2021 NATIONAL EX FORMULARY - Elixir Solutions
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2021 NATIONAL EX FORMULARY The following is a list of the most commonly prescribed brand and generic medications. It represents an abbreviated version of the formulary list that is at the core of y our prescription drug benefit plan. The list is not all-inclusive and does not guarantee coverage. Some preferred medications overlap with other clinical programs and may not be covered. In addition to drugs on this list, the majority of generic medications are covered under your plan and you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. Search complete formulary drug information at elixirsolutions.com. PLEASE NOTE: Preferred brand drugs may move to non-preferred status if a generic version becomes available during the year. Any medication approved to enter the market will not be covered until reviewed by Elixir. Not all drugs listed are covered by all prescription drug benefit programs. For specific questions about your coverage, please visit elixirsolutions.com. A ASMANEX carbidopa-levodopa DEXCOM CONTINUOUS GLUCOSE abacavir tablet atazanavir carbidopa-levodopa ER MONITORING SYSTEM abacavir-lamivudine atenolol carbidopa-levodopa-entacapone DEXILANT ABILIFY MAINTENA [INJ] atomoxetine carvedilol diazepam abiraterone atorvastatin carvedilol phosphate ER diazepam rectal gel ABSORICA ATRIPLA cefdinir diclofenac ACCU-CHEK AVIVA PLUS ATROVENT HFA cefprozil diclofenac sodium STRIPS AND KITS AUBAGIO* cefuroxime axetil diclofenac sodium gel 1% ACCU-CHEK COMPACT PLUS AUSTEDO* celecoxib diclofenac sodium solution STRIPS AND KITS azelaic acid gel cephalexin dicloxacillin ACCU-CHEK GUIDE STRIPS AND KITS azelastine CERDELGA* DIFICID ACCU-CHEK SMARTVIEW azithromycin CEREZYME [INJ]* digoxin STRIPS AND KITS AZOPT CETROTIDE [INJ]* diltiazem ER acetic acid acitretin cholestyramine dimethyl fumarate DR ACUVAIL B ciclopirox diphenoxylate-atropine acyclovir capsule, tablet balsalazide CILOXAN OINTMENT dipyridamole ER-aspirin adapalene BAQSIMI CIMDUO divalproex sodium ADEMPAS* BASAGLAR [INJ] cinacalcet divalproex sodium ER ADDERAL XR BD ULTRAFINE INSULIN CIPRODEX DIVIGEL ADVAIR DISKUS SYRINGES AND NEEDLES ciprofloxacin donepezil ADVAIR HFA BELBUCA ciprofloxacin-dexamethasone DOPTELET* ADYNOVATE* BELSOMRA citalopram dorzolamide AFINITOR* benzoyl peroxide CITRANATAL dorzolamide-timolol AIMOVIG [INJ] BESIVANCE clarithromycin DOVATO AJOVY [INJ] BETASERON [INJ]* clarithromycin ER doxazosin albuterol inhalation solution BETHKIS* CLIMARA PRO doxepin albuterol sulfate CFC-free aerosol BETIMOL clindamycin doxycycline hyclate ALECENSA* BETOPTIC S clindamycin gel, solution doxycycline monohydrate DR capsule alendronate BEVESPI AEROSPHERE clindamycin-benzoyl peroxide dronabinol alfuzosin ER bicalutamide clobazam DUAVEE aliskiren BIDIL clobetasol cream, foam, gel, lotion, duloxetine allopurinol BIKTARVY ointment, shampoo DUPIXENT [INJ]* alosetron bosentan* clonazepam DUREZOL ALPHAGAN P BOSULIF* clopidogrel DUROLANE alprazolam BREO ELLIPTA clotrimazole dutasteride ALUNBRIG* BREZTRI AEROSPHERE clozapine dutasteride-tamsulosin amantadine BRILINTA codeine-acetaminophen DYMISTA ambrisentan brimonidine colchicine tablet amiloride bromfenac colesevelam E AMITIZA BRYHALI COMBIGAN econazole amlodipine budesonide capsule COMBIPATCH eletriptan amlodipine-atorvastatin budesonide ER COMPLERA ELIGARD [INJ]* amlodipine-olmesartan budesonide inhalation suspension CONCERTA ELIQUIS amlodipine-telmisartan BUNAVAIL COPAXONE [INJ]* EMGALITY [INJ] amlodipine-valsartan buprenorphine transdermal COPIKTRA* EMVERM amlodipine-valsartan-HCTZ buprenorphine-naloxone sublingual CORLANOR ENBREL [INJ]* amoxicillin bupropion CORTIFOAM ENDOMETRIN amoxicillin-clavulanate bupropion ER COSENTYX [INJ]* ENSTILAR amphetamine-dextroamphetamine BYSTOLIC CREON CRINONE entacapone mixed salts cromolyn sodium entecavir ANDRODERM C cyclobenzaprine ENTRESTO ANNOVERA CABOMETYX* EPCLUSA* ANORO ELLIPTA calcipotriene D EPIDUO aprepitant calcipotriene-betamethasone DALIRESP epinephrine auto-injector [INJ] ARANESP [INJ]* calcitonin-salmon darifenacin ER EPIPEN [INJ] aripiprazole calciumacetate DESCOVY EPIPEN JR [INJ] ARISTADA [INJ] candesartan desonide EPISIL ARISTADA INITIO [INJ] candesartan-HCTZ desoximetasone ergotamine-caffeine armodafinil carbamazepine desvenlafaxine ER ERIVEDGE* ARNUITY ELLIPTA carbamazepine ER dexamethasone [INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary
2021 NATIONAL EX FORMULARY Continued
ERLEADA* GILENYA* K metoclopramide
erlotinib glatiramer KESIMPTA [INJ]* metolazone
erythromycin glimepiride ketoconazole metoprolol succinate ER
erythromycin solution glipizide ketoconazole shampoo 2% metoprolol tartrate
erythromycin-benzoyl peroxide glipizide ER ketorolac metronidazole
erythromycins glipizide-metformin KEVZARA [INJ]* minocycline
ESBRIET* GLUCAGEN HYPOKIT [INJ] KISQALI* MIRENA*
escitalopram GLUCAGON EMERGENCY KIT [INJ] KISQALI FEMARA CO-PACK mirtazapine
esomeprazole GLYXAMBI KITABIS PAK* misoprostol
estradiol GONAL-F [INJ]* KOGENATE FS [INJ]* mometasone
estradiol-norethindrone GRALISE KOVALTRY [INJ]* montelukast
ESTRING granisetron KYLEENA* morphine
eszopiclone GRANIX [INJ]* morphine ER
ethinyl estradiol-drospirenone GRASTEK L morphine suppository
ethinyl estradiol-drospirenone-levomefolate guanfacine ER lactulose solution MOVANTIK
ethinyl estradiol-etonogestrel GVOKE [INJ] lamivudine moxifloxacin
ethinyl estradiol-levonorgestrel lamotrigine MULPLETA*
ethinyl estradiol-norelgestromin H lamotrigine ER MULTAQ
ethinyl estradiol-norethindrone acetate HARVONI* lansoprazole mupirocin ointment
ethinyl estradiol-norethindrone acetate-iron hydrochlorothiazide lanthanum carbonate MUSE
ethinyl estradiol-norgestimate HUMALOG [INJ] LANTUS [INJ] MYDAYIS
ethosuximide HUMALOG MIX [INJ] LASTACAFT MYRBETRIQ
EUCRISA HUMATROPE [INJ]* latanoprost
EUFLEXXA [INJ]* HUMIRA [INJ]* LATUDA N
EVAMIST HUMULIN 70/30 [INJ] levalbuterol tartrate CFC-free aerosol nadolol
everolimus* HUMULIN N [INJ] LEVEMIR [INJ] NAFTIN
EVOTAZ HUMULIN R [INJ] levetiracetam naloxone injection
ezetimibe HUMULIN R U-500 [INJ] levetiracetam ER NAMZARIC
ezetimibe-simvastatin hydrocodone ER levocarnitine naproxen
hydrocodone-acetaminophen levofloxacin naratriptan
F hydrocortisone levothyroxine NARCAN NASAL SPRAY
famotidine hydrocortisone butyrate LIALDA NATAZIA
FARXIGA hydrocortisone enema linezolid nateglinide
FASENRA [INJ]* hydromorphone LINZESS neomycin-polymyx in B-bacitracin-
fenofibrate hydromorphone ER liothyronine hydrocortisone
fenofibric acid DR HYSINGLA ER lisinopril neomycin-polymyx in B-dexamethasone
fentanyl transdermal lisinopril-HCTZ neomycin-polymyx in B-hydrocortisone
fentanyl transmucosal lozenge I LO LOESTRIN FE NEULASTA [INJ]*
FETZIMA ibandronate LOKELMA NEULASTA ONPRO [INJ]*
FIASP [INJ] IBRANCE* loperamide NEUPOGEN [INJ]*
FINACEA FOAM ibuprofen lorazepam NEUPRO
finasteride ILEVRO losartan NEVANAC
FIRAZYR [INJ]* imatinib mesylate losartan-HCTZ NEXLETOL
FLOVENT DISKUS imiquimod loteprednol NEXLIZET
FLOVENT HFA INCRUSE ELLIPTA lovastatin niacin ER
fluconazole INGREZZA* luliconazole nifedipine ER
fludrocortisone INSULIN LISPRO [INJ] LUMIGAN NINLARO*
flunisolide INVOKAMET LUPRON DEPOT [INJ]* nitrofurantoin
fluocinonide INVOKAMET XR LYNPARZA* nitroglycerin lingual spray
fluorouracil cream 5% INVOKANA LYRICA CR nitroglycerin sublingual
fluorouracil solution Ipratropium inhalation solution LYUMJEV NIVESTYM [INJ]*
fluoxetine ipratropium-albuterol inhalation solution NORDITROPIN [INJ]*
fluticasone irbesartan M NORVIR
fluvastatin irbesartan-HCTZ MAXIDEX NOVOEIGHT*
FML FORTE IRESSA* MAYZENT* NOVOLIN 70/30 [INJ]
FML S.O.P. ISENTRESS meclizine NOVOLIN N [INJ]
FORTEO [INJ]* isosorbide dinitrate medroxyprogesterone NOVOLIN R [INJ]
fosinopril isosorbide mononitrate megestrol acetate NOVOLOG [INJ]
fosinopril-HCTZ itraconazole meloxicam NOVOLOG MIX 70/30 [INJ]
FREESTYLE LIBRE CONTINUOUS ivermectin memantine NUBEQA*
GLUCOSE MONITORING SYSTEM mesalamine DR NUCALA [INJ]*
furosemide J mesalamine ER NUCYNTA
FYCOMPA JANUMET mesalamine suppository NUCYNTA ER
JANUMET XR mesalamine suspension NUEDEXTA
G JANUVIA metformin NURTEC ODT
gabapentin JARDIANCE metformin ER NUWIQ [INJ]*
galantamine JENTADUETO methadone nystatin
galantamine ER JENTADUETO XR methoxsalen
GELSYN-3 [INJ]* JIVI* methylphenidate O
gentamicin methylprednisolone OCREVUS [INJ]*
GENVOYA ODEFSEY
[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary2021 NATIONAL EX FORMULARY Continued
ODOMZO* PREMPHASE silodosin tolterodine
OFEV* PREMPRO SIMBRINZA tolterodine ER
ofloxacin prenatal vitamins SIMPONI [INJ]* topiramate
ofloxacin otic PREZCOBIX simvastatin torsemide
olanzapine PREZISTA SKYLA TOUJEO [INJ]
olmesartan primidone SKYRIZI [INJ]* TOVIAZ
olmesartan-amlodipine-HCTZ probenecid solifenacin TRADJENTA
olmesartan-HCTZ prochlorperazine SOLIQUA [INJ] tramadol
olopatadine PROCRIT [INJ]* SOMATULINE DEPOT [INJ]* tramadol ER
omega-3 acid ethyl esters PROCTOFOAM-HC SOMAVERT travoprost
omeprazole progesterone, micronized SOOLANTRA trazodone
OMNIPOD DASH INSULIN PROLASTIN-C [INJ]* sotalol TRELEGY ELLIPTA
INFUSION PUMP PROLIA [INJ]* SPIRIVA TREMFYA [INJ]*
OMNIPOD INSULIN INFUSION PUMP promethazine spironolactone-HCTZ TRESIBA [INJ]
ondansetron propranolol SPRYCEL* tretinoin
ONETOUCH ULTRA STRIPS AND KITS propranolol ER STELARA SC [INJ]* triamcinolone
ONETOUCH VERIO STRIPS AND KITS PULMICORT FLEXHALER STIOLTO RESPIMAT triamterene
ONEXTON PYLERA STRIBILD triamterene-HCTZ
ONZETRA XSAIL pyrimethamine STRIVERDI RESPIMAT trifluridine
OPSUMIT* SUBSYS TRIJARDY XR
ORALAIR Q sucralfate trimethobenzamide
ORENITRAM* QTERN sulfacetamide TRINTELLIX
ORILISSA quetiapine sulfamethoxazole-trimethoprim TRIUMEQ
oseltamivir quetiapine ER sulfasalazine TROKENDI XR
OSPHENA quinapril sulfasalazine DR trospium
OTEZLA* quinapril-HCTZ sulfide lotion 2.5% trospium ER
OVIDREL [INJ]* QVAR REDIHALER sumatriptan TRULICITY [INJ]
oxazepam SUNOSI TRUVADA
oxcarbazepine R SUPARTZ FX TYMLOS [INJ]*
OXTELLAR XR RAGWITEK SUPRAX TYSABRI [INJ]*
oxybutynin raloxifene SUPREP
oxybutynin ER ramelteon SUTENT U
oxycodone ramipril SYMBICORT UBRELVY
oxycodone-acetaminophen ranolazine ER SYMFI UDENYCA [INJ]*
OXYCONTIN rasagiline SYMFI LO UPTRAVI*
OZEMPIC [INJ] RASUVO [INJ] SYMJEPI [INJ]
REBIF [INJ]* SYMLINPEN [INJ] V
P REBINYN* SYMTUZA valacyclovir
pantoprazole RELENZA SYNJARDY valganciclovir
paroxetine HCl repaglinide SYNJARDY XR valproic acid
paroxetine HCl ER REPATHA [INJ] SYNTHROID valsartan
paroxetine mesylate RESTASIS valsartan-HCTZ
PAZEO RETACRIT [INJ]* T vancomycin capsule
peg 3350-electrolytes REYVOW tacrolimus VARUBI
penicillin VK RHOPRESSA tadalafil VASCEPA
PENTASA ribavirin TAKHZYRO [INJ]* VELPHORO
PERFOROMIST RINVOQ* TALTZ [INJ]* VELTASSA
phenobarbital risedronate tamsulosin VEMLIDY
phenytoin risperidone TAYTULLA venlafaxine
phenytoin sodium ER rivastigmine TAZORAC venlafaxine ER capsule
PHESGO rivastigmine transdermal TEGSEDI [INJ]* verapamil ER
PHOSLYRA rizatriptan TEKTURNA HCT V-GO INSULIN INFUSION PUMP
PICATO ROCKLATAN telmisartan VIBERZI
pimecrolimus ropinirole telmisartan-HCTZ VICTOZA [INJ]
pindolol ropinirole ER TEMIXYS vigabatrin
pioglitazone rosuvastatin terazosin VIIBRYD
pioglitazone-glimepiride RUBRACA* terbinafine tablet VIMPAT
pioglitazone-metformin RUCONEST [INJ]* testosterone gel VIOKACE
potassium chloride liquid RYBELSUS testosterone solution VISTOGARD
PRALUENT [INJ] RYDAPT tetrabenazine VOSEVI*
pramipexole tetracycline VOTRIENT*
pramipexole ER S tiagabine VRAYLAR
prasugrel SANCUSO timolol maleate solution VUMERITY*
pravastatin SAVELLA TIVICAY VYVANSE
PRED MILD SAXENDA TOBI PODHALER*
prednisolone acetate 1% scopolamine transdermal TOBRADEX OINTMENT W
prednisolone solution selegiline selenium TOBRADEX ST warfarin
prednisone SEREVENT tobramycin
pregabalin sertraline tobramycin inhalation solution X
PREMARIN sevelamer carbonate tobramycin-dexamethasone XARELTO
PREMARIN CREAM sildenafil TOLAK XELJANZ XR*
[INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary2021 NATIONAL EX FORMULARY Continued XELJANZ* XIFAXAN 550 MG XIGDUO XR XIIDRA XOLAIR [INJ]* XOSPATA XTAMPZA ER XTANDI* XULTOPHY [INJ] Y YONSA* YUPELRI Z zafirlukast ZARXIO [INJ]* ZEJULA* ZEMBRACE SYMTOUCH ZENPEP ZEPOSIA* ZIEXTENZO zileuton ER ZIOPTAN ziprasidone zolmitriptan zolpidem zolpidem ER zolpidem sublingual ZOMIG NASAL SPRAY zonisamide ZUBSOLV ZYCLARA [INJ] - Injectable Drug | * denotes a Specialty Drug | ALL CAPS are brand and lower case are generic Elixir • 2021 National EX Formulary
2021 NATIONAL EX FORMULARY Continued STEP THERAPIES *Requires trial and failure of one primary treatment product THERAPEUTIC CATEGORY PRIMARY TREATMENT SECONDARY TREATMENT* ANTICOAGULANTS Anticoagulants Eliquis, Xarelto Pradaxa DIABETES Diabetic Test Strips OneTouch Products All other products not OneTouch Dipeptidyl Peptidase-4 Inhibitors (DPP-4) Januvia, Janumet, Janumet XR, Tradjenta, Jentadueto, Kazano, Kombiglyze XR, Nesina, Onglyza & Combinations Jentadueto XR Glucagon-Like Peptide-1 Agonists (GLP-1) Ozempic, Rybelsus, Trulicity, Victoza Bydureon, Byetta Insulin Humulin, Novolin Novolin Relion Rapid Acting Insulin Fiasp, Humalog, Insulin Lispro, Novolog Apidra RESPIRATORY Long Acting Muscarinic Antagonist Atrovent HFA, Incruse Eliipta, Spiriva, Yupelri Tudorza Pressair About Elixir | elixirsolutions.com With the unique ability to optimize the full pharmacy care experience, Elixir is crafting solutions for today’s pharmacy benefits challenges. For more information, visit elixirsolutions.com. © 2020 Elixir - All Rights Reserved. 20-5016 Last Updated 01/2021
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