCE SGM BENICAR) omega-3 acid ethyl esters fluconazole EPCLUSA SGM ICLUSIG SGM olmesartan- VASCEPA griseofulvin ultramicrosize HARVONI SGM IRESSA SGM hydrochlorothiazide itraconazole PA SOVALDI SGM KISQALI SGM (generic BENICAR HCT) PCSK9 INHIBITORS nystatin KISQALI FEMARA CO- telmisartan PRALUENT SGM VOSEVI ◊ SGM PACK SGM posaconazole delayed-rel telmisartan- REPATHA SGM tablet (generic NOXAFIL) § HERPES AGENTS RYDAPT SGM hydrochlorothiazide terbinafine tablet PA SPRYCEL SGM valsartan § BETA-BLOCKERS acyclovir TASIGNA SGM voriconazole valsartan-hydrochlorothiazide atenolol famciclovir NOXAFIL INJECTION, bisoprolol valacyclovir § MISCELLANEOUS § ANGIOTENSIN II SUSPENSION carvedilol § INFLUENZA AGENTS LYNPARZA SGM RECEPTOR ANTAGONIST / labetalol § ANTIMALARIALS RUBRACA SGM CALCIUM CHANNEL metoprolol succinate ext-rel oseltamivir (generic ZEJULA SGM BLOCKER COMBINATIONS atovaquone-proguanil metoprolol tartrate TAMIFLU) QL/PA chloroquine amlodipine-olmesartan nadolol RELENZA QL/PA mefloquine (generic AZOR) pindolol Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 2 propranolol PULMONARY ARTERIAL oxcarbazepine § ANTIPARKINSONIAN ADDERALL XR B4G propranolol ext-rel HYPERTENSION phenobarbital AGENTS CONCERTA B4G BYSTOLIC § ENDOTHELIN RECEPTOR phenytoin amantadine MYDAYIS ANTAGONISTS phenytoin sodium extended benztropine VYVANSE § BETA-BLOCKER / primidone ambrisentan (generic bromocriptine DIURETIC COMBINATIONS tiagabine § FIBROMYALGIA LETAIRIS) SGM carbidopa-levodopa atenolol-chlorthalidone topiramate carbidopa-levodopa ext-rel pregabalin (generic LYRICA) bosentan (generic bisoprolol- valproic acid carbidopa-levodopa- SAVELLA TRACLEER) SGM hydrochlorothiazide zonisamide entacapone OPSUMIT SGM § HUNTINGTON'S DISEASE metoprolol- DILANTIN 30 MG entacapone hydrochlorothiazide AGENTS § PHOSPHODIESTERASE FYCOMPA pramipexole INHIBITORS OXTELLAR XR tetrabenazine (generic § CALCIUM CHANNEL pramipexole ext-rel (generic QUDEXY XR XENAZINE) BLOCKERS sildenafil 20 mg SGM MIRAPEX ER) TROKENDI XR rasagiline (generic AZILECT) HYPNOTICS amlodipine PROSTACYCLIN RECEPTOR VIMPAT ropinirole § BENZODIAZEPINES diltiazem ext-rel AGONISTS selegiline felodipine ext-rel § ANTIDEMENTIA temazepam UPTRAVI SGM trihexyphenidyl nifedipine ext-rel donepezil APOKYN SGM § NONBENZODIAZEPINES verapamil ext-rel PROSTAGLANDIN galantamine NEUPRO VASODILATORS galantamine ext-rel eszopiclone § DIGITALIS GLYCOSIDES PARLODEL 5 MG REMODULIN SGM memantine (generic zolpidem digoxin RYTARY TYVASO SGM NAMENDA) zolpidem ext-rel digoxin pediatric elixir ZELAPAR VELETRI SGM rivastigmine BELSOMRA DIRECT RENIN INHIBITORS / VENTAVIS SGM rivastigmine transdermal ANTIPSYCHOTICS § TRICYCLICS DIURETIC COMBINATIONS (generic EXELON PATCH) § ATYPICALS SOLUBLE GUANYLATE NAMZARIC doxepin (generic SILENOR) aliskiren (generic CYCLASE STIMULATORS aripiprazole (generic TEKTURNA) ANTIDEPRESSANTS ABILIFY) MIGRAINE ADEMPAS SGM clozapine TEKTURNA HCT § MONOAMINE OXIDASE ACUTE MIGRAINE AGENTS § MISCELLANEOUS olanzapine § Ergotamine Derivatives § DIURETICS INHIBITORS (MAOIs) quetiapine hydralazine phenelzine dihydroergotamine injection, acetazolamide quetiapine ext-rel (generic methyldopa tranylcypromine spray acetazolamide ext-rel SEROQUEL XR) midodrine MARPLAN ergotamine-caffeine (generic amiloride risperidone phenoxybenzamine (generic CAFERGOT) amiloride-hydrochlorothiazide § SELECTIVE SEROTONIN ziprasidone DIBENZYLINE) migergot bumetanide REUPTAKE INHIBITORS ABILIFY MAINTENA ranolazine ext-rel (generic chlorthalidone (SSRIs) ARISTADA § Triptans RANEXA) furosemide ARISTADA INITIO eletriptan (generic RELPAX) citalopram hydrochlorothiazide INVEGA SUSTENNA QL/PA CENTRAL NERVOUS escitalopram indapamide INVEGA TRINZA naratriptan QL/PA SYSTEM fluoxetine methazolamide LATUDA rizatriptan QL ANTIANXIETY paroxetine HCl metolazone RISPERDAL CONSTA sumatriptan injection QL/PA paroxetine HCl ext-rel spironolactone- § BENZODIAZEPINES VRAYLAR sumatriptan nasal spray sertraline hydrochlorothiazide alprazolam QL/PA TRINTELLIX § MISCELLANEOUS torsemide clonazepam tablet sumatriptan tablet QL/PA VIIBRYD chlorpromazine triamterene- diazepam zolmitriptan QL/PA hydrochlorothiazide lorazepam § SEROTONIN fluphenazine ZEMBRACE SYMTOUCH oxazepam NOREPINEPHRINE haloperidol HEART FAILURE ZOMIG NASAL SPRAY REUPTAKE INHIBITORS perphenazine QL/PA BIDIL § MISCELLANEOUS (SNRIs) pimozide CORLANOR buspirone thiothixene PREVENTIVE MIGRAINE duloxetine ENTRESTO clomipramine trifluoperazine AGENTS venlafaxine fluvoxamine venlafaxine ext-rel Monoclonal Antibodies NITRATES § ATTENTION DEFICIT § ORAL § ANTICONVULSANTS HYPERACTIVITY DISORDER AIMOVIG § TRICYCLIC AJOVY isosorbide dinitrate carbamazepine ANTIDEPRESSANTS (TCAs) amphetamine- dextroamphetamine mixed EMGALITY isosorbide mononitrate carbamazepine ext-rel amitriptyline isosorbide mononitrate ext- diazepam rectal gel salts § MOOD STABILIZERS desipramine rel divalproex sodium atomoxetine (generic doxepin (generic lithium carbonate divalproex sodium ext-rel STRATTERA) § SUBLINGUAL / SINEQUAN) lithium carbonate ext-rel ethosuximide dexmethylphenidate TRANSLINGUAL imipramine HCl gabapentin dexmethylphenidate ext-rel MOVEMENT DISORDERS nortriptyline nitroglycerin lingual spray lamotrigine (generic FOCALIN XR) AUSTEDO SGM nitroglycerin sublingual tablet lamotrigine ext-rel § MISCELLANEOUS dextroamphetamine INGREZZA SGM (generic NITROSTAT) lamotrigine orally AGENTS dextroamphetamine ext-rel disintegrating tablet bupropion guanfacine ext-rel (generic § MULTIPLE SCLEROSIS § TRANSDERMAL INTUNIV) AGENTS (generic LAMICTAL ODT) bupropion ext-rel nitroglycerin transdermal levetiracetam mirtazapine methylphenidate dalfampridine ext-rel (generic levetiracetam ext-rel trazodone methylphenidate ext-rel AMPYRA) SGM Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 3 glatiramer (generic § VASOMOTOR SYMPTOM NOVOLOG MIX 70/30 PARATHYROID HORMONES § ENDOMETRIOSIS COPAXONE) SGM AGENTS TOUJEO FORTEO SGM danazol AUBAGIO SGM paroxetine mesylate (generic TRESIBA TYMLOS SGM ORILISSA BETASERON SGM BRISDELLE) SYNAREL COPAXONE SGM § INSULIN SENSITIZERS CONTRACEPTIVES GILENYA SGM ENDOCRINE AND pioglitazone § MONOPHASIC ESTROGENS MAYZENT METABOLIC ethinyl estradiol-desogestrel § ORAL § INSULIN SENSITIZER / REBIF SGM ethinyl estradiol- estradiol ACROMEGALY BIGUANIDE COMBINATIONS TECFIDERA SGM drospirenone PREMARIN TYSABRI SGM SANDOSTATIN LAR SGM pioglitazone-metformin ethinyl estradiol- SIGNIFOR LAR SGM § TRANSDERMAL § MUSCULOSKELETAL § INSULIN SENSITIZER / drospirenone-levomefolate SOMATULINE DEPOT SGM estradiol THERAPY AGENTS SULFONYLUREA (generic BEYAZ, SOMAVERT SGM DIVIGEL COMBINATIONS SAFYRAL) baclofen ethinyl estradiol-ethynodiol EVAMIST carisoprodol 350 mg § ANDROGENS pioglitazone-glimepiride testosterone cypionate diacetate chlorzoxazone § VAGINAL testosterone enanthate § MEGLITINIDES ethinyl estradiol- cyclobenzaprine levonorgestrel estradiol vaginal cream dantrolene testosterone solution nateglinide ethinyl estradiol- (generic ESTRACE) metaxalone ANDRODERM repaglinide norethindrone acetate estradiol vaginal tablet methocarbamol SODIUM-GLUCOSE ethinyl estradiol- (generic VAGIFEM) ANTIDIABETICS orphenadrine-aspirin-caffeine CO-TRANSPORTER 2 norethindrone acetate ESTRING tizanidine tablet § ALPHA-GLUCOSIDASE (SGLT2) INHIBITORS (generic MINASTRIN 24 PREMARIN CREAM INHIBITORS § MYASTHENIA GRAVIS INVOKANA FE) ESTROGEN / PROGESTINS acarbose JARDIANCE ethinyl estradiol-norgestimate pyridostigmine (generic § ORAL AMYLIN ANALOGS ethinyl estradiol-norgestrel MESTINON) SODIUM-GLUCOSE estradiol-norethindrone pyridostigmine ext-rel SYMLINPEN CO-TRANSPORTER 2 § BIPHASIC ethinyl estradiol- (generic MESTINON (SGLT2) INHIBITOR / ethinyl estradiol-desogestrel norethindrone acetate § BIGUANIDES TIMESPAN) BIGUANIDE COMBINATIONS LO LOESTRIN FE PREFEST metformin § NARCOLEPSY metformin ext-rel (generic INVOKAMET PREMPHASE INVOKAMET XR § TRIPHASIC PREMPRO armodafinil (generic GLUCOPHAGE XR) SYNJARDY ethinyl estradiol-desogestrel NUVIGIL) PA ethinyl estradiol- § TRANSDERMAL § BIGUANIDE / SYNJARDY XR modafinil PA levonorgestrel CLIMARA PRO SULFONYLUREA POSTHERPETIC COMBINATIONS SODIUM-GLUCOSE ethinyl estradiol- COMBIPATCH NEURALGIA CO-TRANSPORTER 2 norethindrone glipizide-metformin ESTROGEN / SELECTIVE (SGLT2) INHIBITOR / ethinyl estradiol-norgestimate GRALISE DIPEPTIDYL PEPTIDASE-4 ESTROGEN RECEPTOR DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS (DPP-4) INHIBITOR FOUR PHASE MODULATOR PSYCHOTHERAPEUTIC - COMBINATIONS NATAZIA COMBINATIONS MISCELLANEOUS JANUVIA TRADJENTA GLYXAMBI DUAVEE § ALCOHOL DETERRENTS § EXTENDED CYCLE QTERN FERTILITY REGULATORS disulfiram DIPEPTIDYL PEPTIDASE-4 ethinyl estradiol- VIVITROL SGM (DPP-4) INHIBITOR / § SULFONYLUREAS levonorgestrel GNRH / LHRH BIGUANIDE COMBINATIONS glimepiride ANTAGONISTS § OPIOID ANTAGONISTS § PROGESTIN ONLY JANUMET glipizide ganirelix acetate (generic naloxone injection norethindrone JANUMET XR glipizide ext-rel GANIRELIX) SGM naltrexone JENTADUETO § INJECTABLE CETROTIDE SGM NARCAN NASAL SPRAY ANTIOBESITY JENTADUETO XR medroxyprogesterone INJECTABLE § OVULATION STIMULANTS, § PARTIAL OPIOID AGONIST acetate 150 mg/mL INCRETIN MIMETIC AGENTS GONADOTROPINS / OPIOID ANTAGONIST SAXENDA PA DEPO-SUBQ PROVERA chorionic gonadotropin - COMBINATIONS OZEMPIC TRULICITY ORAL novarel SGM buprenorphine-naloxone PROGESTIN INTRAUTERINE VICTOZA CONTRAVE PA DEVICE GONAL-F SGM sublingual tablet GONAL-F RFF SGM ZUBSOLV INCRETIN MIMETIC AGENT / CALCIUM RECEPTOR KYLEENA OVIDREL SGM INSULIN COMBINATIONS ANTAGONISTS MIRENA PSEUDOBULBAR AFFECT SKYLA SOLIQUA cinacalcet (generic § OVULATION STIMULANTS, AGENTS XULTOPHY SENSIPAR) SGM SYNTHETIC NUEDEXTA § TRANSDERMAL clomiphene INSULINS CALCIUM REGULATORS ethinyl estradiol- § SMOKING DETERRENTS norelgestromin FIASP § BISPHOSPHONATES GAUCHER DISEASE bupropion ext-rel HUMULIN R U-500 alendronate § VAGINAL CERDELGA SGM CHANTIX * LANTUS ibandronate CEREZYME SGM NICOTROL ethinyl estradiol- NICOTROL NS LEVEMIR risedronate etonorgestrel (generic § GLUCOCORTICOIDS NOVOLIN 70/30 NUVARING) NOVOLIN N § CALCITONINS dexamethasone NOVOLIN R calcitonin-salmon fludrocortisone NOVOLOG hydrocortisone Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 4 methylprednisolone § VASOPRESSINS mesalamine suspension § PHOSPHODIESTERASE IDIOPATHIC prednisolone sodium desmopressin spray, tablet CORTIFOAM INHIBITORS THROMBOCYTOPENIC phosphate sildenafil (generic VIAGRA) PURPURA AGENTS prednisolone syrup VASOPRESSIN RECEPTOR § IRRITABLE BOWEL QL PROMACTA SGM prednisone ANTAGONISTS SYNDROME tadalafil (generic CIALIS) RAYOS SAMSCA SGM alosetron (generic QL/PA PAROXYSMAL NOCTURNAL LOTRONEX) HEMOGLOBINURIA (PNH) § GLUCOSE ELEVATING § MISCELLANEOUS AMITIZA § URINARY AGENTS AGENTS cabergoline LINZESS ANTISPASMODICS SOLIRIS SGM diazoxide (generic levocarnitine VIBERZI oxybutynin PROGLYCEM) H.P. ACTHAR SGM oxybutynin ext-rel § PLATELET AGGREGATION GLUCAGEN HYPOKIT § LAXATIVES INHIBITORS solifenacin (generic GLUCAGON EMERGENCY GASTROINTESTINAL lactulose VESICARE) clopidogrel KIT peg 3350-electrolytes tolterodine dipyridamole § ANTIDIARRHEALS polyethylene glycol 3350 tolterodine ext-rel dipyridamole ext-rel-aspirin HUMAN GROWTH diphenoxylate-atropine MOVIPREP (generic AGGRENOX) trospium HORMONES loperamide SUPREP prasugrel (generic EFFIENT) trospium ext-rel GENOTROPIN SGM MYRBETRIQ BRILINTA § ANTIEMETICS OPIOID-INDUCED HUMATROPE SGM TOVIAZ SEROSTIM SGM doxylamine-pyridoxine CONSTIPATION § PLATELET SYNTHESIS ZORBTIVE SGM delayed-rel (generic MOVANTIK § VAGINAL INHIBITORS DICLEGIS) ANTI-INFECTIVES anagrelide § HYPERPARATHYROID dronabinol PANCREATIC ENZYMES clindamycin TREATMENT, VITAMIN D granisetron CREON STEM CELL MOBILIZERS metronidazole ANALOGS meclizine VIOKACE MOZOBIL SGM terconazole calcitriol (1,25-D3) metoclopramide ZENPEP CLEOCIN SUPPOSITORY THROMBOCYTOPENIA paricalcitol (generic ondansetron prochlorperazine § PROSTAGLANDINS AGENTS ZEMPLAR) § MISCELLANEOUS promethazine misoprostol MULPLETA bethanechol PHENYLKETONURIA trimethobenzamide § PROTON PUMP phenazopyridine § MISCELLANEOUS TREATMENT AGENTS SANCUSO INHIBITORS potassium citrate ext-rel KUVAN SGM VARUBI ELMIRON cilostazol lansoprazole deferasirox (generic § PHOSPHATE BINDER § ANTISPASMODICS omeprazole EXJADE) SGM HEMATOLOGIC AGENTS chlordiazepoxide-clidinium pantoprazole CHEMET calcium acetate dicyclomine DEXILANT ANTICOAGULANTS sevelamer carbonate hyoscyamine sulfate § INJECTABLE IMMUNOLOGIC hyoscyamine sulfate ext-rel § SALIVA STIMULANTS (generic RENVELA) enoxaparin AGENTS PHOSLYRA hyoscyamine sulfate orally cevimeline FRAGMIN AUTOIMMUNE AGENTS VELPHORO disintegrating tablet pilocarpine tablet § ORAL COSENTYX SGM POTASSIUM-REMOVING § CHOLELITHOLYTICS STEROIDS, RECTAL ENBREL SGM warfarin AGENTS ursodiol EPIFOAM HUMIRA SGM ELIQUIS LOKELMA PROCTOFOAM-HC OTEZLA SGM § H2 RECEPTOR XARELTO VELTASSA STELARA SGM ANTAGONISTS § ULCER THERAPY XELJANZ SGM § SYNTHETIC HEPARINOID- PROGESTINS cimetidine COMBINATIONS XELJANZ XR SGM LIKE AGENTS § ORAL famotidine PYLERA fondaparinux § DISEASE-MODIFYING medroxyprogesterone INFLAMMATORY BOWEL § MISCELLANEOUS ANTIRHEUMATIC DRUGS norethindrone HEMATOPOIETIC GROWTH DISEASE sucralfate FACTORS (DMARDs) progesterone, micronized § ORAL AGENTS ARANESP SGM hydroxychloroquine GENITOURINARY leflunomide VAGINAL balsalazide EPOGEN SGM CRINONE budesonide delayed-rel § BENIGN PROSTATIC NEULASTA SGM methotrexate ENDOMETRIN capsule HYPERPLASIA NIVESTYM SGM OTREXUP SGM budesonide ext-rel tabs alfuzosin ext-rel RETACRIT SGM RASUVO SGM § SELECTIVE ESTROGEN (generic UCERIS) UDENYCA SGM doxazosin HEREDITARY ANGIOEDEMA RECEPTOR MODULATORS mesalamine delayed-rel dutasteride (generic raloxifene (generic LIALDA) HEMOPHILIA A AGENTS RUCONEST SGM AVODART) OSPHENA mesalamine ext-rel (generic dutasteride-tamsulosin ADYNOVATE IMMUNOMODULATORS APRISO) (generic JALYN) JIVI THYROID AGENTS INTERFERONS sulfasalazine finasteride KOGENATE FS § ANTITHYROID AGENTS sulfasalazine delayed-rel KOVALTRY INTRON A SGM silodosin (generic RAPAFLO) methimazole PENTASA NOVOEIGHT PEGASYS SGM tamsulosin propylthiouracil terazosin NUWIQ MISCELLANEOUS § RECTAL AGENTS § THYROID SUPPLEMENTS hydrocortisone enema ERECTILE DYSFUNCTION HEMOPHILIA B AGENTS ILARIS SGM levothyroxine mesalamine suppository ALPROSTADIL AGENTS REBINYN liothyronine (generic CANASA) MUSE QL Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 5 § IMMUNOSUPPRESSANTS hydroxyzine HCl § NASAL STEROIDS tretinoin PA halobetasol Generally, single-source brand flunisolide tretinoin gel microsphere PA § ANTITUSSIVES § EMOLLIENTS drugs (products for which a fluticasone generic is not available) and benzonatate § ACTINIC KERATOSIS ammonium lactate 12% generic drugs indicated for the mometasone (generic NASONEX) fluorouracil prevention of transplant rejection ANTITUSSIVE imiquimod § LOCAL ANESTHETICS are formulary. COMBINATIONS triamcinolone PICATO lidocaine-prilocaine QL/PA NUTRITIONAL / § OPIOID PHOSPHODIESTERASE-4 § ANTIBIOTICS § ROSACEA SUPPLEMENTS codeine-chlorpheniramine- INHIBITORS pseudoephedrine gentamicin azelaic acid (generic VITAMINS AND MINERALS DALIRESP codeine-guaifenesin liquid mupirocin FINACEA GEL) § FOLIC ACID / PULMONARY FIBROSIS silver sulfadiazine doxycycline monohydrate codeine-guaifenesin- COMBINATIONS AGENTS (generic ORACEA) pseudoephedrine folic acid § ANTIFUNGALS metronidazole codeine-promethazine ESBRIET SGM folic acid-vitamin B6-vitamin codeine-promethazine- OFEV SGM ciclopirox FINACEA FOAM B12 phenylephrine clotrimazole MIRVASO FOLTX hydrocodone-homatropine SEVERE ASTHMA econazole SOOLANTRA DUPIXENT SGM ketoconazole § PRENATAL VITAMINS § NON-OPIOID luliconazole (generic LUZU) § SCABICIDES AND FASENRA SGM prenatal vitamins naftifine cream 2%, gel 1% PEDICULICIDES dextromethorphan- NUCALA SGM CITRANATAL brompheniramine- XOLAIR SGM (generic NAFTIN) crotamiton pseudoephedrine nystatin malathion § MISCELLANEOUS § STEROID / BETA AGONIST JUBLIA PA permethrin 5% dextromethorphan- phytonadione (generic promethazine COMBINATIONS NAFTIN GEL 2% MEPHYTON) § MISCELLANEOUS SKIN budesonide-formoterol NASCOBAL BETA AGONISTS, ANTIPSORIATICS AND MUCOUS MEMBRANE (generic SYMBICORT) INHALANTS ADVAIR DISKUS B4G § Oral podofilox RESPIRATORY § SHORT ACTING ADVAIR HFA acitretin CONDYLOX GEL BREO ELLIPTA methoxsalen DENAVIR ALPHA-1 ANTITRYPSIN albuterol inhalation solution DULERA REGRANEX DEFICIENCY AGENTS albuterol sulfate CFC-free § Topical ARALAST NP SGM aerosol (generic PROAIR MOUTH / THROAT / DENTAL § STEROID INHALANTS calcipotriene PROLASTIN-C SGM HFA) AGENTS levalbuterol inhalation budesonide inhalation SORILUX suspension § ANESTHETICS - TOPICAL § ANAPHYLAXIS solution ARNUITY ELLIPTA § ATOPIC DERMATITIS ORAL TREATMENT AGENTS PROAIR HFA ASMANEX pimecrolimus (generic lidocaine viscous epinephrine auto-injector PROAIR RESPICLICK FLOVENT DISKUS ELIDEL) EPIPEN PROTECTANTS LONG ACTING FLOVENT HFA tacrolimus (generic EPIPEN JR MUGARD Hand-held Active Inhalation PULMICORT FLEXHALER PROTOPIC) § ANTICHOLINERGICS QVAR REDIHALER EUCRISA ARCAPTA § STEROIDS - MOUTH / ipratropium inhalation SEREVENT CORTICOSTEROIDS THROAT § XANTHINES solution STRIVERDI RESPIMAT triamcinolone paste theophylline ext-rel tablet § Low Potency SPIRIVA Nebulized Passive Inhalation ELIXOPHYLLIN alclometasone OPHTHALMIC ANTICHOLINERGIC / BETA PERFOROMIST THEO-24 desonide AGONIST COMBINATIONS § ANTIALLERGICS fluocinolone § BETA AGONISTS, ORAL MISCELLANEOUS hydrocortisone azelastine § SHORT ACTING ipratropium spray CAPEX SHAMPOO cromolyn sodium ipratropium-albuterol albuterol TEXACORT SOLUTION olopatadine inhalation solution albuterol ext-rel TOPICAL LASTACAFT BEVESPI AEROSPHERE terbutaline § Medium Potency PAZEO COMBIVENT RESPIMAT DERMATOLOGY § CYSTIC FIBROSIS betamethasone valerate STIOLTO RESPIMAT ACNE § ANTI-INFECTIVES tobramycin inhalation fluticasone LONG ACTING § Oral hydrocortisone butyrate bacitracin solution SGM isotretinoin hydrocortisone valerate ciprofloxacin ANORO ELLIPTA BETHKIS SGM mometasone erythromycin CAYSTON SGM § Topical ANTICHOLINERGIC / BETA triamcinolone gentamicin PULMOZYME SGM AGONIST / STEROID adapalene PA levofloxacin INHALANT COMBINATIONS § LEUKOTRIENE benzoyl peroxide § High Potency moxifloxacin (generic MODULATORS clindamycin gel, solution betamethasone dipropionate MOXEZA, VIGAMOX) TRELEGY ELLIPTA montelukast clindamycin-benzoyl desoximetasone neomycin-polymyxin B- § ANTIHISTAMINES, LOW zafirlukast peroxide (generic diflorasone cream gramicidin SEDATING ACANYA, BENZACLIN) fluocinonide ofloxacin levocetirizine § MAST CELL STABILIZERS erythromycin solution polymyxin B-bacitracin cromolyn inhalation solution erythromycin-benzoyl § Very High Potency polymyxin B-trimethoprim § ANTIHISTAMINES, peroxide betamethasone dipropionate sulfacetamide ointment, SEDATING § NASAL ANTIHISTAMINES sulfacetamide lotion 10% augmented solution 10% clemastine 2.68 mg azelastine tazarotene (generic clobetasol, except shampoo tobramycin cyproheptadine TAZORAC) PA diflorasone ointment BESIVANCE Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 6 § ANTI-INFECTIVE / ILEVRO Selective XIIDRA § SYMPATHOMIMETICS ANTI-INFLAMMATORY BETOPTIC S brimonidine 0.15%, 0.2% COMBINATIONS § Steroidal § PROSTAGLANDINS ALPHAGAN P 0.1% neomycin-polymyxin B- dexamethasone § CARBONIC ANHYDRASE latanoprost bacitracin-hydrocortisone fluorometholone INHIBITORS travoprost (generic SYMPATHOMIMETIC / BETA- neomycin-polymyxin B- loteprednol (generic dorzolamide TRAVATAN Z) BLOCKER COMBINATIONS dexamethasone LOTEMAX) AZOPT LUMIGAN COMBIGAN neomycin-polymyxin B- prednisolone acetate 1% FML FORTE § CARBONIC ANHYDRASE RETINAL DISORDERS OTIC hydrocortisone FML S.O.P. INHIBITOR / BETA- EYLEA § ANTI-INFECTIVES sulfacetamide-prednisolone PRED MILD BLOCKER COMBINATIONS LUCENTIS acetic acid phosphate 10%/0.25% tobramycin-dexamethasone dorzolamide-timolol ofloxacin otic § ANTIVIRALS RHO KINASE INHIBITORS suspension 0.3%/0.1% CARBONIC ANHYDRASE RHOPRESSA trifluridine § ANTI-INFECTIVE / ZYLET INHIBITOR / ANTI-INFLAMMATORY BETA-BLOCKERS SYMPATHOMIMETIC RHO KINASE INHIBITOR / ANTI-INFLAMMATORIES COMBINATIONS § Nonselective COMBINATIONS PROSTAGLANDIN § Nonsteroidal COMBINATIONS neomycin-polymyxin B- levobunolol SIMBRINZA hydrocortisone bromfenac ROCKLATAN timolol maleate solution CIPRODEX diclofenac DRY EYE DISEASE BETIMOL ketorolac RESTASIS ACUVAIL QUICK REFERENCE DRUG LIST A amiloride-hydrochlorothiazide AZOPT budesonide inhalation cefprozil amiodarone suspension cefuroxime axetil ABILIFY MAINTENA AMITIZA B budesonide-formoterol celecoxib (generic abiraterone (generic amitriptyline bacitracin (generic SYMBICORT) CELEBREX) ZYTIGA) SGM amlodipine baclofen bumetanide cephalexin ABSTRAL PA/QL amlodipine-benazepril balsalazide buprenorphine transdermal CERDELGA SGM acarbose amlodipine-olmesartan BARACLUDE SOLUTION (generic BUTRANS) CEREZYME SGM acetazolamide (generic AZOR) BELBUCA QL/PA QL/PA CETROTIDE SGM acetazolamide ext-rel ammonium lactate 12% BELSOMRA buprenorphine-naloxone cevimeline acetic acid amoxicillin benazepril sublingual tablet CHANTIX * acitretin amoxicillin-clavulanate benazepril- bupropion CHEMET ACUVAIL amoxicillin-clavulanate ext-rel hydrochlorothiazide bupropion ext-rel chlordiazepoxide-clidinium acyclovir amphetamine- benzonatate buspirone chloroquine adapalene PA dextroamphetamine mixed benzoyl peroxide butalbital-acetaminophen- chlorpromazine ADDERALL XR B4G salts benztropine caffeine chlorthalidone ADEMPAS SGM ampicillin BESIVANCE butalbital-aspirin-caffeine chlorzoxazone ADVAIR DISKUS B4G anagrelide betamethasone dipropionate BYSTOLIC cholestyramine ADVAIR HFA ANDRODERM betamethasone dipropionate chorionic gonadotropin - ADYNOVATE ANORO ELLIPTA augmented C novarel SGM AIMOVIG APOKYN SGM betamethasone valerate cabergoline ciclopirox AJOVY ARALAST NP SGM BETASERON SGM CABOMETYX SGM cilostazol albendazole (generic ARANESP SGM bethanechol calcipotriene CIMDUO ALBENZA) QL/PA ARCAPTA BETHKIS SGM calcitonin-salmon cimetidine albuterol aripiprazole (generic BETIMOL calcitriol (1,25-D3) cinacalcet (generic albuterol ext-rel ABILIFY) BETOPTIC S calcium acetate SENSIPAR) SGM albuterol inhalation solution ARISTADA BEVESPI AEROSPHERE candesartan CIPRODEX albuterol sulfate CFC-free ARISTADA INITIO BIDIL candesartan- ciprofloxacin aerosol (generic PROAIR armodafinil (generic BIKTARVY hydrochlorothiazide citalopram HFA) NUVIGIL) PA bisoprolol CAPEX SHAMPOO CITRANATAL alclometasone ARNUITY ELLIPTA bisoprolol- captopril clarithromycin alendronate ASMANEX hydrochlorothiazide captopril-hydrochlorothiazide clarithromycin ext-rel alfuzosin ext-rel atenolol bosentan (generic carbamazepine clemastine 2.68 mg ALINIA atenolol-chlorthalidone TRACLEER) SGM carbamazepine ext-rel CLEOCIN SUPPOSITORY aliskiren (generic atomoxetine (generic BOSULIF SGM carbidopa-levodopa CLIMARA PRO TEKTURNA) STRATTERA) BREO ELLIPTA carbidopa-levodopa ext-rel clindamycin allopurinol atorvastatin BRILINTA carbidopa-levodopa- clindamycin gel, solution alosetron (generic atovaquone brimonidine 0.15%, 0.2% entacapone clindamycin-benzoyl LOTRONEX) atovaquone-proguanil bromfenac carisoprodol 350 mg peroxide (generic ALPHAGAN P 0.1% AUBAGIO SGM bromocriptine carvedilol ACANYA, BENZACLIN) alprazolam AUSTEDO SGM budesonide delayed-rel CAYSTON SGM clobetasol, except shampoo amantadine azelaic acid (generic capsule cefadroxil clomiphene ambrisentan (generic FINACEA GEL) budesonide ext-rel tabs cefdinir clomipramine LETAIRIS) SGM azelastine (generic UCERIS) cefixime (generic SUPRAX) clonazepam tablet amiloride azithromycin clonidine Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 7 clonidine transdermal dextromethorphan- enalapril EYLEA GLUCAGEN HYPOKIT clopidogrel promethazine enalapril-hydrochlorothiazide ezetimibe (generic ZETIA) GLUCAGON EMERGENCY clotrimazole diazepam ENBREL SGM ezetimibe-simvastatin KIT clotrimazole troches diazepam rectal gel ENDOMETRIN (generic VYTORIN) GLYXAMBI clozapine diazoxide (generic enoxaparin GONAL-F SGM COARTEM PROGLYCEM) entacapone F GONAL-F RFF SGM codeine-acetaminophen QL diclofenac entecavir tablet famciclovir GRALISE codeine-chlorpheniramine- diclofenac sodium ENTRESTO famotidine granisetron pseudoephedrine diclofenac sodium gel 1% EPCLUSA SGM FASENRA SGM griseofulvin ultramicrosize codeine-guaifenesin liquid (generic VOLTAREN GEL) EPIFOAM febuxostat (generic ULORIC) guanfacine codeine-guaifenesin- diclofenac sodium- epinephrine auto-injector felodipine ext-rel guanfacine ext-rel (generic pseudoephedrine misoprostol EPIPEN fenofibrate INTUNIV) codeine-promethazine dicloxacillin EPIPEN JR fenofibric acid codeine-promethazine- dicyclomine EPIVIR-HBV SOLUTION fentanyl citrate (generic H phenylephrine DIFICID eplerenone FENTORA) PA/QL H.P. ACTHAR SGM colchicine tablet (generic diflorasone cream EPOGEN SGM fentanyl transdermal QL/PA halobetasol COLCRYS) diflorasone ointment ergotamine-caffeine (generic fentanyl transmucosal haloperidol COLCRYS diflunisal CAFERGOT) lozenge PA/QL HARVONI SGM colesevelam (generic digoxin ERLEADA SGM FIASP HUMATROPE SGM WELCHOL) digoxin pediatric elixir erythromycin FINACEA FOAM HUMIRA SGM colestipol dihydroergotamine injection, erythromycin delayed-rel finasteride HUMULIN R U-500 COMBIGAN spray erythromycin ethylsuccinate flecainide HYALGAN COMBIPATCH DILANTIN 30 MG erythromycin solution FLOVENT DISKUS hydralazine COMBIVENT RESPIMAT diltiazem ext-rel erythromycin stearate FLOVENT HFA hydrochlorothiazide CONCERTA B4G diphenoxylate-atropine erythromycin-benzoyl fluconazole hydrocodone ext-rel (generic CONDYLOX GEL dipyridamole peroxide fludrocortisone ZOHYDRO ER) QL/PA CONTRAVE PA dipyridamole ext-rel-aspirin ESBRIET SGM flunisolide hydrocodone-acetaminophen COPAXONE SGM (generic AGGRENOX) escitalopram fluocinolone QL CORLANOR disopyramide estradiol fluocinonide hydrocodone-homatropine CORTIFOAM disulfiram estradiol vaginal cream fluorometholone hydrocortisone COSENTYX SGM divalproex sodium (generic ESTRACE) fluorouracil hydrocortisone butyrate CREON divalproex sodium ext-rel estradiol vaginal tablet fluoxetine hydrocortisone enema CRINONE DIVIGEL (generic VAGIFEM) fluphenazine hydrocortisone valerate cromolyn inhalation solution dofetilide (generic TIKOSYN) estradiol-norethindrone fluticasone hydromorphone QL/PA cromolyn sodium SGM ESTRING fluvastatin hydromorphone ext-rel crotamiton donepezil eszopiclone fluvoxamine QL/PA cyclobenzaprine dorzolamide ethambutol FML FORTE hydroxychloroquine cyproheptadine dorzolamide-timolol ethinyl estradiol-desogestrel FML S.O.P. hydroxyzine HCl doxazosin ethinyl estradiol- folic acid hyoscyamine sulfate D doxepin (generic SILENOR) drospirenone folic acid-vitamin B6-vitamin hyoscyamine sulfate ext-rel dalfampridine ext-rel (generic doxepin (generic ethinyl estradiol- B12 hyoscyamine sulfate orally AMPYRA) SGM SINEQUAN) drospirenone-levomefolate FOLTX disintegrating tablet DALIRESP doxycycline hyclate (generic BEYAZ, fondaparinux HYSINGLA ER QL/PA danazol doxycycline monohydrate SAFYRAL) FORTEO SGM dantrolene (generic ORACEA) ethinyl estradiol-ethynodiol fosinopril I dapsone doxylamine-pyridoxine diacetate fosinopril-hydrochlorothiazide ibandronate DARAPRIM delayed-rel (generic ethinyl estradiol- FRAGMIN IBRANCE SGM deferasirox (generic DICLEGIS) etonorgestrel (generic furosemide ibuprofen EXJADE) SGM dronabinol NUVARING) FYCOMPA ICLUSIG SGM DENAVIR DUAVEE ethinyl estradiol- ILARIS SGM DEPO-SUBQ PROVERA DULERA levonorgestrel G ILEVRO DESCOVY duloxetine ethinyl estradiol- gabapentin imipramine HCl desipramine DUPIXENT SGM norelgestromin galantamine imiquimod desmopressin spray, tablet dutasteride (generic ethinyl estradiol- galantamine ext-rel indapamide desonide AVODART) norethindrone ganirelix acetate (generic INGREZZA SGM desoximetasone dutasteride-tamsulosin ethinyl estradiol- GANIRELIX) SGM INTRON A SGM dexamethasone (generic JALYN) norethindrone acetate GEL-ONE INVEGA SUSTENNA DEXILANT ethinyl estradiol- gemfibrozil INVEGA TRINZA dexmethylphenidate E norethindrone acetate GENOTROPIN SGM INVOKAMET dexmethylphenidate ext-rel econazole (generic MINASTRIN 24 gentamicin INVOKAMET XR dexmethylphenidate ext-rel eletriptan (generic RELPAX) FE) GENVOYA INVOKANA (generic FOCALIN XR) QL/PA ethinyl estradiol-norgestimate GILENYA SGM ipratropium inhalation dextroamphetamine ELIGARD SGM ethinyl estradiol-norgestrel glatiramer (generic solution dextroamphetamine ext-rel ELIQUIS ethosuximide COPAXONE) SGM ipratropium spray dextromethorphan- ELIXOPHYLLIN etodolac glimepiride ipratropium-albuterol brompheniramine- ELMIRON EUCRISA glipizide inhalation solution pseudoephedrine EMGALITY EVAMIST glipizide ext-rel irbesartan EMVERM EVOTAZ glipizide-metformin Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 8 irbesartan- LOKELMA MOVIPREP OFEV SGM pilocarpine tablet hydrochlorothiazide loperamide moxifloxacin (generic ofloxacin pimecrolimus (generic IRESSA SGM lorazepam MOXEZA, VIGAMOX) ofloxacin otic ELIDEL) isoniazid losartan MOZOBIL SGM olanzapine pimozide isosorbide dinitrate losartan-hydrochlorothiazide MUGARD olmesartan (generic pindolol isosorbide mononitrate loteprednol (generic MULPLETA BENICAR) pioglitazone isosorbide mononitrate ext- LOTEMAX) MULTAQ olmesartan-amlodipine- pioglitazone-glimepiride rel lovastatin mupirocin hydrochlorothiazide pioglitazone-metformin isotretinoin LUCENTIS MUSE QL (generic TRIBENZOR) podofilox itraconazole PA luliconazole (generic LUZU) MYDAYIS olmesartan- polyethylene glycol 3350 ivermectin (generic LUMIGAN MYRBETRIQ hydrochlorothiazide polymyxin B-bacitracin STROMECTOL) LUPRON DEPOT SGM (generic BENICAR HCT) polymyxin B-trimethoprim LYNPARZA SGM N olopatadine posaconazole delayed-rel J nabumetone omega-3 acid ethyl esters tablet (generic NOXAFIL) JANUMET M nadolol omeprazole potassium citrate ext-rel JANUMET XR malathion naftifine cream 2%, gel 1% ondansetron PRALUENT SGM JANUVIA MARPLAN (generic NAFTIN) OPSUMIT SGM pramipexole JARDIANCE MAYZENT NAFTIN GEL 2% ORILISSA pramipexole ext-rel (generic JENTADUETO meclizine naloxone injection orphenadrine-aspirin-caffeine MIRAPEX ER) JENTADUETO XR medroxyprogesterone naltrexone oseltamivir (generic prasugrel (generic EFFIENT) JIVI medroxyprogesterone NAMZARIC TAMIFLU) QL/PA pravastatin JUBLIA PA acetate 150 mg/mL naproxen OSPHENA praziquantel (generic mefloquine naproxen sodium OTEZLA SGM BILTRICIDE) QL/PA K meloxicam naratriptan QL/PA OTREXUP SGM PRED MILD ketoconazole memantine (generic NARCAN NASAL SPRAY OVIDREL SGM prednisolone acetate 1% ketorolac NAMENDA) NASCOBAL oxaprozin prednisolone sodium KISQALI SGM mesalamine delayed-rel NATAZIA oxazepam phosphate KISQALI FEMARA CO- (generic LIALDA) nateglinide oxcarbazepine prednisolone syrup PACK SGM mesalamine ext-rel (generic neomycin-polymyxin B- OXTELLAR XR prednisone KOGENATE FS APRISO) bacitracin-hydrocortisone oxybutynin PREFEST KOVALTRY mesalamine suppository neomycin-polymyxin B- oxybutynin ext-rel pregabalin (generic LYRICA) KUVAN SGM (generic CANASA) dexamethasone oxycodone QL/PA PREMARIN KYLEENA mesalamine suspension neomycin-polymyxin B- oxycodone-acetaminophen PREMARIN CREAM metaxalone gramicidin QL PREMPHASE L metformin neomycin-polymyxin B- OXYCONTIN QL/PA PREMPRO labetalol metformin ext-rel (generic hydrocortisone OZEMPIC prenatal vitamins lactulose GLUCOPHAGE XR) NEULASTA SGM PRIFTIN lamivudine tablet methadone QL/PA NEUPRO P primidone lamotrigine methazolamide niacin ext-rel pantoprazole PROAIR HFA lamotrigine ext-rel methimazole NICOTROL paricalcitol (generic PROAIR RESPICLICK lamotrigine orally methocarbamol NICOTROL NS ZEMPLAR) probenecid disintegrating tablet methotrexate nifedipine ext-rel PARLODEL 5 MG prochlorperazine (generic LAMICTAL ODT) methoxsalen nitrofurantoin paroxetine HCl PROCTOFOAM-HC lansoprazole methyldopa nitrofurantoin ext-rel paroxetine HCl ext-rel progesterone, micronized LANTUS methylphenidate nitroglycerin lingual spray paroxetine mesylate (generic PROLASTIN-C SGM LASTACAFT methylphenidate ext-rel nitroglycerin sublingual tablet BRISDELLE) PROMACTA SGM latanoprost methylprednisolone (generic NITROSTAT) PAZEO promethazine LATUDA metoclopramide nitroglycerin transdermal peg 3350-electrolytes propafenone leflunomide metolazone NIVESTYM SGM PEGASYS SGM propafenone ext-rel levalbuterol inhalation metoprolol succinate ext-rel norethindrone penicillin VK propranolol solution metoprolol tartrate nortriptyline pentamidine (generic propranolol ext-rel LEVEMIR metoprolol- NOVOEIGHT NEBUPENT) propylthiouracil levetiracetam hydrochlorothiazide NOVOLIN 70/30 PENTASA PULMICORT FLEXHALER levetiracetam ext-rel metronidazole NOVOLIN N PERFOROMIST PULMOZYME SGM levobunolol midodrine NOVOLIN R perindopril PYLERA levocarnitine migergot NOVOLOG permethrin 5% pyrazinamide levocetirizine minocycline NOVOLOG MIX 70/30 perphenazine pyridostigmine (generic levofloxacin MIRENA NOXAFIL INJECTION, phenazopyridine MESTINON) levothyroxine mirtazapine SUSPENSION phenelzine pyridostigmine ext-rel lidocaine viscous MIRVASO NUCALA SGM phenobarbital (generic MESTINON lidocaine-prilocaine QL/PA misoprostol NUCYNTA QL/PA phenoxybenzamine (generic TIMESPAN) LINZESS modafinil PA NUCYNTA ER QL/PA DIBENZYLINE) liothyronine mometasone NUEDEXTA phenytoin Q lisinopril montelukast NUWIQ phenytoin sodium extended QTERN lisinopril-hydrochlorothiazide morphine QL/PA nystatin PHOSLYRA QUDEXY XR lithium carbonate morphine ext-rel QL/PA phytonadione (generic quetiapine lithium carbonate ext-rel morphine suppository QL/PA O MEPHYTON) quetiapine ext-rel (generic LO LOESTRIN FE MOVANTIK ODEFSEY PICATO SEROQUEL XR) Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 9 quinapril sevelamer carbonate SYMLINPEN tramadol ext-rel QL/PA VENTAVIS SGM quinapril-hydrochlorothiazide (generic RENVELA) SYMTUZA trandolapril verapamil ext-rel QVAR REDIHALER SIGNIFOR LAR SGM SYNAREL trandolapril-verapamil ext-rel VIBERZI sildenafil 20 mg SGM SYNJARDY (generic TARKA) VIBRAMYCIN SYRUP R sildenafil (generic VIAGRA) SYNJARDY XR tranylcypromine VICTOZA raloxifene QL travoprost (generic VIIBRYD ramipril silodosin (generic RAPAFLO) T TRAVATAN Z) VIMPAT ranolazine ext-rel (generic silver sulfadiazine tacrolimus (generic trazodone VIOKACE RANEXA) SIMBRINZA PROTOPIC) TRECATOR VIVITROL SGM rasagiline (generic AZILECT) simvastatin tadalafil (generic CIALIS) TRELEGY ELLIPTA voriconazole RASUVO SGM SIVEXTRO QL/PA TRESIBA VOSEVI ◊ SGM RAYOS SKYLA tamsulosin tretinoin PA VRAYLAR REBIF SGM solifenacin (generic TASIGNA SGM tretinoin gel microsphere PA VYVANSE REBINYN VESICARE) tazarotene (generic triamcinolone REGRANEX SOLIQUA TAZORAC) PA triamcinolone paste W RELENZA QL/PA SOLIRIS SGM TECFIDERA SGM triamterene- warfarin REMODULIN SGM SOMATULINE DEPOT SGM TEKTURNA HCT hydrochlorothiazide repaglinide SOMAVERT SGM telmisartan trifluoperazine X REPATHA SGM SOOLANTRA telmisartan- trifluridine SORILUX trihexyphenidyl XARELTO RESTASIS hydrochlorothiazide sotalol trimethobenzamide XELJANZ SGM RETACRIT SGM temazepam SOVALDI SGM trimethoprim XELJANZ XR SGM RHOPRESSA terazosin SPIRIVA TRINTELLIX XIFAXAN 550 MG ribavirin SGM terbinafine tablet PA spironolactone TROKENDI XR XIIDRA rifampin terbutaline spironolactone- trospium XOLAIR SGM RIFATER terconazole hydrochlorothiazide trospium ext-rel XTAMPZA ER QL/PA risedronate testosterone cypionate SPRYCEL SGM TRULICITY XTANDI SGM RISPERDAL CONSTA testosterone enanthate STELARA SGM TYMLOS SGM XULTOPHY risperidone testosterone solution rivastigmine STIOLTO RESPIMAT tetrabenazine (generic TYSABRI SGM Y rivastigmine transdermal STRIVERDI RESPIMAT XENAZINE) TYVASO SGM (generic EXELON PATCH) SUBSYS PA/QL tetracycline YONSA SGM rizatriptan QL sucralfate TEXACORT SOLUTION U Z ROCKLATAN sulfacetamide lotion 10% THEO-24 UDENYCA SGM ropinirole sulfacetamide ointment, theophylline ext-rel tablet UPTRAVI SGM zafirlukast rosuvastatin (generic solution 10% thiothixene ursodiol ZEJULA SGM CRESTOR) sulfacetamide-prednisolone tiagabine ZELAPAR RUBRACA SGM phosphate 10%/0.25% timolol maleate solution V ZEMBRACE SYMTOUCH RUCONEST SGM sulfamethoxazole- tinidazole valacyclovir ZENPEP RYDAPT SGM trimethoprim tizanidine tablet valganciclovir (generic ziprasidone RYTARY sulfasalazine tobramycin VALCYTE) zolmitriptan QL/PA sulfasalazine delayed-rel tobramycin inhalation valproic acid zolpidem S sulindac solution SGM valsartan zolpidem ext-rel SAMSCA SGM sumatriptan injection QL/PA tobramycin-dexamethasone valsartan-hydrochlorothiazide ZOMIG NASAL SPRAY SANCUSO sumatriptan nasal spray suspension 0.3%/0.1% vancomycin QL/PA SANDOSTATIN LAR SGM QL/PA tolterodine VARUBI zonisamide SAVELLA sumatriptan tablet QL/PA tolterodine ext-rel VASCEPA ZORBTIVE SGM SAXENDA PA SUPARTZ FX topiramate VELETRI SGM ZUBSOLV selegiline SUPRAX SUSPENSION 500 torsemide VELPHORO ZYLET SEREVENT MG/5 ML, TABLET TOUJEO VELTASSA ZYTIGA 500 MG SGM SEROSTIM SGM SUPREP TOVIAZ VEMLIDY sertraline SYMFI TRADJENTA venlafaxine SYMFI LO tramadol QL/PA venlafaxine ext-rel LIST OF LEVEL 3 OR NON-PREFERRED DRUGS DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ ADCIRCA SGM sildenafil 20 mg SGM AZELEX adapalene PA, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide (generic ALVESCO ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, ACANYA, BENZACLIN), erythromycin solution, erythromycin- FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER benzoyl peroxide, tazarotene (generic TAZORAC) PA, tretinoin PA, ALREX azelastine, cromolyn sodium, loteprednol (generic LOTEMAX), tretinoin gel microsphere PA olopatadine, LASTACAFT, PAZEO BECONASE AQ flunisolide, fluticasone, mometasone (generic NASONEX), ANTARA fenofibrate, fenofibric acid triamcinolone AVONEX SGM glatiramer (generic COPAXONE) SGM, AUBAGIO SGM, BENZACLIN clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN) BETASERON SGM, COPAXONE SGM, GILENYA SGM, BYDUREON OZEMPIC, TRULICITY, VICTOZA MAYZENT, REBIF SGM, TECFIDERA SGM, TYSABRI SGM BYETTA OZEMPIC, TRULICITY, VICTOZA Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 10 DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ CARDIZEM LA diltiazem ext-rel LIVALO atorvastatin, ezetimibe-simvastatin (generic VYTORIN), fluvastatin, lovastatin, pravastatin, rosuvastatin (generic CRESTOR), CARDURA XL alfuzosin ext-rel, doxazosin, silodosin (generic RAPAFLO), simvastatin tamsulosin, terazosin MAVENCLAD glatiramer (generic COPAXONE) SGM, AUBAGIO SGM, CIALIS QL/PA sildenafil (generic VIAGRA) QL, tadalafil (generic CIALIS) QL/PA BETASERON SGM, COPAXONE SGM, GILENYA SGM, DAYTRANA dexmethylphenidate ext-rel (generic FOCALIN XR), MAYZENT, REBIF SGM, TECFIDERA SGM, TYSABRI SGM dextroamphetamine ext-rel, methylphenidate ext-rel, MENTAX ciclopirox, clotrimazole, econazole, ketoconazole ADDERALL XR B4G, CONCERTA B4G, MYDAYIS, VYVANSE NESINA JANUVIA, TRADJENTA DIPENTUM balsalazide, mesalamine delayed-rel (generic LIALDA), mesalamine ext-rel (generic APRISO), sulfasalazine, OMNARIS flunisolide, fluticasone, mometasone (generic NASONEX), sulfasalazine delayed-rel, PENTASA triamcinolone DUREZOL dexamethasone, fluorometholone, loteprednol (generic LOTEMAX), ONGLYZA JANUVIA, TRADJENTA prednisolone acetate 1%, FML FORTE, FML S.O.P., PRED MILD OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide OXISTAT ciclopirox, clotrimazole, econazole, ketoconazole, nystatin EDARBI, candesartan, candesartan-hydrochlorothiazide, irbesartan, EDARBYCLOR irbesartan-hydrochlorothiazide, losartan, losartan- PRADAXA ELIQUIS, XARELTO hydrochlorothiazide, olmesartan (generic BENICAR), olmesartan- PULMICORT budesonide inhalation suspension hydrochlorothiazide (generic BENICAR HCT), telmisartan, 1 MG/2 ML telmisartan-hydrochlorothiazide, valsartan, valsartan- INHALATION hydrochlorothiazide SUSPENSION EDEX QL MUSE QL QNASL flunisolide, fluticasone, mometasone (generic NASONEX), ENABLEX oxybutynin ext-rel, solifenacin (generic VESICARE), tolterodine, triamcinolone tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, QSYMIA PA CONTRAVE PA, SAXENDA PA TOVIAZ RELISTOR MOVANTIK FARXIGA INVOKANA, JARDIANCE ROZEREM eszopiclone, zolpidem, zolpidem ext-rel FOSRENOL calcium acetate, sevelamer carbonate (generic RENVELA), PHOSLYRA, VELPHORO SIMPONI SGM COSENTYX SGM, ENBREL SGM, HUMIRA SGM, OTEZLA SGM, STELARA SGM, XELJANZ SGM, XELJANZ XR SGM FROVA QL eletriptan QL/PA, naratriptan QL/PA, rizatriptan QL, sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, STAXYN QL sildenafil (generic VIAGRA) QL, tadalafil (generic CIALIS) QL/PA zolmitriptan QL/PA, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY QL/PA TRANSDERM-SCOP meclizine GELNIQUE oxybutynin ext-rel, solifenacin (generic VESICARE), tolterodine, TUDORZA PRESSAIR SPIRIVA tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ VIEKIRA PAK SGM EPCLUSA SGM, HARVONI SGM KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR ZETONNA flunisolide, fluticasone, mometasone (generic NASONEX), KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR triamcinolone LAZANDA PA/QL fentanyl citrate (generic FENTORA) PA/QL, fentanyl transmucosal lozenge PA/QL, ABSTRAL PA/QL, SUBSYS PA/QL LEVITRA QL sildenafil (generic VIAGRA) QL, tadalafil (generic CIALIS) QL/PA LIST OF EXCLUDED DRUGS † DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ ACTICLATE doxycycline hyclate APEXICON E betamethasone dipropionate, desoximetasone, diflorasone cream, fluocinonide ADMELOG FIASP, NOVOLOG APIDRA, APIDRA FIASP, NOVOLOG ADRENACLICK epinephrine auto-injector, EPIPEN, EPIPEN JR SOLOSTAR AFREZZA FIASP, NOVOLIN R, NOVOLOG APLENZIN bupropion, bupropion ext-rel ALTOPREV atorvastatin, ezetimibe-simvastatin (generic VYTORIN), ARICEPT 23 MG donepezil, galantamine, galantamine ext-rel, fluvastatin, lovastatin, pravastatin, rosuvastatin (generic memantine (generic NAMENDA), rivastigmine, NAMZARIC CRESTOR), simvastatin ASACOL HD balsalazide, mesalamine delayed-rel (generic LIALDA), amlodipine-atorvastatin amlodipine WITH atorvastatin mesalamine ext-rel (generic APRISO), sulfasalazine, amphetamine- ADDERALL XR B4G sulfasalazine delayed-rel, PENTASA dextroamphetamine ATELVIA alendronate, ibandronate, risedronate mixed salts ext-rel AUVI-Q epinephrine auto-injector, EPIPEN, EPIPEN JR AMRIX cyclobenzaprine AVIDOXY DK doxycycline hyclate ANDROGEL testosterone solution, ANDRODERM BASAGLAR LANTUS, TRESIBA Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 11 DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ BINOSTO alendronate, ibandronate, risedronate EXTAVIA glatiramer (generic COPAXONE) SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE SGM, GILENYA SGM, BRAVELLE GONAL-F SGM, GONAL-F RFF SGM MAYZENT, REBIF SGM, TECFIDERA SGM, TYSABRI SGM BUNAVAIL buprenorphine-naloxone sublingual tablet, ZUBSOLV FABIOR adapalene PA, benzoyl peroxide, clindamycin gel, CADUET amlodipine WITH atorvastatin clindamycin solution, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), erythromycin solution, erythromycin- CAMBIA diclofenac sodium, meloxicam, naproxen benzoyl peroxide, tazarotene (generic TAZORAC) PA, tretinoin PA, tretinoin gel microsphere PA CARAC fluorouracil, imiquimod, PICATO FLECTOR diclofenac sodium, carisoprodol 250 mg carisoprodol 350 mg diclofenac sodium gel 1% (generic VOLTAREN GEL), meloxicam, CENTANY AT mupirocin naproxen CLINDACIN ETZ clindamycin gel, clindamycin solution, erythromycin solution FLUOROPLEX fluorouracil, imiquimod, PICATO CLINDACIN PAC clindamycin gel, clindamycin solution, erythromycin solution fluticasone-salmeterol ADVAIR DISKUS B4G CLINDAGEL clindamycin gel, clindamycin solution, erythromycin solution FOLLISTIM AQ GONAL-F SGM, GONAL-F RFF SGM clobetasol shampoo clobetasol foam, clobetasol solution FORTAMET metformin, metformin ext-rel (generic GLUCOPHAGE XR) CLOBEX SHAMPOO clobetasol foam, clobetasol solution FORTESTA testosterone solution, ANDRODERM CONZIP tramadol QL/PA, tramadol ext-rel QL/PA FOSAMAX PLUS D alendronate, ibandronate, risedronate COREG CR atenolol, bisoprolol, carvedilol, labetalol, metoprolol succinate ext- FULPHILA NEULASTA SGM, UDENYCA SGM rel, metoprolol tartrate, nadolol, pindolol, propranolol, GELSYN-3 GEL-ONE, HYALGAN, SUPARTZ FX propranolol ext-rel, BYSTOLIC GLUMETZA metformin, metformin ext-rel (generic GLUCOPHAGE XR) COSOPT PF dorzolamide-timolol, latanoprost, travoprost (generic TRAVATAN Z) HELIXATE FS KOGENATE FS cyclobenzaprine ext-rel cyclobenzaprine HORIZANT gabapentin, GRALISE DELZICOL balsalazide, mesalamine delayed-rel (generic LIALDA), HUMALOG FIASP, NOVOLOG mesalamine ext-rel (generic APRISO), sulfasalazine, sulfasalazine delayed-rel, PENTASA HUMALOG MIX 50/50 NOVOLOG MIX 70/30 DESVENLAFAXINE ER duloxetine, venlafaxine, venlafaxine ext-rel HUMALOG MIX 75/25 NOVOLOG MIX 70/30 DIOVAN HCT candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, HUMULIN NOVOLIN losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide HYMOVIS GEL-ONE, HYALGAN, SUPARTZ FX (generic BENICAR HCT), telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide INNOPRAN XL atenolol, bisoprolol, carvedilol, labetalol, metoprolol succinate ext- rel, metoprolol tartrate, nadolol, pindolol, propranolol, DORYX doxycycline hyclate propranolol ext-rel, BYSTOLIC doxycycline hyclate ext- doxycycline hyclate INSULIN LISPRO, FIASP, NOVOLOG rel tablet INSULIN LISPRO doxycycline monohydrate doxycycline hyclate KWIKPEN 150 mg capsule INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel DUEXIS celecoxib (generic CELEBREX); diclofenac sodium, meloxicam or JALYN dutasteride-tamsulosin (generic JALYN), dutasteride (generic naproxen WITH lansoprazole, omeprazole, pantoprazole or AVODART) or finasteride WITH alfuzosin ext-rel, doxazosin, DEXILANT silodosin (generic RAPAFLO), tamsulosin or terazosin DYMISTA flunisolide, fluticasone, mometasone (generic NASONEX) or LESCOL XL atorvastatin, ezetimibe-simvastatin (generic VYTORIN), triamcinolone WITH azelastine fluvastatin, lovastatin, pravastatin, rosuvastatin (generic EDLUAR eszopiclone, zolpidem, zolpidem ext-rel CRESTOR), simvastatin EPIDUO, adapalene PA, benzoyl peroxide, clindamycin gel, LIPITOR atorvastatin, ezetimibe-simvastatin (generic VYTORIN), EPIDUO FORTE clindamycin solution, clindamycin-benzoyl peroxide (generic fluvastatin, lovastatin, pravastatin, rosuvastatin (generic ACANYA, BENZACLIN), erythromycin solution, erythromycin- CRESTOR), simvastatin benzoyl peroxide, tazarotene (generic TAZORAC) PA, LORTAB ELIXIR hydrocodone-acetaminophen QL tretinoin PA, tretinoin gel microsphere PA LUNESTA eszopiclone, zolpidem, zolpidem ext-rel esomeprazole lansoprazole, omeprazole, pantoprazole, DEXILANT metformin ext-rel metformin, metformin ext-rel (generic GLUCOPHAGE XR) EUFLEXXA GEL-ONE, HYALGAN, SUPARTZ FX (generic FORTAMET) EVOCLIN clindamycin gel, clindamycin solution, erythromycin solution metformin ext-rel metformin, metformin ext-rel (generic GLUCOPHAGE XR) EVZIO naloxone injection, NARCAN NASAL SPRAY (generic GLUMETZA) EXFORGE amlodipine-olmesartan (generic AZOR) methylphenidate ext-rel CONCERTA B4G EXFORGE HCT amlodipine-olmesartan-hydrochlorothiazide (generic MINOCIN doxycycline hyclate, minocycline TRIBENZOR) MONOVISC GEL-ONE, HYALGAN, SUPARTZ FX MORGIDOX KIT doxycycline hyclate Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 12 DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ DRUG NAME(S) PREFERRED ALTERNATIVE(S) ‡ NATESTO testosterone solution, ANDRODERM SYNVISC, SYNVISC- GEL-ONE, HYALGAN, SUPARTZ FX ONE NEUPOGEN NIVESTYM SGM TESTIM testosterone solution, ANDRODERM NEXIUM lansoprazole, omeprazole, pantoprazole, DEXILANT testosterone gel testosterone solution, ANDRODERM NORDITROPIN GENOTROPIN SGM, HUMATROPE SGM TIVORBEX diclofenac sodium, meloxicam, naproxen NORITATE azelaic acid (generic FINACEA GEL), doxycycline monohydrate (generic ORACEA), metronidazole, TOBI tobramycin inhalation solution SGM, BETHKIS SGM FINACEA FOAM, SOOLANTRA TOBI PODHALER tobramycin inhalation solution SGM, BETHKIS SGM NORPACE CR disopyramide TOBRADEX OINTMENT neomycin-polymyxin B-hydrocortisone, neomycin-polymyxin B- NUTROPIN AQ, GENOTROPIN SGM, HUMATROPE SGM bacitracin-hydrocortisone, neomycin-polymyxin B- NUTROPIN AQ NUSPIN dexamethasone, sulfacetamide-prednisolone 10%/0.25%, tobramycin-dexamethasone suspension 0.3%/0.1%, ZYLET omeprazole-sodium lansoprazole, omeprazole, pantoprazole, DEXILANT bicarbonate capsule TOBRADEX ST neomycin-polymyxin B-hydrocortisone, neomycin-polymyxin B- bacitracin-hydrocortisone, neomycin-polymyxin B- OMNITROPE GENOTROPIN SGM, HUMATROPE SGM dexamethasone, sulfacetamide-prednisolone 10%/0.25%, ONEXTON adapalene PA, benzoyl peroxide, clindamycin gel, tobramycin-dexamethasone suspension 0.3%/0.1%, ZYLET clindamycin solution, clindamycin-benzoyl peroxide (generic TREXIMET eletriptan QL/PA, naratriptan QL/PA, rizatriptan QL, ACANYA, BENZACLIN), erythromycin solution, erythromycin- sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, benzoyl peroxide, tazarotene (generic TAZORAC) PA, zolmitriptan QL/PA, ZEMBRACE SYMTOUCH, tretinoin PA, tretinoin gel microsphere PA ZOMIG NASAL SPRAY QL/PA ONZETRA XSAIL eletriptan QL/PA, naratriptan QL/PA, rizatriptan QL, TRIBENZOR amlodipine-olmesartan-hydrochlorothiazide (generic sumatriptan nasal spray QL/PA, sumatriptan tablet QL/PA, TRIBENZOR) zolmitriptan QL/PA, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY QL/PA TRIGLIDE fenofibrate, fenofibric acid ORTHOVISC GEL-ONE, HYALGAN, SUPARTZ FX VELTIN adapalene PA, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide (generic OXYTROL oxybutynin ext-rel, solifenacin (generic VESICARE), tolterodine, ACANYA, BENZACLIN), erythromycin solution, erythromycin- tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, benzoyl peroxide, tazarotene (generic TAZORAC) PA, TOVIAZ tretinoin PA, tretinoin gel microsphere PA PENNSAID diclofenac sodium, VENTOLIN HFA albuterol sulfate CFC-free aerosol (generic PROAIR HFA), diclofenac sodium gel 1% (generic VOLTAREN GEL), meloxicam, PROAIR HFA, PROAIR RESPICLICK naproxen VIMOVO celecoxib (generic CELEBREX); diclofenac sodium, meloxicam or PLAVIX clopidogrel, prasugrel (generic EFFIENT), BRILINTA naproxen WITH lansoprazole, omeprazole, pantoprazole or PREVACID SOLUTAB lansoprazole, omeprazole, pantoprazole, DEXILANT DEXILANT PROCORT CORTIFOAM VIVLODEX diclofenac sodium, meloxicam, naproxen PROCRIT EPOGEN SGM, RETACRIT SGM VOGELXO testosterone solution, ANDRODERM PROLENSA bromfenac, diclofenac, ketorolac, ACUVAIL, ILEVRO XERESE acyclovir oral, famciclovir, valacyclovir PROTONIX lansoprazole, omeprazole, pantoprazole, DEXILANT XOPENEX HFA albuterol sulfate CFC-free aerosol (generic PROAIR HFA), PROAIR HFA, PROAIR RESPICLICK PROVIGIL armodafinil (generic NUVIGIL) PA, modafinil PA ZARXIO NIVESTYM SGM PROVENTIL HFA albuterol sulfate CFC-free aerosol (generic PROAIR HFA), PROAIR HFA, PROAIR RESPICLICK ZEGERID CAPSULE lansoprazole, omeprazole, pantoprazole, DEXILANT RELION INSULIN NOVOLIN INSULIN ZEGERID POWDER lansoprazole, omeprazole, pantoprazole, DEXILANT FOR ORAL REQUIP XL pramipexole, ropinirole SUSPENSION RETIN-A MICRO adapalene PA, benzoyl peroxide, clindamycin gel, ZIANA adapalene PA, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide (generic clindamycin solution, clindamycin-benzoyl peroxide (generic ACANYA, BENZACLIN), erythromycin solution, erythromycin- ACANYA, BENZACLIN), erythromycin solution, erythromycin- benzoyl peroxide, tazarotene (generic TAZORAC) PA, benzoyl peroxide, tazarotene (generic TAZORAC) PA, tretinoin PA, tretinoin gel microsphere PA tretinoin PA, tretinoin gel microsphere PA ropinirole ext-rel pramipexole, ropinirole ZIPSOR diclofenac sodium, meloxicam, naproxen SAIZEN GENOTROPIN SGM, HUMATROPE SGM ZOLPIMIST eszopiclone, zolpidem, zolpidem ext-rel SITAVIG valacyclovir ZOMACTON GENOTROPIN SGM, HUMATROPE SGM SOLODYN doxycycline hyclate, minocycline ZORVOLEX diclofenac sodium, meloxicam, naproxen SOMA 250 MG carisoprodol 350 mg ZUPLENZ granisetron, ondansetron SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV ZYCLARA fluorouracil, imiquimod, PICATO SUMAXIN CP azelaic acid (generic FINACEA GEL), doxycycline monohydrate (generic ORACEA), metronidazole, FINACEA FOAM, SOOLANTRA Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 13 Also excluded from coverage: Drugs that are only FDA approved for cosmetic indications are excluded from the plan and are not eligible for a medical exception. Examples include, but are not limited to: Botox Cosmetic, hydroquinone-containing products, Latisse, Propecia, Renova and Vaniqa. KEY Generic drugs are listed in lowercase italics. Brand-name drugs are listed in CAPS. Symbol Meaning § Generics are available in this class and should be considered the first line of prescribing. B4G Brand for Generic medication (see note below). Brand-name product is dispensed at the generic copayment. † You will be responsible for the full cost of non-formulary products that are excluded from coverage unless a request for a medical exception is approved. Information on the medical exception process can be found below in the For Your Information section. ‡ The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. ◊ For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). * This drug may be available as a generic in 2020 or 2021. When a generic is available, mandatory generic substitution will apply, unless the brand-name drug has been placed on Level 1. PA A Prior authorization is required for coverage. PA/QL A Prior Authorization is required for coverage and a quantity limit applies to the drug. QL A Quantity limit applies to the drug. QL/PA Initial Quantity limit is applied to the drug. Additional quantities may be authorized through a Prior authorization. SGM Specialty Guideline Management applies to the drug (Empire Plan Specialty Pharmacy Program medication). 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. Any brand-name drug for which a generic drug becomes available may be designated as a non-preferred drug. 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 drugs on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand-name drugs in CAPS and generic drugs in lowercase italics. Listed drugs 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 https://www.empireplanrxprogram.com to check coverage and copay information for a specific medicine. The Flexible Formulary has an additional feature called Brand for Generic (B4G) which saves you money on certain Brand-Name drugs that have a new generic available. When advantageous to the Plan, this feature allows a Brand-Name drug to be placed on Level 1, the lowest copayment level, and the new generic equivalent to be placed on Level 3, the highest copayment level or excluded. These placements are for a limited time, typically six months, and may be revised mid-year when such changes are advantageous to The Empire Plan. You will be notified when B4G savings are available. We will also notify your pharmacist so that the lowest cost option will always be dispensed. Please refer to the Empire Plan Prescription Drug Program website at https://www.empireplanrxprogram.com for the most current information regarding the B4G feature. The Empire Plan has implemented a medical exception process for prescription drugs that are excluded from the Flexible Formulary. Enrollees and their physicians must first evaluate whether covered drugs on the Flexible Formulary are appropriate alternatives. After an appropriate trial of formulary alternatives, an enrollee's physician may submit a letter of medical necessity to CVS Caremark which details the enrollee's formulary alternative trials and any other clinical documentation supporting medical necessity. The physician can fax the exception request to 1-888-487-9257. If an exception is approved, the Level 1 copay will apply for generic drugs and the Level 3 copay (and ancillary charge, if applicable) will apply for brand-name drugs. 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. ©2020. All rights reserved. 106-1047832NY-1-070120 Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 14