Dear Member, The Pocket Drug List is a continuously reviewed list of drugs that best represents the current clinical judgment of our providers and other experts in the diagnosis and treatment of different diseases. The full drug list contains additional prescribing and clinical information that assists in promoting the highest quality affordable care to you, our patient. This sheet, with perforated punch-out cards, identifies which commonly prescribed drugs your physician should prescribe when ordering your prescription drugs through our program. Simply punch these cards out to carry with you to your physician, and present them to your physician when your prescription is being written. To make use of this Pocket Drug List simpler, the preferred drugs are listed by clinical category. Note that only a few clinical categories require use of a preferred drug – most other categories not listed below do not generally differentiate preferred vs. non-preferred drugs and are usually offered to you at your lower brand copay with some exceptions. Covered generic drugs are given preferred status and will be dispensed whenever possible regardless of the clinical category. All strengths of a drug listed on the Pocket Drug List are considered preferred unless noted, although your specific pharmacy benefit plan may impose restrictions or choose not to cover some drugs listed. The listing on the next panel provides the clinical category, therapeutic class, and the preferred drug(s) within each class. Note that two small pocket formulary cards have been included in the third panel for your convenience to punch out and carry in your wallet as necessary. This Pocket Drug List is subject to change. Please visit www.mc-rx.com to print the most up-to-date document. Click on ‘Resources’, and look under ‘Drug and Formulary Lists’ to find the current pocket formulary document. For additional punch-out cards, please contact your benefits office or the Call Center at 855-828-1484.

“Pocket” Drug List – 2020

CLINICAL CATEGORY DRUG CLASS PREFERRED DRUG

ADD/ADHD Agents ADD/ADHD Generics, Adhansia XR, Daytrana, Mydayis, Quillivent, Quillichew, Vyvanse

Antibiotics All Orals Generics, Dificid Anticonvulsants All Classes Generics, Dilantin 30mg ONLY, Spritam Anti-Depressants SSRI, Other Classes Generics, Fetzima, Trintellix, Viibryd

Anti-Diabetic Agents Insulins DPP-4 Agents GLP-1 Agents SGLT-2 Inhibitors Monitors, Strips

Apidra, Fiasp, Lantus, Levemir, Novolin, Novolog, Novolog Mix, Toujeo, Tresiba Kombiglyze, Januvia/Janumet XR,Jentaducto, Onglyza, Tradjenta Ozempic, Rybelsus Tab, Trulicity, Soliqua, Symlin Pen, Victoza, Xultophy Farxiga, Glyxambi, Invokana/Invokamet, Jardiance, Qtern, Synjardy, Xigduo OneTouch Verio, One Touch Verio Flex

Anti-Inflammatory/ Analgesic Agents

NSAIDS, Other Topicals Fibromyalgia

Generics Generics

Anti-Migraine Triptans/CGRP Generics, Aovy, Emgality Anti-Parkinson’s All Classes Generics Blood Modifiers Platelet Aggregators

Anti-Coagulants Generics, Brilinta Generics, Eliquis, Pradaxa, Xarelto

Cardiovascular Agents

ACE Inhibitors, Others ARBs/ARB “Combos” Beta-blockers “Combos” Calcium Channel Blockers Statins Other Cholesterol Agents

Generics Generics, Byvalson, Edarbi, Edarbyclor Generics, Bystolic Generics Generics Generics, Praluent Inject

Contraceptives Oral Contraceptive Packs Generics, Beyaz, Natazia, Yaz, Safyral

HRT Agents Estrogens “Combos” Progestins/Androgenics

Divigel, Climara Pro, Minivelle, Xulane Patch Generics

Gastrointestinal Agents

Anti-Ulcer & PPIs Bowel & Colon Agents

All OTC PPIs, Generics, Dexilant Amitiza, Apriso, Lialda, Linzess, Motegrity, Viberzi, Xifaxan 550

Impotency Drugs Erectile Dysfunction Generics, Stendra

Ophthalmic Antibiotics Allergy & Antihistamines Glaucoma / Prostaglandins Anti-Inflammatory Other

Generics, Azasite, Moxeza, Vigamox, Zymaxid Generics, Pazeo Alphagan P, Betimol, Combigan, Cosopt-PF, Simbrinza, Lumigan, Zioptan Generics, Alrex, Ilevro, Lotemax, Prolensa Restasis

Psychotropic Anti-Psychotics (Atypicals) Generics, Saphris, Vraylar

Respiratory Agents Oral Non-Sedating/Others Allergy Asthma/COPD Agents Specialty Respiratory Agents Anaphylaxis Agents

OTC Products, Generics Dymista, Nasonex, Qnasl, Advair, Arcapta, Anoro, Arnuity, Breo, Flovent, Incruse, ProAir HFA, Qvar, Serevent, Spiriva, Stiolto, Striverdi, Symbicort, Ventolin Dupixent, Fasera, Nucala Epipen, Epipen Jr.

Sedatives Sleeping Agents Generics, Silenor Topical Skin Agents

Psoriasis Agents Antifungals Agents Acne Agents

Generics, Bryhall, Duobrii, Enstilar Foam, Taclonex, Tazorac Gel ONLY, Vanos Cream Generics, Ertaczo, Jublia, Luzu, Naftin Gel 2% Generics, Acanya, Aczone 7.5% Pump, Ziana

Urological Benign Prostate Hyperplasia Urologic Agents

Generics Generics, Myrbetriq

USE GENERICS WHENEVER POSSIBLE

Please punch out the cards at right to keep in your wallet and show to your physician as necessary upon getting a

written prescription.

Call Center: 855-828-1484

MC- Rx Pocket Drug List – 2020 CATEGORY DRUG CLASS PREFERRED DRUG

ADD/ADHD ADD/ADHD Generics, Adhansia XR, Daytrana, Mydayis, Quillivent, Quillichew, Vyvanse

Antibiotics All Orals Generics, Dificid Anticonvulsants All Classes Generics, Dilantin 30mg ONLY, Spritam Anti-Depressants SSRI, Other Classes Generics, Fetzima, Trintellix, Viibryd Anti-Diabetic Agents Insulins

DPP-4 Agents GLP-1 Agents SGLT-2 Inhibitors Monitors, Strips

Apidra, Fiasp, Lantus, Levemir, Novolin, Novolog, Novolog Mix, Toujeo, Tresiba Kombiglyze, Januvia/Janumet XR,Jentaducto, Onglyza, Tradjenta Ozempic, Rybelsus Tab, Trulicity, Soliqua, Symlin Pen, Victoza, Xultophy Farxiga, Glyxambi, Invokana/Invokamet, Jardiance, Qtern, Qternment XT, Synjardy, Xigduo OneTouch Verio, One Touch Verio Flex

Anti-Inflammatory NSAID, Other Topicals Fibromyalgia

Generics Generics

Anti-Migraine Triptans/CGRP Generics, Aovy, Emgality Anti-Parkinson’s All Classes Generics Blood Modifiers Platelet Aggregators

Anti-Coagulants Generics, Brilinta Generics, Eliquis, Pradaxa, Xarelto

Cardiovascular Agents

ACE Inhibitors, Others ARBs/ARB “Combos” Beta-blockers “Combos” Calcium Channel Blockers Statins Other Cholesterol Agents

Generics Generics, Byvalson, Edarbi, Edarbyclor Generics, Bystolic Generics Generics Generics, Praluent Inject

Contraceptives O/C Packs Generics, Beyaz, Natazia, Yaz, Safyral HRT Agents

Estrogens Progestins/Androgenics

Divigel, Climara Pro, Minivelle, Xulane Patch Generics

Gastrointestinal Anti-Ulcer & PPIs Bowel & Colon Agents

All OTC PPIs, Generics, Dexilant Amitiza, Apriso, Lialda, Linzess, Motegrity, Viberzi, Xifaxan 550

MC-Rx Pocket Drug List – 2020 CATEGORY DRUG CLASS PREFERRED DRUG

ADD/ADHD ADD/ADHD Generics, Adhansia XR, Daytrana, Mydayis, Quillivent, Quillichew, Vyvanse

Antibiotics All Orals Generics, Dificid, Anticonvulsants All Classes Generics, Dilantin 30mg ONLY, Spritam Anti-Depressants SSRI, Other Classes Generics, Fetzima, Trintellix, Viibryd Anti-Diabetic Agents Insulins

DPP-4 Agents GLP-1 Agents SGLT-2 Inhibitors Monitors, Strips

Apidra, Fiasp, Lantus, Levemir, Novolin, Novolog, Novolog Mix, Toujeo, Tresiba Kombiglyze, Januvia/Janumet XR,Jentaducto, Onglyza, Tradjenta Ozempic, Rybelsus Tab, Trulicity, Soliqua, Symlin Pen, Victoza, Xultophy Farxiga, Glyxambi, Invokana/Invokamet, Jardiance, Qtern, Qternment XT, Synjardy, Xigduo OneTouch Verio, One Touch Verio Flex

Anti-Inflammatory NSAID, Other Topicals Fibromyalgia

Generics Generics

Anti-Migraine Triptans/CGRP Generics, Aovy, Emgality Anti-Parkinson’s All Classes Generics Blood Modifiers Platelet Aggregators

Anti-Coagulants Generics, Brilinta Generics, Eliquis, Pradaxa, Xarelto

Cardiovascular Agents

ACE Inhibitors, Others ARBs/ARB “Combos” Beta-blockers “Combos” Calcium Channel Blockers Statins Other Cholesterol Agents

Generics Generics, Byvalson, Edarbi, Edarbyclor Generics, Bystolic Generics Generics Generics, Praluent Inject

Contraceptives O/C Packs Generics, Beyaz, Natazia, Yaz, Safyral, HRT Agents

Estrogens Progestins / Androgenics

Divigel, Climara Pro, Minivelle, Xulane Patch Generics

Gastrointestinal Anti-Ulcer & PPIs Bowel & Colon Agents

All OTC PPIs, Generics, Dexilant Amitiza, Apriso, Lialda, Linzess, Motegrity, Viberzi, Xifaxan 550

22002200

PPoocckkeett FFoorrmmuullaarryy

Your Clinically Preferred

Drug List

855-828-1484

Mail Service: 800-662-0586

www.MC-Rx.com

1255 Professional Parkway Gainesville, GA 30507

This Pocket Drug List is subject to change. Please visit www.procarerx.com to print the most up-to-date document. Click on ‘Resources’, and look under ‘Drug and Formulary Lists’ to find the current pocket formulary document. For additional punch-out cards, please contact your benefits office or the Call Center at 855-828-1484.

PLAN BENEFIT DESIGN MAY OVERRIDE FORMULARY COVERAGE

NOTE: Generic products are always preferred for dispensing if allowed by the plan’s benefit design. Additionally, drug categories not specifically mentioned on this card should be considered ‘preferred’ if included for coverage. If you have any questions, please contact:

Call Center: 855-828-1484 Mail Service: 800-662-0586 http://www.mc-rx.com https://memberaccess.procarerx.com

MC-Rx Pocket Drug List – 2020 CATEGORY DRUG CLASS PREFERRED DRUG Impotency Erectile Dysfunction Generics, Stendra Ophthalmic Antibiotics

Allergy & Antihistamines Glaucoma / Prostaglandins Anti-Inflammatory Other

Generics, Azasite, Moxeza, Vigamox, Zymaxid Generics, Pazeo Alphagan P, Betimol, Combigan, Cosopt-PF, Simbrinza, Lumigan, Zioptan Generics, Alrex, Ilevro, Lotemax, Prolensa Restasis

Psychotropics Anti-Psychotics (Atypicals) Generics, Saphris, Vraylar Respiratory Agents

Oral Non-Sedating, Others Allergy Inhalers Asthma/COPD Agents Specialty Respiratory Agents Anaphylaxis Agents

OTC Products, Generics Dymista, Nasonex, Qnasl, Advair, Arcapta, Anoro, Arnuity, Breo, Flovent, Incruse, ProAir HFA, Qvar, Serevent, Spiriva, Stiolto, Striverdi, Symbicort, Ventolin Dupixent, Fasera, Nucala Epipen, Epipen Jr.

Sedatives Sleeping Agents Generics, Silenor Topical Skin Agents

Psoriasis Agents Antifungals Agents Acne Agents

Generics, Bryhall, Duobrii, Enstilar Foam, Taclonex, Tazorac Gel ONLY, Vanos Cream Generics, Ertaczo, Jublia, Luzu, Naftin Gel 2% Generics, Acanya, Aczone 7.5% Pump, Ziana

Urological Benign Prostate Hyperplasia Urologic Agents

Generics Generics, Myrbetriq

PLAN BENEFIT DESIGN MAY OVERRIDE FORMULARY COVERAGE NOTE: Generic products are always preferred for dispensing if allowed by the plan’s benefit design. Additionally, drug categories not specifically mentioned on this card should be considered ‘preferred’ if included for coverage. If you have any questions, please contact:

Call Center: 855-828-1484 Mail Service: 800-662-0586

http://www.mc-rx.com https://memberaccess.procarerx.com

MC-Rx Pocket Drug List – 2020 CATEGORY DRUG CLASS PREFERRED DRUG Impotency Erectile Dysfunction Generics, Stendra Ophthalmic Antibiotics

Allergy & Antihistamines Glaucoma / Prostaglandins Anti-Inflammatory Other

Generics, Azasite, Moxeza, Vigamox, Zymaxid Generics, Pazeo Alphagan P, Betimol, Combigan, Cosopt-PF, Simbrinza, Lumigan, Zioptan Generics, Alrex, Ilevro, Lotemax, Prolensa Restasis

Psychotropics Anti-Psychotics (Atypicals) Generics, Saphris, Vraylar Respiratory Agents

Oral Non-Sedating, Others Allergy Inhalers Asthma/COPD Agents Specialty Respiratory Agents Anaphylaxis Agents

OTC Products, Generics Dymista, Nasonex, Qnasl, Advair, Arcapta, Anoro, Arnuity, Breo, Flovent, Incruse, ProAir HFA, Qvar, Serevent, Spiriva, Stiolto, Striverdi, Symbicort, Ventolin Dupixent, Fasera, Nucala Epipen, Epipen Jr.

Sedatives Sleeping Agents Generics, Silenor Topical Skin Agents

Psoriasis Agents Antifungals Agents Acne Agents

Generics, Bryhall, Duobrii, Enstilar Foam, Taclonex, Tazorac Gel ONLY, Vanos Cream Generics, Ertaczo, Jublia, Luzu, Naftin Gel 2% Generics, Acanya, Aczone 7.5% Pump, Ziana

Urological Benign Prostate Hyperplasia Urologic Agents

Generics Generics, Myrbetriq